Natural history of concentric left ventricular geometry in community-dwelling older adults without heart failure during seven years of follow-up

Presence of concentric left ventricular (LV) geometry has important pathophysiologic and prognostic implications. However, little is known about its natural history in older adults. Of the 5,795 community-dwelling adults ≥65 years of age in the Cardiovascular Health Study, 1,871 without baseline heart failure had data on baseline and 7-year echocardiograms. Of these 343 (18%) had baseline concentric LV geometry (concentric remodeling 83%, concentric LV hypertrophy [LVH] 17%) and are the focus of the present study. LV geometry at year 7 was categorized into 4 groups based on LVH (LV mass indexed for height >51 g/m2·?) and relative wall thickness (RWT): eccentric hypertrophy (RWT ≤0.42 with LVH), concentric hypertrophy (RWT >0.42 with LVH), concentric remodeling (RWT >0.42 without LVH), and normal (RWT ≤0.42 without LVH). At year 7, LV geometry normalized in 57%, remained unchanged in 35%, and transitioned to eccentric hypertrophy in 7% of participants. Incident eccentric hypertrophy occurred in 4% and 25% of those with baseline concentric remodeling and concentric hypertrophy, respectively, and was associated with increased LV end-diastolic volume and decreased LV ejection fraction at year 7. Previous myocardial infarction and baseline above-median LV mass (>39 g/m2·?) and RWT (>0.46) had significant unadjusted associations with incident eccentric LVH; however, only LV mass >39 g/m2·? (odds ratio 17.52, 95% confidence interval 3.91 to 78.47, p <0.001) and previous myocardial infarction (odds ratio 4.73, 95% confidence interval 1.16 to 19.32, p = 0.031) had significant independent associations. In conclusion, in community-dwelling older adults with concentric LV geometry, transition to eccentric hypertrophy was uncommon but structurally maladaptive.     

Left ventricular hypertrophy and geometry in untreated essential hypertension is associated with blood levels of aldosterone and procollagen type III amino-terminal peptide.

BACKGROUND: The present study examined the role of aldosterone in left ventricular hypertrophy (LVH) and geometry in patients with untreated essential hypertension (EHT), and investigated the contribution of myocardial fibrosis to the process of LVH. METHODS AND RESULTS: The relationship of the plasma aldosterone concentration (PAC) to LVH and left ventricular (LV) geometry was investigated in 57 consecutive patients with untreated EHT. PAC correlated with both LV mass index (LVMI: r=0.46, p=0.0004) and relative wall thickness (RWT: r=0.33, p=0.013). In patients with LVH (LVMI > or =125 g/m(2)), the serum concentration of procollagen type III amino-terminal peptide (PIIINP), a marker of myocardial fibrosis, correlated with RWT (r=0.46, p=0.029). These patients were divided into 2 groups: concentric hypertrophy (CH) with RWT > or =0.44, and eccentric hypertrophy (EH) with RWT <0.44. The serum PIIINP concentration was significantly higher in the CH group than in the EH group (0.52+/-0.02 ng/ml vs 0.44+/-0.03 ng/ml, respectively; p<0.05). CONCLUSIONS: Aldosterone may be involved in LVH and LV geometry, particularly in the development of CH. Myocardial fibrosis seems more strongly involved in the hypertrophic geometry of CH than with EH.     

Left ventricular concentric geometry during treatment adversely affects cardiovascular prognosis in hypertensive patients

Left ventricular (LV) mass and geometry predict risk for cardiovascular events in hypertension. Regression of LV hypertrophy (LVH) may imply an important prognostic significance. The relation between changes in LV geometry during antihypertensive treatment and subsequent prognosis has not yet been determined. A total of 436 prospectively identified uncomplicated hypertensive subjects with a baseline and follow-up echocardiogram (last examination 72+/-38 months apart) were followed for an additional 42+/-16 months. Their family doctor gave antihypertensive treatment. After the last follow-up echocardiogram, a first cardiovascular event occurred in 71 patients. Persistence of LVH from baseline to follow-up was confirmed as an independent predictor of cardiovascular events. Cardiovascular morbidity and mortality were significantly greater in patients with concentric (relative wall thickness > or =0.44) than in those with eccentric geometry (relative wall thickness <0.44) in patients presenting with LVH (P=0.002) and in those without LVH (P=0.002) at the follow-up echocardiogram. The incidence of cardiovascular events progressively increased from the first to the third tertile of LV mass index at follow-up (partition values 91 and 117 g/m2), but for a similar value of LV mass index it was significantly greater in those with concentric geometry (OR: 4.07; 95% CI: 1.49 to 11.14; P=0.004 in the second tertile; OR: 3.45; 95% CI: 1.62 to 7.32; P=0.001 in the third tertile; P<0.0001 in concentric versus eccentric geometry). Persistence or development of concentric geometry during follow-up may have additional prognostic significance in hypertensive patients with and without LVH.     

