Dimitris Chatzis

Left ventricular diastolic dysfunction is accompanied by increased aortic stiffness in the early stages of essential hypertension: a TDI approach.

Objective To investigate the inter-relationship between aortic stiffness and left ventricular (LV) diastolic function in subjects with newly diagnosed uncomplicated essential hypertension. Methods We studied 106 consecutive newly diagnosed subjects (aged 51 years, 80 males) with stage I–II essential hypertension, and 50 normotensives matched for age, sex and body mass index. LV diastolic function was estimated by pulsed tissue Doppler imaging (TDI) echocardiography, averaging diastolic mitral annular velocity measurements (Emav, Amav, Emav/Amav ratio) from four separate sites (basal septal, lateral, anterior, and inferior LV wall). Moreover, aortic stiffness was evaluated by non-invasive carotid–femoral pulse wave velocity (c–f PWV) measurement. Results Hypertensives compared with normotensives exhibited greater LV mass index and Amav (110 versus 95 g/m2 and 10 versus 8.8 cm/s, respectively, P < 0.001 for both cases), and greater c–f PWV (8.47 versus 7.48 m/s, P < 0.03), as well as lower Emav and Emav/Amav values, (8.4 versus 10 cm/s and 0.82 versus 1.15, respectively, P < 0.001 for both cases). In the group of hypertensives, a univariate analysis revealed that c–f PWV was negatively associated with Emav (r = −0.305, P = 0.005), as well as with Emav/Amav ratio (r = −0.437, P < 0.001). Moreover, a multivariate analysis showed that the TDI-derived Emav/Amav ratio was significantly associated with age (P = 0.001), relative wall thickness (P = 0.006) and c–f PWV (P = 0.03), while the conventional Doppler-derived E/A ratio was significantly associated only with age (P = 0.001). Conclusions TDI-detected LV diastolic dysfunction is accompanied by increased aortic stiffness in newly diagnosed essential hypertension, suggesting that there may be a common pathophysiological pathway linking these two entities.

Left ventricular hypertrophy versus chronic kidney disease as predictors of cardiovascular events in hypertension : a Greek 6-year-follow-up study

Objectives We assessed the comparative prognostic role of left ventricular hypertrophy (LVH) and chronic kidney disease (CKD) for major cardiovascular events in a prospective observational study in Greek essential hypertensive patients. Methods We followed up 1652 hypertensive patients (mean age 54.3 years, 696 male patients, office blood pressure 147/93 mmHg) free of cardiovascular disease for a mean period of 6 years. CKD and echocardiographically detected LVH were evaluated at baseline along with five major traditional risk factors [age > 65 years, sex, current smoking, diabetes mellitus and dyslipidemia (low density lipoprotein > 160 mg/dl)]. End points of interest were the incidence of coronary artery disease, stroke, all-cause mortality and their composite. Results At the end of follow-up, coronary artery disease was the most prevalent (5.2%), followed by stroke (5%) and total mortality (3.1%). The presence of both LVH and CKD is associated with a 2.5-fold increase in coronary artery disease (P = 0.034), four-fold in stroke (P = 0.002) and 3.2-fold in the composite (P < 0.001), whereas the presence of LVH alone was associated with a 2.5-fold higher risk for stroke (P = 0.009) and 1.7-fold for the composite (P = 0.018). By multivariate Cox regression analysis, LVH (hazard ratio = 1.53, P = 0.036) and CKD (hazard ratio = 1.66, P = 0.039) turned out to be independent prognosticators of the composite end point, whereas age more than 65 years (hazard ratio = 4.59, P < 0.001) and the presence of LVH (hazard ratio = 2.01, P = 0.043) were the only predictors of stroke. Conclusions In hypertensive patients free of cardiovascular disease, CKD and LVH are both independent prognosticators of the composite end point of all-cause death and cardiovascular morbidity, whereas LVH but not CKD is a major predictor for stroke.

