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

Myocardial Deformation Imaging Meta-Analysis in Two Cohorts of Patients from UAE and Heart Hospital Hamadmedical Corporation: A Potential Role in Assessment of Coronary Artery Disease Severity and Myocardial Viability

Introduction: The increasing prevalence of heart failure (HF) in coronary artery disease (CAD) urgently requires the establishment of new imaging techniques for early diagnosis and also to guide treatment of patients presented with acute coronary syndromes (ACS). Conventional echocardiography (CE) and electrocardiogram (ECG) are the gold standard methods in assessing myocardial ischemia (MI) and the function of the heart in patients with coronary artery disease (CAD). The lack of ST elevation by ECG and regional wall motion abnormalities by CE in non-ST segment elevation myocardial infarction (NSTEACS) in ACS patients reflect limited sensitivity of ECG and CE in identifying patients with acute coronary occlusion (ACO) and proper assessment of myocardial viability. Aim of this study: This study now evaluates the ability of strain parameters in grading the severity of CAD to detect myocardial viability in ACS through a comparative meta-analysis in two cohorts of patients living in the UAE and Qatar. The study investigates the diagnostic accuracy of left ventricular longitudinal systolic strain function (GLS) by 2D-speckle tracking echocardiography (2D-STE), Territorial Longitudinal Strain (TLS) analysis and post systolic strain (PSS) in ACS patients admitted at the emergency departments. All the patients had acute chest pain which is highly suggestive of NSTEACS along with coronary angiography (CA). Methods: The study recruited two groups, comprising of 347 patients, who were presented with acute coronary syndrome (NSTEACS) at the emergency department. The first group had 214 consecutive patients who had acute chest pain and high-risk profile and they were admitted to the emergency department at Eastern Emirates Hospitals, El-Fujairah-Dibba (EEEH), UAE. The second group consisted of 133 from emergency department at Heart Hospital- Hamad Medical Corporation (HHHMC), Qatar. In both groups, 85% of the patients were men with ages from 32 to 65 years (mean ± SD: 49.4 ± 9.5 years). Significant CAD was defined as having at least one epicardial vessel with ≥ 70% or left main>50% stenosis. All patients enrolled in this study underwent basic echocardiography, speckle tracking analysis, and coronary angiography. In 70 patients, PSS was calculated and myocardial perfusion imaging (MPI) was utilized as gold standards for the assessment of myocardial viability in patients with documented NSTEACS. The sensitivity, specificity, positive and negative predictive values of peak longitudinal systolic strain (2D-STE) and PSS were calculated. Left ventricular systolic strain was displayed as bull’s eye plot and territorial longitudinal strain (TLS) in the territory of the infarct-related artery. They were obtained within 24 hours from admission. Coronary angiography (CA) was performed within 24 hours from admission and used as a reference tests to assess the severity of CAD. Results: Echocardiogram obtained from the patients showed any no wall motion abnormalities at rest, although speckle tracking analysis was abnormal in 167 patients. In the first group of patients from the UAE, GLS showed a high sensitivity of 80% and a very high specificity of 93% for detection of significant CAD. In addition, PSS demonstrated a high sensitivity of 80% with an average specificity of 57%. The combination of GLS and PSS showed a further increase in sensitivity, specificity with positive and negative predictive values of 98%, 91%, 99% and 97%, respectively. Therefore, a very high correlation of GLS and PSS with coronary angiography was demonstrated: =0.90, p<0.0001 and R=0.88, p<0.0001, respectively. Furthermore, PSS showed a very high concordance with MPI scan (stress-rest-re injection studies) in detection of ischemic viable myocardium with very high sensitivity of 85%, r=0.79. In the Qatari (HHHMC) patients, a multi-vessel disease or left main disease (MV) was documented in 53.6%, and those with single vessel disease (SV) in 46.4%. LAD, circumflex and RCA lesions were found in 65, 50 and 39 patients, respectively. A control group of 129 cases was selected from outpatients referred to the echocardiography unit. The results showed that in comparison to CA, GLS sensitivity and specificity were 84% and 70%, respectively in all the patients. The sensitivity of GLS was 87% in MV and 80% in SV. Territorial strain sensitivity was 50%, 74% and 84.6% for the left anterior descending artery (LAD), circumflex and right coronary artery (RCA), respectively compared to specificity values of 64%, 65% and 61.7%, respectively. Conclusion: It is concluded that GLS by speckle tracking analysis is definitely an accurate method in early diagnosis of the severity of CAD in patients presenting with NSTE ACS. The combined use of GLS and PSS showed very high diagnostic accuracy for the identification of significant CAD in these patients. Strain imaging by STE may be applied to diagnose the severity of myocardial ischemia by showing reduction in peak systolic strain. Moreover, it is equally important to demonstrate post-systolic shortening which is a characteristic feature of ischemic viable myocardium after ACS requiring revascularization

Micro Vascular and Macro Vascular Disease in Systemic Hypertension: The Role of Cardiac Imaging and Nitric Oxide Synthase Gene Polymorphism

