An Evaluation on Initial Deficiency of Left Ventricular Systolic Function in Patients with Systemic Hypertension by Speckle Tracking Echocardiography
D. T. Nguyen, V. A. Nguyen, L. D. Do, and N. Doan
Abstract
Background Speckle tracking echocardiography 2D (STE 2D), a newtechnology, allows rapid and accurate analysis of regional and global left ventricular systolic function. Aim The aim of this study was to assess subclinical left
ventricular systolic dysfunction in the patients with systemic hypertension with preserved ejection fraction by using STE 2D. Methods 2D echocardiography images of left ventricular were acquired in six sections-apical 4-chamber,
2-chamber, 3-chamber, parasternal short axis at the basal, mid, and apical levels in 194 subjects (151 hypertensive patients and 43 healthy controls). The imageswere analysed by QLAB software version 9.0. Long, circumferential and radial strain were quantified in 18-segments. Result Peak systolic long strain, circumferential strain, radial strain and longitudinal-circumferential systolic index were markedly decreased in patients with systemic hypertension comparing with control group (−11.57 ± 2.37%vs. −16.52 ± 1.19%;
−13.52 ± 4.97% vs. −17.92 ± 2.39%; 10.24 ± 3.4% vs.
12.33 ± 1.94%; −12.55 ± 2.83% vs. −17.22 ± 1.44%, p < 0.001). Besides, the average of systolic blood pressure in normal longitudinal-circumferential systolic index group is lower than abnormal that group (127.93 ± 9.02 mmHg vs. 139.92 ± 12.51 mmHg, p < 0.001) and the average of systolic blood pressure in normal systolic index group is lower than abnormal that group (128.57 ± 8.1 mmHg vs.
141.96 ± 12.39 mmHg, p < 0.001). Conclusion although left ventricular ejection fraction is normal by conventional echocardiography, there is an early decline in systolic function by STE method and mean systolic blood pressure in the groups with normal systolic strain parameters are lower than that with abnormal strain parameters.
Keywords
Left ventricular systolic deficiency
_
Hypertension_
Speckle tracking echocardiography 1 Introduction
The incidence of systemic hypertension in Vietnam is increasing rapidly. In 1960, the prevalence of systemic hypertension was about 1%, in 1992 was 11.7% and after 10 years the frequency up to 16.9%. Most recently (2008) the frequency of systemic hypertension in Vietnam was 25.1% [1]. Systemic hypertension causes many complications in many organs; cardiovascular complications are one
of the early complications of hypertension. Although there are many facilities for diagnosis and treatment, the frequency of cardiovascular mortality remains high. Therefore, early detection of cardiac complications can improve the frequency of heart failure and reduce cardiovascular mortality.
Echocardiography is a common method of assessing cardiac function, especially systolic function. Left ventricular ejection
fraction is a commonly used parameter in assessment of systolic function. However, the old technique of measurement of this parameter is based on the change in volume so it is affected by loading conditions [2]. Recent studies show that speckle-tracking echocardiography may detect early subclinical systolic dysfunction despite normal ejection fraction [3, 4] this novel technique can assist identify initial
D. T. Nguyen
Can Tho University of Medicine and Pharmacy, Can Tho, Vietnam
V. A. Nguyen
Hue University of Medicine and Pharmacy, Hue, Vietnam L. D. Do _ N. Doan (&)
Ha Noi Medical University, Ha Noi, Vietnam
e-mail: [email protected]; [email protected] N. Doan
Griffith University, The University of Queensland & Queensland University of Technology, Brisbane, Australia
© Springer Nature Singapore Pte Ltd. 2020
V. Van Toi et al. (eds.), 7th International Conference on the Development of Biomedical Engineering in Vietnam (BME7), IFMBE Proceedings 69, https://doi.org/10.1007/978-981-13-5859-3_101
591
cardiac problems owing to hypertension. Therefore, this study carries out “An Evaluation On Initial Deficiency Of Left Ventricular Systolic Function In Patients With Systemic Hypertension By Speckle Tracing Echocardiography”.
2 Materials and Method 2.1 Population
The cross-sectional description study consisted of 194 subjects:
151 hypertensive patients with normal left ventricular ejection fraction and 43 healthy patients from Bach Mai Hospital in Hanoi and National Heart Institute. All subjects were asked for history, clinical examination, taking blood pressure, blood glucose test, lipid test, electrocardiogram and echocardiography. Hypertension: according to the standards of the Vietnam Heart Association in 2015 and according to the European Society of Hypertension/European Cardiovascular Association in 2013 [5].