Brain natriuretic peptide as an integrator of cardiovascular stiffening in hypertension

BACKGROUND Left ventricular (LV) diastolic dysfunction and impairment of aortic elastic properties represent common sequelae of hypertension. We investigated the relationships of these cardiovascular adaptations with brain natriuretic peptide (BNP) levels in newly-diagnosed hypertension. METHODS 200 consecutive hypertensives without LV hypertrophy (aged 52 years, 134 males, office BP=151.4/95.5 mmHg) underwent 24 hour ambulatory BP measurement as well as aortic stiffness and LV diastolic function assessment by means of carotid-femoral pulse wave velocity (c-f PWV) measurement and Tissue Doppler Imaging (TDI), respectively. Based on BNP values patients were classified into tertiles. RESULTS Hypertensives in the highest, compared to those in the lowest BNP tertile had significantly higher 24 h pulse pressure (by 6.2 mmHg, p=0.002), lower 24 h diastolic BP (by 5.7 mmHg, p=0.014), decreased Em/Am ratio (by 0.09, p=0.048) and increased c-f PWV (by 0.7 m/s, p=0.042). Moreover, hypertensives in the highest, compared with those in the lowest and the medium tertile of BNP, exhibited significantly lower Em (by 1.2 cm/s, p=0.001 and 1 cm/s, p=0.004, respectively) and higher E/Em ratio (by 1.3, p=0.018 and 1.3, p=0.014, respectively). BNP was significantly associated with E/Em ratio, 24 h pulse pressure and c-f PWV independently from age. CONCLUSION In hypertensives plasma BNP levels are associated not only with LV diastolic dysfunction but also with aortic stiffening. These findings suggest that BNP even within normal range constitutes a surrogate for cardiovascular functional impairment in the setting of essential hypertension without LV hypertrophy.

Evidence for no global effect of metabolic syndrome per se on early hypertensive sequelae.

Objective In the present study we assessed the impact of metabolic syndrome (MS) and its components on markers of cardiovascular and renal damage in a population of essential hypertensives. Methods A total of 651 consecutive, untreated and non-diabetic hypertensives (age 54 ± 12 years, 340 males) who were included in the 3H Study, an ongoing registry of hypertension-related target organ damage, were considered for analysis. Left ventricular mass was indexed both for body surface area (LVMBSA) and for height2.7 (LVMheight2.7). Diastolic function was estimated by means of both conventional and tissue Doppler imaging (TDI) methods. Arterial stiffness was evaluated on the basis of carotid to femoral pulse wave velocity (c-f PWV) and microalbuminuria (MA) as albumin to creatinine ratio (ACR) 22–300 mg/g in men and 31–300 mg/g in women in two non-consecutive morning spot urine samples. Results MS (Adult Treatment Panel III criteria) was present in 201 hypertensives (30.9%). Hypertensives with MS had increased logACR (by 10%, P = 0.01) and higher prevalence of MA (17 versus 8%, P < 0.001). Both groups exhibited similar values of LVMBSA, transmitral and TDI-derived indexes and c-f PWV (NS for all) while LVMheight2.7 was significantly higher in hypertensives with MS (by 2.6 g/m2.7, P = 0.023). Multiple regression analysis revealed that MS was an independent predictor only of logACR (β = 0.110, P = 0.007) and MA (odds ratio = 2.577, P < 0.001), while components of blood pressure affected all studied indices of organ damage. Conclusions MS per se does not deteriorate cardiac adaptations and aortic stiffness beyond haemodynamic load in hypertension. The MS-related unfavourable effect is limited to the level of the glomerulus.

Exaggerated exercise blood pressure response is related to tissue Doppler imaging estimated diastolic dysfunction in the early stages of hypertension

We investigated the plausible interrelationship of exaggerated blood pressure response (EBPR) during exercise with left ventricular (LV) diastolic dysfunction, both associated with adverse cardiovascular outcomes, in the early stages of essential hypertension (EH). Sixty-five consecutive patients (aged 54 years, 56 males) with stage I to II EH underwent 24-hour ambulatory blood pressure (BP) recording and treadmill exercise testing and were classified as subjects with (n = 21) and without EBPR (n = 44) based on the systolic BP elevation at peak exercise (>/=210 mm Hg for men and >/=190 mm Hg for women). LV diastolic function was estimated by pulsed tissue Doppler imaging (TDI), averaging diastolic mitral annular velocities (Em, Am) from four separate sites (LV lateral, septal, anterior, and inferior wall). Hypertensives with EBPR, compared with those without EBPR, exhibited increased 24-hour pulse pressure by 4.8 mm Hg (P < .05) and significantly lower values of Em/Am ratio by 0.07 (P < .05). Univariate logistic regression analysis revealed that only 24-hour pulse pressure (odds ratio [OR] = 1.069; P = .043) and Em/Am (OR = 0.041; P = .049) were independent predictors of EBPR. Hypertensives with EBPR compared to their counterparts without EBPR are characterized by more pronounced LV diastolic dysfunction - assessed by TDI. Moreover, the increased pulsatile load seems to be a common denominator of these hypertension-linked states.

