Left Ventricular Mass-to-Strain Ratio to Predict Change in Left Ventricular Hypertrophy and Prognosis in Hypertensive Heart Disease.

Evidence on systolic dysfunction, as assessed by left ventricular (LV) mechanics, in hypertensive heart disease phenotyped by abnormal LV geometric patterns is still limited. Thus, we performed a systematic meta-analysis of 2D/3D speckle-tracking studies in order to provide an updated comprehensive information on this topic. The PubMed, OVID-MEDLINE, and Cochrane library databases were analyzed to search for articles published from the inception up to 31 January 2021. Studies were identified by using MeSH terms and crossing the following search items: 'myocardial strain', 'left ventricular mechanics', 'speckle tracking echocardiography', 'systolic dysfunction', 'hypertensive heart disease', 'left ventricular hypertrophy', left ventricular remodeling", 'concentric hypertrophy', 'eccentric hypertrophy'. Overall, data of 267 normotensive controls and 712 hypertensive patients (234 normal geometry, 97 LV concentric remodeling, 176 eccentric LVH, and 205 concentric LVH) from eight studies were considered. Pooled ejection fraction was similar in normotensives and in the whole group of hypertensive patients: (SMD 0.037 ± 0.05, confidence interval (CI): 0.14/0.07, P = 0.51) as well as in hypertensive subgroups. LVMI, and E/e' gradually increased from hypertensive patients with normal geometry and concentric remodeling, to patients with eccentric and concentric LVH. LV global longitudinal strain (GLS) was lower in all hypertensive groups compared with normotensive controls, in particular, in the eccentric (SMD 1.14 ± 0.22, CI: 0.69/1.59, P < 0.0001) and concentric LVH group (SMD 1.37 ± 0.21, CI: 0.95/1.79, P < 0.0001). The meta-analysis restricted to hypertensive patients showed that GLS gradually deteriorated from hypertensive patients with normal LV geometry, across those with concentric remodeling, to participants with eccentric and concentric LVH (-19.5 ± 0.6 versus -18.8 ± 0.73 versus -17.6 ± 0.66 versus -16.5 ± 0.6%, P < 0.001 for trend). Statistical significance was reached when GLS of the concentric and eccentric LVH group but not the concentric remodeling was compared with the normal geometry one. The present meta-analysis confirms that GLS performs better than ejection fraction in identifying systolic dysfunction in the hypertension setting. More importantly, it suggests that this occurs in patients with altered LV structure and geometry, such as LVH.

