Prognostic implications of left ventricular diastolic dysfunction with preserved systolic function following acute myocardial infarction

The contribution of diastolic dysfunction in patients with preserved left ventricular (LV) systolic function to impaired functional status and cardiac mortality in myocardial infarction (MI) is unknown. In the present study, assessment of LV diastolic function was performed by Doppler analysis of the mitral and pulmonary venous flow, and the propagation velocity of early mitral flow by color M-mode Doppler echocardiography in 183 consecutive patients at day 5-7 following their first acute MI. Patients were classified into four groups: group A: preserved LV systolic and diastolic function (n = 73); group B: LV systolic dysfunction with preserved diastolic function (n = 10); group C: LV diastolic dysfunction with preserved systolic function (n = 60); group D: combined LV systolic and diastolic dysfunction (n = 40). The cardiac mortality rate at 1 year was significantly higher in groups C (13%) and D (38%) compared to A (2%) (p < 0.01). Multivariate regression analysis identified LV diastolic dysfunction (p = 0.001), Killip class >or=II (p = 0.006), and age (0.008) as predictors of cardiac death or readmission due to heart failure. The presence of LV diastolic dysfunction with preserved systolic dysfunction is associated with increased morbidity and mortality following acute MI.     

Left ventricular diastolic dysfunction as an early manifestation of diabetic cardiomyopathy

AIMS/HYPOTHESIS: Early determination of myocardial manifestations of diabetes mellitus is of major importance, since myocardial involvement considerably influences the prognosis of diabetic patients. The aim of this study was to investigate whether young patients with insulin-dependent diabetes mellitus and normal systolic left ventricular (LV) function already show a diastolic LV dysfunction and an increased risk of arrhythmias. METHODS: Echocardiography was performed in 87 patients suffering from type I diabetes mellitus, without known cardiac disease and in 87 controls. Patients with a known manifest cardiac disease or a long-term diabetic syndrome were excluded. Morphological parameters were determined using M-mode echocardiography. Doppler echocardiography was used to evaluate parameters of LV diastolic function. The risk of arrhythmia was assessed by means of electrocardiography, heart rate variability, and late potential analysis. RESULTS: The left atrial and ventricular dimensions and systolic functional parameters of all patients were normal. A diastolic dysfunction with a reduction in early diastolic filling, an increase in atrial filling, an extension of isovolumetric relaxation and deceleration time was documented in diabetic patients, as well as an increased number of supraventricular and ventricular premature beats. CONCLUSION: Even young patients with diabetes mellitus suffer from a diastolic dysfunction while systolic ventricular function is normal. Therefore, echocardiography with measurements of diastolic functional parameters appears to be a sensitive method for evaluating the manifestation and course of early diabetic cardiomyopathy.     

Left ventricular diastolic and systolic function during isometric exercise: an echocardiographic study

Normal subjects of both sexes between 20 and 63 years were examined with M-mode echocardiography. Blood pressure (BP), heart rate (HR), and left ventricular (LV) diastolic and systolic function were measured at rest and at the end of a standardized maximal isometric handgrip test. BP and HR increased about 25%. This increase in cardiac work had no significant influence on LV systolic function. Diastolic function (myocardial relaxation and maximum rate of LV filling), however, improved significantly. Isometric handgrip test is a suitable exercise test in combination with M-mode echocardiography. Studies on LV function during exercise may improve the sensitivity for detection of mild LV dysfunction.     

Maximal longitudinal contraction velocity in assessment of left ventricular systolic function: a pulsed tissue Doppler and M-mode study

AIMS: During recent years the maximal longitudinal contraction velocity (MLCV), measured by either pulsed tissue Doppler or M-mode, has been suggested as an index of left ventricular (LV) systolic function. The aims of the present study were to compare MLCV with ejection fraction (EF) in consecutive patients with known or suspected heart failure and to compare measures from recordings by pulsed tissue Doppler with recordings by M-mode. METHODS AND RESULTS: Sixty-four consecutive patients with suspected or known heart failure, referred to echocardiography, were included. Twelve of these patients had decreased LV systolic function defined as EF < 50% calculated by the biplane Simpson's rule, while a significantly (P > 0.05) higher proportion of 23 had decreased function defined as decreased MLCV recorded by pulsed tissue Doppler. Measures from M-mode recordings were significantly lower (P < 0.001) than the corresponding measures from tissue Doppler recordings. CONCLUSIONS: The study shows that higher values of MLCV are obtained by pulsed tissue Doppler than by M-mode. Reference values can therefore not be used interchangeably. The results also suggest that MLCV is a more sensitive index of LV systolic function than EF.     

