S. Kostic

[OP.7B.07] FIFTEEN-YEAR PROGNOSTIC SIGNIFICANCE OF ELECTROCARDIOGRAPHIC LEFT VENTRICULAR HYPERTROPHY IN PATIENTS WITH ARTERIAL HYPERTENSION

Objective: The aim of the study was to examine the predictive value of various electrocardiographic criteria for left ventricular hypertrophy (LVH) obtained at the beginning of the study in patients with essential arterial hypertension and echocardiographic LVH who were treated according to Guidelines, through a fifteen year follow-up period. Design and method: The study included 83 examined patients (53 male and 30 female; age 55.3 ± 8.1 years) with echocardiographic LVH. The LVH cutpoints were 134 g/m2 for male and 110 g/m2 for female patients. Electrocardiographic LVH was determined by Gubner–Ungerleider voltage, Lewis voltage, voltage of R wave in aVL lead, Lyon-Sokolow viltage, Cornell voltage and Cornell product, voltage RV6 and RV5 ratio, Romhilt-Estes score, Framingham criterion and Perugia criterion. Clinical and laboratory examinations, electrocardiography, echocardiography, exercise stress test, and 24-hours ambulatory blood pressure monitoring were carried out. Results: Average left ventricular mass index (LVMI) was 170.3 ± 31.6 g/m2, while the duration of hypertension was 12.1 ± 7.7 years. Adverse cardiovascular events occurred in 32 (38.5%) patients. At the beginning of the study, both groups, i.e. with and without adverse events, showed equal baseline characteristics, values of blood pressure and echocardiographic parameters. Positive Lyon-Sokolow score (17.6% vs. 47.3%; p < 0.05), Lewis voltage (9.8% vs. 21.9%; p < 0.05), Cornell voltage (15.7% vs. 37.5%; p < 0.05), and Cornell product (9.8% vs. 34.4%; p < 0.01) were more frequent in group with new cardiovascular events as compared to group without cardiovascular events. Multiple regression stepwise analyses separated Cornell product (standardized coefficient beta 0.303; p < 0.001) as compared to other criteria of hypertrophy after adjustments in terms of gender, age BMI and LVMI (model: R 0.303, R2 0.092, adjusted R square 0.081, standardized error of estimate 0.46951). Odd ratio for this criterion was 4.819 (95% CI 1.486–15.627). Conclusions: Patients with echocardiographic left ventricular hypertrophy who had positive Lewis voltage, Lyon-Sokolow voltage, Cornell voltage, and Cornell product showed worse fifteen-year outcome. The strongest predictor of cardiovascular events was positive result of Cornell product. Such patients should be recognized as early as possible, and treated more aggressively.

[PP.11.34] THE PREVALENCE OF METABOLIC SYNDROME IN PATIENTS WITH HYPERTENSION AND ITS IMPACT ON ASYMPTOMATIC CAROTID ATHEROSCLEROSIS

Objective: Increased cardiovascular risk in hypertensive patients might be partially attributable to metabolic disturbances. Carotid intima-media thickness (C-IMT) is a useful surrogate marker of early carotid atherosclerosis. Objective: To determine the prevalence of metabolic syndrome in patients with hypertension and its impact on asymptomatic carotid atherosclerosis. Design and method: The study included 391 subjects, divided into two groups. The first group consisted of patients with AH, n = 342 (age: 66,56 ± 09,52, female gender: 51%). Control group consisted of the examinees without AH, n = 49. For all patients there was determined: presence of risk factors for cardiovascular disease, SCORE risk, laboratory analyses, anthropometric measurements. MetS was diagnosed according to Adult Treatment Panel III criteria. The carotid artery intima-media thickness and carotid plaques were measured by B-mode ultrasound. Results: The prevalence of the MetS in the first group was 58% v.s.10% in the control group (p < 0,0001). The average number of components MetS was 2,76 ± 0.53 in first group (vs.1,30 ± 0.70 in control group, p < 0,0001). Hypertensive patients were divided into 2 groups according to the presence of MetS. Metabolic syndrome had 198 patients, there were no differences in age. Subjects with MetS had a higher average number of risk factors, SCORE risk, body mass index (p < 0,0001), serum acid level (p < 0,0001), more frequently had diabetes, hyperlipidemia and obesity (p < 0,0001). C-IMT were significantly higher in the group with MetS (0,91 ± 0,21 vs. 0,81 ± 0,17, p < 0,0001). The high C-IMC values (> = 0.90) were observed in 50,57% patients with MetS, p < 0,001. Patients with MetS had more frequently one or more carotid plaques (p = 0,04), higher average number of carotid plaques (p = 0,01) and percentage of stenosis (p = 0,01). In Mets group plaques were mostly fibrocalcified (30%), followed by fibrous (22%) and calcified, in non MetS group were mostly fibrous (36,6%). As the most important factors associated with carotid atherosclerosis multivariate regression analysis singled out age, number of components MetS (p = 0,002), serim acid level (p < 0,0001), hyperlipidemia (p = 0,035) and obesity (p = 0,03). Conclusions: Hypertensive patients in a significant percentage have metabolic syndrome. Our data suggest that MetS were independently associeted with subclinical carotid atherosclerosis in patients with hypertension.

