Mechano-energetic efficiency in patients with hypertrophic cardiomyopathy with and without sarcomeric mutations

Hypertrophic cardiomyopathy (HCM) is mainly caused by sarcomeric mutations which may affect myocardial mechano-energetic efficiency (MEE). We investigated the effects of sarcomeric mutations on MEE. A non-invasive pressure/volume (P/V) analysis was performed. We included 49 genetically screened HCM patients. MEEi was calculated as the ratio between stroke volume and heart rate normalized by LV mass. Fifty-seven percent (57%) HCM patients carried a sarcomeric mutation. Patients with and without sarcomeric mutations had similar LV ejection fraction, heart rate, LV mass, and LV outflow gradient. Younger age at diagnosis, family history of HCM, and lower MEEi were associated with presence of sarcomeric mutation (p = 0.017; p = 0.001 and p = 0.0001, respectively). Lower MEEi in HCM with sarcomeric mutation is not related to significant differences on filling pressure as shown on P/V analysis. Sarcomeric mutations determine a reduction of the LV pump performance as estimated by MEEi in HCM. Lower MEEi may predict a positive genetic analysis.

Prediction of incident atrial fibrillation in hypertrophic cardiomyopathy

BACKGROUND AND AIM

Atrial fibrillation (AF) is the most common sustained arrhythmia in hypertrophic cardiomyopathy (HCM) with significant effects on outcome. We aim to compare the left atrial (LA) diameter measurement with HCM-AF Score in predicting atrial fibrillation (AF) development in HCM.

METHODS

From the regional cohort of the Campania Region, Italy, 519 HCM patients (38% women, age45 ± 17 years) without history of AF, were enrolled in the study. The primary clinical endpoint was the development of AF, defined as at least 1 episode documented by ECG.

RESULTS

During the follow-up (mean 8 ± 6, IQ range 2.5-11.2 years), 99 patients (19%) developed AF. Patients who developed AF were more symptomatic, had higher prevalence of ICD implantation, had larger LA diameter, greater left ventricular (LV) maximal wall thickness and LV outflow tract obstruction (p < 0.01). Both LA diameter and HCM-AF score were higher in patients who developed AF versus those who did not (LA diameter 49 ± 7 versus 43 ± 6 mm; HCM-AF score 22 ± 4 versus 19 ± 4; p < 0.0001); however, ROC curve analysis demonstrated that LA diameter had a significant greater area under the curve than HCM-AF Score (p < 0.0001). At 5 years follow-up, a LA diameter > 46 mm, showed a similar accuracy in predicting AF development of HCM-AF score ≥ 22, which identifies patients at high risk to develop AF.

CONCLUSION

Our analysis shows that LA diameter, a worldwide and simple echocardiographic measure, is capable alone to predict AF development in HCM patients.

Pitfalls and Tips in the Assessment of Aortic Stenosis by Transthoracic Echocardiography

Aortic stenosis (AS) is a valvular heart disease that significantly contributes to cardiovascular morbidity and mortality worldwide. The condition is characterized by calcification and thickening of the aortic valve leaflets, resulting in a narrowed orifice and increased pressure gradient across the valve. AS typically progresses from a subclinical phase known as aortic sclerosis, where valve calcification occurs without a transvalvular gradient, to a more advanced stage marked by a triad of symptoms: heart failure, syncope, and angina. Echocardiography plays a crucial role in the diagnosis and evaluation of AS, serving as the primary non-invasive imaging modality. However, to minimize misdiagnoses, it is crucial to adhere to a standardized protocol for acquiring echocardiographic images. This is because, despite continuous advances in echocardiographic technology, diagnostic errors still occur during the evaluation of AS, particularly in classifying its severity and hemodynamic characteristics. This review focuses on providing guidance for the imager during the echocardiographic assessment of AS. Firstly, the review will report on how the echo machine should be set to improve image quality and reduce noise and artifacts. Thereafter, the review will report specific emphasis on accurate measurements of left ventricular outflow tract diameter, aortic valve morphology and movement, as well as aortic and left ventricular outflow tract velocities. By considering these key factors, clinicians can ensure consistency and accuracy in the evaluation of AS using echocardiography.

Beyond Aortic Stenosis: Addressing the Challenges of Multivalvular Disease Assessment

Aortic stenosis (AS) can often coexist with other valvular diseases or be combined with aortic regurgitation (AR), leading to unique pathophysiological conditions. The combination of affected valves can vary widely, resulting in a lack of standardized diagnostic or therapeutic approaches. Echocardiography is crucial in assessing patients with valvular heart disease (VHD), but careful consideration of the hemodynamic interactions between combined valvular defects is necessary. This is important as it may affect the reliability of commonly used echocardiographic parameters, making the diagnosis challenging. Therefore, a multimodality imaging approach, including computed tomography or cardiac magnetic resonance, is often not just beneficial but crucial. It represents the future of diagnostics in this intricate field due to its unprecedented capacity to quantify and comprehend valvular pathology. The absence of definitive data and guidelines for the therapeutic management of AS in the context of multiple valve lesions makes this condition particularly challenging. As a result, an individualized, case-by-case approach is necessary, guided primarily by the recommendations for the predominant valve lesion. This review aims to summarize the pathophysiology of AS in the context of multiple and mixed valve disease, with a focus on the hemodynamic implications, diagnostic challenges, and therapeutic options.

Diagnosis and Clinical Implication of Left Ventricular Aneurysm in Hypertrophic Cardiomyopathy

Hypertrophic cardiomyopathy (HCM) is a genetic disease with heterogeneous clinical presentation and prognosis. Within the broad phenotypic expression of HCM, there is a subgroup of patients with a left ventricular (LV) apical aneurysm, which has an estimated prevalence between 2% and 5%. LV apical aneurysm is characterized by an area of apical dyskinesis or akinesis, often associated with regional scarring. To date, the most accepted pathomechanism of this complication is, in absence of coronary artery disease, the high systolic intra-aneurysmal pressure, which, combined with impaired diastolic perfusion from lower stroke volume, results in supply-demand ischemia and myocardial injury. Apical aneurysm is increasingly recognized as a poor prognostic marker; however, the efficacy of prophylactic anticoagulation and/or intracardiac cardioverted defibrillator (ICD) in improving morbidity and mortality is not yet clearly demonstrated. This review aims to elucidate the mechanism, diagnosis and clinical implication of LV aneurysm in patients with HCM.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Global longitudinal strain and quantitative sensory testing in pre-symptomatic patients with mutation for transthyretin amyloidosis

Background

Hereditary transthyretin (ATTRv) amyloidosis is a rare, autosomal dominant, and devastating disease. If untreated, the disease is fatal within 4–15 years from onset.

