Left Ventricular Cavity Size Research Articles

Cardiac disease in dialysis patients in a Jamaican Hospital: echocardiographic findings that predict mortality

The aim of the study was to assess, by echocardiography, the cardiac abnormalities in a group of patients with chronic renal failure and to determine the cardiovascular predictors of mortality. The study comprised forty-five patients from the Renal Unit, University Hospital of the West Indies, Kingston, Jamaica, and was undertaken between October 1, 1998 and July 31, 2000. All echocardiography was done by a single operator. The parameters assessed were systolic dysfunction, diastolic dysfunction, ejection fraction, regional wall motion abnormalities and valvular disease. Left ventricular cavity size, septal and posterior wall thickness were measured and left ventricular mass calculated. Demographic data were obtained directly from each patient by interview. The patients were mainly of African/mixed-African origin. Their mean age was 43.2 +/- 16.0 years. The average body mass index was 23.7 +/- 6.9. Twenty-eight (60.9%) patients were male and seventeen (39.1%) female. Hypertension, chronic glomerulonephritis and diabetes mellitus were the leading causes of chronic renal failure. Blood pressure was controlled at a mean value of 145/90 mm Hg pre-dialysis and 140/90 mm Hg postdialysis. The mean duration of renal failure was 2.8 years. Echocardiographic M-mode and two dimensional apical, four chamber view measurements indicated that mean left ventricular internal diameter (LVID) diastole was 55.7 +/- 7.9 mm (normal 38-56 mm) and LVID systole was 38.9 +/- 9.8 mm (normal 24-45 mm); the mean thickness of the chamber walls was 10.3 +/- 2.8 mm and 10.6 +/- 2.4 mm for the interventricular septum (normal 6-11 mm) and left ventricular posterior wall (normal 6-11 mm) respectively. Diastolic dysfunction was seen in 15 (34%) patients and systolic dysfunction in 12 (23%) patients who had ejection fractions less than 50%. The mean left ventricular ejection fraction was 56.3% +/- 16% (normal 65-85%), mean stroke volume was 82.9 +/- 27.2 mls (normal 51-96 ml). After 21 months enrolment in the study, Kaplan Meier analysis revealed a two-year mortality of 28.3%. Cox regression analysis indicated that a history of smoking current or past, low haemoglobin level, high aorta flow velocities, severity of mitral regurgitation and a negative association with serum creatinine were independent predictors of mortality. The correction of anaemia and control of other factors that impact negatively on cardiac function in dialysis patients is vital to enhance survival.

Apical Ballooning Syndrome

Case presentation: A 60-year-old woman presented to the emergency department 2 hours after the onset of severe retrosternal chest pain that started soon after she was told that her son had died in a car accident. A 12-lead ECG demonstrated ST-elevation in the precordial leads (Figure 1), and the plasma troponin T level was elevated at 0.07 ng/mL. A diagnosis of acute ST-elevation myocardial infarction was made, and the patient was admitted for emergency coronary angiography, which revealed normal coronary arteries. The left ventriculogram showed severe systolic dysfunction involving the mid and apical segments (Data Supplement Movie I). Figure 1. Twelve-lead ECG demonstrating ST-segment elevation in precordial leads. Physicians have long been aware of the possible association between stress and cardiovascular events. Awareness has increased of a distinct cardiac syndrome that was originally described in the Japanese population and was called Takotsubo cardiomyopathy, named after the octopus-trapping pot with a round bottom and narrow neck that resembles the left ventriculogram during systole in these patients.1,2 Other names used to describe the condition include apical ballooning syndrome (ABS), broken heart syndrome, and stress or ampulla cardiomyopathy. The precise incidence of ABS is unknown, but it may account for 1% to 2% of patients who present with an acute myocardial infarction.3 The majority of patients have a clinical presentation that is indistinguishable from an acute coronary syndrome. Most present with chest pain at rest, although some patients have dyspnea alone as their initial presenting symptom. Rarely, patients present with syncope or an out-of-hospital cardiac arrest.4 ABS appears to occur almost exclusively in postmenopausal women; however, a few cases have been reported in younger women and males.4 The patients are usually hemodynamically stable, but clinical findings of mild-to-moderate congestive heart failure …

Guidelines for the Diagnosis and Management of Hypertrophic Cardiomyopathy

Definition and Prevalence H cardiomyopathy (HCM) is a primary cardiac disorder characterised by hypertrophy, usually of the left ventricle, in the absence of other loading conditions, such as aortic stenosis, hypertension or thyroid disease. Although previously thought of as a rare disorder, recent population-based clinical studies suggest the increases with the Valsalva manoeuvre and is related to dynamic obstruction. There is frequently a fourth heart sound. The echocardiogram is the investigation which most reliably confirms the diagnosis of HCM and which provides detailed information about the distribution and severity of hypertrophy, the left ventricular cavity size, assessment of left ventricular systolic and diastolic function, left ventricular outflow tract obstruction (in

