Change In Left Ventricular Mass Index Research Articles

Efficacy and tolerability of oral stevioside in patients with mild essential hypertension: A two-year, randomized, placebo-controlled study

Background: Stevioside, a natural glycoside isolated from the plant Stevia rebaudiana Bertoni, has been used as a commercial sweetening agent in Japan and Brazil for >20 years. Previous animal and human studies have indicated that stevioside has an antihypertensive effect. Objectives: This study was undertaken to investigate the long-term (2-year) efficacy and tolerability of stevioside in patients with mild essential hypertension. Secondary objectives were to determine the effects of stevioside on left ventricular mass index (LVMI) and quality of life (QOL). Methods: This was a multicenter, randomized, double-blind, placebo-controlled trial in Chinese men and women aged between 20 and 75 years with mild essential hypertension (systolic blood pressure [SBP] 140–159 mm Hg and diastolic blood pressure [DBP] 90–99 mm Hg). Patients took capsules containing 500 mg stevioside powder or placebo 3 times daily for 2 years. Blood pressure was measured at monthly clinic visits; patients were also encouraged to monitor blood pressure at home using an automated device. LVMI was determined by 2-dimensional echocardiography at baseline and after 1 and 2 years of treatment. QOL was assessed using the Medical Outcomes Study 36-Item Short-Form Health Survey. Electrocardiographic, laboratory, and QOL parameters were assessed at the beginning of treatment, and at 6 months, 1 year, and 2 years. Results: One hundred seventy-four patients (87 men, 87 women) were enrolled in the study, and 168 completed it: 82 (42 men, 40 women; mean [SD] age, 52 [7] years) in the stevioside group and 86 (44 women, 42 men; mean age, 53 [7] years) in the placebo group. After 2 years, the stevioside group had significant decreases in mean (SD) SBP and DBP compared with baseline (SBP, from 150 [7.3] to 140 [6.8] mm Hg; DBP, from 95 [4.2] to 89 [3.2] mm Hg; P < 0.05) and compared with placebo ( P < 0.05). Based on patients' records of self-monitored blood pressure, these effects were noted beginning ∼1 week after the start of treatment and persisted throughout the study. There were no significant changes in body mass index or blood biochemistry, and the results of laboratory tests were similar in the 2 groups throughout the study. No significant difference in the incidence of adverse effects was noted between groups, and QOL scores were significantly improved overall with stevioside compared with placebo ( P < 0.001). Neither group had a significant change in mean LVMI. However, after 2 years, 6 of 52 patients (11.5%) in the stevioside group had left ventricular hypertrophy (LVH), compared with 17 of 50 patients (34.0%) in the placebo group ( P < 0.001). Of those who did not have LVH at baseline, 3 of 46 patients (6.5%) in the stevioside group had developed LVH after 2 years, compared with 9 of 37 patients (24.3%) in the placebo group ( P < 0.001). Conclusions: In this 2-year study in Chinese patients with mild hypertension, oral stevioside significantly decreased SBP and DBP compared with placebo. QOL was improved, and no significant adverse effects were noted.

Regression of left ventricular hypertrophy after conversion to nocturnal hemodialysis

Left ventricular hypertrophy (LVH) is an independent risk factor for mortality in the dialysis population. LVH has been attributed to several factors, including hypertension, excess extracellular fluid (ECF) volume, anemia and uremia. Nocturnal hemodialysis is a novel renal replacement therapy that appears to improve blood pressure control. This observational cohort study assessed the impact on LVH of conversion from conventional hemodialysis (CHD) to nocturnal hemodialysis (NHD). In 28 patients (mean age 44 +/- 7 years) receiving NHD for at least two years (mean duration 3.4 +/- 1.2 years), blood pressure (BP), hemoglobin (Hb), ECF volume (single-frequency bioelectrical impedance) and left ventricular mass index (LVMI) were determined before and after conversion. For comparison, 13 control patients (mean age 52 +/- 15 years) who remained on self-care home CHD for one year or more (mean duration 2.8 +/- 1.8 years) were studied also. Serial measurements of BP, Hb and LVMI were also obtained in this control group. There were no significant differences between the two cohorts with respect to age, use of antihypertensive medications, Hb, BP or LVMI at baseline. After transfer from CHD to NHD, there were significant reductions in systolic, diastolic and pulse pressure (from 145 +/- 20 to 122 +/- 13 mm Hg, P < 0.001; from 84 +/- 15 to 74 +/- 12 mm Hg, P = 0.02; from 61 +/- 12 to 49 +/- 12 mm Hg, P = 0.002, respectively) and LVMI (from 147 +/- 42 to 114 +/- 40 g/m2, P = 0.004). There was also a significant reduction in the number of prescribed antihypertensive medications (from 1.8 to 0.3, P < 0.001) and an increase in Hb in the NHD cohort. Post-dialysis ECF volume did not change. LVMI correlated with systolic blood pressure (r = 0.6, P = 0.001) during nocturnal hemodialysis. There was no relationship between changes in LVMI and changes in BP or Hb. In contrast, there were no changes in BP, Hb or LVMI in the CHD cohort over the same time period. Reductions in BP with NHD are accompanied by regression of LVH.

