How to estimate LVH in Hypertensive...
Transcript of How to estimate LVH in Hypertensive...
How to estimate LVH in Hypertensive Patients
DRAGAN LOVIC Clinic for internal disease Intermedica ESH Hypertensive Excellence Center
Left Ventricular Hypertrophy (LVH) represents the heart response to increased biomechanical stress such is hypertension
Left ventricular hypertrophy (LVH) in hypertension is in
its early stages - successful compensatory mechanism and an adaptation of the growing stress of the left ventricle
But it is also the first stage towards the development of a clear clinical picture of the disease
Devereux R. B. 1995.
LVH Development can be divided into three phases
ADAPTIVE PHASE
COMPENSATORY PHASE - reversible contractile Dysfunction
PATHOLOGICAL STAGE - irreversible contractile Dysfunction
Child heart
Adults
Heart
Heart of athletes
Hypertensive heart
Phisiology of the Heart, Arnold M. Katz, Raven Press, New York, 1992, from Linzbach 1960
Patients heart with dilated cardiomyopathy
Child heart
Adult heart
Hear of athlete
Hypertensive
Phisiology of the Heart, Arnold M. Katz, Raven Press, New York, 1992, from Linzbach 1960
Patients heart with dilated cardiomiopathy
Physiology
Hypertrophy
Pathology
Hypertrophy
Phisiology of the Heart, Arnold M. Katz, Raven Press, New York, 1992, from Linzbach 1960
Physiology
Hypertrophy
Pathology Hypertrophy
Phisiology of the Heart, Arnold M. Katz, Raven Press, New York, 1992, from Linzbach 1960
Physiology Hypertrophy
Pathology Hypertrophy
Coming to increase in
normal heart contractility
Phisiology of the Heart, Arnold M. Katz, Raven Press, New York, 1992, from Linzbach 1960
Physiology Hypertrophy
Pathology Hypertrophy
Coming to an increase in
normal heart contractility
Coming to weakening of the contractile ability of the heart
!!
!!
!!!!
!!
53%!on therapy
!!!!
HYPERTENSION: Treatment and
control
NHANES III, Burt et al (1995)
24 % regulated
29% unregulated
47%!no therapy
57.319.7
3.8
1.7
2.3 14.6Bolesti srca i krvnih sudova
Maligne bolesti
Povrede i trovanja
Šećerna bolest
HOBP
Ostalo
The percentage of the most common
non-infectious causes of death in Serbia
Institut za javno zdravlje Dr Milan Jovanović Batut” 2007 godina
LHV Prevalence Prevalence varied widely depending of: - Severity and duration of Hypertension - Different diagnostic modalities and criteria - Patients compliance ect. Electrocardiography LVH : 1 -8 % Echocardiography LVH : -20-30 % in moderate hypertension -50-60% in severe hypertension
Prevalence of LVH in HTA pts, by Age NHANES III (1988-1994) USA
1316
18
22
0
5
10
15
20
25
40-54 55-64 65-74 75 +
Pe
rce
n
Age
LVH Prevalence Meta analysis of 30 studies,37700 patients
Prevalence : 36 -41 % ,similar in male and female
Eccentric & Concentric : 22% vs 15% Cuspidi C et all.J Hum. Hypertension 2012
The median LVH prevalence: - 33% in primary care settings (10 studies) - 65% in secondary care settings (11studies)
Pewsner D, et al. Accuracy of ECG in Dg of LVH in AHT: systematic review. BMJ 2007;335(7622):711. Review.
DEVELOPMENT OF LVH Monitoring studies
Daily levels of blood pressure over 140/90 mmHg, and the night over 120/80 mmHg (no night-fall pressure level)
Framingham Heart Study
The direct link between left ventricular mass and the development of hypertension in previously normotensive individuals
Modified after Dzau & Braunwald Am Heart J 1991
Risk factors Hyperlipidemia Hypertension Diabetes Smoking
Atherosclerosis
CAD
Myocardial ischemia Neurohormonal
activation
Loss of muscle Sudden
death Remodeling
Ventricular dilation
Heart Failure
Coronary thrombosis
Myocardial infarction Arrhythmias
Stroke
Renal failure
LV Hypertrophy
Sudden death
Rhythm disorders
Left Ventricular hypertrophy
Arterial Hypertension
Lozano JV, et al. The ERIC-HTA study. Rev Esp Cardiol. 2006; 59: 136-42.
