Relationship between total ejection isovolume index and neurohormonal effects in patients with essential hypertension

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POSTERS: Heart Failure/Hypertrophy

forward and backward waves to be distinguished at any site. It has been proposed that wave reflection is increased in heart failure (HF). 24 patients with Class II-III heart failure (mean age 66⫾8yrs) were studied. The group was subdivided into hypertensives (HT: 130⫾19/72⫾13) and non-hypertensives (NT: 114⫾18/65⫾9 mmHg). Carotid flow and BP were measured by pulsed Doppler U/S and arterial tonometry. Brachial BP and ejection fraction (EF) were also measured. Carotid pulse wave velocity (c), dI, augmentation index (AI) and wave reflection were calculated. Data are means ⫾ SD, p was calculated using Student’s t-test. Despite similar EF [31⫾9 (HT); 30⫾14% (NT)], dI⫹c1, a measure of ventricular wave power, did not differ between the groups [219⫾110(HT); 177⫾124 mWm-2 (NT)]. AI was markedly increased in HT [18.6⫾12.6(HT); 1.7⫾4.1% (NT)p⬍0.01]. Cerebral reflection was similar in both groups [17.2⫾7.1(HT); 18.1⫾8.6% (NT)], but reflection from the body was significantly increased in HT [14.1⫾16.4(HT), 4.7⫾4.7 (NT), p⬍0.01]. c did not differ significantly [13.5⫾6.2 (HT); 10.9⫾5.0 ms-1 (NT)]. These data show that heart failure patients are not homogeneous in terms of wave reflection patterns. Co-existing hypertension is associated with an additional burden on the heart due to wave reflection from the periphery. In contrast the reflection pattern from the cerebral circulation is not affected by hypertension. Differing categories of heart failure may benefit from specifically tailored therapy. Key Words: heart failure, wave intensity analysis, hypertension

P-535 RELATIONSHIP BETWEEN LEFT VENTRICULAR MASS AND 24 HOUR BLOOD PRESSURE PROFILES IN BLACK-AFRICAN PATIENTS WITH SEVERE HYPERTENSION Ivo V. Radevski, E. Libhaber, G. P. Candy, Z. P. Valtchanova, P. Sareli. 1Department of Cardiology, Chris Hani-Baragwanath Hospital, Bertsham, South Africa The relationship between left ventricular mass (LVM) and ambulatory blood pressure (ABP) profiles has not been investigated in black African patients with severe hypertension. Fifty nine patients Black patients with ambulatory day diastolic blood pressures (DBP) ⱖ110 and ⱕ140mm Hg with echocardiographic determined LVM, received either nisoldipine (n⫽30; 40 mg once daily) or enalapril (n⫽29; 40mg/D) for 2 months in a double blind randomised trial. The patients (33 female) aged (46⫾9 years; BSA (1.8⫾0.2 kg/m2)) had baseline mean 24h ambulatory BP 180⫾13/118⫾6 mm Hg. Patients receiving nisoldipine (NP) decreased mean 24h ABP (180⫾12/119⫾7 mm Hg to 143⫾15/94⫾9 mm Hg) and LVM index (LVMI 146⫾41 to 124⫾34g/m2) significantly. In contrast, those receiving enalapril a modest decrease in mean 24h ABP (179⫾14/117⫾5 mm Hg to 169⫾19/110⫾12 mm Hg; p⬍0.001 for change in SBP and DBP compared to NP) was without regression of the LVMI (139⫾38 to 139⫾49 g/m2; p⬍0.002 for the change compared to NP). For the whole group, a stepwise regression model for baseline LVM showed age, gender, 24h SBP (but not 24h DBP) and body weight to be predictors of LVM (R2⫽0.49; p⬍0.0001). The degree of change in LVMI correlated with degree of change in the 24h, daytime and nighttime SBP profiles (r⫽0.28, 0.33 and 0.27 respectively; all p⬍0.05). There was no correlation between the corresponding DBP profiles and the degree LVMI regression. In conclusion, 24h SBP but not 24h DBP, is a strong predictor of LVM in black African patients with severe hypertension and the degree of LVMI regression correlated with degree of change in SBP but not DBP profiles. Key Words: left ventricular hypertrophy, Severe Hypertension, Left Ventricular Mass Regression

