Left-ventricular hypertrophy (LVH) is a cardinal manifestation of hypertensive organ damage associated with an increased cardiovascular (CV) risk. We reviewed recent literature on the prevalence of ...LVH, as assessed by echocardiography, in order to offer an updated information on the magnitude of subclinical alterations in LV structure in contemporary human hypertension. A MEDLINE search using key words 'left ventricular hypertrophy', 'hypertension', 'echocardiography' and 'cardiac organ damage' was performed in order to identify relevant papers. Full articles published in English language in the last decade, (1 January 2000-1 December 2010), reporting studies in adult or elderly individuals, were considered. A total of 30 studies, including 37,700 untreated and treated patients (80.3% Caucasian, 52.4% men, 9.6% diabetics, 2.6% with CV disease) were considered. LVH was defined by 23 criteria; its prevalence ranged from 36% (conservative criteria) to 41% (less conservative criteria) in the pooled population. LVH prevalence was not different between women and men (range 37.9-46.2 versus 36.0-43.5%, respectively). Eccentric LVH was more frequent than concentric hypertrophy (range 20.3-23.0 versus 14.8-15.8, respectively, P<0.05); concentric phenotype was found in a consistent fraction (20%) of both genders. Despite the improved management of hypertension in the last two decades, LVH remains a highly frequent biomarker of cardiac damage in the hypertensive population. Our analysis calls for a more aggressive treatment of hypertension and related CV risk factors leading to LVH.
Aim
Information on systolic dysfunction, as assessed by left-ventricular (LV) mechanics, in patients with pheochromocytoma after surgical treatment is scanty. We performed a systematic meta-analysis ...of speckle tracking echocardiographic studies to provide an updated comprehensive information on this issue.
Methods
The PubMed, OVID-MEDLINE, and Cochrane library databases were analyzed to search for articles published from the inception up to May 31st 2021. Studies were identified using MeSH terms and crossing the following search items: “myocardial strain” “left ventricular mechanics”, “speckle tracking echocardiography”, “systolic dysfunction”, “pheochromocytoma”, and “paraganglioma”.
Results
A total of 92 surgically treated patients with pheochromocytoma/paraganglioma were included in 3 longitudinal studies. Successful surgical treatment was associated with a decrease in relative wall thickness (SMD − 0.25 ± 0.10, CI − 0.45/− 0.05,
p
< 0.01) and an improvement in global longitudinal strain (SMD − 0.45 ± 0.10, CI − 0.66/− 0.24,
p
< 0.0001). The favorable effects of treatment on LV geometry and mechanics were not accompanied by significant changes in ejection fraction (SMD − 0.07 ± 0.10, CI − 0.27/0.12,
p
= 0.44).
Conclusions
This meta-analysis adds a new piece of evidence, suggesting that surgical treatment of patients with pheochromocytoma impacts favorably on LV geometry and LV mechanics, and, more importantly, the assessment of LV changes in this setting can no longer rely on conventional echocardiographic parameters such as ejection fraction.
BACKGROUND
Left atrial enlargement (LAE) is a marker of hypertensive heart disease associated with increased cardiovascular risk. We reviewed recent literature about the prevalence of LAE, as ...assessed by echocardiography, to update our information about the clinical relevance of this cardiac phenotype in human hypertension.
METHODS
We performed a search of MEDLINE using the key words "left atrial enlargement," "left atrial dilatation," "left atrial size," "hypertension," "echocardiography," and "atrial fibrillation" to identify relevant papers. We considered full articles published in English from January 1, 2000 to July 1, 2012 reporting studies involving adult individuals.
RESULTS
We analyzed a total of 15 studies, including 10,141 untreated and treated subjects. LAE was defined according to 11 different criteria (4 studies applied two or three criteria), and its prevalence consistently varied among studies, from 16.0-83.0%, with a prevalence in the pooled population of 32%. A gender-based analysis of 9 studies (8,588 patients) showed the prevalence of LAE as being similar in women and men (OR, 1.23; 95% CI, 0.83-1.83; P = 0.30). Data provided by 10 studies (n = 9,354 patients) showed the prevalence of left-ventricular hypertrophy as being significantly higher in patients with LAE (68.2%) than in their counterparts without LAE (41.8%) (OR, 2.97; 95% CI, 2.68-3.29; P
< 0.01).
