Impact of preprocedural left ventricle hypertrophy and geometrical patterns on mortality following TAVR

BACKGROUND

In contrast to surgical aortic valve replacement, left ventricle (LV) hypertrophy (LVH) had not been clearly associated with mortality following transcatheter aortic valve replacement (TAVR).

METHODS

We performed a retrospective analysis of patients enrolled in the Israeli multicenter TAVR registry for whom preprocedural LV mass index (LVMI) data were available. Patients were divided into categories according to LVMI: normal LVMI and mild, moderate, and severe LVH. Mild LVH was regarded as the reference group. Additionally, LV geometry patterns were examined (concentric and eccentric LVH, and concentric remodeling).

RESULTS

The cohort consisted of 1,559 patients, 46.5% male, with a mean age of 82.2 (±6.8) years and mean LVMI of 121 (±29) g/m². Rates of normal LVMI and mild, moderate, and severe LVH were 31% (n = 485), 21% (n = 322), 18% (n = 279), and 30% (n = 475), respectively. Three-year mortality rates for normal LVMI and mild, moderate, and severe LVH were 19.8%, 18.3%, 23.7%, and 24.4%, respectively. Compared to mild LVH, moderate LVH and severe LVH were independently associated with an increased risk for all-cause mortality (hazard ratio [HR] 1.58, 95% CI 1.15-2.18, P = .005; HR 1.46, 95% CI 1.1-1.95, P = .009; respectively). Concentric LVH was independently associated with a decreased risk for mortality compared to normal LV geometry (HR 0.75, 95% CI 0.63-0.89, P = .001). Compared to concentric LVH, eccentric LVH was independently associated with a 33% increased risk for mortality (HR 1.33, 95% CI 1.11-1.60, P = .002).

CONCLUSIONS

Mild concentric LVH confers a protective effect among patients with severe aortic stenosis undergoing TAVR. However, hypertrophy becomes maladaptive, and an increased baseline LVMI, eccentric pattern particularly, may be associated with all-cause mortality in this population.

A 4-tiered classification of left ventricular hypertrophy based on left ventricular geometry: the Dallas heart study

BACKGROUND

Left ventricular hypertrophy (LVH) is traditionally classified as concentric or eccentric, based on the ratio of LV wall thickness to chamber dimension. We propose a 4-tiered LVH classification based on LV concentricity(0.67) (mass/end-diastolic volume(0.67)) and indexed LV end-diastolic volume (EDV).

METHODS AND RESULTS

Cardiac MRI was performed in 2803 subjects and LVH (n=895) was defined by increased LV mass/height(2.7). Increased concentricity(0.67) and indexed EDV were defined at the 97.5th percentile of a healthy subpopulation. Four geometric patterns resulted: increased concentricity without increased EDV ("thick hypertrophy," n=361); increased EDV without increased concentricity ("dilated hypertrophy," n=53); increased concentricity with increased EDV ("both thick and dilated hypertrophy," n=13); and neither increased concentricity nor increased EDV ("indeterminate hypertrophy," n=468). Compared with subjects with isolated thick hypertrophy, those with both thick and dilated hypertrophy had a lower LV ejection fraction and higher NT-pro-BNP and BNP levels (P</=0.001 for all). Subjects with dilated hypertrophy had a lower LV ejection fraction and higher troponin T, NT-pro-BNP, and BNP levels versus those with indeterminate hypertrophy (P<0.001 for all). Subjects with indeterminate LVH versus those without LVH had increased LV mass (by definition) but also a higher LV ejection fraction and no increase in troponin or natriuretic peptide levels.

CONCLUSIONS

Concentric or eccentric LVH can each be subclassified into 2 subgroups, yielding 4 distinct geometric patterns. Many subjects currently classified with eccentric LVH can be reclassified into an indeterminate subgroup that has better LV function and comparable levels of biomarkers reflecting cardiac stress as compared with those without LVH.

Left ventricular hypertrophy in hypertensive type 2 diabetic patients according to renal function

AIM

Cardiovascular disease is the main cause of death in diabetic patients undergoing haemodialysis. Dialysis and hypertension increase left ventricular hypertrophy (LVH), a strong predictor of cardiovascular events. This study evaluated left ventricular structure and function in three groups of hypertensive type 2 diabetic patients with different renal function, and assessed the factors associated with LVH, in an Afro-Caribbean population.

METHODS

Left ventricular structure and function were measured by ultrasonography. Group 1 consisted of 150 patients with normal renal function, group 2 included 183 patients with renal dysfunction and the third group comprised 75 dialysis patients.