Relationship between home blood pressure and longitudinal changes in target organ damage in treated hypertensive patients.

Cross-sectional studies have shown that home blood pressure (BP) correlates with hypertensive target organ damage better than clinic BP. However, there have been few longitudinal studies regarding the predictive value of home BP on the changes in organ damage in treated hypertensive patients. Clinic and home BP over a 12-month period, antihypertensive medication use, echocardiographic and electrocardiographic results, and serum creatinine and urinary protein levels were examined in 209 treated hypertensive patients in 1993. These patients were prospectively followed for 5 years. The patients were divided into 4 subgroups according to hypertension control as follows: good control (<140/90 mmHg for clinic BP, <135/85 mmHg for home BP), improved, worsened, and poor control. The average clinic BP was 147.0+/-14.9/87.0+/-7.6 mmHg (mean+/-SD) in 1993 and 146.0+/-13.7/84.1+/-7.5 mmHg in 1998. The average home BP was 136.8+/-10.4/84.3+/-7.6 mmHg in 1993 and 136.1+/-9.7/81.2+/-7.7 mmHg in 1998. The left ventricular mass index (LVMI) positively correlated with both home systolic BP and clinic systolic BP in 1998 but not in 1993. The correlation tended to be closer for home BP than for clinic BP. LVMI did not change in patients with good or improved home systolic BP, while it increased in those with poor or worsened home systolic BP. The relationship between changes in LVMI and clinic BP was not significant. In conclusion, Home BP was more effective than clinic BP as a predictor of changes in left ventricular hypertrophy in treated hypertensive patients. Home BP should be controlled to below 135/85 mmHg to prevent cardiac hypertrophy.

Effects of hormone replacement therapy on left ventricular hypertrophy and growth-promoting factors in hypertensive postmenopausal women.

We investigated the effects of hormone replacement therapy (HRT) on left ventricular hypertrophy (LVH) and growth-promoting factors in hypertensive postmenopausal women (PMW) with LVH. Twenty-one Japanese hypertensive PMW (age 55.3+/-0.8 years) with LVH who had never received HRT volunteered to participate in this study. Eleven subjects received a daily dose of HRT (0.625 mg conjugated equine estrogen, 2.5 mg medroxyprogesterone acetate) orally for 12 months. Ten PMW who refused HRT were enrolled as controls. Blood pressure and serum angiotensin-converting enzyme (ACE) activity, plasma aldosterone, and insulin resistance were measured. M-mode echocardiography and blood pressure measurements were performed in all patients. Data obtained before and after 12 months of HRT were compared. No significant differences in blood pressure were observed between the two groups after 12 months of HRT. In the HRT group, the LV mass index (p<0.01), serum ACE activity (p<0.01), and plasma aldosterone (p<0.01) levels were reduced after 12 months of treatment. The changes in serum ACE activity and plasma aldosterone were not correlated with the change in LV mass index in the HRT group. No significant changes in blood pressure, LV mass index, serum ACE activity, plasma aldosterone, or insulin resistance were observed in the control group. HRT contributed to the reduction of LV mass in hypertensive PMW. However, the effect of HRT on LVH did not appear to be associated with changes in growth-promoting factors, such as blood pressure, serum ACE activity, plasma aldosterone, and insulin resistance.

Pulse pressure is the best predictor of future left ventricular mass and change in left ventricular mass: 10 years of follow-up.