A new parameter of pulsed-wave tissue Doppler imaging: IVRa

Objective: We investigated how velocity of isovolumetric relaxation period on pulsed‐wave tissue Doppler trace (IVRa and IVRb) is affected by the left ventricular (LV) geometry changes. Methods: Two hundred cases without exclusion criteria were included in the study. Normal LV mass index (LVMI) and normal relative wall thickness (RWT) was assigned to group 1 (n = 72). Concentric remodeling (normal LVMI and increased RWT) was defined to group 2 (n = 25). Eccentric LV hypertrophy (LVH) (increased LVMI and normal RWT) was defined to group 3 (n = 62). And finally, concentric LVH (increased LVMI and increased RWT) was defined to group 4 (n = 41). Results: Patients with LVH (groups 3 and 4) were older than group 1 (P = 0.017 and 0.001). It was observed in the assessment of M‐mode ECHO parameters that the aortic valve diameter, aortic valve opening, LV end‐systolic diameter (LVESD), LV end‐diastolic diameter (LVEDD), and left atrium (LA) were higher in cases with eccentric LVH. It was shown that Ea velocity and Sa velocity time integral (Sa‐VTI) were decreased with LV geometry change. However, IVRa velocity and E/Ea were increased as LV geometry change. A positive correlation between IVRa velocity and LVMI (correlation ratio = 34%, P = 0.000) was found. Similarly, a positive correlation between IVRa velocity and RWT (correlation ratio = 17%, P = 0.025) was found. Conclusion: IVRa velocity exhibits a positive correlation with LV geometry changes indicating that IVRa velocity is affected by LV geometry like the other parameters influenced by LV geometry.     

Arterial hypertension,left ventricular geometry and QT dispersion in a middle-aged Estonian female population

The aim of the present study was to determine the prevalence of Left ventricular hypertrophy (LVH) and different left ventricular (LV) geometric patterns in the middle-aged women population of Tallinn, to assess the relationship between LV geometry, age, blood pressure and LV repolarization duration and inhomogeneity. A random sample of the population, 482 women aged 35-59, was examined in the framework of a cardiovascular risk factors survey for the WHO/CINDI programme years 1999-2000. Patients with valvular pathology, primary cardiomyopathy, atrial fibrillation, bundle branch blocks and flat T wave on electrocardiography (ECG) were excluded; 398 (82.2%) of the participants underwent echocardiography (Echo) and standard 12-lead ECG at rest and were included in the study. LVH was defined if left ventricular mass (LVM), LVM/height and LVM/BSA were >198 g, >121 g/m and > 120 g/m2, respectively. Arterial hypertension was determined in 23.1% of the women. The prevalence of arterial hypertension was three times higher in those aged 50-59 than in those aged 40-49 (37.4% vs 13.2%; p < 0.05). Different geometric patterns were found as follows: concentric hypertrophy in 9.1%; eccentric hypertrophy 33.9%; concentric remodelling 9.5% and normal geometry 47.5% of the participants. Concentric hypertrophy was found exclusively in hypertensive women and increased with age. No age-related eccentric hypertrophy and concentric remodelling differences were found, either in the normotensive or in the hypertensive group. Prolonged QT dispersion--a marker of increased myocardial electrical instability, was associated with LVH and arterial hypertension and was related mostly to concentric hypertrophy in hypertensives.     

Mean QRS, ventricular gradient and left ventricular mass in patients with eccentric left ventricular hypertrophy.