AJH–April 2001–VOL. 14, NO. 4, PART 2

P-536 UTILITY OF BNP AS A BIOMARKER FOR ASSESSING FUNCTIONAL CLASS DURING THERAPY IN A HEART FAILURE SPECIALTY CLINIC Shang C. Lee, Tracy L. Stevens, Sharon M. Sandberg, Denise M. Heublein, Susan M. Nelson, Douglas W. Mahoney, Michihisa Jougasaki, Margaret M. Redfield, John C. Burnett. 1Internal Medicine, Mayo Clinic, Rochester, MN, United States Although studies have suggested that circulating levels of the biologically active C-terminal ANP and the biologically inactive N-terminal ANP and BNP have diagnostic utility in the detection of left ventricular systolic dysfunction, no studies have directly assessed the relative value of these peptides prospectively in monitoring functional class of patients undergoing treatment over time for congestive heart failure (CHF). Further, value of the natriuretic peptides as compared to non-invasive measurement of left ventricular ejection fraction (LVEF) in assessing symptom status during treatment of CHF also has not been reported. The current study was designed to compare the utility of plasma ANP (both C-terminal ANP and N-terminal ANP) and plasma BNP as well as LVEF in assessing NYHA Class I-IV during the outpatient treatment of CHF. Ninety-eight subjects with known CHF were evaluated. Baseline LVEF measured with echocardiography and natriuretic peptides measured with radioimmunoassay were obtained. NYHA class was determined independently by attending HF specialists. Forty-one subjects were re-studied during a 6-12 month follow-up period during which drug therapy was optimized. At baseline, all natriuretic peptides and LVEF correlated positively with NYHA class (P ⬍ 0.005). Plasma BNP however was a more sensitive and specific marker for NYHA class when compared to LVEF or the other natriuretic peptides by ROC analysis. At follow-up, only changes of BNP, not LVEF nor the other natriuretic peptides, correlated to changes of NYHA class after optimizing therapy (P ⫽ 0.04). When comparing the two visits, BNP decreased (-45% ⫾ 12%, N ⫽ 14, P ⫽ 0.002) in subjects whose NYHA class improved while BNP remained unchanged (-1% ⫾ 10%, N ⫽ 25, P ⫽ 0.95) in those whose NYHA class remained stable. There was no change in LVEF in those whose NYHA class improved or remained unchanged (⫹40% ⫾ 22%, P ⫽ 0.09 and ⫹14% ⫾ 10%, P ⫽ 0.20, respectively). This investigation demonstrates the superiority of plasma BNP compared to C-terminal ANP, N-terminal ANP or LVEF by echocardiography in assessing NYHA class. In addition, this study importantly documents that plasma BNP is a more sensitive biomarker than ANP and LVEF by echocardiography in the follow up of patients undergoing therapy for CHF. Plasma BNP can be a useful tool in managing CHF patients. Key Words: Natriuretic Peptides, Heart Failure, Biomarker

P-537 RELATIONSHIP BETWEEN TOTAL EJECTION ISOVOLUME INDEX AND NEUROHORMONAL EFFECTS IN PATIENTS WITH ESSENTIAL HYPERTENSION Tomohiko Shigemasa, Eiji Miyajima, Kazuo Kimura, Osamu Tochikubo, Satoshi Umemura. 1Cardiovascular Center, Yokohama City University, School of Medicine, Yokohama, Kanagawa, Japan It is known that left ventricular diastolic dysfunction is preliminary to systolic dysfunction in patients with essential hypertension (EH). The purpose of this study was to examine the relationship between the a Doppler-derived index (total ejection isovolume index : TEI index) of combined systolic and diastolic myocardial performance and neurohormonal effects or circadian blood pressure (BP) changes in patients with EH. We examined ambulatory 24-hour BP and echocardiography in 52 untreated patients with EH (53⫾2⬍SE⬎ y; 30 men and 22 women). TEI index was univariately significantly related to nighttime mean BP (r⫽0.44, p⬍0.005) and left ventricular mass index (r⫽0.49, p⬍0.001). Furthermore, 20 inpatients (53⫾3 y; 15 men and 5 women) of 52 with