Ambulatory blood pressure correlates more closely with left ventricular mass (LVM) than casual blood pressure in cross-sectional studies, but prospective evidence is very limited. To evaluate the best predictors of LVM and change in LVM during 10 years of follow-up, in a prospective study. At baseline, blood pressure was recorded by casual measurements and 24 h intra-arterial ambulatory monitoring. The study participants were 97 healthy, untreated, 35-45-year-old men (34 normotensive, 29 borderline hypertensive, and 34 mildly hypertensive). At 10-year follow-up, echocardiography was performed in 86 (89%) of the men; echocardiographic data were available both at baseline and at follow-up from 70 (72%) of them. Individuals who were not receiving antihypertensive medication (n = 66) were included in the prediction of LVM index (LVMI), which was analysed as a continuous variable. The blood pressure variables that were best in predicting the LVMI were: 24 h pulse pressure (r = 0.308, P = 0.012), night-time pulse pressure (r = 0.291, P = 0.018), daytime pulse pressure (r = 0.253, P = 0.041), and casual systolic blood pressure (r = 0.212, P = 0.088). The LVMI was best predicted by a model including 24 h pulse pressure, positive family history of hypertension, body mass index, and age (adjusted coefficients of determination (adj.R2) = 0.197; that for the casual blood pressure model was adj.R2 = 0.140). During the follow-up, LVMI increased by +7.5 g/m2 and +23 g/m2 in individuals receiving and not receiving antihypertensive medication, respectively (P = 0.015). The change in LVMI was best predicted by the change in casual pulse pressure and use of antihypertensive medication (adj.R2 = 0.102). Ambulatory blood pressure improved the prediction of future LVMI compared with that obtained from casual measurements. To our knowledge, this is the longest prospective follow-up to show that pulse pressure is the most significant blood pressure parameter in predicting future LVMI and change in LVMI.

Extracellular matrix gene expression correlates to left ventricular mass index after surgical induction of left ventricular hypertrophy.

The cardiac extracellular matrix (ECM) is a dynamic entity maintaining the structural and functional properties of the myocardium. Little is known about alterations in ECM regulation during controlled induction of compensated left ventricular hypertrophy (LVH) using experimental aortic stenosis. Fifteen growing sheep received supra-coronary banding at an age of 7 +/- 1 months whereas 10 age-matched sheep served as the control group (C). Explantation of the hearts was performed 8.3 +/- 1 months after banding. Gene sequences for sheep matrix metalloproteinase (MMP)-1,-2,-3,-9 and tissue inhibitors (TIMP)-1,-2,-3 were isolated and cloned. Then mRNA and protein gene expression analyses were performed. Concentric LVH with no evidence of heart failure was diagnosed at explantation. Left ventricular mass index (LVMI) was 150 +/- 33 g/m2 (LVH) versus 88 +/- 23 (C) and 82 +/- 21 (baseline) (p < 0.01 versus LVH). Parallel to LVH there was a significant increase in mRNA and protein expression for MMP-1,-2,-3, -9 and for TIMP-1,-2 whereas there was a significant decrease in TIMP-3 gene expression. A close correlation between changes in LVMI and ECM gene expression was found. Compensated LVH goes along with a significant modification of MMP and TIMP gene expression. Alterations in ECM gene expression may be part of the adaptive process during left ventricular remodeling.

Changes in left ventricular mass in children and adolescents during chronic dialysis.

Left ventricular hypertrophy (LVH) is an independent risk factor for cardiac mortality in adults with end-stage renal disease (ESRD). It is prevalent in pediatric patients on chronic dialysis. The objectives of this study were to evaluate left ventricular mass (LVM) in children and adolescents at the initiation of dialysis and to assess its changes during chronic dialysis therapy. In this longitudinal analysis, 29 patients aged 4-18 years had an echocardiographic evaluation within 90 days of starting dialysis therapy and a follow-up study at least 6 months later. LVH was defined as LVM index (g/m2.7) > 95th percentile for normal children and adolescents. On the initial echocardiogram 20 of 29 (69%) patients had LVH and 24 patients (83%) had abnormal LV geometry (38% eccentric LVH, 31% concentric LVH, and 14% concentric remodelling). Patients with LVH were more likely to be on antihypertensive medications (16/20) than patients without LVH (3/9) (P = 0.005). Repeat echocardiogram, performed after 10 +/- 3 months on chronic dialysis, showed no significant difference in the mean LVM index (49.6 +/- 17.5 g/m2.7 and 49.7 +/- 16.1 g/m2.7, respectively) or in the prevalence of LVH or LV geometric pattern. However, 14 of 29 patients had a progressive increase in LVM index and 15 patients had regression. Multiple regression analysis showed that baseline LVM index (P = 0.005) and interval change in indexed systolic blood pressure (P = 0.027) were independent predictors for LVM index changes. In summary, LVH and abnormal LV geometry are already prevalent in children and adolescents with renal failure at the time of initiation of dialysis therapy, indicating that LVH develops during the pre-ESRD course. Early intervention to control blood pressure may be an important factor to improve and prevent progression of LVH in pediatric patients with ESRD.

