Giuseppino Massimo Ciavarella

Right Ventricular Dysfunction in Patients with End-Stage Renal Disease

Background: While chronic dialysis treatment has been suggested to increase pulmonary pressure values, right ventricular dysfunction (RVD) is a major cause of death in patients with end-stage renal disease. We investigated the impact of different dialysis treatments on right ventricular function. Methods: We examined 220 subjects grouped as follows: healthy controls (n = 100), peritoneal dialysis (PD; n = 26), hemodialysis (HD) with radial arteriovenous fistula (AVF; n = 62), and HD with brachial AVF (n = 32). Echocardiography including tissue Doppler imaging (TDI) of the right ventricle was performed in all patients. Results: Pulmonary pressure values progressively rose from controls across the 3 dialysis groups (21.7 ± 6.8, 29.7 ± 6.7, 37.9 ± 6.7 and 40.8 ± 6.6 mm Hg, respectively; p < 0.001). TDI indices of right ventricular function were more impaired in HD patients, particularly in those with brachial AVF. RVD, assessed by TDI myocardial performance index, was higher in HD patients compared with PD patients (71.3 vs. 34.6%, p < 0.001). Moreover, the prevalence of RVD further increased in patients with brachial AVF compared with the radial access (90.6 vs. 61.3%, p < 0.001). Conclusions: Compared to DP, HD increases the risk of RVD, particularly in the presence of brachial AVF. TDI may detect early functional failure of the right ventricle in HD patients.

Reduced levels of N-terminal-proatrial natriuretic peptide in hypertensive patients with metabolic syndrome and their relationship with left ventricular mass.

Objectives The metabolic syndrome (MS) is associated with left ventricular hypertrophy (LVH). Previous evidence has shown that LVH is favoured by low levels of atrial natriuretic peptide (ANP), independently from blood pressure (BP), in hypertension. Although levels of natriuretic peptides are known to be lower in obesity, plasma ANP levels have not yet been assessed in MS. We aimed to assess the ANP levels and their relationship with left ventricular mass (LVM) in patients affected by MS. Methods One hundred and twenty-eight essential hypertensive patients were included in the study: 51 with MS and 77 without MS. Clinical, echocardiographical and biochemical parameters, and levels of both N-terminal (NT)-proANP and alphaANP were assessed. Results Hypertensive patients affected by MS had higher LVM and increased frequency of LVH. NT-proANP levels were significantly lower in MS, independent of waist circumference (WC). Log(NT-proANP) levels were significantly inversely related to left ventricular mass index (LVMI) (β = −0.360, P < 0.001) and LVM/height2.7 (β = −0.370, P < 0.001) in the whole hypertensive population by multiple linear regression analysis. The relationship of log(NT-proANP) with LVM was more enhanced in patients with MS. Conclusions The present study demonstrates that levels of NT-proANP are significantly reduced in hypertensive patients affected by MS, and they are significantly inversely related to the increased LVM observed in these patients. Our findings, while supporting previous experimental and clinical evidence of the antihypertrophic role of ANP in hypertension, may help to identify one of the possible mechanisms directly underlying LVH in MS.

Do diabetes, metabolic syndrome or their association equally affect biventricular function? A tissue Doppler study

Metabolic syndrome (MetS) and type 2 diabetes (T2DM) have been associated with an impairment of left (LV) and right ventricular (RV) function as well as an increased risk of heart failure (HF). However, it remains unclear whether these clinical entities or their associations promote a similar derangement of biventricular function. Overall, 345 patients without overt cardiovascular disease consecutively underwent routine blood chemistry including high-sensitivity C reactive protein (hs-CRP) and echocardiographical examination with conventional and tissue Doppler imaging (TDI) of both ventricles. According to the ATP III criteria and fasting glucose levels, the study population was stratified into four groups: (1) healthy controls (n=120); (2) MetS without T2DM (n=84); (3) T2DM without MetS (n=49); and (4) MetS+T2DM (n=92). The Myocardial performance index (MPI) of the RV and LV was obtained with a multi-segmental approach using TDI. Patients with MetS and T2DM exhibited a similar impairment of biventricular function compared with healthy controls, whereas a further decline was observed in patients having both MetS and T2DM. In addition to MetS markers, hs-CRP exhibited the strongest association with the MPI of both ventricles. Regression analyses indicated that individual MetS markers were inferior to MetS in identifying subtle cardiac dysfunction. Independent associations of MetS and T2DM with biventricular dysfunction were comparable, and the coexistence of MetS and T2DM exhibited the highest risk for biventricular dysfunction. Our findings emphasize the importance of MetS as an equivalent of T2DM and support a synergic effect of these clinical conditions on cardiac organ damage requiring more aggressive therapeutic strategies to prevent HF.