Issue Highlights

HomeCirculationVol. 114, No. 3Issue Highlights Free AccessIn BriefPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessIn BriefPDF/EPUBIssue Highlights Originally published18 Jul 2006https://doi.org/10.1161/circ.114.3.183Circulation. 2006;114:183PLASMA PHOSPHOLIPIDTRANSFATTY ACIDS, FATAL ISCHEMIC HEART DISEASE, AND SUDDEN CARDIAC DEATH IN OLDER ADULTS: THE CARDIOVASCULAR HEALTH STUDY, by Lemaitre et al.Higher dietary consumption of trans fatty acids has been associated with elevated risk of coronary heart disease. Data are limited, however, regarding variation in coronary risk according to the type of trans fatty acid, eg, trans-isomers of oleic acid (trans-18:1) versus trans-isomers of linoleic acid (trans-18:2). In this issue of Circulation, Lemaitre and colleagues conducted a nested case-control study using data from elderly participants in the Cardiovascular Health Study. The investigators compared plasma trans-18:1 and trans-18:2 levels (collected 3 years before occurrence of events) in 214 individuals (cases) with fatal coronary heart disease with plasma levels of these trans fatty acids in 214 matched controls. They report that higher plasma trans-18:2 levels were associated with greater risk of fatal ischemic heart disease and sudden cardiac death in multivariable analyses that adjusted for clinical and lifestyle risk factors including plasma levels of n-3 polyunsaturated fatty acids. In contrast, higher levels of trans-18:1 were associated with lower risk. These observations suggest that different types of trans-isomers in the diet may influence coronary risk differentially. If confirmed, these findings suggest that current efforts at decreasing trans fatty acid intake in foods should take into consideration their trans-18:2 content. See p 209.PREVALENCE, CLINICAL PROFILE, AND SIGNIFICANCE OF LEFT VENTRICULAR REMODELING IN THE END-STAGE PHASE OF HYPERTROPHIC CARDIOMYOPATHY, by Harris et al.A minority of patients with hypertrophic cardiomyopathy (HCM) enter a phase known as “end-stage,” thought to be represented by systolic dysfunction, left ventricular dilation, and thinning of previously hypertrophied walls. In this issue of Circulation, Harris and colleagues provide results of the largest group of end-stage patients reported to date, culled from a large multicenter cohort of over 1200 HCM patients. These data demonstrate a far more diverse pattern of left ventricular (LV) remodeling than has been appreciated—including a significant number of patients who, despite an abnormal ejection fraction, still maintain normal LV cavity size and/or persistently hypertrophied LV walls. Furthermore, the clinical course appears largely unfavorable, with a substantial number of sudden arrhythmic deaths as well as heart failure events or transplantations occurring over a short period following clinical recognition. This study provides broader insight into the prevalence, morphology, and clinical course of this unique subset of HCM patients, with the hope of earlier disease recognition and with implications for aggressive treatment interventions. See p 216.ANGIOTENSIN II TYPE I RECEPTOR BLOCKADE PREVENTS ALCOHOLIC CARDIOMYOPATHY, by Cheng et al.The mechanism responsible for alcoholic cardiomyopathy is not known. Cheng et al caused myocardial dysfunction in dogs by feeding them alcohol once daily accounting for 33% of daily calorie intake. Alcohol caused activation of the renin-angiotensin system (RAS) at virtually all levels, including increased plasma angiotensin, renin activity, myocardial angiotensin-converting-enzyme activity and cardiac myocyte angiotensin II type 1 receptor expression. Alcohol was also associated with abnormalities in myocardial contractility, and at the isolated myocyte level, with reduced shortening, prolonged relaxation, and decreased calcium transient amplitude. Treatment with the angiotensin receptor blocker ibresartan reduced the activation of the RAS and corrected the functional abnormalities at the myocardial and isolated myocyte levels. These observations thus implicate the RAS in the pathophysiology of alcoholic myocardial dysfunction, and suggest a potentially useful therapeutic role for the angiotensin receptor blocker. See p 226.Visit http://circ.ahajournals.org:Clinician UpdateAcute Pulmonary Embolism: Part II: Treatment and Prophylaxis. See p e42.Images in Cardiovascular MedicineHereditary Hemorrhagic Telangiectasia With Pulmonary Arteriovenous Fistulas. See p e48.Iatrogenic Left Ventricle-to-Coronary Venous Fistula. See p e50.Epicardial Radiofrequency Catheter Ablation of Ventricular Tachycardia in the Vicinity of Coronary Arteries Is Facilitated by Fusion of 3-Dimensional Electroanatomical Mapping With Multislice Computed Tomography. See p e51. Download figureDownload PowerPointCorrespondenceSee p e53. Previous Back to top Next FiguresReferencesRelatedDetails July 18, 2006Vol 114, Issue 3 Advertisement Article InformationMetrics https://doi.org/10.1161/circ.114.3.183 Originally publishedJuly 18, 2006 PDF download Advertisement SubjectsHeart Failure