Thus, diagnosis in the early stages of ATTRv amyloidosis is crucial to start treatment and to prevent or delay disease progression. However, the diagnosis of symptomatic ATTRv amyloidosis in TTR gene mutation carriers may be challenging.

Purpose

We aimed identifying early indexes of cardiac and/or neurological involvement in pre-symptomatic subjects (carriers) harboring a TTR gene mutation.

Methods

Eight TTR-mutation carriers (mean age 51±9 years, 5 males) constituted the study populations. Mutations identified were: Val30Met in 4, and Phe64Leu in the remaining 4 patients. Patients underwent tactile and thermal quantitative sensory testing (QST), 99mTc-labeled bisphosphonate (HMDP) scintigraphy with the evaluation of Perugini score, and comprehensive echocardiogram with evaluation of global longitudinal strain (GLS).

Results

Table 1 reports results in overall patients. PADO indicates predicted age of disease onset. MWT indicates maximal wall thickness at echocardiography.

There was a strong and inverse correlation between the °C degree at HPT and GLS (r=−0.790; p=0.02, demonstrating that a worse HPT corresponded a better GLS (Figure 1).

Conclusion

GLS and QST findings support an early involvement of heart and small nerve fibers even many years before the PADO. Interestingly, cardiac impairment seems to not parallel that of small nerve fibers. An inhomogeneous accumulation of fibrils, as well possible different pathophysiological mechanisms in heart and nerve fibers, might result in a variable organ impairment at least in the earliest stage of disease.

Our observation needs to be tested in a wider population with such a rare disease.

Funding Acknowledgement

Type of funding sources: None.

Mechano-energetic efficiency in patients with hypertrophic cardiomyopathy with and without sarcomeric mutations

Background

Hypertrophic Cardiomyopathy (HCM) is mainly caused by sarcomeric mutations. In about 40% of cases the causal mutation is unknown. Myocardial mechano-energetic efficiency per unit of left ventricular (LV) mass (MEEi) is an echocardiographic parameter of LV pump performance. Sarcomeric mutations may affect energy efficiency.

Purpose

We investigated the effects of the presence of sarcomeric mutations on MEEi in patients with HCM.

Methods

We included 49 genetically screened HCM patients (50±10 years, 27% women) with LV ejection fraction &gt;50%, LV maximal wall thickness &gt;14 mm and no moderate to severe mitral regurgitation. MEEi was calculated as the ratio between stroke volume and heart rate, normalized by LV mass. Echo-LV mass was calculated as LV epicardial minus LV endocardial volumes in 4 and 2 chamber views multiplied by 1.05, a method validated with nuclear magnetic resonance.

Results

27 HCM patients carried a sarcomeric mutation (HCM-Sarc; 55%). As shown in the table, patients with and without sarcomeric mutations (HCM-Sarc vs HCM-NoSarc) had similar LV ejection fraction, heart rate, LV mass and LV outflow tract gradient. HCM-Sarc showed early age at diagnosis, higher frequency of HCM family history and significantly reduced MEEi as compared with HCM-NoSarc. Presence of sarcomeric mutation could be predicted by younger age, lower MEEi and by family history of HCM (overall p&lt;0.05).

Conclusions

In a population of HCM patients, the presence of a sarcomeric mutation is the only determinant of reduced the LV pump performance as estimated by MEEi. MEEi may be used as an imaging biomarker in sarcomeric mutation carriers.

Funding Acknowledgement

Type of funding sources: None.

HCM-AF South Italy score for prediction of new-onset atrial fibrillation in patients with hypertrophic cardiomyopathy: data from a derivation and validation italian cohorts

Background

Only one score for prediction of new-onset atrial fibrillation (AF) in patients with hypertrophic cardiomyopathy (HCM) has been developed in North America (HCM-AF North America score).

Purpose

To develop a new score (HCM-AF South Italy score) in an Italian derivation cohort and to test the new score with that from North America, in an Italian validation cohort.

Methods

A cohort of 228 patients with HCM and without history of AF, followed at referral center 1 for HCM, was used for model development. A cohort of 226 patients without history of AF, followed at referral center 2, was used for external validation. During follow-up (IQR 3–13 years, median 8 years), 59 (26%) patients developed new-onset AF. Data in the development cohort generated the HCM-AF South Italy score, a point score to predict AF probability: left atrial dimension &gt;49 mm (+5 points), age at clinical evaluation &lt;55 years (+2 points), the use of angiotensin-converting enzyme (ACE) or inhibitor or angiotensin receptor blocker (ARB) at initial evaluation (+2 points), low left ventricular (LV) ejection fraction (&lt;50%) (+2 points), LV outflow tract obstruction (LVOTO) &gt;25 mmHg (+2 points), NYHA class &gt;1 (+1 point).

Results

Patients from the validation cohort were older, had lower prevalence of HCM family history, lower systolic and diastolic blood pressure, taken fewer drugs like beta-blockers, ACE or ARB, calcium-channel blockers, and antiarrhythmic drugs and had lower LVOTO than patients from the derivation cohort, (overall p&lt;0.05). During follow-up (IQR 1–10 years, median 5 years), 25 (11%) patients developed AF. ROC curve analysis demonstrated that HCM-AF South Italy score was superior to HCM-AF North America score (Figure). A HCM- AF South Italy score &gt;4 identified patients at risk of AF with a sensitivity of 48%, specificity of 76%, PPV of 20% and NPV of 92%.

Conclusion

Although derived and tested in little and quite different populations, the performance of the HCM-AF South Italy score was superior to that of the score developed in North America.

Funding Acknowledgement

Type of funding sources: None.

