Marijana Tadic

White-coat hypertension, as defined by ambulatory blood pressure monitoring, and subclinical cardiac organ damage: a meta-analysis.

Aim: The clinical and prognostic relevance of white-coat hypertension (WCH) has not been fully elucidated; in particular, the association of this blood pressure phenotype with suclinical organ damage remains unclear. We performed a systematic meta-analysis in order to provide a comprehensive information on cardiac structural and functional changes in WCH, as defined by ambulatory blood pressure monitoring. Design: Studies were identified by the following search terms: ‘white-coat hypertension’, ‘isolated clinic hypertension’, ‘cardiac organ damage’, ‘target organ damage’, ‘left ventricle’, ‘left ventricular hypertrophy’, ‘cardiac hypertrophy’, ‘ventricular dysfunction’, and ‘echocardiography’. Results: A total of 7382 untreated adult patients (2493 normotensive, 1705 WCH, and 3184 hypertensive individuals) included in 25 studies were considered. Left ventricular mass index was higher in WCH than in normotensive patients [standardized difference in mean (SDM) 0.50, P < 0.01]; mitral E/A ratio was lower (SDM −0.27, P < 0.01) and left atrium larger (SDM 0.29, P < 0.05) in WCH than in the normotensive counterparts. Hypertensive patients showed a greater left ventricular mass index (SDM 0.42, P < 0.01), reduced E/A (SDM −0.15, P < 0.01), and larger left atrium diameter (SDM 0.27, P < 0.01) than WCH patients. Conclusions: Our meta-analysis shows that alterations in cardiac structure and function in WCH patients, as defined by ambulatory blood pressure monitoring, are intermediate between sustained hypertensive patients and normotensive controls. The study supports the view that WCH should not be further considered a fully benign entity.

To dip or not to dip? The unique relationship between different blood pressure patterns and cardiac function and structure.

Dipping and nondipping blood pressure (BP) patterns are associated with different levels of target organ damage and cardiovascular risk. The aim of our investigation was to determine the relationship between different BP patterns (dipping, nondipping, extreme dipping and reverse dipping type) and cardiac structure, and function in hypertensive patients. This cross-sectional study included 376 hypertensive patients. All subjects underwent 24-h ambulatory BP monitoring, and complete two-dimensional, pulsed and tissue Doppler echocardiography. Most of the parameters of the left ventricular (LV) diastolic function (E/A, e′/a′, E/e′) significantly and progressively deteriorated from the extreme dippers to the dippers and nondippers, and finally to the reverse dippers. In contrast, LV structural parameters (IVS, RWT, LV mass index) showed a statistically important difference only by comparing the dippers and the extreme dippers with the rest of the patients. Simultaneously, the right ventricular (RV) structural parameter (RVT, right ventricular thickness), and most RV diastolic parameters significantly and progressively worsened from the extreme dippers, over the dippers and the nondippers, to the reverse dippers. Daytime and night time systolic BP, nocturnal systolic BP fall, and the nondipping and the reverse dipping status were independently associated with LV and RV structure, as well as with diastolic function. LV and RV structure, and diastolic function were significantly more impaired with the nondippers and the reverse dippers compared with others.

Two- and Three-Dimensional Speckle Tracking Analysis of the Relation Between Myocardial Deformation and Functional Capacity in Patients With Systemic Hypertension

The purpose of this study was to investigate left ventricular (LV) mechanics in hypertensive patients by 2- and 3-dimensional (3D) speckle tracking imaging, and determine the relation between the LV mechanics and functional capacity in this population. This cross-sectional study included 51 recently diagnosed, untreated, hypertensive patients, 49 treated subjects with well-controlled arterial hypertension, 52 treated participants with uncontrolled hypertension, and 50 controls adjusted by gender and age. All the subjects underwent 24-hour blood pressure monitoring, complete 2-dimensional and 3D examination, and cardiopulmonary exercise testing. 3D global longitudinal, circumferential, radial, and area strains were similar between the control group and well-controlled hypertensive patients but significantly decreased in comparison with patients with untreated or inadequately controlled hypertension. Similar findings were obtained for LV torsion and twist rate, whereas LV untwisting rate significantly deteriorated from the controls, across the well-controlled group, to the patients with untreated or uncontrolled hypertension. Peak oxygen uptake was significantly lower in the patients with untreated and uncontrolled hypertension than in the controls and the well-treated hypertensive patients. Peak oxygen uptake was independently associated with LV untwisting rate (β = 0.28, p = 0.03), 3D LV ejection fraction (β = 0.31, p = 0.024), and 3D global longitudinal strain (β = 0.26, p = 0.037) in the whole hypertensive population in our study. In conclusion, LV mechanics and functional capacity are significantly impaired in the patients with uncontrolled and untreated hypertension in comparison with the controls and the well-controlled hypertensive patients. Functional capacity is independently associated with 3D global longitudinal strain, LV untwisting rate, and 3D LV ejection fraction.