Left ventricular (LV) hypertrophy (LVH), detected either by electrocardiography (ECG) or echocardiography (ECHO), has long been recognized as a powerful predictor of serious cardiovascular (CV) sequelae. A very large and highly consistent body of evidence indicates that LVH is not only an adaptation to increased hemodynamic load in hypertension, but is also independently associated with an enhanced risk for myocardial infarction, cardiac sudden death, congestive heart failure, and stroke in the general population, as well as in patients with systemic hypertension, coronary heart disease, chronic kidney disease, and atrial fibrillation. Intriguingly, the cumulative incidence of cardiovascular events increases progressively with increasing LV mass (LVM), without evidence of any threshold separating the postulated “compensatory” from “pathological” LVH. In other words, patients with LVM in the upper-normal range already have increased risk for CV events. Moreover, various studies suggest that LVH reversal is beneficial beyond blood pressure (BP) reduction and treatment by demonstrating that CV events occur in a higher proportion of individuals in whom LVH progresses rather than regresses. There are several determinants for the development of LVH. Hemodynamic factors such as BP, large artery structure and stiffness, and volume load are important. In addition, nonhemodynamic mechanisms such as trophic factors mediated by the sympathetic nervous system, the renin-angiotensin-aldosterone system, and other neurohormonal mediators play an important role in the development of LVH. ECHO is more sensitive than ECG in diagnosing LVH and may help in the more precise stratification of overall risk and in the determination of therapy for hypertensive patients. Furthermore, ECHO measurement of LV cavity size and of myocardial relative wall thickness allows the assessment of LV geometry. The traditional classification of LV geometry in hypertensive heart disease comprised the condition of normal LVM and geometry and three abnormal LV geometric patterns: concentric LV remodeling, eccentric LVH, and concentric LVH. These LV geometric patterns have been associated with different demographic and clinical characteristics including age, sex, metabolic factors, BP levels, LV systolic and diastolic function, hemodynamic profile, extracardiac target organ damage, and CV morbidity and mortality. In particular, it has been reported that concentric LVH, connoting severe pressure overload, is associated with worse outcome than eccentric LVH or concentric remodeling. However, whether abnormal LV geometric patterns carry prognostic information beyond that provided by LV mass remains uncertain. More recently, the investigators of the Dallas Heart Study (DHS) refined this classification of hypertensive LV geometric abnormalities by introducing the concept that LVH could exist in dilated or nondilated forms, adding concentric dilated and nondilated as well as eccentric dilated and nondilated subtypes. The authors of the DHS suggested that eccentric LVH with no dilatation appeared to provide a lower risk for coronary artery disease and myocardial function impairment than in the remaining three groups of cardiac hypertrophy. However, this cross-sectional study did not present results on outcome, and the subsequent prospective investigations yielded conflicting results regarding the prognostic role of these new subtypes of LV geometric abnormalities. Nevertheless, the correct indication for ECHO in hypertensive patients is still a matter of debate. Indeed, advocating ECHO for the assessment of LVH in all hypertensive individuals would have enormous cost implications, as a result of the high number of patients. This imaging modality is more time-consuming than ECG and requires considerable skill to perform. Even though more accurate and sophisticated modalities to diagnose LVH exist, such as ECHO, computerized tomography, magnetic resonance, and, more recently, three-dimensional ECHO, ECG remains the first-choice technique to diagnose LVH in patients with hypertension because it is widely available, easy to perform, specific, inexpensive, reproducible, and of established prognostic value. ECG can also be used to detect patterns of ventricular overload or “strain” (known to indicate more severe risk), ischemia, conduction defects, and arrhythmias. Current guidelines for the management of hypertension strongly recommend ECG as the only examination to be performed in all hypertensive patients for detection of LVH. Even if ECG assessment of LVH has been incorporated among standard tests in hypertension guidelines, a recent Italian survey showed that such a recommendation is largely ignored in current clinical practice. Indeed, in this survey, <40% of the study sample had Address for correspondence: Giuseppe Mul e’, MD, Via Monte San Calogero, 29 90146 Palermo, Italy E-mail: giuseppe.mule@unipa.it

BACKGROUNDWe aimed to investigate left ventricular (LV) global longitudinal strain (GLS) in end-stage renal disease patients and its change after kidney transplantation (KT).METHODSWe retrospectively reviewed patients who underwent KT between 2007 and 2018 at two tertiary centers. We analyzed 488 patients (median age, 53 years; 58% male) who had obtained echocardiography both before and within 3 years after KT. Conventional echocardiography and LV GLS assessed by two-dimensional speckle-tracking echocardiography were comprehensively analyzed. Patients were classified into three groups according to the absolute value of pre-KT LV GLS (|LV GLS|). We compared longitudinal changes of cardiac structure and function according to pre-KT |LV GLS|.RESULTSCorrelation between pre-KT LV EF and |LV GLS| were statistically significant, but the constant was not high (r = 0.292, p < 0.001). |LV GLS| was widely distributed at corresponding LV EF, especially when the LV EF was > 50%. Patients with severely impaired pre-KT |LV GLS| had significantly larger LV dimension, LV mass index, left atrial volume index, and E/e’ and lower LV EF, compared to mildly and moderately reduced pre-KT |LV GLS|. After KT, the LV EF, LV mass index, and |LV GLS| were significantly improved in three groups. Patients with severely impaired pre-KT |LV GLS| showed the most prominent improvement of LV EF and |LV GLS| after KT, compared to other groups.CONCLUSIONSImprovements in LV structure and function after KT were observed in patients throughout the full spectrum of pre-KT |LV GLS|.

Cardiac remodelling patterns and proteomics: the keys to move beyond ejection fraction in heart failure?

