Electrocardiographic left ventricular hypertrophy in renal transplant recipients: prognostic value and impact of blood pressure and anemia

Left ventricular hypertrophy (LVH) is an independent risk factor for death and cardiovascular disease in the general population and dialysis patients. However, the causes and consequences of LVH have not been well described in renal transplant recipients (RTR). A retrolective cohort study was conducted in 473 RTR who were alive and free of cardiac disease at 1 yr. LVH was defined using the Cornell electrocardiographic (EKG) criteria. A total of 416 patients had an interpretable first-year EKG (88%), and 284 had an interpretable fifth-year EKG (78% of 5-yr survivors). Baseline characteristics were similar in patients with and without EKG. Of 416 patients, 57 had LVH in the first year, whereas 38 of 284 patients had LVH in the fifth year, of which 18 cases were de novo. Baseline LVH was a risk factor for death (RR 1.9 [1.22, 3.22]) and congestive heart failure (CHF) (RR 2.27 [1.08, 4.81]) and was independent of other major prognostic variables. Persistent or de novo LVH in the fifth year predicted subsequent death (RR 2.15 [1.14,4.01]) and CHF (2.71 [1.17, 6.30]). Anemia and diastolic BP were independent risk factors for increasing Cornell voltage (a marker of LV mass) between first and fifth years. Systolic BP was the only predictor of de novo LVH at 5 yr. It seems that EKG LVH is a significant risk factor for death and CHF in RTR and that anemia and hypertension are risk factors for LV growth. Whether aggressive treatment of hypertension and anemia can improve outcomes merits further study.     

Morning blood pressure is useful for detection of left ventricular hypertrophy in hemodialysis patients

Background

When diagnosing hypertension (HT) it is essential to determine not only the level of raised blood pressure (BP), but also how the condition relates to organ damage. The best time to measure BP for diagnosing HT in patients on hemodialysis (HD) remains unclear.

Methods

A total of 100 HD patients (mean age 63.8?years, 60 males) were studied. Left ventricular hypertrophy (LVH) was detected by echocardiography and BP monitored for 1?week at 20 different times in the morning and night, before and after dialysis. We also checked for masked HT, i.e., patients with weekly morning HT, but not pre-dialysis HT.

Results

Average BP for the week was 141.9?±19.0/79.6?±?10.6?mmHg, with 68 patients classified as hypertensive. Average morning BP was 144.6?±?19.8/81.7?±?11.3?mmHg, and 71 patients had weekly morning HT. In addition, 62 patients had LVH and 51 patients had relative morning HT. Multiple logistic analyses showed that LVH was associated with weekly morning HT, morning HT on HD and non-HD days, average HT, and relative morning HT. However, evening, pre-dialysis, and post-dialysis HT showed no association with LVH. Masked HT was found in 20?% of patients. If HT had been diagnosed using only pre-dialysis BP, 20 of the 71 patients with weekly morning HT would not have been detected.

Conclusion

Morning BP is useful for detecting LVH in HD patients. Monitoring of morning BP may be superior to measurements taken at other times for diagnosing HT.     

Aortic stiffness, left ventricular hypertrophy and weekly averaged blood pressure (WAB) in patients on haemodialysis.

BACKGROUND: In haemodialysis (HD) patients, no consensus has been reached with regard to the desired blood pressure (BP) level and when or how BP should be monitored. Moreover, BP variability over a period of 1 week has not been well studied in HD patients. METHODS: The present study is an observational study that comprised 101 HD patients (65 males and 36 females). We used daily home blood pressure (HBP) monitoring to record a total of 20 points of BP over a period of 1 week, including measurements of the wake-up and night BPs; this was in addition to the BP recorded before and after each HD session that occurred three times a week. The average of these 20 BP measurements was defined as the weekly averaged blood pressure (WAB). Finally, we studied the relationship between the WAB and left ventricular hypertrophy (LVH) or aortic stiffness measured by baPWV. RESULTS: The systolic (142.5+/-19.5 mmHg) and diastolic (.78.8+/-9.9 mmHg) WABs were almost consistent with the wake-up BP on the day after the midweek dialysis session (R2=0.709 and 0.775, respectively). The WAB showed significant positive correlations with the left ventricular mass index (LVMI) (R=0.387, P<0.001) and baPWV (R=0.226, P<0.05), whereas the predialysis systolic BP did not show a significant positive correlation with the LVMI. CONCLUSION: The WAB is a useful marker for evaluating the BP of HD patients and correlates well with the LVMI or baPWV.     

