Morphological and functional cardiac consequences of rapid hypertension treatment: a cohort study

Background Left ventricular (LV) hypertrophy (LVH) in uncontrolled hypertension is an independent predictor of mortality, though its regression with treatment improves outcomes. Retrospective data suggest that early control of hypertension provides a prognostic advantage and this strategy is included in the 2018 European guidelines, which recommend treating grade II/III hypertension to target blood pressure (BP) within 3 months. The earliest LVH regression to date was demonstrated by echocardiography at 24 weeks. The effect of a rapid guideline-based treatment protocol on LV remodelling, with very early BP control by 18 weeks remains controversial and previously unreported. We aimed to determine whether such rapid hypertension treatment is associated with improvements in LV structure and function through paired cardiovascular magnetic resonance (CMR) scanning at baseline and 18 weeks, utilising CMR mass and feature tracking analysis. Methods We recruited participants with never-treated grade II/III hypertension, initiating a guideline-based treatment protocol which aimed to achieve BP control within 18 weeks. CMR and feature tracking were used to assess myocardial morphology and function immediately before and after treatment. Results We acquired complete pre- and 18-week post-treatment data for 41 participants. During the interval, LV mass index reduced significantly (43.5 ± 9.8 to 37.6 ± 8.3 g/m2, p < 0.001) following treatment, accompanied by reductions in LV ejection fraction (65.6 ± 6.8 to 63.4 ± 7.1%, p = 0.03), global radial strain (46.1 ± 9.7 to 39.1 ± 10.9, p < 0.001), mid-circumferential strain (− 20.8 ± 4.9 to − 19.1 ± 3.7, p = 0.02), apical circumferential strain (− 26.0 ± 5.3 to − 23.4 ± 4.2, p = 0.003) and apical rotation (9.8 ± 5.0 to 7.5 ± 4.5, p = 0.003). Conclusions LVH regresses following just 18 weeks of intensive antihypertensive treatment in subjects with newly-diagnosed grade II/III hypertension. This is accompanied by potentially advantageous functional changes within the myocardium and supports the hypothesis that rapid treatment of hypertension could improve clinical outcomes. Trial registration: ISRCTN registry number: 57475376 (assigned 25/06/2015).

Left Ventricular Systolic Function Has Strong Independent Genetic Background from Diastolic Function: A Classical Twin Study

Background and Objectives: No data are available on whether the heritability of left ventricle (LV) systolic and diastolic parameters are independent of each other. Therefore, our aim was to assess the magnitude of common and independent genetic and environmental factors defining LV systolic and diastolic function. Materials and Methods: We analyzed 184 asymptomatic twins (65% female, mean age: 56 ± 9 years). Transthoracic echocardiography was performed to measure LV systolic (global longitudinal and circumferential strain; basal and apical rotation) and diastolic (early diastolic velocity of mitral inflow and lateral mitral annulus tissue; deceleration time and early diastolic strain rate) parameters using conventional and speckle-tracking echocardiography. Genetic structural equation models were evaluated to quantify the proportion of common and specific genetic (Ac, As) and environmental factors (Ec, Es) contributing to the phenotypes. Results: LV systolic parameters had no common genetic or environmental heritability (Ac range: 0–0%; Ec range: 0–0%; As range: 57–77%; Es range: 24–43%). Diastolic LV parameters were mainly determined by common genetic and environmental effects (Ac range: 9–40%; Ec range: 11–49%; As range: 0–29%; Es range: 0–51%). Systolic parameters had no common genetic or environmental factors (Ac = 0%; Ec = 0%) with diastolic metrics. Conclusions: Systolic LV parameters have a strong genetic predisposition to any impact. They share no common genetic or environmental factors with each other or with diastolic parameters, indicating that they may deteriorate specifically to given effects. However, diastolic functional parameters are mainly affected by common environmental influences, suggesting that pathological conditions may deteriorate them equally. Estimation of the genetic and environmental influence and interdependence on systolic and diastolic LV function may help the understanding of the pathomechanism of different heart failure classification types.

Differences in Left Ventricular Function at Rest and during Isometric Handgrip Exercise in Elite Swimmers, Water Polo Players, and Artistic Swimmers

