Original Article

The relationship between left ventricular deformation and different geometric patterns according to the updated classification: findings from the hypertensive population Marijana Tadic a,b, Cesare Cuspidi c, Anka Majstorovic a, Vesna Kocijancic a, and Vera Celic a,b

Objective: We sought to investigate left ventricular mechanics in hypertensive patients with different geometric patterns by using two-dimensional (2DE) and three-dimensional (3DE) strain analysis. Methods: This cross-sectional study included 197 hypertensive individuals who underwent a complete 2DE and 3DE examination. We applied the new updated criteria of left ventricular geometry that considered left ventricular mass index, left ventricular end-diastolic diameter and relative wall thickness. According to this classification the individuals were divided into six groups: normal geometry, concentric remodelling, eccentric nondilated left ventricular hypertrophy (LVH), concentric LVH, dilated LVH and concentric-dilated LVH. Results: Multidirectional 2DE and 3DE left ventricular strain decreased from the hypertensive patients with normal geometry, across the individuals with left ventricular concentric remodelling, eccentric nondilated LVH, to the patients with concentric LVH and dilated LVH patterns. The reduction of left ventricular systolic and early diastolic strain rates was noticed to be heading in the same direction, as well as the elevation of late diastolic strain rates. Left ventricular twist and torsion were increased in the participants with concentric and dilated LVH patterns. Reduced 2DE and 3DE strains were associated with concentric and dilated LVH patterns independent of demographic and clinical parameters. Conclusion: Left ventricular deformation in hypertensive patients is significantly impacted by left ventricular geometry. Concentric and dilated LVH patterns have the greatest unfavourable effect on 2DE and 3DE left ventricular mechanics. The updated classification of left ventricular geometry provides valuable and comprehensive information about left ventricular mechanical deformation and function in hypertensive population. Keywords: hypertension, left ventricular geometry, left ventricular hypertrophy, three-dimensional speckle tracking, two-dimensional speckle tracking Abbreviations: 2DE, two-dimensional echocardiography; 3DE, three-dimensional echocardiography; A, late diastolic mitral flow obtained by pulsed Doppler; BP, blood

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pressure; BSA, body surface area; E, early diastolic mitral flow obtained by pulsed Doppler; e0 , average of the peak early diastolic relaxation velocity of the septal and lateral mitral annulus assessed by tissue Doppler; IVS, interventricular septum; LV, left ventricle; LVH, left ventricular hypertrophy; LVIDd, left ventricular internal end-diastolic diameter; LVMI, left ventricular mass index; PWT, posterior wall thickness; RWT, relative wall thickness

INTRODUCTION

T

he Framingham study shows that left ventricular hypertrophy (LVH) has been associated with increased cardiovascular and total mortality, independently of traditional cardiovascular risk factors [1]. However, different patterns of left ventricular geometry have a different impact on cardiovascular outcome. Verdecchia et al. [2] have demonstrated that left ventricular concentric remodelling is an independent predictor of increased cardiovascular risk in hypertensive patients with normal left ventricular mass, whereas Koren et al. [3] have reported that concentric LVH has the highest risk for cardiovascular death and all-cause mortality in hypertensive population. The traditional classification of left ventricular geometry patterns takes into account left ventricular mass and relative wall thickness, but not left ventricular dilatation. This was the reason why Khouri et al. [4] in the Dallas Heart Study developed a new classification of LVH that included left ventricular concentricity and left ventricular end-diastolic volume, and provided two completely new patterns: dilated and concentric-dilated LVH. Bang et al. [5] applied

Journal of Hypertension 2015, 33:1954–1961 a University Clinical Hospital Center ‘Dr Dragisa Misovic - Dedinje’, Cardiology Department, bFaculty of Medicine, Belgrade, Serbia and cUniversity of Milan-Bicocca and Istituto Auxologico Italiano, Clinical Research Unit, Meda, Italy

Correspondence to Marijana Tadic, MD, PhD, University Clinical Hospital Center ‘Dr Dragisa Misovic - Dedinje’, Heroja Milana Tepica 1, Belgrade 11000, Serbia. E-mail: [email protected] Received 25 January 2015 Revised 24 March 2015 Accepted 30 March 2015 J Hypertens 33:1954–1961 Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved. DOI:10.1097/HJH.0000000000000618

Volume 33  Number 9  September 2015

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

Left ventricular deformation and geometry

a new classification and found that patients with eccentric LVH had the similar survival as individuals with normal left ventricular mass, whereas mortality risk gradually increased from the participants with eccentric dilated LVH, over the individuals with concentric nondilated LVH, to the patients with concentric dilated LVH. The interest in the left ventricular mechanics is constantly growing, and it seems that ejection fraction, the primary parameter of left ventricular systolic function, will shortly be replaced by the left ventricular deformation in everyday clinical practice. This assumption is based on large studies that have demonstrated the superiority of left ventricular global longitudinal strain over left ventricular ejection fraction (LVEF) or left ventricular wall motion score index in a prediction of cardiovascular adverse events [6,7]. Investigators have already studied the influence of different left ventricular geometry patterns on left ventricular mechanics, estimated by two-dimensional (2DE) speckle tracking analysis [8–10], or three-dimensional (3DE) strain analysis [11]. However, there are no data about left ventricular deformation in various left ventricular geometry patterns classified according to the new criteria. The aim of the present study was to investigate 2DE and 3DE left ventricular mechanics in hypertensive patients with the different geometric patterns defined by the updated Dallas criteria.