Effect of closure of the arteriovenous fistula on left ventricular dimensions in renal transplant patients

Left ventricular hypertrophy is common in renal transplant patients. One of the factors that might contribute to this phenomenon is the persisting presence of an arteriovenous (AV) fistula. Several reports have described the presence of high-output cardiac failure, which subsided after closure of the AV fistula. However, the long-term effects of elective closure of the AV fistula on left ventricular dimensions in stable renal transplant patients have never been prospectively studied. Twenty patients (15 male, 5 female; mean age 51+/-12 years) with a well-functioning renal transplant were included. Patients with severe heart failure (NYHA III or IV) were excluded. Before and 3-4 months after closure of the AV fistula, an echocardiogram was performed. Fistula flow was assessed by colour duplex-Doppler sonography. Mean fistula flow was 1790+/-648 ml/min. After closure of the fistula, left ventricular end-diastolic diameter (LVEDD) (51.5+/-5.8 vs 49.3+/-5.4 mm, P<0.01) and left ventricular mass index (LVMi) (135.0+/-34.1 vs 119.8+/-23.2) decreased. The change in LVMi after fistula closing was significantly related to the LVMi and LVEDD before operation (r=0.74 and r=0.60, P<0.01), but not to fistula flow. Interventricular septal and posterior-wall diastolic thickness did not change. Heart rate decreased (72+/-10 vs 69+/-9, P:=0.03) Blood pressure and creatinine clearance did not change. Closure of the arteriovenous fistula in stable renal transplant patients results in a decrease in LVMi, due to a reduction in LVEDD. The change in LVMi is significantly related to the LVMi and LVEDD before fistula closing. In patients with a well-functioning allograft and persistent LV dilatation, closure of the AV fistula might be considered.

Left ventricular mass and atrial volume determined by cine magnetic resonance imaging in essential hypertension

To evaluate the relationship between left atrial volume determined by cine magnetic resonance imaging and progression of left ventricular hypertrophy (LVH), left atrial volume and echocardiographic left ventricular mass (LVM) were measured in 30 hypertensive patients (15 without LVH and 15 with LVH) and 10 normotensive control subjects. We also evaluated the effects of antihypertensive therapy on the cardiac chamber volumes and LVM in hypertensive patients. The cardiac chamber volumes and LVM were indexed by body surface area. Although there were no significant differences in left ventricular chamber volumes among the three groups, both maximum and minimum left atrial volume indexes, and the LVM index were greater in hypertensive patients with LVH than in the other two groups. The LVM index was correlated with maximum left atrial volume index (r = 0.74, P < .0001), and minimum left atrial volume index (r = 0.76, P < .0001), respectively. Furthermore, in multivariate models, the LVM index was significantly correlated with maximum left atrial volume index. In hypertensive patients with LVH, both maximum and minimum left atrial volume indexes, and the LVM index significantly reduced after treatment. The percent of changes in maximum left atrial volume index after treatment was significantly correlated with the percent of changes in LVM index after treatment. In conclusion, our data indicate that LVH is an independent determinant of left atrial enlargement, and both LVH and left atrial enlargement may be reversed by some effective therapeutic interventions.

Effect of hemoglobin levels in hemodialysis patients with asymptomatic cardiomyopathy

Hemoglobin levels below 10 g/dL lead to left ventricular (LV) hypertrophy, LV dilation, a lower quality of life, higher cardiac morbidity, and a higher mortality rate in end-stage renal disease. The benefits and risks of normalizing hemoglobin levels in hemodialysis patients without symptomatic cardiac disease are unknown. One hundred forty-six hemodialysis patients with either concentric LV hypertrophy or LV dilation were randomly assigned to receive doses of epoetin alpha designed to achieve hemoglobin levels of 10 or 13.5 g/dL. The study duration was 48 weeks. The primary outcomes were the change in LV mass index in those with concentric LV hypertrophy and the change in cavity volume index in those with LV dilation. In patients with concentric LV hypertrophy, the changes in LV mass index were similar in the normal and low target hemoglobin groups. The changes in cavity volume index were similar in both targets in the LV dilation group. Treatment-received analysis of the concentric LV hypertrophy group showed no correlation between the change in mass index and a correlation between the change in LV volume index and mean hemoglobin level achieved (8 mL/m2 per 1 g/dL hemoglobin decrement, P = 0.009). Mean hemoglobin levels and the changes in LV mass and cavity volume index were not correlated in patients with LV dilation. Normalization of hemoglobin led to improvements in fatigue (P = 0.009), depression (P = 0.02), and relationships (P = 0.004). Normalization of hemoglobin does not lead to regression of established concentric LV hypertrophy or LV dilation. It may, however, prevent the development of LV dilation, and it leads to improved quality of life.

