Myocardial mass affects diagnostic performance of non-hyperemic pressure-derived indexes in the assessment of coronary stenosis.

Background Several non-hyperemic pressure-derived Indexes (NHPI) have been introduced for the assessment of coronary stenosis, showing a good correlation with fractional flow reserve (FFR). Notably, either the assessment of NHPI during adenosine administration (NHPIADO) or the Hybrid Approach (NHPIHA), combining NHPI with FFR, have been showed to increase the accuracy of such indexes. It remains unclear whether diagnostic performance might be affected by the extent of the subtended myocardial mass. METHODS: We enrolled consecutive patients with an intermediate coronary stenosis assessed with NHPI and FFR. NHPI were also measured during adenosine (ADO) administration (NHPIADO). The amount of jeopardized myocardium was assessed using the Duke Jeopardy Score (DJS). With FFR as reference, we assessed the accuracy of NHPI, NHPIADO and NHPIHA according to the extent of the subtended myocardium. RESULTS: One-hundred-seventy stenoses from 151 patients were grouped according to the DJS as follows: A) Small Extent (SE, n = 82); B) Moderate Extent (ME, n = 53); C) Large Extent (LE, n = 35). As compared with FFR, NHPI showed a significantly different accuracy, as assessed by the Youden's index, according to the extent of the jeopardized myocardium (SE: 0.39 ± 0.05, ME: 0.68 ± 0.06, LE: 0.28 ± 0.06, p < 0.001). Conversely, both the NHPIADO (SE: 0.76 ± 0.02, ME: 0.88 ± 0.02, LE: 0.82 ± 0.02, p = 0.72) and NHPIHA (SE: 0.82 ± 0.07, ME: 0.84 ± 0.02, LE: 0.88 ± 0.02, p = 0.70) allowed for a better diagnostic accuracy regardless of the amount of myocardium subtended. CONCLUSIONS: Diagnostic performance of NHPI might be affected by the extent of myocardial territory subtended by the coronary stenosis. A hybrid approach might be useful to overcome this limitation.

Sex-specific echocardiographic reference values: the women's point of view.

: Clinical presentation, diagnosis and outcomes of cardiac diseases are influenced by the activity of sex steroid hormones. These hormonal differences explain the later development of heart diseases in women in comparison with men and the different clinical picture, management and prognosis. Echocardiography is a noninvasive and easily available technique for the analysis of cardiac structure and function. The aim of the present review is to underline the most important echocardiographic differences between sexes. Several echocardiographic studies have found differences in healthy populations between women and men. Sex-specific difference of some of these parameters, such as left ventricular (LV) linear dimensions and left atrial volume, can be explained on the grounds of smaller body size of women, but other parameters (LV volumes, stroke volume and ejection fraction, right ventricular size and systolic function) are specifically lower in women, even after adjusting for body size and age. Sex-specific differences of standard Doppler and Tissue Doppler diastolic indices remain controversial, but it is likely for aging to affect LV diastolic function more in women than in men. Global longitudinal strain appears to be higher in women during the childbearing age - a finding that also highlights a possible hormonal influence in women. All these findings have practical implications, and sex-specific reference values are necessary for the majority of echocardiographic parameters in order to distinguish normalcy from disease. Careful attention on specific cut-off points in women could avoid misinterpretation, inappropriate management and delayed treatment of cardiac diseases such as valvular disease and heart failure.

Determinants of myocardial mechanics in top-level endurance athletes: three-dimensional speckle tracking evaluation.