The spatial ventricular gradient (G) and the mean QRS-T angle were examined in 12 patients with angiographically determined eccentric left ventricular hypertrophy (LVH), as compared with 12 normal control subjects. In these 24 patients, a high significant correlation (r = 0.88) was obtained between the magnitude of the spatial mean QRS and LV mass. Although correlations were obtained between the magnitude of the spatial G or the spatial mean QRS-T angle and LV mass, they were lower (r = 0.56, 0.71 respectively). The magnitude of the spatial G (0.190 +/- 0.049 MVSec) in the eccentric LVH group increased significantly (p less than 0.001) in comparison with the control value (0.105 +/- 0.032 mVSec), while in the eccentric LVH group, decreased G/QRS (p less than 0.02), decreased T/QRS (p less than 0.05), and increased QRS-T angle (p less than 0.02) were observed. Furthermore, decreased G/QRS and widening of the QRS-T angle were observed in cases of LVH only. In cases of mild or moderate LVH, normal G/QRS ratios with definitely increased G magnitude and normal QRS-T angle were observed. It is concluded that the magnitude of the spatial mean QRS closely relates to an increase in LV mass. Therefore, should the magnitude of G increase proportionally to an increase in total muscle volume in ideal hypertrophy, then the widening of the QRS-T angle observed in LVH would be due not only to the large ARS complex but also to an alteration in the ventricular gradient.     

Echocardiographic assessment of myocardial fibrosis in young men with arterial hypertension and different types of left ventricular remodeling

In order to study structural functional characteristics of myocardium including parameters of myocardial fibrosis according echocardiography data in men with various levels of arterial pressure (AP) we examined 215 men aged 18-25 (mean 21.1+/-0,1) years with history of elevated AP at casual measurement. AP phenotype (normotension, stable arterial hypertension [AH], unstable AH) was determined on the basis of multiple measurements of clinical AP and 24 hour AP monitoring. At echocardiography we assessed presence of left ventricular (LV) hypertrophy (LVH), type of LV geometry, proportionality of LV myocardial mass (LVMM), diastolic function. Myocardial fibrosis was assessed by pixel density distribution range (PDDR) with the use of analysis of reflected signal. There were no manifestations of LV remodeling in subjects with normal AP. Concentric LV remodeling was found in 27.5 and 60.5% of patients with unstable and stable AH, respectively. Concentric LVH was found only in patients with stable AH (4.8%). Disproportionally high LVMM was found in 16.1% of subjects with stable AH. In a combined group with concentric LV remodeling and LVH rate of disproportionally high LVMM was 20.8%. We noted significant (p<0.001) increase of PDDR in stable AH (181.4+/-2.2) compared with PDDR in normal AP (164.6+/-4.6) and unstable AH (160.1+/-2.7). In stable I degree AH PDDR (177.3+/-2.2) was insignificantly lower than in II degree AH (185.7+/-3.9). PDDR in concentric LV remodeling was 180.5+/-2.3, in concentric LVH- 166.8+/-13.2, in normal LV geometry - 168.4+/-2.5. PDDR in disproportionally high LVMM was higher than in proportional LVMM. Independent interrelationship was found between PDDR and body mass index (r=0.17; p=0.03), duration of AH (r=0.17; p=0.03), isovolumic relaxation time (r= 0.15; p=0.04). In young men LV remodeling can be detected at the stage of unstable AH. In stable AH degree of myocardial fibrosis was associated with higher AP level, concentric LV geometry, disproportionally high LVMM, lowering of diastolic function.     

Differential effect of elevated blood pressure on left ventricular geometry types in black and white young adults in a community (from the Bogalusa Heart Study)

Hypertension and left ventricular (LV) hypertrophy are both more common in blacks than in whites. The aim of the present study was to test the hypothesis that blood pressure (BP) has a differential effect on the LV geometry types in black versus white asymptomatic young adults. As a part of the Bogalusa Heart Study, echocardiography and cardiovascular risk factor measurements were performed in 780 white and 343 black subjects (aged 24 to 47 years). Four LV geometry types were identified as normal, concentric remodeling, eccentric, and concentric hypertrophy. Compared to the white subjects, the black subjects had a greater prevalence of eccentric (15.7% vs 9.1%, p <0.001) and concentric (9.3% vs 4.1%, p <0.001) hypertrophy. On multivariate logistic regression analyses, adjusting for age, gender, body mass index, lipids, and glucose, the black subjects showed a significantly stronger association of LV concentric hypertrophy with BP (systolic BP, odds ratio [OR] 3.74, p <0.001; diastolic BP, OR 2.86, p <0.001) than whites (systolic BP, OR 1.50, p = 0.037; and diastolic BP, OR 1.35, p = 0.167), with p values for the race difference of 0.007 for systolic BP and 0.026 for diastolic BP. LV eccentric hypertrophy showed similar trends for the race difference in the ORs; however, the association between eccentric hypertrophy and BP was not significant in the white subjects. With respect to LV concentric remodeling, its association with BP was not significant in either blacks or whites. In conclusion, elevated BP levels have a greater detrimental effect on LV hypertrophy patterns in the black versus white young adults. These findings suggest that blacks might be more susceptible than whites to BP-related adverse cardiac remodeling.     