Hypertrophic cardiomyopathy and caesarean section: intraoperative use of transthoracic echocardiography

A pregnant woman with severe hypertrophic cardiomyopathy was monitored with transthoracic echocardiography to guide management of fluids and vasopressors during elective caesarean section. After insertion of intravenous, arterial and central venous cannulae, a transthoracic echocardiogram was performed noting left ventricular cavity size and contractility, systolic anterior motion of the mitral valve and left ventricular outflow tract obstruction. Following combined spinal-epidural anaesthesia, serial examinations were made intraoperatively. Short-lived haemodynamic instability ensued just before the incision and with administration of oxytocin. Her postoperative course was complicated by post-partum haemorrhage requiring radiological intervention but she ultimately recovered fully. Maintaining preload to avoid worsening of left ventricular outflow tract obstruction is essential in these patients. A transthoracic echocardiogram is easily performed, of low risk and provides more useful information than a pulmonary artery catheter.

Effect of Body Mass Index on Left Ventricular Cavity Size and Ejection Fraction

Extreme obesity is known to be associated with left ventricular (LV) systolic dysfunction. The relation of lesser degrees of obesity and LV systolic function is controversial. This study assessed the relation between body mass index (BMI; weight in kilograms divided by height in meters squared) and the LV ejection fraction (EF) and volumes in 1,806 subjects with normal technetium-99m sestamibi myocardial perfusion imaging results. BMI was evaluated as a continuous and a categorical variable (normal >18.5 and <25, overweight > or =25 and <30, obese > or =30 and <35, and severely obese > or =35 kg/m(2)). The prevalence of an EF < or =50% was similar in normal, overweight, obese, and severely obese subjects. On univariate analysis, only severely obese women had mildly reduced LVEFs. LV end-diastolic and end-systolic volumes increased linearly from normal to obese men and women, respectively (each p <0.01). On multiple linear regression analysis (R = 0.5, p <0.001), BMI (p = 0.03) and diabetes (p <0.001) influenced the EF adversely, whereas age and female gender were protective (p <0.001). However, on gender-stratified analysis, diabetes, not BMI, independently predicted the EF in men and women. BMI remained an independent predictor of greater end-diastolic volumes in men and women (p <0.01) even after accounting for co-morbidities. In conclusion, mild obesity was associated with LV dilatation, but the LVEF was preserved even with severe obesity. Weight control may be recommended to reduce the incidence of obesity-related co-morbidities and their impact on adverse LV remodeling.

Effects of angiotensin-converting enzyme inhibition on mitral regurgitation severity, left ventricular size, and functional capacity

Mitral regurgitation (MR) is a progressive disorder that leads to left ventricular (LV) dilatation and dysfunction. Previous small studies have shown conflicting results regarding the benefits of afterload reduction for MR. We assessed by serial echocardiography the effects of ramipril on MR severity and LV size by a number of quantitative methods in 26 asymptomatic patients with moderate to severe MR at baseline and again after 6 months of ramipril treatment. We also evaluated exercise capacity, neurohormonal levels, and the Minnesota Living With Heart Failure score. Despite a significant reduction in blood pressure with ramipril, there was no change in MR severity. MR severity, as assessed by effective regurgitant orifice area, was reduced in individuals with baseline systolic blood pressure (SBP) > or = 140 mm Hg (55.1 +/- 26 vs 37.4 +/- 35.4 mm2, P = .03), but not in individuals with SBP < 140 mm Hg (39.7 +/- 37.7 vs 46.1 +/- 34.1 mm2, P = not significant). Neither LV cavity size, exercise capacity, nor the Minnesota Living With Heart Failure score exhibited a significant change. Patients with MR do not experience significant changes in MR severity, LV size, or functional status after 6 months of treatment with angiotensin-converting enzyme inhibition. However, patients with SBP > or = 140 mm Hg represent a subgroup that shows reduction in MR. These data are consistent with current American College of Cardiology/American Heart Association guidelines, which reserve the use of afterload reduction for MR patients with systemic hypertension or LV dysfunction.