Impact of volume control on left ventricular hypertrophy in dialysis patients

BACKGROUND: Left ventricular hypertrophy (LVH), which strongly predicts cardiac mortality, is seen in more than 60% of end-stage renal disease patients. The aim of this study was to prospectively investigate the effect of salt restriction and strict volume control on blood pressure and LVH. METHOD: Nineteen hypertensive patients on chronic hemodialysis (HD) treatment (age 52 +/- 17 years, 7 women) were included in the study. Treatment consisted of 12-h HD per week, during which as much ultrafiltration (UF) was applied as possible without an excessive blood pressure (BP) drop. Special attention was given to dietary salt restriction. Predialysis mean BP (MBP), body weight (BW), cardio-thoracic index (CTI) and echocardiographic results were recorded at baseline and after 6 and 12 months. RESULTS: All patients reached acceptable BP (< 140/90 mmHg) within three months (10-75 days) with our strict volume control strategy. Mean pre-dialysis BP was 127 +/- 17/78 +/- 9 mm Hg at baseline, 120 +/- 9/75 +/- 6 mm Hg at the 6th month and 118 +/- 11/73 +/- 5 mm Hgat the 12th month. The incidence of symptomatic hypotension gradually decreased from a mean of 22% to 11% and 7%, respectively during follow-up. Left ventricular mass index decreased from 164 +/- 64 to 112 +/- 36 g/m2. CTI, left atrial, left ventricular systolic and diastolic diameters significantly decreased in all patients. Inter-dialytic weight gain was 930 +/- 70 g/day in the follow-up period. Hematocrit did not significantly differ at the first, second and last visits. CONCLUSION: Normal BP and improvement of cardiac structure, in particular a reduction of LVH could be reached in all our patients by intensifying salt restriction and UF.     

慢性肾脏病患者血压非勺型节律与左心室肥厚之间的关系

目的 探讨24 h动态血压（ABPM）非勺型节律与慢性肾脏病（CKD）患者左心室肥厚（LVH）之间的关系。 方法 共有257例CKD 1~5期患者入选,根据肾功能分为两组：CKD1~3期组和CKD4~5期组。采用GE Marquette Tonoport V Eng动态血压计测定各组患者动态血压参数和昼夜节律;心脏彩色多普勒超声了解心脏结构的改变,并探讨血压非勺型节律与LVH之间的关系。 结果 CKD患者血压正常的生理节律丧失的现象普遍,总体血压非勺型昼夜节律发生率达75.4％,即使在血压正常者中也达到71.3%,随着肾功能下降血压非勺型昼夜节律的发生率也在上升。CKD患者血压非勺型节律组的心脏结构改变较勺型组明显,LVH的发生率也较高。相关性分析显示左室心肌质量指数（LVMI）与血压水平、非勺型的昼夜节律等相关。多元逐步回归分析显示24 h-收缩压（SBP）（β = 0.417,P < 0.01）、三酰甘油 （β = -0.132,P = 0.007）、血红蛋白（Hb）（β = -0.394,P = 0.016）及性别（β = 0.158,P = 0.039）是影响LVMI的独立危险因素。 结论 CKD患者的血压非勺型昼夜节律现象普遍,并随着肾功能的下降其发生率逐渐升高。血压非勺型节律患者心脏结构改变更明显,LVH的发生率高。非勺型节律与LVMI密切相关。     

Effects of anemia and left ventricular hypertrophy on cardiovascular disease in patients with chronic kidney disease