RESULTS

Left ventricular mass/height(2.7) increased from group 1 to groups 2 and 3 (49.00g/m(2.7), 57.12g/m(2.7) and 59.75g/m(2.7), respectively; P<0.0001). The prevalences of LVH were 48.3% in group 1, 64.8% in group 2 and 70.3% in the dialysis patients (P=0.001). LVH was more concentric than eccentric in groups 2 and 3. The factors significantly associated with LVH were obesity in groups 1 and 2, and an increase of 10mmHg in pulse pressure in groups 2 and 3, according to multivariate logistic-regression analysis.

CONCLUSION

Our study confirmed that, in a population of Afro-Caribbean hypertensive type 2 diabetic patients, renal failure was associated to an increased left ventricular mass/height(2.7). The data show that the variables associated with LVH differ according to renal profile. This finding will be of value in the treatment and follow-up of these patients.

Strain rate imaging differentiates hypertensive cardiac hypertrophy from physiologic cardiac hypertrophy (athlete's heart)

BACKGROUND

This study sought to determine whether strain rate imaging could distinguish between individuals with hypertensive left ventricular hypertrophy (LVH) and those with strength-training athletic LVH.

METHODS

In all, 108 participants (30 hypertensive LVH, 30 strength-training LVH, 48 control) were enrolled. In addition to a baseline echocardiogram, strain, peak systolic strain rate (SR(S)), peak early diastolic strain rate (SR(E)), and peak late diastolic strain rate values were compared in the apical 4-chamber view.

RESULTS

Athletes had no significant differences in strain, SR(S), SR(E), or peak late diastolic strain rate compared with control subjects (P = .11, .99, .85, and .09, respectively). Individuals with hypertensive LVH had significantly decreased strain, SR(S), and SR(E) (-16.8 +/- 3.2%, -0.99 +/- 0.15 s(-1), and 1.54 +/- 0.40 s(-1), respectively) compared with control subjects (-21.7 +/- 3.5%, -1.31 +/- 0.27 s(-1), and 2.35 +/- 0.57 s(-1), respectively; all P < .0001).

CONCLUSION

Hypertensive LVH has significant longitudinal strain, SR(S), and SR(E) reductions versus control. The lack of these reductions in athletes suggests that strain rate imaging may have clinical use in discerning the physiologic LVH state.

Influence of wall stress and left ventricular geometry on the accuracy of dobutamine stress echocardiography

OBJECTIVE

The goal of this study was to determine whether wall stress at rest and during stress could explain the influence of left ventricular (LV) morphology on the accuracy of dobutamine stress echocardiography (DSE).

BACKGROUND

The sensitivity of DSE appears to be reduced in patients with concentric remodeling, but the cause of this finding is unclear.

METHODS

We studied 161 patients without resting wall motion abnormalities who underwent DSE and coronary angiography. Patients were classified into four groups according to relative wall thickness (normal <0.45) and LV mass (normal </=131 g/m(2) in men and </=100 g/m(2) in women): normal geometry, concentric remodeling, concentric hypertrophy, and eccentric hypertrophy. Significant coronary artery disease was defined as >/=50% stenosis. Circumferential (cESS) and meridional end-systolic wall stress (mESS) were calculated at rest and peak DSE.

RESULTS

Both false-negative and false-positive results for DSE were present in 35 patients (22%). The accuracy of DSE in patients with concentric remodeling (61%) was lower than that in patients with normal geometry (85%, p < 0.05) or concentric hypertrophy (86%, p < 0.05), but the accuracy with eccentric hypertrophy (64%, p < 0.05) was lower than with concentric hypertrophy. Patients in lowest quartile of cESS and mESS at peak had significantly lower sensitivity and accuracy than those in the highest quartile. A reduced cESS at peak (p = 0.012), presence of concentric remodeling (p = 0.044), and eccentric hypertrophy (p = 0.012) were significant predictors of both false-negative and false-positive results for DSE.

CONCLUSIONS

The accuracy of DSE is influenced by the LV geometric pattern and peak wall stress.

