Left ventricular concentric remodelling and extracardiac target organ damage in essential hypertension

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Age related prevalence of severe left ventricular hypertrophy in essential hypertension : echocardiographic findings from the ETODH study

Aim. We sought to investigate the prevalence and correlates of severe left ventricular hypertrophy (LVH) in relation to age in a large cohort of essential hypertensives referred to a single outpatient hypertension clinic. Methods. A total of 3752 (mean age 53\ub113 years, 53% men) untreated (29.5%) and treated hypertensive patients categorized in three age groups (I: 18-40 years; II: 41-64 years; III: 6565 years) were considered for this analysis. All patients underwent extensive investigations searching for target organ damage. LVH, defined as LV mass 6549/45 g/m 2.7 in men/women, respectively, was graded as mild, moderate and severe according to Lang's report. Results. LVH prevalence was 29.4% in group I, 48.2% in group II and 63.6% in group III. Overall, more than one fourth of patients with LVH had a severely increased LV mass index; the likelihood of having severe LVH was two- and four-fold higher in elderly hypertensives than in their middle-aged and young counterparts, respectively. Increasing age and LVH degree were both associated with a greater prevalence of concentric LV geometry as well as of extra-cardiac organ damage (i.e. carotid intima-media thickness). Conclusions. LVH is a highly prevalent organ damage in essential hypertensives, particularly in the elderly, who exhibited a more severe increase of LV mass index, higher relative wall thickness and extra-cardiac organ damage compared with young and middle-aged sub-groups. Our findings suggest that the assessment of cardiovascular risk by grading LVH rather than simply defining the presence/absence of this cardiac phenotype could improve therapeutic strategies in the hypertensive population, particularly in the elderly

Left ventricular hypertrophy and cardiovascular risk stratification : impact and cost-effectiveness of echocardiography in recently diagnosed essential hypertensives

BACKGROUND: Echocardiography is more accurate than electrocardiography in the assessment of cardiac target organ damage related to hypertension, thus leading to a more precise stratification of total cardiovascular risk. However, ultrasound examination of the heart on a routine basis remains a matter of debate. OBJECTIVE: To evaluate the impact and cost-effectiveness of echocardiographic examination on global risk stratification in low and medium-risk hypertensive patients in relation to age and sex. METHODS: A total of 580 untreated hypertensive individuals (355 men and 225 women, mean age 47.8 +/- 11.4 years), classified at low to medium risk, according to routine clinical work-up suggested by the 2003 European Society of Hypertension/European Society of Cardiology guidelines, were included in the study. Total risk was reassessed by adding the results of ultrasound examination of the heart. Left ventricular hypertrophy (LVH) was defined as a left ventricular mass index of 125 g/m2 or more in men and 110 g/m2 or more in women. The impact of LVH in stratifying risk was assessed according to age (< 50 and &rt; or= 50 years) and sex. RESULTS: According to routine classification, 16.3% (n= 93) of the 580 patients were considered to be at low added risk and 83.7% (n= 487) at medium added risk. In the whole population, echocardiographic LVH was found in 86 patients (14.8%) who were then reclassified in the high-risk stratum. The prevalence rates of patients reclassified in the high-risk class as a consequence of LVH detection, according to age and sex, were as follows: 8.9% in men under 50 years, 12.3% in women under 50 years, 26.7% in men aged 50 years and over and 15.3% in women aged 50 years and over. The cost per detected case of LVH was 595 euros in patients under 50 years of age and 290 euros in those 50 years of age and older. CONCLUSIONS: Our findings indicate that the prevalence of LVH, and consequently the probability of upgrading the total cardiovascular risk profile, is highest in the group of old hypertensive men; echocardiography has a limited impact on the risk reclassification in younger patients and an unfavourable cost-effectiveness profile. Our data thus do not support the systematic ultrasound assessment of the heart in all uncomplicated hypertensive individuals

Left ventricular hypertrophy and cardiovascular risk stratification : impact and cost-effectiveness of echocardiography in recently diagnosed essential hypertensives