METHODOLOGY This cross-sectional study enrolled 197 hypertensive patients who were referred to our outpatient clinic due to echocardiographic examination or annual regular checkup. Arterial hypertension was diagnosed according to the current guidelines [12]. Clinic blood pressure values were obtained in two separate visits 3 weeks apart. Blood pressure was measured by conventional sphygmomanometer in the morning hours by taking the average value of two consecutive measurements in the sitting position 10 min apart. Blood pressure was calculated as average values between all the measurements. Exclusion criteria were symptoms or signs of heart failure, coronary artery disease, previous cerebrovascular events, atrial fibrillation, congenital heart disease, valve heart disease (more than mild), neoplastic disease, liver cirrhosis, kidney failure or endocrinological diseases including type 2 diabetes mellitus. Individuals with unsatisfactory 3DE acquisitions (eight participants) were also excluded from any further analyses. Anthropometric measures (height, weight) and laboratory analyses (level of fasting glucose, blood creatinine, total cholesterol and triglycerides) were obtained from all the individuals included in the study. BMI and body surface area (BSA) were calculated for each patient. The study was approved by the local Ethics Committee, and informed consent was obtained from all the participants.

Echocardiography Echocardiographic examinations were performed by using a commercially available Vivid 7 (GE Vingmed, Horten, Norway) ultrasound machine equipped with both a Journal of Hypertension

2.5 MHz transducer and a 3 V matrix probe for 3DE data set acquisitions. Reported values of all 2DE parameters were obtained as the average value of three consecutive cardiac cycles. Left ventricular end-diastolic (LVIDd) and end-systolic diameters, posterior wall (PWT) and septum thickness (IVS) were measured according to the recommendations [13]. Relative wall thickness (RWT) was calculated according to the formula: (2 x posterior wall thickness)/left ventricular end-diastolic diameter. LVEF was calculated by using the biplane method. left ventricle (LV) mass (LVM) was calculated by using the corrected ASE method: 0.8  [1.04  {(LVIDd þ IVSd þ PWTd)3 - LVIDd3}] þ 0.6 [14], and indexed for the BSA (LVMI). Cut-off values for LVIDd, LVMI and RWT were used from the recently published guidelines [14]. The upper limit of LVIDd for women is 5.2 cm and for men is 5.8 cm; cut-off for LVMI for women is 95 and 115 g/m2 for men; and cut-off for RWT is 0.42. The new classification system includes determination of left ventricular volume [4]; however, we used a linear model of estimation of left ventricular dilatation, which is more frequently used in everyday clinical practice. All individuals were divided into six groups: normal left ventricular geometry (normal LVMI, LVIDd and RWT), concentric remodelling (normal LVMI and LVIDd, increased RWT), eccentric nondilated LVH (increased LVMI, normal LVIDd and RWT); concentric LVH (increased LVMI and RWT, normal LVIDd), dilated LVH (increased LVMI and LVIDd, normal RWT) and concentric-dilated LVH (increased LVMI, LVIDd and RWT). However, due to relatively small study group and further statistical analysis, we merged dilated and concentricdilated LVH in one group. This decision was also based on two important facts: the Dallas criteria potentiate the role of left ventricular dilatation, which we estimated by left ventricular end-diastolic diameter; and our findings showed that concentric and eccentric-dilated LVH groups have the most similar 2DE and 3DE strains, significantly lower than patients with other left ventricular geometric patterns. Left atrial volume was measured just before mitral valve opening. Left atrial volume was determined according to the biplane area-length method in four and two-chamber views and indexed for BSA. Pulsed-wave Doppler assessment of transmitral left ventricular was obtained in the apical four-chamber view according to the guidelines [15]. Tissue Doppler imaging was used to obtain left ventricular myocardial velocities in the apical four-chamber view, with a sample volume placed at the septal and lateral segments of the mitral annulus during early and late diastole (e0 and a0 ), and systole (s). The average of the peak early diastolic relaxation velocity (e0 ) of the septal and lateral mitral annulus was calculated, and the E/e0 ratio was computed.

