Małgorzata Kloch-Badełek

Pulsatile but Not Steady Component of Blood Pressure Predicts Cardiovascular Events in Coronary Patients

Although the differences between central and peripheral blood pressure (BP) values have been known for decades, the consequences of decision making based on peripheral rather than central BP have only recently been recognized. There are only a few studies assessing the relationship between intraaortic BP and cardiovascular risk. In addition, the relationship between central BP and the risk of cardiovascular events in a large group of coronary patients has not yet been evaluated. Therefore, the aim of the study was to determine the prognostic significance of central BP-derived indices in patients undergoing coronary angiography. Invasive central BPs were taken at baseline, and study end points were ascertained during over a 4.5-year follow-up in 1109 consecutive patients. The primary end point (cardiovascular death or myocardial infarction or stroke or cardiac arrest or heart transplantation or myocardial revascularization) occurred in 246 (22.2%) patients. Central pulsatility was the most powerful predictor of the primary end point (hazard ratio [HR] 1.30, 95% confidence interval [CI] 1.14 to 1.48). Central pulse pressure was also independently related to the primary end point (HR 1.25, 95% CI 1.09 to 1.43). Central mean BP as well as peripheral BP parameters were not independently related to the primary end point risk. Central pulsatility was also related to risk of cardiovascular death or myocardial infarction or stroke. The pulsatile component of BP is the most important factor related to the cardiovascular risk in coronary patients. It is more closely associated with cardiovascular risk than steady component of BP.

Impact and pitfalls of scaling of left ventricular and atrial structure in population-based studies

Background: Several allometric methods for indexing cardiac structures to body size have been proposed but the optimal way for normalization of cardiac structures is still controversial. We aimed to estimate the allometric exponents that best describe the relationships between cardiac dimensions and body size, propose normative values, and analyze how the different scaling metrics influence the prevalence of left ventricular hypertrophy (LVH) and chambers enlargement as well as predictive models for cardiovascular outcome in the community. Methods: We measured left ventricular end-diastolic dimension, end-diastolic volume, left ventricular mass, and left atrial volume in randomly recruited population cohorts (n = 1509; 52.8% women; mean age, 47.8 years). Results: In a healthy subgroup (n = 656), the allometric exponents that described the relationships between left ventricular end-diastolic dimension and body size were 1, 0.5, and 0.33 for body height, body surface area (BSA), and estimated lean body mass, respectively. With regard to left ventricular end-diastolic volume, left ventricular mass, and left atrial volume the allometric exponents for body height were 2.9, 2.7, and 2.0, respectively; for BSA, they ranged from 1.7 to 1.8; for estimated lean body mass all exponents were around 1. These exponents were used to appropriately scale the cardiac dimensions to body size and derived sex-specific cut-off limits for different indexed cardiac dimensions. The hazard ratios of cardiovascular outcome were highest for LVH defined by left ventricular mass/height2.7. Conclusion: Our study resulted in a proposal for thresholds for various indexed cardiac dimensions. Left ventricular mass indexed to height was sensitive in detection of LVH associated with obesity and slightly better predicted outcome.

Doppler indexes of left ventricular systolic and diastolic function in relation to the arterial stiffness in a general population.

Background: Late-systolic loading of the left ventricular (LV) is determined by arterial wave reflections and central vascular stiffening. We, therefore, investigated the relationship between various Doppler indexes reflecting LV systolic and diastolic function and arterial stiffness in the framework of a large population study of randomly recruited study participants. Methods: In 1233 study participants (51.7% women; mean age, 48 years; 41.5% hypertensive), using conventional and tissue Doppler imaging, we measured: the transmitral early (E) and late (A) diastolic velocities; tissue Doppler imaging systolic and early (e′) and late diastolic mitral annular velocities; and end-systolic longitudinal and radial strain. Using applanation tonometry, we assessed central pulse pressure (cPP), augmentation pressure and carotid-femoral pulse wave velocity. Results: After full adjustment, transmitral E and A peaks increased with augmentation pressure and cPP (P less than 0.0001) and e′ was positively associated with cPP (P = 0.013). The E/e′ ratio increased significantly with augmentation pressure (P less than 0.0001), cPP (P less than 0.0001) and pulse wave velocity (P = 0.048). Although accounting for covariables, all arterial indexes were on average significantly higher in the diastolic dysfunction group with elevated filling pressure (n = 171) when compared to participants with normal diastolic function (n = 961; P ⩽ 0.0004) or with impaired relaxation (n = 101; P ⩽ 0.008). Longitudinal strain decreased independently with mean arterial pressure (P = 0.03). The correlation between radial strain and the arterial indexes shifted from positive at middle age (50–60 years) to negative at older (P less than 0.0001 for interaction). Conclusion: Our study underscored the importance of arterial characteristics as a mediator of LV systolic and diastolic dysfunction. We demonstrated an age-dependent relationship between radial strain and indexes of arterial stiffness.

