Beruflich Dokumente
Kultur Dokumente
SUMMARY Cardiovascular complications are a major source of morbidity and mortality in hypertensive
patients. To assess the prevalence of anatomic and functional abnormalities of the heart in such patients, we
studied 234 asymptomatic subjects with mild-to-moderate systemic hypertension by echocardiography. After
adjusting the echocardiographic values for age and body surface area, we found abnormally increased ventric-
ular septal and/or posterobasal free-wall thickness in 61% of the hypertensive subjects. We found increased
left atrial, aortic root, and left ventricular internal dimension (at end-diastole) in 5-7%, and decreased mitral
valve closing velocity (E-F slope) and left ventricular ejection fraction were noted in six and 15% of the sub-
jects, respectively. Four percent of the patients had disproportionate septal thickening (i.e., ventricular septal-
to-left ventricular free-wall thickness ratio > 1.3). In contrast to the high prevalence of cardiac abnormalities
detected by echocardiography, less than 10% of the hypertensive subjects had abnormal 12-lead ECGs or ab-
normal chest x-rays. These findings demonstrate a high prevalence of cardiac abnormalities in a population of
Downloaded from http://circ.ahajournals.org/ by guest on February 5, 2018
asymptomatic hypertensive subjects. These abnormalities can be detected by echocardiography before they are
otherwise apparent.
serum creatinine
> 1.7 mgWc (range) 77 = 7 _ (1 .7-2.7 mg%) 16 = 7 % (1.7-2.2 mg %)
*Only one hypertensive subject who was continued on therapy had grade 3 hypertensive retinopathy. All
other subjects had grades < 2.
such therapy had diastolic blood pressures lower than below the tips of the mitral valve leaflets. Both
95 mm Hg at the time of echocardiographic study. thicknesses were measured in the portion of the car-
However, all hypertensive subjects had had diastolic diac cycle that occurs after rapid ventricular filling but
blood pressure . 95 mm Hg on two or more before atrial systole (fig. lA).6 Posterobasal left ven-
measurements within 1 year before study. Only two tricular wall was measured near the damped portion
hypertensive subjects had diastolic blood pressures of the record (fig. lA). Left ventricular transverse
greater than 130 mm Hg at the time of echocardio- dimensions at end-diastole and at end-systole were
graphic study. None of the subjects had evidence of a measured in the same portion of the record and taken
known secondary cause of hypertension by history, as the maximal and minimal distances between sep-
physical examination or routine laboratory tests. tum and posterior left ventricular wall, respectively
One hundred twenty-eight of the hypertensive sub- (fig. lA).7 Left atrial dimension was measured as the
jects had systemic arterial blood pressure recorded maximal distance between the posterior aortic root
(sitting) on two or three clinic visits during the 6 wall and the posterior left atrial wall. Measurements
months before echocardiographic study (with no were taken in the damped portion of the record when
change in treatment status during these visits). The the ultrasonic beam passed through the aortic valve
average of these blood pressures was used for assess- leaflets.7-9 Aortic root dimension was measured in the
ment of the relation of echocardiographic measure- same portion of the recording. This measurement was
ments to severity of hypertension. made from the midpoint of the line denoting the
anterior aortic root wall to the midpoint of the line
Echocardiographic Measurements denoting the posterior aortic root wall at end-diastole.
M-mode echocardiograms were performed with the The mitral valve E-F slope, corresponding to the rate
patient on his or her left side. An Aerotech transducer of early diastolic closure of the anterior leaflet of the
ultrasound receiver, a Honeywell 1856 Line Scan mitral valve, was measured at a point in which the ex-
Recorder, a Hewlett-Packard X-Y display, and a cursion of the anterior mitral leaflet was maximal and
custom-built video amplifier were used. Studies were both leaflets were visualized (fig. lB).10
performed with the transducer in the fourth intercos- Values derived from the measurements included es-
tal space near the left sternal edge. If necessary, the timated left ventricular mass," percent fractional
transducer was moved laterally and/or to a different shortening of the left ventricular transverse dimen-
interspace so that both mitral leaflets could be sion," and left ventricular ejection fraction, which was
visualized with the transducer perpendicular to the calculated using the cubed assumption to estimate left
chest wall. To obtain consistent and reproducible ventricular volume.'3
recordings, the T-scan method was used.6 Electrocardiographic Measurements
Figure 1 shows illustrative echocardiograms which
indicate where measurements were taken. The Two hundred seventeen of the hypertensive subjects
thickness of the ventricular septum and posterobasal had standard 12-lead ECGs within 1 day to 12 weeks
left ventricular wall were measured at or slightly of the echocardiographic study (median 1 day). No
ECHOCARDIOGRAPHY IN HYPERTENSIVE SUBJECTS/Savage et at. 625
Downloaded from http://circ.ahajournals.org/ by guest on February 5, 2018
TS 0'71
z
w
8
;I ,:,(!,1I7I tMean systolic blood pressure was significantly higher than
that of each of the three younger age groups (p <0.01).
tIean systolic blood pressure was significantly higher than
that of eaah of the four younger age groups (p <0.001).
