Stress-corrected Midwall Shortening Research Articles

Higher Acceleration/Ejection Time Ratio Predicts Impaired Outcome in Aortic Valve Stenosis.

Acceleration time (AT)/ejection time (ET) ratio is a marker of aortic valve stenosis (AS) severity and predicts outcome in moderate-severe AS. We explored the association of increased AT/ET ratio on prognosis in 1530 asymptomatic patients with presumably mild-moderate AS, normal ejection fraction, and without known diabetes or cardiovascular disease. Patients were part of the SEAS study (Simvastatin Ezetimibe Aortic Stenosis). Patients were grouped according to the optimal AT/ET ratio threshold to predict cardiovascular death and heart failure hospitalization. Low-gradient severe AS was identified as combined valve area ≤1.0 cm2 and mean gradient <40 mm Hg. Outcome was assessed in Cox regression analyses, and results are reported as hazard ratio and 95% CI. Higher AT/ET ratio was significantly associated with lower systolic blood pressure, lower left ventricular ejection fraction, lower stress-corrected midwall shortening, low flow, and with higher left ventricular mass and higher peak aortic jet velocity. AT/ET ratio ≥0.32 provided the optimal cutoff for predicting incident cardiovascular death and heart failure hospitalization in the total study sample. In patients with low-gradient severe AS, this threshold was >0.32. AT/ET ratio ≥0.32 had a 79% higher risk of cardiovascular death and heart failure hospitalization (hazard ratio, 1.79 [95% CI, 1.20-2.68]). In patients with low-gradient severe AS, AT/ET ratio >0.32 was associated with a 2-fold higher risk of cardiovascular death and heart failure hospitalization (hazard ratio, 2.15 [95% CI, 1.22-3.77]). In asymptomatic nonsevere AS and low-gradient severe AS, higher AT/ET ratio was associated with increased cardiovascular morbidity and mortality. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT00092677.

Higher acceleration ejection time ratio predicts impaired prognosis in mild to moderate aortic stenosis

Abstract Introduction Acceleration/ejection time (AT/ET) ratio is a marker of aortic stenosis (AS) severity, and a predictor of outcome in severe AS. The importance of ejection dynamics in mild and moderate AS has been less investigated. Purpose To investigate the impact of increased AT/ET ratio on prognosis in patients with mild-moderate AS. Methods Data from 1635 patients with asymptomatic mild-moderate AS with preserved ejection fraction enrolled in the Simvastatin and Ezetimibe in Aortic Stenosis study was analysed. Covariates of higher AT/ET ratio was identified in linear regression analysis. Outcome was assessed in Cox regression analyses and reported as hazard ratio (HR) and 95% confidence interval (CI) per 1 standard deviation (SD) higher AT/ET ratio. Median follow-up time was 4 years. Results The total study population included 38% female, mean age 67 years and average peak aortic jet velocity was 3.02 m/s. Higher AT/ET ratio was significantly associated with lower ejection fraction, higher LV mass, higher aortic jet velocity, lower systolic blood pressure, low stroke volume index and lower stress-corrected midwall shortening (all p&amp;lt;0.05). In Cox regression analyses, adjusting for these confounders including age and gender, 1 SD higher AT/ET ratio predicted a 29% increase in hazard for major cardiovascular events, 25% for cardiovascular death and hospitalization for heart failure and 23% increase in hazards for all-cause mortality (Table). Conclusion In asymptomatic mild-moderate AS patients free from diabetes and known cardiovascular disease, higher AT/ET ratio was associated with increased risk for major cardiovascular events, cardiovascular death and hospitalization for heart failure and all-cause mortality independent of traditional risk markers. Funding Acknowledgement Type of funding source: None

Concentric left ventricular remodelling is associated with subclinical systolic dysfunction in patients with psoriatic arthritis