Tissue Doppler indexes of left ventricular systolic function in relation to the pulsatile and steady components of blood pressure in a general population

Objectives: To our knowledge, no population study described the association of the radial and longitudinal components of left ventricular strain with blood pressure (BP) components in continuous analyses. We therefore investigated these associations in participants randomly recruited from the general population in the framework of the family-based European Project on Genes in Hypertension. Methods: In 334 participants (55.4% women; mean age, 43.6 year), using tissue Doppler imaging (TDI), we measured the end-systolic longitudinal strain (mean 20.9%) and peak systolic strain rate (1.29 s−1) from the basal portion of the left ventricular inferior and posterior free walls and radial stain (51.1%) and strain rate (3.40 s−1) of the left ventricular posterior wall. Models included in addition to covariables and confounders both SBP and DBP or both pulse pressure (PP) and mean arterial pressure (MAP). Effect sizes were expressed per 1-SD increase in BP. Results: Longitudinal strain (−0.62%; P = 0.04 and −0.64%; P = 0.007), but not strain rate, decreased with DBP and MAP. Radial strain (4.0 and −3.4%; P ⩽ 0.001) and strain rate (0.38 and −0.18 s−1; P ⩽ 0.04) independently increased with SBP and decreased with DBP. Accordingly, radial strain (2.9%; P < 0.0001) and strain rate (0.22 s−1; P = 0.0005) increased with higher PP, but were not related to MAP. Conclusion: In the general population, BP is an independent determinant of left ventricular systolic function as measured by TDI. Radial function increased with PP, the pulsatile BP component, whereas longitudinal function decreased with the steady component of BP as expressed by MAP or DBP.

Intima–media thickness correlates with features of metabolic syndrome in young people with a clinical diagnosis of familial hypercholesterolaemia

BACKGROUND Familial hypercholesterolaemia (FH) is a monogenic lipid metabolism disorder characterised by markedly elevated serum low-density lipoprotein (LDL) cholesterol level due to a mutation in the LDL receptor gene. Clinical features of FH include premature atherosclerosis and coronary artery disease. AIM To explore associations between noninvasive markers of atherosclerosis including intima-media thickness (IMT) and pulse wave velocity (PWV) and blood lipids, blood pressure (BP) and obesity in a group of young patients with FH. METHODS Study population included 36 patients aged < 35 years with the diagnosis of FH based on the Simon Broome Register criteria, and their 49 relatives who comprised the control group free of FH. RESULTS Mean IMT values were higher in FH patients than controls (0.60 ± 0.19 vs. 0.53 ± 0.07 mm, respectively, p < 0.05).Mean body mass index (BMI) and waist circumference were similar in patients and controls. The prevalence of carotid atherosclerotic plaques was significantly higher among FH patients (n = 6) than in controls (n = 1) (21.4% vs. 2.6%, p = 0.012). Arterial hypertension was present in 27.8% of patients with FH and 16.3% of subjects in the control group. Systolic blood pressure (SBP) in FH patients correlated significantly with age (r = 0.35), BMI (r = 0.48) and waist circumference (r = 0.47), and diastolic blood pressure (DBP) correlated with BMI (r = 0.42) and waist circumference (r = 0.41). PWV correlated significantly with age (r = 0.44), SBP (r = 0.63) and DBP (r = 0.52). We did not find any correlations between IMT and serum lipids, BP or obesity indices in FH patients. CONCLUSIONS Our findings show a higher rate of arterial hypertension in young FH patients compared to their relatives free of FH, with significant associations between BP and indices of obesity and arterial stiffness. Intensive lipid lowering and antihypertensive therapy along with a reduction in central fat may be considered a mandatory treatment strategy in young FH patients to prevent atherosclerosis and increased arterial stiffness.