§Mean diastolic blood pressture was significantly lower than
those of the subjects aged 41 to 60 (p <0.02) but was similar
to suibjects in the other age groups (p >0.05).
6
Downloaded from http://circ.ahajournals.org/ by guest on February 5, 2018
SEPTAL THICKNESS
z 20 LEFT ATRIAL DIMENSION
_FREE=-WREE-WALL
_ THICKNESS FIGURE 3. Effect of age on echocar-
<C 10 __-
-1
AORTIC ROOT DIMENSION
00O 0- : 7--7_ -._. diographic measurements in hypertensive
FRACTION subjects. Mean echocardiographic values for
ZHF
-Z -10 each age decade is compared with that of
wF
z
Z w
-20 hypertensive subjects in the 21-30 age group
ID -20) after adjustment of echocardiographic
w
values to a body surface area of 1.8 m2,
-40 *For mitral valve E-F slope n = 227.
-50
AGE IN YEARS
E
E
z
w
z
I
-j
>
-J
30 F
20
10 r-
A
ECHOCARDIOGRAPHY IN HYPERTENSIVE SUBJECTS/Savage et al.
SEPTAL THICKNESS
- .40
I-IDooe"
---410690"
3,-,'--Ab9*AAA
1
FREE-WALL THICKNESS
D.)O"
...
.Q&l 1.8486.;.16.6665=2612122t=
.'
,
-1
, 4040416SAAA
700
600 F
500
400
300
k
LV MASS (grams)
'A
A
4!!.A
A
,)1-1, *A
A
-.o
.-
*AAA
_''-1041."
.AA
..* 1000"
.400AAAAA
40**A&"
.-4MDA&"
175
150
125
100_
75
'(206)
,
MITRAL VALVE
E-F SLOPE* (mm/sec)
.t:
ii'
X-4-
4.X
±4
..
627
Downloaded from http://circ.ahajournals.org/ by guest on February 5, 2018
-j OAA&A"
Ljl .I
A
00" e
200 O"
A
4MAAA
50 IL
9O"
,1R
I ;.j 35
O 1 o1 I4
FIGURE 4. Distribution of absolute echocardiographic measurements of ventricular septum, left ventric-
ular free wall, mitral valve E-F slope, and derived left ventricular mass in 234 hypertensive subjects. On this
and all subsequent figures: open circles = patients on no medication, closed circles = patients on antihyper-
tensive medication other than propranolol, and closed triangles = patients on propranolol with or without
other antihypertensive medication. LV = left ventricular. *For mitral valve E-F slope n = 227.
60 OA
A.
I.: A
OSAA
0
00"
E 50 .,. OAAAAAA
E 41408SAAAA "A
A
z OOAAAAAA
40 S"
SO
.
*-0
-:10 -:4
z
w 4a"
0 .
-:-,. -,( .-
-..
..-
I
I
.-.
z 301- O"
. OA
-4"WAA
1-
.- .- , 's &A"
w 400
-
A&
0 -A
00
20 F O"
10i
n I
u
FIGURE 5. Distribution of absolute echocardiographic measurements of left ventricular dimensions at end-
diastole and end-systole, and left atrial and aortic root dimensions in 234 hypertensive subjects.
L VTDD = left ventricular transverse dimension at end-diastole; L VTD, = left ventricular transverse dimen-
sion at end-systole.
628 CIRCULATION VOL 59, No 4, APRIL 1979
200
175
1 125 t
F- 125
O'-~ ~ ~ -. .:- . -. .
SEPTAL
THICKNESS
*(244)
ECHOCARDIOGRAPHY IN HYPERTENSIVE SUBJECTS/Savage et al.
. E W
S
.
FREE-WALL
THICKNESS
T Wt
W ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~..........
LV MASS
-,(299)
(230)
E
MITRAL VALVE
E-F SLOPE*
...
FIGURE 7. Distribution
slope.
of
diographic ventricular septal thickness, left
r 0 ;|; : ventricular free-wall thickness, left ventric-
............ular mass, and mitral valve F-F slope in 234
629
echocar-
O~~~~~~~~~~~~~~~~~~~~~~~..... ...
25 .
D ,'.-~~~~~~... __ . ....---
]<7Xr
LEFT ATRIAL AORTIC ROOT
LVTDD LVTD5 DIMENSION DIMENSION
< 150
Z1252. -J yPL
.....0.
