how to estimate lvh in hypertensive patients · 2013. 2. 19. · clinic for internal disease...

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