CONCLUSIONS
Our analysis shows that LAE is present in a relevant fraction of the hypertensive population. Because LAE is an independent predictor of cardiovascular events, the accurate detection of this phenotype may improve the evaluation of risk in hypertensive patients.
OBJECTIVE:We aimed to examine the predictive value of longitudinal and circumferential strain on adverse cardiovascular (CV) outcome in the hypertensive patients during 5 years of follow-up.
DESIGN ...AND METHOD:This investigation included 190 untreated hypertensive patients who were recruited for this study in the period between 2011 and 2013. All participants underwent laboratory analysis, 24-h BP monitoring and comprehensive echocardiographic examination at baseline. The patients were followed for at least 5 years (70 ± 8 months) and follow-up data were collected for 177 participants. The adverse outcome was defined as the hospitalization due to CV disease (stroke, arrhythmias, myocardial infarction, heart failure) or CV death.
RESULTS:Adverse CV events were observed in 27 (15%) hypertensive patients during follow-up period. Cox regression analysis showed that reduced left ventricular (LV) longitudinal strain (<|-16.5%|) was associated with the increased risk of adverse events (hazard ration (HR) 2.56, 95% confidence interval (CI)1.23–7.09, p = 0.009) independently of age, sex, BMI, 24-h systolic blood pressure and LV mass index. Reduced LV circumferential strain (<|-20.0%|) was also associated with increased risk of adverse events (HR 2.11, 95%CI1.09–8.46, p = 0.031) independently of aforementioned demographic and clinical parameters. Reduced LV radial strain (<37.5%) did not have predictive value of adverse events during 5-year follow-up period (HR 1.52, 95%CI0.83–6.69, p = 0.092). Reduced LV twist was associated with adverse events, but its predictive value vanished after adjustment for other demographic and clinical parameters.
CONCLUSIONS:Left ventricular longitudinal and circumferential strains represent the important predictors of CV adverse events in the hypertensive patients. LV mechanics is useful prognostic tool in recently diagnosed hypertensive patients and its determination should be incorporated in the initial echocardiographic examination.
OBJECTIVE:The association between pre-hypertension (pre-HTN) and subclinical cardiac organ damage is not well defined. We performed a systematic meta-analysis of echocardiographic studies in order to ...provide a comprehensive information on cardiac structural and functional changes in untreated pre-HTN subjects.
DESIGN AND METHOD:Studies were identified by crossing the following search termspre-hypertension, high normal blood pressure, heart, left ventricular hypertrophy, left ventricular function, diastolic function, left atrial size, aortic root size, echocardiography.
RESULTS:A total 73,556 subjects (44,170 normotensive, 17,314 pre-HTN, and 12,072 HTN individuals) of both genders were included in 20 studies. Left ventricular (LV) mass index was greater in pre-HTN than in normotensives (standard means difference SMD0.32 ± 0.07, p < 0.001). Mitral E/A ratio was lower (SMD−0.34. ± 0.05,p < 0.001), E/e’ ratio (SMD0.26 ± 0.02, p < 0.001) and left atrium (LA) diameter higher (SMD0.55 ± 0.02, p < 0.001) in pre-HTN than in normotensive counterparts. HTN subjects showed a greater LV mass index (SMD0.27 ± 0.03, p < 0.001), reduced E/A (SMD−0.38 ± 0.08, p < 0.001), increased E/e’ ratio (SMD0.38 ± 0.09, p < 0.001), and LA diameter (SMD0.31 ± 0.12, p < 0.001) than pre-HTN subjects
CONCLUSIONS:Our meta-analysis shows that alterations in cardiac structure and function in pre-HTN subjects are intermediate between normotensive and HTN individuals. These findings reinforce the view that pre-HTN should not be longer considered a benign entity.
