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1.  The Association of HIV Infection with Left Ventricular Mass/Hypertrophy 
Left ventricular hypertrophy (LVH) is an independent predictor of major cardiovascular events. Cardiovascular risk is increased among human immunodeficiency virus (HIV)-infected patients. To assess LV mass/hypertrophy in HIV infection, 654 women enrolled in the Women's Interagency HIV Study underwent transthoracic echocardiography. There were 454 HIV-infected and 200 uninfected women, mean age 40.8 ± 9.3 years. LV mass/height2.7 was similar between the HIV-infected and the HIV-uninfected groups (41.4 ± 11.1 vs. 39.9 ± 10.3 g/h2.7; p = 0.37). The prevalence of LVH was similar between the two groups (LVH by LV mass/height2.7 criteria 15.0% vs. 13.0%, p = 0.29). Relative wall thickness (RWT), defined as the ratio of LV wall thickness to cavity diameter, was also similar between the HIV-infected and HIV-uninfected groups (0.36 ± 0.05 vs. 0.37 ± 0.06, p = 0.16). On multiple linear regression analysis adjusting for age, W/H ratio, triceps skinfold thickness, systolic/diastolic BP, diabetes, hypertension and dyslipidemia; HIV status (b = 2.08, p = 0.02, CI 0.27–3.88); weight (b per kg = 0.15, p<0.01, CI 0.08–0.22); and smoking duration (b per one-year increase = 0.08, p = 0.03, CI 0.01–0.16) were independent correlates of LV mass/height2.7 (Model R2 = 0.20, p<0.001). Weight (aOR = 1.04, CI 1.01–1.06) and smoking duration (aOR = 1.03, CI 1.01–1.06) were independent correlates of LVH. Being HIV negative, increased age, increased triceps skinfold thickness, and higher W/H ratio were independent correlates of higher RWT. Among HIV-infected women, higher LV mass was not associated with a history of AIDS-defining illness, nadir CD4+ count <200 cells/μl, or with the duration of highly active antiretroviral therapy (HAART). Women taking NRTIs had higher LV mass. Higher RWT was associated with current CD4+ count. In conclusion, HIV infection is associated with greater LV mass but not with a higher prevalence of LVH. Among HIV-infected women, RWT, but not LV mass, is associated with the degree of immunosuppression.
PMCID: PMC2801578  PMID: 19397399
2.  Severe aortic stenosis without left ventricular hypertrophy: prevalence, predictors, and short-term follow up after aortic valve replacement. 
Heart  1996;76(3):250-255.
OBJECTIVES: The purpose of the present study in patients with severe aortic stenosis was to assess the prevalence of absent left ventricular hypertrophy (LVH) (determined according to mass criteria), to identify predictors of absent LVH, and to assess short-term left ventricular adaptation and prognosis after aortic valve replacement. METHODS: Left ventricular mass (LVM) was determined by echocardiography in 109 men and 101 women with severe aortic stenosis (mean pressure gradient < or = 50 mm Hg). LVH was defined as LVM > or = 109 g/m2 in women and LVM > or = 134 g/m2 in men. RESULTS: One hundred and eighty nine patients showed LVH (group 1) (90%; mean (SD) age 65 (14) years), and 21 showed no LVH (group 2) (10%, age 57 (21) years P = 0.02 for difference in age). Twelve (6%) of those without LVH had increased relative wall thickness (that is, > or = 0.45 with LV concentric remodelling) and nine (4%) showed no macroscopically detectable hypertrophic adaptation. The following variables were associated with the absence of LVH: low body surface area, low body mass index, and increased cardiac index. 76/210 patients were followed up a mean of six months after aortic valve replacement. The frequency of adequate ventricular adaptation to the decreased afterload after aortic valve replacement was higher in patients with LVH than in those without. Mortality six months after aortic valve replacement was lower, but not significantly, in patients with LVH (7.6%) than in those without LVH (12.5%, P = 0.10). CONCLUSIONS: A tenth of patients with severe aortic stenosis did not develop LVH according to mass criteria; 4% of the patients did not have any macroscopic signs of myocardial adaptation to the pressure overload despite longstanding disease. Small body size was independently associated with lack of LVH according to mass criteria. Six months after aortic valve replacement, ventricular adaptation was more often adequate in patients with LVH than in those without.
PMCID: PMC484516  PMID: 8868985
3.  Left Ventricular Mass and Geometry and the Risk of Ischemic Stroke 
Background and Purpose
Left ventricular hypertrophy (LVH) is a risk factor for cardiovascular events, but its effect on ischemic stroke risk is established mainly in whites. The effect of LV geometry on stroke risk has not been defined. The aim of the present study was to evaluate whether LVH and LV geometry are independently associated with increased ischemic stroke risk in a multiethnic population.
A population-based case-control study was conducted on 394 patients with first ischemic stroke and 413 age-, sex-, and race-ethnicity–matched community control subjects. LV mass was measured by transthoracic echocardiography. LV geometric patterns (normal, concentric remodeling, concentric or eccentric hypertrophy) were identified. Stroke risk associated with LVH and different LV geometric patterns was assessed by conditional logistic regression analysis in the overall group and age, sex, and race-ethnic strata, with adjustment for established stroke risk factors.
Concentric hypertrophy carried the greatest stroke risk (adjusted odds ratio [OR], 3.5; 95% confidence interval [CI], 2.0 to 6.2), followed by eccentric hypertrophy (adjusted OR, 2.4; 95% CI, 2.0 to 4.3). Concentric remodeling carried slightly increased stroke risk (adjusted OR, 1.7; 95% CI, 1.0 to 2.9). Increased LV relative wall thickness was independently associated with stroke after adjustment for LV mass (OR, 1.6; 95% CI, 1.1 to 2.3).
LVH and abnormal LV geometry are independently associated with increased stroke risk. LVH is strongly associated with ischemic stroke in all age, sex, and race-ethnic subgroups. Increased LV relative wall thickness imparts an increased stroke risk after adjustment for LV mass and is of additional value in stroke risk prediction.