The effect of left ventricular geometry on myocardial performance index in hypertensive patients]

OBJECTIVE: The aim of this study was to investigate the relationship between the myocardial performance index (MPI) and left ventricular (LV) geometry in hypertensive patients. METHODS: The MPI, which is a marker of systolic and diastolic ventricular function, was measured in 64 hypertensive patients and in 15 healthy persons (Control). According to the value of relative wall thickness (RWT) and LV mass index (LVMI), hypertensive patients were subdivided into four groups: normal (N), 17 patients (26.6%); concentric remodeling (CR), 21 patients (32.8%); concentric hypertrophy (CH), 16 patients (25%); and eccentric hypertrophy (EH), 10 patients (15.6%). RESULTS: A higher MPI was found in all patient groups (N, 0.56+/-0.11; CR, 0.59+/-0.11; CH, 0.68+/-0.19; EH, 0.57+/-0.10) compared with the controls (0.44+/-0.09) (p=0.004, p<0.001, p<0.001 and p = 0.002, respectively). In the CH group, the MPI was also higher than in N, CR and EH groups (p=0.006, p<0.03 and p=0.009, respectively). No significant difference was found among N, CR and EH groups. The MPI was correlated with LVMI (r=0.28, p=0.014), RWT (r=0.24, p=0.035) and interventricular septum diastolic thickness (r=0.32, p=0.004). CONCLUSION: The systolic and diastolic LV functions are impaired in all subgroups of hypertensive patients according to their LV geometry compared to control group. This impairment is more advanced in patients with concentric hypertrophy than in those with the other LV geometric patterns.     

Associations of Left Ventricular Hypertrophy and Geometry with Adverse Outcomes in Patients with CKD and Hypertension

Background and objectives

Left ventricular hypertrophy (LVH) and abnormal left ventricular (LV) geometry predict adverse outcomes in the general and hypertensive populations, but findings in CKD are still inconclusive.

Design, setting, participants, & measurements

We enrolled 445 patients with hypertension and CKD stages 2–5 in two academic nephrology clinics in 1999–2003 who underwent both echocardiography and ambulatory BP monitoring. LVH (LV mass >100 g/m² [women] and >131 g/m² [men]) and relative wall thickness (RWT) were used to define LV geometry: no LVH and RWT≤0.45 (normal), no LVH and RWT>0.45 (remodeling), LVH and RWT≤0.45 (eccentric), and LVH and RWT>0.45 (concentric). We evaluated the prognostic role of LVH and LV geometry on cardiovascular (CV; composite of fatal and nonfatal events) and renal outcomes (composite of ESRD and all-cause death).

Results

Age was 64.1±13.8 years old; 19% had diabetes, and 22% had CV disease. eGFR was 39.9±20.2 ml/min per 1.73 m². LVH was detected in 249 patients (56.0%); of these, 125 had concentric LVH, and 124 had eccentric pattern, whereas 71 patients had concentric remodeling. Age, women, anemia, and nocturnal hypertension were independently associated with both concentric and eccentric LVH, whereas diabetes and history of CV disease associated with eccentric LVH only, and CKD stages 4 and 5 associated with concentric LVH only. During follow-up (median, 5.9 years; range, 0.04–15.3), 188 renal deaths (112 ESRD) and 103 CV events (61 fatal) occurred. Using multivariable Cox analysis, concentric and eccentric LVH was associated with higher risk of CV outcomes (hazard ratio [HR], 2.59; 95% confidence interval [95% CI], 1.39 to 4.84 and HR, 2.79; 95% CI, 1.47 to 5.26, respectively). Similarly, greater risk of renal end point was detected in concentric (HR, 2.33; 95% CI, 1.44 to 3.80) and eccentric (HR, 2.30; 95% CI, 1.42 to 3.74) LVH. Sensitivity analysis using LVH and RWT separately showed that LVH but not RWT was associated with higher cardiorenal risk.

Conclusions

In patients with CKD, LVH is a strong predictor of the risk of poor CV and renal outcomes independent from LV geometry.     