Impact of Age and Heart Rate on Strain-Derived Myocardial Work in a Population of Healthy Subjects

Background: The influence of age and gender on strain-imaging-derived myocardial work (MW) was recently investigated in healthy subjects. No information is available on the impact of heart rate (HR) on MW. Methods: 177 healthy subjects (47% men, mean age 42 years) underwent an echo-Doppler exam, including quantification of global longitudinal strain (GLS). Cuff blood pressure was used as a surrogate of left ventricular peak pressure to estimate global work index (GWI), global constructive work (GCW), global wasted work (GWW) and global work efficiency (GWE). Statistical analyses were performed according to age and HR tertiles. Results: GWW was higher in the third HR tertile, i.e., ≥74 bpm (74.7 ± 33.6 mmHg %) than in the first HR tertile (<66 bpm) (61.0 ± 32.5 mmHg %) (p < 0.02). In the pooled population, by adjusting for systolic blood pressure, GLS, E/e’ ratio and left atrial volume index, age was independently associated with GCW (β = 0.748) and GWI (β = 0.685) (both p < 0.0001) and HR with GWW (β = 0.212, p = 0.006) and GWE (β = −0.204, p = 0.007). Conclusions: In healthy subjects age shows a mild influence on GCW. HR exerts an independent negative impact on GWW and GWE: the higher HR the greater wasted work and lower myocardial efficiency.

Association between common cardiovascular risk factors and clinical phenotype in patients with hypertrophic cardiomyopathy from the European Society of Cardiology (ESC) EurObservational Research Programme (EORP) Cardiomyopathy/Myocarditis registry

AIMS

The interaction between common cardiovascular risk factors (CVRF) and hypertrophic cardiomyopathy (HCM) is poorly studied. We sought to explore the relation between CVRF and the clinical characteristics of patients with HCM enrolled in the EURObservational Research Programme (EORP) Cardiomyopathy registry.

METHODS AND RESULTS

1739 patients with HCM were studied. The relation between hypertension (HT), diabetes (DM), body mass index (BMI), and clinical traits was analysed. Analyses were stratified according to the presence or absence of a pathogenic variant in a sarcomere gene. The prevalence of HT, DM, and obesity (Ob) was 37, 10, and 21%, respectively. HT, DM, and Ob were associated with older age (P<0.001), less family history of HCM (HT and DM P<0.001), higher New York Heart Association (NYHA) class (P<0.001), atrial fibrillation (HT and DM P<0.001; Ob p = 0.03) and LV (left ventricular) diastolic dysfunction (HT and Ob P<0.001; DM P = 0.003). Stroke was more frequent in HT (P<0.001) and mutation-positive patients with DM (P = 0.02). HT and Ob were associated with higher provocable LV outflow tract gradients (HT P<0.001, Ob P = 0.036). LV hypertrophy was more severe in Ob (P = 0.018). HT and Ob were independently associated with NYHA class (OR 1.419, P = 0.017 and OR 1.584, P = 0.004, respectively). Other associations, including a higher proportion of females in HT and of systolic dysfunction in HT and Ob, were observed only in mutation-positive patients.

CONCLUSION

Common CVRF are associated with a more severe HCM phenotype, suggesting a proactive management of CVRF should be promoted. An interaction between genotype and CVRF was observed for some traits.

Aortic thrombosis: the forgotten source of ischemic stroke. A case report and systematic review of the literature

Ischemic stroke represents one of the most important health problems in industrialized countries, both for epidemiological and socio-economic impact. The presence of thrombi in the aorta is rare and its treatment has not been uniquely defined. Here we report the case of an 82-years-old man with aortic thrombosis and acute ischemic stroke.

Determinants of aortic root dilatation over time in patients with essential hypertension: The Campania Salute Network

BACKGROUND

Determinants of changes of aortic root dimension over time are not well defined.

DESIGN

We investigated whether specific phenotype and treatment exist predicting changes in aortic root dimension in hypertensive patients from the Campania Salute Network.

METHODS

N = 4856 participants (age 53 ± 11 years, 44% women) were included. At first and last available echocardiograms, we measured aortic root and a z-score of aortic root (AOz) was generated as the difference between measured and predicted aortic root, derived from a healthy reference population. Aortic root dilatation (ARD) was defined as AOz >75th percentile of distribution.

RESULTS

At baseline, 3642 patients (75%) exhibited normal aortic root, and 1214 (25%) ARD. After a follow-up of 6.1 years (interquartile range 3.0-8.8 years), 366 (11%) patients with initial normal aortic root exhibited ARD, whereas 457(38%) with initial ARD exhibited normal aortic root. At multivariate analysis patients with incident ARD were most likely to be women, obese, with left ventricular hypertrophy, lower systolic but higher diastolic blood pressure and stroke volume index at baseline, and higher average value of diastolic blood pressure during follow-up (p < 0.05); whereas patients normalizing their ARD were non-obese women with lower baseline systolic blood pressure, stroke volume index, average diastolic blood pressure during follow-up and longer follow-up time (p < 0.05). Anti-renin-angiotensin system (anti-RAS) was associated with 45% greater probability to normalize aortic root dimension.

CONCLUSIONS

Volume (stroke volume index) and pressure loads (diastolic blood pressure) influence aortic root dimension over time. Aortic root normalization, reflecting a more favourable haemodynamic load, is predictable in non-obese women with lower diastolic blood pressure, taking more anti-RAS therapy. This suggest that sex elicits a different response in aortic walls to pathological stimuli.

Fractional flow reserve in patients with reduced ejection fraction

AIMS

Fractional flow reserve (FFR) has never been investigated in patients with reduced ejection fraction and associated coronary artery disease (CAD). We evaluated the impact of FFR on the management strategies of these patients and related outcomes.

METHODS AND RESULTS

From 2002 to 2010, all consecutive patients with left ventricular ejection fraction (LVEF) ≤50% undergoing coronary angiography with ≥1 intermediate coronary stenosis [diameter stenosis (DS)% 50-70%] treated based on angiography (Angiography-guided group) or according to FFR (FFR-guided group) were screened for inclusion. In the FFR-guided group, 433 patients were matched with 866 contemporary patients of the Angiography-guided group. For outcome comparison, 617 control patients with LVEF >50% were included. After FFR, stenotic vessels per patient were significantly downgraded compared with the Angiography-guided group (1.43 ± 0.98 vs. 1.97 ± 0.84; P < 0.001). This was associated with lower revascularization rate (52% vs. 62%; P < 0.001) in the FFR-guided vs. the Angiography-guided group. All-cause death at 5 years of follow-up was significantly lower in the FFR-guided as compared with Angiography-guided group [22% vs. 31%. HR (95% CI) 0.64 (0.51-0.81); P < 0.001]. Similarly, rate of major adverse cardiovascular and cerebrovascular events (MACCE: composite of all-cause death, myocardial infarction, revascularization, and stroke) was significantly lower in the FFR-guided group [40% vs. 46% in the Angiography-guided group. HR (95% CI) 0.81 (0.67-0.97); P = 0.019]. Higher rates of death and MACCE were observed in patients with reduced LVEF compared with the control cohort.

