Effects of dipper and non-dipper status of essential hypertension on left atrial mechanical functions

doi:10.1016/j.ijcard.2003.08.017

International Journal of Cardiology

Volume 96, Issue 3, September 2004, Pages 419-424

https://doi.org/10.1016/j.ijcard.2003.08.017 Get rights and content

Abstract

Aim: This study was designed in order to investigate the effects of dipper and non-dipper status of hypertension on left atrial mechanical (reservoir, conduit and booster pump) functions with left atrial volume measurements by means of two-dimensional echocardiography in untreated systemic hypertensive patients. Method: A total of 27 untreated dipper hypertensive patients, group I (15 female, 12 male, mean age 57±12 years); 23 untreated non-dipper hypertensive patients, group II (12 female, 11 male, mean age: 53±18 years); and 25 voluntary healthy individuals, group III (13 female, 12 male, mean age 53±10 years) were included into the study. Twenty-four hour blood pressure (BP) measurement was performed by the cuff-oscillometric method to evaluate the nocturnal decrease of BP. The patients whose night time mean blood pressure measurements were found 10% or more lower compared to mean day time measurements were classified as dipper hypertensive patients and the ones with a decrease of less than 10% were classified as non-dipper hypertensive patients. Left atrial (LA) volumes were measured echocardiographically according to biplane area-length method in apical four-chamber and two-chamber views. LA maximal volume (V_max) was recorded at the onset of mitral opening, LA minimal volume (V_min) was recorded at the onset of mitral closure and LA presystolic volume (V_p) was recorded at the beginning of the atrial systole (p wave on ECG). All volume measurements were corrected to body surface area, and following LA emptying functions parameters were calculated: LA passive emptying volume (LAPEV)=V_max−V_p, LA passive emptying fraction (LAPEF)=LAPEV/V_max, Conduit volume (CV)=left ventricular output volume-(V_max−V_min), LA active emptying volume (LAAEV)=V_p−V_min, LA active emptying fraction (LAAEF)=LAAEV/V_p, LA total emptying volume (LATEV)=V_max−V_min, LA total emptying fraction (LATEF)=LATEV/V_max. Results: LA volume indexes, V_max, V_min, and V_p, were significantly increased in the hypertensive subgroups (groups I and II) than in controls (p<0.001, p<0.001, p<0.001, respectively), but no significant difference was found in the V_p values between group I and group II. V_max and V_min were larger in non-dipper hypertensive group than in dipper hypertensive group (p<0.05 and p<0.05, respectively). LAPEV and LAPEF were observed to be significantly reduced in both dipper and non-dipper hypertensives than in control (p<0.001 and p<0.05, respectively), and this difference was more obvious in non-dipper than dipper cases (p<0.001). Conduit volume was significantly lower in hypertensive groups than controls (p<0.05). LA active emptying volume (p<0.001) and LAA active emptying fraction (p<0.001) were significantly greater in hypertensive cases than in controls. Furthermore, LA active emptying volume in non-dipper hypertensive subjects was significantly greater than dipper hypertensive cases (p<0.05). Left atrial total emptying volume and left atrial total emptying fraction in both hypertensive groups were similar to control (p>0.05). Conclusions: Atrial reservoir and booster pump functions increase in hypertensive patients, but this result is more prominent in non-dipper hypertensives than in dipper hypertensive patients.

Introduction

Left atrium (LA) has an important supplement in left ventricular output volume. Left ventricular filling is maintained by LA reservoir function during ventricular systole, and LA passive conduit function during early diastole and active contractile function during late diastole with the presence of normal sinus rhythm [1], [2], [3], [17]. It is well known that essential hypertension deteriorates LA functions [3]. Blood pressure (BP) is characterized by alteration of rhythm along 24 h in hypertensive patients [4]. Mean BP values reveal 10–20% lower values in the night, compared to daytime measurements. This condition is called “dipper”' change. But in some hypertensives, contrary to this normal change, nighttime BP lowering does not occur or shows a decrease less than 10% which is called “non-dipper” change [5]. It is known that target organ injury occurs more severe in non-dipper hypertensive patients than in dipper status of hypertension (DH) and non-dipper status of hypertension (NDH) itself is a risk factor increasing the mortality [6], [7]. The most commonly used noninvasive technique to evaluate LA performance is Doppler echocardiography. However, Doppler echocardiography is limited since it provides no information about LA size. Although the use of this technique to evaluate LA booster pump function has been described, it is not suitable for the assessment of reservoir and conduit phases of LA function. Measurement of LA volumes at different phases of the cardiac cycle was proven to be useful for evaluating LA performance [15]. According to our knowledge, the effects of DH and NDH on left atrial reservoir, conduit, and booster pump functions have not been investigated in hypertensive patients. Therefore, this study was designed in order to investigate the effects of dipper and non-dipper status of hypertension on left atrial mechanical functions with left atrial volume measurements by means of two-dimensional echocardiography in untreated systemic hypertensive patients.