‘Hot spot’–‘cool cath’: Myocardial perfusion scintigraphic findings in coronaro-cameral micro-communications

A 50-year-old gentleman with end-stage alcoholic cirrhosis was referred for cardiac risk stratification prior to orthotropic liver transplantation. He had no significant prior cardiac history. A dobutamine stress test with single photon emission computed tomography–myocardial perfusion imaging (SPECT-MPI) using Technitium 99 was performed. Resting and stress EKG did not show any signs of ischemia. SPECT-MPI revealed a small, nonreversible, mild defect in the inferoseptal and inferior wall, which was thought to be due to sub-diaphragmatic attenuation artifact. However, there was a focal area of significantly increased (‘hot spot’) tracer uptake localized to the mid-ventricular anterolateral segments, mainly on rest images (Fig. 1, arrowheads). The stress images showed essentially normal tracer uptake in the corresponding region. The left ventricular cavity size and wall motion, lung–heart ratio and ejection fraction were normal.

The prognostic significance of horizontal plane QRS axis in elderly heart failure

In order to investigate whether horizontal plane QRS axis predicts the prognosis in elderly heart failure, we studied 80 consecutive patients by clinical assessment, ECG, Doppler and echocardiography. All patients were followed up for 2 years, 12 died and 68 survived. Age, gender distribution, blood pressure, co-existing diagnoses and medication were all similar between those who died and those who survived. The NYHA classification was significantly worse, left ventricular (LV) cavity size was greater, LV systolic function was lower in those who died than in survivors, despite similar LV wall thickness. On ECG, heart rate, PR interval, QT interval and frontal QRS axis did not differ between the two groups. The QRS duration was significantly longer and the horizontal QRS axis projected to a substantially more posterior direction in those who died than in survivors. The sensitivity and specificity of a horizontal QRS axis ≤ − 30° for predicting death in 2 years were 75% and 62%, respectively. The former is above the sensitivity of a NYHA ≥ 3 and the latter is above the specificity of a LV shortening fraction ≤ 20%. The combination of a QRS horizontal axis ≤ − 30° and NYHA ≥ 3 predicted 2 year mortality with a sensitivity of 75% and specificity of 91%. In conclusion, a left posterior QRS axis of the horizontal plane in elderly heart failure indicates an adverse prognosis, particularly when combined with NYHA classification and echocardiographic assessment.

Hemodynamic function of the standard St. Jude bileaflet disc valve has no clinical impact 10 years after aortic valve replacement

Objectives: Size mismatch and impaired left ventricular function have been shown to determine the hemodynamic function of the standard St. Jude bileaflet disc valve early after aortic valve replacement (AVR). We aimed to analyse St. Jude valve hemodynamic function and its clinical impact in the survivors of a prospective series 10 years after AVR for aortic stenosis. Design: Forty-three survivors aged 32–90 years from a prospective series attended a follow-up study with Doppler echo and radionuclide cardiography 10 years after AVR for aortic stenosis. Six patients with significant left sided valve regurgitation were excluded from further analysis: they had significantly lower St. Jude valve gradient and left ventricular ejection fraction (LVEF) and larger mass index (LVMi) than 37 without. Results: In the 37 patients without left sided valve regurgitation peak and mean gradients were inversely related to St. Jude valve geometric orifice area (GOA) indexed for either body surface area or left ventricular end-diastolic dimension (LVEDD). The gradients correlated directly with LVEDD but not with LVEF or LVMi. Eleven patients with hypertension had higher peak gradients (31±13 versus 22±8 mmHg, p < 0.05), lower LVEF, and higher LVEDD and LVMi than 26 without. Peak gradient was greater than 35 mmHg in five hypertensive patients with normal LVEF but lesser than 30 mmHg in six with impaired LVEF. Supranormal LVEF and severe size mismatch identified the remaining patients (N = 3) with peak gradient above 35 mmHg. In a multilinear regression analysis GOA indexed for LVEDD, hypertension, and LVEF were independently related to peak gradient. Conclusion: High gradients of the standard St. Jude bileaflet disc valve 10 years after AVR was primarily related to systemic hypertension and mismatch between valve and left ventricular cavity size. Hypertension and left sided valve regurgitation, but not St. Jude valve gradient or size mismatch, were the dominant determinants of left ventricular hypertrophy and impaired function.

Chronic beta-adrenoreceptor activation increases cardiac cavity size through chamber remodeling and not via modifications in myocardial material properties.