PMCID: PMC2812917  PMID: 12958319
echocardiography; heart ventricle; hypertrophy; left ventricular; stroke
4.  Natural History of Concentric Left Ventricular Geometry in Community-Dwelling Older Adults without Heart Failure during Seven Years of Follow-up 
The American journal of cardiology  2010;107(2):321-324.
The presence of concentric left ventricular (LV) geometry has important pathophysiologic and prognostic implications. However, little is known about its natural history in older adults. Of the 5795 community-dwelling adults, ≥65 years, in the Cardiovascular Health Study, 1871 without baseline heart failure had data on baseline and 7-year echocardiography. Of these 343 (18%) had baseline concentric LV geometry (concentric remodeling, 83% and concentric LV hypertrophy, 17%) and are the focus of the current study. LV geometry at year 7 was categorized into 4 groups based on LV hypertrophy (LVH; LV mass indexed for height >51 g/m2.7) and relative wall thickness (RWT): eccentric hypertrophy (RWT ≤0.42 with LVH), concentric hypertrophy (RWT >0.42 with LVH), concentric remodeling (RWT >0.42 without LVH), and normal (RWT ≤0.42 without LVH). At year 7, LV geometry normalized in 57%, remained unchanged in 35%, and transitioned to eccentric hypertrophy in 7% of participants. Incident eccentric hypertrophy occurred in 4% and 25% of those with baseline concentric remodeling and concentric hypertrophy respectively, and was associated with increased LV end-diastolic volume and decreased LV ejection fraction at year-7. Prior myocardial infarction and baseline above-median LV mass (>39 g/m2.7) and RWT (>0.46) had significant unadjusted associations with incident eccentric LV hypertrophy; however, only LV mass >39 g/m2.7 (odds ratio, 17.52; 95% CI, 3.91–78.47; p<0.001) and prior myocardial infarction (odds ratio, 4.73; 95% CI, 1.16–19.32; p=0.031) had significant independent associations. In conclusion, in community-dwelling older adults with concentric LV geometry, transition to eccentric hypertrophy was uncommon but structurally maladaptive.
PMCID: PMC3022324  PMID: 21129719
concentric left ventricular remodeling; concentric left ventricular hypertrophy; eccentric left ventricular hypertrophy
5.  The Association Between Left Ventricular Hypertrophy and Biomarkers in Patients on Continuous Ambulatory Peritoneal Dialysis 
Korean Circulation Journal  2009;39(11):488-493.
Background and Objectives
Left ventricular hypertrophy (LVH) is a major cardiovascular complication and an important predictor of mortality in patients with end stage renal disease. Some studies have shown that the serum aldosterone levels are correlated with LVH in non-diabetic patients undergoing hemodialysis. The objective of this study was to elucidate the relationships between serum biomarkers, including aldosterone, and echocardiographic findings, such as LVH, in patients on peritoneal dialysis.
Subjects and Methods
Thirty patients on continuous ambulatory peritoneal dialysis (CAPD) for >12 months at Soonchunhyang University Cheonan Hospital were included. Transthoracic echocardiography was performed and the left ventricular mass index (LVMI) was calculated using the Devereux formula. Serum biomarkers {N-terminal pro B-type natriuretic peptide (NT-proBNP), troponin T, C-reactive protein, renin, and aldosterone} were measured.
Sixteen of 30 patients had LVH on the basis of the LVMI. The mean serum aldosterone level was 62.53±60.73 pg/mL (range, 5.03-250.68 pg/mL). LVH, on the basis of the LVMI, was not correlated with the serum aldosterone level. The serum aldosterone levels were not associated with echocardiographic findings, even with co-existing diabetes mellitus. The LVMI had a negative correlation with the hemoglobin (r=-0.405, p=0.029) and hematocrit (r=-0.374, p=0.042), and a positive correlation with NT-proBNP (r=0.560, p=0.002). The other biomarkers (renin, aldosterone, troponin T, and C-reactive protein) were not correlated with the LVMI. The LVMI was correlated with the left atrium volume index (r=0.675, p<0.001).
NT-proBNP is a good marker to predict LVH in patients undergoing CAPD. The serum aldosterone level is not correlated with LVMI, even with co-existing diabetes mellitus.
PMCID: PMC2790132  PMID: 19997545
Aldosterone; Left ventricular hypertrophy; Peritoneal dialysis; Type-B natriuretic peptide
6.  The Association of Long-Functioning Hemodialysis Vascular Access with Prevalence of Left Ventricular Hypertrophy in Kidney Transplant Recipients 
BioMed Research International  2014;2014:603459.
Left ventricular hypertrophy (LVH) is frequently observed in chronic dialysis patients and is also highly prevalent in kidney transplant recipients. This study evaluates the impact of long-functioning hemodialysis vascular access on LVH in single center cohort of kidney transplant recipients. 162 patients at 8.7 ± 1.8 years after kidney transplantation were enrolled. Echocardiography, carotid ultrasound, and assessment of pulse wave velocity were performed. LVH was defined based on left ventricular mass (LVM) indexed for body surface area (BSA) and height2.7. There were 67 patients with and 95 without patent vascular access. Both study groups were comparable with respect to gender, age, duration of dialysis therapy, and time after transplantation, kidney graft function, and cardiovascular comorbidities. Patients with patent vascular access were characterized by significantly elevated LVM and significantly greater percentage of LVH, based on LVMI/BSA (66.7 versus 48.4%, P = 0.02). OR for LVH in patients with patent vascular access was 2.39 (1.19–4.76), P = 0.01. Regression analyses confirmed an independent contribution of patent vascular access to higher LVM and increased prevalence of LVH. We concluded that long-lasting patent hemodialysis vascular access after kidney transplantation is associated with the increased prevalence of LVH in kidney transplant recipients.