Changing perspectives in the echocardiographic approach of hypertensive heart disease

IntroductionJoint Guidelines of the European Society of Hypertension and European Society of Cardiology recommend the use of echo in arterial hypertension only when a more sensitive detection of left ventricular (LV) hypertrophy (LVH) than that provided by ECG is considered useful. This occurs in the presence of a high global cardiovascular risk. The assessment of LV diastolic and systolic function has not considered able to add prognostic information to LV mass.ObjectivesThe present review aims at the need of making more comprehensive the evaluation of the hypertensive heart The progression of hypertensive heart towards heart failure includes, in fact, alterations LV diastolic properties which are globally defined as diastolic dysfunction. The independent prognostic value of E/e’ ratio recently demonstrated in the hypertensive setting should encourage an assessment which combines standard Doppler mitral inflow with pulsed Tissue Doppler of mitral annulus and, possibly, left atrial volume index. The potential advantages of novel ultrasound imaging are evident. The predominant importance of longitudinal strain derived by Speckle Tracking Echocardiography is demonstrated in hypertensive patients and could be used to identify subclinical LV systolic dysfunction. The assessment of LV longitudinal systolic function by pulsed Tissue Doppler may be however considered more than an alternative. The quantitation of LV mass by real-time three-dimensional echocardiography appears very attractive because it is feasible, rapid in both acquisition and reading procedures and accurate in comparison with cardiac magnetic resonance but its use is limited by its high costs.ConclusionsAn exhaustive study of the hypertensive heart should include not only the estimation of LV mass and geometry but also the non invasive assessment of LV filling pressure and, possibly, of longitudinal systolic function.     

Noninvasive assessment of left ventricular diastolic function: comparative analysis of pulsed Doppler ultrasound and digitized M-mode echocardiography

The relation between Doppler and digitized M-mode echocardiographic indexes of left ventricular (LV) diastolic function was analyzed. Diastolic variables obtained with these 2 techniques were compared in 19 normal volunteers and in 25 patients with a variety of cardiac diseases. The 2 techniques were in agreement in distinguishing normal from abnormal diastolic function in 20 of the 25 patients (80%) with cardiac disease. Furthermore, a close linear relation with a high correlation coefficient and a small standard error of the estimate was identified between measurements of isovolumic relaxation determined by Doppler and by M-mode echocardiography (r = 0.82, standard error of the estimate = 18 ms). Doppler indexes of diastolic filling such as the slope (descent) and the duration of the early diastolic flow-velocity peak did not show a close correlation with the peak rate and the time to peak rate of increase in LV internal dimension determined by digitized echocardiography. Thus, Doppler and digitized echocardiography were consistent in distinguishing normal from abnormal diastolic function in most of the study patients, although specific variables of LV ventricular filling determined by the 2 techniques were not closely related. In addition, Doppler and M-mode echocardiographic measurements of isovolumic relaxation showed an excellent correlation.     

Instantaneous assessment of left ventricular midwall mechanics with tissue Doppler tracking technique

BACKGROUND: Left ventricular (LV) systolic function is better characterized by midwall mechanics in patients with LV hypertrophy than by endocardial LV function, and the midwall mechanics is an independent predictor of prognosis. However, a complex calculation is currently required to assess it, and it is not routinely assessable in clinical practice. Tissue Doppler imaging enables tracking of a point within the LV wall though a cardiac cycle; we tested our hypothesis that the tissue Doppler tracking technique provides an instantaneous and reliable evaluation of midwall mechanics. METHODS: LV M-mode echocardiogram was recorded in 18 subjects with conventional echocardiography and with tissue Doppler imaging. The midwall shortening was calculated from the data obtained with conventional echocardiography for the comparison with that measured with the tissue Doppler tracking technique. The tissue Doppler-determined midwall shortening correlated well with conventionally calculated value (r=.84, P<.0001), and their difference was small irrespective of absolute value of the midwall shortening. CONCLUSIONS: The midwall mechanics can be instantaneously and accurately evaluated with the tissue Doppler tracking technique.     