Multivariate analysis: LVH was independently associated with Advanced age, Male gender, Obesity Diabetes, Smoking, Poor BP control, Genetics and chronic stress CV or renal disease
-hypercholesterolemia and hipertrigliceridemia -insulin resistance and high insulin -Vegetative nerve system dysfunction- dominance of sympathetic activity
Left ventricular mass during life in male and female
Giovani de Simone et all. Left ventricular hypertrophy: old marker ,new poblem. J. Hypertension 29;2011:1480-1482
Pathophysiological factors
Hypertensive heart disease
hypertension
LVH Systolic Disfunction LV
Dyastolic disfunction LV
EF LVEDV Dilatation LV
Syndrome of low cardiac output
Ventricular arrhytmias
EF LVEDV Dilatation LV
Fill pressure LV
Lung congestion dyspnea
Shepherd et al.Mayo Foundation, 1989.
25-30%
The pathophysiological pathway from arterial hypertension to left ventricular hypertrophy and
cardiovascular events
Lovic D, Tsioufis C, Manolis A et all. In Press
Hypertens)Res)2005;)28:)1913202)
Haemodynamic factors
J)Clin)Hypertens)2007;)9:)546350)
Most important factors in development of fibrosis
Myocardial fibrosis
A – Perivascular B – Microscopic scar
C – interstitial fibrosis
J)Clin)Hypertens)2007;)9:)546350)
J)Cardiol)1988;)18:3533361)
Correlation between diastolis dysfunction and myocardial fibrosis
LVH diagnosis in clinical practice
ECG - SOKOLOV LYON INDEX > 35 mm - CORNEL voltage criteria > 2440 mm/
sec Echocardiography - IVS > 11mm - PW > 11mm - EDD < 39-56 mm LEFT VENTRICULAR MASS INDEX - male >115 gr/m² - female > 95 gr/m²
Ro GRAFIC - TORACO-CARDIAL INDEX <
2. 1 3D Contrast
Echocardiography Cardiovascular Magnetic
Resonance
EUROPIEN SOCIETY OF HYPERTENSION; EUROPIEN SOCIETY OF CARDIOLODY
GUIDELINES COMMITEE, 2007
Confirmation of LVH
Electrocardiography left ventricular hypertrophy Confirmation Echocardiography confirmation of left ventricular hypertrophy
Insufficiently reliable Widely accessible
Reliable Less accessible
ECG in AH
LVH AF
CD
disction aortae
For the detection of complications:
In 1906 Einthoven published the 1st organized presentation of normal and abnormal ECGs recorded with a string galvanometer, including LVH!
Einthoven W. Le telecardiogramme. Arch Int de Physiol 1906;4:132-164 (translated into English. Am Heart J 1957;53:602-615)
1. Increase in QRS amplitude 2. Increase in QRS duration 3. Left axis deviation 4. ST segment shift 5. T wave inversion 6. P wave amplitude & morphology changes
Estes EH Jr, Jackson KP. The ECG in LVH: past and future. J Electrocardiol 2009; 42:589-92.
There are 6 ECG changes in LVH:
Described:
>30 ECG LVH indexes!
Pewsner D, et al. Accuracy of ECG in Dg of LVH in AHT:
systematic review. BMJ 2007;335(7622):711. Review.
Cornell SV3 + RaVL >2.4 mV (men) >2.0 mV (women)
+/- Romhilt-Estes score ≥5 points
+/- Typical strain pattern
Perugia score
Among the HTN pts with ECG LVH
only 11.2% had both
the Cornell voltage & Sokolow-Lyon criterion.
AHA/ACCF/HRS recommendations for ECG: JACC 2009; 53:992-1002.
Hypertrophy in patients with severe long-standing untreated hypertension
The thickened walls up to 2 cm, without increasing size
Diagnostic Atlas of the Heart, J. Willis Hurst & Joseph S. Alpert, Raven Press, New York, 1994
Heart in Hypertension Early and ongoing consequences of insufficiently regulated hypertension
The increase in left ventricular mass increase myocytes, but not in their number
Concentric hypertrophy Eccentric hypertrophy Irregular hypertrophy
Increase wall thickness without increasing cardiac cavity (end-diastolic pressure initially normal) Increase ventricular cavity with a corresponding increase in thickness of the ventricular wall The presence of zones of hypertrophy and fibrosis (microarterial associated with coronary artery disease)
Fabio Angeli et all. Echocardiography left ventricular hypertrophy. J. Hypertension 2012;30; 2279-2284
Fabio Angeli et all. Echocardiography left ventricular hypertrophy. J. Hypertension 2012;30; 2279-2284
Echocardiographic diagnosis of left ventricular
hypertrophy and cardiac function disorder caused by hypertension
1.Concentric LVH
2.Wall thickness
>11mm
3.EDD LV
normal or decrease
4.LA >40mm
5.diastolic disfunction
ECHO changes in LVH
Eur)J)Echocardiogr)2009;)10:)1653193)
Measurement of diastolic dysfunction LV
Eur)J)Echocardiogr)2009;)10:)1653193)
Measurement of diastolic dysfunction LV
Eur)J)Echocardiogr)2009;)10:)1653193)
Predictive value, availability and cost effectiveness of some markers of organ damage
+ ++++ +++ Microalbuminuria
+ ++++ +++ Est. Glomerular Filtration Rate or Creatinine Clearance
++++ ++ ? Cerebral lacunae/ White matter lesions
+++ + ++ Endothelial dysfunction
++ + ? Circulatory collagen markers
++ + ? Cardiac/Vascular tissue composition
++++ + + Coronary calcium content
+ ++ ++ Ankle-Brachial index
++ + +++ Arterial stiffness (Pulse wave velocity)
++ +++ +++ Carotid Intima-Media Thickness
++ +++ +++ Echocardiography + ++++ ++ Electrocardiography
Cost-effectiveness
Availability CV predictive value Marker
Left ventricular hypertrophy and cardiovascular events
LOVIC D et all . The inportance of left ventricular hypertrophy in arterial hypertension . Internist 2010; 2(3);137-139.