Impact of preprocedural left ventricle hypertrophy and geometrical patterns on mortality following TAVR

BackgroundThis study investigated whether left ventricular (LV) global longitudinal strain (LV-GLS), as an LV function parameter less affected by mitral valve (MV) repair or prosthesis, is associated with clinical outcomes in patients with surgically treated MV disease.MethodsAmong 750 patients who underwent MV surgery, we assessed LV-GLS by speckle tracking echocardiography in 344 patients (148 men, mean age 58 ± 13 years) who showed preserved LV ejection fraction on echocardiography between 6 months and 2 years after MV surgery and who did not undergo aortic valve surgery. The assessed clinical events included admission for worsening of heart failure and cardiac death.ResultsDuring a period of 42.4 ± 26.0 months, 32 (9.3%) patients were hospitalized for worsening heart failure, and 3 (0.8%) died due to cardiac causes. The absolute value of LV-GLS (|LV-GLS|) was significantly lower in patients with clinical events than in those without (12.1 ± 3.1 vs. 15.0 ± 3.2%, p < 0.001) despite comparable LV ejection fraction between groups. |LV-GLS| showed predictive value for clinical events (cut-off 13.9%, area under the curve 0.744, p < 0.001). Patients with |LV-GLS| ≤14.0% had poorer outcomes than those with |LV-GLS| >14.0% (log-rank p < 0.001). Prognosis was worse in patients with |LV-GLS| ≤14.0% and pulmonary hypertension than among those who with |LV-GLS| ≤14.0% without pulmonary hypertension (log rank p < 0.001). In nested Cox proportional hazard regression models, reduced |LV-GLS| was independently associated with the occurrence of clinical events.ConclusionsIn patients with surgically treated MV and preserved LV ejection fraction, assessment of LV-GLS provides functional information associated with cardiovascular outcomes.

Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): University Hospital Center of Tlemcen Introduction Hypertension is a well-established risk factor for cardiovascular disease. It causes left ventricular (LV) pressure overload, and, changes in cardiac geometry and LV hypertrophy(LVH). LVH as well as patterns of abnormal geometry have been associated with adverse outcomes. Global longitudinal strain (GLS) has been used to detect early subclinical myocardial dysfunction in a broad spectrum of cardiac conditions and thereby provides a novel approach for LV risk assessment in patients with hypertension. Purpose This study is intended to assess the clinical and echocardiographic factors associated with and predictive for early impairment of left ventricular function as assessed using GLS evaluation in hypertensive patients. Methods Cross-sectional descriptive study, with a total number of 130 hypertensive and with the objective of evaluating the study of longitudinal function by 2D strain in patients with systemic hypertension with preserved LVEF and the determination of predictors the decrease GLS in this population. A complete study echo cardiographic, including LVEF biplane Simpson method, calculation of left ventricular mass indexed and relative parietal thickness to differentiate the eccentric and concentric LVH, analysis diastolic function and finally the study of longitudinal strain of the LV by the speckle tracking technique (calculation of GLS) to seek a possible decline in the GLS and establish a possible correlation between this drop and power and LVH the diagnosis of subclinical hypertensive heart disease. Results The prevalence of left ventricular hypertrophy (LVH) was found in (66%) in this population. half of the patients (49%) presented a concentric hypertrophy, It was clearly noted that 73%of the patients had a relative wall thickness (RWT)&amp;gt;0.42. Alterations in diastolic function were detected in 89% of the group, 18% had severe diastolic dysfunction with elevation in filling pressure. Analysis of the longitudinal systolic function of the left ventricle took the average GLS as a reference value. The mean GLS was found to be -16.9 ± 3.2%, within a range between -25% and-11.6%. Low GLS values (&amp;gt;-17%) were found in 45.5% of the general population. In particular, 34.4% of the patients had no left ventricular hypertrophy (LVH) and 50.7% of them presented LVH. The average systolic and diastolic blood pressures, taken at the time of echocardiographic analysis, were found higher in the subgroup of hypertensive patients with low GLS. Very low GLS values (&amp;gt;-13%) were found in 11% of the general population. Statistical analysis revealed significant correlation between the decrease in GLS and diabetes the values of blood pressure and elevated filling pressures. Conclusion The evaluation of longitudinal systolic function provides new insight of myocardial function in hypertension that could improve the pathophysiological understanding and identify high-risk heart failure patients eligible for preventive strategies.