Objectives: Subclinical left ventricular (LV) abnormalities have been reported in echocardiographic studies of patients with psoriatic arthritis (PsA). Left ventricular systolic dysfunction (LVSD) often coexists with concentric LV remodelling, an unfavourable prognostic factor that is commonly found in patients at high cardiovascular risk. However, it is unclear whether PsA is associated with concentric LV remodelling. This cross-sectional study assesses the prevalence of and factors associated with concentric LV remodelling in a cohort of patients with PsA, and tests the hypothesis that concentric LV remodelling is a major determinant of LVSD in PsA. Method: We evaluated 101 adults attending an outpatient clinic with PsA diagnosed according to the ClASsification criteria for Psoriatic ARthritis (CASPAR). All patients were free of cardiovascular disease. Patients with PsA were compared with 101 controls matched for age, gender, body mass index, hypertension, and diabetes. Echocardiography was performed: concentric LV remodelling was defined if the relative wall thickness was > 0.43; stress-corrected mid-wall shortening was used as an index of LVSD and considered impaired if < 86.5%. Results: Concentric LV remodelling was found in 58% of patients with PsA and 18% of controls (p < 0.001). LVSD was found in a significantly higher proportion of patients with PsA (56%, p < 0.001) than controls. The presence of PsA yielded a 10-fold higher probability of having LVSD [odds ratio (OR) 9.6, 95% confidence interval (CI) 4.2–21.9, p < 0.0001]. In patients with PsA, concentric LV remodelling increased the risk of LVSD four-fold (OR 3.7, 95% CI 1.3–10.2, p = 0.013). Conclusion: Most asymptomatic patients with PsA have concentric LV remodelling, which is closely associated with subclinical LVSD.

HYPERTENSION IS ASSOCIATED WITH MORE ABNORMAL LEFT VENTRICULAR GEOMETRY AND SYSTOLIC MYOCARDIAL DYSFUNCTION IN OVERWEIGHT AND OBESITY

Objective: To study the impact of hypertension on left ventricular (LV) geometry and systolic myocardial function in women and men with increased body mass index (BMI), but without known cardiovascular disease.Design and method: We performed a cross-sectional analysis of 535 participants (59% women) in the the FAT associated CardiOvasculaR dysfunction (FATCOR) study. Hypertension was defined as use of antihypertensive treatment or elevated 24-hour blood pressure. Abnormal LV geometry was identified as increased relative wall thickness or LV mass index by echocardiography. Systolic myocardial function was assessed by speckle tracking global longitudinal strain (GLS) and stress-corrected midwall shortening (scMWS). Obesity was defined as a BMI 30.0 kg/m2 or larger. Results: Hypertension was associated with older age, higher GLS, lower scMWS and higher prevalences of obesity and abnormal LV geometry (all p < 0.01) (Table). In multivariable regression analyses, hypertension was associated with higher (less negative) GLS (β=-0.16, p = 0.001), lower scMWS (β=-0.12, p = 0.009) and prevalent abnormal LV geometry (odds ratio 1.60 {95% confidence interval 1.01–2.53}, p = 0.047) independent of presence of obesity and older age. Conclusions: In women and men with increased BMI without known cardiovascular disease, hypertension was associated with more abnormal LV geometry and impaired systolic myocardial function.

Disease activity is associated with reduced left ventricular systolic myocardial function in patients with rheumatoid arthritis

ObjectivesDisease activity has emerged as a new, independent risk factor for cardiovascular disease in patients with rheumatoid arthritis (RA). We tested if disease activity in RA was associated with lower...

Combined Circumferential and Longitudinal Left Ventricular Systolic Dysfunction in Patients with Rheumatoid Arthritis without Overt Cardiac Disease

Background Patients with rheumatoid arthritis have an increased risk for cardiovascular disease. Because of accelerated atherosclerosis and changes in left ventricular (LV) geometry, circumferential and longitudinal (CL 95% CI, 1.01–1.06; P = .04) and concentric LV geometry (odds ratio, 2.76; 95% CI, 1.07–7.15; P = .03). By multiple logistic regression analysis, rheumatoid arthritis emerged as an independent predictor of combined CL 95% CI, 1.06–6.25). The relationship between sc-MS and S′ was statistically significant in the subgroup of 142 patients without combined CL r 2 = 0.19, P It appears clear that, starting from the same 198 patients included in the database, different sub-groups of patients were selected and analyzed in the two papers (they had different echocardiographic characteristics) and, consequently, different factors emerged by the statistical analyses as covariates associated with the different phenotypes of LVSD considered. Importantly, both papers E and J had a very long gestation because all reviewers for the different journals found several and important issues that merited to be addressed: a lot of changes were proposed and much additional information was required, particularly by the reviewers of paper E. Considering this context, it emerges that although paper E was written well before paper J, the two manuscripts were accepted at the same time (we received the letters of acceptance within a couple of weeks). Thus, the uncertainty about the fate of both manuscripts made it very difficult (if not impossible) to cite either of them in the other one and, afterward, we just did not think about this point anymore. Of note, the idea to combine in the analysis longitudinal function came therefore well after the starting process of revision of the paper E and was, in some way inspired by a reviewer's comment. That is why we did not put both findings in the same paper. We think that our explanations provide the broad audience of your journal a perspective of transparency and our respect for the readers' right to understand how the work described in the paper J relates to other work by our research group. Giovanni Cioffi On behalf of all co-authors Ombretta Viapiana, Federica Ognibeni, Andrea Dalbeni, Davide Gatti, Carmine Mazzone, Giorgio Faganello, Andrea Di Lenarda, Silvano Adami, and Maurizio Rossini

