Impact of systemic hypertension on right ventricular function Impact de l'hypertension artérielle sur le ventricule droit

Transcription

1 article original Cardiologie T u n i s i e n n e Imact of systemic hyertension on right ventricular function Imact de l'hyertension artérielle sur le ventricule droit Meriem Drissa, Sana Helali, Madiouni Meriem, Yosri Ben Hamida, Habiba Drissa Cardiology deartment of la rabta hosital Résumé Objectif: Évaluer l'imact de l'hyertension artérielle sur la fonction ventriculaire droite. Méthodes: Nous avons inclus 60 atients atteints d'hyertension artérielle non contrôlée (groue A) et 60 sujets sains témoins (groue B). Les deux groues inclus sont indemnes de diabète, de cardioathies ischémiques, de valvuloathies Les 2 groues étaient aariés selon l âge et le sexe. Résultats: Il existait ne augmentation significative de l'éaisseur ariétale, du diamètre de l'oreillette gauche, de l'indice de masse ventriculaire gauche dans le groue A. La fraction d'éjection du ventricule gauche était comarable entre les deux groues. Le diamètre diastolique du ventricule droit (VD), la fraction d'éjection du VD, l'excursion systolique tricuside du lan annulaire (TAPSE) et la variation de la fraction de raccourcissement de surface du VD étaient comarables entre les 2 groues. La vitesse systolique S 'mesurée au niveau l anneau tricuside et le strain longitudinal global étaient significativement lus bas chez les atients hyertendus (9 ± 2 cm versus 14 ± 1 cm / s, <0,01) et (-12 ± 2,6% versus - 20,1 ±0.2% <0,01) reflétant un dysfonctionnement systolique infra clinique du VD. De lus, le ic de vélocité récoce (Ea) au niveau de l'anneau tricuside était significativement lus bas dans le groue A (7,9 ± 1,9 cm / s vs -13,1 ± 2,1, <0,01) avec comme conséquence un raort moindre Ea / Aa chez les atients hyertendus. Conclusion : Notre étude a révélé une dysfonction systolique et diastolique du VD chez les atients hyertendus non contrôlés. Le doler tissulaire et le strain rate ont ermis une la détection de ces anomalies à un stade infra clinique. Mots-clés Hyertension artérielle, ventricule droit, échocardiograhie, strain Summary Purose: To evaluate the imact of arterial hyertension on right ventricular function Methods: We included 60 atients with uncontrolled hyertension without any associated athology (grou A ) and 60 healthy subjects control (grou B). Subjects included in both grous were free from diabetes, valvular disease and ischemic heart disease. The 2 grous have a comarable average age and sex ratio. Results: There was a significant increase in arietal thickness, left atrium diameter, left ventricular mass index in grou A. The left ejection fraction was comarable between two grous. The diastolic diameter of the RV, the ejection fraction of the RV, the tricusid annular lane systolic excursion (TAPSE) and the fractional area change were comarable between the 2 grous. The systolic velocity S measured at the level of the annulus tricusid and the global longitudinal strain rate were significantly lower in hyertensive atients(9 ±2 cm versus 14±1 cm/s, ) and ( 12. ± 2.6 % versus 20.1 ± 2 % )reflecting subclinical RD systolic dysfunction. In addition, the early (Ea) eak velocity at the tricusid annulus was significantly lower in grou A (7.9± 1.9 cm/s versus ± 2.1, with a consequence lower Ea /Aa suggestion a RV relaxation disorder Conclusion : Our study revealed a RV dysfunction in uncontrolled hyertension atients, Doler tissue and 2D strain were very owerful in detection of RV abnormalities at an early subclinical stage Keywords Hyertension, right ventricle, echocardiograhy, strain Corresondance Mariem Drissa Cardiology deartment of la rabta hosital Mariemdrissa@yahoo.fr Cardiologie Tunisienne - Volume 14 N

2 M. Drissa & al. introduction left ventricular structural and functional changes in atients with arterial hyertension are well established. However, the influence of arterial hyertension on right ventricular (rv) remodeling is still being investigated. The aim of the current study was to determinate the rv systolic and diastolic function in uncontrolled hyertensive atients and comare these echocardiograhic findings to the results of control subjects. MeTHods We conducted a rosective study in la rabta hosital deartment between sixty uncontrolled hyertensive atients (grou a) were comared to age and gender matched 60 healthy control subjects (grou B). grou a atients has hyertension since 4 years, hyertension was uncontrolled under trile theray because of oor treatment adherence.otherwise atients were freedom from any signs of right or of left heart failure. Patients with other causes of left ventricle (lv) hyertrohy, myocardial disease, ischemic heart disease, valvular heart disease, or ulmonary diseases were excluded. all subjects had echocardiograhy erformed with the use of a ViVid 8. Patients were exlored by conventional echocardiograhy