Relation of arterial stiffness to diastolic dysfunction in hypertensive heart disease.

OBJECTIVES: To examine the relation of arterial compliance to diastolic dysfunction in hypertensive patients with suspected diastolic heart failure (HF). PATIENTS: 70 medically treated hypertensive patients with exertional dyspnoea (40 women, mean (SD) age 58 (8) years) and 15 normotensive controls. MAIN OUTCOME MEASURES: Mitral annular early diastolic velocity with tissue Doppler imaging and flow propagation velocity were used as linear measures of diastolic function. Arterial compliance was determined by the pulse pressure method. RESULTS: According to conventional Doppler echocardiography of transmitral and pulmonary venous flow, diastolic function was classified as normal in 33 patients and abnormal in 37 patients. Of those with diastolic dysfunction, 28 had mild (impaired relaxation) and nine had advanced (pseudonormal filling) dysfunction. Arterial compliance was highest in controls (mean (SD) 1.32 (0.58) ml/mm Hg) and became progressively lower in patients with hypertension and normal function (1.04 (0.37) ml/mm Hg), impaired relaxation (0.89 (0.42) ml/mm Hg), and pseudonormal filling (0.80 (0.45) ml/mm Hg, p = 0.011). In patients with diastolic dysfunction, arterial compliance was inversely related to age (p = 0.02), blood pressure (p < 0.001), and estimated filling pressures (p < 0.01) and directly related to diastolic function (p < 0.01). After adjustment for age, sex, body size, blood pressure, and ventricular hypertrophy, arterial compliance was independently predictive of diastolic dysfunction. CONCLUSIONS: In hypertensive patients with exertional dyspnoea, progressively abnormal diastolic function is associated with reduced arterial compliance. Arterial compliance is an independent predictor of diastolic dysfunction in patients with hypertensive heart disease and should be considered a potential target for intervention in diastolic HF.

Pulse pressure vs. total arterial compliance as a marker of arterial health.

BACKGROUND: Brachial pulse pressure (BPP) is a predictor of outcome in epidemiologic studies, but brachial and aortic pulse pressure (AoPP) may not correspond and both are influenced by multiple parameters including arterial properties and cardiac output. We sought to what extent pulse pressure (PP) measurements reflected direct measurement of arterial properties, assessed as total arterial compliance (TAC). METHODS: We studied 123 patients (76 men; age 55 +/- 11); 31 normal controls, 46 patients with coronary artery disease and 46 patients with hypertension. PP was determined from brachial cuff pressure and TAC was measured by simultaneous radial applanation tonometry and pulsed wave Doppler of the LV outflow. AoPP was calculated using a transfer function from the radial waveform. RESULTS: There was a significant difference between BPP and AoPP (57 +/- 16 vs. 45 +/- 14; P < 0.0001), although TAC correlated with BPP (r = -0.72; P = 0.01) and AoPP (r = -0.66; P = 0.01). In a multiple linear regression, the difference between BPP and AoPP was predicted by cardiac output (CO) (P = 0.002) and gender (P = 0.03). Bland-Altman analysis showed the best correspondence between BPP and AoPP in the middle tertile (CO 4.7 to 5.7 L min(-1)) with less correlation in the low and high tertiles. The same analysis by gender showed a higher difference in women than men (14 +/- 6 vs. 10 +/- 5; P < 0.0001). The difference between BPP and AoPP showed the best correlation in the control group and the worst in the hypertension group. CONCLUSION: BPP correlates with TAC in men with normal cardiac function. However, in women, in patients at the low and high extremes of function, and in patients with preclinical and overt cardiovascular disease, there appears to be incremental value in measuring TAC.

Intravascular ultrasound assessment of ambiguous coronary lesions.

Accurate assessment of coronary lesions is essential for clinical decision-making. While angiography has long been accepted as the gold standard investigation, this technique provides only a planar 2-D silhouette of the arterial lumen and therefore has limited accuracy in the setting of vessel tortuosity or overlap, bifurcational and eccentric lesions, and diffusely diseased arteries. By providing high-resolution cross-sectional imaging through the arterial wall, intravascular ultrasound (IVUS) can overcome many of these limitations and accurately quantify angiographically indeterminate lesions. Angiographic evaluation of the left main coronary artery presents particular challenges that are ideally resolved with IVUS examination. The role of IVUS in the assessment of coronary stenoses of angiographically intermediate severity (50-70%) continues to evolve. Recent data correlating IVUS with intracoronary flow and pressure measurements suggest that epicardial coronary artery lesions with minimum lumen area of less than 3-4 mm2 may be haemodynamically significant. In addition to accurately quantifying minimum lumen diameter and area at the lesion site, IVUS can characterise coronary artery plaque morphology, and it may have the potential to predict plaque complications.

An unusual case of aortic dissection in Turner's syndrome.

Cardiovascular malformations are common in patients with Turner's syndrome. Aortic coarctation and bicuspid aortic valve are the most frequently occurring abnormalities, and are associated with cystic medial necrosis of the aortic wall. Aortic dissection is an uncommon but catastrophic complication of the 'aortopathy' of Turner's syndrome. We report the unusual case of a Turner's syndrome patient (with a bicuspid aortic valve and previous coarctation repair) who died following an intramural haemorrhage of the aortic root that was complicated by dissection and rupture, with no evidence of aortic intimal tear. The role of intramural haemorrhage in the pathogenesis of acute aortic syndromes in Turner's syndrome patients is unclear. The condition may be associated with atypical clinical presentations, it can be difficult to confirm with imaging techniques, and it carries a high risk of progression to classical aortic dissection and death. This case therefore highlights the need for a high index of suspicion when assessing Turner's syndrome patients presenting with chest pain syndromes. Furthermore, the effective management of Turner's syndrome patients with cardiovascular abnormalities requires the development of evidence-based preventive (such as echocardiographic surveillance of aortic dilatation) and interventional strategies.