Prevalence and Factors Associated with Subclinical Left Ventricular Systolic Dysfunction Evaluated by Mid-Wall Mechanics in Rheumatoid Arthritis.

Patients with rheumatoid arthritis (RA) have an increased cardiovascular event rate, mainly due to the arterial stiffness which leads to coronary atherosclerosis and concentric left ventricular (LV) geometry. These conditions predispose to LV systolic dysfunction (LVSD), which can be detected by stress-corrected mid-wall shortening (sc-MS), an early prognosticator of cardiovascular events in asymptomatic patients with arterial hypertension and/or diabetes. In these subjects, sc-MS is frequently impaired even though LV ejection fraction (LVEF) is preserved. In this study, we analyzed the prevalence and the factors associated with asymptomatic LVSD measured by sc-MS among patients with RA and verified whether RA per se was independently related to LVSD. We prospectively recruited 198 outpatients with RA without overt cardiac disease between January and June 2014 and compared them to 198 controls matched for age, gender, body mass index, and prevalence of hypertension and diabetes. sc-MS was taken as index of LVSD and considered impaired if <86.5%. Impaired sc-MS was detected in 110 (56%) RA patients and in 30 (15%) controls (P < 0.001), whereas LVEF was impaired (value <50%) in six (3%) RA patients and in two (1%) controls (P = ns). Multiple logistic regression analysis revealed that RA was independently associated with impaired sc-MS (Exp β 2.01 [CI 1.12-3.80], P = 0.02) together with increased LV mass and concentric geometry. More than half RA patients without overt cardiac disease have LVSD detectable by sc-MS. RA emerges as a condition closely related to LVSD. These findings might explain the high risk for adverse cardiovascular events in RA patients.

Insights from Cardiac Mechanics after Three Decades from Successfully Repaired Aortic Coarctation

Patients who underwent a successful repair of the aortic coarctation show chronic hyperdynamic state and normal left ventricular (LV) geometry; however, there are few data regarding the LV systolic function in the long term. Accordingly, we assessed LV systolic mechanics and factors associated with LV systolic dysfunction (LVSD) in patients with repaired CoA. Clinical and echocardiographic data from 19 repaired CoA were analyzed 28 ± 13 years after surgery. Stress-corrected midwall shortening (sc-MS) and mitral annular peak systolic velocity (S') were analyzed as indexes of LV circumferential and longitudinal systolic function, respectively. Echocardiographic data of CoA patients were compared with 19 patients matched for age and hypertension and 38 healthy controls. Sc-MS was considered impaired if <89%, S' if <8.5 cm/s (10th percentiles of healthy controls, respectively). There were no statistical differences between study groups in LV volumes, mass and geometry. LV ejection fraction and Sc-MS were similar in all groups, however, CoA group had a significantly lower peak S' in comparison with matched and healthy controls (7.1 ± 1.3, 10.3 ± 1.9, and 11.1 ± 1.5, respectively; all P < 0.001). Prevalence of longitudinal LVSD defined as low S' was 84% in CoA, 13% in matched, and 5% in healthy control group (all P<0.05). Multivariate logistic regression analysis revealed that low peak S' was independently related to higher E/E' ratio and the presence of CoA. Patients who underwent a successful repair of CoA commonly show asymptomatic longitudinal LVSD associated with worse LV diastolic function in the long-term follow-up.