[PP.01.19] PREDICTORS OF CARDIOVASCULAR EVENTS IN HYPERTENSIVE PATIENTS WITH HIGH CARDIOVASCULAR RISK

Objective: Hypertension is a major risk factor for cardiovascular events. Patients at high risk are particularly vulnerable and require adequate treatment and control. The treatment is complex and requires good control of blood pressure and all modifiable risk factors associated with the protection of target organ damage. The goal of this study is to determine which factors have predictive significance of cardiovascular events in patients with hypertension and high cardiovascular risk. Design and method: We studied 258 participants (60% females). Each participant underwent asymptomatic organ damage: 12-lead electrocardiogram examinations, two-dimensional and Doppler echocardiographs, Doppler sonography of the carotid arteries, and laboratory investigations were prospectively followed for fatal and non-fatal cardiovascular event and total mortality over a median of 7 years. Results: Mean age in the beginning of the study was 62.7 ± 9 years, body mass index of 28.9 ± 4. kg/m2, office blood pressure of 150.3 ± 20/87.6 ± 13 mmHg, left ventricular mass index (LVMI) of 129.8 ± 29 g/m2, carotid intima -media thickness (IMT) of 0.92 ± 0.2 mm. Diabetes mellitus (DM) was in 28% patients, mean total cholesterol 5.74 ± 1 mmol/l. At a follow-up, the incidence of non-fatal and fatal cardiovascular events was 18.2%, and total mortality was 4.7%. Major cardiovascular events were more common in men (p = 0.019) and were highly correlated with systolic blood pressure (SBP) at the beginning of the study (p = 0.038), with cholesterol at the beginning of the study(p = 0.019) and at the end of the study (p = 0.028), glucoses at the beginning of the study(p = 0.004), DM at the beginning (p = 0.001) and at the end (p = 0.006), LVMI (p < 0.001) and IMT (p < 0.001) at the beginning. Patients with a cardiovascular death were significantly older (p = 0.002), had higher SBP at the beginning (p = 0.017) and higher IMT (p = 0.017). During the study 7.4% of participants got cancer and its positive correlation with DM was determined at the end of the study (p = 0.002) and with IMT at the end of the study (p = 0.037). Conclusions: Main predictors of major cardiovascular events among patients with hypertension and high risk are: age, male sex, SBP, DM and IMT.

[PP.36.06] THE IMPACT OF SERUM URIC ACID ON ASYMPTOMATIC CAROTID ATHEROSCLEROSIS AND RENAL DISEASE IN HYPERTENSIVE PATIENTS