Left ventricular (LV) hypertrophy (LVH) may be eccentric or concentric (2 × LV posterior wall thickness relative to LV end-diastolic dimension ≤ 0.42 or > 0.42, respectively). The LV diastolic function between age-matched hypertensive patients with eccentric and concentric LVH was compared in the present study. Echocardiography was used to measure LV mass index (LV mass/body surface area; LVMI) as an index of LVH. LV diastolic function was assessed by measurements of peak early transmitral flow velocity (E)/peak late transmitral flow velocity (A) (the E/A ratio), peak early diastolic mitral annular velocity (e') and the E/e' ratio. Although LVMI, E/A and e' did not differ between the two groups, E/e' was significantly higher (worse) in patients with concentric LVH (13.4 ± 5.4) than in those with eccentric LVH (11.1 ± 3.6). Among hypertensive patients with LVH, those with concentric LVH may, therefore, have more severe LV diastolic dysfunction than those with eccentric LVH even if their LVMIs, which reflect the degree of LVH, are similar.

Usefulness of Stress Echocardiography for Risk Stratification and Prognosis of Patients With Left Ventricular Hypertrophy

Do diurnal changes in blood pressure affect myocardial work indices?

Left ventricular longitudinal strain in professional athletes, a useful tool to detect an athletes hearts?

The main objective of this study was to determine whether myocardial strain and myocardial work are altered in hypertension and whether the strain is independent of hypertension-induced left ventricular hypertrophy. Two systematic literature searches were conducted using Medline and EMBASE through to June 30, 2022. In the first, search terms left ventricular strain or speckle tracking AND hypertension and left ventricular hypertrophy were used in conjunction with Boolean operators to identify articles reporting left ventricular strain in patients with hypertension. In the second, the terms Global cardiac or myocardial work AND hypertension were used to identify articles. Publication bias was assessed by examination of funnel plots and calculation of the Failsafe N and Duval and Tweedie's Trim and fill. The results were presented as Forrest plots. Global longitudinal strain (GLS) was significantly lower in patients with hypertension compared to those without hypertension with a mean difference of 2.0 0.1 (standard error of mean(SEM)) in the fixed effect model. Global circumferential strain (GCS) was significantly lower in hypertension. The mean difference between the hypertensive and non-hypertensive groups was 1.37 0.17. Global radial strain (GRS) was significantly (p 0.05) greater in hypertension. However, this difference was significant in only 3 and of borderline significance in 3 of 14 studies where GRS was measured. The mean difference between the hypertensive and non-hypertensive groups was 1.5 0.5 using the fixed effects model. There was a significant relationship between GLS and GCS as well as between GCS and GRS but no significant relationship between GLS and GRS. There was no significant difference in left ventricular ejection fraction (LVEF) between the hypertension and no hypertension groups. There was no significant relationship between LVEF and either GLS or GCS but a significant negative correlation was found between LVEF and GRS. GLS was further reduced in persons with hypertension and left ventricular hypertrophy (LVH) compared to hypertension without LVH. In contrast, there were no or minimal differences in GCS and GRS for individuals with hypertension and LVH compared to those without LVH. Global myocardial work index (GWI) and Global constructive work (GCW) were significantly greater in patients with hypertension compared to controls. Global wasted work (GWW) indicated significantly less wasted work in controls compared to hypertension. In contrast, Global work efficiency (GWE) was significantly lower in hypertension compared to the control. There was a significant reduction in GLS and GCS in hypertension while GRS was increased. The reduction in GLS in hypertension was not dependent on the presence of LVH. GLS was further reduced in persons with hypertension when LVH was present. In contrast, there were no or minimal differences in GCS and GRS for individuals with LVH compared to those without LVH. GLS was independent of left ventricle (LV) ejection fraction. GWI, GCW and GWW were greater in hypertension while GWE was lower in hypertension compared to controls. These data support the contention that GLS and indices of global work are early markers of hypertensive heart disease.

