Determinants of ascending aorta dilation in essential hypertension

Transcription

1 ΜΟΝΑΔΑ ΠΡΟΛΗΠΤΙΚΗΣ ΚΑΡΔΙΟΛΟΓΙΑΣ ΚΑΙ ΑΝΤΙΥΠΕΡΤΑΣΙΚΟ ΙΑΤΡΕΙΟ ΚΑΡΔΙΟΛΟΓΙΚΟΥ ΤΜΗΜΑΤΟΣ Γ.Ν.Α ΙΠΠΟΚΡΑΤΕΙΟ Determinants of ascending aorta dilation in essential hypertension Ι. Μπαμπάτσεβα-Βαγενά, Ε. Χατζησταματίου, Δ. Κωνσταντινίδης, Κ. Μανάκος, Γ. Μέμο, Γ. Μουστάκας, Κ. Τραχανάς, Ε. Βέργη, Α. Φερέτου, Ι. Μπαφάκης, Α. Αυγεροπούλου, Ι. Καλλικάζαρος

2 MALES FEMALES Determinants of Aortic Diameter Laurence Campens et al. Am J Cardiol 2014;114:914

3

4 Prevalence of Ascending aortic dilatation in essential hypertension 18% 16,90% 16% 14% 12% 12,50% 10% 8% 6% 8,30% 8,50% 6,20% 5,20% Male Female 4% 2% 2,00% 3,10% 0% Palmieri V et al (2001 Cuspidi C et al (2006) Cuspidi C et al (2010) Milan A et al (2013)

5 Objective To assess the prevalence and to evaluate the determinants of AAD in newly hypertensive never treated patients.

6 Design and Methods We studied 780 consecutive newly diagnosed hypertensive patients. (51±13 years, 45% females). Detailed personal and familial history. Physical examination of the cardiovascular system. Anthropometric measurements. Glycemic and lipidemic profile. Thyroid gland function. Office BP, ABPM, HBPM Carotid and renal arteries DUPLEX. Kidney u/s cf-pwv and using Sphygmocor ACR. Full 2D, Doppler and TDI echocardiographic study, including ascending aorta diameter.

7 Exclusion Criteria Hypertensive patients under treatment more than 3 months. Secondary Hypertension (SAS and thyroid dysfunction included). Drugs White coat Hypertension DM type I and II Familial Dyslipidemia Autoimmune, Inflammatory and Malignant Diseases Pregnancy and feeding More than mild AoV disease and BAV Connective tissue diseases i.e Marfan syndrome.

8 End-diastolic leading edge to leading edge convention AA Diameter 35 mm AA Diameter >35 mm Normal AA, n=550 Dilated AA, n=230

9 Prevalence = 30% DAA (n= 230) 82 (10%) 148 (19%) Male Female

10 Characteristics by AA Diameter NAA (n=550) DAA (n=230) , P<0.001 P< ,4 35,7 P=0.002 P= ,6 53,5 40,2 42,2 P= ,4 56,9 71, ,8 10,3 9,8 4,

11 Characteristics by AA Diameter 10 NAA (n=550) DAA (n=230) ,1 8, , , ,13 1,16 0 E/A ratio TDI e/a ratio CVD risk factors PWV,m/sec TODs ABI

12 100 P< Office HR bpm 24h HR bpm Day HR bpm Night HR bpm 0 Normal AA Dilated AA

13 Correlations of DAA 0,35 0,3 0,271 0,305 p<0.001 for all r 0,25 0,2 0,15 0,225 0,144 0,201 0,191 0,154 0,164 0,182 0,159 0,147 0,1 0,05 0-0,05 Age Male gender Carot. Plaque BMI Waist Circ Hip Circ Abd.Obes Alc. Cons U.A HDL PLTs Folic Acid Homocys. -0,1-0,15-0,125-0,103

14 Correlations of DAA 0,3 p<0.001 for all 0,237 0,2 0,1 0,16 0,198 0,141 0,141 0,188 0,138 0,188 0,105 0,127 0,203 0,183 0,199 0,146 r 0-0,1-0,138-0,2-0,198-0,3-0,298-0,4

15 Multivariate Logistic regression OR 95% CI P value Age <0.001 Male gender <0.001 BMI Alcohol Intermediate consumption Heavy consumption Heart Rate 24hr ABPM Males*Intermediate alcohol consumption Males*Heavy alcohol consumption <0.001

16 Conclusions Ascending aorta dilation is already present in one third of newly diagnosed essential hypertensive patients. Older age, male gender, high alcohol intake and BMI are independent predictors of this condition, with increased heart rate to possess beneficial effects, probable due to diminished stroke volume and cyclic aortic expansion.

