Hypertensive Cardiomyopathy: Diagnostic Approach and Clinical Differentiation from Hypertrophic Cardiomyopathy

Hypertensive Cardiomyopathy (HTN-CM) is a structural cardiac disorder generally accompanied by concentric or eccentric Left Ventricular Hypertrophy (LVH) associated with diastolic or/and systolic dysfunction in patients with persistent systemic hypertension. It occurs in the absence of other cardiac diseases capable of causing myocardial hypertrophy or cardiac dysfunction. Long standing arterial hypertension (HTN) leads to structural and functional myocardial abnormalities resulting in myocardial ischemia, fibrosis, and hypertrophy. HTN-CM is predominantly a disease of impaired relaxation rather than impaired contractility, although subtle myocardial systolic abnormalities could be detected recently by Global Longitudinal Systolic Strain (GLS) Speckle Tracking Echocardiography (STE). Importantly, the accompanying LVH is itself a risk factor for mortality and morbidity and is considered an independent predictor for Sudden Cardiac Death (SCD). Therefore, early detection of LVH development in patients with Hypertensive Hypertrophic Cardiomyopathy (HTN-CM) is crucial for optimal treatment. In addition to pathological findings, echocardiography and cardiac magnetic resonance imaging are ideal tools for the diagnosis of HTN-CM and can differentiate it from Hypertrophic Cardiomyopathy (HCM). Timely diagnosis of this condition and utilization of appropriate treatment are required to improve morbidity and mortality in hypertensive patients. This review presents an overview of utilization of multidisciplinary imaging modalities approach for proper diagnosis of HTN-CM and its differentiation from HCM. Relevant article highlighted key points in differentiation of HTN-CM from HCM and the effects of hypertension on cardiac hypertrophy and heart failure development are discussed in clinical case study

Updates Regarding Prediction and Prevention of Sudden Cardiac Death

Sudden cardiac death (SCD) remains a major public health problem globally, especially in the United States causing more than 300,000 deaths annually. SCD from cardiac arrest is the most common cause of death worldwide, accounting for >50% of all deaths from cardiovascular diseases (CVDs) and it is characterized by unexpected collapse due to an underlying cardiovascular cause. The condition usually results from an electrical disturbance in the heart that disrupts its pumping action, stopping blood flow to the body. When the heart stops, the lack of oxygenated blood can causes death or permanent brain damage within minutes. Time is extremely critical when someone or a clinician is helping an unconscious person who is not breathing. SCD represents a major challenge for the clinician because most episodes occur in individuals without previously known cardiac disease. Hence, an early prediction of individuals at risk of SCD is the holly-grail of all physicians. Because most individuals experiencing SCD currently are not identifiable as being at high risk, community-based public access to defibrillation programs is essential to save lives and more so to improve neurological and functional outcomes for cardiac arrest victims. In order to prevent SCD, it is imperative to impose an aggressive management of cardiovascular risk factors, including performing exercise regularly, educating patients about the dangers of CVDs, promoting a healthy diet, restricting consumption of sugar, saturated fat, salt and smoking cessation to promote a heart healthy behavior to all, young children in particular. Finally, a preclinical prediction of patients at risk of SCD and early detection of the disease is crucial for early intervention and definitely will reduce the incidence of sudden cardiac death dramatically

Sub-clinical Detection of Left Ventricular Myocardial Dysfunction in Valvular Heart Diseases: A State-of-the-Art Review in a Speckle Tracking Echocardiography and Myocardial Performance