Abstract 15297: Active Rheumatoid Arthritis is Associated With Subclinical Left Ventricular Systolic Myocardial Dysfunction

Introduction: Patients with rheumatoid arthritis (RA) have comparable cardiovascular risk to patients with diabetes mellitus. Lately, disease activity has emerged as a new, independent risk factor for cardiovascular disease in RA patients. Hypothesis: We tested if RA disease activity was associated with subclinical systolic left ventricular (LV) dysfunction independent of traditional cardiovascular risk factors. Methods: Echocardiography was performed in 78 patients with active RA (Simplified Disease Activity Index [SDAI] &gt;3.3), 41 patients in remission (SDAI ≤3.3), and 46 controls, all without known cardiac disease. LV endocardial systolic function was determined by biplane Simpson ejection fraction and LV myocardial function by stress-corrected midwall shortening (scMWS) and global longitudinal strain (GLS). Results: Patients with active RA had higher frequencies of hypertension, diabetes and use of disease modifying antirheumatic drugs (all p&lt;0.05) compared to patients in remission, while age and sex did not differ from RA patients in remission (Table). LV ejection fraction was normal in all groups, while mean GLS and scMWS were reduced in RA patients with active disease compared to RA in remission (p&lt;0.05) (Table). In multivariate analyses, having active RA was associated with lower GLS (β=0.21) and scMWS (β=-0.22, both p&lt;0.05) independent of cardiovascular risk factors and LV ejection fraction. Assessment of RA disease activity by other composite scores yielded similar results. Conclusions: Active RA is associated with subclinical reduced LV systolic myocardial function despite normal ejection fraction, and independent of presence of hypertension and diabetes.

STA106. Maternal cardiac function before and during preeclampsia: We must study the heart in pregnancy

Objective Most studies during pregnancy have assessed maternal left ventricular (LV) function by load-dependent indices, assessing only chamber function. The aim of this study was to assess afterload-adjusted LV myocardial and chamber systolic function at 24 weeks’ gestation and 6 months postpartum in high-risk normotensive pregnant women. Methods A group of 118 high-risk women with bilateral notching of the uterine arteries underwent an echocardiographic examination to evaluate midwall mechanics (midwall shortening (mFS%) and stress-corrected midwall shortening (SCmFS%)) of the LV at 24 weeks’ gestation and 6 months postpartum. Patients were followed until delivery and pregnancies were classified retrospectively as uneventful (uncomplicated outcome) or complicated. A control group of 54 low-risk women with uneventful pregnancies without bilateral notching was also enrolled. Results The pregnancy was uneventful in 74 (62.7%) women, whereas 44 (37.3%) developed complications. At 24 weeks’ gestation, mFS% and SCmFS% were greater in the uncomplicated-outcome compared with the complicated-outcome group (25.9 ± 4.8 vs 18.8 ± 5.0%, P 0.001 and 107.9 ± 18.4 vs 77.9 ± 20.7%, P 0.001 , respectively). At 6 months postpartum, SCmFS% remained greater in the uncomplicated-outcome compared with the complicated-outcome group (100.4 ± 21.6 vs 87.8 ± 19.1, P 0.05 ). In the uncomplicated outcome group, SCmFS% was higher during pregnancy than it was postpartum, whereas in the complicated outcome group, it was lower during pregnancy than it was postpartum ( P 0.05 ). Conclusions Maternal cardiac midwall mechanics appear to be enhanced (SCmFS% increased compared with controls) during pregnancy compared with postpartum in high-risk patients with uncomplicated pregnancy, whereas midwall mechanics are depressed both during pregnancy and postpartum in patients with pregnancy complications

Relationship of left ventricular systolic function to persistence or development of electrocardiographic left ventricular hypertrophy in hypertensive patients: implications for the development of new heart failure.