Section snippets

Study groups

The study population consisted of group I, 27 untreated dipper essential hypertensive (15 female, 12 male, mean age: 57±12years); group II, 23 untreated non-dipper essential hypertensive patients (12 female, 11 male, mean age; 53±18 years) and group III, 25 volunteers (13 female,12 male, mean age: 53±10 years) without evidence of cardiovascular disease served as age matched healthy subjects. All patients were in sinus rhythm. None of the patients was receiving anti-hypertensive drugs at the

Statistical analysis

All data are expressed as mean±S.D. echocardiographic parameters of both hypertensive patients and control group. Statistical analyses were performed with a commercially available SPSS 9.0 statistics programme (SPSS, Chicago, IL, USA). Differences among groups were assessed with the chi-square test for categorical variables. Comparisons among groups were made using one-way factorial analysis of variance, followed by the Scheffé test. Relationship between various variables were examined with

Results

Clinical characteristics, M-Mode and two-dimensional echocardiographic measurements are listed in Table 1. The number of patients, male to female ratio, the value of body surface areas were similar to hypertensive groups and the controls. During echocardiogram, the systolic, diastolic blood pressure and pulse pressure were similar in DH and NDH in hypertensive patients. No difference in heart rate was found among the three groups at the time of the echocardiogram. The measurements of left

Discussion

Left atrial (LA) functions consist of reservoir, conduit and booster pump functions at different stages of cardiac cycle. Left atrial reservoir functions occur during ventricular systole, passive conduit function occur in early diastole and booster pump function occur during ventricular diastole in the presence of sinus rhythm. The importance of LA mechanical emptying function increases in patients with left ventricular dysfunction, aortic stenosis, hypertrophic obstructive cardiomyopathy and

Conclusion

Our findings indicate that atrial reservoir and booster pump functions increase in hypertensive patients but this result is more prominent in non-dipper hypertensives than in dipper hypertensive patients.