700
600
500
400
300
200
100
8 Ye
ar P
roba
bilit
y Pe
r 1,0
00
Systolic BP: Cholesterol: Glucose Intol.: Cigaretes: ECG-LVH:
105 >>> 185 185
0 0 0
105 >>> 185 335
0 0 0
105 >>> 185 335
+ 0 0
105 >>> 185 335
+ + 0
105 >>> 185 335
+ + +
Kannel, 1983
))))))Framingham Heart Study (1983) CV Risk Gradient Profile 703
459
326
210
46
Comparisons of initial demographic and clinical characteristics between
dippers and non-dippers
Hye Rim An et all,* Non-Dipper Status and Left Ventricular Hypertrophy as Predictors of Incident Chronic Kidney Disease J Korean Med Sci. 2011
Non-dipper status and LVH as independent predictors of incident chronic kidney disease
Relation between renal impairment and LV structure and function
Shah A. et all. The relationship between renal impairment and LVH. J Hypertens. 2011;28:1829-1836
In hypertensive patients free of cardiovascular disease, CKD and LVH are both independent prognosticators of the composite end point of all-cause death and cardiovascular morbidity, whereas LVH but not CKD is a major predictor for stroke
Tsioufis C. et all Left ventricular hypertrophy versus chronic kidney disease as predictors of cardiovascular events in hypertension: a Greek 6-year-follow-up study. J Hypertens. 2009
Increased left ventricular mass is a predictor of subsequent kidney dysfunction and should be considered in renal risk stratification in a broad spectrum of men with high cardiovascular risk
Tsioufis C et all.Left ventricular hypertrophy as a determinant of renal outcome in patients with high cardiovascular risk. J Hypertens. 2010 Nov;28
LVH is an important risk factor in HTN:
5-10x increase in CV risk!
Kannel W. et al. Ann Intern Med 1969;71:89-105.
Kannel WB, et al Ann Intern Med 1970;72:813-22.
Haider AW, et al. JACC 1998;32:1454-9. Verdecchia P, et al. JACC 1998;31:383-90. Sundström J, et al. Circulation
2001;103:2346-51.
LVH and CV Risk Total mortality > 6X HF risk > 7x
1Increase MI LV for 50 g/m2 RR >1.49 in male ; RR>1.57 for female
2Linearn integration LVH and CV events starts 105 g/m2 -male and 91 g/m2 - female
3Increase IM LV for 1SD(29 g/m2) >31% riskCVD 1CirculaDon)1997;)96:18633)1873)2Hypertension)2000;)5:5803)586)3CirculaDon))1983;)68:4703476)
LVH and obesity
The Aging Process of the Heart Obesity Is the Main Risk Factor for Left Atrial Enlargement During Aging!!
The MONIKA/KORA Study
Stritzke J. et al., JACC 2009;54:1982
Adjusted Mean Values for Absolute Changes of iLA
0
iLA
(m
l/m
)
2
4
6
8
10
1. 0 2.9 5.4 6.0
Normal weight normotensive
Normal weight hypertensive
Obese normotensive
Obese hypertensive
0.079 <0.001* <0.001#
The Aging Process of the Heart...
Obesity Is the Main Risk Factor for Left Atrial Enlargement During Aging!! The MONIKA/KORA Study
Stritzke J. et al., JACC 2009;54:1982
Prevalence Odds Ratios for Left Atrial Enlargement
Prevalence Odds Ratio 0.5 1 2.0 3.0 4.0 5.0 0.6 0.7 0.8 0.9
Female Gender Age
Obesity Hypertension
Copyright ©2003 American Heart Association
Verdecchia, P. et al. Hypertension 2003;41:218-223
Incidence of at least 1 episode of AF in hypertensive subjects in sinus rhythm sorted by LV hypertrophy at echocardiography
Body weight, body mass index and waist-to-hip ratio were strongly correlated to all LV parameters.