PMCID: PMC3925527  PMID: 24616896
7.  Comparison of Left Ventricular Hypertrophy, Fibrosis and Dysfunction According to Various Disease Mechanisms such as Hypertension, Diabetes Mellitus and Chronic Renal Failure 
Left ventricular hypertrophy (LVH) has been known as an important predictor of prognosis of cardiovascular disease. Carboxy-terminal propeptide of procollagen type I (PIP) is related with myocardial fibrosis. We sought to analyze the differences in the characteristics of LVH, myocardial fibrosis, and LV functions among hypertension (HBP), diabetes mellitus (DM) and chronic renal failure (CRF).
We enrolled consecutive patients with LVH. Patients were grouped as HBP (n=50), DM (n=41), CRF (n=31). Age and sex-matched normal control was also enrolled (n=32). Echocardiography and blood sampling for serum PIP level measuring was performedin all participants.
There were no differences in baseline characteristics except systolic blood pressure among four groups. In three patients groups, their LV mass indices were significantly increased than control. Serum PIP level in CRF was much higher than others (CRF 1505.5 vs. HBP 868.7 vs. DM 687.5 vs. control 826.4, p<0.0001). LV diastolic and systolic function evaluated by E', E/E, S' and midwall fractional shortening was significantly decreased in three patients groups. However, LAVi was significantly elevated and LV ejection fraction was significantly decreased in CRF compared to others. In correlation analysis, indices of diastolic function were weakly, but statistically correlated with PIP (E': r=0.234, p=0.006; LAVi: r=0.231, p=0.006).
In CRF, LV function was more deteriorated and serum PIP was more elevated when compared to HBP or DM. Therefore, myocardial fibrosis may play an important role to LV dysfunction as well as LV hypertrophy in CRF in some degree.
PMCID: PMC2889394  PMID: 20661337
Left ventricular hypertrophy; Carboxy-terminal propeptide of procollagen type I; Fibrosis
8.  Impact of Donor Left Ventricular Hypertrophy on Survival After Heart Transplant 
Left ventricular hypertrophy (LVH) of the donor heart is believed to increase the risk of allograft failure after transplant. However this effect is not well quantified, with variable findings from single-center studies. The United Network for Organ Sharing database was used to analyze the effect of donor LVH on recipient survival. Three cohorts, selected in accordance with the American Society of Echocardiography guidelines, were examined: recipients of allografts without LVH (<1.1 cm), with mild LVH (1.1–1.3 cm) and with moderate–severe LVH (≥1.4 cm). The study group included 2626 patients with follow-up of up to 3.3 years. Mild LVH was present in 38% and moderate-severe LVH in 5.6% of allografts. Predictors of mortality included a number of donor and recipient characteristics, but not LVH. However, a subgroup analysis showed an increased risk of death in recipients of allografts with LVH and donor age >55 years, and in recipients of allografts with LVH and ischemic time ≥4 h. In the contemporary era, close to half of all transplanted allografts demonstrate LVH, and survival of these recipients is similar to those without LVH. However, the use of allografts with LVH in association with other high-risk characteristics may result in increased mortality.
PMCID: PMC3602908  PMID: 21906259
Heart transplantation; left ventricular hypertrophy; outcomes; survival
9.  Regression of pressure-induced left ventricular hypertrophy is characterized by a distinct gene expression profile 
Left ventricular hypertrophy (LVH) is a highly prevalent and robust predictor of cardiovascular morbidity and mortality. Existing studies have finely detailed mechanisms involved with its development, yet clinical translation of these findings remains unsatisfactory. We propose an alternative strategy focusing on mechanisms of LVH regression rather than its progression and hypothesize that LVH regression is associated with a distinct genomic profile
Minimally-invasive transverse arch banding and debanding (or their respective sham procedures) were performed in C57Bl6 male mice. LVH was assessed physiologically by transthoracic echocardiography, structurally by histology, and molecularly by real-time PCR. Mouse hearts were genomically analyzed with Agilent mouse 44k developmental gene chips.
Compared to controls, animals banded for 28 days developed a robust hypertrophic response by heart weight/body weight ratio, histology, echocardiography, and fetal gene expression. These parameters were reversed within 1 week of debanding. Whole genome arrays on LV tissue revealed 288 genes differentially expressed during progression, 265 genes differentially expressed with regression, and only 23 genes shared by both processes. Signaling-related expression patterns were more prevalent with regression rather than the structural-related patterns associated with LVH progression. In addition, regressed hearts showed comparatively more changes in energy metabolism and protein production.
This study demonstrates an effective model for characterizing LVH and reveals that regression is genomically distinct from its development. Further examination of these expression profiles will broaden our understanding of LVH and provide a novel therapeutic paradigm focused on promoting regression of LVH, not just halting its progression.
PMCID: PMC3335190  PMID: 19154930
10.  Soluble Tumor Necrosis Factor Receptor 1 Level Is Associated With Left Ventricular Hypertrophy: The Northern Manhattan Study 
American journal of hypertension  2009;22(7):763-769.
Although inflammatory markers may be associated with risk of cardiovascular events, few data are available regarding these markers and their association with left ventricular hypertrophy (LVH). We sought to evaluate whether inflammatory markers were independently associated with LVH in a multiethnic population in northern Manhattan.
A population-based cross-sectional study was conducted in 660 participants without stroke, who had undergone both transthoracic echocardiography and testing for soluble tumor necrosis factor receptor (sTNFR) 1, interleukin (IL)-6, and high-sensitivity C-reactive protein (hsCRP). LV mass was calculated according to an established formula. LVH was defined as LV mass greater than the 90th percentile of the participants.