Left ventricular hypertrophy (LVH) and anemia are highly prevalent in moderate chronic kidney disease (CKD). Because anemia may potentiate the adverse effects of LVH on cardiovascular outcomes, the effect of both anemia and LVH on outcomes in CKD was examined. Data from four community-based longitudinal studies were pooled: Atherosclerosis Risk in Communities Study, Cardiovascular Health Study, Framingham Heart Study, and Framingham Offspring Study. Serum creatinine levels were calibrated indirectly across studies, and GFR was estimated using the Modification of Diet in Renal Disease equation. CKD was defined as GFR between 15 and 60 ml/min per 1.73 m(2). LVH was based on electrocardiogram criteria. Anemia was defined as hematocrit <36% in women and 39% in men. The primary outcome was a composite of myocardial infarction, stroke, and death; a secondary cardiac outcome included only myocardial infarction and fatal coronary heart disease. Among 2423 patients with CKD, 96% had electrocardiogram and anemia data. Median follow-up was 102 mo. In adjusted analysis, LVH was associated with increased risk for composite and cardiac outcomes (hazard ratio [HR], 1.67 [95% confidence interval (CI), 1.34 to 2.07] and 1.62 [95% CI, 1.18 to 2.24], respectively), whereas anemia was associated with increased risk for the only composite outcome (HR, 1.51 [95% CI, 1.27 to 1.81]). The combination of anemia and LVH was associated with an increased risk for both study outcomes compared with individuals with neither risk factor (HR, 4.15 [95% CI, 2.62 to 6.56] and 3.92 [95% CI, 2.05 to 7.48]; P = 0.02 and 0.01 for interaction term, respectively). The combination of anemia and LVH in CKD identifies a high-risk population.     

Body fluid spaces and blood pressure in hemodialysis patients during amelioration of anemia with erythropoietin

Blood pressure (BP) may increase in hemodialysis patients during treatment of anemia with recombinant human erythropoietin (r-HuEPO). Since fluid volume is a determinant of BP in dialysis patients, changes in body fluid spaces during r-HuEPO therapy could affect BP. Thus, 51Cr-labeled red blood cell (RBC) volume, inulin extracellular fluid (ECF) volume, and urea total body water (TBW), as well as cardiac output, plasma renin activity (PRA), and plasma aldosterone concentration were determined postdialysis before and after r-HuEPO therapy in patients in whom changes in BP could be managed by ultrafiltration alone. Eleven patients entered the study: one had a renal transplant and two required addition of antihypertensive drug therapy and were excluded; eight, of whom two required antihypertensive drug therapy following the study, were included in the analyses. Results revealed an increase in predialysis hemoglobin from 67 to 113 g/L (6.7 to 11.3 g/dL) (P = 0.001) during 18 +/- 6 weeks of therapy. Predialysis diastolic BP increased from 80 to 85 mm Hg (P = 0.07), while postdialysis diastolic BP was unchanged at 73 mm Hg. 51Cr-RBC volume increased, from 0.7 to 1.3 L (P = 0.004). ECF tended to decrease, from 13.7 to 10.8 L (P = 0.064), while TBW decreased to a similar extent, but not significantly, 34.3 to 31.2 L (P = 0.16). Postdialysis ECF volume was positively correlated with mean arterial BP at baseline (r = 0.89, P = 0.007) and after therapy (r = 0.74, P = 0.035). However, the regression lines for this relationship were different (P = 0.022) before and after therapy.(ABSTRACT TRUNCATED AT 250 WORDS)     

Blood pressure in hemodialysis patients during amelioration of anemia with erythropoietin.

This study analyzed blood pressure in hemodialysis patients treated with epoetin beta in multicenter trials. Antihypertensive drugs were prescribed as usual. Placebo-controlled trials compared epoetin (100 to 150 U/kg; N = 151) with placebo (N = 78) for 82 days. Hemoglobin (108 +/- 18 versus 75 +/- 14 g/L) (mean +/- SD) and diastolic blood pressure (84 +/- 14 versus 78 +/- 15 mm Hg) were greater (P less than 0.05) after epoetin. Clinically important increases in blood pressure (increases in diastolic blood pressure greater than or equal to 10 mm Hg and/or drug therapy) were more frequent with epoetin (58 versus 37%; P = 0.005). A dose-response trial compared epoetin, 25 U/kg (N = 42), 100 U/kg (N = 40), and 200 U/kg (N = 39) for 138 days. Increases in hemoglobin were dose dependent, but clinically important increases in blood pressure were not. In analyses of all patients treated with epoetin (N = 272), no baseline or final level of hemoglobin, or rate of hemoglobin rise, was a threshold for a rise in blood pressure. Patients requiring antihypertensive drugs or having uncontrolled hypertension (diastolic blood pressure greater than 90 mm Hg) at baseline had decreases in blood pressure (P less than 0.05) with antihypertensive therapy. Thus, compared with placebo, 21% of patients had clinically important increases in blood pressure during amelioration of anemia. The baseline or final levels of hemoglobin, the extent or rate of hemoglobin rise, or uncontrolled hypertension or antihypertensive drug use at baseline were not confirmed as risks. Antihypertensive drug therapy was important for blood pressure control.     