Impact of dialysis modality on the appropriateness of left ventricular mass in patients with end-stage renal disease

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Abnormal Regulation of Renin Angiotensin Aldosterone System Is Associated With Right Ventricular Dysfunction in Hypertension

BACKGROUND Right ventricular dysfunction (RVD) is a major predictor of cardiovascular mortality. Inadequate suppression of the renin-angiotensin-aldosterone system (RAAS) after postural manoeuvres favours alterations of left ventricular (LV) function. The effects of RAAS dysregulation on RV performance remain elusive. The present study investigated RV function in hypertensive patients with or without altered RAAS activation. METHODS Plasma renin activity (PRA) and plasma aldosterone concentration (PAC) were measured in 104 newly diagnosed hypertensive patients after both supine and upright positioning to assess dynamic changes of RAAS induced by antigravitational stress. Twenty-four-hour ambulatory blood pressure monitoring and echocardiographic evaluation of the right ventricle including tissue Doppler imaging (TDI) were performed. Patients were divided as follows: (1) normal PRA and PAC (N group [n = 58]), (2) suppressible RAAS after supine positioning (SR group [n = 24]), and (3), nonsuppressible RAAS (NSR group [n = 22]). RVD was identified by the TDI-derived myocardial performance index (MPI) calculated with a multisegmental approach. RESULTS Patients in the NSR group had reduced indices of RV function compared with patients in the N and SR groups. MPI of the right ventricle as well as prevalence of RVD were also significantly higher in the NSR group. Regression models showed that inadequate RAAS suppression was independently associated with RVD, regardless of blood pressure values and LV dysfunction (LVD). CONCLUSIONS Patients without supine normalization of RAAS display a significant impairment of RV function. Our findings suggest that a dynamic RAAS evaluation may help to identify hypertensive patients at higher risk of RVD.

Synergic effect of high renin and aldosterone levels on inappropriate left ventricular mass and systolic function: A tissue Doppler study

Left ventricular dysfunction (LVD) is a harmful condition leading to increased cardiovascular morbidity and mortality. Among the complex pathophysiological factors contributing to the development of LVD, the renin–angiotensin–aldosterone system (RAAS) has been recognized to play a pivotal role. Hyperactivation of RAAS promotes structural and functional changes leading to myocardial fibrosis, stiffness and left ventricular hypertrophy [1–4]. A large proportion of patients with altered RAAS homeostasis presents with isolated increase in plasma renin activity (PRA) or aldosterone concentrations (PAC). However, data about the impact of isolated hyperreninemia or hyperaldosteronism on LV geometry and function are not exhaustive. Moreover, it remains unclearwhether the coexistence of high renin and aldosterone has a synergic effect on cardiac damage. LV mass (LVM) exceeding compensatory values for individual cardiac load has been recently described as inappropriate left ventricular mass (ILVM). This adverse phenotype of cardiac hypertrophy is emerging as a key determinant of cardiovascular risk [5]. In the present study we investigated the individual contribution of isolated PRA and PAC elevations on ILVM and LVD. PRA and PAC were measured in 133 young newly diagnosed hypertensive subjectswho had never been treatedwith RAAS blockers or other antihypertensive drugs. The study population was stratified as follows: 1) normal PRA and PAC (N) [n = 45]; 2) high PRA and normal PAC (hyperreninemia, HR)

A Novel Electrocardiographic T-Wave Measurement (Tp-Te Interval) as a Predictor of Heart Abnormalities in Hypertension: A New Opportunity for First-Line Electrocardiographic Evaluation.

The aim of the study was to evaluate the role of conventional and new markers of early cardiac organ damage (OD) on 12‐lead electrocardiography (ECG) in 25 outpatients with newly diagnosed untreated essential hypertension compared with 15 normotensive, otherwise healthy individuals. Each participant underwent ECG, echocardiographic, and blood pressure (BP) measurements. Conventional and new ECG indexes for cardiac OD (Tp‐Te interval, ventricular activation time, and P‐wave analysis) were also measured. Clinic and 24‐hour ambulatory BP levels as well as left ventricular mass indexes were significantly higher in hypertensive than in normotensive patients. No significant differences were found between the two groups for ECG and echocardiographic markers of OD. Only Tp‐Te interval was higher in hypertensive than in normotensive individuals (3.06 mm vs 2.24 mm; P<.0001), even after adjustment for anthropometric and clinical parameters. Preliminary results of this study demonstrated prolonged Tp‐Te interval in newly diagnosed, untreated hypertensive outpatients compared with normotensive individuals.