The mean age was 67.4 ± 8.8 years, 35.5% were men, 61.7% were Hispanic, 19.7% were black, and 18.6% were white. In univariate analyses, hsCRP, IL-6 and sTNFR1 were significantly associated with LV mass. Multiple linear regression analyses demonstrated that sTNFR1 (P = 0.0008) was associated with LV mass after adjusting for demographic and medical risk factors, but hsCRP and IL-6 were not. When all markers were included in the same model, sTNFR1 remained significant, but hsCRP and IL-6 did not. Compared with the lowest quartile of sTNFR1, those in the highest quartile were more likely to have LVH (Odds ratio = 1.84, 95% Confidence interval, 0.97 to 3.64, P = 0.06).
Soluble TNFR1, but not hsCRP nor IL-6, is independently associated with increased LV mass. Chronic subclinical inflammation including the TNFR1-associated system may contribute to LVH.
PMCID: PMC2848526  PMID: 19390513
echocardiography; epidemiology; left ventricular hypertrophy; inflammation
11.  Left ventricular hypertrophy among black hypertensive patients: focusing on the efficacy of angiotensin converting enzyme inhibitors 
BMC Research Notes  2014;7:45.
Left ventricular hypertrophy (LVH) is an independent cardiovascular risk factor in patients with essential hypertension. The main objective of this study was to assess the echocardiographic prevalence of left ventricular hypertrophy in patients with hypertension, its risk factors and effect of antihypertensive drugs on its prevalence.
A hospital based cross sectional study was conducted on 200 hypertensive patients on treatment in southwest Ethiopia. A pretested structured questionnaire was used to collect data from participants and their clinical records. Blood pressure and anthropometric measurements were taken according to recommended standards. Left ventricular mass was measured by transthoracic echocardiography. Associations between categorical variables were assessed using chi-square test and odds ratio with 95% confidence interval. Logistic regression model was done to identify risks factors of LVH. P values of < 0.05 were considered as statistically significant.
The mean age, systolic blood pressure, diastolic blood pressure and body mass index were 55.7 ± 11.3 years, 139.2 ± 7.7 mmHg, 89.2 ± 5.7 mmHg and 24.2 ± 3.4 Kg/m2 respectively. The overall prevalence of LVH among these study subjects was 52%. Age ≥50 years (OR: 3.49, 95% CI 1.33-9.14, P = 0.011), female gender (OR: 7.69, 95% CI 3.23-20.0, P < 0.001), systolic blood pressure ≥140 mmHg (OR: 2.85, 95% CI 1.27-6.41, P = 0.011), and duration of hypertension (OR: 3.59, 95% CI 1.47-8.76, P = 0.005) were independent predictors of left ventricular hypertrophy. Angiotensin converting enzyme (ACE) inhibitors were the only antihypertensive drugs associated with lower risk of left ventricular hypertrophy (OR: 0.08, 95% CI 0.03-0.19, p < 0.001).
Left ventricular hypertrophy was found to be highly prevalent in hypertensive patients in Ethiopia. ACE inhibitors were the only antihypertensive drugs associated with reduced risk of LVH. We thus recommend strategies to early detect and treat hypertension and to timely screen for LVH among patients with hypertension. Multicenter prospective studies in Africa settings would be ideal to identify the best antihypertensive agents in black Africans.
PMCID: PMC3900673  PMID: 24444396
Hypertension; Left ventricular hypertrophy; Cardiovascular disease; Angiotensin converting enzyme inhibitors; Ethiopia; Africa
12.  Structural and Functional Cardiac Abnormalities in Adolescent Girls with Poorly Controlled Type 2 Diabetes 
Diabetes Care  2009;32(5):883-888.
Type 2 diabetes is associated with left ventricular hypertrophy (LVH) and diastolic dysfunction, which may eventually lead to clinical heart failure. We sought to determine the cardiovascular effects of adolescent-onset type 2 diabetes.
We recruited diabetic girls (8 with type 2 and 11 with type 1 diabetes) from a hospital diabetes service and nondiabetic control subjects (9 lean and 11 overweight) from the schools of the diabetic subjects. Echocardiography and measurements were performed by a single observer, blinded to subject group allocation, and included M-mode left ventricular dimensions, two-dimensional left ventricular mass, Doppler diastolic flows, estimation of left ventricular filling pressure, and systolic longitudinal motion. Left ventricular mass was indexed to height and fat-free body mass. ANOVA was used to compare the groups.
The groups were similar in age and height, but significant differences in body composition were observed. Subjects with type 2 diabetes had larger left ventricular dimensions and left ventricular mass, which persisted when indexed to height. Diastolic filling was impaired in both diabetic groups, and systolic longitudinal function was lower in the type 2 diabetic group. Half of the group with type 2 diabetes met the published criteria for LVH and left ventricular dilatation; 25% had evidence of elevated left ventricular filling pressure in association with structural abnormalities.
This study has demonstrated preclinical abnormalities of cardiac structure and function in adolescent girls with type 2 diabetes, despite the short duration of diabetes and highlights the potential high cardiovascular risk occurring in adolescent type 2 diabetes.
PMCID: PMC2671111  PMID: 19196881
13.  Prevalence and patterns of left ventricular hypertrophy in patients with predialysis chronic renal failure. 
Journal of Korean Medical Science  1998;13(5):488-494.
Left ventricular hypertrophy (LVH) is an independent risk factor for cardiac death. This study evaluates the prevalence and patterns of LVH in patients with predialysis chronic renal failure (CRF) and analyses the relationship between LVH and various predisposing factors. Sixty-two CRF patients were recruited from the renal clinic with serum creatinine over 2 mg/dl. Using echocardiography, we calculated the left ventricular mass index (LVMI) and relative wall thickness (RWT), and classified the patients into four groups (Group 1: normal, Group 2: concentric remodelling, Group 3: concentric hypertrophy, Group 4: eccentric hypertrophy). Prevalence and patterns of LVH in patients with CRF were as follows; 6.5% in Groups 1 and 2, 56.5% in Group 3 and 30.5% in Group 4. LVMI increases with progressive renal function decline. There were linear correlations between LVMI and systolic and diastolic blood pressure (BP), serum creatinine (Scr) and intact parathyroid hormone (PTH) in patients with predialysis CRF and also inverse linear correlations between LVMI and creatinine clearance (Ccr) and hemoglobin. In conclusion, we demonstrate the high prevalence of LVH (87%) in patients with predialysis CRF and concentric hypertrophy (56.5%) was the main pattern of LVH. Several factors such as anemia, systolic and diastolic BP, renal function and PTH influence LVMI.