Long-term changes in left ventricular hypertrophy after renal transplantation.

Concentric and eccentric left ventricular hypertrophy are common progressive disorders in dialysis patients and are associated with cardiac failure and death. Although partial regression of these abnormalities is known to occur during the first post-transplant year, their long-term evolution is unknown. A total of 143 of 433 dialysis patients participating in a long-term prospective cohort study received renal transplants. Laboratory parameters were assessed monthly. Echocardiography was performed annually. Left ventricular mass index (LVMI) and cavity volume index were calculated according to standard formulae. Multiple linear regression was used to model change in LVMI as a function of baseline clinical and laboratory variables. LVMI fell from 161 g/m2 at 1 year to 146 g/m2 (P=0.009) g/m2 after 2 years. No further regression was seen in years 3 and 4. Left ventricular volume index showed similar trends, with a decline from year 1 to year 2 (P=0.05) followed by stabilization in years 3 and 4. Older age, long duration of hypertension, need for more than one antihypertensive, high pulse pressure in normal-size hearts, and low pulse pressure in dilated hearts were significantly associated with failure of regression of LVMI between the first and second years (MLR, P<0.000001, r2=0.57). Regression of left ventricular hypertrophy continues beyond the first year after renal transplantation, reaching a nadir at 2 years and persisting into the third and fourth posttransplant years. Failure to regress was associated with older age, hypertension, high pulse pressure in normal-size hearts and low pulse pressure in dilated hearts.

Serial change in echocardiographic parameters and cardiac failure in end-stage renal disease.

Echocardiographic abnormalities are the rule in patients starting dialysis therapy and are associated with the development of cardiac failure and death. It is unknown, however, whether regression of these abnormalities is associated with an improvement in prognosis. As part of a prospective cohort study with mean follow-up of 41 mo, 227 patients had echocardiography at inception and after 1 yr of dialysis therapy. Improvements in left ventricular (LV) mass index, volume index, and fractional shortening were seen in 48, 48, and 46%, respectively. Ninety patients had developed cardiac failure by 1 yr of dialysis therapy. Twenty-six percent of the remaining 137 patients subsequently developed new-onset cardiac failure. The mean changes in LV mass index were 17 g/m(2) in those who subsequently developed cardiac failure compared with 0 g/m(2) among those who did not (P = 0.05). The corresponding values were -8 versus 0% for fractional shortening (P < 0.0001). The associations between serial change in both LV mass index and fractional shortening and subsequent cardiac failure persisted after adjusting for baseline age, diabetes, ischemic heart disease, and the corresponding baseline echocardiographic parameter. Regression of LV abnormalities is associated with an improved cardiac outcome in dialysis patients. Serial echocardiography adds prognostic information to one performed at baseline.

Effect of endurance exercise training on left ventricular size and remodeling in older adults with hypertension.

It is not known whether exercise training can induce a reduction of blood pressure (BP) and a regression of left ventricular hypertrophy (LVH) in older hypertensive subjects. This study was designed to determine whether endurance exercise training, by lowering BP, can induce regression of LVH and left ventricular (LV) concentric remodeling in older hypertensive adults. We studied 11 older adults with mild to moderate hypertension (BP 152.0 +/- 2.5/91.3 +/- 1.5 mm Hg, mean +/- SE), 65.5 +/- 1.2 years old, who exercised for 6.8 +/- 3.8 months. Seven sedentary hypertensive (BP 153 +/- 3/89 +/- 2 mm Hg) subjects, 68.5 +/- 1 years old, served as controls. LV size and geometry and function were assessed with the use of two-dimensional echocardiography. Exercise training increased aerobic power by 16% (p < .001), and it decreased systolic (p < .05) and diastolic (p < .05) BP, LV wall thickness (from 12.8 +/- 0.4 mm to 11.3 +/- 0.3 mm; p < .05), and the wall thickness-to-radius (h/r) ratio (from 0.48 +/- 0.02 to 0.41 +/- 0.01; p < .05). There were no significant changes in the controls. The changes in LV mass index (deltaLVMI) were different between the two groups. LV mass index decreased in the exercise group (deltaLVMI - 14.3 +/- 3.3 g) but not in the controls (deltaLVMI 1.4 +/- 4.1 g; p = .009). A multiple stepwise regression analysis showed that among clinical and physiological variables including changes in resting systolic BP, aerobic power, body mass index, and systolic BP during submaximal and maximal exercise, only the reduction in resting systolic BP correlated significantly with a regression of concentric remodeling (delta h/r ratio r = .80; p = .003). The other variables did not add to the ability of the model to predict changes in the h/r ratio. The data suggest that exercise training can reduce BP and induce partial regression of LVH and LV concentric remodeling in older adults with mild or moderate hypertension.