[OP.7D.08] SEVERE RESISTANT HYPERTENSION EXHIBITS THE GREATEST CARDIOVASCULAR RISK AMONG TREATED UNCONTROLLED HYPERTENSIVES: A 4-YEAR FOLLOW-UP STUDY

Objective: Data regarding the prognosis of resistant hypertension (RHT) with respect to its severity is limited. We investigated the cardiovascular risk of severe RHT among patients with treated uncontrolled hypertension. Design and method: In a prospective observational study, 1700 hypertensive patients (aged 57±12 years, 50% males) with office blood pressure (BP) >or = 140 and/or 90mmHg despite antihypertensive treatment, were followed for a mean period of 3.6±1.8 years. At baseline, clinical data were collected and patients underwent echocardiographic measurements, routine blood testing and additional workup for exclusion of secondary causes of RHT. Three groups were identified depending on presence of RHT (office-based uncontrolled hypertension under at least 3 drugs including a diuretic) and levels of office systolic BP: 1,187 patients (70%) without RHT, 313 (18%) with not-severe RHT (systolic BP < 160mmHg) and 200 (12%) with severe RHT (systolic BP >or = 160mmHg). Endpoint of interest was cardiovascular morbidity set as the composite of coronary heart disease and stroke. Results: During follow-up, 58 events were recorded (9.5 cases per 1,000 person-years). Incidence rates of cardiovascular events were 7.1 cases per 1,000 person-years in the group without RHT, 12.4 cases per 1,000 person-years in the group with not-severe RHT and 18 cases per 1,000 person-years in the severe RHT group. Unadjusted analysis showed that compared to uncontrolled patients without RHT, patients with not-severe RHT exhibited a similar risk but patients with severe RHT had a significantly higher risk by 2.5 times (CI: 1.28–4.73, p = 0.007) for the composite cardiovascular outcome. Multivariate cox regression revealed that even after adjusting for a series of established risk factors, severe RHT remained as an independent predictor of the cardiovascular outcome, (OR:2.57, CI:1.27–5.19, p = 0.008). Conclusions: Among treated yet uncontrolled hypertensive patients, severe RHT exhibits a significantly higher cardiovascular risk indicating the need for prompt management.

P-406: Increased aortic stiffness is accompanied by left ventricular diastolic dysfunction in newly diagnosed hypertensives without left ventricular hypertrophy

Since both augmented arterial stiffness and left ventricular (LV) diastolic dysfunction are associated with adverse cardiovascular prognosis, the aim of this study was to investigate the relationship between these two parameters in the early stages of essential hypertension. Towards this end, we studied 53 newly diagnosed patients with stage I-II essential hypertension (aged 51.5 years, office blood pressure (BP) 148/97 mmHg) and 29 age and sex-matched normotensive controls. LV diastolic function was assessed by measuring mitral annular velocities (peak early [Em], and peak late diastolic velocity [Am], Em/Am ratio) with pulsed Tissue Doppler Imaging (TDI). Measurements were performed on four separate sites (basal septal, lateral, anterior and inferior LV wall) and the average values were used. Aortic stiffness was evaluated by means of a computerized method (Complior SP), on the basis of pulse wave velocity (PWV) measurements. Hypertensives compared to normotensives did not differ significantly regarding their metabolic status, while they had greater LV mass index (110 24 g/m vs 95 20 g/m, p 0.01) and greater RWT (0.46 0.08 vs 0.4 0.04, p 0.001). Furthermore, hypertensives compared to normotensives exhibited greater PWV values (8.47 1.5 vs 7.48 1.2 cm/sec, p 0.003) and lower Em and Em/Am ratio values (8.4 1.4 vs 10 1.6 cm/sec and 0.82 0.09 vs 1.15 0.16 respectively, p 0.001 for both cases). In the total population, aortic PWV was positively correlated with age (r 0.353, p 0.001), office systolic BP (r 0.358, p 0.001), office diastolic BP(r 0.28, p 0.05) and RWT (r 0.424, p 0.001), while it was negatively associated with Em (r -0.305, p 0.005) and Em/Am ratio (r -0.437, p 0.001). In conclusion, despite the absence of LV hypertrophy, increased aortic stiffness is associated with LV diastolic dysfunction in the early stages of essential hypertension, suggesting that there maybe a common pathophysiologic pathway linking these two entities.