Objective: Serum uric acid represents an important risk factor for cardiovascular (CV) and renal disease in patients with hypertension. Carotid intima-media thickness (C-IMT) is a useful surrogate marker of early carotid atherosclerosis. To examine relation between serum uric acid (sUA) and asymptomatic carotid atherosclerosis and renal disease in patients with hypertension. Design and method: Study included 315 participants without manifested CV disease,274 with hypertension (mean age 66,75 ± 7.45 years, 108 men), 41 controls (mean age 56,16 ± 13,37, 15 men). For all patients was determined: presence of CV risk factors, SCORE risk, laboratory analysis and anthropometric measurements. Hyperuricemia was defined as a sUA value >420 &mgr;mol/L for males or >360 &mgr;mol/L for females. C-IMT and carotid atherosclerotic plaques were evaluated by B-mode ultrasound. Results: Hypertensive patients were divided into 2 groups according to level sAU. The first group (I) consisted of subjects with normal sUA, n = 200 (73%), the second (II) group patients with elevated sUA, n = 74 (27%). The average value of sUA was 289,91 ± 62,32 in I group, 443,81 ± 58,83 &mgr;mol/L in II group (p < 0,0001). Patients with high sUA had significantly higher average number of risk factors (p = 0,047), SCORE risk (p = 0,01), body mass index (p = 0,0001), prevalence of diabetes (p = 0,01) and obesity (p = 0,0001). C-IMT were significantly higher in II group (0.99 ± 0,22vs 0,80 ± 0,17,p < 0,0001). The high C-IMT were observed in 66% patients in II group vs 22% in I group, p < 0,0001. Patients with elevated sUA had more frequently one or more carotid plaques (p = 0,001), higher average number of plaques (p < 0,0001) and percentage of stenosis (p < 0,0001). In I group plaques were mostly fibrous (28%), in II group fibrocalcified (35%). Creatinine clearance and glomerular filtration rate were lower in II group (MDRD p < 0,001). Univariate regression analysis showed that sAU was associated with C-IMT, number of carotid plaques and percentage of stenosis (p < 0.0001), creatinine (p < 0.0001), obesity (p < 0.0001), SCORE risk (p < 0.0001), number of risk factors (p = 0.01) and duration of hypertension (p = 0,001). In multiple regression analysis sAU was independently related with C-IMT (beta = 0.202;p < 0.0001), percentage of stenosis (beta = 0.013;p = 0.04), creatinine (beta = 0,308, p < 0.0001) and obesity (beta = 0,219, p < 0.0001). Conclusions: Our data suggest that elevated uric acid were independently correlated with subclinical carotid atherosclerosis in patients with hypertension.

[PP.33.01] EVALUATION OF HYPERTENSIVE PATIENTS: TEN YEARS PROGNOSTIC SIGNIFICANCE OF NON-INVASIVE PARAMETERS

Objective: In practice, it is of utmost importance to predict the outcome for every patient at the beginning of the treatment. The aim was to examine the correlation between non-invasive parameters and outcomes in patients (pts) with essential arterial hypertension (AH) and left ventricular hypertrophy (LVH) during the ten years of follow-up. Design and method: All 124 pts with AH and LVH (57.0 ± 8.0 years; 84 male and 40 female) were examined by means of echocardiography (two independent examiners - Acuson-Sequoia), exercise testing, 24-h Holter monitoring, 24-h ambulatory blood pressure monitoring, heart rate variability and QTc interval dispersion. Patients used regular medicament therapy according to currently valid guidelines during the period of follow-up. Results: During the ten years period of follow-up in 40 (32.3%) pts occurred cardiovascular and cerebrovascular adverse events (AE). At the beginning of the study pts with AE had greater: LVMI (178.9 ± 29.5 g/m2 vs. 165.5 ± 29.5 g/m2; p < 0.05) and left atrial diameter (41.6 ± 6.1 mm vs. 39.2 ± 4.3 mm; p < 0.05). In pts with AE QTc dispersion was greater than in pts without AE (64.1 ± 24.7 ms vs. 54.8 ± 19.4 ms; p < 0.05). In pts with AE Cornell product was more frequently positive than in pts without AE (35% vs. 22.2%; p < 0.01). Positive Lyon-Sokolow score for left ventricular hypertrophy did not achieve statistical significance (25% vs. 11.9%; p = 0.06). Other non/invasive parameters did not achieve statistical significance. Using multiple linear regression analysis the best predictors of worse prognosis were Cornell product and QTc dispersion greater than 65 ms (standardized coefficient beta: for left atrial diameter 0.234; p < 0.01 and QTc dispersion 0.184; p < 0.05 and for the model: R = 0.314, R2 = 0.099, adjusted R2 = 0.084 standard error of the estimate = 0.449; p < 0.05). Conclusions: Patients with positive Cornell product for left ventricular hypertrophy and greater QTc dispersion, especially greater than 65 ms, have worse outcome during the ten years in spite of regular medical treatment.

4B.09: DIABETES MELLITUS AND ORGAN DAMAGE, CARDIOVASCULAR DISEASE AND MORTALITY IN HYPERTENSIVE PATIENTS: FOLLOW-UP STUDY.