Two-dimensional strain analysis 2DE strain analysis was performed by using three apical (long-axis, four and two-chamber) views and three parasternal short-axis views of the left ventricle (LV, basal, just below the mitral level; mid-ventricle, at the papillary muscle level; and apical) [16]. A commercially available software (EchoPAC 110.1.2; GE-Healthcare, Horten, Norway) was used for 2DE strain quantitation. www.jhypertension.com

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2DE longitudinal strain and strain rates were calculated by averaging all the values of regional peak longitudinal strain values obtained in three apical views. 2DE circumferential strain and radial strain and strain rates were assessed as the average of the left ventricular six regional values measured in the parasternal short-axis view, at the level of papillary muscles. To evaluate left ventricular twist, tracking points were placed on end-diastolic frame short-axis views obtained at basal and apical left ventricular levels [16]. Left ventricular twist was computed as the sum of basal and apical rotation. Left ventricular torsion was calculated when left ventricular twist was divided by enddiastolic left ventricular base-to-peak length.

Three-dimensional examination and threedimensional strain analysis A full-volume acquisition of the left ventricular was obtained by harmonic imaging from the apical approach. Six ECG-gated consecutive beats were acquired during end-expiratory breath-hold to generate left ventricular full volume. Depth size and volume size were adjusted to obtain a temporal resolution higher than 30 volumes/s. All data sets were analysed off-line using a commercially available software (4D Auto LVQ; GE-Vingmed, Horten, Norway). The 3DE global deformation parameters: longitudinal strain, circumferential strain, radial strain and area strain were calculated as weighted averages of the regional values from the 17 myocardial segments at end-systole [17]. If at least three segments were rejected, global strain values were not calculated, and these patients were excluded from any further analyses.

Statistical analysis All the parameters were tested for normal distribution using the Kolmogorov–Smirnov test. Continuous variables were

presented as mean  standard deviation and compared by the analysis of equal variance (ANOVA), as they showed normal distribution. Bonferroni posthoc analysis was used for the comparison between different groups. The differences in proportions were compared by using the x2 test or Fisher’s exact test. The correlation between different left ventricular geometry patterns and impaired 2DE and 3DE strains, independent of age, BMI, SBP level and left ventricular mass, was determined by multivariate logistic regression [odds ratio (OR) and 95% confidence interval (95% CI)]. Considering the fact that guidelines regarding cut-off values for 2DE and 3DE strains are still missing, we used data from meta-analysis and large population study [18,19]. Intraobserver and interobserver variability for 2DE and 3DE left ventricular mechanical parameters were analysed in 20 study participants using interclass correlation coefficients. The P value less than 0.05 was considered statistically significant.

RESULTS Using modified Dallas criteria, we identified 85 patients with normal left ventricular geometry, 28 participants with concentric left ventricular remodelling, 42 individuals eccentric nondilated LVH, 30 individuals with concentric LVH, five patients with dilated and seven participants with concentric-dilated LVH. Patients with dilated and concentric-dilated LVH were joined in the same group. Age of the participants in the study gradually increased from hypertensive patients with normal left ventricular geometry to participants with concentric, dilated or concentric-dilated LVH (Table 1). There was no sex difference among groups. BMI and BSA increased in the same direction, but without statistical significance. Blood pressure values progressively increased from individuals with normal left ventricular geometry to patients with dilated or concentric-dilated

TABLE 1. Demographic characteristics and clinical parameters of study population

Age (years) Female (%) BMI (kg/m2) BSA (m2) Clinic SBP (mmHg) Clinic DBP (mmHg) Antihypertensive drugs (%) Diuretics (%) Beta-blockers (%) Plasma glucose (mmol/l) Serum creatinine (mmol/l) Triglycerides (mmol/l) Total cholesterol (mmol/l)

Normal LV geometry (n ¼ 85)

Concentric LV remodelling (n ¼ 28)

Eccentric nondilated LVH (n ¼ 42)

Concentric LVH (n ¼ 30)

Dilated and concentric-dilated LVH (n ¼ 12)

P

48  8, 42 (49) 25.7  3.2 1.9  0.18y 135  12,,z 81  8, 15 (18),,z 4 (5),,y 2 (2)yy 4.9  0.8 66  9 1.7  0.3 5.1  0.8

49  7 11 (39) 26.5  3 1.94  0.19 140  14 84  7{ 6 (21),# 3 (11),zz 1 (3.5) 5.1  0.7 64  8 1.9  0.4 5.2  0.7

51  9 27 (64) 27.3  3.4 2  0.17y 144  12z 85  7 18 (43)z 8 (19)y,r 3 (7) 5.2  0.6 67  9 1.8  0.4 5.2  0.9

54  8 14 (47) 27.7  3.8 1.98  0.18 149  15 88  10 18 (60),# 12 (40),zz 4 (13)yy 5.6  0.7 65  8 2  0.5 5.6  1

59  6, 4 (33) 28.4  4.1 2.02  0.2 156  14, 91  9,{ 8 (67), 7 (58),,yyy 2 (17) 5.4  0.8 70  8 1.9  0.3 5.4  1.1

The relationship between left ventricular deformation and different geometric patterns according to the updated classification: findings from the hypertensive population.

We sought to investigate left ventricular mechanics in hypertensive patients with different geometric patterns by using two-dimensional (2DE) and thre...
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