CONCLUSIONS

In patients with reduced LVEF and CAD, FFR-guided revascularization was associated with lower rates of death and MACCE at 5 years as compared with the Angiography-guided strategy. This beneficial impact was observed in parallel with less coronary artery bypass grafting and more patients deferred to percutaneous coronary intervention or medical therapy.

Prognostic value of reduced heart rate reserve during exercise stress-echocardiography in hypertrophic cardiomyopathy

Background

Heart rate reserve (HRR) during exercise evaluates chronotropic incompetence and is a prognostically important marker of cardiac autonomic dysfunction, additive to regional wall motion abnormalities (RWMA) in patients with coronary artery disease.

Objectives

To assess determinants and prognostic value of HRR in patients with hypertrophic cardiomyopathy (HCM).

Methods

From 1998 to 2019, we enrolled 774 HCM patients (age = 48.8±15.9 years, 410 men) with exercise stress echocardiography (ESE) in 10 certified centres of the international stress echo network. During ESE we assessed: left ventricular outflow tract obstruction (LVOTO, significant when &gt;50 mmHg); RWMA; HRR (peak/ rest heart rate), 344 in beta-blockers therapy (44.4%). Patients were followed for a median 49 months (IQ range, 25–78 months). The study end-point was all-cause mortality.

Results

During ESE, we observed stress-induced RWMA in 42 (5.4%) and LVOTO in 248 (33%); HRR was 1.92.±0.41. There were no difference in patients with normal and abnormal HRR with and without beta-blockers therapy (147, 41.1% vs 211, 58.9%, p=0.079). During follow-up, 43 deaths occurred. Beta blockers therapy in univariate analysis did not have prognostic role (HR 1.105, 95% CI 0.602–2.028, p=0.768). The lowest HRR quartile (≤1.62) had a 10-fold higher 6-year death rate (10.9%) than the highest quartile (&gt;2.16, 1.04%): see figure. At multivariable analysis, lowest HRR quartile (HR 2.074, 95% CI 1.082–6.773, p=0.034), age (HR 1.045, 95% CI 1.014–1.077, p=0.004), maximal wall thickness (HR 1.137, 95% CI 1.054–1.226, p=0.001), stress-induced RWMA s(HR 4.289, 95% CI 1.733–10.615, p=0.002) and ≥ moderate mitral regurgitation at rest (HR 3.127, 95% CI 1.507–6.488, p=0.002) predicted death.

Conclusions

A blunted HRR during ESE predicts adverse outcome independent of inducible RWMA in HCM patients. Autonomic dysfunction deserves consideration as a potential therapeutic target in this disease.

Figure 1

Funding Acknowledgement

Type of funding source: None

Increased carotid cross-sectional area is a marker of organ damage in young hypertensive patients

Background

Common Carotid artery (CA) cross sectional area (CCSA) is strictly related to vessel remodelling stimulated by mechanical stress due to arterial hypertension. Accordingly, increased CCSA might represent an early marker of vascular target organ damage independently of presence of atherosclerotic plaque.

Purpose

To assess early correlates and prognostic impact of CCSA in a large population of young treated HTN patients.

Methods

We selected 970 hypertensive patients, 18 to 40 years old (mean age 34±5 yrs; 30% women) of the Campania Salute Network registry with available CA ultrasound and follow-up data, free of overt cardiovascular (CV) disease. CCSA was computed as:

CCSA = π [(CAd/2 + IMT)2 – (CAd/2)2]

where CAd = CA diameter and IMT = mean intima media thickness. Participants were compared by CCSA tertiles.

Results

Compared to the lowest and intermediate tertiles, patients in the highest tertile were more often male, smokers, older, and had higher body mass index (BMI), diastolic blood pressure (BP), higher fasting glucose, triglycerides, LDL cholesterol and uric acid, with lower level of HDL cholesterol. They also exhibited higher left ventricular mass index and IMT and had more often carotid atherosclerotic plaque (all p&lt;0.05). During a median follow-up of 45 months, 22 incident composite CV events occurred. In Cox-Regression analyses, adjusting for the above covariates, presence of carotid plaque and classes of antihypertensive medications, increased CCSA was significantly associated with increased CV risk (HR 1.08/mm2; 95% CI 1.02–1.13; p&lt;0.01).

Conclusions

In a population of young hypertensive patients, increased CCSA is related to metabolic and atherosclerotic disease and is associated with increased CV risk, also independently of overt carotid plaque.

Funding Acknowledgement

Type of funding source: None

HFpEF score discriminates severity of cardiovascular profile in asymptomatic treated hypertensive patients: the campania salute network

Background

The heart failure with preserved ejection fraction (HFpEF) score is easy to use and potentially useful to discriminate HFpEF from noncardiac causes of dyspnea. HFpEF score may be expressed also as probability to have HFpEF.

Purpose

We investigated whether a high HFpEF score can identify specific cardiovascular (CV) profile in treated hypertensive patients even without dyspnea.

Methods

From September to December 2019, we consecutively enrolled treated hypertensive patients without dyspnea, with normal left ventricular (LV) ejection fraction (&gt;50%), and chronic kidney disease of no more than stage III. In addition to standard echocardiographic parameters we evaluated: 1) inappropriate LV mass, identified as a percent of predicted LV mass &gt;128%, 2) myocardial energetic efficiency as the ratio of stroke volume to heart rate normalized by LV mass (MEEi), and 3) an estimate of arterial stiffness, i.e. the ratio of pulse pressure and stroke index (by allometric normalization by height), as previously reported. The probability of HFpEF was calculated from the HFpEF score, using body mass index, pulmonary systolic pressure, mitral E/E' ratio, age, and history or evidence of atrial fibrillation.

Results

188 patients with complete data were analyzed (42% women, age 61±14 years, 9% diabetic). Patients were then divided into 3 groups according to HFpEF probability tertiles and compared by ANOVA and trend analysis (Table 1).

Conclusions

Probability of HFpEF using HFpEF score and non-standard echocardiographic parameters identify worse CV profile in treated hypertensive patients without dyspnea.