Tissue Doppler imaging in the evaluation of left ventricular diastolic function

PURPOSE OF REVIEW: Describe the rationale behind, and clinical use of, tissue Doppler (TD) imaging in the assessment of left ventricular (LV) diastolic function, with a focus on recent developments. RECENT FINDINGS: Tissue Doppler imaging is a novel echocardiographic technique that directly measures myocardial velocities. Systolic TD measurements assess left and right ventricular myocardial contractile function. Diastolic TD values reflect myocardial relaxation, and in combination with conventional Doppler measurements, ratios (E/Ea) have been developed to estimate LV filling pressures. TD values and derived ratios have been demonstrated to be valuable in the diagnosis of elevated LV filling pressures, clinical congestive heart failure (CHF), and the prognosis of patients with cardiac disease and CHF. New TD indices have now been developed to assess myocardial relaxation and LV filling pressures, and the impact of LV systolic function on the use of TD imaging has recently been described. TD echocardiography is being used in an ever-widening group of patients for the assessment of LV diastolic function, and its correlation to, and comparison with, B-type natriuretic peptide is an active area of current investigation. SUMMARY: This review focuses on new developments in the clinical use of TD echocardiography in the evaluation of left ventricular diastolic function.     

Modern evaluation of left ventricular diastolic function using Doppler echocardiography

The evaluation of left ventricular (LV) diastolic function is an essential component of the echocardiographic examination for dyspneic patients with impaired or preserved LV systolic function. Doppler echocardiography in combination with two-dimensional echocardiographic findings can assist the diagnosis of underlying cardiac dysfunction, give an estimate of LV filling pressures, guide heart failure treatment, and provide important prognostic information. This article reviews the essentials of modern Doppler assessment of diastolic function and highlights recent updates, areas of controversy, and future applications.     

Relative merits of M-mode echocardiography and tissue Doppler imaging for prediction of response to cardiac resynchronization therapy in patients with heart failure secondary to ischemic or idiopathic dilated cardiomyopathy

M-mode echocardiography (using the septal-to-posterior wall motion delay [SPWMD]) and color-coded tissue Doppler imaging (TDI; using the septal-to-lateral delay in peak systolic velocity) have been proposed for assessment of left ventricular (LV) dyssynchrony and prediction of response to cardiac resynchronization therapy (CRT). In this study, a head-to-head comparison between M-mode echocardiography and color-coded TDI was performed for assessment of LV dyssynchrony and prediction of response to CRT. Consecutive (n = 98) patients with severe heart failure (New York Heart Association class III/IV), LV ejection fraction < or =35%, and QRS duration >120 ms underwent CRT. Before pacemaker implantation, LV dyssynchrony was assessed by M-mode echocardiography (SPWMD) and color-coded TDI (septal-to-lateral delay). At baseline and 6 months after implantation, clinical and echocardiographic parameters were evaluated. SPWMD measurement was not feasible in 41% of patients due to akinesia of the septal and/or posterior walls or poor acoustic windows. Conversely, the septal-to-lateral delay could be assessed in 96% of patients. At 6-month follow-up, 75 patients (77%) were classified as responders to CRT (improvement > or =1 New York Heart Association class). The sensitivity and specificity of SPWMD were lower compared with those of septal-to-lateral delay (66% vs 90%, p <0.05; 50% vs 82%, p = NS, respectively). In conclusion, LV dyssynchrony assessment was feasible in 59% of patients with M-mode echocardiography compared with 96% (p <0.05) when color-coded TDI was used. Color-coded TDI was superior to M-mode echocardiography for prediction of response to CRT.     

Effect of preload reduction by hemodialysis on conventional and novel echocardiographic parameters of left ventricular structure and function