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Fig. 1) All PA intervals were averaged over three consecutive beats. The difference between the lateral and tricuspid PA intervals was defined as interatrial electromechanical delay, and the difference between the septal and tricuspid PA intervals was defined as intra-atrial electromechanical delay [18]. Fasting blood glucose, total cholesterol, triglyceride, low density lipoprotein, high density lipoprotein and HbA1c values were measured from venous blood collected from the pre-DM and non-DM groups after fasting for 8 h.
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Global Longitudinal strain (GLS) and strain rate (GLSR) were assessed by STE, and Intra- and interatrial electromechanical delay (EMD) were measured utilizing tissue Doppler imaging (TDI) in 108 pre-diabetic patients and 72 age and gender matched healthy volunteers.
The GLS (− 19.4 ± 2.8 vs. 23.8 ± 2.1%; p < 0.001) and GLSR () were significantly lower in prediabetics when compared with the healthy control. Pre-diabetic patients had significantly prolonged PA lateral, PA septum and PA tricuspid. The intra- (PA septum-PA tricuspid) and interatrial (PA lateral-PA tricuspid) electromechanical delays were prolonged compared to controls (p < 0.0001, p < 0.05, p < 0.001, and p < 0.002, respectively). The GLS%, GLSR and atrial electromechanical delay were highly significantly correlated with fasting blood glucose, and modestly correlated to systolic blood pressure, total cholesterol, triglycerides, and left ventricular mass index.
GLS%; GLSR assessed by STE was decreased; intra- and interatrial electromechanical delays were prolonged, in pre-diabetic subjects. These non-invasive indices broaden the spectrum of subclinical myocardial dysfunction in pre-diabetic patients.
The association between heart rate variability and biatrial phasic function in arterial hypertension
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However, recent investigations have demonstrated that RA volume and/or function are important predictors of morbidity and mortality in patients with heart failure, coronary artery disease, pulmonary embolism, or Eisenmenger syndrome.4–7 LA phasic function and mechanics have been investigated in arterial hypertension previously,8–10 whereas the data about RA functional remodeling are scarce and mostly provided by our study group.11,12 Sympathovagal disbalance in systemic hypertension evaluated by heart rate variability (HRV) parameters has been revealed earlier.13–15
We sought to investigate (1) left atrial (LA) and right atrial (RA) phasic function and mechanics; (2) heart rate variability (HRV); and (3) their relationship in untreated hypertensive patients. This cross-sectional study involved 73 untreated hypertensive patients and 51 subjects without cardiovascular risk factors with similar gender and age. All the subjects underwent a 24-hour Holter monitoring and comprehensive two- and three-dimensional echocardiography examination. LA and RA reservoir and conduit function, estimated by total and passive atrial emptying fractions and systolic and early diastolic strain rates, were reduced in the hypertensive patients. On the other hand, LA and RA booster function, assessed by active atrial emptying fraction and late diastolic strain rate, was increased in this group. All time and frequency domain heart-rate variability parameters were reduced in the hypertensive subjects. In the whole study population, parameters of cardiac sympathovagal balance (standard deviation of all normal RR intervals, root mean square of the difference between the coupling intervals of adjacent R-R intervals, 24-hour low-frequency domain [0.04–0.15 Hz], 24-hour high-frequency domain [0.15–0.40 Hz], and 24-hour total power [0.01–0.40 Hz]) correlated with LA and RA volume indexes, biatrial booster function assessed by active emptying fraction, biatrial longitudinal function evaluated by longitudinal strain; and biatrial expansion index. LA and RA phasic function and mechanics are significantly impaired in the untreated hypertensive patients. Heart-rate variability parameters are also deteriorated in the hypertensive population. Biatrial function and mechanics correlated with cardiac autonomic nervous system indexes in the whole study population.
Nighttime ambulatory blood pressure is associated with atrial remodelling and neurohormonal activation in patients with idiopathic atrial fibrillation
2013, Revista Espanola de Cardiologia
La hipertensión es un factor de riesgo de fibrilación auricular. Parece que la activación del sistema renina-angiotensina interviene en el crecimiento auricular con la liberación de los péptidos natriuréticos auricular y cerebral. El objetivo de este estudio es evaluar la relación de la presión arterial ambulatoria y los valores de péptidos natriuréticos con el tamaño auricular izquierdo en sujetos normotensos con fibrilación auricular idiopática.
Se llevó a cabo un estudio transversal en pacientes con fibrilación auricular idiopática. Se registraron los siguientes parámetros durante la realización del estudio: presión arterial en la consulta y ambulatoria de 24 h, péptidos natriuréticos auricular y cerebral, renina en plasma, aldosterona y enzima de conversión de la angiotensina.
Se incluyó en el estudio a un total de 48 pacientes (media de edad, 55 ± 10 años; el 70,6% varones). La media de valores de presión arterial en sedestación en la consulta fue de 132,49 ± 14,9/80,96 ± 9,2 mmHg. La media de presión arterial ambulatoria de 24 h sistólica y diastólica fue de 121,10 ± 8,3/72,11 ± 6,8 mmHg (diurna, 126,8 ± 9,7/77,58 ± 7,9 mmHg; nocturna, 114,56 ± 11,6/68,6 ± 8,8 mmHg). Se observó una clara tendencia al aumento del tamaño auricular izquierdo con los valores más elevados de presión arterial ambulatoria, que alcanzaba significación estadística para los valores nocturnos (r = 0,34; p = 0,020 para la presión sistólica; r = 0,51; p = 0,0001 para la diastólica). Se observó una correlación significativa entre los valores de péptido natriurético auricular y la presión arterial nocturna sistólica (r = 0,297; p = 0,047) y diastólica (r = 0,312; p = 0,037). Se observaron también correlaciones significativas entre el tamaño auricular izquierdo y las cifras de péptido natriurético auricular (r = 0,577; p < 0,0001) y péptido natriurético cerebral (r = 0,379; p = 0,012).
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Hypertension is a risk factor for atrial fibrillation. Activation of the renin-angiotensin-system seems to be involved in atrial enlargement, with release of atrial and brain natriuretic peptides. The aim of this study was to evaluate the relationship between ambulatory blood pressure and levels of natriuretic peptides, with left atrial size in normotensives with idiopathic atrial fibrillation.
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Forty-eight patients (mean age 55 [10] years; 70.6% male) were included in the study. Mean office sitting blood pressure values were 132.49 (14.9)/80.96 (9.2) mmHg. Mean 24-h ambulatory systolic and diastolic blood pressure values were 121.10 (8.3)/72.11 (6.8) mmHg (daytime, 126.8 [9.7]/77.58 [7.9] mmHg; nighttime, 114.56 [11.6]/68.6 [8.8] mmHg). A clear trend towards increased left atrial size with higher ambulatory blood pressure values was noted, which was statistically significant for nighttime values (r=0,34; P=.020 for systolic and r=0,51; P=.0001 for diastolic). A significant correlation between atrial natriuretic peptide and nighttime systolic (r=0,297; P=.047) and diastolic (r=0,312; P=.037) blood pressure was observed. Significant correlations were also observed between left atrial size and atrial natriuretic peptide levels (r=0,577; P<.0001) and brain natriuretic peptide levels (r=0,379; P=.012).
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Full English text available from: www.revespcardiol.org/en
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Effects of dipper and non-dipper status of essential hypertension on left atrial mechanical functions

Abstract

Introduction

Section snippets

Study groups

Statistical analysis

Results

Discussion

Conclusion

J. Am. Coll. Cardiol.

Am. J. Cardiol.

J. Am. Coll. Cardiol.

J. Am. Soc. Echocardiogr.

Am. Heart J.

Am. J. Hypertens.

Am. J. Hypertens.

Am. Heart J.

A clinic appraisal of left atrial function

Eur. Heart J.

Contribution of atrial reservoir function to ventricular filling in hypertensive patients

Hypertension

Twenty-four-hour ambulatory blood pressure in men and women aged 17 to 80 years: the allied Irish bank study

J. Hypertens.

Dippers versus non-dippers

J. Hypertens.

The clinical significance of diurnal blood pressure variations. Dippers and non-dippers

Circulation