Funding Acknowledgement

Type of funding source: None

P5457Assessment of carotid cross sectional area in hypertensive patients: phenotyping and prognostic validation in the campania salute network

Background

Increased intima media thickness (IMT) of common carotid artery (CA) is considered the hallmark of vascular hypertension-mediated target organ damage, even though vessel remodeling due to mechanical stress can be accompanied also by changes in diameter.

Purpose

We developed a method computing both diameter and IMT of CA, and assessed correlates and prognostic impact of carotid cross sectional area (CCSA) in a large registry of treated hypertensive patients.

Methods

We selected 7049 hypertensive patients of the Campania Salute Network registry free of overt cardiovascular (CV) disease and with available CA ultrasound (54±11 yrs; 57% male). CCSA was computed as:

π × [((CA diameter + 2 × (mean IMT)) / 2)]2 − π × [((CA diameter) / 2)]2.

Results

CCSA was considered high if >90th percentile of the sex-specific distribution (>48 mm2 in men and >41 mm2 in women). Higher CCSA correlated with older age, male sex, higher pulse pressure (PP), higher total and LDL cholesterol and presence of diabetes (p<0.01 for all). During a median follow-up of 45 months (IQR 19–92), 324 incident composite major and minor CV events occurred. In Cox regression analysis high CCSA was associated with more than 100% increased risk of incident CV events (p<0.0001, figure), independently of the effect of older age, male sex, PP>60mmHg, presence of left ventricular hypertrophy (LVH), carotid plaque (CP), and less anti-RAS therapy (p<0.05 for all).

Conclusions

In treated hypertensive patients, increased CCSA is associated with worse metabolic and lipid profile and predict incident CV events, independently of high PP, presence of LVH and CP.

Left Ventricular Mass in Hypertrophic Cardiomyopathy Assessed by 2D-Echocardiography: Validation with Magnetic Resonance Imaging

We aim to validate echocardiographic left ventricular (LV) mass (echoLVM) in sixty-one patients with hypertrophic cardiomyopathy (HCM), using cardiac magnetic resonance measures (cmrLVM) as gold standard. cmrLVM was calculated using LV short-axis images, from base to apex, whereas echoLVM by LV epicardial minus LV endocardial volumes in 4 and 2 chamber views, using Simpson disk summation; trabeculae and papillary muscle were excluded in both cmrLVM and echoLVM. cmrLVM and echoLVM were not different by paired t test (145 ± 66 vs 147 ± 61; p = 0.240), and their correlation was good (r = 0.977; p < 0.0001). Intraclass correlation demonstrated reliability of echoLVM with cmrLVM (ρ = 0.987; Cls = 0.978-0.992; p < 0.0001). LV end-diastolic volume was higher by CMR than that by echo (137 ± 33 vs 85 ± 28 mL, p < 0.0001), resulting in a lower mass/volume ratio (1.1 ± 0.4 vs 1.8 ± 0.8, p < 0.0001). EchoLVM may be determined in patients with HCM. However, mass/volume ratio is higher by echocardiography than that by CMR.

Unattended Automated Office Blood Pressure Measurement and Cardiac Target Organ Damage, A Pilot Study

INTRODUCTION

The ESC-2018 guidelines suggest the use of Unattended automated office blood pressure (UAOBP) to avoid or at least reduce the white coat effect, even if do not support its use as preferred method.

AIM

To assess the pressure difference between UAOBP and Attended office blood pressure (AOBP) and to evaluate their correlations with target organ damage in hypertensive patients.

METHODS

UAOBP and AOBP were taken in a cohort of 48 outpatients. The pressure difference between the 2 methods and their correlation with anthropometric and cardiac parameters were analyzed.

RESULTS

Unattended systolic and diastolic BP were lower than Attended systolic and diastolic BP (135 ± 17 mmHg vs 139 ± 21 mmHg and 79 ± 10 mmHg vs 82 ± 10 mmg). ΔDBP was significantly directly correlated with female sex (r = 0.347, p = 0.016) and it was lower in men compared to women (0.11 ± 8.9 mmHg vs 6.07 ± 7.42 mmHg, p = 0.016). Correlation coefficients for LVMi and RWT for attended and unattended BP were not statistically different (for LVMi r = 0.286 vs r = 0.381, p = 0.61, for RWT r = 0.413 vs r = 0.363, p = 0.78). The relationship between attended and unattended BP was described by the following equation: y = - 4.68 + 1.06*x; where Y is the attended systolic BP and X is the unattended systolic BP; in accordance with this equation, an unattended systolic BP of 140 mmHg corresponds to an attended systolic BP of 143.7 mmHg.

CONCLUSIONS

UAOBP provides significantly lower values than AOBP. The difference in BP values between the two methods is much lower than the one obtained in most clinical studies.

CHA2DS2-VASc score and left atrial volume dilatation synergistically predict incident atrial fibrillation in hypertension: an observational study from the Campania Salute Network registry

Arterial hypertension is a leading risk factor for developing atrial fibrillation. CHA₂DS₂-VASc score can help to decide if patients with atrial fibrillation need anticoagulation. Whether CHA₂DS₂-VASc may predicts incident atrial fibrillation and how it interacts with left atrial dilatation is unknown. We tested this hypothesis in a large registry of treated hypertensive patients. From 12154 hypertensive patients we excluded those with prevalent atrial fibrillation (n 51), without follow-up (n 3496), or carotid ultrasound (n 1891), and low ejection fraction (i.e. <50%, n 119). A CHA₂DS₂-VASc score ≥3 was compared with CHA₂DS₂-VASc score ≤2. Incident symptomatic or occasionally detected atrial fibrillation was the end-point of the present analysis. At baseline, 956 (15%) patients exhibited high CHA₂DS₂-VASc; they were older, most likely to be women, obese and diabetic, with lower glomerular filtration rate, and higher prevalence of left ventricular hypertrophy, left-atrial dilatation and carotid plaque (all p < 0.005). Prevalent Stroke/TIA was found only in the subgroup with high CHA₂DS₂-VASc. During follow-up (median = 54 months) atrial fibrillation was identified in 121 patients, 2.57-fold more often in patients with high CHA₂DS₂-VASc (95% Cl 1.71–4.86 p < 0.0001). In multivariable Cox analysis, CHA₂DS₂-VASc increased incidence of atrial fibrillation by 3-fold, independently of significant effect of left-atrial dilatation (both p < 0.0001) and other markers of organ damage. Incident AF is more than doubled in hypertensive patients with CHA₂DS₂-VASc ≥3. Coexisting CHA₂DS₂-VASc score >3 and LA dilatation identify high risk subjects potentially needing more aggressive management to prevent AF and associated cerebrovascular ischemic events.