BACKGROUND: Echocardiography is more accurate than electrocardiography in the assessment of cardiac target organ damage related to hypertension, thus leading to a more precise stratification of total cardiovascular risk. However, ultrasound examination of the heart on a routine basis remains a matter of debate. OBJECTIVE: To evaluate the impact and cost-effectiveness of echocardiographic examination on global risk stratification in low and medium-risk hypertensive patients in relation to age and sex. METHODS: A total of 580 untreated hypertensive individuals (355 men and 225 women, mean age 47.8 \ub1 11.4 years), classified at low to medium risk, according to routine clinical work-up suggested by the 2003 European Society of Hypertension/European Society of Cardiology guidelines, were included in the study. Total risk was reassessed by adding the results of ultrasound examination of the heart. Left ventricular hypertrophy (LVH) was defined as a left ventricular mass index of 125 g/m or more in men and 110 g/m or more in women. The impact of LVH in stratifying risk was assessed according to age (< 50 and 65 50 years) and sex. RESULTS: According to routine classification, 16.3% (n = 93) of the 580 patients were considered to be at low added risk and 83.7% (n = 487) at medium added risk. In the whole population, echocardiographic LVH was found in 86 patients (14.8%) who were then reclassified in the high-risk stratum. The prevalence rates of patients reclassified in the high-risk class as a consequence of LVH detection, according to age and sex, were as follows: 8.9% in men under 50 years, 12.3% in women under 50 years, 26.7% in men aged 50 years and over and 15.3% in women aged 50 years and over. The cost per detected case of LVH was \u20ac595 in patients under 50 years of age and \u20ac290 in those 50 years of age and older. CONCLUSIONS: Our findings indicate that the prevalence of LVH, and consequently the probability of upgrading the total cardiovascular risk profile, is highest in the group of old hypertensive men; echocardiography has a limited impact on the risk reclassification in younger patients and an unfavourable cost-effectiveness profile. Our data thus do not support the systematic ultrasound assessment of the heart in all uncomplicated hypertensive individuals

Prevalence and correlates of aortic root dilatation in patients with essential hypertension : relationship with cardiac and extracardiac target organ damage

Objective: To assess the prevalence of aortic root dilatation in a large cohort of uncomplicated hypertensive patients and to evaluate the relations of aortic root size to different markers of cardiac and extracardiac target organ damage (TOD). Methods: A total of 3366 untreated and treated essential hypertensive patients (mean age, 53 \ub1 12 years) consecutively attending our out-patient hypertension clinic and included in the Evaluation of Target Organ Damage in Hypertension (an observational ongoing registry of hypertension-related TOD) were considered for this analysis. All patients underwent routine examinations, 24-h urine collection for microalbuminuria, echocardiography and carotid ultrasonography. Results: Aortic root dilatation, defined by the sex-specific echocardiographic criteria of 40 mm in men and 38 mm in women, was present in 8.5% of men and in 3.1% of women. Compared with 3160 patients with normal aortic size, the group of 206 patients with an enlarged aortic root was older, had higher diastolic blood pressure values and included a greater fraction of subjects under antihypertensive treatment, with type 2 diabetes and metabolic syndrome. The prevalence of left ventricular hypertrophy, carotid intima-media thickening, plaques and microalbuminuria was significantly higher in patients with aortic root dilatation. According to a logistic regression analysis, left ventricular hypertrophy, carotid atherosclerosis, overweight and metabolic syndrome were the main independent and potentially modifiable predictors of aortic root dilatation in the whole hypertensive population as well as in untreated and treated hypertensive patients separately. Conclusions: Our study shows that hypertensive patients with aortic root enlargement have more pronounced alterations in cardiac structure and geometry as well as in carotid artery morphology compared with those without the enlargement. Aortic root dilatation therefore appears to be a useful marker of high cardiovascular risk related to TOD. Whether this alteration independently predicts cardiovascular morbidity remains to be proven

Left ventricular hypertrophy and cardiovascular risk stratification : impact and cost-effectiveness of echocardiography in recently diagnosed essential hypertensives