Synergic effects of renin and aldosterone on right ventricular function in hypertension: A tissue Doppler study

Background Right ventricular dysfunction (RVD) is associated with poor cardiovascular outcome. The renin–angiotensin–aldosterone system is involved in alterations of the left ventricular geometry and function. Detrimental effects of the renin–angiotensin–aldosterone system on the right ventricular function are being postulated, but data supporting this assumption are still lacking. The aim of the study was to assess the impact of hyperreninemia, hyperaldosteronism or their combination on right ventricular function in hypertensive individuals. Methods Plasma renin activity (PRA) and plasma aldosterone concentrations (PACs) were measured in 116 hypertensive patients, divided as follows: normal PRA and PAC (n = 38); high PRA and normal PAC (hypereninemia) (n = 26); normal PRA and high PAC (hyperaldosternism) (n = 27); high PRA and PAC (HRA) (n = 25). Echocardiographic evaluation of the left and right ventricles (RV), including tissue Doppler imaging, was performed. RVD was identified by tissue Doppler Imaging-derived Myocardial Performance Index, calculated with a multisegmental approach. Results Indices of the right ventricular structure and function, as well as the prevalence of RVD, were higher in hyperreninemia and hyperaldosternism groups as compared with the normal group, and a further increase was observed in the HRA patients. Regression models showed a similar risk of RVD in the hyperreninemia and hyperaldosternism patients, regardless of systemic and pulmonary pressure, as well as left ventricular dysfunction. Notably, patients with both hyperreninemia and hyperaldosternism exhibited the strongest association with RVD as compared with patients with only hyperreninemia or hyperaldosternism. Conclusions Isolated hyperreninemia or hyperaldosternism determines a similar impairment of the right ventricular function, whereas their combination is further detrimental. Renin and aldosterone may represent early biomarkers of right ventricular dysfunction in hypertension.

Pulmonary Hypertension in Patients with Chronic Kidney Disease

An unexpectedly high prevalence of pulmonary hypertension (PH) has been detected by Doppler echocardiography in chronic kidney disease (CKD) patients and found to be associated with overall poor outcome. A number of pathogenetic mechanisms appears to act synergistically in producing such a condition, the relative importance of which is a matter of ongoing investigation. This chapter will review the literature on the topic and summarizes what can be drawn from published studies. Our work and experience at Sant’Andrea University Hospital is also extensively reported and area for future research addressed.

Effects of Carvedilol Therapy on Autonomic Function and Baroreflex Sensitivity in Individuals with Newly-Diagnosed Essential Hypertension

AbstractObjective: To investigate the effects of carvedilol therapy on autonomic cardiovascular regulation and baroreflex sensitivity, by short-term spectral analysis of heart rate (R-R) and systolic blood pressure (S-S) variability. Patients and Methods: The trial was conducted in 12 adults (seven men and five women, mean age 37 ±7 years) with newly diagnosed hypertension. Patients were classified as having mild or moderate hypertension (stages I to II). R-R, S-S and respiratory signals were recorded during rest and after sympathetic activation by head-up tilt, before and after receiving a 15-day course of carvedilol (25mg once daily). Cross-spectral analysis of R-R and S-S signals was used to determine the baroreflex sensitivity index (α index). Results: At rest after carvedilol therapy, the R-R and S-S LF (low frequency) normalised units (nu) significantly decreased (p = 0.0002 and p = 0.003, respectively), while the HF (high frequency) component reciprocally increased. The R-R LF/HF ratio decreased significantly (1.28 ±1.58 vs 0.41 ±0.29, p = 0.008). The α index also increased significantly (12.04 ±6.25 vs 16.05 ±7.45, p = 0.002). During tilt, carvedilol therapy reduced the R-R and S-S LF (p = 0.0003 and 0.002, respectively), but preserved the LF increase normally induced by passive ortho-statism, and significantly increased the α index (6.18 ±1.97 vs 8.89 + 3.29, p = 0.014). Conclusion: Our findings suggested that carvedilol attenuates cardiovascular sympathetic responsiveness and improves baroreflex sensitivity.