Aortic Root Dilatation Is Associated With Incident Cardiovascular Events in a Population of Treated Hypertensive Patients: The Campania Salute Network

BACKGROUND

Aortic root (AR) dimension (ARD) at the Valsalva sinuses has been associated with incident cardiovascular (CV) events in population-based studies, but this effect could be due to the association with increased left ventricular (LV) mass. There is also uncertainty on how to define clear-cut AR dilatation. Thus, we analyzed the Campania Salute Network (CSN) registry to (i) establish criteria for evaluation of ARD, (ii) propose cut-points for AR dilatation, and (iii) determine whether AR dilatation has prognostic value independent of LV hypertrophy (LVH).

METHODS

We analyzed hypertensive patients with available follow-up, in sinus rhythm and free of prevalent valvular and CV disease (n = 8,573). AR exceeding the 75th percentile of the AR z-score (Ao-Z) obtained by comparison with the value predicted by age, sex, and height (i.e., Ao-Z > 0.80) was considered dilated.

RESULTS

Patients with baseline-dilated ARD by Ao-Z were more likely to be younger, men, and obese and had higher baseline blood pressure (BP; all <0.02) but similar kidney function as those without ARD dilatation. In multivariable Cox regression model, dilated ARD predicted 36% increased rate of CV events, independently of older age, male sex, systolic BP, LVH, and class of antihypertensive medications used during follow-up (95% confidence interval: 1.07-1.71, P = 0.011).

CONCLUSIONS

In the context of a population of treated hypertensive patients, ARD defined by z-score of predicted values is an independent predictor of CV events regardless of LVH and other common confounders.

CLINICAL TRIALS REGISTRATION

Trial Number NCT02211365.

Left ventricular hypertrophy offsets the sex difference in cardiovascular risk (the Campania Salute Network)

BACKGROUND

In general, women have lower risk for cardiovascular disease. We tested whether this sex-specific protection persists also in the presence of hypertensive left ventricular hypertrophy (LVH).

METHODS

12,329 women and men with hypertension and free from prevalent cardiovascular disease enrolled in the prospective Campania Salute Network registry were followed over a median of 4.1years. Subjects were grouped according to the absence or the presence of LVH identified by echocardiography using validated sex-specific cut-off values of LV mass index (>47g/m^2.7 in women and >50g/m^2.7 in men). Main outcome was major cardiovascular events (MACE; combined acute coronary syndromes, stroke, hospitalization for heart failure and incident atrial fibrillation).

RESULTS

The cardiovascular risk profile accompanying LVH did not differ between sexes, but presence of obesity and diabetes carried higher probability for LVH in women, and LVH was more prevalent in women than men (43.4 vs. 32.1%, p<0.001). Among patients without LVH (n=7764), women had a 35% lower hazard rate (HR) for MACE (n=179) than men (95% confidence interval [CI] 0.44-0.96, p=0.031) in Cox regression analysis adjusting for cardiovascular risk factors and antihypertensive treatment during follow up. In contrast, among patients with LVH (n=4565), women had a similar HR for MACE as men (HR 0.94 [95% CI 0.69-1.30], p=0.720).

CONCLUSION

This study demonstrates that presence of LVH in hypertension offsets the female sex-protection in cardiovascular risk. Thus among hypertensive subjects with LVH, women and men have comparable cardiovascular risk.

Is increased uric acid a risk factor or a defensive response? The Campania Salute Network

BACKGROUND AND AIMS

Circulating uric acid (UA) is positively associated with body mass index (BMI), blood glucose, blood pressure (BP), markers of inflammation, and altered lipid profile. UA has also anti-oxidative properties which might be beneficial for cardiovascular (CV) system. It is still debated whether or not UA is independently associated with increased CV morbidity and/or mortality.

METHODS AND RESULTS

We studied prognostic impact of UA in 8833 hypertensive adults (mean age 53 ± 12 yrs, 3857 women) from the Campania Salute Network, without prevalent CV disease and more than stage 3 CKD. We calculated standardized UA Z-score, adjusted for age, sex, glomerular filtration rate, and BMI. Low and high UA and UA Z-score quartiles were compared to the 2 middle quartiles assumed to be "normal". Prevalence of obesity and diabetes was higher in low and high than in normal UA Z-score group (all p < 0.001). Systolic BP, left ventricular mass, carotid intima thickness were significantly higher and ejection fraction was reduced in the presence of high UA Z-score (all p < 0.001). Over 33-months average follow-up, incident major CV end-points (MACE) were not significantly different among low, normal and high UA or UA Z-score. In the latter analysis, however, incident MACE tended to be more frequent in the low than the high UA Z-score. Despite the results of multivariable analyses, the effect of less aggressive therapy in low UA Z-score cannot be excluded with certainty.

CONCLUSION

In treated hypertensive patients, high levels of UA normalized for major biological determinants do not independently predict CV outcome. CLINICALTRIALS.

GOV IDENTIFIER

NCT02211365.

Target Organ Damage and Target Systolic Blood Pressure in Clinical Practice: The Campania Salute Network

BACKGROUND

Lowering systolic blood pressure (SBP) below the conventional threshold (140 mm Hg) reduces left ventricular (LV) hypertrophy and incident cardiovascular (CV) events. We assessed whether different thresholds of SBP as the average value during follow-up (FU) have different impact on changes in target organ damage (TOD).

METHODS

From the Campania Salute Network registry, we selected 4,148 hypertensive patients with average SBP-FU <140 mm Hg, and without history of prevalent CV or chronic kidney disease (i.e., <stage IV CKD). Patients were divided in "Tight" (SBP-FU <130 mm Hg) or "Usual" (SBP-FU ≥130) BP control. At baseline and at the last available control visit, we assessed LV mass index (LVMi, g/m2.7), carotid intimal-medial thickness (IMT, mm), and glomerular filtration rate by CKD-EPI equation (GFR, ml/min/1.73 m2) as markers of TOD. Time trend of TOD for tight and usual subgroups were compared, adjusting for significant confounders.