Heart valve disease, left ventricular hypertrophy, and heart failure: a lifelong relationship and continuing clinical responsibility.

Background Early detection of risk factors for left ventricular (LV) dysfunction may be useful in patients with high blood pressure (HBP). Methods Patient from an outpatient HBP clinic underwent a two-dimensional Doppler-coupled echocardiography with determination of LV global longitudinal strain (GLS) by speckle-tracking. Results Among 200 patients (mean age 61.7 ± 9.7 years), 155 were overweight, 93 had diabetes, 83 had dyslipidemia, and 109 had uncontrolled HBP. LV hypertrophy (LVH) was found in 136 patients (68%), including concentric ( n = 106) and eccentric ( n = 30) LVH. Diastolic dysfunction patterns were observed in 178 patients (89%), and increased filling pressures were observed in 37 patients (18.5%). GLS ranged from -25% to -11.6% (mean -16.9 ± 3.2%). Low GLS values (>-17%) were found in 91 patients (45.5%), 68 with and 23 without LVH. In univariate analysis, a reduced GLS was associated with HBP lasting for >10 years (odds ratio (OR) = 3.51, 95% confidence interval (CI) 1.73-7.09; p = 0.002), uncontrolled HBP (OR = 3.55, 95% CI 1.96-6.43; p < 0.0001), overweight (OR = 2.01, 95% CI 0.93-4.31; p = 0.0028), diabetes (OR = 2.21, 95% CI 1.25-3.90; p = 0.006), dyslipidemia (OR = 2.16, 95% CI 1.22-3.84; p = 0.008), renal failure (OR = 4.27, 95% CI 1.80-10.10; p = 0.001), an increased Cornell index (OR = 3.70, 95% CI 1.98-6.90; p < 0.0001), concentric LVH (OR = 9.26, 95% CI 2.62-32.73; p = 0.001), remodeling (OR = 8.51, 95% CI 2.18-33.23; p = 0.002), and filling pressures (OR = 7.1, 95% CI 2.9-17.3; p < 0.0001). In multivariable analysis, duration of HBP ( p = 0.038), uncontrolled BP ( p = 0.006), diabetes ( p = 0.023), LVH ( p = 0.001), and increased filling pressures ( p = 0.003) remained associated with GLS decline. Conclusion Early impairment of LV function, detected by a reduced GLS, is associated with long-lasting, uncontrolled HBP, overweight, related metabolic changes, and is more pronounced in patients with LVH.

Hypertensive Cardiomyopathy (HTN-CM) is a structural cardiac disorder generally accompanied by concentric or eccentric Left Ventricular Hypertrophy (LVH) associated with diastolic or/and systolic dysfunction in patients with persistent systemic hypertension. It occurs in the absence of other cardiac diseases capable of causing myocardial hypertrophy or cardiac dysfunction. Long standing arterial hypertension (HTN) leads to structural and functional myocardial abnormalities resulting in myocardial ischemia, fibrosis, and hypertrophy. HTN-CM is predominantly a disease of impaired relaxation rather than impaired contractility, although subtle myocardial systolic abnormalities could be detected recently by Global Longitudinal Systolic Strain (GLS) Speckle Tracking Echocardiography (STE). Importantly, the accompanying LVH is itself a risk factor for mortality and morbidity and is considered an independent predictor for Sudden Cardiac Death (SCD). Therefore, early detection of LVH development in patients with Hypertensive Hypertrophic Cardiomyopathy (HTN-CM) is crucial for optimal treatment. In addition to pathological findings, echocardiography and cardiac magnetic resonance imaging are ideal tools for the diagnosis of HTN-CM and can differentiate it from Hypertrophic Cardiomyopathy (HCM). Timely diagnosis of this condition and utilization of appropriate treatment are required to improve morbidity and mortality in hypertensive patients. This review presents an overview of utilization of multidisciplinary imaging modalities approach for proper diagnosis of HTN-CM and its differentiation from HCM. Relevant article highlighted key points in differentiation of HTN-CM from HCM and the effects of hypertension on cardiac hypertrophy and heart failure development are discussed in clinical case study.