Chronic beta-adrenoreceptor (beta-AR) activation increases left ventricular (LV) cavity size by promoting a rightward shift in LV diastolic pressure-volume (P-V) relations in association with increases in low-tensile strength myocardial (non-cross-linked) collagen concentrations. Because diastolic P-V relations are determined by chamber remodeling as well as by myocardial material properties (indexed by myocardial stiffness), both of which are associated with modifications in myocardial collagen cross-linking, we evaluated whether chamber remodeling or alterations in myocardial material properties govern beta-AR-mediated modifications in diastolic P-V relations. The effects of chronic administration of isoproterenol (Iso; 0.04 mg.kg(-1).day(-1) from 12 to 19 mo of age) to spontaneously hypertensive rats (SHRs) on LV cavity dimensions, LV diastolic P-V relations, myocardial collagen characteristics, myocardial stiffness constants [e.g., the slope of the LV diastolic stress-strain relation (k)], and LV chamber and myocardial systolic function were assessed. SHRs at 19 mo of age had normal LV diastolic P-V relations, marked myocardial fibrosis (using a pathological score), increased myocardial cross-linked (insoluble to cyanogen bromide digestion) type I and type III collagen concentrations, and enhanced myocardial k values. Iso administration to SHRs resulted in enlarged LV cavity dimensions mediated by a rightward shift in LV diastolic P-V relations, increased volume intercept of the LV diastolic P-V relation, decreased LV relative wall thickness despite a tendency to augment LV hypertrophy, and increased non-cross-linked type I and type III myocardial collagen concentrations. Iso administration resulted in reduced pump function without modification of intrinsic myocardial systolic function. However, despite increasing myocardial non-cross-linked concentrations, Iso failed to alter myocardial k in SHRs. These results suggest that beta-AR-mediated rightward shifts in LV diastolic P-V relations, which induce decreased pump function, are mediated by chamber remodeling but not by modifications in myocardial material properties.

Midwall mechanics in physiologic and hypertensive concentric hypertrophy

Objective We sought to analyze and compare midwall fractional shortening (mFS), and its relations with circumferential end-systolic stress (cESS) and relative wall thickness (RWT), among subjects with physiologic concentric left ventricular (LV) hypertrophy, patients with hypertension and concentric LV hypertrophy, and control subjects. Methods A total of 51 normotensive athletes and 56 young patients with hypertension and echocardiographic evidence of concentric LV hypertrophy were enrolled. In addition, 49 age- and sex-matched control subjects were recruited. LV cavity size and wall thicknesses, LV mass, RWT, cESS, and mFS were determined by echocardiography. Results The 3 groups were similar in age, sex, height, weight, body surface area, LV diameters, and conventional indices of systolic function. LV thicknesses, RWT, LV mass, and LV mass index were similarly increased in the athletes and in the hypertensive group when compared with the control subjects. A similar depression in mFS was observed in both the athletes (22.4 ± 2.6%) and hypertensive group (22.5 ± 3.6%) in comparison with the control group (24.5 ± 2.5%, P = .0003). The depression in mFS was still significant after taking into account the effect of cESS, but was no more evident after indexation of mFS by RWT or LV mass. At regression analysis, the relation between mFS and cESS showed a steeper negative slope in the patients with hypertension than in the other 2 groups. Conclusions MFS is similarly depressed in physiologic and hypertensive concentric LV hypertrophy. The depression is abolished by adjustment for RWT or LV mass, suggesting that geometric factors are the major determinants of midwall performance in both types of concentric LV hypertrophy. However, an impaired response to different values of cESS seems to exist only in hypertensive concentric LV hypertrophy, because increasing levels of cESS may be associated with more evident mFS depression in patients with hypertension than in the athletes and control subjects.

Fatty acid metabolism assessed by 125I-iodophenyl 9-methylpentadecanoic acid (9MPA) and expression of fatty acid utilization enzymes in volume-overloaded hearts.

The peroxisome proliferator-activated receptor (PPAR) alpha is a member of the nuclear receptor superfamily and regulates gene expression of fatty acid utilization enzymes. In cardiac hypertrophy and heart failure by pressure-overload, myocardial energy utilization reverts to the fetal pattern, and metabolic substrate switches from fatty acid to glucose. However, myocardial metabolism in volume-overloaded hearts has not been rigorously studied. The aim of the present study was to examine fatty acid metabolism and protein expressions of PPARalpha and fatty acid oxidation enzymes in volume-overloaded rabbit hearts. Volume-overload was induced by carotid-jugular shunt formation. Sham-operated rabbits were used as control. Chronic volume-overload increased left ventricular weight and ventricular cavity size, and relative wall thickness was decreased, indicating eccentric cardiac hypertrophy. (125)I-iodophenyl 9-methylpentadecanoic acid (9MPA) was intravenously administered, and animals were sacrificed at 5 min after injection. The 9MPA was rapidly metabolized to iodophenyl-3-methylnonanoic acid (3MNA) by beta-oxidation. Lipid extraction from the myocardium was performed by the Folch method, and radioactivity distribution of metabolites was assayed by thin-layer chromatography. The protein was extracted from the left ventricular myocardium, and levels of PPARalpha and fatty acid oxidation enzymes were examined by Western blotting. Myocardial distribution of 9MPA tended to be more heterogeneous in shunt than in sham rabbits (P = 0.06). In volume-overloaded hearts by shunt, the conversion from 9MPA to 3MNA by beta-oxidation was faster than the sham-control hearts (P < 0.05). However, protein levels of PPARalpha and fatty acid utilization enzymes were unchanged in shunt rabbits compared with sham rabbits. These data suggest that myocardial fatty acid metabolism is enhanced in eccentric cardiac hypertrophy by volume-overload without changes in protein expressions of PPARalpha and fatty acid utilization enzymes. Our data may provide a novel insight into the subcellular mechanisms for the pathological process of cardiac remodelling in response to mechanical stimuli.

