Does the reduction in systolic blood pressure alone explain the regression of left ventricular hypertrophy?

Systolic blood pressure (SBP) is an important determinant of the development and regression of left ventricular hypertrophy (LVH) in hypertensive humans. However, comparative assessments with other BP components are scarce and generally limited in size. As part of the Progetto Ipertensione Umbria Monitoraggio Ambulatoriale (PIUMA), 743 hypertensive subjects underwent echocardiography and 24-h ambulatory BP monitoring before and after an average of 3.9 years of treatment. The changes in left ventricular mass showed a significant direct association with the changes in 24-h SBP (r=0.40), diastolic blood pressure (DBP) (r=0.33) and pulse pressure (PP) (r=0.35). Weaker associations were found with the changes in clinic BP (r=0.32, 0.31 and 0.16, respectively). In a multivariate linear regression analysis, the changes in 24-h SBP were the sole independent determinants of the changes in left ventricular mass (LVM) according to the following equation: percentage changes in LVM=0.73 x (percentage changes in 24-h SBP) -0.48 (P<0.0001). For any given reduction in 24-h SBP, the reduction in LVM did not show any association with the changes in DBP and PP, either clinic or ambulatory. These data indicate that SBP is the principal determinant of LVH regression in hypertensive humans.     

Is Doppler tissue velocity during early left ventricular filling preload independent?

Background: Transmitral Doppler flow indices are used to evaluate diastolic function. Recently, velocities measured by Doppler tissue imaging have been used as an index of left ventricular relaxation.     

Is there a relationship between exercise systolic blood pressure response and left ventricular mass? The Framingham Heart Study.

OBJECTIVE: To assess the association between an exaggerated exercise systolic blood pressure response and the occurrence of left ventricular hypertrophy in healthy, normotensive individuals. DESIGN: Cross-sectional survey using M-mode echocardiography to measure left ventricular mass and to detect left ventricular hypertrophy. SETTING: The Framingham Heart Study. SUBJECTS: Eight-hundred sixty men and 1118 women were studied who were free of cardiovascular or pulmonary disease, who were not taking any antihypertensive or cardiovascular medications, and who successfully achieved at least 90% of their age-predicted maximum heart rate during a monitored exercise treadmill test. All subjects had normal baseline and exercise electrocardiograms. MEASUREMENTS AND MAIN RESULTS: Men with a peak exercise systolic blood pressure of 210 or more and women with a peak exercise systolic blood pressure of 190 or more were considered to have an "exaggerated" blood pressure response; 122 men and 67 women met these criteria. Subjects with an exaggerated exercise systolic blood pressure response had 10% higher left ventricular mass than those with a normal exercise systolic blood pressure response (in men: 115 +/- 25 compared with 105 +/- 24 g/m, P less than 0.001; in women: 86 +/- 22 compared with 73 +/- 16 g/m, P less than 0.001); they also had a higher prevalence of left ventricular hypertrophy (in men: odds ratio, 1.34, 95% CI, 1.00 to 1.80; in women: odds ratio, 2.12, CI, 1.48 to 3.03). After adjusting for age, resting systolic blood pressure, and body mass index, however, subjects with an exaggerated exercise systolic blood pressure response had only 5% higher left ventricular mass (in men: 111 +/- 2.1 compared with 106 +/- 0.8 g/m, P = 0.02; in women: 80 +/- 1.8 compared with 74 +/- 0.4 g/m, P = 0.002), and they no longer had a statistically increased prevalence of left ventricular hypertrophy (in men: odds ratio, 1.21, CI, 0.87 to 1.67; in women: odds ratio, 1.30, CI, 0.84 to 2.01). CONCLUSIONS: The apparent relation between exercise systolic blood pressure response and left ventricular mass is confounded by age, resting systolic blood pressure, and body mass; the degree of confounding is such that the biologic significance of this relationship should be questioned.     

Should the target for blood pressure control specify both a systolic and a diastolic component?

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) Report recommends, as the target for hypertension control, achieving both a systolic and diastolic goal. We suggest, however, that specifying both a systolic and a diastolic component for the blood pressure goal can be confusing to physician and patient. Furthermore, literal interpretation and application of this JNC 7 recommendation could result in overtreatment, undertreatment, or institution of treatment for hypertension when none is needed. Specific scenarios illustrating how inappropriate treatment could result from literal interpretation and application of the JNC 7 recommendations are presented. Our recommended blood pressure goal for hypertensives is: Sitting systolic blood pressure consistently in the 120s or less, if tolerated. This recommendation is evidence based, easy to understand, and achievable. Its rationale is discussed.     

Is blood pressure the major determinant of left ventricular mass in subjects over 50 years of age?