Changes in midwall systolic performance and cardiac hypertrophy reduction in hypertensive patients

OBJECTIVE: To investigate changes in left ventricular (LV) performance, as evaluated by measurement of midwall LV fractional shortening (FS), after reduction of cardiac hypertrophy. DESIGN AND METHODS: Echocardiographic evaluation of LV anatomy and function was performed by M-mode echocardiography at baseline, after long-term antihypertensive therapy, and after treatment withdrawal in 68 asymptomatic hypertensive patients (50 males, 18 females, age range 22-62 years). Patients were divided according to the presence of LV hypertrophy (LVH) at baseline (LV mass index, LVMI, > or = 51 g/m(2.7)). RESULTS: At baseline patients with concentric (relative wall thickness > 0.44) LV hypertrophy (n = 38) or remodelling (n = 7) had reduced midwall shortening with respect to patients with normal LV geometry (n = 4) or eccentric LVH (n = 19); no differences were observed for endocardial FS. After long-term treatment (average 15 months), in 11 patients LV mass remained within normal limits, in 45 patients LVH reduction was obtained, while in 12 patients LV mass remained persistently elevated. Midwall FS was significantly increased in patients with reduction of LVH both during treatment and after withdrawal of treatment, while it remained significantly lower in patients with persistently elevated LV mass. Changes in midwall fractional shortening were independently associated with modifications in relative wall thickness (P < 0.00001), with changes in end-diastolic dimensions (P < 0.0001) and those of LVMI (P< 0.02) as shown by multivariate analysis. CONCLUSION: LV midwall systolic performance significantly improved after reduction of LVH, even in the presence of high blood pressure values. Modifications in relative wall thickness are more independently associated with changes, in LV diastolic dimensions and mass, to midwall improvement     

Longitudinal global and regional left ventricular function in patients with hypertensive disease (tissue Doppler echocardiography data)

Impulse tissue doppler study was carried out in 154 patients with hypertensive disease (age 35-60 years) and 39 practically healthy volunteers (mean age 43.4+/-5.5 years). According to left ventricular geometry the following groups of patients were distinguished (after A.Ganau): with normal geometry (n=47), with concentric remodeling (n=12), with concentric hypertrophy (n=53), and with eccentric hypertrophy (n=42). Tissue doppler spectrum was registered from mitral annulus and 15 left ventricular segments. The following characteristics were obtained: in each annular spectrum - maximal velocities of peaks s(m), e(m), a(m), ratio e(m)/a(m), isovolumic relaxation time (ivrt) and their average values (from 6 measurements); in each left ventricular segmental spectrum - maximal velocities of waves s, e, a, ratio e/a and segmental ivrt. Compared with healthy persons patients with hypertension had lowered longitudinal global systolic function of the left ventricle. Patients with concentric left ventricular hypertrophy had least values of e(m), e(m)/a(m), ivrt(m) and greatest number of dysfunctional (e/a<1.0 and ivrt>90 ms) segments. Some hypertensive patients with normal values of transmitral blood flow had signs of segmental diastolic dysfunction. Among patients with normal left ventricular geometry isolated segmental diastolic dysfunction was revealed according to e/a in 12 of 20 (60%), according to ivrt in 11 of 22 (50%). All patients with concentric and eccentric left ventricular hypertrophy had segmental diastolic dysfunction. Thus impulse tissue doppler study is indicated to patients with hypertension and normal parameters of transmitral flow for assessment of longitudinal segmental diastolic left ventricular function.     

Relative wall thickness is an independent predictor of left ventricular systolic and diastolic dysfunctions in essential hypertension.

The objective of this study was to elucidate the relationship between left ventricular geometry and left ventricular (LV) function in patients with untreated essential hypertension. We evaluated LV systolic and diastolic functions by M-mode echocardiography in 24 normotensive control subjects (NC) and 129 patients with essential hypertension. Patients were divided into four groups according to the relative wall thickness and LV mass index: a normal left ventricle (n=57), a concentric remodeling (n=7), a concentric hypertrophy (n=31), and an eccentric hypertrophy (n=34) group. LV systolic function as measured by midwall fractional shortening (FS) was significantly decreased in both the concentric remodeling and concentric hypertrophy groups; no differences were observed for endocardial FS. LV diastolic function as measured by isovolumic relaxation time (IRT) was also decreased in both the concentric remodeling and concentric hypertrophy groups. In multivariate analysis, relative wall thickness (p<0.0001), end-systolic wall stress (p<0.0001), and systolic blood pressure (p=0.002) were independently associated (r2=0.72) with midwall FS in a model including age, LV mass index, body mass index, diastolic blood pressure and IRT. In addition, relative wall thickness (p=0.0008) and age (p<0.0001) were independently associated (r2=0.31) with IRT in a model including LV mass index, end-systolic wall stress, body mass index, systolic and diastolic blood pressures and midwall FS. We conclude that LV geometry as evaluated by relative wall thickness may provide a further independent stratification of LV systolic and diastolic functions in essential hypertension.     