OBJECTIVE:In the Pressioni Arteriose Monitorate e Loro Associazioni (PAMELA) study, clinical, metabolic variables as well as office, home, and ambulatory blood pressure (BP) values were measured ...contemporaneously at baseline and after a ten-year period of follow-up, which allowed us to assess the value of selective and combined elevation of these BPs in predicting new onset metabolic syndrome (MetS).
DESIGN AND METHOD:The present analysis included 1,182 participants without MetS at baseline, as defined by the APT III criteria. Based on office, 24-hour ambulatory BP and home values, subjects were divided into 4 groupsnormal, with coat hypertension (WCH), masked hypertension (MH); and sustained hypertension (SH).
RESULTS:As compared to subjects with in-office and out-of-office BP normality a greater age- and gender-adjusted incidence of new onset Mets was observed in WCH (OR = 2.03, CI:1,21-3.41, p = 0.007), MH (OR = 2.55, CI:1.26–5.17; p = 0.009) and SH (OR = 2.28, CI:1.43–3.99, p = 0.0009) when out-of-office BP was defined by ambulatory criteria. This was not the same when out-of-office BP was based on home criteria, as only the WCH group showed a significant greater OR risk (2.16, CI1.28–3.63, p = 0.003).
CONCLUSIONS:Our study provides evidence that isolated or combined BP elevations when identified by office/ambulatory measurements, carry an increase in risk of new onset MetS, while classifying the population by combining office/home BPs only WCH is associated with a greater risk of incident MetS. In a clinical perspective, a comprehensive evaluation of BP status based on office/ambulatory measurements may substantially improve the risk stratification of new onset MetS and to activate measures for its prevention
OBJECTIVE:Studies addressing the association between a reduced drop of heart rate (HR) at night with subclinical organ damage and cardiovascular events in the general population are scanty. We ...evaluated this issue in subjects enrolled in the Pressioni Monitorate E Loro Associazioni (PAMELA) study.
DESIGN AND METHOD:At entry 2,021 subjects underwent diagnostic tests including laboratory investigations, 24-h ambulatory blood pressure (BP) monitoring and echocardiography. Participants were followed from the initial medical visit for a time interval of 148 ± 27 months. To explore the association of circadian HR rhythm and outcomes participants were classified in the primary analysis according to quartiles of nocturnal HR decrease. In secondary analyses the population was also classified according non-dipping nocturnal HR (defined as a drop in average HR at night lower than 10% compared to day-time values) and next in four categories(1) BP/HR dipper, 2) BP/HR non dipper, 3) HR dipper/BP non dipper, 4) HR non dipper/BP dipper).
RESULTS:A flattened circadian HR rhythm (i.e. lowest quartile of night-time HR dip) was independently associated to left atrial (LA) enlargement, but not to left ventricular hypertrophy; moreover, it was predictive of fatal and non-fatal cardiovascular events, independently of several confounders (hazard ratio 1.8, CI1.13–2.86, p < 0.01 vs highest quartile).
CONCLUSIONS:A blunted dipping of nocturnal HR is associated to preclinical cardiac damage in terms of LA enlargement and is predictive cardiovascular morbidity and mortality in the general population.
OBJECTIVE:The aim of this study was to evaluate the influence of gender on left ventricular (LV) mechanics in hypertensive individuals.
DESIGN AND METHOD:This cross-sectional study included 198 ...untreated hypertensive subjects and 107 normotensive controls who underwent 24-hour ambulatory blood pressure monitoring and comprehensive two-dimensional echocardiographic examination including strain assessment.
RESULTS:There was no difference in 24-h blood pressure between hypertensive men and women. LV mass index was significantly higher men than in women in hypertensive and normotensive group. Hypertensive men and women had significantly lower 2D LV global longitudinal, circumferential and radial strains than their normotensive counterparts. LV global longitudinal strain was lower in hypertensive men than in women (−20.2 ± 2.3 vs. −18.8 ± 2.0, p < 0.01). LV global circumferential strain was also worse in hypertensive men than in men (−21.4 ± 2.9 vs. −19.5 ± 2.5, p < 0.01). The difference in LV radial strain was not discovered between hypertensive women and men. Assessment of layer-specific LV strain showed that endocardial and mid-myocardial longitudinal and circumferential strains were significantly lower in hypertensive population and especially in hypertensive men comparing with hypertensive women. Furthermore, LV twist was significantly higher in hypertensive women than in hypertensive men (20.6 ± 6.8 degree vs. 21.6 ± 7.3 degree, p = 0.02). Female gender and arterial hypertension, as well as their interaction, were associated with LV hypertrophy, reduced LV global longitudinal strain and increased LV twist.