The weak relation of systolic blood pressure to left ventricular (LV) mass in hypertension has frequently been regarded as evidence of non-hemodynamic stimuli to muscle growth. Anyway, left ventricular hypertrophy (LVH) is associated with a significantly increased risk for cardiovascular events. Data were obtained from M-mode echocardiograms in 10 normotensives and 58 hypertensives over 50 years (range 50-85 years); 18 hypertensives; were without (LVH -) and 40 were with LVH (LVH +) - when LV mass, normalized for body surface area, was calculated according to the Penn's Convention. Cardiac output was derived by Teicholz formula for LV volumes. End-systolic stress/end-systolic dimension ratio (ESS/ ESD r), an index of myocardial contractility, was calculated as previously validated in the literature. We found that, in subjects ranging from 50 to 85 years of age, the presence of LV hypertrophy is not necessarily associated with raised blood pressure levels. Systolic function was substantially preserved among the study groups, irrespective of their age, hypertensive condition and/or presence of LVH. The increased wall thickness in subjects with LVH was associated with a significant reduction in wall stress (thus suggesting an adequateness of the compensatory role of LVH - at least at the observed stage of the hypertrophy process) and with a significant decrease of the contractile performance. On the multivariate analysis, the observed relation of LV mass to blood pressure and myocardial contractility (r = 0.621, P < 0.001) may explain some apparently conflicting findings, such as the lack of LV hypertrophy in a number of hypertensive patients.     

Understanding and clinical application of acute dilation of the left ventricle on ventricular arrhythmias

In this issue of the Journal of Geriatric Cardiology,Yin et al discussed the effects of calcium preconditioning(CPC) and streptomycin (S) on acute dilation of the leftventricle.     

Study of left ventricular systolic dysfunction,left ventricular diastolic dysfunction and pulmonary hypertension in CKD 3b-5ND patients—A single centre cross-sectional study

IntroductionCardiovascular diseases are associated with increased morbidity and mortality among CKD (chronic kidney disease) population. Recent studies have found increasing prevalence of PH (pulmonary hypertension) in CKD population. Present study was done to determine prevalence and predictors of LV (left ventricular) systolic dysfunction, LVDD (left ventricular diastolic dysfunction) and PH in CKD 3b-5ND (non-dialysis) patients.MethodsA cross sectional observational study was done from Jan/2020 to April/2021. CKD 3b-5ND patients aged ≥15 yrs were included. Transthoracic 2D (2 dimensional) echocardiography was done in all patients. PH was defined as if PASP (pulmonary artery systolic pressure) value above 35 mm Hg, LV systolic dysfunction was defined as LVEF (left ventricular ejection fraction) ≤ 50% and LVDD as E/e′ ratio >14 respectively. Multivariate logistic regression model was done to determine the predictors.ResultsA total of 378 patients were included in the study with 103 in stage 3b, 175 in stage 4 and 100 patients in stage 5ND. Prevalence of PH was 12.2%, LV systolic dysfunction was 15.6% and LVDD was 43.65%. Predictors of PH were duration of CKD, haemoglobin, serum 25-OH vitamin D, serum iPTH (intact parathyroid hormone) and serum albumin. Predictors of LVDD were duration of CKD and presence of arterial hypertension. Predictors of LV systolic dysfunction were eGFR (estimated glomerular filtration rate), duration of CKD, serum albumin and urine protein.ConclusionIn our study of 378 CKD 3b-5ND patients prevalence of PH was 12.2%, LV systolic dysfunction was 15.6% and LVDD was 43.65%.     

Are left ventricular diastolic function and diastolic asynchrony important determinants of response to cardiac resynchronization therapy?

Cardiac resynchronization therapy (CRT) has been shown to reduce symptoms and reverse left ventricular (LV) remodeling. It is not known, however, whether diastolic function will improve after CRT and diastolic asynchrony will predict LV reverse remodeling. Seventy-six patients (mean age 65 +/- 12 years, 74% men) who received CRT were studied at baseline and after 3 months. Diastolic function was assessed by transmitral Doppler and tissue Doppler imaging. LV systolic and diastolic asynchrony were assessed by the time to peak myocardial contraction (Ts) and early diastolic relaxation (Te) using the 6 basal, 6 mid-segmental model. There were 42 responders (55%) with LV reverse remodeling (defined as a reduction of LV end-systolic volume >or=15%). Parameters of systolic function were significantly improved only in the responders. For diastolic function, there were reductions of transmitral E velocity in the 2 groups, without any change in atrial velocity or the E/A ratio. Tissue Doppler imaging revealed that myocardial early diastolic velocity was unchanged in responders but was significantly worsened in nonresponders. The systolic asynchrony index (the SD of Ts of 12 LV segments) correlated significantly with LV reverse remodeling (r = -0.64, p <0.001) but not the diastolic asynchrony index (the SD of Te of 12 LV segments) (r = -0.10, p = NS). The systolic asynchrony index was the only independent predictor of reverse remodeling (beta = -0.99, 95% confidence interval -1.41 to -0.58, p <0.001). In conclusion, CRT improves systolic function and systolic asynchrony but has a neutral effect on diastolic function and diastolic asynchrony. LV reverse remodeling response is determined by the severity of prepacing systolic asynchrony but not diastolic asynchrony or the diastolic filling pattern.     