Impact of Recombinant Human Erythropoietin Treatment on Left Ventricular Hypertrophy and Cardiac Function in Dialysis Patients

The results of anemia correction by recombinant human erythropoietin (rHuEPO) therapy with regard to cardiac function and left ventricular hypertrophy in dialysis patients are controversially discussed. The aim of the study was to assess the effects of therapy rHuEPO on cardiac morphology and function in dialysis patients. We studied 11 clinically stable hemodialysis patients with severe renal anemia (hematocrit <27%) and increased left ventricular mass index (LVMi) with no history of coronary or valvular heart disease, systemic disease, severe hyperparathyroidism, hypertension stage 2 or higher, transfusion-dependent anemia, and concurrent rHuEPO treatment. The patients were treated with rHuEPO administered subcutaneously once or twice weekly at a mean dose of 80 ± 31 IU/kg week until the hematocrit was >30% and underwent a complete Doppler echocardiographic study at baseline and at follow-up (after 12.2 ± 2.9 months). At follow-up, ejection fraction and fractional shortening significantly increased from 62.7 ± 13.8 to 67.8 ± 9.7% (p < 0.05) and from 35.5 ± 9.8 to 39.4 ± 7.1% (p < 0.05), respectively, whereas mean velocity of circumferential fiber shortening demonstrated a trend towards amelioration from 1.18 ± 0.23 to 1.27 ± 0.27 circ/s (n.s.). LVMi and morphological data remained unchanged throughout the study. Nevertheless, LVMi changes showed two different behaviors with respect to baseline values: in 6 patients with higher baseline values, LVMi decreased from 229 ± 36 to 191 ± 45 g/m² (p < 0.05), while it worsened in 5 patients with less marked LVMi, increasing from 141 ± 32 to 186 ± 40 g/m² (p < 0.05). Our data demonstrate that partial correction of renal anemia with rHuEPO therapy seems to improve cardiac performance and to induce a regression of left ventricular hypertrophy, particularly in patients with greater baseline hypertrophy, ultimately confirming the multifactorial pathogenesis of left ventricular hypertrophy.

Reduction of Cardiovascular Structural Changes by Nifedipine GITS in Essential Hypertensive Patients

The aim of this study was to evaluate the effect of the calcium antagonist Nifedipine GITS in a double-blind, randomized comparison with the diuretic hydrochlorothiazide (HCTZ) on reduction of left ventricular (LV) mass and minimal vascular resistance in a group of essential hypertensives with left ventricular hypertrophy (LVH). The effects on blood pressure and on echocardiographic LV functional parameters were also analysed. After two months of randomized treatment with Nifedipine GITS or HCTZ, if diastolic blood pressure was > 90 mmHg, a combination of the two drugs was given and was continued for 24 weeks. M-mode, 2D-guided echocardiography was used to measure LV mass index (LVMI) according to the ?Penn convention?. Minimal vascular resistance was measured in the forearm, from arterial pressure and maximal blood flow, using a strain gauge plethysmography. All examinations were performed before and after 8 and 24 weeks of treatment. Changes in LVMI were analysed at 8 weeks and at 24 weeks in patients receiving monotherapy (?according to protocol? analysis), and also at the end of treatment in patients taking Nifedipine or HCTZ monotherapy or the combination of the two drugs (?intention to treat? analysis). Both Nifedipine and HCTZ significantly reduced systolic and diastolic blood pressure (p < 0.001), without any significant difference between the two drug treatments. Heart rate was not significantly modified by either treatment. A progressive decrease in LVMI was observed after 8 and 24 weeks of treatment with Nifedipine monotherapy (ANOVA, p = 0.03), while the decrease in LVMI during HCTZ treatment did not progress further at 24 weeks (ANOVA, p = 0.49). A significant reduction of minimal vascular resistance was observed in patients treated with Nifedipine GITS monotherapy (ANOVA, p = 0.001), but not in the HCTZ group (ANOVA, p = 0.06). Comparison of changes of forearm minimal vascular resistance, considering baseline values, could demonstrate a greater effect during Nifedipine monotherapy as compared to HCTZ monotherapy. In conclusion, in a group of hypertensive patients with LVH, treatment for 24 weeks with Nifedipine GITS alone or in combination with HCTZ induced a significant reduction in LVMI and of forearm vascular structural changes, as evaluated by minimal vascular resistance. The decrease of minimal vascular resistance was significantly greater in patients treated with Nifedipine monotherapy, as compared to those given HCTZ.