Microalbuminuria is associated with unfavourable cardiac geometric adaptations in essential hypertensive subjects

We sought in this study to examine the relationship between microalbuminuria and cardiac geometry since a slight increased urinary albumin excretion (UAE) and increased left ventricular (LV) mass have both been identified as predictors of cardiovascular events in hypertensive subjects. For this purpose, microalbuminuria was determined in three non-consecutive 24-h urine samples as UAE of 20-200 mg/24 h in a group of 249 untreated hypertensive subjects. Echocardiographic classification of patients into LV geometric patterns was based on relative wall thickness values and on gender-specific values for LV mass index (LVMI). The group of patients with microalbuminuria (n = 119) was matched for age, sex, body mass index, smoking status and plasma cholesterol level with the group of patients without microalbuminuria (n = 130). Subjects with microalbuminuria had significantly increased LVMI (111 vs 90 g/m(2), P < 0.0001), relative wall thickness (0.46 vs 0.41, P < 0.001) and office systolic and diastolic blood pressure (161 vs 148 and 101 vs 97 mmHg, respectively, P < 0.005). For the pooled population, UAE was positively correlated to LVMI (r = 0.46, P < 0.001) and relative wall thickness (r = 0.47, P < 0.001). In the entire population, normal LV geometry, concentric LV remodelling, eccentric and concentric LV hypertrophy was found in 34%, 33%, 12% and 21%, respectively. The prevalence of normal LV geometry was significantly higher in normoalbuminuric compared with microalbumnuric subjects (55 vs 14%, P < 0.001) while the prevalence of concentric LV hypertrophy was significantly higher in microalbuminuric compared with normoalbuminuric subjects (32 vs 5%, P < 0.0001). Multiple regression analysis revealed that concentric LV hypertrophy was significantly associated with increased values of UAE and mean arterial pressure. In conclusion, the higher prevalence of unfavourable LV geometric patterns in hypertensive subjects with microalbuminuria compared with those without microalbuminura, may account for the worse cardiovascular outcomes associated with the presence of an increased UAE in hypertensive subjects.     

Effect of endurance exercise training on left ventricular size and remodeling in older adults with hypertension

BACKGROUND: It is not known whether exercise training can induce a reduction of blood pressure (BP) and a regression of left ventricular hypertrophy (LVH) in older hypertensive subjects. This study was designed to determine whether endurance exercise training, by lowering BP, can induce regression of LVH and left ventricular (LV) concentric remodeling in older hypertensive adults. METHODS: We studied 11 older adults with mild to moderate hypertension (BP 152.0 +/- 2.5/91.3 +/- 1.5 mm Hg, mean +/- SE), 65.5 +/- 1.2 years old, who exercised for 6.8 +/- 3.8 months. Seven sedentary hypertensive (BP 153 +/- 3/89 +/- 2 mm Hg) subjects, 68.5 +/- 1 years old, served as controls. LV size and geometry and function were assessed with the use of two-dimensional echocardiography. RESULTS: Exercise training increased aerobic power by 16% (p < .001), and it decreased systolic (p < .05) and diastolic (p < .05) BP, LV wall thickness (from 12.8 +/- 0.4 mm to 11.3 +/- 0.3 mm; p < .05), and the wall thickness-to-radius (h/r) ratio (from 0.48 +/- 0.02 to 0.41 +/- 0.01; p < .05). There were no significant changes in the controls. The changes in LV mass index (deltaLVMI) were different between the two groups. LV mass index decreased in the exercise group (deltaLVMI - 14.3 +/- 3.3 g) but not in the controls (deltaLVMI 1.4 +/- 4.1 g; p = .009). A multiple stepwise regression analysis showed that among clinical and physiological variables including changes in resting systolic BP, aerobic power, body mass index, and systolic BP during submaximal and maximal exercise, only the reduction in resting systolic BP correlated significantly with a regression of concentric remodeling (delta h/r ratio r = .80; p = .003). The other variables did not add to the ability of the model to predict changes in the h/r ratio. CONCLUSIONS: The data suggest that exercise training can reduce BP and induce partial regression of LVH and LV concentric remodeling in older adults with mild or moderate hypertension.     