Purpose: Elite swimmers (SW) have reduced diastolic function compared to elite runners, possibly as an adaptation to the aquatic training environment. Water polo players (WP) and artistic swimmers (AS) are exposed to the same hydrostatic pressures as SW, but are subject to different training intensities, postures, and hemodynamic stressors. Our purpose was to compare resting and exercising cardiac function in elite SW, WP, and AS, to characterize the influence of training for aquatic-sport on left ventricular (LV) adaptation.Methods: Ninety athletes (SW:20M/17F; WP:21M/9F; AS:23F) at the 2019 FINA World Championships volunteered for resting and stress (3min 30% maximal isometric handgrip) echocardiographic assessment of LV global function and mechanics. Results: Male SW displayed improved resting systolic and diastolic function compared to WP; however, both groups maintained stroke volume under high-pressure handgrip stress (SW:∆-4±12%; WP:∆-1±13%, P=0.11). There were no differences between female SW and WP resting LV function, but SW demonstrated improved function over AS. During isometric handgrip, all female sport athletes maintained stroke volume (SW:∆3±16%; WP:∆-10±11%; AS:∆-2±14%, P=0.46), but WP had improved apical rotation (∆1.7±4.5°), which was reduced in AS (∆-3.1±4.5°) and maintained in SW (∆-0.5±3.8°, P=0.04). Unlike SW and WP, AS displayed a unique maintenance of early filling velocity during handgrip exercise (SW:∆-3.5±14.7cm/s; WP:∆-15.1±10.8cm/s; AS:∆1.5±15.3cm/s, P=0.02).Conclusion: Among male athletes, SW display primarily volume-based functional adaptations distinct from the mixed volume-pressure adaptations of WP; however, both groups can maintain stroke volume with increased afterload. Female SW and WP do not demonstrate sport-specific differences like males, perhaps owing to sex-differences in adaptation, but have greater volume-based adaptations than AS. Lastly, AS display unique functional adaptations, that may be driven by elevated pressures under low-volume conditions.

The Role of Speckle Tracking Echocardiography in the Evaluation of Common Inherited Cardiomyopathies in Children and Adolescents: A Systematic Review

Speckle tracking echocardiography (STE) has gained importance in the evaluation of adult inherited cardiomyopathies, but its utility in children is not well characterized. We conducted a systematic review to evaluate the role of STE in pediatric inherited cardiomyopathies. PubMed, EMBASE, Web of Science, Scopus, CENTRAL and CINAHL databases were searched up to May 2020, for terms related to inherited cardiomyopathies and STE. Included were dilated cardiomyopathy (DCM), hypertrophic cardiomyopathy (HCM), left ventricular non-compaction (LVNC) and arrhythmogenic cardiomyopathy (ACM). A total of 14 cohorts were identified, of which six were in DCM, four in HCM, three in LVNC and one in ACM. The most commonly reported STE measurements were left ventricular longitudinal strain (Sl), circumferential strain (Sc), radial strain (Sr) and rotation/torsion/twist. Sl, Sc and were abnormal in all DCM and LVNC cohorts, but not in all HCM. Apical rotation and twist/torsion were increased in HCM, and decreased in LVNC. Abnormal STE parameters were reported even in cohorts with normal non-STE systolic/diastolic measurements. STE in childhood cardiomyopathies can detect early changes which may not be associated with changes in cardiac function detectable by non-STE methods. Longitudinal and circumferential strain should be introduced in the cardiomyopathy echocardiography protocol, reflecting current practice in adults.

Impact of Right Ventricular Function on Left Ventricular Torsion and Ventricular Deformations in Pulmonary Artery Hypertension Patients

Introduction: Ventricular interdependence in pulmonary arterial hypertension (PAH) by the use of most recent echocardiographic techniques are still rare. The current case-controlled study aims to assess left ventricular (LV) torsion in patients with PAH. Methods: The study included 42 cases of moderate to severe PAH and 42 age and gender-matched healthy controls between March 2016 and January 2018. All the patients and controls undergo routine practice echocardiography using the Vivid 7-echocardiography (2.5MHz transducer) system. Results: The LV twisting parameters, peak basal rotation, peak apical rotation, and twist were similar among both cases and controls, however, LV torsion was significantly (p=0.04) impacted. Right ventricular (RV) longitudinal deformation was clinically significant in the cases compared to controls: RV systolic strain imaging (p=0.001, 95%CI-9.75 to -2.65), RV systolic strain rate (p=0.01, 95%CI-0.99 to -0.09), and RV late diastolic strain rate (p=0.01, 95%CI-0.64 to -0.85). Although PAH did not impact longitudinal LV deformations significantly. At basal level circumferential strain and strain rate were significantly impacted (p=0.005, 95%CI-4.38 to -0.70; p=0.004, 95%CI-0.35 to -0.07) in the PAH group, while the radial strain was preserved. All RV echocardiographic parameters and LV end-diastolic dimension, LV end-systolic volume in the PAH were affected significantly (p=0.002, 95%CI-19.91 to -4.46; p=0.01, 95%CI-8.44 to -2.77). However, only a weak correlation (p=0.05, r =-0.20) was found between tricuspid annular plane systolic excursion and LV Tei index. Conclusion: RV pressure overload directly affects RV longitudinal systolic deformation further influences the interventricular septal and LV geometry, which impaired LV torsion.