couled to tissue doler and 2d strain. several arameters have been collected for the two grous and comared :left ventricle mass, setum thickness, lv ejection fraction, left atrium area, anatomic characteristics of rv (wall thickness, basal diameter),systolic function of rv was assessed by (fractional area changes, rv ejection fraction (rvef), tricusid annular lane systolic excursion (TaPse)), systolic velocity s using tissue doler and global longitudinal strain rate(gls), diastolic function was assessed by tricusid flow with standard ulsed doler by measurements of early diastolic eak flow velocity (e), late diastolic eak flow velocity (a), and the ratio of early to late flow velocity eaks (e/a ratio) and by tissue doler of right ventricular lateral at tricusid annulus characterized by myocardial early (ea) and atrial (aa) eak velocities and ratio ea/aa ratio. statistical tests We calculated simle frequencies and relative frequencies (ercentages) for qualitative variables, means, medians and standard deviations for quantitative variables.we used the chi-square test and the student test resectively for the comarison of two ercentages and two averages, in all the statistical tests, the significance level was fixed at0.05 results general characteristics of the hyertensive and control grous were listed in Table1 echocardiograhic lv characteristics for both grous were reorted in table 2. lv setum wall thickness, lv mass index,left atrium area were increased in hyertensive grou (1,3cm,220g/m2, 21cm2) versus (0.8cm,125 g/m2,14 cm2) in control grou attesting a lv hyertrohy.lv ejection fraction was also comarable between the 2 grous. Table 1 : General characteristics of our oulation Age Sex ratio(female) BMI Diabete (mmol) Systolic BP(mmhg) Diastolic BP( mmhg ) BP :blood ressure Grou A 56 ± ±1 4.9 ± ±4 90 ±2 lv ef :left ventricule ejection fraction Grou B 52 ±7 assessment of functional and anatomical characteristics of the right ventricle of both grous were reorted in table 3. grou a resented a rv wall thickness (5.4 mm versus 2.6mm in grou B,) while rv diameter were comarable in both grous.concerning rv systolic function many arameters were assessed(table 3). Fractional area changes, rvef and TaPse were normal in hyertensive atients and comarable to control grou. Whereas eak s velocity at tricusid annulus was reduced (9 ±2 cm versus 14±1 cm/s(< 0.01) (figure 1).gls was also significantly altered in grou a ( 12. ± 2.6% versus 20.1 ± 0.2 % (figure2). By using tissue doler and strain rate we attested a subclinical systolic function of rv in asymtomatic hyertensive ±4 4.4 ± ±2 72±5 Ns P<0.001 P<0.001 Table2 : Echocardiograhic left ventricle characteristics for both grous LV setum thickness (cm) LV mass index (g/m2) LV EF(%) Left Atrium area cm 2 Grou A 1,3± ± 3 21 ± 0,5 Grou B 0.8± ±1 14 ±06 <0,01 Cardiologie Tunisienne 117

3 IMaCT of SYSTeMIC HYerTeIoN on right VeNTrICular function atients. diastolic function was also assessed using ulsed doler which revealed a tricusid e/a ratio<0.8 in 92% of hyertensive atients attesting robable relaxation disorder. a comlement of exloration using tissue doler at annulus tricusid showed a decreased in ea (-7.9± 1.9 cm/s in hyertensive grou vs ± 2.1, in control) and with consequence a low ea/aa ratio in grou a.confirming the relaxation disorder of rv Table 3 : Echocardiograhic characteristics of the right ventricle in both grous RV wall thikness (mm) RV Diametre (mm) RV EF(%) Fraction area Change(RV)% TAPSE(mm) Tricusid annulus S velocity cm/s) RVGLS(%) E/A tricusid Ea Tricusid annulus(cm/s) Ea/Aa tricusid Grou A ±4 62± ±1 18 ±1 9± 2-12 ± ± ± ±0.1 GrouB ± 0,2 65 ± ±1 20± ± 1-20 ± ± ± ±03 < 0.01 rv: right ventricle, rvef: right ventricle ejection fraction, T apse: tricusid annular lane systolic excursion, gls :global longitudinal strain Figure 1 : Tricusid annulus S velocity cm/s reduced in hyertensive atients grou Figure2 : a reduced RV GLS ( %) in hyertensive grou RV GLS :right ventricular global longitudinal strain discussion systemic hyertension induces a rogressive increase of left ventricular (lv) mass with consequent lv hyertrohy (lvh) and imairment of diastolic and systolic lv function.[1,2].in our study hyertrohy and increased mass index of lv was reorted in hyertensive grou us a consequence of uncontrolled blood ressure. But ejection fraction was still reserved. influence of arterial hyertension on lv ventricle is well established. However, the effect on right ventricular (rv) remodeling is still being investigated [1].The evaluation of the rv structure in the clinical ractice considers the assessment of rv wall thickness, which was already confirmed as an imortant redictor of morbidity and- mortality in the global oulation free of cardiovascular disease.