Echocardiographic assessment of right ventricular function in responders and non-responders to cardiac resynchronization therapy.

Introduction The aim of this study was to determine whether baseline right ventricular (RV) function assessed by standard echocardiography may indicate patients who will respond to cardiac resynchronization therapy (CRT). Material and methods The data of 57 patients (54 men, 95%), aged 66.4 ±8.7 years with heart failure (HF) having a CRT device implanted were collected. All patients had left ventricular ejection fraction (LVEF) ≤ 35% and QRS complex duration ≥ 120 ms. Echocardiographic examination with tissue Doppler imaging techniques and complex RV evaluation were performed at baseline and three months after CRT onset. Results Three months after CRT implantation, patients responding to CRT, defined as a reduction of left ventricle end-systolic volume (LVESV) of at least 10% (n = 34), compared to patients with a reduction of LVESV of less than 10% (n = 23), had at baseline a smaller right atrium diameter (47.85 ±11.33 mm vs. 52.65 ±8.69 mm; p = 0.028), higher TAPSE (14.56 ±2.57 mm vs. 13.04 ±2.93 mm; p = 0.030) and lower grade of tricuspid valve regurgitation (1.82 ±0.97 vs. 2.3 ±0.88; p = 0.033). Conclusions This study showed that there are differences in baseline right ventricular function between responders and non-responders to CRT. Yet in our study, none of the baseline RV parameters provided any value in identifying patients who would respond to CRT.

Baseline tissue Doppler imaging-derived echocardiographic parameters and left ventricle reverse remodelling following cardiac resynchronization therapy introduction

Introduction The aim of the study was to assess the relation of baseline mechanical dyssynchrony with the left ventricular end-systolic volume (LVESV) decrease following cardiac resynchronization (CRT) therapy introduction. Material and methods Sixty consecutive patients (aged 66.3 ± 8.7 years; 57 men) with chronic heart failure (71.7% of ischaemic and 28.3% of non-ischaemic origin) and current indications for CRT were assessed before and 3 months after biventricular heart stimulator implantation. Longitudinal movements of twelve segments of the left ventricle (LV) (6 basal and 6 midlevel) and two segments of the right ventricle (RV) were analysed using tissue Doppler imaging (TDI) techniques with time from onset of Q wave in ECG to peak systolic velocity in colour-coded TDI (TTDI), time to peak strain (Tstrain) and time to peak strain rate (Tstrain rate). Minimal and maximal time differences within LV and between LV and RV walls were calculated. Results In the study group LVEF and 6-min walk test distance increased, while NYHA class, NT-proBNP level, left ventricular end-diastolic volume and LVESV decreased. Significant correlations between the magnitude of LVESV reduction with maximal time differences between Tstrain of 12 LV segments (r=0.34, p = 0.017) and time differences between TTDI basal LV-RV segments (r = –0.29, p=0.041) were found. Conclusions Only a few TDI-derived parameters such as maximal time differences between Tstrain of 12 LV segments and TTDI difference of LV-RV basal segments can be useful to predict the magnitude of left ventricle reverse remodelling after CRT introduction.

Heritability and other determinants of left ventricular diastolic function in the family-based population study.

Background: Understanding to what extent genetic factors influence diastolic Doppler indexes is an important issue in view of the relation of left ventricular diastolic dysfunction with outcome. We, therefore, investigated the heritability of left ventricular diastolic traits and the composite diastolic score in nuclear families recruited from the general population. Methods: In a random sample of 316 nuclear families (452 parents and 600 offspring, mean age, 58.5 and 33.3 years), we measured transmitral early and late diastolic velocities (E and A) by pulsed wave Doppler, and mitral annular velocities (e’ and a’) by tissue Doppler. Using principal component analysis, we summarized seven Doppler indexes – namely, E, A, e’ and a’ velocities, and their ratios – into a single diastolic score. To calculate the heritability of diastolic indexes, we used variance decomposition in nuclear families and offspring as implemented in SOLAR and SAS, and the regression slope of offspring on mid-parent residual values. Results: In variance decomposition analyses in nuclear families, the abovementioned traits with adjustment for covariables had moderate heritability ranging from 0.27 to 0.43 (P < 0.0001 for all). The parent–offspring concordances of all diastolic indexes were significant and ranged from 0.17 for A (P = 0.009) to 0.42 for e’ (P < 0.0001). In nuclear families and offspring, the heritability estimates of the composite diastolic score were 0.42 and 0.64, respectively (P < 0.0001). Conclusion: Our study demonstrated moderate heritability of various indexes reflecting left ventricular diastolic function in nuclear families. The observation highlights the necessity of further research into the genes that affect left ventricular diastolic function.