Morning hypertension assessed by home monitoring is a strong predictor of concentric left ventricular hypertrophy in patients with untreated hypertension

This study was performed to test whether morning hypertension defined by the morning-evening difference in home blood pressure (BP) (MEdif) and the average of morning and evening BP (MEave) is a determinant of concentric left ventricular hypertrophy (LVH). The authors enrolled patients with untreated hypertension and performed echocardiography and home BP monitoring for 14 consecutive days. All patients were classified into 4 groups by the MEave and MEdif and morning hypertension was defined by MEave ≥135 mm Hg and MEdif ≥15 mm Hg. Left ventricular (LV) geometry was classified as normal, concentric remodeling, eccentric LVH, or concentric LVH. The morning hypertensive patients had a higher LV mass index and relative wall thickness than the other groups. According to multivariable logistic regression analysis, morning hypertensive patients had a significantly increased risk of the concentric LVH (odds ratio, 6.5; 95% confidence interval, 2.5-17.2; P<.001) compared with home normotensive patients with MEdif <15 mm Hg, after adjusting for confounders. Moreover, even among the home normotensives (white-coat hypertensives), patients with MEdif ≥15 mm Hg had a higher percentage of concentric remodeling than those with MEdif <15 mm Hg (32.5% vs 14.7%, P=.017). Morning hypertension defined by the MEdif and MEave is a strong determinant of concentric LVH, suggesting that this definition could be used to determine the cardiovascular risk of morning hypertension.     

Progressive hypertrophy regression with sustained pressure reduction in hypertension: the Losartan Intervention For Endpoint Reduction study

OBJECTIVE : To examine the time course of left ventricular (LV) geometric response to blood pressure (BP) control during 2 years of systematic antihypertensive treatment. DESIGN : A total of 754 hypertensive patients with left ventricular hypertrophy (LVH) by Cornell voltage-duration product or Sokolow-Lyon voltage criteria on a screening electrocardiogram had their LV mass measured by echocardiogram at enrolment in the Losartan Intervention For Endpoint Reduction (LIFE) trial, and after 12 and 24 months of blinded therapy with losartan-based or atenolol-based regimens. SETTING : The LIFE trial, in which hypertensive patients with electrocardiographic LVH (Cornell voltage-duration product > 2440 mm x ms and/or Sokolow-Lyon voltage criteria SV1 + RV5-6 > 38 mm) were randomized to >or= 4 years double-blinded treatment with losartan or atenolol. PARTICIPANTS : A total of 754 LIFE participants with serial echocardiographic measurements of LV geometry. INTERVENTIONS : None. MAIN OUTCOME MEASURES : LV wall thicknesses, diameter and mass, and its indices. RESULTS : Mean systolic/diastolic BP fell from 173/95 to 150/84 mmHg after 1 year (P < 0.001) and to 148/83 mmHg at year 2 (P = not significant). Mean echocardiographic LV mass fell from 233 g at baseline to 206 g after 1 year (P < 0.001, adjusted for change in systolic BP) and to 195 g at year 2 (P < 0.001 versus year 1), with a parallel decrease in indexed LV mass [from 56.1 to 49.7 g/m2.7 (P < 0.001), to 47.1 g/m2.7 (P < 0.001 versus year 1)]. Relative wall thickness decreased from 0.41 at baseline to 0.37 at year 1 (P < 0.001), to 0.36 at year 2 (P < 0.001 versus year 1). As a result, there were serial decreases in prevalences of eccentric LVH [44 to 38%, and to 30% (P < 0.001 versus year 1)] and concentric LVH [24 to 7% (P < 0.001), to 2% (P < 0.05 versus year 1)], and increases in the proportion with normal LV geometry [22 to 50% (P < 0.001), and to 64% (P < 0.01 versus year 1)]. CONCLUSIONS : Sustained BP reduction in hypertensive patients with target organ damage causes continued decrease in echocardiographic LV mass and prevalence of anatomic LVH for at least 2 years despite only small BP decreases after the first year of blinded therapy. These data document cardiac benefit of sustained BP control and suggest that maximum LVH regression with effective antihypertensive treatment requires at least 2 years.     