Objective: Diabetes mellitus is an important contributor to a vascular damage inducing a high risk of macro-and microvascular complications. In this study, we tried to evaluate the proposed correlation of diabetes with target organ damage and cardiovascular disease and mortality in hypertensive patients. Design and method: We studied 134 participants (91 females, 43 males). Each participant underwent asymptomatic organ damage: 12-lead electrocardiogram examination, two-dimensional and Doppler echocardiography, colour Doppler sonography of the carotid arteries, laboratory investigations were prospectively followed for total and cardiovascular mortality and disease over a median of 6 years. Results: They had a mean age of 62.9 ± 8.5 years, body mass index of 28.9 ± 3.68 kg/m2, office blood pressure of 158 ± 16.7/91 ± 10.8 mmHg, index left ventricular mass (LVM) of 139.1 ± 3.99 g/m2, carotid intima-medial thickness (IMT) of 0.94 ± 0.25 mm and presence of a plaque in 69 (51.5%) participants. Diabetes mellitus was found in 41 (30.6%) participants (group I). The mean value of blood pressure (144 vs. 145.9 mmHg), visit-to-visit blood pressure variability (16.8 vs. 16.9 mmHg), serum total cholesterol (5.25 vs. 5.4 mmol/l), and fasting serum triglycerides (1.83 vs. 1.77 mmol/l) did not differ between the groups in the end of the study. In group I, 27(66%) participants presence of a plaques in carotids, vs. 43(46%) participants in group II (p < 0.04). Mean Carotid IMT of 1.01 ± 0.22 in group I, vs. 0.91 ± 0.26 mm in group II (p < 0.04). Echocardiographic mean LVM index of 140.4 ± 30.1 in group I and 138.5 ± 31.66 g/m2 in group II (ns). A total of 5 (3.7%) participants died from cardiovascular disease, 4 patients from group I and 1 patients from group II (p < 0.02). Major CV events were observed in 13 participants (31.7%) from group I, while there were 13 (14%)(group II) (p < 0.02). In group I, 6 (14.6%) participants developed a malignant disease vs. 9(9.7%) participant in group II (ns). Conclusions: Diabetes mellitus in hypertensive patients is associated with higher incidences of asymptomatic carotid disease and major cardiovascular events.

EFFECTS OF THE EARLY ONE YEAR TREATMENT IN HYPERTENSIVE LEFT VENTRICULAR HYPERTROPHY AND SIGNIFICANCE ON CARDIOVASCULAR EVENTS IN THE FUTURE: PP.22.373

Left ventricular hypertrophy (LVH) is a powerful predictor of cardiovascular morbidity and mortality. Ambulatory blood pressure monitoring (ABPM) has been proved to be superior to clinic blood pressure measurement for cardiovascular risk stratification and LVH. Objective: The aim of the present follow-up study was to evaluate the prognostic significance of the early investigated parameters as well as the effects of the changed investigated parameters after 12 month treatment on the long term prognosis of the patients with hypertensive LVH. Patients and Methods: A total of 73 age matched, no diabetic, hypertensive male (n = 44, aged 55.4 ± 8 years) and female (n = 29, aged 57.3 ± 6 years) patients with echocardiographically proved LVH, were analyzed for cardiovascular death, fatal or non-fatal myocardial infarction and stroke and revascularization procedures after 12 year follow-up. Each patient underwent: Doppler Echocardiography, Exercise stress testing, 24-hour ABPM, Holter monitoring and heart rate variability (standard deviation of all 24-hour NN intervals (SDNN, ms). Results: After 12 years of observation, 12 patients (16%) had serious cardiovascular incidents and 6 died (8%). Presence of metabolic syndrome at the beginning of the study influenced the appearance of significant cardiovascular events and death, one year earlier than in patients without MS. Multivariant analysis of investigated parameters after one year treatment showed that the death risk increases the missing of average daily diastolic BP (1.419; (95% CI for Exp(B)-1,049–1.918; p = 0.023), rising of the average night systolic BP (1.206; (95% CI for Exp(B)-1,039–1.399; p = 0.014) as well as rising of average night heart rate(1.306; (95% CI for Exp(B)-1,023–1.668; p = 0.032). Increasing of LVM index (1.014; 95% CI for Exp(B)-1,002–1.026; p = 0.026) and higher decrease of night diastolic BP (1.247; 95% CI for Exp(B)-1,083–1.437; p = 0.002). suggest the risk of both significant cardiovascular events and death. Conclusion: Increase of LVM index and poor 24 hour BP regulation are major predictors of future serious cardiovascular incidents in hypertensive patients with LVH.