< 50___
Z
z
w.25___
o_ _ _ I I I
FIGURE 8. Distribution of echocardiographic left ventricular transverse dimension at end-diastole
(L VTDD) and at end-systole (L VTD3), and left atrial and aortic root dimensions in 234 hypertensive sub-
jects. Each value is plotted as a percentage of the predicted value determined from normal data. Shaded
areas represent the 95% prediction interval derived from normal data.
630 CIRCULATION VOL 59, No 4, APRIL 1979
TABLLE 4. Correlation Coefficients of Blood Pressure vs Echo- Left ventricular enlargement was detected by chest
cardiographic .Ieasurcertents in 128 Hypertensive Subjects x-ray in nine of 168 hypertensive subjects (5%) who
Systolic Diastolic Mean had recent chest x-rays. Six of the nine subjects (67%)
blood blood arterial had increased left ventricular wall thickness and in-
pressure pressure pressure creased left ventricular mass by echocardiogram. Left
Ventricular septal ventricular enlargement was detected by chest x-ray in
thickness 0.209* 0.346t 0.314$ only six of 81 hypertensive subjects (7%) who had left
Left ventricular ventricular enlargement (at end-diastole) or increased
free-wall thickness 0.291$ 0.4681 0.430$ left ventricular mass by echocardiogram, or both.
Left ventricular mass 0.231t 0.319$ 0.311t
Left ventricular transverse Discussion
dimension at end-diastole 0.022 -0.026 -0.003
Left ventricular transverse Previous studies of normotensive subjects without
dimension at end-systole - 0.083 0.010 -0.040 clinically apparent heart disease have shown changes
Left atrial dimension 0.204* 0.166 0.208*
in echocardiographic measurements with increasing
age and body surface area.4' I The changes associated
Aortic root dimension -0.082 0.010 -0.040 with increasing age include increased aortic root and
Ejection fraction 0.120 -0.029 0.050 left atrial size, increased left ventricular wall
Percent fractional thickness, and decreased mitral valve E-F slope. In the
Downloaded from http://circ.ahajournals.org/ by guest on February 5, 2018
correlations were found between systemic arterial These findings are consistent with those of Schlant et
blood pressure and left ventricular wall thicknesses, al.2 and Pisarczyk and Ross.2'
left ventricular mass and left atrial dimension. Schlant In summary, echocardiography identifies anatomic
et al.2 found poorer correlations between left ventric- and functional cardiac abnormalities in a large per-
ular wall thicknesses and diastolic pressure than those centage of asymptomatic hypertensive subjects before
found in the present study. However, their series was abnormalities are detected by ECG or chest x-ray.
smaller than ours. In addition, they correlated left This conclusion is strengthened by correcting the
ventricular wall thicknesses with a single diastolic echocardiographic values for effects of body surface
pressure measurement, while two or more measure- area and age. Whether echocardiography should be
ments from separate clinic visits were used in the pres- used for routine screening of such subjects will depend
ent study. partly on the prognostic significance of these abnor-
Disproportionate septal hypertrophy has been re- malities.
ported in 47%,18 30%,19 10%,' and less than 1%2 of sub-
jects with hypertension. We found this abnormality in Acknowledgments
4% of our hypertensive subjects (nine of 234). Exclu-
sion of subjects with angina pectoris, evidence of The authors gratefully acknowledge the excellent technical
myocardial infarction and severe hypertension from assistance of Joyce McKay and Cora Burn in obtaining the echocar-
diograms. The assistance of Pamela Peters and Rose Aceto in the
our study population may have lowered the prevalence logistics of evaluating the large number of patients is greatly ap-
of disproportionate septal thickening. However, it preciated. We also acknowledge Erica Brittain for help with the
Downloaded from http://circ.ahajournals.org/ by guest on February 5, 2018
16. Henry WL, Ware JH, Gardin JM, Hepner SI, McKay J, 19. Toshima H, Koga Y, Yoshioka H, Ayiyoshi T, Kimura N:
Weiner M: Echocardiographic measurements in normal sub- Echocardiographic classification of hypertensive heart disease:
jects: growth-related changes that occur between infancy and a correlative study with clinical features. Jpn Heart J 16: 377.