Influence of curve morphology and location on the efficacy of rigid conservative treatment in patients with adolescent idiopathic scoliosis

Aims The aim of the present study was to answer the question whether curve morphology and location have an influence on rigid conservative treatment in patients with adolescent idiopathic scoliosis (AIS). Methods We retrospectively analyzed AIS in 127 patients with single and double curves who had been treated with a Chêneau brace and physiotherapeutic specific exercises (B-PSE). The inclusion criteria were the presence of structural major curves ≥ 20° and < 50° (Risser stage 0 to 2) at the time when B-PSE was initiated. The patients were divided into two groups according to the outcome of treatment: failure (curve progression to ≥ 45° or surgery) and success (curve progression < 45° and no surgery). The main curve type (MCT), curve magnitude, and length (overall, above and below the apex), apical rotation, initial curve correction, flexibility, and derotation by the brace were compared between the two groups. Results In univariate analysis treatment failure depended significantly on: 1) MCT (p = 0.008); 2) the apical rotation of the major curve before (p = 0.007) and during brace treatment (p < 0.001); 3) the initial and in-brace Cobb angles of the major (p = 0.001 and p < 0.001, respectively) and minor curves (p = 0.015 and p = 0.002); 4) major curve flexibility (p = 0.005) and the in-brace curve correction rates (major p = 0.008, minor p = 0.034); and 5) the length of the major curve (LoC) above (p < 0.001) and below (p = 0.002) the apex. Furthermore, MCT (p = 0.043, p = 0.129, and p = 0.017 in MCT comparisons), LoC (upper length p = 0.003, lower length p = 0.005), and in-brace Cobb angles (major p = 0.002, minor p = 0.027) were significant in binary logistic regression analysis. Conclusion Curve size, location, and morphology were found to influence the outcome of rigid conservative treatment of AIS. These findings may improve future brace design and patient selection for conservative treatment. Cite this article: Bone Joint J 2021;103-B(2):373–381.

Habitual Cannabis Use is Associated with Altered Cardiac Mechanics and Arterial Stiffness, but not Endothelial Function in Young Healthy Smokers

Cigarette smoking is amongst the most detrimental behaviours to cardiovascular health, resulting in arterial stiffening, endothelial dysfunction, and structural/functional alterations to the myocardium. Similar to cigarettes, cannabis is commonly smoked and next to alcohol, is the most commonly used recreational substance in the world. Despite this, little is known about the long-term cardiovascular effects of smoking cannabis. This study explored the associations of cardiovascular structure and function with cannabis use in ostensibly healthy young participants (n=35). Using echocardiography, carotid-femoral pulse wave velocity (cfPWV), and brachial flow-mediated dilation (FMD) we performed a cross-sectional assessment of cardiovascular function in cannabis users (n=18), and controls (n=17). There were no differences in cardiac morphology or traditional resting measures of systolic or diastolic function between cannabis users and controls (all p>0.05); whereas cannabis users demonstrated reduced peak apical rotation compared to controls (cannabis users: 5.5±3.8, controls: 9.6±1.5; p = 0.02). Cannabis users had higher cfPWV compared to controls (cannabis users: 5.8±0.6m/s, controls: 5.3±0.7m/s; p = 0.05), while FMD was similar between cannabis users and controls (cannabis users: 8.3±3.3%, controls: 6.8±3.6%; p= 0.7). Young, healthy, cannabis users demonstrate altered cardiac mechanics and greater aortic stiffness. Further studies should explore causal links between cannabis smoking and altered cardiovascular function.

Comparison of left ventricular rotational mechanics between term and extremely premature infants over the first week of age

ObjectiveLeft ventricle (LV) rotational mechanics is an emerging tool to characterise LV function, but warrants further evaluation in neonates. The aim of this study was to compare LV rotational mechanics between term and extremely preterm babies over the first week of age.MethodsIn this prospective study, we serially assessed LV rotational parameters in 50 term infants and compared them with a historical dataset of 50 preterm infants born <29 weeks gestation. LV basal and apical rotation, LV twist, LV twist/untwist rate and torsion were derived using two-dimensional speckle tracking echocardiography at three time points over the first week of age.ResultsThere was no change in LV twist, LV torsion, basal rotation or apical rotation in term infants over the study period (all p>0.05). LV twist and torsion were higher in preterm infants, and increased over time. In preterm infants, basal rotation evolved from anticlockwise to clockwise rotation. Apical rotation remained anticlockwise in both groups (all p>0.05). LV twist rate (LVTR) and untwist rate was higher in preterm infants and increased over the three time points (all p>0.05). There was a strong positive correlation between LV torsion and LV untwist rate (LVUTR) in the entire cohort during the third scan.ConclusionTerm infants exhibit minimal LV twist which remains unchanged over the first week of age. This is in contrast to premature infants who demonstrate increasing indices of twist, torsion, LVTR and LVUTR over the first week, likely as a compensatory mechanism for reduced LV compliance.