[ECG in ventricular hypertrophy]

The electrophysiological criteria for the diagnosis of ventricular hypertrophies, in the light of the sequence of ventricular depolarization and repolarization, are described. Hypertrophy of the right ventricle due to sustained systolic overloading can be global or segmental. In the first case, the magnitude and manifestation of the main vectors resulting from depolarization of this ventricle, i.e., IIs, IIr and IIIr, are increased. In the second case, the magnitude and manifestation of only some vectors resulting from its depolarization are increased; for example, vector IIr (right parietal) in the most frequent type of Fallot's tetralogy and vector IIIr (right basal) in chronic corpulmonale of obstructive origin. Left ventricular hypertrophy, which is generally of global type (aortic stenosis, systemic arterial hypertension), induces an increase in magnitude and manifestation of all the main vectors resulting from depolarization of this ventricle: I (first septal), II (left parietal) and III (left basal). But the left ventricular hypertrophy can also be of segmental type; for example, in idiopathic hypertrophic cardiomyopathy, in which the manifestation of an anteroseptal vector usually predominates. Biventricular hypertrophies produce different electrocardiographic patterns, depending on the preponderance of right or left electromotive ventricular forces. An example of electrocardiographic findings in biventricular hypertrophy is presented. It corresponds to an 18 year-old woman with a large patent ductus arteriosus compressing the left inferior laryngeal nerve, which produced a cardio-vocal syndrome. The patient had pulmonary and systemic hypertension and arterial hyposaturation. The surgical treatment of the patent ductus arteriosus normalized the pulmonary pressure as well as the arterial saturation.

Relationship between plasma level of cardiotrophin-1 and left ventricular mass index in patients with dilated cardiomyopathy

OBJECTIVES

The study evaluated the relationship between plasma cardiotrophin-1 (CT-1) concentration and left ventricular (LV) mass in dilated cardiomyopathy (DCM) patients with congestive heart failure (CHF).

BACKGROUND

Cardiotrophin-1 is a newly identified member of the interleukin-6 (IL-6) family of cytokines and one of the endogenous ligands for gp130 signaling pathways in the heart, and it has potent hypertrophic and survival effects on cardiac myocytes. However, the clinical significance of CT-1 is poorly understood.

METHODS

We measured the plasma CT-1 level in 51 consecutive patients with DCM. Patients were classified into two groups: small LV mass index group and large LV mass index group, based on the median level of LV mass index.

RESULTS

The plasma CT-1 level was increased in DCM patients with the severity of CHF and was significantly higher in the large LV mass group than in the small LV mass group, despite the absence of a difference in LV ejection fraction between the two groups. In addition, there was a significant positive correlation between the plasma CT-1 level and the LV mass index (r = 0.627, p < 0.0001). According to stepwise multivariate analyses among hemodynamic and neurohumoral factors, a high plasma CT-1 level showed an independent and significant positive relationship with a large LV mass index in patients with DCM.

CONCLUSIONS

These results indicate that the plasma CT-1 level is increased in patients with DCM and is significantly correlated with the LV mass index, suggesting that CT-1 plays an important role in structural LV remodeling in patients with DCM.

Adjustment of ECG left ventricular hypertrophy criteria for body mass index and age improves classification accuracy. The effects of hypertension and obesity

Population-based data from the Framingham Heart Study have served as the basis for adjusting electrocardiographic (ECG) criteria for echocardiographically determined left ventricular hypertrophy (LVH) for two determinants of their sensitivity: body mass index and age. Estimated regression equations that predict echo-derived left ventricular mass from an ECG LVH voltage criterion, body mass index, and age, for 1,468 men and 1,883 women, provide a simple and effective means of adjusting that criterion for these variables. The authors evaluated five different ECG LVH criteria, comparing the performances of their original and adjusted versions within this database. All adjusted criteria significantly outperformed their unadjusted counterparts. Of these five criteria, the Cornell voltage duration product, (RAVL + SV3). QRS interval, exhibited the greatest sensitivity at all levels of specificity for both sexes (39 and 51% sensitivity at 95% specificity in men and women, respectively). Its performance was further evaluated with separate adjustment algorithms developed for lean versus obese and normotensive versus hypertensive men and women. Age and body mass index adjustment produced significant improvements for both lean and obese women and for obese men. A marginal gain in sensitivity was found in lean normotensive men. Within the relatively small subgroup of lean hypertensive men, no improvement was observed. These results suggest that among Caucasian adults, the Cornell voltage duration product adjusted for body mass index and age offers significant improvement for the detection of echocardiographically determined LVH in all but lean men; within the latter group, it loses no sensitivity in comparison with the original criterion.

[Can regression of left ventricular hypertrophy be proposed as a substitute criterion in trials of morbidity/mortality in hypertension?]