BACKGROUND: Echocardiography is more accurate than electrocardiography in the assessment of cardiac target organ damage related to hypertension, thus leading to a more precise stratification of total cardiovascular risk. However, ultrasound examination of the heart on a routine basis remains a matter of debate. OBJECTIVE: To evaluate the impact and cost-effectiveness of echocardiographic examination on global risk stratification in low and medium-risk hypertensive patients in relation to age and sex. METHODS: A total of 580 untreated hypertensive individuals (355 men and 225 women, mean age 47.8 \ub1 11.4 years), classified at low to medium risk, according to routine clinical work-up suggested by the 2003 European Society of Hypertension/European Society of Cardiology guidelines, were included in the study. Total risk was reassessed by adding the results of ultrasound examination of the heart. Left ventricular hypertrophy (LVH) was defined as a left ventricular mass index of 125 g/m or more in men and 110 g/m or more in women. The impact of LVH in stratifying risk was assessed according to age (< 50 and 65 50 years) and sex. RESULTS: According to routine classification, 16.3% (n = 93) of the 580 patients were considered to be at low added risk and 83.7% (n = 487) at medium added risk. In the whole population, echocardiographic LVH was found in 86 patients (14.8%) who were then reclassified in the high-risk stratum. The prevalence rates of patients reclassified in the high-risk class as a consequence of LVH detection, according to age and sex, were as follows: 8.9% in men under 50 years, 12.3% in women under 50 years, 26.7% in men aged 50 years and over and 15.3% in women aged 50 years and over. The cost per detected case of LVH was \u20ac595 in patients under 50 years of age and \u20ac290 in those 50 years of age and older. CONCLUSIONS: Our findings indicate that the prevalence of LVH, and consequently the probability of upgrading the total cardiovascular risk profile, is highest in the group of old hypertensive men; echocardiography has a limited impact on the risk reclassification in younger patients and an unfavourable cost-effectiveness profile. Our data thus do not support the systematic ultrasound assessment of the heart in all uncomplicated hypertensive individuals

Age and target organ damage in essential hypertension : role of the metabolic syndrome

Objective: We sought to investigate the association of the metabolic syndrome (MS) with cardiovascular alterations in essential hypertensives in relation to age. Methods: A total of 3266 untreated and treated hypertensive patients categorized in three age groups (I: 17 to 40 years; II: 41 to 64 years; III: >64 years) were considered for this analysis. All patients underwent extensive investigations searching for target organ damage (TOD). The MS was defined according to Advanced Technology Laboratories (ATP) III criteria. Results: In the entire population, the risk of left ventricular hypertrophy (LVH), carotid abnormalities, and microalbuminuria increased by 2.5 (P = .003), 2.2 (P = .005), and 1.5 times (P = .01), respectively, in the presence of MS after adjusting for several confounders. Prevalence of LVH (group I: 39% v 22%; group II: 53% v 35%; group III: 69% v 52%, P < .01 for all), carotid thickening (group I: 8% v 2%; group II 29% v 19%; group III: 69% v 52%, P < .05 for all) and microalbuminuria (group I: 20% v 11%; group II: 16% v 8%; group III: 18% v 11%, P 64 .05 for all) was significantly higher in patients with MS than in their counterparts across all age groups. Conclusions: In hypertensive patients the MS amplifies TOD regardless of patient's age, thus increasing cardiovascular risk. This synergistic effect may accelerate the early development of TOD in young hypertensives and enhance the age-associated cardiovascular alterations in the elderly

Effects of angiotensin II receptor blockade-based therapy with losartan on left ventricular hypertrophy and geometry in previously treated hypertensive patients

Background. The 2003 European Society of Hypertension/ European Society of Cardiology (ESH/ESC) guidelines recommend angiotensin II receptor antagonists (AIIRAs) as a first-line therapy in hypertensives with left ventricular hypertrophy (LVH). Aim. We investigated the long- term effects of an AIIRA- based therapy on left ventricular (LV) structure and geometry in previously, unsatisfactorily treated essential hypertensive patients. Methods. Sixty- eight consecutive patients referred to our hypertension hospital outpatient clinic with: (i) LVH (LV mass index, LVMI &rt;= 51 g/ m(2.7) in men and &rt;= 47 g/m(2.7) in women), (ii) uncontrolled clinic blood pressure (BP &rt;= 140 and/or 90 mmHg) and (iii) antihypertensive therapy not including angiotensin-converting enzyme (ACE) inhibitors or AIIRAs were selected for this study. Two-dimensionally guided M-mode echocardiograms were carried out at baseline and after 6, 12, 18 and 24 months of follow-up. In all patients, losartan (50-100 mg/day, mean dose 82 mg/day) was added as first step to the previous therapy. Additional drugs, tailored to the single patient, were added, if necessary, to achieve target BP values (< 140/90 mmHg). Results. Overall, 59 patients completed the study with the primary efficacy measurements (LVMI) at all appropriate times. A significant reduction in both clinic systolic BP and diastolic BP was found across the entire period of study respect to baseline (-17/10, 222/12, 224/13 and 226/14 mmHg at 6, 12, 18 and 24 months, p < 0.001 respectively), leading to target clinic BP in 75.6% of cases. LVMI was significantly lower after 1 year of treatment (-11 +/- 12%, p < 0.05) with a further significant reduction at the end of treatment (-22 +/- 18%, p < 0.01). The proportion of patients achieving normalization of LVMI was 47.4% and more importantly, the prevalence of concentric LVH fell from 38.9% to 6.7% (p < 0.01). Conclusions. Our findings indicate that long- term intensive treatment based on the AIIRA losartan induced a normalization of LVH in about 50% of patients and more importantly caused an almost complete regression of concentric LVH, the most dangerous adaptive pattern. The transition from concentric to normal or eccentric LV geometry may have in these high-risk patients a favourable prognostic implication in addition to the recognized positive effect of reducing LVMI