Elevation of plasma brain natriuretic peptide is a hallmark of diastolic heart failure independent of ventricular hypertrophy

ObjectivesWe tested a hypothesis that elevation of the plasma level of brain natriuretic peptide (BNP) is one of the characteristics of patients with diastolic heart failure (DHF) independent of left ventricular (LV) hypertrophy. BackgroundThe clinical characteristics of DHF are not well acknowledged, although DHF has become a great social burden. Such a lack of clinical information leads to inaccuracy in the diagnosis of DHF. We have demonstrated enhancement of ventricular production of BNP with progression of maladaptive ventricular hypertrophy, but not with development of compensatory hypertrophy in an animal DHF model. MethodsOf 372 patients who presented to the emergency department because of acute pulmonary congestion without acute coronary syndrome between January 1996 and May 2002, those with an ejection fraction ≥45% upon admission, who were stably controlled at least for a year in our outpatient clinics, comprised the DHF group (n = 19). A control group consisted of 22 hypertensive patients with a LV mass index greater than or equal to its minimum value of the DHF group and an ejection fraction ≥45%, in whom cardiac symptoms had not occurred. ResultsDespite a similar distribution of LV mass index, the BNP level was higher in the DHF group than in the control group (149 ± 38 vs. 31 ± 5 pg/ml, p < 0.01). There was no difference in LV cavity size or parameters derived from pulsed Doppler transmitral flow velocity curves. ConclusionsAn elevation of BNP may be a hallmark of patients with or at risk of DHF among subjects with preserved systolic function independent of LV hypertrophy.

Influence of Perindopril on Left Ventricular Remodeling in Essential and Secondary Hypertension

Background: To evaluate the relation between the left ventricular hypertrophy (LVH) regression and changes of LV diastolic function under the influence of perindopril in patients (pts) with hypertension. Methods: Fifty-two pts with essential hypertension (EH) and 36- with secondary arterial hypertension (SAH) of renal genesis with II-III grade hypertension, LVH and abnormal mitral flow pattern have been studied to assess effect of perindopril (up to 4 mg/day) on left ventricular remodeling. Each subject was underwent two-dimensional and Doppler-echocardiography. LV mass index (LVMI), LV end-diastolic diameter (EDD), septal and posterior wall thickness (SWT, PWT) were evaluated, the following parameters of LV diastolic function were assessed by Doppler echocardiographic analysis of the diastolic transmitral flow: the maximal early- (E) and late–(A) velocity of diastolic filling; the E/A ratio, the deceleration time (DT) and the isovolumetric relaxation time (IVRT). Examination was performed at baseline and after 48 weeks of treatment with perindopril. Results: In pts with EH systolic BP (SBP) was reduced on average from 190±22 to 136±10 mm Hg., diastolic BP (DBP) from 113±11.2 to 84±12 mm Hg. In pts with SAH there was detected reduction of SBP and DBP from 206±24 to 142±10 mm Hg and 115±11.1 to 86±11 mm Hg, respectively. LVMI was reduced by 14.2 % in EH and by 13.0 % in SAH (p<0.01 for both). PWT decreased by 12.2 % in EH (p<0.01) and by 7.4 % in SAH (p<0.05), SWT by 6 % (p<0.05) and 14.6 % (p<0.001), respectively. Perindopril treatment produced shortening of IVRT (102.6±4.24 vs 146.8±7.90 ms in EH, and 102.0±2.92 vs 154.0±6.00 ms in SAH, p<0.01 for both), DT (180.0±7.42 vs. 230.0±12.9 ms in EH, p<0.01 and 184.0±7.86 vs. 204.6±9.60 ms in SAH, p<0.05), E (68.8±6.4 vs. 50.0±10.0 cm/s in EH and 56.0±10.3 vs. 46.0±10.0 cm/s in SAH, p<0.05 for both), increased E/A ratio (from 0.82±0.10 to 0.96±0.12 in EH and from 0.70±0.04 to 0.86±0.16 in SAH, p<0.05 for both) and had trend toward decreasing A (68.8±10.0 vs. 86.2±12.0 cm/s in EH and 70.0±10.4 vs. 82.5±12.3 in SAH cm/s, p = NS for both). At the end of follow up normal mitral flow pattern was detected in 46.8 % pts with EH and 39.2 % pts with SAH. Increased in E/A was related to reduction of SWT in pts with SAH (r = 0.69, p<0.05), while in EH at the account of diminution of the LV EDD (r = 0.50, p<0.05). Conclusion: Perindopril treatment has significantly ptoduced the attenuation of the left ventricular remodeling process in pts with EH and SAH. Diastolic function improvement in pts with SAH was related to the reduction of SWT, while in EH -to the reduction of the left ventricular cavity size.