Hypertension is a cardiovascular risk factor. In addition to simple normalisation of the blood pressure, the true objective of treatment of hypertension should, therefore, be reduction of the excess risk and it is in terms of morbi-mortality that the real benefits of antihypertensive therapy should be evaluated. However, trials of morbi-mortality are long and costly so that intermediate criteria are proposed for assessing therapeutic benefits with measurement of left ventricular mass as one of the best candidates. The concept is interesting but it is essential to question its clinical pertinence. In order that an intermediary criterion be acknowledged as a substitution criterion, it has to fulfil the following conditions: it must be simple, reliable and reproducible to measure it must be modifiable by therapeutic intervention it must be closely related to the degree of risk, whichever way it changes the amplitude of its changes must provide a quantitative prediction of risk-associated changes finally, in the particular case of hypertension, the benefit of the improvement of the substitute criterion should be distinguished from the benefits due to lowering the blood pressure alone. Left ventricular mass measured by echocardiography is the most documented intermediate substitution criterion over the last 20 years. It fulfils most of the conditions of a substitute criterion. However, the relationship between its reduction with treatment and the reduction of risk, independently of the change in blood pressure, remains to be shown.

Magnitude of left ventricular hypertrophy and risk of sudden death in hypertrophic cardiomyopathy

BACKGROUND

Sudden death is known to be a possible consequence of hypertrophic cardiomyopathy. Quantification of the risk of sudden death, however, remains imprecise for most patients with this disease.

METHODS

We assessed the relation between the magnitude of left ventricular hypertrophy and mortality in 480 consecutive patients with hypertrophic cardiomyopathy. The patients were categorized into five subgroups according to maximal wall thickness: 15 mm or less, 16 to 19 mm, 20 to 24 mm, 25 to 29 mm, and 30 mm or more. Their ages ranged from 1 to 89 years (median, 47).

RESULTS

Over a mean follow-up period of 6.5 years, 65 of the 480 patients (14 percent) died: 23 suddenly, 15 of heart failure, and 27 of noncardiac causes or stroke. The risk of sudden death increased progressively and in direct relation to wall thickness (P=0.001), ranging from 0 per 1000 person-years (95 percent confidence interval, 0 to 14.4) for a wall thickness of 15 mm or less to 18.2 per 1000 person-years (95 percent confidence interval, 7.3 to 37.6) for a wall thickness of 30 mm or more and almost doubling from each wall-thickness subgroup to the next. The cumulative risk 20 years after the initial evaluation was close to zero for patients with a wall thickness of 19 mm or less but almost 40 percent for wall thicknesses of 30 mm or more. As compared with the other subgroups, patients with extreme hypertrophy were the youngest (mean age, 31 years), and most (41 of 43) had mild symptoms or no symptoms; of the 12 patients who were less than 18 years old at the initial evaluation, 5 died suddenly.

CONCLUSIONS

In hypertrophic cardiomyopathy, the magnitude of hypertrophy is directly related to the risk of sudden death and is a strong and independent predictor of prognosis. Young patients with extreme hypertrophy, even those with few or no symptoms, appear to be at substantial long-term risk and deserve consideration for interventions to prevent sudden death. The majority of patients with mild hypertrophy are at low risk and can be reassured regarding their prognosis.

Left ventricular geometry and function in patients with aortic stenosis: gender differences

BACKGROUND

Gender differences in cardiac size have been described in normal and pathological conditions in human and animals. Sex determination of a pattern of hypertrophy as a response to pressure overload has not been extensively evaluated and is still poorly understood in humans.

METHODS AND RESULTS

To investigate the influence of gender in the left ventricle remodelling and preservation of the left ventricle function 195 adults (140 men and 55 women) with isolated aortic stenosis were evaluated. The mean age was 52 +/- 11 years for men and 53 +/- 13 years for women. All the patients had similar degree of aortic stenosis finally treated with valve replacement, similar clinical status and no signs of coronary artery disease in coronary angiograms. On echocardiography the left ventricle of women had a smaller the end systolic (30.5 +/- 7.8 vs. 39.4 +/- 11.2, P<0.001) and the end diastolic (49.4 +/- 9 vs. 57.3 +/- 11, P<0.001) chamber size. The female left ventricle generated a higher relative wall thickness (0.65 +/- 0.21 vs. 0.52 +/- 0.12, P<0.01), a greater fractional shortening (35.3 +/- 8.5 vs. 32.0 +/- 9.0, P<0.01) and a higher ejection fraction (64.4 +/- 12.7 vs. 57.5 +/- 14.6, P<0.001). The left ventricle posterior wall thickness and the septal thickness indexes were similar in both groups. There were also significant differences between the two groups in the left ventricle mass index.