AJH–April 2001–VOL. 14, NO. 4, PART 2

POSTERS: Heart Failure/Hypertrophy

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EH were also examined plasma (PNE) and urinary norepinephrine (UNE), plasma renin activity (PRA), plasma aldosterone concentration (PAC) after ingested a diet of 7g salt (NaCl) per day for a week. By multiple regression analysis, TEI index was significantly related to PAC as an independent variable (R2⫽0.40, p⬍0.005) but not to nighttime mean BP, PRA, PNE, and UNE. Since TEI index was significantly related to nighttime mean BP, it was suggested that TEI index would be useful for an index of the severity of hypertensive target organ damage. Moreover, since TEI index was strongly related to PAC rather than BP, PAC might be correlated with both left ventricular systolic and diastolic function.

is possible to achieve regression LVH, but it has not been proved what impact regression LVH has on arrhythmia markers. Methods: 75 patients with II-III stage hypertension (43 male) average age 55.9 ⫾ 8 and LVH determinated by echocardiography have been treated for a year. Arrhythmia parameters were the following: ventricular arrhythmias have been registered after 24 hour Holter monitoring and graded according to Lown; QT dispersion and heart rate variability (HRV) have been determined by time analysis from Holter monitoring. Results: After a year treatment a significant LV mass reduction (A) has been achieved in 37 patients (51%). Variable

Before Th

After Th

Key Words: total ejection isovolume index, left ventricular hypertrophy, aldosterone

LVMI (A) (g/m2) LVMI (B) (g/m2) VES (Lown) (A) VES (Lown) (B) VT and couplets (A) VT and couplets (B) QTc dispersion (A) QTc dispersion (B) SDNN (A) SDNN (B)

172 ⫾ 35.6 152.6 ⫾ 21.3 2.88 ⫾ 1.37 2.21 ⫾ 1.7 15 (20.5%) 9 (12.3%) 61.7 ⫾ 22.4 48.5 ⫾ 21.7 123.3 ⫾ 26 116.5 ⫾ 22.2⫾

142.1 ⫾ 25* 158.7 ⫾ 25.8 2 ⫾ 1.4* 2.1 ⫾ 1.48 6 (8.2%)* 7 (9,6%) 48.3 ⫾ 17.7* 50.8 ⫾ 21.2 129.3 ⫾ 29.1 118.4 ⫾ 23.4

P-538 ASSOCIATION BETWEEN CIRCULATING OXIDIZED LOW DENSITY LIPOPROTEIN LEVELS AND LEFT VENTRICULAR HYPERTROPHY IN PATIENTS WITH ESSENTIAL HYPERTENSION Minoru Takaoka, Shigeru Yamano, Yuta Yamamoto, Rie Sasaki, Kazuhiro Dohi. 1First Department of Internal Medicine, Nara Medical University, Kashihara, Nara, Japan [Purpose] Oxidative stress plays an important role in the pathogenesis of vascular injury and in the progression of atherosclerosis. Elevated levels of oxidized low density lipoprotein (OxLDL) have been reported to be a risk factor for coronary artery disease. We investigated the potential association between circulating OxLDL levels and left ventricular hypertrophy in patient with essential hypertension. [Methods] Thirty hypertensive patients ( 14 men and 16 women, mean age, 63years) were enrolled in this study. Left ventricular hypertrophy was evaluated with M-mode echocardiographic measurements of the left ventricle, as left ventricular mass index (LVMI). Common carotid artery vascular mass (VM) was also calculated as ( ␳L␲ { (CAD/2⫹IMT)2(CAD/2)2} ). CAD : vessel diameter of the common carotid artery, IMT : intima-media thickness ). Circulating OxLDL levels were measured by an enzyme immunoassay with use of specific antibodies against OxLDL ( FOH1a / DLH3 ) and apolipoprotein B. [Results] Circulating OxLDL levels were significantly higher in hypertensive patients with left ventricular hypertrophy than in those without left ventricular hypertrophy ( LVH 28.0⫾9.7 U/ml, non-LVH 21.5⫾9.0 ; p⫽0.03 ). Multiple regression analysis showed that the risk factors for LMVI in patients with essential hypertension were circulating OxLDL levels and VM. (p⫽0.01) [Conclusions] These results indicate that circulating OxLDL levels may be an independent risk factor for left ventricular hypertrophy in patients with essential hypertension. Key Words: oxidized low density protein, left ventricular hypertrophy, carotid artery vascular mass