BACKGROUND: Available studies of the effect of hemodialysis (HD) on left ventricular (LV) performance brought ambiguous results. Therefore we aimed to investigate the effect of acute preload reduction induced by HD on conventional and novel parameters of LV structure and function. METHODS: Thirty-six patients underwent echocardiography 1 hour prior to and 1 hour following regular HD. M-mode, two-dimensional, and Doppler echocardiography were used to analyze conventional LV structural and functional parameters. Systolic and diastolic mitral annular velocities assessed by pulsed-wave tissue Doppler echocardiography (PW-TDE) and flow propagation velocity (Vp) of early LV inflow were measured as novel indices of LV systolic and diastolic function. RESULTS: After HD, all heart chambers including LV significantly reduced in their size. The reduction in LV mass was also observed. Parameters of LV systolic function-ejection fraction and systolic mitral annular velocity, significantly improved, whereas fractional shortening did not. As for LV diastolic function, conventional Doppler parameters and Vp were substantially changed after HD. Conversely, PW-TDE diastolic velocities were not significantly affected. CONCLUSIONS: The fluid removal induced by HD leads to a substantial decrease in LV size and mass. The improvement of LV longitudinal contraction documented by PW-TDE seems to be responsible for the increase in global LV systolic function after HD. While standard Doppler parameters of LV diastolic function and Vp are significantly affected by preload reduction, PW-TDE diastolic indices appears to be less load dependent. Therefore, PW-TDE represents a promising method for the LV diastolic function assessment in patients on HD.     

Doppler echocardiographic measurement of low velocity motion of the left ventricular posterior wall

A new noninvasive method using pulsed Doppler echocardiography was developed to assess left ventricular (LV) posterior wall motion dynamics. Seventeen normal subjects and 23 patients undergoing cardiac catheterization were prospectively studied. The sample volume was placed within the LV posterior wall endocardium just apical to the mitral valve sulcus using a posteriorly angulated low parasternal view. The wall filter was set at 100 Hz to record the low velocities of the LV posterior wall motion. The Doppler signal was morphologically similar to the rate of change of the LV posterior wall endocardium excursion obtained by a digitized M-mode echocardiogram, and showed 3 major waves: a systolic wave (S), an early diastolic wave (E) and a late diastolic wave (A). The peak velocities of LV posterior wall endocardium excursion were also determined by M-mode echocardiographic technique. We found a significant linear correlation between peak E-wave velocity and M-mode peak diastolic endocardial velocity (r = 0.90, p less than 0.001) and between peak S-wave velocity and M-mode peak systolic endocardial velocity (r = 0.81, p less than 0.001). M-mode peak systolic endocardial velocity showed an important overlap between control subjects and patients with normal and patients with abnormal LV posterior wall motion on the angiogram. In contrast, peak S-wave velocity was a better discriminator, and a peak S-wave velocity less than 7.5 cm/s was associated with abnormal LV posterior wall motion with an 83% sensitivity, 100% specificity and 95% accuracy. In patients with coronary artery disease but normal systolic LV posterior wall motion and normal global systolic LV function, peak S-wave velocity was not different when compared to control subjects. Peak E-wave velocity and E/A were significantly lower than in control subjects (p less than 0.01) and peak A-wave velocity was greater (p less than 0.01). In conclusion, these data suggest that pulsed Doppler echocardiography can be used for the direct analysis of LV posterior wall instantaneous low velocities and appears to be more informative than M-mode technique for systolic measurements. Thus, detection of abnormal LV posterior wall diastolic motion by pulsed Doppler echocardiography may, upon additional confirmation, be used as a new noninvasive method to gain insight into global LV diastolic performance.     

Echocardiographic findings in nine patients with cardiac amyloidosis: their correlation with necropsy findings

The echocardiographic abnormalities of nine patients with cardiac amyloidosis were correlated with their postmortem findings. All had congestive heart failure and autopsy-proven amyloidosis. M-mode echocardiographic features included (1) small or normal left ventricular (LV) dimensions; (2) thickened interventricular septa and posterior LV walls (89%); (3) left atrial enlargement (89%); and (4) reduced LV distensibility (78%, 100%) and contractility (22%, 44%). Serial M-mode echocardiography revealed that cardiac amyloidosis was initially manifested as diastolic LV dysfunction rather than systolic dysfunction. The final stage of this disease was characterized by severe impairment of both systolic and diastolic LV functions. Two-dimensional echocardiography provided additional features: (1) a more accurate diagnosis of pericardial effusion (67%) and (2) a characteristic "granular sparkling" appearance of the ventricular wall (55%). In four of five cases, these hyperrefractile myocardial echoes corresponded to scattered amyloid deposits histopathologically. There was no correlation between the types of amyloid deposits and the hyperrefractile myocardial echoes. Thus, cardiac involvement in systemic amyloidosis could be non-invasively assessed by M-mode and two-dimensional echocardiography.     