CONCLUSIONS

Gender has an important influence on the left ventricle adaptation pattern to pressure overload due to aortic stenosis. Women developed a greater degree of left ventricle hypertrophy documented as changes in left ventricle geometry (increased relative wall thickness, left ventricular mass) and left ventricle function (fractional shortening and ejection fraction).

Left ventricular hypertrophy in northern and Siberian populations

Characteristics of left ventricular hypertrophy (LVH) were investigated in random samples of the Chukotka coastal Native population (131 males) and in the urban Novosibirsk population (627 males) aged 30-59. Standard epidemiological methods employing electrocardiography (EKG) and echocardiography (EchoCG) were used. The frequency of EKG-LVH in the urban population was about six percent. The prevalence of LVH in Chukotka was more than twice as high as in Novosibirsk, as determined by both EKG and EchoCG criteria. About half of EchoCG-LVH cases in Natives and one-fifth of those in the city population could not be explained by conventional reasons. Advanced family surveys in Novosibirsk established the fact that myocardial hypertrophy exhibits a family aggregation in first-degree relatives of normotensive probands affected by LVH. The data demonstrate an inherited predisposition for LVH and suggest the need for molecular-genetic analysis.

The impact of scalar variable and process on athlete-control comparisons of cardiac dimensions

PURPOSE

This study compared linear left ventricular dimensions and mass (LVM), before and after normalizing for body dimensions via allometric and ratio-standard scaling.

METHODS

Height (HT; m), body mass (BM; kg), body surface area (BSA; m2), and fat-free mass (FFM; kg) were measured in elite male weight lifters (N = 11) and age-matched controls (N = 45). Septum (ST), posterior wall (PWT), and internal dimension in diastole (LVIDd) were measured from M-mode echocardiographic traces and used to calculate LVM. Via multivariate allometric scaling, common group power function exponents were identified for all cardiac dimensions related to all body size scalars. t-tests were used to compare group differences in absolute and scaled data.

RESULTS

BM, FFM, and BSA, as well as absolute LVM (262 +/- 54 vs 206 +/- 39) and ST (11 +/- 1 vs 9 +/- 1), were greater in the athletes (P < 0.05). All exponents conformed to dimensionality theory within 95% confidence limits. Fat-free mass presented the highest multiple R value and the least residual sum of squares of any scalar variable. If FFM was used to scale, no difference in LVM remained (P > 0.05).

CONCLUSIONS

Data suggest that any group effect on cardiac dimensions is substantially altered by the scaling procedure. The choice of the most appropriate variable and process for partitioning out any effect of body dimensions on cardiac dimensions in similar studies requires attention.

Relation of electrocardiographic left ventricular hypertrophy with and without T-wave changes to systemic blood pressure, body mass, and serum lipids and blood glucose levels in Japanese men

Left ventricular (LV) hypertrophy, especially combined with an abnormal ST-T, is considered 1 of many coronary risk factors. Seven hundred forty-nine Japanese men were selected according to their electrocardiographic findings, i.e., normal electrocardiogram, LV hypertrophy without an abnormal ST-T segment, LV hypertrophy with a flat T wave, and LV hypertrophy with a negative T wave. Coronary risk factors were compared among these 4 age-matched groups. Groups with LV hypertrophy with negative or flat T waves had larger body mass index (24.9 vs 22.9 kg/m2), higher mean systemic blood pressure (111 vs 95 mm Hg), larger LV mass (265 vs 157 g), higher blood glucose (110 vs 100 mg/dl), higher serum triglyceride (148 vs 122 mg/dl), higher total cholesterol (206 vs 198 mg/dl), and lower high-density lipoprotein cholesterol (47 vs 54 mg/dl) than the normal group or the group with LV hypertrophy without T-wave change. Among these risk factors, blood pressure and glucose remained higher even after the adjustment by body mass index or by body mass index and blood pressure. Electrocardiographic LV hypertrophy with a changed T wave signified higher risk of coronary artery disease in Japanese men.