Persistence or development of ECG left ventricular hypertrophy (LVH) by Cornell product criteria is associated with an increased risk of developing heart failure compared with regression or continued absence of LVH. We postulated that this association might be in part mediated via worse left ventricular systolic function in patients with new or persistent ECG LVH. Baseline and year-3 ECG LVH and left ventricular midwall shortening (MWS) were examined in 725 hypertensive patients in the Losartan Intervention For Endpoint reduction in hypertension (LIFE) echocardiographic substudy. Sex-specific criteria were used for abnormal MWS (<14% in men and <16% in women) and abnormal stress-corrected MWS (scMWS; <87% in men and <90% in women). Cornell product LVH greater than 2440 mm ms defined ECG LVH. Between baseline and year-3 follow-up, there was continued absence or regression of ECG LVH in 427 patients and persistence or development of new LVH in 298 patients. At baseline, although there were no significant differences in the mean values of MWS and scMWS, patients with persistence or development of ECG LVH at year 3 had significantly higher baseline prevalences of abnormal MWS (41.9 vs. 30.2%, P = 0.001) and abnormal scMWS (27.4 vs. 20.5%, P = 0.034). At year-3 follow-up, persistence or development of new LVH was associated with significantly lower mean MWS (16.5 ± 2.3 vs. 17.2 ± 1.9%, P < 0.001) and scMWS (104.2 ± 13.1 vs. 106.5 ± 10.9%, P = 0.005), and with higher prevalence and odds of abnormal MWS [23.8 vs. 10.8%, P < 0.001, odds ratio (OR) 2.50, 95% confidence interval (CI) 1.66-3.75, P < 0.001] and abnormal scMWS (11.0 vs. 5.8%, P = 0.011, OR 2.02, 95% CI 1.16-3.51, P = 0.013). After controlling for differences in age, sex, race, treatment group, baseline and change from baseline to year 3 of heart rate, Sokolow-Lyon voltage, systolic and diastolic pressure and baseline severity of LVH by Cornell product, persistent or new ECG LVH remained associated with two-fold increased odds of abnormal MWS (OR 2.20, 95% CI 1.39-3.47, P = 0.001) or scMWS (OR 1.90, 95% CI 1.03-3.50, P = 0.040) at year 3. Persistence or development of new ECG LVH during antihypertensive therapy is associated with an increased risk of left ventricular systolic dysfunction after 3 years' follow-up. These findings provide insight into a possible mechanism by which changes in ECG LVH are associated with the changing risk of developing heart failure. http://clinicaltrials.gov/ct/show/NCT00338260?order=1.

Does metabolic syndrome worsen systolic dysfunction in diabetes? The shortwave study.

Patients with metabolic syndrome (MetS) have high cardiovascular event rates. The additional effect of MetS on left ventricular (LV) systolic function in patients with type 2 diabetes mellitus (T2DM) is unknown. We studied the relation between MetS and LV systolic function in T2DM patients without coronary artery disease (CAD). Clinical and echocardiographic data from 331 T2DM patients were analyzed. Prevalence of MetS was assessed based on NCEP ATPIII definition. Stress-corrected midwall shortening (sc-MS) and mitral annular peak systolic velocity (S') were analyzed as indexes of circumferential and longitudinal shortening, respectively. Sc-MS was impaired if <89 %, S' if <8.5 cm/s (10th percentile of healthy controls). MetS was diagnosed in 172 patients. Sc-MS and S' were similar in T2DM patients with and without MetS (91 ± 14 vs 92 ± 15 %; 9.8 ± 2.0 vs 9.5 ± 2.1 cm/s, respectively; p = ns) but significantly reduced comparing to controls (102 ± 11 % and 10.8 cm/s; p < 0.0001). Impairment of sc-MS and S' were detected in 37 vs 40 % and in 29 vs 32 % of T2DM patients with and without MetS (p = ns), respectively. LV systolic function measured as sc-MS and S' is frequently impaired in T2DM patients without CAD; however, the coexistence of MetS is not associated with more severe LV systolic dysfunction. Further pathological mechanisms have to be considered to explain the negative prognostic impact of MetS in T2DM patients.

Usefulness of Subclinical Left Ventricular Midwall Dysfunction to Predict Cardiovascular Mortality in Patients With Type 2 Diabetes Mellitus

In this study, we tested the hypothesis that impaired midwall shortening predicts cardiovascular (CV) mortality in patients with type 2 diabetes mellitus (DM). In patients with DM without overt cardiac disease, systolic left ventricular (LV) function analyzed by midwall shortening may be impaired although LV ejection fraction is preserved. Impaired midwall shortening is an early independent prognosticator of adverse clinical outcome in patients with arterial hypertension. We analyzed the echocardiographic data from 360 outpatients with DM collected during the years 1990 to 2007. Patients had no history or symptoms attributable to cardiac disease. Stress-corrected midwall shortening (sc-MS) was taken as index of systolic LV function and considered impaired if <89%. The study outcome was CV mortality. At baseline, impaired sc-MS was detected in 140 patients (39%). During a mean follow-up period of 11 years, 54 patients (15%) died, 31 (8.6%) of them from CV causes. CV deaths occurred in 21 of 140 patients (15%) with impaired sc-MS and in 10 of 220 patients (4.5%) with normal sc-MS (p=0.006). Multivariate Cox regression analysis revealed that impaired sc-MS (hazard ratio 1.03, 95% confidence interval 1.01 to 1.08, p=0.039), together with lower estimated glomerular filtration rate (hazard ratio 0.96, 95% confidence interval 0.93 to 0.99, p=0.004), was independently associated with CV mortality even after adjustment for age, diabetes duration, hemoglobin A1c, left atrial diameter, and heart valve calcium. In conclusion, subclinical systolic LV dysfunction as measured by sc-MS occurs frequently in patients with DM without overt cardiac disease and independently predicts long-term CV mortality in such patients together with lower estimated glomerular filtration rate.

