JS ISH-ESH-2 UPDATE ON THE DETECTION AND FOLLOW-UP OF EARLY HYPERTENSIVE HEART DISEASE

Enrico Agabiti Rosei
Journal of Hypertension 2016, 34 Suppl 1 - ISH 2016 Abstract Book: e192-e193
27754006
Current Hypertension Guidelines emphasize the importance of assessing the presence of preclinical organ damage. In fact, an extensive evaluation of organ damage may increase the number of patients classified at high CV risk and therefore strongly influence the clinical management of patients. Hypertensive heart disease remains to date the form of organ damage for which there is the greatest amount of evidence of a strong independent prognostic significance. In the presence of a chronic pressure overload, a parallel addition of sarcomers takes place with an increase in myocyte width, which in turn increases left ventricular wall thickness; myocyte hypertrophy is also associated with apoptosis, collagen deposition and ventricular fibrosis with an impairment of coronary hemodynamics as well, thus profoundly influencing functional properties of the left (and right) ventricle. The development of LVH represents a step toward the development of clinical cardiovascular diseases, such as congestive heart failure, ischemic heart disease, stroke and sudden death. Therefore, accurate assessment of cardiac anatomy and function might be of help for a prompter identification of early alterations that may predispose hypertensive patients to cardiovascular events.The Guidelines of the European Society of Hypertension and of the European Society of Cardiology include echocardiography among the recommended techniques to be considered in hypertensive patients. In fact, echocardiography is a relatively easy method, is repeatable, is specific and more sensitive measure of LVH than electrocardiography. The relationship between LV mass at baseline and incidence of cardiovascular events is continuous and independent of other cardiovascular risk factors, and has been confirmed in various subsets of patients. In addition changes in LV mass parallel the occurrence of cardiovascular fatal and non-fatal events, independently of blood pressure and other cardiovascular risk factors. Nevertheless, LV mass reproducibility represents one of the major technical limitations of echocardiography and LV mass calculation may be not reliable in patients with previous myocardial infarction or with asymmetrical hypertrophy, assuming a prolate ellipsoid shape for the left ventricle. For this reason LV mass measurement with cardiac magnetic resonance (CMR) imaging, which is indubitably more accurate and reproducible, has been proposed, but with obvious limitations related to availability and costs of the technique.Three-dimensional echocardiographic (3DEcho) imaging represents a relevant innovation in cardiovascular imaging. The development of fully sampled matrix-array transducers, together with significant improvements in hardware and software of ultrasound systems, has made possible excellent real-time imaging of the beating heart in 3D. More recent studies indicate that 3DEcho has an excellent accuracy and provides better correlations that 2-dimensional echocardiography with MRI measurements.Echocardiography may also give useful information on cardiac functional changes, including systolic and diastolic abnormalities. LV diastole may be accurately evaluated by assessment of transmitral flow velocities, mitral annular pulsed tissue Doppler imaging and left atrial volume assessment. In uncomplicated hypertensives LV systolic dysfunction, as assessed by LV shortening fraction (FS) and ejection fraction (EF), expressing endocardial fibers shortening are usually preserved or even "supernormal", while midwall FS is reduced. In the absence of major structural abnormalities, the TDI measurement of longitudinal myocardial systolic velocity has been proposed as a reliable index of myocardial performance, independent of LV preload and afterload.Compared to the conventional 2D traditional approach, 3D echo offers the opportunity for a more sophisticated assessment of LV function, by the improvement in the accuracy of the evaluation of left ventricular and left atrial volumes by eliminating the need for geometric modelling. Speckle tracking echocardiography (STE) is a relatively new technique based on the analysis of interference patterns and natural ultrasound beam reflections generated by tissue motion, which allows the derivation of multiple parameters of myocardial function and may be performed on 2D or 3D echocardiographic or on cardiac magnetic resonance imaging. Global longitudinal strain seems to be the most clinically useful parameter to detect subclinical systolic myocardial dysfunction. In addition segmental and global diastolic strain rate and LV diastolic untwist may be used to assess LV relaxation and diastolic function.Cardiac computed tomography is used for the estimation of coronary plaque imaging and may be used for the estimation of a suspected aortic aneurysm or an aortic dissection, while the indications to the use of cardiac magnetic resonance have largely increased. CMR may be applied not only for the assessment of LV mass and cardiac chambers volumes, but also to visualize the amount and distribution of focal myocardial fibrosis usually associated to hypertensive heart disease.In conclusion 3DEchocardiography, CMR and tissue tracking technology are the most promising tool to provide accurate measures of cardiac structure and function for a more timely identification of preclinical organ damage.The prognostic significance of changes in EKG criteria of LVH has been demonstrated in the Framingham population, in high CV risk patients, in hypertensives with isolated systolic hypertension or with EKG-LVH. Other observational, prospective studies have examined the potential clinical benefits of regression of echocardiographic detectable LVH, and have demonstrated that changes in LV mass, during treatment, may imply an important prognostic significance in hypertensive patients. These studies have clearly shown that subjects who failed to achieve LVH regression or in whom LVH developed during follow-up are much more likely to suffer morbid events than those in whom LVH regressed or never developed. However, regression to normal of LVH still maintains a high risk in comparison with persistently normal LV mass. Further information has been derived from the LIFE echocardiographic substudy: in 930 patients with EKG LVH, a decrease of 25 gr/m (i.e.one standard deviation) of LV mass index was associated with a 20% reduction of the primary end-point, adjusting for type of treatment, basal and treatment BP, and basal LV mass index.Changes in geometric adaptation seem to imply a prognostic value, independent of changes in LV mass. The persistence or the development of a concentric geometry during treatment have been found associated to a greater incidence of cardiovascular events, independent of changes in LV mass. The LIFE study has provided results that confirm the prognostic influence of LV geometry, in addition to changes in LV mass. The better prognosis associated to regression of LVH may be related to the improvement of systolic and diastolic function, to the increase of coronary flow reserve and to the decrease of cardiac arrhythmias. However, the independent prognostic significance of changes in the left atrium, systolic and diastolic function should be confirmed by further studies.

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