Purpose of the state-of-the-art review: Left ventricular (LV) global longitudinal strain (GLS) is recently recognized as a more sensitive measure of LV myocardial systolic function compared with LV ejection fraction (LVEF). In addition, left ventricular GLS , myocardial performance index (MPI) and maximum rate of LV pressure rise during isovolumetric contraction (LV dP/dtmax) are more reproducible than traditional assessment of LV systolic function by two dimensional echocardiography (2DE) LVEF. These underutilized techniques can detect preclinical myocardial dysfunction in patients who are at risk of LV failure in valvular-induced heart disease . Current guidelines for diagnosis and treatment of valvular heart disease (VHD) include LVEF as one of the parameters to take into consideration in the clinical decision-making. However, a large body of evidence has shown that left ventricular GLS, MPI and LV dP/dtmax have been classically considered as a sensitive marker of LV contractility and inotropic state. In turn GLS and myocardial performance may be a better prognosticator than LVEF in aortic and mitral valve heart diseases. This timely state-of-the-art review, appraised the evidence and role of GLS, MPI and dP/dT as clinical tools in patients with aortic and mitral valve disease. Recent findings: Left ventricular GLS has been shown to be prognostic in low-flow, low-gradient severe aortic stenosis with preserved LVEF. The role of left ventricular GLS, Tei index (MPI) and maximum rate of LV pressure rise (LV dP/dtmax) in patients with aortic regurgitation and mitral valve diseases (regurgitation and stenosis) is less well established. Summary: Echocardiography is considered the primary non-invasive imaging tool for valvular heart disease assessment and the cornerstone method in diagnosing and evaluating the morphology and severity of aortic and mitral valve diseases. Currently, diagnostic-cardiac catheterization is no more recommended except in very rare cases when echocardiographic image quality is suboptimal, non-diagnostic and when the results of 2DE are discrepant with clinical data. Once clinical decision-making is based on the 2DE and three dimensional echocardiographic in assessment of the severity of mitral and aortic valve diseases, it is crucial that standards should be adopted to maintain accuracy and consistency across echocardiographic laboratories. This illustrative review article assesses left ventricular systolic function (LVEF) employing two and/or three dimensional echocardiography in comparison to GLS, MPI and LV dP/dtmax, especially applied for aortic valve (AV) and mitral valve (MV) diseases. It is noteworthy that this document only provides echocardiographic standards rather than making recommendations for clinical management. Conclusion: It is concluded that GLS, MPI and maximum rate of LV pressure rise during isovolumetric contraction (LV dP/dtmax) are recommended and more so, they should be increasingly used to identify subclinical LV myocardial dysfunction in patients with mitral and aortic valve heart diseases, to identify optimal timing for surgery and prognosticate outcomes after surgery

Prediction of Preclinical Myocardial Dysfunction among Obese Diabetics with Preserved Ejection Fraction Using Tissue Doppler Imaging and Speckle Tracking Echocardiography

Background. Obesity and type 2 diabetes mellitus (T2DM) are two interrelated and preventable disorders. However, they are responsible for significant global mortality from cardiovascular diseases (CVDs). Clinical studies have demonstrated that global longitudinal strain (GLS) using speckle tracking echocardiography (STE), can assess myocardial function accurately in apparently, healthy patients with diabetes and obesity in the settings of acute and chronic ischemia and suspected cardiomyopathy without heart failure. No such studies have been published to date regarding subclinical detection of cardiac dysfunction among obese patients with T2DM. This study aims to investigate the role of STE in the early pre-clinical diagnosis of impairment of diastolic and systolic dysfunction in obese patients with T2DM. This study also investigated whether it is possible to detect early pre-clinical impairment of diastolic and systolic dysfunction in obese T2DM patients, via Tissue Doppler Imaging (TDI), maximum rate of left ventricular pressure development (peak dP/dt) and GLS using STE for comparison. Subjects and Methods. After clearance from the review board of Dibba- Hospital, Alfujairah, UAE, all the available records of patients with the diagnosis of obesity and diabetes were examined. The study included 214 patients presenting with obesity in conjunction with diabetes and 93 age-matched healthy control subjects. STE was performed among all the patients and subjects along with Tissue Doppler Imaging (TDI). This study assessed maximal rate of pressure rise during ventricular contraction (peak dP/dt) and global longitudinal strain (GLS) using STE methods. Transthoracic echocardiography, myocardial Doppler-derived systolic (sm), early diastolic velocity (em) and GLS were also obtained, among all the subjects. Results. The results show that cardiac functions via conventional echocardiography (CE) were similar in the 2 groups. Using TDI and conventional mitral Doppler flow, obese subjects with diabetes showed an evidence of diastolic function abnormalities in the form of lower Ea velocity (9.5 ± 2.9 vs. 18.4 ± 3.5 cm/s, p < 0.0001), an increased Aa velocity (16.5 ± 2.4 vs. 14.1 ± 2.2 cm/s p < 0.05), higher left ventricular filling pressure (E/Ea = 12 ± 4.4 vs 8±3.1), p 35) (n = 26) had reduced LV systolic and diastolic function compared with healthy controls. Regarding, systolic function indices, the findings revealed lower average longitudinal peak systolic strain, sm and reduced em, although, LV ejection fraction remained normal (56.48% ± 8.81). Among subjects with severe obesity (n = 26), the findings reveal that global longitudinal presystolic strain (GLPSS) is highly correlated with maximum rate of pressure development of LV (dp/dt), although the LVEF remained normal, in comparison to systolic strain and dp/dt. (.5% ±1.4 vs -19.54% ± 4.5; p < 0.001), in the age-matched healthy subjects. However, the frequency/grade of DCM detected by STE, among patients having obesity with T2DM, correlated closely with the degree of obesity, metabolic abnormalities and clustering of other major risk factors, especially high blood pressure. The findings also revealed that chest pain due to coronary heart disease (CAD), dyspnea and DCM were more common among female patients compared to men. Conclusion. The results indicate that patients having obesity with T2DM should be advised to undertake early TDI and STE for early diagnosis of decreased cardiac diastolic and systolic dysfunctions and cardiomyopathy, which is likely to be missed by conventional echocardiography. Significant differences in regional and global strain were also identified between the severely obese diabetic (BMI ≥ 35), (GLPSS (-13) patients compared to less obese subjects