Ventricular structure and function in children with sickle cell disease using conventional and tissue Doppler echocardiography

Conventional 2-dimensional, M-mode, and spectral Doppler echocardiographic techniques have documented abnormal ventricular function in adults with sickle cell disease (SCD), but assessments in children are conflicting. Tissue Doppler echocardiography (TDE) provides additional information about myocardial function. Two-dimensional, M-mode, tricuspid regurgitation jet velocity (TRJV) data, and tissue Doppler echocardiographically derived myocardial velocity measurements of left ventricular (LV) and right ventricular function were taken from children with SCD compared to those of similar healthy historical controls and correlated with clinical characteristics and hemoglobin levels. Compared to 55 controls, 54 children with SCD (mean age 14.2 years, range 6 to 21) had a larger left ventricle, greater LV mass, and higher LV fractional shortening; 30% had increased pulmonary artery pressure (TRJV ≥2.5 m/s). Conventional echocardiographic measurements of LV systolic function and spectral Doppler measurements of LV and right ventricular diastolic function were essentially normal, but TDE indicated that 31% of SCD children had evidence of LV diastolic dysfunction (peak early diastolic velocity of LV inflow Doppler/peak early diastolic velocity at lateral mitral valve annulus >8), a finding that correlated with lower hemoglobin levels. Although decreasing hemoglobin levels in children with SCD correlated with LV hypertrophy, LV dilation, and LV diastolic dysfunction, long-term transfusion or hydroxyurea therapy did not affect these measurements. In conclusion, 1/3 of children with SCD had tissue Doppler echocardiographic evidence of LV diastolic dysfunction, which was correlated with hemoglobin levels. Adding serial assessments of ventricular function with TDE to conventional echocardiography may detect early cardiac changes, especially in children with severe anemia.     

Impaired diastolic function in active rheumatoid arthritis. Relationship with disease duration.

OBJECTIVE: Using digitized M-mode and Doppler echocardiography, we evaluated left ventricular (LV) function in 54 patients (43 women and 11 men; mean age 50 years) suffering from active rheumatoid arthritis (RA) without obvious cardiovascular disease, and compared them with 54 age- and sex-matched normal subjects. RESULTS: No differences were found in LV end-diastolic diameter, systolic function and parietal thickness between the patients and controls. However, a significant reduction in various indexes of LV diastolic function was found, including E/A (ratio of early to late filling waves of mitral inflow Doppler) and the peak lengthening rate of the LV diameter (an index of LV relaxation evaluated by M-mode echocardiography). The former was correlated with patient age and was independent of disease duration, while the latter was more markedly correlated with disease duration than with patient age. CONCLUSION: The relationship between diastolic impairment and disease duration in active RA may open new perspectives in the study of RA-associated cardiovascular disease.     

Iodine-123 Metaiodobenzylguanidine Scintigraphic Assessment of Myocardial Sympathetic Innervation in Patients With Familial Amyloid Polyneuropathy

Objectives. This study attempted to assess myocardial sympathetic innervation using iodine-123 (I-123) metaiodobenzylguanidine (MIBG) imaging in patients with familial amyloid polyneuropathy.Background. Signs and symptoms of cardiac autonomic dysfunction are commonly seen in patients with cardiac amyloidosis. However, the incidence and magnitude of abnormalities in myocardial sympathetic nerve function by means of I-123 MIBG imaging and their relation to clinical findings, cardiac function and the results of thallium-201 (Tl-201) and technetium-99m pyrophosphate (Tc-99m PYP) myocardial scanning have not yet been clarified.Methods. We performed M-mode, two-dimensional and Doppler echocardiography and I-123 MIBG, Tl-201 and Tc-99m PYP imaging of the heart in 12 patients with familial amyloid polyneuropathy and biopsy-proved cardiac amyloidosis.Results. Ten of 12 patients had no clinical evidence of overt heart disease, but left ventricular (LV) wall thickening was observed in 4 of these 10. Left ventricular percent fractional shortening and Doppler transmitral flow velocity patterns were found to be normal in all 12 patients. Eight of 12 patients showed no myocardial MIBG accumulation, with limited uptake in the remaining 4 demonstrated only in the LV anterior wall. Diffuse but mild myocardial uptake of Tc-99m PYP occurred in only 4 of 12 patients, and all 12 had normal results on Tl-201 myocardial scanning. Complete defects on myocardial MIBG scans were found in five of eight patients with negative findings on Tc-99m PYP myocardial scanning. The incidence and magnitude of myocardial uptake of MIBG were independent of clinical findings, extent of endomyocardial amyloid deposition, electrocardiographic QRS voltage and ventricular wall thickness.Conclusions. Patients with familial amyloid polyneuropathy show a high incidence of myocardial adrenergic denervation with viable myocardium that can be identified very early in cardiac amyloidosis, before the development of clinically apparent heart disease, ventricular wall thickening, significant LV systolic and diastolic dysfunction and positive findings on Tc-99m PYP myocardial scanning.(J Am Coll Cardiol 1997;29:168–74)>     