Twenty-four hour blood pressure profile and left ventricular hypertrophy early after renal transplantation

BACKGROUND: Left ventricular hypertrophy is common in renal transplant patients but the factors influencing its development remain to be determined. The present investigation was conducted to study the effect of blood pressure load on the left ventricular mass of recently transplanted patients using 24-h ambulatory blood pressure monitoring (ABPM). METHODS: We studied 30 renal transplant (RT) patients (36.1+/-13.7 years old, 11 males, 26 Whites, 4 diabetics, 15 under antihypertensive medication, 21 recipients of cadaver donors, and all treated with steroids, cyclosporin and azathioprine and with adequate (serum creatinine < 1.8 mg/100 ml) renal function). The median duration of dialysis treatment before transplant was 37 months, and the studies were performed during the first 40 days post-transplantation. Blood pressure was measured after a 15-min rest (casual blood pressure) and during a 24-h period with a SpaceLabs apparatus. Echocardiograms were obtained from all patients. RESULTS: Mean left ventricular mass index (LVMI) was 153+/-44 g/m2; casual systolic and diastolic BP (mmHg) was 152+/-25 and 92+/-13, whereas systolic and diastolic 24-h BP was 133+/-12 and 85+/-8, respectively. The systolic sleeping BP/awake systolic BP (SSBP/ASBP) ratio was 0.94+/-0.07, and 73% of the patients did not show a significant (>10%) fall of systolic blood pressure during sleep. Multivariate analysis showed that awake systolic blood pressure was the only variable that independently influenced LVMI after adjusting for confounding factors (regression coefficient = 0.49, p = 0.01). Casual systolic and diastolic BP, sleeping systolic and diastolic blood pressure, 24-h heart rate, age, race, gender, smoking, body mass index, duration of dialysis, diabetes, antihypertensive and immunosuppressive drugs and levels of hematocrit, creatinine and serum lipids did not correlate with LVMI. CONCLUSION: The data indicate that left ventricular hypertrophy during the early post-transplant period is mainly influenced by awake blood pressure load. They also suggest that ABPM may be more useful in the diagnosis and management of post-transplant hypertension than casual BP. The findings emphasize the importance of rigid blood pressure control in renal transplant recipients.     

慢性肾功能不全患者纠正贫血对逆转左心室肥大的观察

慢性肾功能不全（CRI）患者常并发贫血及左心室肥大（LVH）．影响长期生存。本研究观察纠正CRI患者贫血对LVH的影响。     

Influence of chronic renal insufficiency on left ventricular diastolic function in hypertensives without left ventricular hypertrophy

BACKGROUND: Patients with chronic renal insufficiency (CRI) have a much greater cardiovascular risk than the general population. Moreover, hypertension is common in these patients, as is left ventricular hypertrophy (LVH) and diastolic dysfunction, which contribute to a worse prognosis. While these findings are well established for end-stage renal disease, fewer data are available in mild to moderate CRI. Furthermore, little is known about diastolic function in CRI patients without LVH. METHODS: We performed a cross-sectional study to evaluate LV structure and function in hypertensives with CRI, compared with hypertensives with normal renal function (EH), by means of mitral inflow and tissue Doppler echocardiography. Patients with LVH were excluded from both groups. RESULTS: CRI patients had higher left ventricular end-diastolic diameter, end-systolic diameter (p<0.0001 and p=0.0001, respectively) and left ventricular mass index (LVMI) (p<0.0001) than EH patients. The CRI group also showed greater alterations of the diastolic function indexes than hypertensives: lower E-wave peak velocity (p=0.02), E-wave peak velocity to A-wave peak velocity ratio (p=0.03) and early diastolic myocardial velocity (p=0.04), higher A-wave peak velocity (p=0.07), E-deceleration time (p=0.02) and isovolumic relaxation time (p=0.0001). Multiple regression analysis demonstrated that renal function was a predictor of LVMI and diastolic function independently of age, sex, pulse pressure, body mass index and duration of hypertension. CONCLUSIONS: Our data showed a greater alteration of diastolic function in the CRI group, in part independent of LVMI. In CRI, factors other than LVMI and blood pressure seem to play an important role in causing early diastolic dysfunction.     