Is white-coat hypertension a risk factor for carotid atherosclerosis? A review and meta-analysis.

The association of white-coat hypertension (WCH) with target organ damage is still debated; in particular, the relationship of this blood pressure phenotype with subclinical vascular damage remains controversial. Thus, we carried out a systematic review and meta-analysis to provide updated information on carotid structural changes in WCH. Studies were identified using the following search terms: ‘white coat hypertension’, ‘isolated clinic hypertension’, ‘carotid artery’, ‘carotid atherosclerosis’, ‘carotid intima-media thickness’, ‘carotid damage’, ‘carotid thickening’. Full articles published in the English language in the last two decades reporting studies on adults were considered. A total of 3478 untreated patients, 940 normotensive (48% men), 666 WCH (48% men), and 1872 hypertensive individuals (57% men) included in 10 studies, were analyzed. Common carotid intima-media thickness (IMT) showed a progressive increase from normotensive (718±36 &mgr;m) to WCH (763±47 &mgr;m, standardized mean difference 0.54±0.13, P<0.01) and to hypertensive patients IMT (817±47 &mgr;m, standardized mean difference 0.45±0.14, P<0.01). After assessing data for publication bias, only the difference between normotensive and WCH patients remained significant. Our meta-analysis documents that common carotid IMT, a prognostically validated marker of vascular damage, is greater in WCH patients than in true normotensive individuals and is not different from sustained hypertensives. This finding supports the concept that WCH is not an entirely benign condition.

Left Ventricular Mechanics in Untreated Normotensive Patients with Type 2 Diabetes Mellitus: A Two‐ and Three‐dimensional Speckle Tracking Study

Our aim was to investigate left ventricular (LV) mechanics estimated by two‐ (2DE) and three‐dimensional echocardiography (3DE) strains in subjects with type 2 diabetes mellitus (DM).

Multimodality Evaluation of the Right Ventricle: An Updated Review

The assessment of the volumes, function, and mechanics of the right ventricle (RV) is very challenging because of the anatomical complexity of the RV. Because RV structure, function, and deformation are very important predictors of cardiovascular morbidity and mortality in patients with heart failure, pulmonary hypertension, congenital heart disease, or arrhythmogenic RV cardiomyopathy, it is of great importance to use an appropriate imaging modality that will provide all necessary information. In everyday clinical practice, 2‐dimensional echocardiography (2DE) represents a method of first choice in RV evaluation. However, cardiac magnetic resonance (CMR) remained the gold standard for RV assessment. The development of new imaging tools, such as 3‐dimensional echocardiography (3DE), provided reliable data, comparable with CMR, and opened a completely new era in RV imaging. So far, 3DE has shown good results in determination of RV volumes and systolic function, and there are indications that it will also provide valuable data about 3‐dimensional RV mechanics, similar to CMR. Two‐dimensional echocardiography–derived strain is currently widely used for the assessment of RV deformation, which has been proven to be a more significant predictor of functional capacity and survival than CMR‐derived RV ejection fraction. The purpose of this review is to summarize currently available data about RV structure, function, and mechanics obtained by different imaging modalities, primarily 2DE and 3DE, and their comparison with CMR and cardiac computed tomography.

Risk of mortality in relation to an updated classification of left ventricular geometric abnormalities in a general population: the Pamela study.

Aim: We estimated the risk of cardiovascular and all-cause mortality associated with left ventricular geometric patterns, as defined by a new classification system proposed by the Dallas Heart Study, in 1716 representatives of the general population of Monza enrolled in the Pressioni Monitorate e Loro Associazioni (PAMELA) study. Methods: Cut-points for abnormal left ventricular geometric patterns were derived from reference values of the healthy fraction of the PAMELA population by combining left ventricular mass (LVM) index, left ventricular diameter and relative wall thickness. Death certificates were collected over an average 211 months follow-up period. Results: During follow-up, 89 fatal cardiovascular events and 264 all-cause deaths were recorded. Concentric remodelling was the most common left ventricular geometric abnormality (9.4%) followed by eccentric nondilated left ventricular hypertrophy (LVH) (6.3%), concentric LVH (4.6%) and eccentric dilated LVH (3.5%). Compared with normal left ventricular geometry, concentric LVH [hazard ratio 2.20, 95% confidence interval (95% CI) 1.44–3.37, P < 0.0003], eccentric dilated LVH (hazard ratio 1.90, 95% CI 1.17–3.08, P = 0.009) and eccentric nondilated LVH (hazard ratio 1.57, 95% CI 1.07–2.31, P = 0.02) predicted the risk of cardiovascular mortality, after adjustment for baseline covariates, including ambulatory blood pressure. Similar findings were observed for all-cause mortality. Only concentric LVH maintained a significant prognostic value for both outcomes after adjustment for baseline differences in LVM index. Conclusion: The new classification system of left ventricular geometric patterns may improve mortality risk stratification in a general population. The risk is markedly dependent on LVM values; only concentric LVH provides a prognostic information beyond that conveyed by cardiac mass.

