Novel Index of Maladaptive Myocardial Remodeling in Hypertension

Vera J Goh, Thu-Thao Le, Jennifer Bryant, Jia Ing Wong, Boyang Su, Chi-Hang Lee, Chee Jian Pua, Chloe P Y Sim, Briana Ang, Tar Choon Aw, Stuart A Cook, Calvin W L Chin, Vera J Goh, Thu-Thao Le, Jennifer Bryant, Jia Ing Wong, Boyang Su, Chi-Hang Lee, Chee Jian Pua, Chloe P Y Sim, Briana Ang, Tar Choon Aw, Stuart A Cook, Calvin W L Chin

Abstract

Background: Hypertensive left ventricular hypertrophy (HTN-LVH) is a leading cause of heart failure. Conventional patterns of cardiac geometry do not adequately risk-stratify patients with HTN-LVH. Using cardiovascular magnetic resonance, we developed a novel Remodeling Index (RI) that was designed to detect an exaggerated hypertrophic response to hypertension and tested its potential to risk-stratify hypertensive patients.

Methods and results: The RI was derived using LaPlace's Law (), and normal RI ranges were established in 180 healthy volunteers. The utility of the RI was examined in 256 asymptomatic hypertensive patients and 10 patients with heart failure with preserved ejection fraction. Hypertensive patients underwent multimodal cardiac assessment: contrast-enhanced cardiovascular magnetic resonance, echocardiograms, 24-hour blood pressure monitoring, and cardiac biomarkers (high-sensitivity cardiac troponins, NT-proBNP [N-terminal pro-B-type natriuretic peptide], and galectin-3). Blood pressure accounted for only 20% of the variance observed in LV mass. Although there was no association between blood pressure and myocardial fibrosis, LV mass was independently associated with fibrosis. Compared with hypertensive patients without LVH (n=191; 74.6%) and those with HTN-LVH and normal RI (n=50; 19.5%), patients with HTN-LVH and low RI (HTN-LVH/low RI; n=15, 5.9%) had an amplified myocardial response: elevated indexed LV masses (83±24 g/m2), more fibrosis (73%), and higher biomarkers of myocardial injury and dysfunction (P<0.05 for all). RI was similar in HTN-LVH/low RI and heart failure with preserved ejection fraction (4.1 [3.4-4.5] versus 3.7 [3.4-4.0], respectively; P=0.15).

Conclusions: We suggest that RI provides an approach for stratifying hypertensive patients and is suitable for testing in other disease cohorts to assess its clinical utility.

Clinical trial registration: URL: https://ichgcp.net/clinical-trials-registry/NCT02670031" title="See in ClinicalTrials.gov">NCT02670031.

Keywords: blood pressure; heart diseases; hypertrophy, left ventricular; magnetic resonance imaging; natriuretic peptide, brain.

© 2017 The Authors.

Figures

Figure 1.
Figure 1.
Maximal wall thickening were predominantly localized in the basal anterior segments and septum (A). Midwall myocardial fibrosis was predominantly present in the basal and midventricular septum (B). Maximal wall thickness (mm) and proportion of segments (%) with midwall fibrosis are presented in A and B, respectively.
Figure 2.
Figure 2.
Indexed left ventricular (LV) mass correlated positively with interstitial volume assessed on cardiovascular magnetic resonance (A). Compared with those without midwall myocardial fibrosis, hypertensive patients with midwall fibrosis had increased left ventricular mass index (B) and high-sensitive cardiac troponin I concentrations, a marker of myocardial injury (C). Results in B and C presented in box-and-whiskers plot (Tukey method).
Figure 3.
Figure 3.
Sex- and age-specific reference ranges of Remodeling Index (RI) in a healthy population.
Figure 4.
Figure 4.
The Remodeling Index (RI) identifies a subgroup of hypertensive (HTN) patients with advanced left ventricular hypertrophy (LVH; A). These patients had the highest blood pressures (B), left ventricular mass (C), more myocardial fibrosis (D), and elevated markers of myocardial injury and cardiac decompensation (E and F). Results presented in box-and-whiskers plot (Tukey method).

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