Can left ventricular speckle tracking imaging be used in left ventricular non-compaction cardiomyopathy screening? A study of healthy paediatric athletes with and without echocardiographic criteria

Funding Acknowledgements Type of funding sources: Other. Main funding source(s): The study was support by a contractual research partnership between the University of Bristol and Canon Medical Systems UK Background Left ventricular non-compaction (LVNC) is a rare cardiomyopathy, with hypertrabeculation often observed in athletes. In confirmed LVNC, LV systolic strain and rotational mechanics have been shown to be abnormal. Whether healthy athletes meeting echocardiographic LVNC criteria exhibit abnormal myocardial mechanics is not known. Purpose The aim of this study is to evaluate the prevalence of healthy paediatric athletes meeting the Jenni criteria for LVNC and how this relates to LV systolic function and rotational mechanics. Methods Professional athletes under 18 years undergoing comprehensive pre-participation screening (2014-2017) at two sports academies were included. Jenni criteria for LVNC were assessed from short axis LV views. Global and segmental peak systolic longitudinal (Sl) and circumferential strain (Sc), basal rotation (basal Rot) and apical rotation (apical Rot) were calculated using speckle tracking imaging. Results A total of 201 boys (11.9-18 years, median 15.1 years) were included, with diverse ethnicity (47.7% Arab, 28.5% Black, 21.8% White, and 2% other) and sports background (60% football, 21.2% athletics, 18.8% other). Of these n = 16 (8%) met the Jenni criteria for LVNC and were more likely to be of Black ethnicity than Arab or White (12.7% vs 4.4% or 9.5%). There were no differences in global, lateral or septal Sl, basal, mid or apical Sc, basal Rot or apical Rot between participants with or without Jenni criteria for LVNC (Table 1). Conclusions In healthy paediatric athletes, those meeting the criteria for LVNC (8%) do not have abnormal longitudinal, circumferential strain and rotational mechanics, compared to those without LVNC criteria. This finding supports the use of speckle tracking echocardiography as a tool in differentiating pathological changes reported in LVNC from exercise associated adaptations observed in athletes during preparticipation screening. LV mechanics Jenni criteria presence With Jenni criteria Median (IQR) Without Jenni criteria Median (IQR) p value Global LV Sl -18.6% (-19.1;-17.7) -18.6% (-19.7;-17.8) 0.7 Lateral Sl -18.3% (-18.8;-17.2) -18.5% (-19.8;-17.6) 0.5 Septal Sl -18.6% (-20.6;-17.3) -18.7% (-20.1;-17.7) 0.7 Basal LV Sc -23% (-24.6;-21.6) -23.3% (-25.7;-21.6) 0.7 Mid LV Sc -24.9% (-27.1;-23.2) -25.1% (-27.1;-22.5) 0.9 Apical LV Sc -27.8% (-32.3;-24.8) -26% (30.5;-22.4) 0.2 Basal Rot -4o (-4.7;-2.5) -3.8o (-5.3;-2.5) 0.9 Apical Rot 6.4o (5.2;7.1) 4.4 (2.9;7.1) 0.2

Comparison of different strategies on three-dimensional correction of AIS: which plane will suffer?

Purpose There are distinct differences in strategy amongst experienced surgeons from different ‘scoliosis schools’ around the world. This study aims to test the hypothesis that, due to the 3-D nature of AIS, different strategies can lead to different coronal, axial and sagittal curve correction. Methods Consecutive patients who underwent posterior scoliosis surgery for primary thoracic AIS were compared between three major scoliosis centres (n = 193). Patients were treated according to the local surgical expertise: Two centres perform primarily an axial apical derotation manoeuvre (centre 1: high implant density, convex rod first, centre 2: low implant density, concave rod first), whereas centre 3 performs posteromedial apical translation without active derotation. Pre- and postoperative shape of the main thoracic curve was analyzed using coronal curve angle, apical rotation and sagittal alignment parameters (pelvic incidence and tilt, T1–T12, T4-T12 and T10-L2 regional kyphosis angles, C7 slope and the level of the inflection point). In addition, the proximal junctional angle at follow-up was compared. Results Pre-operative coronal curve magnitudes were similar between the 3 cohorts and improved 75%, 70% and 59%, from pre- to postoperative, respectively (P < 0.001). The strategy of centres 1 and 2 leads to significantly more apical derotation. Despite similar postoperative T4-T12 kyphosis, the strategy in centre 1 led to more thoracolumbar lordosis and in centre 2 to a higher inflection point as compared to centre 3. Proximal junctional angle was higher in centres 1 and 2 (P < 0.001) at final follow-up. Conclusion Curve correction by derotation may lead to thoracolumbar lordosis and therefore higher risk for proximal junctional kyphosis. Focus on sagittal plane by posteromedial translation, however, results in more residual coronal and axial deformity.