The increasing detection of asymptomatic left ventricular dysfunction in patients with type 2 diabetes mellitus without overt cardiac disease: Data from the SHORTWAVE study

AimsType 2 diabetes mellitus (DM) is associated with higher risk of heart failure. Over the last three decades several studies demonstrated the presence of asymptomatic systolic and/or diastolic left ventricular (LV) dysfunction (asymLVD) in patients with normal LV ejection fraction (LVEF). Purpose of our study was to assess the prevalence and factors associated with asymLVD in DM patients by echocardiographic indexes more sensitive than LVEF and transmitral flow detected by pulsed Doppler. Methods386 DM patients without overt cardiac disease were enrolled from January to October 2011. Stress-corrected midwall shortening (sc-MS) and mitral annular peak systolic velocity (S′) were considered as indexes of systolic function of circumferential and longitudinal myocardial fibers, respectively. Early diastolic velocity of transmitral flow was divided by early diastolic Tissue Doppler velocity of mitral annulus for identifying diastolic LVD. ResultsasymLVD was detected in 262 patients (68%). 106 (27%) had isolated systolic asymLVD, 61 (16%) isolated diastolic asymLVD; in 95 (25%) systolic and diastolic asymLVD coexisted. Patients with asymLVD were older, had lower glomerular filtration rate, higher levels of glycated hemoglobin, C reactive protein, LV mass, relative wall thickness and prevalence of valve calcifications. Older age (HR 1.1 [1.02–1.18], p=0.01), aortic valve calcifications (HR 6.3 [1.31–30.31], p=0.02), LV concentric geometry defined as relative wall thickness ≥0.43 (HR 15.44 [2.96–80.44], p=0.001) were independent predictors of asymLVD at multivariate analysis. ConclusionsUsing suitable echocardiographic indexes, asymLVD is detectable in two/third of DM patients without overt cardiac disease and is predicted by older age, cardiac valve calcifications and LV concentric remodeling.

Effect of Overweight and Obesity on Cardiovascular Events in Asymptomatic Aortic Stenosis: A SEAS Substudy (Simvastatin Ezetimibe in Aortic Stenosis)

This study investigated whether overweight and obesity impacted outcome in patients with aortic valve stenosis (AS). Increased body mass index (BMI) is a strong predictor of higher cardiovascular (CV) morbidity and mortality in the general population but not among patients undergoing heart surgery. Cardiovascular events in 1,664 patients with initially asymptomatic AS were recorded during a mean of 4.3 years of follow-up in the SEAS (Simvastatin Ezetimibe in Aortic Stenosis) study. Patients were grouped according to baseline BMI class. Overweight (n = 737) and obese patients (n = 334) had higher prevalence of hypertension, more abnormal left ventricular geometry, and lower stress-corrected midwall shortening throughout the study compared with normal weight patients (all p < 0.01). The AS progression rate did not differ between BMI classes. In univariate Cox regression, overweight was associated with a 17% to 22% lower rate of AS-related (p = 0.04) and ischemic CV events (p = 0.05). In multivariate analyses, adjusting for AS severity and differences in baseline characteristics, overweight had no significant influence on the rate of ischemic CV or AS-related events, whereas overweight and obesity had 46% and 67% higher rate of total mortality and 42% and 69% higher rate of combined hospital stay for heart failure and death from any cause, respectively, compared with normal weight patients (all p < 0.05). In patients with initially asymptomatic AS participating in the SEAS study, overweight and obesity did not influence AS progression or rate of AS-related or ischemic CV events but were both associated with increased mortality.