PMCID: PMC3054529  PMID: 9811177
14.  Association of Novel Biomarkers of Cardiovascular Stress With Left Ventricular Hypertrophy and Dysfunction: Implications for Screening 
Currently available screening tools for left ventricular (LV) hypertrophy (LVH) and systolic dysfunction (LVSD) are either expensive (echocardiography) or perform suboptimally (B‐type natriuretic peptide [BNP]). It is unknown whether newer biomarkers are associated with LVH and LVSD and can serve as screening tools.
Methods and Results
We studied 2460 Framingham Study participants (mean age 58 years, 57% women) with measurements of biomarkers mirroring cardiac biomechanical stress (soluble ST‐2 [ST2], growth differentiation factor‐15 [GDF‐15] and high‐sensitivity troponin I [hsTnI]) and BNP. We defined LVH as LV mass/height2 ≥the sex‐specific 80th percentile and LVSD as mild/greater impairment of LV ejection fraction (LVEF) or a fractional shortening <0.29. Adjusting for standard risk factors in logistic models, BNP, GDF‐15, and hsTnI were associated with the composite echocardiographic outcome (LVH or LVSD), odds ratios (OR) per SD increment in log‐biomarker 1.29, 1.14, and 1.18 (95% CI: 1.15 to 1.44, 1.004 to 1.28, and 1.06 to 1.31), respectively. The C‐statistic for the composite outcome increased from 0.765 with risk factors to 0.770 adding BNP, to 0.774 adding novel biomarkers. The continuous Net Reclassification Improvement was 0.212 (95% CI: 0.119 to 0.305, P<0.0001) after adding the novel biomarkers to risk factors plus BNP. BNP was associated with LVH and LVSD in multivariable models, whereas GDF‐15 was associated with LVSD (OR 1.41, 95% CI: 1.16 to 1.70), and hsTnI with LVH (OR 1.22, 95% CI: 1.09 to 1.36). ST2 was not significantly associated with any outcome.
Our community‐based investigation suggests that cardiac stress biomarkers are associated with LVH and LVSD but may have limited clinical utility as screening tools.
PMCID: PMC3886765  PMID: 24200688
biomarkers; echocardiography; heart failure; hypertrophy; screening
15.  Serum cystatin C concentration as an independent marker for hypertensive left ventricular hypertrophy 
Serum cystatin C levels can be used to predict morbidity and mortality in patients with cardiovascular disease. However, the clinical relevance of serum cystatin C levels in patients with hypertensive left ventricular hypertrophy (LVH) has rarely been investigated. We designed the present study to investigate whether serum cystatin C levels are associated with cardiac structural and functional alterations in hypertensive patients.
We enrolled 823 hypertensive patients and classified them into two groups: those with LVH (n = 287) and those without LVH (n = 536). All patients underwent echocardiography and serum cystatin C testing. We analyzed the relationship between serum cystatin C levels and LVH.
Serum cystatin C levels were higher in hypertensive patients with LVH than in those without LVH (P < 0.05). Using linear correlation analysis, we found a positive correlation between serum cystatin C levels and interventricular septal thickness (r = 0.247, P < 0.01), posterior wall thickness (r = 0.216, P < 0.01), and left ventricular weight index (r = 0.347, P < 0.01). When analyzed by multiple linear regression, the positive correlations remained between serum cystatin C and interventricular septal thickness (β = 0.167, P < 0.05), posterior wall thickness (β = 0.187, P < 0.05), and left ventricular weight index (β = 0.245, P < 0.01).
Serum cystatin C concentration is an independent marker for hypertensive LVH.
PMCID: PMC3796704  PMID: 24133518
Hypertension; Left ventricular hypertrophy; Cystatin C
16.  Tissue Doppler Imaging Consistently Detects Myocardial Abnormalities in Patients With Hypertrophic Cardiomyopathy and Provides a Novel Means for an Early Diagnosis Before and Independently of Hypertrophy 
Circulation  2001;104(2):128-130.
—Left ventricular hypertrophy (LVH), the clinical hallmark of familial hypertrophic cardiomyopathy (FHCM), is absent in a significant number of subjects with causal mutations. In transgenic rabbits that fully recapitulate the FHCM phenotype, reduced myocardial tissue Doppler (TD) velocities accurately identified the mutant rabbits, even in the absence of LVH. We tested whether humans with FHCM also consistently showed reduced myocardial TD velocities, irrespective of LVH.
Methods and Results
—We performed 2D and Doppler echocardiography and TD imaging in 30 subjects with FHCM, 13 subjects who were positive for various mutations but did not have LVH, and 30 age- and sex-matched controls (all adults; 77% women). LV wall thickness and mass were significantly greater in FHCM subjects (P<0.01 versus those without LVH and controls). There were no significant differences in 2D echocardiographic, mitral, and pulmonary venous flow indices between mutation-positives without LVH and controls. In contrast, systolic and early diastolic TD velocities were significantly lower in both mutation-positives without LVH and in FHCM patients than in controls (P<0.001). Reduced TD velocities had a sensitivity of 100% and a specificity of 93% for identifying mutation-positives without LVH.
—Myocardial contraction and relaxation velocities, detected by TD imaging, are reduced in FHCM, including in those without LVH. Before and independently of LVH, TD imaging is an accurate and sensitive method for identifying subjects who are positive for FHCM mutations.