RESULTS

During a median of 74 months (interquartile range: 35-108 months), 1,824 patients (44%) were classified as tight control. They were younger, with less prevalent obesity, diabetes, lower initial LVMi, and IMT, and were taking less Ca++-channel blockers during FU than the usual control subgroup (all P < 0.05). In both subgroups, there were no changes over time in LVMi and GFR, whereas the IMT increased during the FU (P < 0.004), with no significant effect of degree of SBP control.

CONCLUSIONS

In a registry of treated hypertensive patients from a tertiary care center, progression of TODs is not related to average SBP during FU.

Higher pulse pressure and risk for cardiovascular events in patients with essential hypertension: The Campania Salute Network

Background

Increased pulse pressure is associated with structural target organ damage, especially in elderly patients, increasing cardiovascular risk.

Design

In this analysis, we investigated whether high pulse pressure retains a prognostic effect also when common markers of target organ damage are taken into account.

Methods

We analysed an unselected cohort of treated hypertensive patients from the Campania Salute Network registry ( n = 7336). Participants with available cardiac and carotid ultrasound were required to be free of prevalent cardiovascular disease, with ejection fraction ≥50%, and no more than stage III Chronic Kidney Disease. The median follow-up was 41 months and end-point was occurrence of major cardiovascular events (i.e. fatal and non-fatal stroke or myocardial infarction and sudden death). Based on current guidelines, pulse pressure ≥60 mm Hg was classified as high pulse pressure ( n = 2356), at the time of the initial visit, whereas pulse pressure <60 mm Hg was considered normal ( n = 4980).

Results

High pulse pressure patients were older, more likely to be women and diabetic, while receiving more antihypertensive medications than normal pulse pressure (all p < 0.0001). High pulse pressure exhibited greater prevalence of left ventricular hypertrophy, and carotid plaque than normal pulse pressure (all p < 0.0001). In Cox regression, high pulse pressure patients had 57% increased hazard of major cardiovascular events, compared to normal pulse pressure (hazard ratio = 1.57; 95% confidence interval: 1.12–2.22, p = 0.01), an effect that was independent of significant prognostic impact of older age, male sex, diabetes, left ventricular hypertrophy, carotid plaque and less prescription of anti-renin–angiotensin system therapy.

Conclusions

High pulse pressure is a functional marker of target organ damage, predicting cardiovascular events in hypertensive patients, even independently of well-known structural markers of target organ damage.

Differential effect of obesity on prevalence of cardiac and carotid target organ damage in hypertension (the Campania Salute Network)

BACKGROUND

Whether increasing body mass index (BMI) is independently associated with parallel increased prevalence of hypertensive vascular and cardiac target organ damage (TOD) needs further clarification.

METHODS

We analyzed 8815 hypertensive patients without prevalent cardiovascular disease, participating in the Campania Salute Network, grouped into BMI classes (normal 20-24.9kg/m², overweight 25-29.9kg/m² and obese ≥30kg/m²). Vascular and cardiac TOD was defined as ultrasound plaque (intima-media thickness>1.5mm) in >1 of the common or internal carotid arteries and echocardiographic left ventricular (LV) hypertrophy (LVH) (LV mass/height^2.7>47g/m^2.7 in women and >50g/m^2.7 in men), respectively.

RESULTS

A majority of patients were either overweight (49%) or obese (27%). In spite of more use of combination therapy, the obese group had higher blood pressure (BP) and prevalence of TOD. In multivariate logistic analyses, obesity was associated with a 6.9 times higher prevalence of LVH (95% confidence interval [CI] 5.84-8.17, p=0.0001), independent of significant associations with female sex, age, diabetes mellitus, office systolic BP, antihypertensive and antiplatelet treatment. In contrast, only a 17% increased prevalence of carotid plaques (OR=1.17; 95% CI 1.02-1.33, p=0.02) was found in obese patients independent of significant effect of male sex, older age and higher clinic systolic BP, an association that disappeared once effect of metabolic risk factors and related therapy was also considered.

CONCLUSIONS

In hypertensive patients participating in the Campania Salute Project, concomitant obesity was associated with a modestly increased prevalence of carotid plaques and a pronounced increase in prevalent LVH.

Left Ventricular Hypertrophy Regression During Antihypertensive Treatment in an Outpatient Clinic (the Campania Salute Network)

Background

Regression of left ventricular (LV) hypertrophy (LVH) has been a goal in clinical trials. This study tests the external validity of results of clinical trials on LVH regression using a large registry from a tertiary care center, to identify phenotypes less likely to achieve regression of LVH.

Methods and Results

Patients from the Campania Salute Network, free of prevalent cardiovascular disease, but with echocardiographic LVH (defined as LV mass index [LVMi] >47 g/m^2.7 in women and >50 g/m^2.7 in men) were included. During a median follow‐up of 67 months, clear‐cut regression of LVH was documented in 14% of patients (13±8% reduction of initial LVMi) or 23% when also considering those with a reduction of LVMi ≥5 g/m^2.7. Patients with persistent LVH were older with longer duration of hypertension, suboptimal blood pressure (BP) control, larger body mass index, LV mass, and carotid intima‐media thickness and included more women and subjects with diabetes mellitus, isolated systolic hypertension, and metabolic syndrome (all P<0.05). Number and class of antihypertensive drugs during follow‐up did not differ between groups. In multiple logistic regression analysis, older age, female sex, obesity, higher baseline LVMi and carotid intima‐media thickness, and suboptimal BP control were significant covariates of persistent LVH (all P≤0.01), independent of diabetes, duration of hypertension, isolated systolic hypertension, follow‐up time and number and class of antihypertensive drugs.

Conclusions

Early initiation of antihypertensive treatment, aggressive BP control, and attention to metabolic aspects are critical to avoid irreversible LVH.

Validation of Left Atrial Volume Estimation by Left Atrial Diameter from the Parasternal Long-Axis View

BACKGROUND

Measurement of left atrial (LA) volume (LAV) is recommended for quantification of LA size. Only LA anteroposterior diameter (LAd) is available in a number of large cohorts, trials, or registries. The aim of this study was to evaluate whether LAV may be reasonably estimated from LAd.