Prevalence and covariates of abnormal left ventricular geometry in never-treated hypertensive patients in Tanzania

Aim. To assess prevalence, type and covariates of abnormal left ventricular (LV) geometry in untreated native Tanzanian patients with hypertension in relation to normotensive controls. Methods. Echocardiography was performed in 161 untreated hypertensive outpatients and 80 normotensive controls at a tertiary hospital in Tanzania. Hypertensive heart disease was defined as presence of increased LV mass or relative wall thickness (RWT). Results. The prevalence of hypertensive heart disease increased with the severity of hypertension and was on average 62.1% among patients and 12.5% in controls. In multivariate analyses, higher LV mass index was associated with higher systolic blood pressure (β = 0.28), body mass index (β = 0.20), peak early transmitral to medial mitral annulus velocity ratio (β = 0.16), and with lower stress-corrected midwall shortening (scMWS) (β = − 0.44) and estimated glomerular filtration rate (β = − 0.16), all p < 0.05. Higher RWT was associated with higher systolic blood pressure (β = 0.16), longer E-wave deceleration time (β = 0.23) and lower scMWS (β = − 0.66), irrespective of LV mass (all p < 0.05). Conclusion. Subclinical hypertensive heart disease is highly prevalent in untreated native hypertensive Tanzanians and associated with both systolic and diastolic LV dysfunction. Management of hypertension in Africans should include high focus on subclinical hypertensive heart disease.

The worrisome liaison between left ventricular systolic dysfunction and mitral annulus calcification in type 2 diabetes without coronary artery disease: Data from the SHORTWAVE study

Background and AimMitral annulus calcification (MAC) is a marker for coronary artery disease (CAD) and predicts poor outcome in the general population. No data are available on MAC in patients with type 2 diabetes. In these patients we assessed prevalence of MAC and the relation between MAC and left ventricular (LV) systolic function. Methods and ResultsAs many as 386 patients with type 2 diabetes without CAD were studied with Doppler echocardiography. LV systolic dysfunction was defined by analyzing 120 healthy subjects. Stress-corrected midwall shortening (sc-MS) and mitral annular peak systolic velocity (peak S′) were considered as indexes of LV circumferential and longitudinal shortening and classified low if <89% and <8.5 cm/s, respectively (10th percentiles of controls). Patients who had MAC (107 = 28%) were older with longer duration of DM and were receiving more anti-hypertension medications than those who had not. At echocardiographic evaluation patients with MAC showed higher LV mass, larger left atrial volume (LAV), reduced sc-MS (88.4 ± 14.9 vs 92.6 ± 14.3%; p = 0.01) and peak S′ (8.9 ± 2.2 vs 10.0 ± 2.0 cm/s; p < 0.001) than patients without MAC. Multiple logistic regression demonstrated older age (OR 1.03 [IC 1.01–1.06], p = 0.009), larger LAV (OR 1.19 [IC 1.11–1.28], p < 0.001) and combined reduction in sc-MS and peak S′ (OR 3.00 [IC 1.57–5.72], p = 0.001) as independent factors associated with MAC. ConclusionsMAC is detectable in one fourth of patients with type 2 diabetes without CAD and is mostly related to LV systolic dysfunction expressed as combined impairment of LV circumferential and longitudinal fibers, independent of age and LAV.

Left ventricular midwall mechanics at 24 weeks' gestation in high‐risk normotensive pregnant women: relationship to placenta‐related complications of pregnancy

Most studies during pregnancy have assessed maternal left ventricular (LV) function by load-dependent indices, assessing only chamber function. The aim of this study was to assess afterload-adjusted LV myocardial and chamber systolic function at 24 weeks' gestation and 6 months postpartum in high-risk normotensive pregnant women. A group of 118 high-risk women with bilateral notching of the uterine arteries underwent an echocardiographic examination to evaluate midwall mechanics (midwall shortening (mFS%) and stress-corrected midwall shortening (SCmFS%)) of the LV at 24 weeks' gestation and 6 months postpartum. Patients were followed until delivery and pregnancies were classified retrospectively as uneventful (uncomplicated outcome) or complicated. A control group of 54 low-risk women with uneventful pregnancies without bilateral notching was also enrolled. The pregnancy was uneventful in 74 (62.7%) women, whereas 44 (37.3%) developed complications. At 24 weeks' gestation, mFS% and SCmFS% were greater in the uncomplicated-outcome compared with the complicated-outcome group (25.9 ± 4.8 vs 18.8 ± 5.0%, P < 0.001 and 107.9 ± 18.4 vs 77.9 ± 20.7%, P < 0.001, respectively). At 6 months postpartum, SCmFS% remained greater in the uncomplicated-outcome compared with the complicated-outcome group (100.4 ± 21.6 vs 87.8 ± 19.1, P < 0.05). In the uncomplicated-outcome group, SCmFS% was higher during pregnancy than it was postpartum, whereas in the complicated-outcome group, it was lower during pregnancy than it was postpartum (P < 0.05). Maternal cardiac midwall mechanics appear to be enhanced (SCmFS% increased compared with controls) during pregnancy compared with postpartum in high-risk patients with uncomplicated pregnancy, whereas midwall mechanics are depressed both during pregnancy and postpartum in patients with pregnancy complications.