Arterial hypertension and left ventricular hypertrophy in hemodialysis patients

The high prevalence of left ventricular hypertrophy (LVH) among hemodialysis patients may be a consequence of inadequate diagnosis and treatment of arterial hypertension (AH). AH is not adaquately controlled in hemodialysis patients probably due to an underestimation of the effective BP load due to the unreliability of clinical BP readings in this population. Furthermore, BP reduction induced by dialysis ultrafiltration is not an acceptable criterion for discontinuing antihypertensive therapy, particularly when LVH coexists. Indeed, the few available interventional studies have demonstrated that strict BP control, together with anemia correction and dialysis adequacy improvement, can induce significant regression of the LVH of hemodialysis patients. Moreover, the decrease of SBP, particularly as a result of ACE-inhibitor therapy, is the most important predictor of LVH regression. Finally the use of ABPM and of echocardiography are recommended for correctly detecting an underlying AH and for tailoring and monitoring the effectiveness of antihypertensive therapy in dialysis patients with LVH.     

Serum interleukin-6 in long-term hemodialyzed patients.

The generation of compounds such as interleukin 1 (IL-1), tumor necrosis factor alpha (TNF alpha), and the possible encounter of circulating cells with endotoxin (LPS) have been demonstrated during hemodialysis. All these factors are able to induce the production of IL-6 by human monocytes. Anaphylatoxins can be generated following complement activation by cellulosic membrane dialysis. C5a is known to potentiate the LPS-induced production of IL-1 and TNF alpha, and we established that recombinant human C5a was able to act synergistically with LPS in the induction of IL-6 by human monocytes. We investigated whether IL-6 could be detected in the serum of long-term hemodialyzed and uremic patients. Using the very sensitive 7TD1 cell line bioassay, we demonstrated that circulating IL-6 activity was present in the serum of all 14 tested patients, whereas it was occasionally present in normal sera. The presence of serum IL-6 was confirmed using an anti-IL-6 antibody and a specific ELISA (109 +/- 36 pg/ml). Most patients had a reproducible level of IL-6 activity throughout a period of 10 days. The dialysis session did not significantly modify these levels and patients had similar serum IL-6 activity at the start, during or the at end of the dialysis session. The different parameters of the dialysis session (i.e. standard or filtrated dialyzates, complement-activating or nonactivating membranes) did not significantly influence the levels of IL-6. Elevated levels of IL-6 were also observed in uremic patients compared to normal donors, although significantly lower than in hemodialyzed patients (p = 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)     

Regression of left ventricular hypertrophy after partial correction of anemia with erythropoietin in patients on hemodialysis: a prospective study.

Myocardial effects of recombinant human erythropoietin (rhEPO) treatment were prospectively investigated in 15 hemodialysis (HD) patients with severe anemia (hematocrit [Ht] 19.7 +/- 2.5%). Echocardiographic studies were performed after a midweek HD session just before and after a year of rhEPO. At the end of the study period, Ht had improved to 32.2 +/- 3.5% and cardiac index significantly decreased (5.48 +/- 1.54 vs 3.97 +/- 0.94 l/min/m2, p less than 0.001). Left ventricular mass index (LVMi) decreased with rhEPO (210.7 +/- 48.3 vs 139 +/- 50 g/m2, p less than 0.05). This decrease was concomitant with a decrease of LV end-diastolic diameter (4.89 +/- 0.44 vs 4.57 +/- 0.64 cm, p less than 0.05), interventricular septum thickness (IVST, 1.42 +/- 0.33 vs 1.07 +/- 0.13 cm, p less than 0.01) and LV posterior wall thickness (LVPWT, 1.28 +/- 0.21 vs 1.01 +/- 0.11 cm, p less than 0.01). Eight patients were hypertensive well controlled with hypotensive drugs (group I) and 7 normotensive (group II). LVMi was higher in group I than in group II before rhEPO (235.2 +/- 40 vs 182.7 +/- 43.1 g/m2, p less than 0.05) and significantly decreased after rhEPO in both groups (28.5% and 41.4% respectively). LVMi remained higher in group I than in group II at the end of the study (168.5 +/- 0.9 vs 106.7 +/- 24 g/m2, p less than 0.025). A moderately elevated IVST/LVPWT was reduced with a year of rhEPO (1.14 +/- 0.40 vs 1.05 +/- 0.15, p less than 0.05), disclosing correction of asymmetric septal hypertrophy. We conclude that left ventricular hypertrophy (LVH) regression is obtained after partial correction of anemia with rhEPO. Previous hypertension with current need of antihypertensive treatment has also a significant effect in the development of LVH. Whether this regression would improve outcome in HD patients remains to be established.     