early adulthood. Circulation 57: 278, 1978 1975
17. Drayer JIM, Savage DD, Henry WL. Mathews EC Jr., Laragh 20. Maron BJ, Edwards JE, Epstein SE: Occurrence of dispropor-
JH, Epstein SE: Incidence of echocardiographic left ventric- tionate ventricular septal thickening in patients with systemic
ular hypertrophy and left atrial enlargement in essential hyper- hypertension. Chest 73: 466, 1978
tension. (abstr) Circulation 54 (suppl II): 11-233, 1976 21. Pisarczyk MJ, Ross AM: Cardiac measurements in hyperten-
18. Criley JM, Blaufuss AH, Abbasi AS: Nonobstructive IHSS. sion: echocardiogram, electrocardiogram and x-ray com-
Circulation 52: 963, 1975 parison. (abstr) Am J Cardiol 37: 162, 1976
SUMMARY Carotid baroreflex function was assessed in 10 normotensive young men and 20 age-matched
subjects with borderline hypertension (successive blood pressures above and below 140/90 mm Hg) by measur-
ing sinus node responses to brief neck suction. Subjects with borderline hypertension were divided into two
equal groups according to their average systolic arterial pressures. Baroreflex responses were reset to function
at higher pressure levels than normal in subjects with mild borderline hypertension, but reflex sensitivity was
normal. Responses were also reset in subjects with more severe borderline hypertension, but reflex sensitivity
was subnormal. The results suggest that a gradation of baroreflex responsiveness exists among patients
classified as having borderline hypertension: Subnormal responsiveness was found in those subjects whose
resting average systolic arterial pressure was 140 mm Hg.
SOON AFTER THE CAROTID ARTERIAL be found in patients with mild degrees of blood
BAROREFLEX was discovered, Koch and Mies' and pressure elevation. Data on this issue are conflicting.
Volhard' suggested that defective baroreflex buffering Takeshita and associates5 found subnormal baroreflex
of blood pressure might cause essential hypertension. responses in young men whose average blood pressure
Despite numerous subsequent attempts to delineate was 160/82 mm Hg, but Julius6 found normal
hypertensive mechanisms, the role of the arterial baro- responses in borderline hypertensive patients whose
reflex in the pathogenesis of hypertension remains an blood pressures were reported to be lower than those
enigma. The validity of the theory of Koch and Mies studied by Takeshita and co-workers. I have
and Volhard has been questioned,3 but the theory has attempted to clarify this issue by using new tech-
not been discredited altogether. The study of Bristow niques to measure baroreflex responses of asymp-
and co-workers4 supports their postulate: In their tomatic young men whose blood pressures oscillate
study arterial baroreceptor-cardiac reflex responses above and below 140/90 mm Hg.
were found to be strikingly depressed in patients with
moderate (average mean arterial pressure 123 mm Methods
Hg), sustained hypertension. In these patients, baro- Seven intensities of neck suction were delivered
receptor reflex malfunction might have contributed to briefly to stretch carotid baroreceptors of young men
the development of hypertension, or it might have with normal blood pressures and young men with
been a consequence of hypertension. borderline hypertension (defined as blood pressures
If a defective baroreceptor reflex mechanism causes above and below 140/90 mm Hg on successive ex-
hypertension, subnormal baroreflex responses should aminations). Sinus node responses were measured.
From the Cardiovascular Center, the Cardiovascular Division,
Hypertensive and Normal Volunteers
the Department of Internal Medicine, and the Veterans Administra- Volunteers, ages 19-25 years, were recruited from
tion and University Hospitals, the University of Iowa College of 900 university students whose blood pressures were
Medicine, Iowa City, Iowa.
Supported by grants HL 14388 and HL 18083 from the Veterans measured during registration. Blood pressures of each
Administration and the National Institutes of Health. volunteer were measured two to four (average 2.85)
Dr. Eckberg is a Clinical Investigator for the Veterans Ad- times with subjects in the sitting position, after 10
ministration. minutes of rest. Weight, height and skin fold
Address for reprints: Dwain L. Eckberg, M.D., Cardiovascular
Research, McGuire VA Hospital, Richmond, Virginia 23249. thickness, measured in the midline midway between
Received August 7, 1978; revision accepted November 8, 1978. the chin and the upper margin of the thyroid cartilage
Circulation 59, No. 4, 1979. were also measured.
Echocardiographic assessment of cardiac anatomy and function in hypertensive subjects.
D D Savage, J I Drayer, W L Henry, E C Mathews, Jr, J H Ware, J M Gardin, E R Cohen, S E
Epstein and J H Laragh
Circulation. 1979;59:623-632
Downloaded from http://circ.ahajournals.org/ by guest on February 5, 2018
doi: 10.1161/01.CIR.59.4.623
Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright © 1979 American Heart Association, Inc. All rights reserved.
Print ISSN: 0009-7322. Online ISSN: 1524-4539
The online version of this article, along with updated information and services, is located on
the World Wide Web at:
http://circ.ahajournals.org/content/59/4/623
Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally
published in Circulation can be obtained via RightsLink, a service of the Copyright Clearance Center, not the
Editorial Office. Once the online version of the published article for which permission is being requested is
located, click Request Permissions in the middle column of the Web page under Services. Further
information about this process is available in the Permissions and Rights Question and Answer document.