[3].previous investigations have shown that rv wall thickness is increased in atients with arterial hyertension[4-7] We reorted the same results in our study since a thickness of rv wall was found in hyertensive atients(5.4 mm versus 2.6 mm in control grou. This adative mechanism imacted ulmonary circulation and rovoked rv remodeling. Many mechanisms were involved in rv hyertrohy in systemic hyertension including overstimulation of the symathetic system and the renin angiotensin aldosterone system could be resonsible for increased ulmonary arteriolar resistance and furthermore for rv hyertrohy [8]and the mechanical interaction between the 2 ventricles through interventricular setum which reresent a structure that determines systolic functions of both the ventricles and it is considered as the lion of the rv function. )[9]. Ventricular interdeendence refers to the fact that the shae, size, and comliance of one ventricle may influence the shae, size, or ressures in the other ventricle; an essential concet for understanding the Cardiologie Tunisienne 118

4 M. Drissa & al. athology of right ventricle (rv) dysfunction.[10].the imairment of rv systolic function in arterial hyertension could be related with increased rv filling ressures, rv hyertrohy, and ventricular interdeendence [ 11]. To evaluate rv systolic function we used different techniques and arameters we did not find any significant difference in rvef between the hyertensive and the healthy grous.todiere[12] in his study including 25 hyertensive atients and 24 controls reorted similar results. Fractional area change (FaC) another arameter of rv systolic function, remains within the normal range for a long time and deteriorates last in the cascade [13]. similar results were observed in our study since FaC was normal in our hyertensive atients. TaPse, a good estimate of rv global systolic function [14], was not reduced in our hyertensive grou. others studies agreed with our results [15,16]. However some authors found the deterioration of rv systolic function by the usage of tissue doler to determinate a reduced of systolic eak velocity of the rv wall at the level of tricusid valve[17,18 ]attesting the role of this technique in detecting myocardial functional changes in secific, diseased regions, even when the function of other segments and the entire chamber is still normal. in fact in our study we reorted that eak s at annulus tricusid was reduced 9 ±1 cm versus 14±1 cm/s, (< 0.01) suggesting a latent subclinical dysfunction of rv even the absence of ejection fraction imairment. The number of studies that investigated rv strain in the atients with arterial hyertension is limited. only recently have the studies that investigate rv mechanics in hyertensive atients aeared. They have shown significant deterioration of rv longitudinal deformation[[16,19]and revealed the association between rv longitudinal strain and functional caacity in hyertensive atients[6,20].our results were in according with those reorted by these revious studies gls is a romising technique to quantify the regional rv ventricular function was a sensitive arameter of rv function that could detect changes at subclinical levels. (13).in our study by using 2dstrain we unmasked a latent rv dysfunction in asymtomatic hyertensive atients who had a normal arameters of rv systolic function such us rvef,tapse and FaC. Hanboly[17] showed not only that rv gls was reduced in hyertensive atients, but also that aical and mid segments of rv free wall were more deteriorated than the basal rv segment in the hyertensive subjects. our atients were only evaluated by global longitudinal strain rate since we had excluded any atients with associated ischemic disease. unlike the uncertainty that exists in the relationshi between arterial hyertension and rv systolic function, almost all investigators agree that arterial hyertension imacts rv diastolic function.[12]. Both ventricles are structurally and functionally interdeendent on each other, so The deterioration of rv diastolic function might ossibly be exlained by increased stiffness of the rv caused by hyertrohy, retrograde transmission of increased lv filling ressure to the ulmonary circulation and ultimately to the rv, negative influence of biohumoral systems [13]. The overall revalence of r diastolic dysfunction was higher than that of right ventricle systolic dysfunction [17]. The evaluation of rv diastolic function was mainly erformed by ulsed doler.in fact diastolic measurements were altered at the level of rv lateral tricusid annulus in.tumuklu [21] echocardiograhic study including 35 atients with arterial hyertension and 30 age and sex- adjusted control subjects, Hanboly(17) also found a tricusid e/a ratio <0.8 in 60% hyertensive atient suggesting a diastolic dysfunction of rv. similar results were reorted in our study when 92% of hyertensive atients resented e/a<0.8 attesting a robable rv relaxation disorder. Tissue doler indices at tricusid annulus adds information in assessment of diastolic rv function. in fact Cicala et al. [15] reorted