Assessment of diastolic function in normal and hypertrophied hearts: comparison of Doppler echocardiography and M-mode echocardiography

Left ventricular (LV) filling was examined by Doppler and M-mode echocardiography in 24 patients with LV hypertrophy (five with aortic stenosis, six with hypertrophic cardiomyopathy, and 13 with LV hypertrophy secondary to systemic hypertension) and in 18 normal subjects. Patients with LV hypertrophy had significantly lower Doppler-determined peak filling rates (218 +/- 17 vs 288 +/- 66 cc/sec, p less than 0.01), but M-mode determined peak rate of chamber enlargement and normalized peak rate of chamber enlargement did not differ significantly between groups. Doppler measures of the ratio between early and late filling were significantly depressed in patients with LV hypertrophy and correlated inversely with age in the normal subjects. The M-mode derived normalized peak rate of chamber enlargement and the Doppler-derived normalized peak filling rate correlated weakly, but significantly, when both groups were combined (r = 0.56, p less than 0.01). Thus Doppler measurements can detect abnormalities of LV filling in patients with LV hypertrophy. These abnormalities are present when M-mode filling indices and systolic function are still normal.     

Noninvasive assessment of cardiopulmonary function in critically ill infants and children

Echocardiography and Doppler echocardiography allow for the accurate noninvasive assessment of cardiac structure and function. Two-dimensional echocardiography accurately demonstrates both normal and abnormal intracardiac and great vessel anatomy and assists in differentiating cardiac from noncardiac causes of respiratory distress. M-mode echocardiography allows for documentation of cardiac chamber size and left ventricular function. Doppler echocardiography is used to measure cardiac output, assess AV and semilunar valve function, detect abnormal flow patterns within the heart and great vessels, and assist in the assessment of pulmonary artery pressures. This article discusses the uses of all these modalities as they apply to the critically ill infant and child.     

Echocardiography in cardiac resynchronization therapy

Cardiac resynchronization therapy (CRT) is a new treatment modality for eligible patients with congestive heart failure (CHF). The premise of CRT is that it decreases inter and intra ventricular inhomogeneity during systolic contraction thereby improving efficiency of cardiac pump function. Presence of cardiac dyssynchrony appears to be a prerequisite for a response to CRT. Traditionally this inhomogeneity in contraction has been determined by electrocardiographic QRS widening. More recently several echocardiographic methods of assessment of dyssynchrony have become available. These methods utilize conventional M-mode and pulsed wave (PW) Doppler as well tissue Doppler imaging (TDI) METHODS: These echocardiographic parameters have been shown to be more important predictors of response to CRT than conventional QRS widening. This article will discuss echocardiographic methods of assessment of dyssynchrony and their role in predicting response to CRT. In addition role of echocardiography in post CRT pacemaker programming will also be discussed.     

Relation between left ventricular mass indexes and cardiac function in hypertensive patients: an approach with Doppler echocardiography]

73 age-matched hypertensive patients, 46 men and 27 women, were divided into the four groups according to left ventricular mass indexes (LVMI) and normal control groups were established correspondingly. Doppler and M-mode echocardiography were used to assess the systolic and diastolic functions of left ventricle (LV) and the alterations of heart construction. It was shown that when the LVMI increased slightly, the internal dimension and systolic function of LV had no significant change, but the diastolic function became abnormal and the left atrium enlarged. When the LVMI increased significantly, both the left atrium and left ventricle enlarged and the systolic and diastolic functions of LV were impaired. It is concluded that increase of LV mass may be present in the early stage of hypertension and left atrial enlargement is an early sign of left ventricular diastolic dysfunction, which occurs before systolic dysfunction in the patients with essential hypertension.