Inappropriately high left-ventricular mass in asymptomatic mild-moderate aortic stenosis

In some patients with aortic stenosis left-ventricular hypertrophy exceeds what is needed to sustain the hemodynamic load imposed by the aortic stenosis, a condition named inappropriately high left-ventricular mass (iLVM). Although iLVM is associated with increased mortality after aortic valve replacement, prevalence and covariates of iLVM in asymptomatic aortic stenosis are unknown. We analyzed baseline data from 1614 patients (67 ± 10 years, 51% hypertensive) recruited in the Simvastatin Ezetimibe in Aortic Stenosis study evaluating placebo-controlled combined simvastatin and ezetimibe treatment in asymptomatic mild-moderate aortic stenosis. iLVM was diagnosed by Doppler echocardiography as LVM greater than 28% of the expected LVM predicted from height, sex and stroke work. iLVM was detected in 268 patients (16.6%), irrespective of concomitant hypertension. Patients with iLVM had higher body weight, LVM and relative wall thickness, higher prevalence of systolic dysfunction (88 vs. 15%) and lower left-ventricular afterload (all P < 0.01) than patients with appropriate LVM in spite of comparable aortic stenosis severity. In multivariate analysis, all these five variables were independently associated with iLVM. The simple coexistence of low stress-corrected midwall shortening and left-ventricular hypertrophy was the best clinical model describing iLVM phenotype (sensitivity 72%, specificity 96%, area under the receiver operating characteristic curve 0.954). iLVM is common in asymptomatic mild-moderate aortic stenosis and unrelated to severity of aortic stenosis or presence of hypertension. iLVM was associated with combined concentric geometry and reduced left-ventricular myocardial contractility, suggesting iLVM in asymptomatic aortic stenosis as a marker of more advanced myocardial disease.

Analysis of Circumferential and Longitudinal Left Ventricular Systolic Function in Patients With Non-Ischemic Chronic Heart Failure and Preserved Ejection Fraction (from the CARRY-IN-HFpEF Study)

Heart failure with preserved left ventricular ejection fraction (HFpEF) is implicitly attributed to diastolic dysfunction, often recognized in elderly patients with hypertension, diabetes, and renal dysfunction. In these patients, left ventricular circumferential and longitudinal shortening is often impaired despite normal ejection fraction. The aim of this prospective study was to analyze circumferential and longitudinal shortening and their relations in patients with nonischemic HFpEF. Stress-corrected midwall shortening (sc-MS) and mitral annular peak systolic velocity (S') were measured in 60 patients (mean age 73 ± 13 years) with chronic nonischemic HFpEF in stable New York Heart Association functional class II or III and compared to the values in 120 healthy controls and 120 patients with hypertension without HFpEF. Sc-MS was classified as low if <89% and S' as low if <8.5 cm/s (the 10th-percentile values of healthy controls). Isolated low sc-MS was detected in 46% of patients with HFpEF, 27% of patients with hypertension, and 2% of controls; isolated low S' was detected in 11% of patients with HFpEF, 7% of patients with hypertension, and 5% of controls; and combined low sc-MS and low S' was detected in 26% of patients with HFpEF, 9% of patients with hypertension, and 5% of controls (HFpEF vs others, all p values <0.001). Thus, any alteration of systolic function was found in 83% of patients with HFpEF. The relation between sc-MS and S' was nonlinear (cubic). Changes in S' within normal values corresponded to negligible variations in sc-MS, whereas the progressive decrease below 8.5 cm/s was associated with substantial decrease in sc-MS. In conclusion, circumferential and/or longitudinal systolic dysfunction is present in most patients with HFpEF. Circumferential shortening normalized by wall stress identifies more patients with concealed left ventricular systolic dysfunction than longitudinal shortening.