Is left ventricular mass in apparently healthy, normotensive men correlated to maximal blood pressure during exercise?

In 95 apparently healthy normotensive men aged 21-69 (mean 44)years with supine bloodpressure(BP) > 150/90 mmHg when >50 years, and > 160/95 when 50 years of age, left ventricularmass (LVM) was measured by M-mode echocardiography and relatedto maximal BP during a symptom-limited ergometer bicycle test.Mean L VM was 195 (±43) g and LVM index (I) 101 (±20) gm^–2body surface area (BSA). The subjects were subdividedinto two groups: Group 1 - 28 subjects (29%) with LVM ;<220 g, and Group 2 = 67 subjects (71%) with LVM>220g. Group1 had a slightly larger BSA (P>0-05), weight (P>0-05)and resting systolic BP (P>0.05). A higher prevalence ofsmokers (P>001) and serum cholesterol levels (P>0.05)were also noted among Group 1 subjects, who had a higher maximalsystolic BP during exercise (P>0.0001). Using linear regressionanalysis, significant positive-correlations were observed betweenLVM and systolic BP at rest (r=0.20, P>0.05), and maximalexercise systolic BP (r=0.32, P>0.001). When correcting fordifferences in age, weight, body surface area, physical performance,smoking and hours of exercise per week, multiple regressionanalysis revealed a significant correlation between LVM andmaximal systolic BP(t=2.38,P=0.020, Partial F=5.64).Thus, inapparently healthy men with normal resting supine BP, the positivecorrelation between L VM and maximal BP during a symptom-limitedexercise test may identify a subgroup at increased risk forsubsequent development of cardiovascular disease.     

Systolic and diastolic left ventricular dysfunction--independent types of cardiac failure or two sides of a single process?

At present disturbances of systolic and diastolic myocardial function are subjected to intensive study. Most researches acknowledge possibility of development of diastolic dysfunction in the absence of systolic dysfunction. Meanwhile disturbances of systolic and diastolic myocardial functions have common pathogenetic and pathomorphological basis representing the essence of cardiac remodeling. Patients with instrumental signs of pure diastolic dysfunction and subjects with combination of disturbances of systolic and diastolic functions have similar clinical symptoms. This literature review deals with problems of relationship between systolic and diastolic dysfunction and expediency of clear delineation of these disturbances.     

Is left ventricular diastolic function an independent marker of prognosis after acute myocardial infarction?

BACKGROUND: In addition to clinical risk markers, indices of left ventricular (LV) systolic function are valuable prognostic markers after acute myocardial infarction (MI). Previous studies have also suggested that LV diastolic function may contribute with prognostic information. The present study assessed whether this assumption applies to a large population of patients with acute MI who underwent thrombolytic therapy. METHODS AND RESULTS: 520 out of 608 patients participating in the ATTenuation by Adenosine of Cardiac Complications (ATTACC) study, with an ST-elevation acute MI underwent two-dimensional and Doppler echocardiographic examination at 4 (range 2-10) days after admission. During the follow-up period of 31 (S.D. +/- 11) months, cardiovascular death occurred in 57 (11%) patients, nonfatal acute MI occurred in 77 (15%), and 124 (24%) patients suffered a combined cardiovascular end-point (either nonfatal acute MI or cardiovascular death). Univariate regression analysis showed that all indices of LV systolic function predicted cardiovascular death and combined cardiovascular end-points. Regarding LV diastolic function only a restrictive filling pattern predicted cardiovascular death. In a multistep multivariate regression analysis in which the variables were introduced in a hierarchic order age, history of systemic hypertension, wall motion score index (WMSi), and history of previous MI and diabetes mellitus were independent predictors of cardiovascular death. A history of systemic hypertension or congestive heart failure were independent predictors of nonfatal acute MI, while a history of systemic hypertension, wall motion score index and diabetes mellitus independently predicted combined cardiovascular end-points. CONCLUSIONS: The results of this study confirmed that clinical risk indicators and LV systolic function were the most important independent predictors of cardiovascular death and combined cardiovascular end-points. LV diastolic function assessed by Doppler-echocardiography did not provide additional prognostic information.     

Is the left ventricular filling pattern restrictive in cardiac amyloidosis?

Abstracts

Echo/Doppler assessment of morphologic and functional abnormalities in restrictive and infiltrative cardiomyopathy