CONCLUSIONS:LV longitudinal and circumferential strains were significantly reduced in hypertensive patients. Endo- and mid-myocardial LV layers were particularly influenced by arterial hypertension. However, hypertensive women suffered more significant changes in LV longitudinal strain and LV twist than hypertensive men.
OBJECTIVE:Masked (MUCH) and white coat uncontrolled hypertension (WUCH) are more and more frequently investigated for their long-term prognostic significance Classification is usually made by a ...single set of office and out-of-office blood pressure (BP) measurements during the treatment period. To evaluate the long-term reproducibility of MUCH and WUCH, an information crucial for determining the long-term prognostic impact of these conditions.
DESIGN AND METHOD:Reproducibility of MUCH and WUCH was assessed in 1664 hypertensive patients recruited for the ELSA study treated with atenolol or lacidipine (+/– additional drugs) during a 4-year period. Office and 24-hour BP was measured at baseline and every year during treatment, allowing repeated classification of either condition.
RESULTS:After 1 year of treatment 21.1% and 17.8% of the patients were classified as MUCH and WUCH, respectively. For both conditions the prevalence was similar in the following years, although with a large change in patients composition because only about 1/3 of patients classified as MUCH or WUCH at one set of office and ambulatory BP measurements maintained the same classification at a subsequent set of measurements. In only 4.5% and 6.2% MUCH and WUCH persisted throughout the treatment period. MUCH and WUCH reproducibility was worse than that of patients showing control or lack of control of both office and ambulatory BP.
CONCLUSIONS:Both MUCH and WUCH display a poor reproducibility over time. This should be taken into account in studies assessing the long-term prognostic value of these conditions based on only one set of BP measurements.
OBJECTIVE:We aimed to evaluate the functional capacity and left ventricular (LV) mechanics, as well as their relationship in the patients with uncomplicated type 2 diabetes.
DESIGN AND METHOD:This ...cross-sectional observational study included 70 controls and 60 patients with uncomplicated diabetes. Included subjects underwent laboratory analysis, cardiopulmonary exercise testing and comprehensive echocardiographic examination.
RESULTS:Oxygen uptake at ventilatory threshold (18.8 ± 3.8 vs. 14.8 ± 3.7 ml/kg/min, p < 0.001), peak oxygen uptake (peak VO2) (28.2 ± 4.2 vs. 19.8 ± 4.4, ml/kg/min, p < 0.001) and oxygen pulse (13.8 ± 2.9 vs. 11.3 ± 3.1 ml/beat, p < 0.001) were significantly lower in the diabetic group, whereas ventilation/carbon dioxide ratio and ventilation/carbon dioxide slope (25.0 ± 2.4 vs. 28.2 ± 3.7, p < 0.001) were significantly higher in this group. Longitudinal, circumferential and radial strains were significantly lower in the diabetic patients than in healthy controls (−21.6 ± 2.9 vs. −18.1 ± 2.2 %, p < 0.001; −22 ± 2.6 vs. −18.6 ± 2.7 %, p < 0.001; 39.4 ± 9.3 vs. 35.5 ± 8.8 %, p < 0.001, respectively). A multivariate regression analysis showed that HbA1c, mitral E/e ratio and peak VO2 were associated with LV longitudinal and circumferential strains independently of age, BMI, systolic blood pressure and LV mass index in the whole study population.
CONCLUSIONS:Our investigation showed that both, functional capacity and LV mechanics were significantly impaired in the uncomplicated diabetic patients. HbA1c, the essential parameter of glucose regulation, LV diastolic function and oxygen consumption were independently associated with LV mechanics in the whole study population. This shows an important role of functional capacity as important markers of preclinical cardiac damage in diabetic population.
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