AIMS: The determinants of systolic function in the performing heart are not completely understood. Aim of the study was to assess the contributors of left ventricular (LV) strain components, using 3D speckle tracking echocardiography (STE) in endurance athletes. METHODS AND RESULTS: A total of 36 top-level male endurance athletes (AT) and 36 age-matched sedentary normal controls (NC) underwent standard and real-time 3D echocardiography. Global longitudinal strain (GLS), global circumferential strain (GCS), global area strain (GAS), and global radial strain (GRS) were assessed using 3D STE. AT had significantly higher GLS (-22.1 ± 4.4 vs. -18.4 ± 3.5%; P < 0.0001), GCS (-17.9 ± 2.4 vs. -16.0 ± 3.2; P = 0.006), and GAS (-35.5 ± 6.7 vs. -30.2 ± 4.9; P < 0.0001), while GRS did not differ significantly with NC. At separate multiple linear regression analyses, heart rate emerged as independent predictor of GLS (ß = -0.37, P < 0.002), GCS (ß = -0.32, P = 0.007), GAS (ß = -0.37, P < 0.001), and GRS (ß = -0.29, P = 0.019); LV mass was independently associated with GLS (ß = 0.34, P = 0.009) and GAS (ß = 0.41, P < 0.001) but not with GCS and GRS, while diastolic blood pressure predicted GCS (ß = -0.46, P < 0.0001), GAS (ß = -0.28; P = 0.006), and GRS (ß = -0.42, P < 0.001). No independent correlation emerged for body surface area and stroke volume. By replacing LV mass with end-diastolic volume, the latter showed independent association with GCS (ß = -0.65, P = 0.028) and with GRS (ß = -0.60, P < 0.05). CONCLUSION: AT have an increased myocardial function at rest when compared with NC, this being elicited mainly by subendocardial and mid-wall fibres. Sinus bradycardia, LV mass, and afterload are independent determinants of supernormal myocardial deformation at rest.

Prognostic value of combined target-organ damage in patients with essential hypertension.

BACKGROUND: Whether the combination of chronic kidney disease (CKD) and left ventricular hypertrophy (LVH) affects the cardiovascular (CV) risk in patients with uncomplicated hypertension is poorly investigated. The aim of this study was to assess the effects of LVH, CKD, and their combination on CV events in hypertension. METHODS: This study analyzed 1,078 patients with essential hypertension. RESULTS: LVH was present in 104 (9.6%) patients, CKD was present in 556 (51.5%) patients, and the combination of LVH and CKD was found in 174 (16.1%) patients. During the follow-up (median = 84 months), 52 CV events were observed (0.64 events/100 patient-years): 6 (2.4%) in patients without target-organ damage (TOD), 6 (5.7%) in patients with LVH, 20 (3.6%) in patients with CKD, and 20 (11.4%) in patients with combined LVH+CKD. Adjusted hazard ratio (HR) for CV events was 1.62 (P = 0.34) for LVH, 0.951 (P = 0.94) for CKD, and 2.45 (P = 0.03) for LVH+CKD. After multivariable Cox proportional hazard analysis, the combination of LVH+CKD was significantly associated with risk of CV events, when the model was adjusted for sex and age (HR = 2.447; P = 0.03) and for the presence of 1 CV risk factor (HR = 3.226; P = 0.02). In contrast, the association of LVH+CKD was no longer significant when the model was adjusted for sex, age, and the presence of ≥ 2 CV risk factors. CONCLUSIONS: The results of this study highlight the relevance of the interactions between TODs and hemodynamic, anthropometric, and metabolic abnormalities in the CV risk stratification of patients with essential hypertension.

Determinants of left ventricular hypertrophy in patients with recent diagnosis of essential hypertension.

OBJECTIVE: Development of left ventricular hypertrophy (LVH) is a multifactorial phenomenon. We retrospectively assessed the risk factors for LVH in patients with recent diagnosis of essential hypertension. METHODS: We analysed 1518 participants with recent diagnosis of essential hypertension (≤2 years). The duration of hypertension was established after cross-checking the patients' history and the records of the general practitioners'. The following cardiovascular (CV) risk factors were considered: age (men >55 years, women >65 years), SBP >140  mmHg, DBP >90  mmHg, obesity, diabetes, hypercholesterolemia, low or high-density lipoprotein (HDL)-cholesterol (men <40  m/dl, women <50  mg/dl), and chronic kidney disease (CKD). RESULTS: Age, prevalence of metabolic diseases, CKD, and the severity of hypertension were higher in patients with LVH. One hundred twenty-two (8%) patients did not have CV risk factors, whereas 288 (19%), 472 (31.1%), 351 (23.1%) and 285 (18.8%) patients had one, two, three and more than three CV risk factors, respectively. At univariate analysis, CV risk factors for LVH where found to be sex, age, SBP, low HDL-cholesterol, obesity, diabetes, CKD, and metabolic syndrome. In the multivariate analysis, the independent predictors of LVH were found to be sex, age, SBP, obesity and diabetes. A significant correlation was found between indexed left ventricular mass and body mass index (r(2) = 0.167), age (r(2) = 0.077) and SBP (r (2)= 0.055). CONCLUSION: This study reveals that, in patients with recent diagnosis of essential hypertension obesity represents the most important modifiable CV risk factor for LVH.