PMCID: PMC2900859  PMID: 11447072
cardiomyopathy; genetics; hypertrophy; systole; diastole
17.  Echocardiographic assessment of inappropriate left ventricular mass and left ventricular hypertrophy in patients with diastolic dysfunction 
Early diagnosis of left ventricular mass (LVM) inappropriateness and left ventricular hypertrophy (LVH) can result in preventing diastolic left ventricular dysfunction and its related morbidity and mortality. This study was performed to determine if diastolic dysfunction is associated with LVH and inappropriate LVM.
Materials and Methods:
One hundred and twenty five uncomplicated hypertension from Isfahan Healthy Heart Program underwent two-dimensional echocardiography. Inappropriate LVM was defined as an LVM index greater than 88 g/m2 of body-surface area in women and greater than 102 g/m2 in men. LVH-defined septal and posterior wall thickness greater than 0/9 cm in women and greater than 1 cm in men, respectively. Echocardiographic parameters, including early diastolic peak velocity (E)/late diastolic peak velocity (A), deceleration time (DT), and E/early mitral annulus velocity (E′) were measured.
The mean systolic and diastolic blood pressure at the patients’ admission day were 142.87 ± 18.12 and 88.45 ± 9.18 mmHg, respectively. Totally, 21.7% of subjects had inappropriate LV mass that moderate and severe abnormal LV mass was revealed in 5.6% and 5.6%, respectively. The mean of age and BMI was significantly higher in patients with moderate left ventricular hypertrophy (P < 0.05). Adjusted by age, gender, BMI, and systolic and diastolic blood pressures, both E/A ratio and deceleration time were higher in those with the severer ventricular hypertrophy. Subjects with severe showed significantly higher BMI 33. 7 ± 3.7 (P < 0.001). There was a slight difference between the grade of diastolic dysfunction and the severity of inappropriate LV mass (P = 0.065). But no significant difference was found between E/A, E/E′, and deceleration time and the level of inappropriate LV mass (P > 0.05). Spearman's Rank test was used to test the correlation between diastolic dysfunction and LV mass (P = 0.025).
LVH is correlated with the severity of diastolic dysfunction manifested by the E/A value and deceleration time, but inappropriate LVM can slightly predict diastolic dysfunction severity in uncomplicated hypertension.
PMCID: PMC3525029  PMID: 23264785
Echocardiographic; left ventricular mass; left ventricular hypertrophy; Diastolic dysfunction
18.  Effect of Telmisartan on the Regression of the Left Ventricular Hypertrophy in the Patients of Essential Hypertension 
Introduction: An increase in the Left Ventricular Mass as a result of muscle hypertrophy, has emerged as a powerful pressure independent risk factor for the cardiovascular mortality and morbidity. It is associated with a risk of death that is 3 times greater than the risk which is associated with hypertension alone. For the development of Left Ventricular Hypertrophy (LVH), in addition to a chronic increase in the pressure and/or volume overload, an elevation in the plasma ACE activity, plasma aldosterone levels, and the angiotensin-II concentrations play a major role .In this study, the effect of Telmisartan, a selective angiotension-II receptor blocker, was compared with that of Atenolol, a selective β1 adrenergic receptor blocker, on the regression of LVH in the patients of essential hypertension.
Material and Method: Essential hypertensive patients with LVH were selected for this study, as per the inclusion and exclusion criteria. This study was carried out on two groups of hypertensive patients with LVH:
Group-1 : The patients who were taking telmisartan 80 mg OD.
Group-2 : The patients who were taking atenolol 50 mg OD.
The blood pressure was measured and echocardiography was done in both the groups, prior to the treatment and 6 months after the treatment in the Department of Cardiology, MKCG Medical College Hospital, Brahmapur, India. The data were analysed by using the Student’s ‘t’ test.
Results: In the cases of Left Ventricular Mass Index (LVMI), which is a better indicator of LVH, in the Atenolol group, the mean value changed from 143.93 ± 2.44 gm/m2 to 130.16 ± 2.88 gm/m2 (t=5.83,p<0.01 versus baseline).In the Telmisartan group, the mean value changed from 184.67 ± 7.14 gm/m2 to 133.41 ± 4.24 gm/m2 (t=12.12, p<0.001 versus baseline). On comparing Telmisartan with Atenolol, Telmisartan was found to produce a greater (27.49%) reduction than Atenolol (9.68%). In the Telmisartan group, 13 patients out of 26 patients achieved a target value of LVMI that was <134 gm/m2 in males and <110 gm/m2 in females (50%). In the Atenolol group, only 9 patients out of 22 patients achieved a target value (40.90%).
Conclusion: Thus, Telmisartan a selective AT1 antagonist, possesses pharmacological effects beyond a blood pressure reduction in which the blockade of the AT1 receptor may lead to attenuation of the growth promoting action of Ang II. From this study, it is clear that Telmisartan is superior to Atenolol in achieving a regression of LVH, which is a better indicator of the cardiovascular morbidity and mortality.
PMCID: PMC3749634  PMID: 23998064
Left ventricular hypertrophy; Hypertension; Telmisartan
19.  Prevalence of residual left ventricular structural changes after one year of antihypertensive treatment in patients of African descent: role of 24-hour pulse pressure 
Cardiovascular Journal of Africa  2012;23(3):147-152.
One year of antihypertensive therapy may normalise left ventricular (LV) structure in 51% of hypertensive patients of European descent. Whether similar effects can be achieved in patients of African descent, who have a high prevalence of concentric LV hypertrophy (LVH) and remodelling, is unknown.
In 103 hypertensive patients in the Baragwanath Hypertension study we evaluated the prevalence of residual LV structural changes (echocardiography) after four and 13 months of stepwise antihypertensive therapy.
After 13 months of therapy, 24-hour blood pressure control was achieved in 47% of patients. At baseline, 51.5% of patients had concentric LVH, 19% eccentric LVH and 12% concentric LV remodelling. Despite changes in LV mass index (p < 0.01) and relative wall thickness (p < 0.05) with treatment, the proportion of patients with a normal LV mass or geometry increased only from 17.5 to 25% (p > 0.05), while 26% remained with concentric LVH (p < 0.001 compared to baseline), 25% with eccentric LVH and 23% with concentric LV remodelling (p < 0.05 compared to baseline). Residual structural changes were associated with 24-hour pulse pressure (p = 0.02), but not with 24-hour systolic or diastolic blood pressure or clinic blood pressure.