METHODS

One hundred forty consecutive patients referred to our outpatient clinics were prospectively enrolled to measure LAd from the long-axis view on two-dimensional echocardiography. LA orthogonal dimensions were also taken from apical four- and two-chamber views. LAV was measured using the Simpson, area-length, and ellipsoid (LAV_e) methods. The first 70 patients were the learning series and the last 70 the testing series (TeS). In the learning series, best-fitting regression analysis of LAV-LAd was run using all LAV methods, and the highest values of F were chosen among the regression equations. In the TeS, the best-fitting regressions were used to estimate LAV from LAd.

RESULTS

In the learning series, the best-fitting regression was linear for the Spearman method (r² = 0.62, F = 111.85, P = .0001) and area-length method (r² = 0.62, F = 112.24, P = .0001) and powered for the LAV_e method (r² = 0.81, F = 288.41, P = .0001). In the TeS, the r² value for LAV prediction was substantially better using the LAV_e method (r² = 0.89) than the Simpson (r² = 0.72) or area-length (r² = 0.70) method, as was the intraclass correlation (ρ = 0.96 vs ρ = 0.89 and ρ = 0.89, respectively). In the TeS, the sensitivity and specificity of LA dilatation by the estimated LAV_e method were 87% and 90%, respectively.

CONCLUSIONS

LAV can be estimated from LAd using a nonlinear equation with an elliptical model. The proposed method may be used in retrospective analysis of existing data sets in which determination of LAV was not programmed.

Effect of diabetes and metabolic syndrome on myocardial mechano-energetic efficiency in hypertensive patients. The Campania Salute Network

Reduced myocardial mechano-energetic efficiency (MEE), estimated as stroke volume/heart rate ratio per g of left ventricular (LV) mass (LVM), and expressed in μl s^-1 g^-1 (MEEi), is a strong predictor of cardiovascular (CV) events, independently of LV hypertrophy and other confounders, including type II diabetes (DM). Decreased MEEi is more frequent in patients with diabetes. In the present analysis we evaluated the interrelation among MEEi, DM and metabolic syndrome (MetS) in the setting of arterial hypertension. Hypertensive patients from the Campania Salute Network, free of prevalent CV disease and with ejection fraction >50% (n=12 503), were analysed. Coexistence of MetS and DM was ordinally categorized into 4 groups: 8235 patients with neither MetS nor DM (MetS-/DM-); 502 without MetS and with DM (MetS-/DM+); 3045 with MetS and without DM (MetS+/DM-); and 721 with MetS and DM (MetS+/DM+). After controlling for sex, systolic blood pressure, body mass index, relative wall thickness (RWT), antihypertensive medications and type of antidiabetic therapy, MEEi was 333 μl s^-1 g^-1 in MetS-/DM-, 328 in MetS-/DM+, 326 in MetS+/DM- and 319 in MetS+/DM+ (P for trend <0.0001). In pairwise comparisons (Sidak-adjusted), all conditions, except MetS-/DM+, were significantly different from MetS-/DM- (all P<0.02). No statistical difference was detected between MetS-/DM+ and MetS+/DM-. Both MetS and DM are associated with decreased MEEi in hypertensive patients, independently to each other, but the reduction is statistically less evident for MetS-/DM+. MetS+/DM+ patients have the lowest levels of MEEi, consistent with the alterations of energy supply associated with the combination of insulin resistance with insulin deficiency.

Development of Left Ventricular Hypertrophy in Treated Hypertensive Outpatients: The Campania Salute Network

There is little information on left ventricular (LV) hypertrophy (LVH) development during antihypertensive treatment. We evaluate incident LVH in a treated hypertensive cohort, the Campania Salute Network registry. We analyzed prospectively 4290 hypertensives (aged 50.3±11.1 years, 40% women) with at least 1-year follow-up, without LVH at baseline. Incident LVH was defined as the first detection of echocardiographic LV mass index ≥47 in women or ≥50 g/m^2.7 in men. During a median 48-month follow-up, 915 patients (21.3%) developed LVH. They were older, more frequently women, and obese (P<0.0001), with initial higher fasting glucose, diastolic and systolic blood pressure, LV mass index, lower heart rate and glomerular filtration rate, longer hypertension history and follow-up, and higher average systolic blood pressure during follow-up (all P<0.05), despite a more frequent treatment with Ca⁺⁺-channel blockers and diuretics (both P<0.02). At multivariable Cox regression, incident LVH was independently associated with older age, female sex, obesity, higher average systolic blood pressure during follow-up, and initial greater LV mass index (all P<0.02). By categorizing patients according to obesity and sex, obesity independently increased the risk for incident LVH in both sexes (obese versus nonobese men: hazard ratio, 1.34; confidence interval, 1.05-1.72; P=0.019; and obese versus nonobese women: hazard ratio, 1.34; confidence interval, 1.08-1.66; P=0.007). Despite more aggressive antihypertensive therapy, 21% of hypertensive patients develop clear-cut LVH. After adjusting for confounders, risk of incident LVH is particular relevant among women and is further increased by the presence of obesity.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT02211365.

Atrial Dilatation Development in Hypertensive Treated Patients: The Campania-Salute Network

BACKGROUND

Left atrial (LA) dilatation is associated with unfavorable outcome in hypertension. However, there are few data on clinical, demographic, and echocardiographic findings correlated with LA dilatation development.

METHODS

From the Campania-Salute Network registry, we identified 5,375 hypertensive patients (52±11 years, 38% women) in normal sinus rhythm, with normal LA diameter (parasternal short-axis <24.0 in women and <25.4mm/m in men), with normal left ventricular (LV) ejection fraction, and with at least 12 months of echocardiographic follow-up. We included in the clinic evaluation type of antihypertensive drugs.

RESULTS

Follow-up duration was of 70±48 months. During follow-up, 647 patients (12%) showed LA dilatation. Patients with incident LA dilatation were older, most likely to be women, more obese, more diabetics, with lower Modification of Diet in Renal Disease, higher total cholesterol, lower uric acid, higher pulse pressure, lower heart rate, higher LV mass, concentric geometry and lower E/A ratio at mitral level, longer E deceleration time, and higher intima-media carotid thickness. They take more drugs, and follow-up was longer (overall P < 0.05). In the Cox analysis, age, female gender, obesity, higher LV mass, LA diameter at baseline, and longer E deceleration time were determinants of LA dilatation. Furthermore, the use of diuretics protected against LA dilatation.

CONCLUSIONS

Our data identify a risk profile for LA dilatation, characterized by older age, female sex, obesity, higher LV mass, and worse diastolic function. In this subgroup of patients, the use of diuretics seems to protect against LA dilatation.