Systemic Hypertension (HTN) accounts for the largest amount of attributable Cardiovascular (CV) mortality worldwide. There are several factors responsible for the development of HTN and its CV complications. Multicenter trials revealed that risk factors responsible for Micro Vascular Disease (MVD) are similar for those attributable to Coronary Artery Disease (CAD) which include tobacco use, unhealthy cholesterol levels, HTN, obesity and overweight, physical inactivity, unhealthy diet, diabetes, insulin resistance, increasing age and genetic predisposition. In addition, the defective release of Nitric Oxide (NO) could be a putative candidate for HTN and MVD. This study reviewed the risk stratification of hypertensive population employing cardiac imaging modalities which are of crucial importance in diagnosis. It further emphasized the proper used of cardiac imaging to determine patients at increased CV risk and identify the management strategy. It is now known that NO has an important eff ect on blood pressure, and the basal release of endothelial Nitric Oxide (eNOS) in HTN may be reduced. Although there are diff erent forms of eNOS gene allele, there is no solid data revealing the potential role of the polymorphism of the eNOS in patients with HTN and coronary vascular diseases. In the present article, the prevalence of eNOS G298 allele in hypertensive patients with micro vascular angina will be demonstrated. This review provides an update on appropriate and justified use of non-invasive imaging tests in hypertensive patients and its important role in proper diagnosis of MVD and CAD. Second, eNOS gene allele and its relation to essential hypertension and angina pectoris are also highlighted

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)

Coenzyme Q10 Modulates Remodeling Possibly by Decreasing Angiotensin-Converting Enzyme in Patients with Acute Coronary Syndrome

The study aims to examine the effects of coenzyme Q10, (a bioenergetic antioxidant), on the indexes of left ventricular remodeling, oxidative damage, and angiotensin-converting enzyme (ACE) level after acute myocardial infarction (AMI) with left ventricular dysfunction. In a double blind, randomized, placebo-controlled, parallel group study (a retrospective analysis of an earlier trial) in 55 patients with left ventricular ejection fraction &lt;50% after AMI, the effects of coenzyme Q10 (120 mg/day) or placebo were studied for 24 weeks. Two-dimensional echocardiography was performed at discharge, (approximately 5&ndash;10 days after admission) and at 6 months after AMI. The results revealed that wall thickness opposite the site of infarction decreased from (mean &plusmn; standard deviation (SD)) 12.2 &plusmn; 2.0 mm to 10.0 &plusmn; 1.8 mm with coenzyme Q10 compared with 12.8 &plusmn; 2.2 mm to 13.3 &plusmn; 2.3 mm with placebo (p &lt; 0.01). Left ventricular mass changed from 236 &plusmn; 72 g to 213 &plusmn; 61 g with coenzyme Q10 compared with 230 &plusmn; 77 g to 255 &plusmn; 86 g with placebo (p &lt; 0.01). Treatment with coenzyme Q10 also prevented alteration of sphericity index which is a ratio of the long and short axis of the left ventricle (which changed from 1.61 &plusmn; 0.28 to 1.63 &plusmn; 0.30 with coenzyme Q10 compared with 1.61 &plusmn; 0.32 to 1.41 &plusmn; 0.31 with placebo (p &lt; 0.05)). Coenzyme Q10 also prevented alteration of the wall thickening abnormality at the infarct site, which changed from 9.4 &plusmn; 3.0 cm2 to 9.1 &plusmn; 2.8 cm2 compared with 10.1 &plusmn; 3.1 to 13.7 &plusmn; 4.2 cm2 with placebo (p &lt; 0.05). End diastolic and systolic volumes also showed significant reduction with coenzyme Q10 compared to placebo. The serum level of ACE showed significant decline in the coenzyme Q10 group compared to the control group. Treatment with coenzyme Q10 early after AMI causes attenuation of left ventricular remodeling and decreases the serum ACE level in patients with left ventricular dysfunction

Extended consensus on blood pressure variability beyond blood pressure for management of hypertension

[no abstract available

Why and How the Indo-Mediterranean Diet May Be Superior to Other Diets: The Role of Antioxidants in the Diet

The Seven Countries Study showed that traditional Japanese and Mediterranean diets are protective against cardiovascular diseases (CVDs). The Japanese diet is considered the healthiest because it provides Japanese populations with the highest longevity and health. DASH and Mediterranean-style diets are also considered healthy diets, although the Indo-Mediterranean-style diet may provide better protective effects among patients with CVDs compared to other diets. The concept of the Indo-Mediterranean type of diet was developed after examining its role in the prevention of CVDs in India, the value of which was confirmed by a landmark study from France: the Lyon Heart Study. These workers found that consuming an alpha-linolenic acid-rich Mediterranean-style diet can cause a significant decline in CVDs and all-cause mortality. Later in 2018, the PREDIMED study from Spain also reported that a modified Mediterranean-style diet can cause a significant decline in CVDs, type 2 diabetes mellitus (T2DM), and cancer. The Indo-Mediterranean diet may be superior to DASH and Mediterranean diets because it contains millets, porridge, and beans, as well as spices such as turmeric, cumin, fenugreek, and coriander, which may have better anti-inflammatory and cardioprotective effects. These foods are rich sources of nutrients, flavonoids, calcium, and iron, as well as proteins, which are useful in the prevention of under- and overnutrition and related diseases. It is known that DASH and Mediterranean-style diets have a similar influence on CVDs. However, the Indo-Mediterranean-style diet may be as good as the Japanese diet due to improved food diversity and the high content of antioxidants