How reliable is isolated clinical hypertension defined by a single 24-h ambulatory blood pressure monitoring?

BACKGROUND: Isolated clinical hypertension (ICH) is characterized by a persistently elevated clinic blood pressure in the presence of a normal day-time or 24-h ambulatory blood pressure (ABP). This definition is based on a single ABP monitoring (ABPM) and little attention has been focused on the reproducibility of this condition. OBJECTIVE: To investigate the reliability of the criteria currently recommended by major hypertension guidelines to detect ICH based on a single 24-h ABPM session. METHODS: A total of 611 never-treated grade 1 and 2 hypertensive patients (mean age 46 \ub1 12 years) referred for the first time to our out-patient clinic, underwent repeated clinic blood pressure measurements, routine investigations, two 24-h periods of ABPM 1-4 weeks apart, cardiac and carotid ultrasound examinations. ABPM was always performed over a working day and the same daily activities were recommended during the two periods. ICH was diagnosed by the following criteria: (i) mean daytime values < 135/85 mmHg or (ii) mean 24-h blood pressure values < 125/80 mmHg during the first ABPM. RESULTS: The overall prevalence of ICH was 7.1% according to criterion (i) and 5.4% according to criterion (ii). Twenty (46.6%) of the 43 patients with mean daytime blood pressure values < 135/85 mmHg during the first ABPM, exceeded this cut-off value during the second ABPM period. Twenty-two (66.6%) of the 33 patients with mean 24-h blood pressure values < 120/80 mmHg during the first ABPM did not confirm a normal blood pressure profile during the second ABPM recording. Cardiovascular involvement was significantly lower in subjects with persistent normal ABP compared to those with non-reproducible ICH pattern or sustained hypertensives. CONCLUSIONS: These findings clearly indicate that: (i) the classification of ICH on the basis of a single ABPM, using the cut-offs suggested by major hypertension guidelines, has a limited short-term reproducibility and (ii) repeated ABPM recordings should be recommended to correctly diagnose patients with ICH and improve cardiovascular risk stratification

Ambulatory blood pressure, target organ damage and left atrial size in never-treated essential hypertensive individuals

Objective: To investigate the relationship between ambulatory blood pressure and different markers of target organ damage with left atrial size in never-treated essential hypertensive individuals. Methods: A total of 519 grade 1 and 2 hypertensive patients (mean age 46 \ub1 12 years), referred for the first time to our outpatient clinic, underwent routine examinations: 24-h urine collection for microalbuminuria, ambulatory blood pressure monitoring over two 24-h periods in 4 weeks, echocardiography and carotid ultrasonography. Results Left atrial diameter was increased in 17.3% of patients. No significant differences were found between subjects with and without increased left atrial size with regard to sex, duration of hypertension, clinic and mean 48-h ambulatory blood pressure, and daytime and night-time values. Compared with 429 patients with normal left atrial size, the 90 patients with enlarged left atria were older, had higher body mass index, were more frequently smokers, and included more individuals with the metabolic syndrome. The prevalence of left ventricular hypertrophy, of intima-media thickening, but not of microalbuminuria was significantly higher in subjects with increased left atrial size. Conclusion Left atrial enlargement is not an early echocardiographic finding in relatively young never-treated hypertensive individuals, as its prevalence is lower than that of well-validated markers of target organ damage, and it is unrelated to ambulatory blood pressure. Overweight, left ventricular hypertrophy, carotid 4ntima-media thickening and metabolic syndrome are independent predictors of left atrial dimension, suggesting that changes in left atrial size represent an adaptive response when high blood pressure is associated with other cardiovascular or metabolic abnormalities