Correlation coefficients between nutritional status, blood pressure and echocardiography parameters of left ventricle
Parameters LVM (g) LVMI (g/m2)
LVEDD (cm)
Wasit circumference (cm) 0,440** 0,111 0,455**
Hip circumference (cm) 0,359** 0,140 0,380** Waist to hip ratio WHR 0,287** 0,028 0,285** Body mass index BMI (kg/
m2) 0,418** 0,215* 0,429**
Systolic pressure (mmHg) 0,316** 0,234* 0,265**
Diastolic pressure (mmHg) 0,392** 0,283** 0,369**
* p<0,05 ** p<0,01
Jakovljevic B. Stojanov V. Lovic D.Eur Int. Med. 2011
Logistic regression model identified obesity (OR=3.12, 95%CI=1.26-4.38) overweight (OR=2.54, 95%CI=1.17-3.01) and waist-to-hip ratio (OR=2.74, 95%CI=1.05-7.13) as significant independent predictors of left ventricular
hypertrophy (assessed by LVM). Multivariate logistic regression model for the
occurrence of LV hypertrophy (dependant variable)* in relation to significant independent variables
Independent variables B P value
Odds ratio (OR)
95% confidence interval for OR
Normal weight 1.00**
Overweight 2.202 0.000 2.54 1.17-3.01 Obesity 3.174 0.003 3.12 1.26-4.38
Waist-to-hip ratio 1.008 0.039 2.74 1.05-7.13
Constant -5.100 0.004 0.006 * LV hypertrophy assessed by LVM ** Reference category Jakovljevic B. Stojanov V. Lovic D. Eur Int. Med. 2011
2007 ESH/ESC Guidelines Preferred Drugs
ISH (elderly) MS (or risk of incident DM) DM Pregnancy Blacks LVH Asympt. atherosclerosis MA Renal dysfunction Previous stroke Previous MI Angina pectoris CHF AF (recurrent) AF (permanent) ESRF/proteinuria PAD
D / CA ACEI / ARB (+CA / low dose D) ACEI / ARB CA / MD / BB D / CA
ACEI / CA / ARB CA / ACEI ACEI / ARB ACEI / ARB
any BP lowering agent BB / ACEI / ARB BB / CA D / BB / ACEI / ARB / antialdo agents ARB / ACEI BB / nonDHCA ACEI / ARB / loop D CA
Condition
Subclinical OD
Clinical Event
35%-40%
20%-25%
>50%
Decrease events (%)
–60
–50
–40
–30
–20
–10
0
Stroke MI HF
Lancet. 2000;355:1955-1964.
Antihypertensive therapy efects
Cardiovascular mortality in LIFE Study
Kjeldsen SE, et al. JAMA. 2002;228:1491-1498
LIFE Study ISH Subgroup ECG-LVH Regression
-14
-12
-10
-8
-6
-4
-2
0 C
han
ge f
rom
base
lin
e (
%)
Losartan
Atenolol
P<0.001
P<0.001
Cornell VD Product Sokolow-Lyon
-211*
-3.9*
-63*
-2.3*
*absolute change from baseline Kjeldsen SE, et al. JAMA. 2002;228:1491-1498.
Salles GF, et al. Am Heart J. 2010 May;159:833-40.
Regression of baseline ECG-LVH during follow-up:
50% Sokolow-Lyon and
34% Cornell voltage, and
25% Cornell product criterion.
Perinopril –Indapamid: effect on the left ventricular diastolic dysfunction and LV
mass in diabetic patients
Advance collaborative group. Effect of perindopril –indapamid on left ventricular diastolic function. Hypertension 29;2011:1439-1447
Perinopril –Indapamid reverse coronary microvascular remodeling and improve flow
Neglia D et all. Perindopril and indapamide reverse coronary Microcircular remodelling. J Hypertension 2011;29:364-372
Arteriosclerosis of carotid arteries and effets of antihypersensitive therapy in patients with LVH
one year study
1.161.171.181.19
1.21.211.221.231.241.25
1st Qtr 2nd Qtr 3rd Qtr
F+AF
020406080100120140160
Sys Sys Dyas Dyas
F+AA
LOVIC D.et all,abstract ESH Meeting 2010
LVH
CAD
Carotid atherosclerosis
Carotid atherosclerosis associated to metabolic syndrome and ischemic heart disease in hypertensive patients with left ventricular hypertrophy Tasic I, Lovic D et all, Abstract ASH 2010
Conclusion
Early detection of AH Detection of additional risk factors for LVH timely treatment -non-pharmacological -pharmacological Natural history of hypertensive LVH is heading towards
HF choice of drugs that block the neurohumoral system, Decreases the level and / or regression of LVH is
achieved. However, hypertension is one of the risk factors leading
to the HF
Yoshido C et all.Role of plasma aldosteron concentrationin regresion of LV mass.J. Hypertension 2011;29;357-363