[PP.21.08] PLASMA VASCULAR ENDOTHELIAL GROWTH FACTOR TYPE C CONCENTRATION AS THE MODULATOR OF THE RELATION BETWEEN URINARY SODIUM EXCRETION AND BLOOD PRESSURE IN HUMANS

Objective: Vascular endothelial growth factor type C (VEGF-C) is a novel marker of sodium accumulation in subcutaneous tissue, not yet explored in humans. The animal studies have demonstrated significant correlation between excess sodium intake, increase in plasma VEGF-C and high blood pressure. The aim of the study was to investigate the relation between sodium intake, plasma VEGF-C concentration and blood pressure in high salt intake population. Design and method: The study group included 198 subjects recruited from the general population of Southern Poland, never treated with antihypertensive medications. Ambulatory blood pressure (ABP) monitors (SpaceLabs 90207) were programmed to obtain measurements each 15 min during the day (6.00–22.00) and each 30 min nighttime. Sodium intake was assessed based on 24-hour urinary sodium excretion. The plasma VEGF-C concentration was measured using ELISA kit in certificated laboratory. Database management and statistical analysis were performed with SAS software (SAS Institute, Cary, NC), version 9.3. Results: The study group included 91 men and 107 women, mean age 40.3 years, office BP 124.8/84.2 mmHg, 24hUVNa 162 mmol/24 h and mean serum VEGF-C concentration 1238 pg/ml. The analyses were adjusted for age, sex, BMI, antihypertensive treatment, smoking, CRP, sodium excretion and alcohol intake. We observed negative association between serum VEGF-C concentration and both SBP (r -0.0017 p 0.0473) and DBP (r -0.0014 p 0.0491) over 24 h. Conclusions: In our high salt intake population, plasma VEGF-C concentration was negatively related to systolic and diastolic blood pressure on 24-hour ambulatory monitoring in multivariate models. Effective subcutaneous sodium accumulation, indirectly represented by plasma VEGF-C, might prevent increase of blood pressure in high salt intake individuals.

[OP.3B.05] MORNING CENTRAL BLOOD PRESSURE SURGE IS RELATED TO AGE

Objective: Morning surge (MS) of peripheral blood pressure (BP) is considered to be an independent risk factor for cardiovascular diseases. However, central MS has not been analyzed so far. Therefore, the aim of the study was to evaluate the variables independently associated with central MS. Design and method: Fifty never treated hypertensives (age 40.4 ± 11.5 years, 35 men) and 50 normotensive subjects (age 38.3 ± 12.0 years, 35 men) participated in the study. Applanation tonometry of the radial artery and n-point forward moving average method have been used to derive 24-h CSP (BPro, HealtStats). The sleep-through MS was calculated as the difference between the morning systolic BP (the average BP during the 2 hours after awakening) and the lowest nighttime systolic BP (the average of the lowest pressure and the 2 readings immediately preceding and after the lowest value). To assess the independent variables which correlate with MS, multiple regression analysis was used. Sex, age, BMI, smoking, 24-h mean heart rate, glucose and creatinine level, and 24-h central systolic BP were included into the model. Results: Mean central MS was 17.3 ± 7.8 mmHg in whole group, 18.6 ± 7.3 mmHg in hypertensives, and 16.1 ± 8.1 mmHg in normotensives (p = NS). There was no significant difference between women and men (16.2 ± 7.5 vs. 17.8 ± 8.0, p = 0.36) but participants at age over 40 years had lower MS compared to younger subjects (15.7 ± 7.0 vs.18.9 ± 8.3, p < 0.05). MS correlated with age (r = −0.26, p = 0.01), but not with 24-h heart rate, 24-h central systolic BP, glucose or creatinine level. Independent variables related to central MS were age (&bgr;±SE −0.30 ± 0.10, p = 0.01) and 24-h mean central systolic BP (&bgr;±SE 0.24 ± 0.10, p < 0.05). Conclusions: Central MS is related to age and mean 24-h central systolic pressure.