17 ΣΑΣ ΕΥΧΑΡΙΣΤΩ

18

19 What Is New in Dilatation of the Ascending Aorta? Review of Current Literature and Practical Advice for the Cardiologist L.. Cozijnsen et al. Circulation. 2011;123:

20 What Is New in Dilatation of the Ascending Aorta? Review of Current Literature and Practical Advice for the Cardiologist L.. Cozijnsen et al. Circulation. 2011;123:

21 Upper Normal Limits: 2.1cm/m 2 vs. (F <35mm, M<40mm) 4.7% DAA (n=36) DAA: 9.3% NAA 3.09±0.41 (Range: ) NAA: 2.2% 4.0cm DAA 3.77±0.37 (Range: ) DAA: 63.9% <4.0cm, 36.1% 4.0cm Females: DAA: 14.7% Males: DAA: 4.8%

22 Evangelista A et al. Eur J Echocardiogr 2010;11:

23 Aortic Root Remodeling Over the Adult Life Course: Longitudinal Data from the Framingham Heart Study. Carolyn S.P. Lam et al. Circulation August 31; 122(9):

24 NAA (n=550) DAA (n=230) p value Age, years 49±13 56±11 <0.001 Female gender,% <0.001 BMI, kg/m 2 28±5 29± Waist circumference, cm 94±13 99±11 <0.001 Abdominal obesity, % Prediabetes, % Alcohol: light/moderate/heavy 85.2/10.3/ /18.8/9.8 <0.001 Snoring, % GFR CKD-EPI, ml/min 90±17 87± PWV, m/sec 8.1± ±1.8 <0.001 PP Amplification, % 129±18 123± Central Pulse period 884± ± Central diastolic duration 561± ± Central Ejection duration to period 37±4 35± Central Diastolic Duration to period 63±4 65± Heart rate, bpm 71±12 68±11 <0.001 Aorta Systolic-Diastolic difference 0.15 ( ) 0.19 ( ) Ejection Fraction, % 66±6 65± LVMi (indexed to height 2.7 ) 39±9 43±10 <0.001 Transmitral E/A ratio 1.16±0.4 1±0.34 <0.001 IVRT, msec 95±20 99± LAVI max 26±8 29±8 <0.001 TDI Em/Am ratio 1± ±0.22 <0.001 E/Em ratio 7.5± ± Left Ventricular Diastolic Dysfunction, % <0.001 Carotid IMT, mm 0.69± ± Carotid Plaques, % Ankle Brachial Index 1.13± ± Office HR, bpm 80±12 75±12 <0.001 Morning Surge, mmhg 23 (15-31) 25 (17-34) hr HR, bpm 75±9 71±8 < hr HR SD 9.8 (8-12) 9 (7-11) hr HR day, bpm 78±9 74±9 < hr HR SD 8.6 (7-10.6) 8 (6.5-10) hr HR night, bpm 66±9 63± Number of CVD risk factors 2 (2-3) 3 (2-4) <0.001 Number of TODs 1 (0-1) 1 (0-2) <0.001 TST maximum achieved heart rate 164 ( ) 157 ( ) 0.021

25 Correlations of DAA r p value Age <0.001 Male Gender <0.001 BMI <0.001 Waist circumference <0.001 Abdominal obesity <0.001 Metabolic syndrome Impaired Glucose metabolism Alcohol consumption <0.001 Snoring Smoking duration GFR CKD-EPI Uric acid <0.001 Triglycerides HDL-cholesterol Homocysteine Flow mediated dilation Pulse Wave Velocity <0.001 Pulse pressure amplification ratio radial to central Central Diastolic time index <0.001 SEVR <0.001 Central pulse period Central diastolic duration <0.001 Central Ejection duration to <0.001 period Central diastolic duration to <0.001 period Central SAP Heart rate <0.001 Aortic diameter Systolic- Diastolic difference Correlations of DAA r p value Ejection fraction <0.001 LVMi (indexed to height 2.7 ) <0.001 Transmitral E/A ratio <0.001 IVRT Velocity propagation, Vp LAVI max <0.001 E/Em ratio <0.001 TDI Em/Am ratio <0.001 Left Ventricular Diastolic <0.001 Dysfunction Carotid IMT Carotid plaques <0.001 Ankle Brachial Index <0.001 Office SAP Office DAP <0.001 Office HR < hr DAP hr HR < hr HR SD < hr HR day < hr HR day SD hr DAP night hr HR night < hr HR night SD <0.001 ESH risk category <0.001 Number of risk factors <0.001 Number of TODs <0.001 Blood Pressure severity <0.001

26 Aortic root dilatation in hypertensive patients: a multicenter survey in echocardiographic practice. Blood Press Oct;20(5): BACKGROUND AND AIM: Aortic root dilatation (ARD) is a cardiovascular phenotype of adverse prognostic value; its prevalence has been mostly investigated in population-based samples and selected hypertensive cohorts. Data from clinical practice are rather scant. Thus, we examined the prevalence and correlates of ARD in a large sample of hypertensive patients referred by general practitioners for a routine echocardiographic examination. METHODS: A total of 2229 untreated and treated hypertensive subjects (mean age 62 years) referred to 17 outpatient echocardiographic laboratories across Italy for detection of hypertensive subclinical cardiac damage were included in the study. ARD was defined by aortic diameter exceeding 3.7 cm in women and 3.9 cm in men. RESULTS: ARD was found in 263 patients, with an overall prevalence of 11.8% (16.9% in men and 6.2% in women, p < 0.05). In multivariate regression analyses, body surface area (BSA), left ventricular (LV) mass and age were in ranking order the most important correlates of aortic root size in the whole population study as well as in men. In women, LV mass and its derivative indexes were the most important independent variables associated to aortic root size. CONCLUSIONS: This multicenter nationwide survey indicates that ARD is a frequent cardiovascular phenotype in hypertensives referred to echo-labs for detection of hypertensive organ damage. BSA, LV mass and age are the most important correlates of this phenotype. The hierarchical order of these factors differs between genders, LV mass being the strongest independent variable in women.