Impact of hypertension on cardiomyopathy, morbidity and mortality in end-stage renal disease

A cohort of 432 ESRD (261 hemodialysis and 171 peritoneal dialysis) patients was followed prospectively for an average of 41 months. Baseline and annual demographic, clinical and echocardiographic assessments were performed, as well as serial clinical and laboratory tests measured monthly while on dialysis therapy. The average mean arterial blood pressure level during dialysis therapy was 101 +/- 11 mm Hg. After adjusting for age, diabetes and ischemic heart disease, as well as hemoglobin and serum albumin levels measured serially, each 10 mm Hg rise in mean arterial blood pressure was independently associated with: the presence of concentric LV hypertrophy (OR 1.48, P = 0.02), the change in LV mass index (beta = 5.4 g/m2, P = 0.027) and cavity volume (beta = 4.3 ml/m2, P = 0.048) on follow-up echocardiography, the development of de novo cardiac failure (RR 1.44, P = 0.007), and the development of de novo ischemic heart disease (RR 1.39, P = 0.05). The association with LV dilation was of borderline statistical significance (OR 1.48, P = 0.06). Mean arterial blood pressures greater than 106 mm Hg were associated with both echocardiographic and clinical endpoints. Paradoxically, low mean arterial blood pressure (RR 1.36 per 10 mm Hg fall, P = 0.009) was independently associated with mortality. The association of low blood pressure with mortality was a marker for having had cardiac failure prior to death. We conclude that even moderate hypertension worsens the echocardiographic and clinical outcome in ESRD patients, especially in those without previous clinical cardiac disease.

Ventricular remodeling following infant-pediatric cardiac transplantation. Does age at transplantation or size disparity matter?

Early left ventricular (LV) remodeling following pediatric cardiac transplantation has not been described. To identify patterns and determinants of change in left ventricular mass and volume posttransplant, we studied 125 consecutive children who underwent cardiac transplantation between January 1, 1989 and July 31, 1993. Two-dimensional imaging-directed M-mode echocardiograms were studied weekly until 26 weeks post-transplant. LV mass and volume (indexed to BSA1.5) were measured. LV mass index increased until 3 weeks post-transplant, and then decreased. The mean decrement in LV mass index after 8 weeks post-transplant (relative to baseline) was significantly larger in patients with donor-recipient weight ratio > 1.5 compared with patients with donor-recipient weight ratio < or = 1.5 (-2.2 g/m3 compared with 33.4 g/m3, respectively, P < 0.01). Multiple linear regression was performed employing donor-recipient weight ratio, time since transplantation, ischemic time, and age at transplant as prognostic variables. Donor-recipient weight ratio (P < 0.0001), time since transplant (P < 0.01), and age at transplant (P = 0.02) were identified as independent predictors of change in LV mass index. Donor-recipient weight ratio (P = 0.001) and time since transplantation (P = 0.02) were independent predictors of change in LV volume index. There was an interaction between donor-recipient weight ratio and time since transplantation, suggesting that donor-recipient weight ratio has an independent effect as well as a time-dependent effect on change in LV mass and volume indices. LV mass and volume indices increased early posttransplant and then decreased; this pattern was temporally predictable, and dependent on donor-recipient weight ratio and age at transplant.