Influence of Left Ventricular Geometric Patterns on Prognosis in Patients With or Without Coronary Artery Disease

Objectives. We sought to examine patterns of left ventricular (LV) geometry as determined by echocardiography and their association with mortality in patients with or without coronary artery disease (CAD).

Background. The independent prognostic role of LV geometry remains uncertain.

Methods. We performed a cohort study based on 988 consecutive patients who underwent both coronary arteriography for presumed CAD and echocardiography and were followed up for a mean of 9 years (range 5 to 13). Patients were classified into four LV geometry patterns: normal, concentric remodeling, eccentric LV hypertrophy (LVH) and concentric LVH.

Results. Patients with concentric LVH consistently showed the largest increase in LV posterior wall and septal thickness and LV mass index, as well as relative wall thickness (RWT), regardless of status of the coronary arteries. This pattern conferred the highest risk of both all-cause and cardiac mortality. Eccentric LVH moderately increased the risk of death compared with normal geometry; no substantial increase in mortality was noted in patients with concentric remodeling. When LV index and RWT were analyzed as continuous measures and considered in the same Cox proportional hazards model, increases in LV mass were independently associated with risk, but this outcome was less clear for RWT.

Conclusions. In this series of patients referred to coronary angiography for suspected CAD, LVH conferred most of the predictive information from echocardiography. Patients with both LVH and abnormal RWT—concentric LVH—represent a group with the greatest mortality risk. Concentric remodeling may not be associated with increased risk of death because the predictive value of RWT is not as strong as for LV mass.     

Left ventricular geometry as an independent predictor for extracardiac target organ damage in essential hypertension

Left ventricular hypertrophy (LVH) is an independent cardiovascular risk factor. It has not been established, however, whether left ventricular geometry is an independent predictor of extracardiac target organ damage in essential hypertension. Study groups were classified according to relative wall thickness: 27 patients with concentric LVH and 50 patients with eccentric LVH. Age and left ventricular mass indexes of two groups were matched. As indexes of extracardiac target organ damage, retinal funduscopic grade, and serum creatinine level were measured. The severity of hypertensive retinopathy and the renal involvement were more severe in patients with concentric LVH than in patients with eccentric LVH. Extracardiac target organ damage was consistently higher in patients with concentric LVH than in those with eccentric LVH. Systemic hemodynamics paralleled ventricular geometric patterns, with higher peripheral resistance and lower aortic compliance in patients with concentric LVH, whereas end-diastolic volumes and stroke volumes were higher in patients with eccentric LVH than in patients with concentric LVH. In addition, total peripheral resistance was related to retinal fundoscopic grade (r = 0.41, P < .01), and serum creatinine level (r = 0.28, P < .05). Even in the presence of an identical degree of LVH, echocardiographically determined left ventricular geometry may provide a further independent stratification of extracardiac target organ damage in essential hypertension.     

Familial predisposition of left ventricular hypertrophy.

OBJECTIVES: The study evaluated the contribution of familial predisposition to the risk of left ventricular hypertrophy (LVH). BACKGROUND: Left ventricular hypertrophy is a multifactorial condition that serves as an important predictor of cardiovascular mortality. At present it is unclear whether familial predisposition contributes to the manifestation of LVH. Thus, we determined whether siblings of subjects with LVH are at increased risk to present with an elevation of LV mass or an abnormal LV geometry. METHODS: Echocardiographic and anthropometric measurements were performed in 2,293 individuals who participated in the echocardiographic substudies of population-based MONICA Augsburg surveys. In addition, a total of 319 siblings of survey participants with echocardiographic evidence of LVH were evaluated. The risk of these siblings to present with LVH or abnormal LV geometry was estimated by comparison with 636 subjects matched for gender and age that were selected from the entire echocardiography study base. RESULTS: Blood pressure, body mass index, age, and gender (i.e., known determinants of LV mass) were comparable in LVH-siblings and the matched comparison group. However, septal and posterior wall thicknesses, relative wall thickness as well as LV mass index were significantly elevated in LVH-siblings (p < 0.001, each) whereas LV dimensions did not differ. Likewise, the prevalence of LVH was raised in LVH-siblings, as was the relative risk of LVH after adjustment for confounders (p < 0.05). More specifically, LVH-siblings displayed increased prevalences of concentric remodeling and concentric LVH (p < 0.05) but not of eccentric LVH. CONCLUSIONS: Familial predisposition appears to contribute to increased LV wall thickness, to the development of LV hypertrophy and abnormal LV geometry.