Even after a year of antihypertensive therapy, a high proportion (74%) of hypertensives of African ancestry retained residual LV structural changes, an effect that was associated with 24-hour pulse pressure but not systolic or diastolic blood pressures or clinic blood pressure in this ethnic group.
PMCID: PMC3721865  PMID: 22354147
left ventricular geometry; antihypertensive therapy; ambulatory blood pressure; pulse pressure
20.  Electrocardiographic Left Ventricular Hypertrophy and Outcome in Hemodialysis Patients 
PLoS ONE  2012;7(4):e35534.
Background and Aims
Electrocardiography (ECG) is the most widely used initial screening test for the assessment of left ventricular hypertrophy (LVH), an independent predictor of cardiovascular mortality in patients with end-stage renal disease (ESRD). However, traditional ECG criteria based only on voltage to detect LVH have limited clinical utility for the detection of LVH because of their poor sensitivity.
This prospective observational study was undertaken to compare the prognostic significance of commonly used ECG criteria for LVH, namely Sokolow-Lyon voltage (SV) or voltage-duration product (SP) and Cornell voltage (CV) or voltage-duration product (CP) criteria, and to investigate the association between echocardiographic LV mass index (LVMI) and ECG-LVH criteria in ESRD patients, who consecutively started maintenance hemodialysis (HD) between January 2006 and December 2008.
A total of 317 patients, who underwent both ECG and echocardiography, were included. Compared to SV and CV criteria, SP and CP criteria, respectively, correlated more closely with LVMI. In addition, CP criteria provided the highest positive predictive value for echocardiographic LVH. The 5-year cardiovascular survival rates were significantly lower in patients with ECG-LVH by each criterion. In multivariate analyses, echocardiographic LVH [adjusted hazard ratio (HR): 11.71; 95% confidence interval (CI): 1.57–87.18; P = 0.016] and ECG-LVH by SP (HR: 3.43; 95% CI: 1.32–8.92; P = 0.011) and CP (HR: 3.07; 95% CI: 1.16–8.11; P = 0.024) criteria, but not SV and CV criteria, were significantly associated with cardiovascular mortality.
The product of QRS voltage and duration is helpful in identifying the presence of LVH and predicting cardiovascular mortality in incident HD patients.
PMCID: PMC3328457  PMID: 22530043
21.  Tissue Doppler Imaging can be useful to distinguish pathological from physiological left ventricular hypertrophy: a study in master athletes and mild hypertensive subjects 
Transthoracic echocardiography left ventricular wall thickness is often increased in master athletes and it results by intense physical training. Left Ventricular Hypertrophy can also be due to a constant pressure overload. Conventional Pulsed Wave (PW) Doppler analysis of diastolic function sometimes fails to distinguish physiological from pathological LVH.
The aim of this study is to evaluate the role of Pulsed Wave Tissue Doppler Imaging in differentiating pathological from physiological LVH in the middle-aged population.
we selected a group of 80 master athletes, a group of 80 sedentary subjects with essential hypertension and an apparent normal diastolic function at standard PW Doppler analysis. The two groups were comparable for increased left ventricular wall thickness and mass index (134.4 ± 19.7 vs 134.5 ± 22.1 gr/m2; p > .05). Diastolic function indexes using the PW technique were in the normal range for both.
Pulsed Wave TDI study of diastolic function immediately distinguished the two groups. While in master athletes the diastolic TDI-derived parameters remained within normal range (E' 9.4 ± 3.1 cm/sec; E/E' 7.8 ± 2.1), in the hypertensive group these parameters were found to be constantly altered, with mean values and variation ranges always outside normal validated limits (E' 7.2 ± 2.4 cm/sec; E/E' 10.6 ± 3.2), and with E' and E/E' statistically different in the two groups (p < .001).
Our study showed that the TDI technique can be an easy and validated method to assess diastolic function in differentiating normal from pseudonormal diastolic patterns and it can distinguish physiological from pathological LVH emphasizing the eligibility certification required by legal medical legislation as in Italy.
PMCID: PMC2774305  PMID: 19845938
22.  Midwall ejection fraction for assessing systolic performance of the hypertrophic left ventricle 
In patients with left ventricular hypertrophy (LVH), LV midwall fractional shortening (FS) is used as a measure of LV systolic performance that is more physiologically appropriate than conventional FS. For evaluation of LV volume and ejection fraction (EF), 2-dimensional (2D) echocardiography is more accurate than M-mode echocardiography. The purpose of this study was to assess systolic performance by midwall EF using 2D speckle tracking echocardiography (STE).
Sixty patients were enrolled in the study. Patients were divided into two groups with LVH (n = 30) and without LVH (control group, n = 30). LV systolic function was compared between the two groups and the relationships of left ventricular mass index (LVMI) with LV systolic parameters, including midwall EF, were investigated.
Midwall EF in the LVH group was significantly lower than that in the control group (42.8±4.4% vs. 48.1±4.1%, p <0.0001). Midwall FS was also significantly lower in the LVH group (13.4±2.8% vs. 16.1±1.5%, p <0.0001), but EF did not differ significantly between the two groups. There were significant correlations between midwall EF and LVMI (r=0.731, p <0.0001) and between midwall FS and LVMI (r=0.693, p <0.0001), with midwall EF having the higher correlation.
These results show that midwall EF can be determined using 2D STE. Midwall EF can be used to monitor LV systolic dysfunction, which is not possible with conventional EF. Evaluation of midwall EF may allow assessment of new parameters of LV systolic function in patients with LV geometric variability.