P-539 IS THE REGRESSION OF LEFT VENTRICULAR HYPERTROPHY ACCOMPANIED BY THE DECREASE OF VENTRICULAR ARRHYTHMIAS? Ivan S. Tasic, Branko K. Lovic, Stevan B. Ilic, Dragan Lj Djordjevic, Natasa L. Miladinovic-Tasic. 1Cardiology, Institute “Niska Banja”, Niska Banja, Serbia, Yugoslavia, 2Cardiology, Institute “Niska Banja”, Niska Banja, Serbia, Yugoslavia, 3Cardiology, Institute “Niska Banja”, Niska Banja, Serbia, Yugoslavia, 4Cardiology, Institute “Niska Banja”, Niska Banja, Serbia, Yugoslavia, 5 Cardiology, Institute “Niska Banja”, Niska Banja, Serbia, Yugoslavia

*p⬍0.05; A: patients with significant LV mass reduction; B: patients with non significant LV mass reduction Conclusion: In patients with significant LV mass reduction significant decrease of ventricular arrhythmias frequency and QT dispersion have been achieved while heart rate variability has improved but not significantly. Key Words: hypertrophy, hypertension, arrhythmias

P-540 UTILITY OF PERINDOPRIL IN HEART FAILURE IN DAILY CLINICAL PRACTICE. THE METRICA STUDY Vivencio Barrios, Federico Lombera, Yolanda Peralta, Luis M. Ruilope. 1METRICA Investigators, Spain Despite the overwhelming evidence of ACE inhibitors (ACEi) in heart failure (HF), the usage of these drugs in clinical practice very often differs from scientific evidence. In fact, patients very rarely achieved the ACEi dosage recommended from randomized clinical trials. In this concern, the different ACEi exhibit significant differences in the feasibility to attain their maximal effective doses. With the aim to evaluate the rate of patients who achieve the effective dose of perindopril in HF and to assess the clinical and radiological efficacy of this ACEi in daily practice, a prospective, multicentre open study called METRICA was designed. This study included patients with HF class I-III, ACEi naive for at least 15 days, no contraindications for ACEi and with informed consent. Patients were initially treated with perindopril 2 mg and at 15 days whether the clinical and analytical tolerability was adequate, the ACEi was titrated to the effective dose (4 mg). Clinical, radiological and analytical follow up was performed at 1, 3 and 6 months. 175 patients (age: 65.8⫾9; 66% males) with HF (5% class I, 63% class II and 32% class III) were included. In 43% HF was due to IHD. 87.5% of patients achieved the effective dose (4 mg); 75% at the first month. 41 of 107 (38%) in class II and 49 of 55 (89%) in class III improved their clinical status. At final visit 33% of patients were in class I, 64% in II, and only 3% in III and the radiological cardio-thoracic index reduced from 0.57 to 0.54 (p⬍0.05). Side effects were observed in 22%, being cough the most frequent (11%). Only 3 patients (1.7%) withdrew. No serious adverse event was observed. In conclusion, in daily clinical practice the great majority of patients with HF (class I-III) achieve the effective dose of perindopril, what could be very useful. The clinical and radiological efficacy and the good tolerability of this drug have been confirmed in this study. Grant/Research Support - Servier

The increase of arrhythmia of hypertensive left ventricular hypertrophy is correlated with the risk of sudden death. In antihypertensive treatment it

Key Words: Heart Failure, Perindopril, ACE inhibitors dosage