27 Prevalence and correlates of aortic root dilatation in patients with essential hypertension: relationship with cardiac and extracardiac target organ damage. J Hypertens Mar;24(3): OBJECTIVE: To assess the prevalence of aortic root dilatation in a large cohort of uncomplicated hypertensive patients and to evaluate the relations of aortic root size to different markers of cardiac and extracardiac target organ damage (TOD). METHODS: A total of 3366 untreated and treated essential hypertensive patients (mean age, 53 +/- 12 years) consecutively attending our out-patient hypertension clinic and included in the Evaluation of Target Organ Damage in Hypertension (an observational ongoing registry of hypertension-related TOD) were considered for this analysis. All patients underwent routine examinations, 24-h urine collection for microalbuminuria, echocardiography and carotid ultrasonography. RESULTS: Aortic root dilatation, defined by the sex-specific echocardiographic criteria of 40 mm in men and 38 mm in women, was present in 8.5% of men and in 3.1% of women. Compared with 3160 patients with normal aortic size, the group of 206 patients with an enlarged aortic root was older, had higher diastolic blood pressure values and included a greater fraction of subjects under antihypertensive treatment, with type 2 diabetes and metabolic syndrome. The prevalence of left ventricular hypertrophy, carotid intima-media thickening, plaques and microalbuminuria was significantly higher in patients with aortic root dilatation. According to a logistic regression analysis, left ventricular hypertrophy, carotid atherosclerosis, overweight and metabolic syndrome were the main independent and potentially modifiable predictors of aortic root dilatation in the whole hypertensive population as well as in untreated and treated hypertensive patients separately. CONCLUSIONS: Our study shows that hypertensive patients with aortic root enlargement have more pronounced alterations in cardiac structure and geometry as well as in carotid artery morphology compared with those without the enlargement. Aortic root dilatation therefore appears to be a useful marker of high cardiovascular risk related to TOD. Whether this alteration independently predicts cardiovascular morbidity remains to be proven.

28 Ascending aortic dilatation, arterial stiffness and cardiac organ damage in essential hypertension. Jan;31(1): Milan A et al. J Hypertens. 2013

29 Distribution, Determinants, and Normal Reference Values of Thoracic and Abdominal Aortic Diameters by Computed Tomography (From the Framingham Heart Study) Age (years) Ascending (mean AA) Women Mean ± SD (95% CI) Men Mean ± SD (95% CI) < ± 2.1 ( ) 15.4 ± 1.6 ( ) ± 2.1 ( ) 16.3 ± 1.8 ( ) ± 2.4 ( ) 17.1 ± 1.8 ( ) ± 2.5 ( ) 18.4 ± 2.0 ( ) Ian S. Rogers et al. Am J Cardiol May 15; 111(10):

30 Effects of Aging and Body Size on Proximal and Ascending Aorta and Aortic Arch: Inner Edge to Inner Edge Reference Values in a Large Adult Population by Two-Dimensional Transthoracic Echocardiography. Absolute values Indexed to BSA Oana Mirea et al. Journal of the American Society of Echocardiography April 2013

31 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases.

32

33 ΜΟΝΑΔΑ ΠΡΟΛΗΠΤΙΚΗΣ ΚΑΡΔΙΟΛΟΓΙΑΣ ΚΑΙ ΑΝΤΙΥΠΕΡΤΑΣΙΚΟ ΙΑΤΡΕΙΟ ΚΑΡΔΙΟΛΟΓΙΚΟΥ ΤΜΗΜΑΤΟΣ Γ.Ν.Α ΙΠΠΟΚΡΑΤΕΙΟ Αρτηριακή υπέρταση και διάταση ανιούσας αορτής Ι. Μπαμπάτσεβα-Βαγενά1, Ε. Χατζησταματίου1, Δ. Κωνσταντινίδης1, Κ. Μανάκος1, Γ. Μέμο1, Γ. Μουστάκας2, Α. Φερέτου1, Κ. Τραχανάς1, Ο. Μητσάκης1, Α. Κασιακόγιας1, Α. Αυγεροπούλου1, Ι. Καλλικάζαρος1 1 Ιπποκράτειο Γενικό Νοσοκομείο, Καρδιολογική Κλινική, Αθήνα, 2 Σισμανόγλειο Γενικό Νοσοκομείο, Αθήνα