Measured haplotype analysis of the aldosterone synthase gene and heart size.

Gene-association studies of heart size and the aldosterone synthase (CYP11B2) gene have produced inconsistent results, possibly because of limitations in the sample size and/or the number and location of the polymorphisms. An analysis of six polymorphisms spanning 6 kb of the CYP11B2 gene in Caucasian British families revealed a limited number of haplotypes because of strong linkage disequilibrium over this small region. The genotype and haplotype information was used in an association study involving 955 members of 229 families phenotyped for echocardiographic measures of heart size. In a mixed effects linear modelling analysis, the G5937C polymorphism was associated with cardiac wall thickness (P=0.02), and the intron conversion and A4550C polymorphisms were associated with left ventricular cavity size (P=0.02 and 0.002, respectively). Measured haplotype analyses confirmed the association of alleles at the intron conversion and G5937C polymorphisms with cardiac wall thickness (P=0.02), and alleles at the intron conversion polymorphism with left ventricular cavity size (P=0.04). The polymorphisms contributed to 2.0-3.4% of the variability in these traits. In summary, genetic polymorphisms at the CYP11B2 gene make a small contribution to quantitative variation in echocardiographic measures of heart size. These results point to the importance of analysing the full extent of genetic variation that captures the haplotype structure of a locus in gene association studies.

IMPACT OF PREPARTICIPATION PORTABLE TWO-DIMENSIONAL ECHOCARDIOGRAPHY IN SCREENING FOR CARDIOVASCULAR DISEASE IN SCHOOL-AGE ATHLETES

Preparticipation physical examination (PPE) typically results in a 0.3%–1.3% denial of participation for various reasons including cardiovascular (CV). Although two-dimensional echocardiography (2-D echo) is the most sensitive test for detecting CV disease, 2-D echo has not typically been part of the PPE because of its high cost. A portable machine has allowed the cost of a 2-D echo to decrease considerably, but its role in routine PPEs is not known. PURPOSE To determine the impact of the portable 2-D echo machine in screening for CV disease in school-age athletes referred for PPEs. METHODS In 2001, we performed PPEs on 1566 school-age athletes (age 12–21 yrs) in the Chicago metropolitan area. During each PPE, the athlete received a portable 2-D echo (1–2 minutes). Short axis and parasternal long axis views were obtained for septal thickness (abnormal ≥ 1.3cm), size of left ventricular cavity, width of the aortic root (abnormal ≥ 3.8cm), and the appearance of the aortic valve. Participation in sports was denied if an abnormality was detected and further evaluation was recommended before participation could be allowed. RESULTS Overall denial rate was 4.95%(81 of 1566 PPEs): 17, abnormal septal thickness; 14, murmur, chest pain or palpitations; 11, hypertension; 10, visual abnormalities; 9, orthopedic abnormalities; 7, uncontrolled asthma; 4, recent surgery; 3, abnormal aortic root; 3, unexplained dizziness; 1, seizure dosorder; 1, enlarged heart 2-D echo; and 1, eating disorder. 2-D echo accounted for 26% of the denials, and increased the denial rate from 3.9% to 4.95%. Of the abnormal portable 2-D echoes, only one athlete was found to have a newly diagnosed dilated cardiomyopathy. No episodes of hypertrophic cardiomyopathy or Marfans were detected. CONCLUSIONS Portable 2-D echo can be performed quickly and inexpensively during the PPE. It increases the rate of denial of participation in sport by 1.05%. In this group of school-age athletes the incidence of newly diagnosed CV disease was low.

Beta-adrenergic activation initiates chamber dilatation in concentric hypertrophy.

It is uncertain whether chronic beta-adrenoreceptor (beta-AR)-activation in hypertension could initiate the progression from compensated left ventricular (LV) hypertrophy to pump dysfunction. It is also uncertain if this effect is through adverse LV remodeling (chamber dilatation with wall thinning and pump dysfunction) or intrinsic myocardial contractile dysfunction. We evaluated the effect of 5 months of isoprenaline (0.02 mg x kg(-1) x d(-1)) on hemodynamics, LV wall thickness, cavity size, and interstitial characteristics in spontaneously hypertensive rats (SHR) with compensated LV hypertrophy. In the absence of myocyte necrosis, changes in volume preload, pressure afterload, and heart rate or decreases in baseline systolic myocardial elastance (load independent measure of intrinsic myocardial contractility), ISO produced a right shift in LV diastolic pressure-volume (P-V) relations (chamber dilatation), a decrease in LV wall thickness despite a further increase in LV weight in SHR, LV pump dysfunction (right shift in LV systolic P-V relations), and deleterious interstitial remodeling (increments in total and noncrosslinked myocardial collagen concentrations). The isoprenaline-induced LV geometric, chamber performance, and interstitial changes were similar to alterations noted during decompensation in older SHR. In summary, in the absence of tissue necrosis and baseline intrinsic myocardial contractile dysfunction, chronic beta-AR activation induces interstitial and chamber remodeling and, hence, pump dysfunction. These data suggest that chronic sympathetic activation initiates the progression from compensated concentric LV hypertrophy in hypertension to cardiac dysfunction primarily through deleterious cardiac remodeling rather than intrinsic myocardial contractile dysfunction.