PMCID: PMC3552820  PMID: 23167789
Midwall ejection fraction; Left ventricular systolic function; Left ventricular hypertrophy; Speckle tracking echocardiography
23.  Impact of HIV Infection on Diastolic Function and Left Ventricular Mass 
Circulation. Heart failure  2009;3(1):132-139.
HIV patients have increased risk for cardiovascular disease, but the underlying mechanisms remain unknown. The purpose of this study was to determine the prevalence of echocardiographic abnormalities among asymptomatic HIV-infected individuals compared to HIV-uninfected individuals.
We performed echocardiography in 196 HIV-infected adults and 52 controls. Left ventricular ejection fraction (LVEF), left ventricular mass indexed to the body surface area (LVMI), and diastolic function were assessed according to American Society of Echocardiography standards. LVMI was higher in HIV-infected patients (77.2g/m2 in HIV patients vs. 66.5g/m2 in controls, p<0.0001). LVEF was similar in both groups. Eight(4%) of the HIV patients had evidence of LV systolic dysfunction (defined as an EF<50%) versus none of the controls; 97(50%) had mild diastolic dysfunction compared to 29% of the HIV-uninfected subjects (p=0.008). After adjustment for hypertension and race, HIV-infected participants had a mean 8g/m2 larger LVMI compared to controls (p=0.001). Higher LVMI was independently associated with lower nadir CD4 T cell count, suggesting that immunodeficiency may play a role in this process. After adjustment for age and traditional risk factors, HIV patients had a 2.4 greater odds of having diastolic dysfunction as compared to controls (p=0.019).
HIV-infected patients had a higher prevalence of diastolic dysfunction and higher LVMI compared to controls. These differences were not readily explained by differences in traditional risk factors and were independently associated with HIV infection. These results suggest that contemporary asymptomatic HIV patients manifest mild functional and morphological cardiac abnormalities which are independently associated with HIV infection.
PMCID: PMC2837081  PMID: 19933410
AIDS; diastole; echocardiography; hypertrophy; inflammation
24.  Performance of electrocardiographic criteria for left ventricular hypertrophy as compared with cardiac computed tomography: from the Rule Out Myocardial Infarction Using Computer Assisted Tomography trial 
Journal of hypertension  2010;28(9):1959-1967.
Cardiac computed tomography (CT) is a state-of-the-art technology that provides an accurate noninvasive method to quantify left ventricular mass for analysis of left ventricular hypertrophy (LVH). We aimed to examine seven ECG-based LVH criteria against two CT indexation criteria for LVH: a CT-specific body surface area cutoff and the obesity-independent height2.7 criteria.
In 333 patients (mean age 53 ± 12 years, 61% men), 64-slice contrast-enhanced CT was performed and 12-lead surface ECG within 24 h. Left ventricular mass was measured at end-diastole. Using both CT indexation criteria, the cohort was subdivided into patients with LVH and without LVH. The seven ECG criteria for LVH were the Cornell voltage index, Cornell voltage duration product, Cornell/strain index, Sokolow–Lyon index, Romhilt–Estes scores at least 4 and at least 5, and Gubner–Ungerleider.
The ECG parameters had high specificities (85–97%) and variable low sensitivities (4–43%) when compared to either CT criteria of LVH. The three Cornell-based methods performed the best (test-positive likelihood ratio: 4.5–6.7), followed by the Sokolow–Lyon and Romhilt–Estes scores (test-positive likelihood ratio: 2.3–4.0). With the exception of the Gubner–Ungerleider criterion, the other six ECG criteria were associated with at least one of the CT-based LVH (adjusted odds ratio 2.4–9.5) and had incremental predictive value beyond that of hypertension history.
Using cardiac CT as a gold standard for LVH assessment, ECG criteria for LVH have high specificities with the three Cornell-based criteria providing the best test performance for identifying patients with LVH.
PMCID: PMC3218429  PMID: 20498615
computed tomography; electrocardiography; left ventricular hypertrophy; left ventricular mass
Hypertension  2011;58(5):920-925.
Left ventricular hypertrophy, a marker for adverse cardiovascular events, is more common in blacks than non-Hispanic whites. Mechanisms leading to left ventricular hypertrophy and mediating its clinical sequelae in blacks are not fully understood. We investigated the associations of 39 candidate biomarkers in distinct biological pathways with left ventricular mass and geometry in blacks. Participants included 1193 blacks (63 ± 9 years, 72% women, 78% hypertensive) belonging to hypertensive sibships. Left ventricular mass was measured by transthoracic echocardiography and indexed to height2.7. Left ventricular geometry was categorized as: normal, concentric remodeling, concentric hypertrophy and eccentric hypertrophy. Generalized estimating equations were employed to assess associations of the 39 biomarkers with left ventricular mass index after adjustment for age, sex, and conventional risk factors. After adjustment for potential confounders, log-transformed levels of the following biomarkers were independently associated with left ventricular mass index: N-terminal pro-brain natriuretic peptide (β±SE= 0.07±0.01 pg/mL, P< 0.0001), mid-regional pro-atrial natriuretic peptide (β±SE= 0.08±0.02 pmol/L, P< 0.0001), mid-regional pro-adrenomedullin (β±SE= 0.09±0.03 nmol/L, P= 0.0006), C-terminal pro-endothelin (β±SE= 0.05±0.02 pmol/L, P=0.0009) and osteoprotegerin (β±SE=0.07±0.02 pg/mL, P=0.0005). The associations of these biomarkers with left ventricular mass index were mainly due to their association with eccentric hypertrophy. Higher circulating levels of natriuretic peptides, adrenomedullin, endothelin and osteoprotegerin were associated with increased left ventricular mass index, providing insights into the pathophysiology of left ventricular hypertrophy in blacks.
PMCID: PMC3249445  PMID: 21986506
left ventricular hypertrophy; biomarkers; brain natriuretic peptide; atrial natriuretic peptide; adrenomedullin; endothelin; osteoprotegerin

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