Left ventricular hypertrophy, treadmill tests, and 24-hour blood pressure in pediatric transplant patients.

BACKGROUND: Hypertension and left ventricular hypertrophy (LVH) are possible complications in pediatric patients after renal transplantation. METHODS: We performed left ventricular echocardiography, 24-hour ambulatory blood pressure monitoring (24-hr ABPM), and treadmill tests in 28 pediatric renal transplant patients (mean age 16.1 +/- 3.7; time since transplantation 36 +/- 23 months). Left ventricular mass (LVM) was indexed for height 2.7. RESULTS: LVH was found in 82% of the patients. Seven of these patients were normotensive by 24-hour ABPM, but five patients showed a hypertensive systolic BP response during the treadmill test. LVM/height 2.7 correlated significantly with the mean 24-hour systolic BP (P = 0.002) and with the maximal exercise systolic BP (P = 0.002). CONCLUSION: LVH is frequent in pediatric renal transplant patients. More information is needed with respect to the risk for LVH, including data from 24-hour ABPM and treadmill testing.     

Cardiac valve calcifications and left ventricular hypertrophy in hemodialysis patients

Cardiac valve calcification (VC) is a common finding in end-stage renal disease patients. It was shown recently that VC is an independent predictor for all-cause and cardiovascular mortality in peritoneal dialysis patients. In hemodialysis (HD) patients, VC was associated with all-cause and cardiovascular mortality, but after adjusting for other cardiovascular risk factors and complications, as well as left ventricular mass index (LVMI), it lost significance. The aim of the study was to assess the relationship between VC and left ventricular hypertrophy in hemodialysis patients. Echocardiographic examination with mitral and aortic valves assessment and LVMI calculation was performed in 65 HD patients ages 49+/-12, with duration of HD therapy 38+/-32 months. VC were found in 32 of 65 patients (49%)-Group VC(+), mitral valve calcifications (MVC) in 10, aortic valve calcifications (AVC) in 9, and both valves calcifications (MVC+AVC) in 13 patients. Patients with VC were older, on HD therapy were longer, had higher systolic and pulse pressure, and had higher LVMI. Patients with both VCs had the highest LVMI. No significant differences were found with respect to Ca, P, PTH, and mean Ca x P product, but the incidence of Ca x P product above 4.43 mmol2/L2 was higher in VC(+) compared with those without VCs. VC coexists with left ventricular hypertrophy, particularly when both valves are calcified. Even short-lasting incidents of increased Ca x P product may lead to cardiac VC.     

Left ventricular hypertrophy is a risk factor independent of hypertension in survival of hemodialyzed patients

Hemodialysis patients have low 5-year survival rates of approximately 60%, and the most common cause of death is cardiovascular diseases. Their population may be considered, therefore, as an accelerated model in analyzing the risk factors for cardiovascular diseases. We previously reported the role of blood pressure, one of the most important risk factors for cardiovascular diseases, in determining the prognosis of hemodialysis patients. In this study, we examined the effect of cardiomegaly detected on chest roentgenogram or electrocardiogram before initiating hemodialysis therapy on survival after introduction to maintenance hemodialysis. One hundred and sixty hemodialysis patients who had no history of ischemic heart disease or arrhythmia were followed up for 88.9 +/- 4.0 months, among whom 69 died. Heart enlargement, defined on chest roentgenogram, was detected in 104 patients, and left ventricular hypertrophy, defined on electrocardiogram, was detected in 105 patients. The presence of either finding shortened their survival. However, Cox's proportional hazards model and logistic multiple regression analysis identified only left ventricular hypertrophy as one of the significant determinants for survival, but heart enlargement was not independent. Correction of systolic hypertension on the maintenance phase had no significant favorable effect on survival in patients with left ventricular hypertrophy, while it improved in those with heart enlargement. This finding, together with those above from Cox's model and logistic analysis strongly suggests that risk from left ventricular hypertrophy is independent of, but one from heart enlargement is dependent on hypertension.