The influence of age on gender-specific differences in the left ventricular cavity size and contractility in patients with hypertrophic cardiomyopathy

Background: The aim of the study was to assess gender-specific differences in left ventricular cavity size, contractility and left ventricular outflow tract obstruction in younger and older subgroups of patients with hypertrophic cardiomyopathy. Methods: We studied retrospectively 153 referred patients with hypertrophic cardiomyopathy (89 males and 64 females). The echocardiographically measured left ventricular end-systolic, end-diastolic dimensions, fractional shortening and occurrence of left ventricular outflow tract gradient were compared between sexes in subgroups of patients ≤50 and >50 years of age. Results: In younger patients with hypertrophic cardiomyopathy, left ventricular end-diastolic and end-systolic dimensions were significantly smaller in females than males (41.9±5.8 vs. 44.7±5 mm P<0.01 23.4±5 vs. 25.2±5.4 mm P<0.05, respectively). Fractional shortening was comparable in both sexes (44.7±7.5 vs. 43.7±8.2% P>0.05). The left ventricular outflow tract gradient occurred in females as frequently as in males (13.3 vs. 17.6% P>0.05). In older patients with hypertrophic cardiomyopathy, left ventricular end-diastolic and end-systolic dimensions were also significantly smaller in females than males (42.5±6 vs. 46.3±3.2 mm P<0.02; 25.7±4.8 vs. 28.6±3.7 mm P<0.01, respectively). In contrast to the younger group, the fractional shortening was significantly higher in females than males (44.4±6.8 vs. 38.2±7.3% P<0.02). The left ventricular outflow tract gradient occurred in females more frequently than in males (63.2 vs. 20.8% P<0.02). Conclusions: In patients with hypertrophic cardiomyopathy, the gender-based differences in the absolute value of left ventricular cavity size persisted with aging. In older females left ventricular contractility was higher and left ventricular outflow tract gradient occurred more frequently than in males. In younger patients with hypertophic cardiomyopathy these sex-based differences were absent. The gender-specific differences in the parameters of left ventricular systolic function became apparent with increasing age.

Assessment of regional systolic and diastolic wall motion velocities in highly trained athletes by pulsed wave Doppler tissue imaging

We studied the relationship between left ventricular (LV) function and the increased LV mass in 18 highly trained rowing athletes (14 men, 4 women; mean age 20.7 ± 4.5 years) using pulsed wave Doppler tissue imaging (PWDTI). Thirteen untrained volunteers, matched for age and body mass index, acted as control participants. Peak systolic, early diastolic (Ev), and late diastolic (Av) myocardial velocities (cm/s); Ev/Av ratio; and isovolumic relaxation time (ms) were measured at the level of basal lateral wall and basal posterior interventricular septum (bas-IVS) segments. In comparison with control participants, athletes showed a greater LV cavity size (P <.05), wall thickness (IVS, P <.001; posterior wall, P <.01), and mass index (P <.001). In athletes, systolic velocity of bas-IVS had increased (P <.001) and was positively correlated with IVS thickness (r = 0.66, P <.005) and LV mass index (r = 0.71, P <.001). Of the PWDTI-measured diastolic indexes, Ev/Av ratio significantly increased in athletes in comparison with control participants in both the examined segments (bas-IVS, P <.05; basal lateral wall, P <.05). When Ev and Av were separately considered, a different behavior was found in the 2 segments: Ev significantly increased in the basal lateral wall (P <.005); Av significantly decreased in the bas-IVS. The increase in the systolic velocity of bas-IVS suggests that septum greatly contributes to the longitudinal LV systolic shortening and increase of stroke volume in athletes compared with untrained participants. Moreover, the behavior of PWDTI diastolic velocities suggests a more effective relaxation activity in the longitudinal axis at the level of lateral wall. This study suggests therefore the usefulness of PWDTI in the assessment of functional properties of “athlete's heart” and differentiation from pathologic cardiac conditions. (J Am Soc Echocardiogr 2002;15:900-5.)