Does the metabolic syndrome impact left-ventricular mechanics? A two-dimensional speckle tracking study.

Objective: To evaluate left-ventricular mechanics estimated by two-dimensional echocardiography (2DE) speckle tracking analyses in patients with the metabolic syndrome. Methods: This cross-sectional study included 95 untreated patients with metabolic syndrome and 65 controls similar by sex and age. Metabolic syndrome was defined by the presence of at least three ATP-AHA-NHLB criteria. All the patients underwent adequate laboratory analyses and complete 2DE examination. Results: 2DE global longitudinal and circumferential strain was significantly decreased in the metabolic syndrome group, whereas 2DE global radial strain was similar between the observed groups. The left-ventricular torsion was similar between the metabolic syndrome participants and the controls; whereas the left-ventricular untwisting rate was significantly increased in the metabolic syndrome group. The increasing number of the metabolic syndrome criteria induces progressive reduction of the left-ventricular longitudinal strain from the individuals with no metabolic syndrome risk factors to the individuals with five metabolic syndrome criteria. The same pattern was not noticed for left-ventricular circumferential and radial strain. The combination of increased blood pressure, abdominal obesity and increased fasting glucose level was associated with the higher level of left-ventricular mechanical impairment comparing with other clusters of the metabolic syndrome components. The multivariate analysis of the metabolic syndrome criteria showed that 24-h mean blood pressure, waist circumference and fasting glucose level were independently associated with 2DE global longitudinal and circumferential myocardial strain, and left-ventricular untwisting rate. The interaction between sex and metabolic syndrome significantly impacts the left-ventricular longitudinal strain and untwisting rate. Conclusion: Left-ventricular mechanics assessed by 2DE strain is significantly impaired in the metabolic syndrome patients. Among all metabolic syndrome components, blood pressure, waist circumference and fasting glucose level are the most responsible for damage of left-ventricular deformation.

Metabolic Syndrome Impacts the Right Ventricle: True or False?

Background: The impact of metabolic syndrome (MS) on the right ventricle (RV) is not clarified. The aim of this study was to evaluate the influence of MS and its components on RV structure and function. Methods: The study included 265 subjects with MS and 118 controls adjusted by age. MS was defined by the presence of ≥3 ATP‐NCEP III criteria. All subjects underwent laboratory blood tests, complete two‐dimensional, pulse, and tissue Doppler echocardiography. We determined the ratio of early and late diastolic tricuspid flow velocities (E/A)t, and the ratio of early diastolic transtricuspid and septal tricuspid annuli flow velocity (E/e′)t. RV Tei index represents the sum of tricuspid isovolumic relaxation time (IVRT) and tricuspid isovolumic contraction time (IVCT) divided by RV ejection time (ET) [(IVRT + IVCT)/ET]. Results: Multiple regression analysis showed that systolic blood pressure (β= 0.104, P = 0.021), waist circumference (β= 0.093, P = 0.033), glucose level (β= 0.087, P = 0.045), left ventricular mass (LVmass) index (β= 0.218, P < 0.001) and relative LV wall thickness (β= 0.144, P = 0.034) were independently associated with the RV hypertrophy. Multivariate analysis showed that waist circumference (β= 0.152, P = 0.013), glucose level (β= 0.119, P = 0.039), LVmass index (β= 0.267, P < 0.001), the relative LV wall thickness (β= 0.184, P = 0.005), RV wall thickness (β= 0.175, P = 0.008), and (E/e′)m (β= 0.143, P = 0.025) were independently associated with (E/e′)t. Similar results were obtained for RV Tei index. Conclusions: MS has an important role in damage of RV structure and function. Among MS criteria systolic blood pressure, waist circumference and glucose level were independently associated with RV structure and function. (Echocardiography 2011;28:530‐538)

What do we currently know about metabolic syndrome and atrial fibrillation

Metabolic syndrome represents a cluster of atherogenic risk factors including hypertension, insulin resistance, obesity, and dyslipidemia. Considering that all of these risk factors could influence the development of atrial fibrillation, an association between atrial fibrillation and the metabolic syndrome has been suggested. Additionally, oxidative stress and inflammation have been involved in the pathogenesis of both metabolic syndrome and atrial fibrillation. The mechanisms that relate metabolic syndrome to the increased risk of atrial fibrillation occurrence are not completely understood. Metabolic syndrome and atrial fibrillation are associated with increased cardiovascular morbidity and mortality. Because atrial fibrillation is the most common arrhythmia, and along with the prevalence of metabolic syndrome constantly increasing, it would be very important to determine the relationship between these 2 entities, especially due to the fact that the risk factors of metabolic syndrome are mainly correctable. This review focused on the available evidence supporting the association between metabolic syndrome components and metabolic syndrome as a clinical entity with atrial fibrillation.