New Insight in the Assessment of Left Ventricular Function in Paradoxical Low Flow Aortic Stenosis Patients with Normal Left Ventricular Ejection Fraction: A Mini-Review

Paradoxical valvular aortic stenosis (VAS) is a challenging area of clinical cardiology for the practitioners. It involves a small aortic valve area, low flow rate and mean pressure gradient although there is normal left ventricular ejection fraction. The aim of this study was to assess left ventricular (LV) dysfunction in a symptomatic severe aortic valve stenosis which is of crucial importance in identifying patients at risk of heart failure, postoperative complications and increased mortality. There are new insights which are involved in assessment of LV myocardial function including global longitudinal strain (GLS) by two-dimensional speckle tracking echocardiography (2D STE), myocardial performance index (MPI) and maximum rate of LV pressure rise (+dP/dt) during isovolumetric contraction time of the LV. This information can provide both diagnostic and prognostic information in addition to standard echocardiographic and clinical parameters. However, a profound understanding of the complex interaction between loading conditions, chamber geometry and contractility is necessary for the correct interpretation of myocardial deformation in order to draw appropriate conclusions in patients with aortic valve disease. This mini review is related to new and novel insights into the assessment of left ventricular function (LVF) in paradoxical low flow aortic stenosis patients with normal left ventricular ejection fraction (LVEF)

New Insight in the Assessment of Left Ventricular Function in Paradoxical Low Flow Aortic Stenosis Patients with Normal Left Ventricular Ejection Fraction: A Mini Review

Paradoxical valvular aortic stenosis (VAS) is a challenging area of clinical cardiology for the practitioners. It involves a small aortic valve area, low flow rate and mean pressure gradient although there is normal left ventricular ejection fraction. The aim of this study was to assess left ventricular dysfunction in a symptomatic severe aortic valve stenosis which is of crucial importance in identifying patients at risk of heart failure, postoperative complications and increased mortality. There are new insights which are involved in assessment of LV myocardial function including global longitudinal strain (GLS), myocardial performance index (MPI) and maximum rate of LV pressure rise (+dP/dt) during isovolumetric contraction time of the ventricle. This information can provide both diagnostic and prognostic information in addition to standard echocardiographic and clinical parameters. However, a profound understanding of the complex interaction between loading conditions, chamber geometry and contractility is necessary for the correct interpretation of myocardial deformation in order to draw appropriate conclusions in patients with aortic valve disease. This mini review is related to new and novel insights into the assessment of left ventricular function (LVF) in paradoxical low flow aortic stenosis patients with normal left ventricular ejection fraction (LVEF)