Comparison of Echocardiographic Changes Associated with Hemodialysis and Renal Transplantation

Long-term hemodialysis has been reported to cause progression of left ventricular (LV) hypertrophy with a tendency toward asymmetric septal hypertrophy. Renal transplantation is believed to reverse some of these changes. The aim of this prospective study was to compare the effects of long-term hemodialysis and of successful renal transplantation on cardiac structure and function assessed by echocardiography. Fifty-three patients were submitted to two echocardiographic evaluations separated by a 30 +/- 8 month interval. At the first control, all patients were on hemodialysis; at the second, 36 patients remained on dialysis while 17 had been submitted to renal transplantation. Age (44 +/- 13 vs. 40 +/- 10 years), gender (male, 50% vs 53%), and duration of dialysis at the initiation of the study (43 +/- 34 vs. 47 +/- 32 months) were comparable in the 2 groups. The prevalence of LV hypertrophy were 83% (first control) and 69% (second control) in the dialysis group and 82% and 71% in the transplant group. Comparisons between the two periods within each group showed that hemodialysis was associated with a significant reduction of the E/A ratio (1.25 +/- 0.4 vs. 1.02 +/- 0.4, p < 0.001) and systolic (155 +/- 28 vs. 137 +/- 26 mm Hg, p < 0.001) and diastolic (94 +/- 21 vs. 84 +/- 16 mm Hg, p < 0.05) blood pressure, and no change in LV mass index (171 +/- 51 vs. 156 +/- 43 g/m2, NS). In the transplanted group, there were reductions in the E/A ratio (1.42 +/- 0.6 vs 1.10 +/- 0.4, p < 0.05) and in LV diastolic dimension (50 +/- 7 vs. 46 +/- 5 mm, p < 0.05), but not in systolic (155 +/- 27 vs. 152 +/- 31 mm Hg, NS) or diastolic (97 +/- 11 vs. 97 +/- 20 mm Hg, NS) blood pressure. The LV mass index also did not change significantly (157 +/- 51 vs. 133 +/- 31 g/m2, NS).(ABSTRACT TRUNCATED AT 250 WORDS)

Angiotensin Converting Enzyme Inhibition with Quinapril and Left Ventricular Mass in the Hypertensive Patient

The effects of quinapril (an angiotensin converting enzyme inhibitor) on cardiac hypertrophy were evaluated in a noncomparative study of 98 patients with mild to moderate hypertension over 4 months. Left ventricular hypertrophy (LVH) was diagnosed using echocardiography in 60% of patients at baseline. Combination therapy with hydrochlorothiazide (HCTZ) was initiated after 1 month in patients with inadequate blood pressure control to achieve a target diastolic pressure reduction from baseline (≥ 10mm Hg) and/or reduction to < 90mm Hg. Left ventricular mass index (LVMI) was significantly reduced for patients of either sex with a baseline diagnosis of LVH, but not for those in whom LVH was not detected at enrolment. Systolic and diastolic blood pressures were also significantly reduced. The response rate was 83%, while 28% of patients required combination therapy with HCTZ. There was no correlation between the hypotensive effects of quinapril and change in LVMI. Furthermore, the addition of a diuretic did not appear to affect the LVMI response. Thus, the amelioration of LVH noted in this investigation appears to be attributable to quinapril.

Prosthetic valves for the small aortic root.

Mechanical aortic valves (AVs) are frequently implanted in small (19 and 21 mm) aortic roots because bioprosthetic valves have unacceptably high gradients and many surgeons do not implant allograft valves. Three mechanical valves in common use today in the United States are the Starr-Edwards (SE), St. Jude Medical (SJ), and the Medtronic-Hall (MH). Clinical hemodynamic studies reveal that the 21-mm SE valve (size 8A) has peak systolic gradients of 13 to 58 mmHg (N = 6) with a calculated effective orifice of 0.7 to 1.4 cm2. The 19-mm SJ valve has a gradient at peak pressure of 17 mmHg and a mean gradient of 22 mmHg (N = 6) with respective exercise gradients of 32 and 38 mmHg (N = 5). For the 21-mm SJ valve the mean gradient was 5.2 +/- 5.3 (N +/- 12) and the gradient at peak pressure was 6.0 mmHg (N = 15). The 21-mm MH valve had resting gradients at peak pressure of 10.5 (N = 3) and 12.4 mmHg (N = 9) and exercise gradients of 15.8 mmHg (N = 9). Six months after AV replacement with small SJ or MH (N = 14) or large (23 mm or greater) (N = 83) valves, cardiac output was 4.7 versus 6.4 L/min (p < 0.03), percent reduction in left ventricular mass index (LVMI) was -8% versus -21% (p < 0.01), exercise duration was 370 versus 555 seconds, and congestive heart failure (CHF) class was 1.9 versus 1.1 (p < 0.0001). Change in LVMI and valve size were the only independent predictors of CHF class.(ABSTRACT TRUNCATED AT 250 WORDS)