that tricusid annular ea/aa ratio was redictor of rv diastolic dysfunction, of the same HanBolY reorted in his study a decreased tricusid ea/aa ratio in hyertensive grou 0.9 ± 0.3 vs ± 0.1 in the control grous, < This same ratio ea/aa was lower in our hyertensive atients attesting a relaxation disorder of rv. limits of study We selected a atients with uncontrolled hyertension. This can be a selection biais since uncontrolled hyertension atients develoed more ventricular hyertrohy and with consequence more rv dysfunction then controlled or mid controlled hyertension atients. -The small size of our oulation is the main limitation of our work, and other single or multi-center studies, including a larger number, will imrove the validity of our results. acknowledgments ii would like to thanks all my coauthors ho had articiated to the elaboration of this manuscrit. Conflicts of interests. no conflicts of interests ConClusion -our study shows the resence of subclinical rv dysfunction in uncontrolled hyertensive atients, reflecting lv / rv interdeendence and the contributory role of the interventricular setum in rv function Cardiologie Tunisienne 119

5 IMaCT of SYSTeMIC HYerTeIoN on right VeNTrICular function Tissue doler and 2d strain were very owerful tools in the early detection of these subclinical functional abnormalities. since rv function is an imortant arameter in cardiac disease a diagnostic of this dysfunction at an early stage incites to a better control of hyertension by using of drugs induce both blood ressure decrease and reduction of cardiac hyertrohy and thus avoiding rv imairment. references 1. Vakili Ba, okin PM, devereux rb. Prognostic imlications of left ventricular hyertrohy. am Heart J 2001;141: Bella Jn, Palmieri V, roman MJ, et al. Mitral ratio of eak early to late diastolic filling velocity as a redictor of mortality in middle aged and elderly adults: The strong Heart study. Circulation 2002;105: Kawut sm, Barr rg, lima Ja, et al. right ventricular structure is associated with the risk of heart failure and cardiovascular death: the Multi- ethnic study of atherosclerosis (Mesa) right ventricle study. Circulation. 2012;126: Cusidi C, sala C, Muiesan Ml,, et al. right ventricular hyertrohy in systemic hyertension: an udated review of clinical studies. J Hyertens. 2013;31: Cusidi C, negri F, giudici V, et al. Prevalence and clinical correlates of right ventricular hyertrohy in essential hyertension. J Hyertens. 2009;27: Tadic M, Cusidi C, suzic-lazic J, et al. is there a relationshi between right- ventricular and right atrial mechanics and functional caacity in hyertensive atients? J Hyertens ;32: ivanovic Ba, Tadic MV, Celic VP. To di or not to di? The unique relationshi between different blood ressure atterns and cardiac function and structure. J Hum Hyertens. 2013;27: schermuly rt, ghofrani Ha, Wilkins Mr, grimminger F. Mechanisms of disease: ulmonary arterial hyertension. nat rev Cardiol. 2011;8: Buckberg gd, Hoffman Ji, Coghlan HC.Ventricular structure- function relations in health and disease: Part i. The normal heart. eur J Cardiothorac surg. 2015;47: [ -Clyne Ca, alert Js, Benotti Jr. interdeendence of the left and right ventricles in health and disease. am Heart J 1989;117: Ferlintz J. right ventricular erformance in essential hyertension. Circulation. 1980;61: Todiere g, neglia d, ghione s, et al. right ventricular remodelling in systemic hyertension: a cardiac Mri study. Heart. 2011;97: Tadic M1, Cusidi C2, Bombelli M. right heart remodeling induced by arterial hyertension: Could strain assessment be helful J Clin Hyertens (greenwich) Feb;20(2): doi: /jch eub 2018 Jan Kaul s, Tei C, Hokins JM, shah PM. assessment of right ventricular function using two dimensional echocardiograhy. am Heart J 1984; 128: Cicala s, galderisi M, Caso P, et al. right ventricular diastolic dysfunction in arterial systemic hyertension: analysis by ulsed tissue doler. eur J echocardiogr. 2002;3: Pedrinelli r, Canale Ml, giannini C. abnormal right ventricular mechanics in early systemic hyertension: a two- dimensional strain imaging study. eur J echocardiogr. 2010;11: Hanboly nh. right ventricle morhology and function in systemic hyertension. nig J Cardiol. 2016;13: gregori M, Tocci g, giammarioli B, et al.. abnormal regulation of renin angiotensin aldosterone system is associated with right ventriculardysfunction in hyertension. Can J Cardiol. 2014;30: Tadic M, Cusidi C, Pencic B, relationshi between right ventricular remodeling and heart rate variability in arterial hyertension. J Hyertens. 2015;33: Tadic M, ivanovic B. Why is functional caacity decreased in hyertensive atients? From mechanisms to clinical studies. J Cardiovasc Med (Hagerstown). 2014;15: Tumuklu MM, erkorkmaz u, ocal a. The imact of hyertension and hyertension- related left ventricle hyertrohy on right ventricle function. echocardiograhy. 2007;24:374- Cardiologie Tunisienne 120