Improved ECG models for left ventricular mass adjusted for body size, with specific algorithms for normal conduction, bundle branch blocks, and old myocardial infarction

Considerable efforts have been invested recently to improve electrocardiographic (ECG) classification accuracy for left ventricular hypertrophy (LVH). This study examines how LVH classification accuracy is influenced by (1) the selection of an echocardiographic standard for LVH, (2) LVH severity level in the test groups, and (3) the adjustment of LVH criteria for obesity and age. Using data obtained from large, community-based populations, this study explores prospects for improving ECG models for LVH classification and examines some of the general characteristics of newer ECG models for estimating left ventricular mass (LVM) on a continuous scale. The results indicate that the apparent ECG classification accuracy for LVH is substantially influenced by echocardiographic standards and criteria for LVH, LVH severity level, and selection criteria for test populations, and these differences explain some of the often substantial differences in test results from clinical versus community-based evaluation studies. The low reproducibility of echocardiographic LVM as the standard is a limiting factor in attempts to improve ECG criteria for LVH and LVM prediction models. Adjustment of ECG amplitudes to anthropometric factors that simultaneously influence LVM may result in confounding effects and may lead to the development of inappropriate models. The performance of ECG models for LVM prediction improved substantially by the inclusion of body weight as a covariate with ECG variables. The addition of standing height and various covariates reflecting obesity did not improve LVM prediction accuracy. Compared to the older LVM prediction models of the Novacode ECG program, the correlation between echocardiographic and ECG estimates of LVM increased sufficiently (from 0.33 to 0.54 in women and from 0.46 to 0.62 in men) to suggest that these improved ECG models are suitable for monitoring LVH progression/ regression in study groups participating in hypertension intervention trials.

Congestive heart failure due to hypertensive ventricular diastolic dysfunction

Left ventricular (LV) diastolic dysfunction is the first discernible manifestation of heart disease in hypertensive patients. Arterial hypertension with LV hypertrophy leads to reduced preload followed by impaired cardiac output (systolic dysfunction stemming from primary diastolic dysfunction). Diastolic dysfunction leads more often than systolic dysfunction to hypertensive heart failure and is in many cases clearly distinguishable from heart failure with low ejection fraction (EF). Mortality due to heart failure from impaired inotropism is higher than mortality due to diastolic dysfunction, but morbidity is lower. Hypertensive cardiomyopathies can be divided into 4 ascending categories, according to the pathophysiologic and clinical impact of hypertension on the heart: Degree I: LV diastolic dysfunction with no associated LV hypertrophy Degree II: LV diastolic dysfunction with echocardiographic LV hypertrophy Degree IIA: Normal exercise capacity in terms of maximal oxygen consumption Degree IIB: Impaired exercise capacity in terms of maximal oxygen consumption Degree III: Congestive heart failure (severe dyspnea and radiographically determined pulmonary edema with normal (> or = 50%) EF Degree IIIA: LV mass/volume ratio > 1.8 with little or no myocardial ischemia Degree IIIB: LV mass/volume ratio < 1.8 with significant myocardial ischemia Degree IV: Profile of dilated cardiomyopathy; LV hypertrophy and impaired EF (< 50%).

[Diastolic dysfunction as a cause of heart failure in the hypertensive patient]

Hypertensive cardiomyopathies can be divided into 4 ascending categories according to the pathophysiologic and clinical impact of hypertension on the heart: Grade I. This category is characterized by LV diastolic dysfunction with no associated LV hypertrophy. Grade II. Patients at this stage present LV diastolic dysfunction with echocardiographic LV hypertrophy. Exercise capacity in terms of maximal oxygen consumption may be normal (Grade IIA) o impaired (Grade IIB). Grade III. This stage is distinguished by the presence of congestive heart failure (severe dyspnea and X-ray pulmonary edema with normal EF (> or = 50%). Patients having LV mass/volume ratio > 1.8 with little or no myocardial ischemia are classified as IIIA, as compared with IIIB patients having LV mass/volume ratio < 1.8 and significant myocardial ischemia. Clinically, these two subgroups can be distinguished as follows: the presence of a fourth sound and the absence of cardiomegaly for classification as IIIA, and a third sound plus cardiomegaly for classification as IIIB. Grade IV. Here the profile is one of dilated cardiomyopathy, LV hypertrophy and impaired EF (< 50%). The 5-year mortality rate is higher for Grade IV patients than for Grade III patients, although the morbility rate is similar in both.

What can we expect in antihypertensive drug therapy?

In the present brief survey on new developments in the drug treatment of essential hypertension, the following issues are summarized: the treatment of hypertension in diabetics, patients with left ventricular hypertrophy, and the elderly; new antihypertensive drugs, including a hybrid (multifactorial) antihypertensive drug with both calcium and alpha 1-adrenoceptor antagonistic activity, as well as angiotensin II-receptor antagonists; and finally, gene therapy in hypertension.