– Control group: healthy people are those with no cardiovascular disease, no diabetes, no hypertension, and normal
systolic ultrasonographic indexes in accordance with the American Heart Association standard.
– Exclusion criteria: non-sinus rhythm, extra ventricular tachycardia, coronary artery disease, cardiac movement abnormalities, mitral stenosis or aortic stenosis, congenital heart disease, cardiomyopathy, pericarditis and cardiomyopathy, poor visual quality (loss > 3 segments of
cardiac muscle).
2.2 Conventional Echocardiography
Cardiac ultrasonography was performed in all subjects using the Philips iE33 ultrasound, probe scanner S4-2. Measurement of left ventricular ejection fraction was done by
M-mode and Simpson method. Calculate relative wall thickness and left ventricular mass index.
2.3 Application of Speckle Tracking Echocardiography
Using offine QLAB software version 9.0. The parameters are strains of 17 cardiac muscle regions at 3 consecutive cardiac cycles. Analysis of longitudinal deformations conducts on parasternal long axis, 2-chamber and 4 chambers in the apex. Analysis of circumferential and radial deformation
conducted on short axis sections at the bottom, middle and apex level of the heart [6].
2.4 Statistics
Means ± standard deviation was used to denote for continuous variables. The difference between the hypertensive
and control groups was determined by independent t-test (by standard deviation). Statistical significance was established at p < 0.05. The outcomes were investigated using SPSS 18.0.
3 Results
3.1 General Characteristics of the Sample See Tables 1, 2, Figs. 1, 2, 3 and 4.
4 Discussion
4.1 General Characteristics of the Sample
There was no difference in age, sex, BMI, BSA, ejection fraction, left ventricular diastolic diameter between the hypertensive group and the control group.
4.2 Evaluating Systolic Function Along the Longitudinal, Circumferential and Horizontal Axis
In Figs. 1 and 2, longitudinal, circumferential and radial strains were reduced in hypertensive patients compared to controls. This finding is consistent with the results of several studies, such as those of Kosmala [7] and Imbalazano [4].
GLS and GRS decline in hypertensive patients. According to Altiok E and et al., the cause of this changes is due to
increase in chronic pressure to the heart wall which promotes collagen synthesis in sub-endothelium layer. Along with this biochemical change, cardiac fibrosis is one of the contributing factors to myocardial dysfunction in hypertensive
patients [2]. Therefore, the longitudinal strain declines.
Sengupta [8] studied on 59 hypertensive patients. It found
that in hypertensive patients without left ventricular hypertrophy, GLS of the endothelium and peripheral layer were
reduced, GCS decreased only in the peripheral layer.
In young patients, Galderisi also found that GLS declined very early phase of complication [9] and even in the
pre-hypertension [10] with speckle tracking echocardiography.
Kosmala [7] also reported that GLS was an early indicator of preclinical left ventricular dysfunction.
Mizuguchi Y’s study in Asian subjects, longitudinal,
circumferential and radial strain were reduced in hypertensive patients with left ventricular hypertrophy [11].
592 D. T. Nguyen et al.
4.3 Evaluation of Left Ventricular Systolic Function in Multiple Directions
Kouzu and et al. reported that total systolic function was the result of myocardial contractility in a many directions, such as longitudinal, circumferential and radial axis [7]. Therefore, the evaluation of systolic function by conventional
method was only a partial evaluation of systolic function.
Daniel and et al. found that longitudinal-circumferential index and systolic index are more sensitive than longitudinal systolic strain and left ventricular ejection fraction. On the other hand, longitudinal-circumferential index and systolic index correlated negatively with NYHA [12]. Our study of perimeter and systolic indexes decreased in hypertensive patients and decreased the most in hypertensive patients with
normal ejection fraction.
Table 1 General characteristics of the sample
Characteristics Control (n = 43) _X + SD_ Hypertension (n = 151) _X + SD_ p Age 58.33 ± 8.21 60.91 ± 8.13 0.068
Sex (male) % 39.7 37.7 0.831 BMI 22.13 ± 2.27 22.83 ± 2.23 0.71 BSA (m2) 1.58 ± 0.144 1.58 ± 0.141 0.96
Systolic BP (mmHg) 114.19 ± 10.63 137.62 ± 12.8 <0.001 Diastolic BP (mmHg) 68.02 ± 9.01 81.52 ± 8.54 <0.001 LVMI (g/m2) 72.44 ± 14.92 87.43 ± 23.68 <0.001 EF- Mode (%) 69.53 ± 5.54 70.65 ± 6.18 0.29 EF-Simpson (%) 65.79 ± 5.71 65.28 ± 6.33 0.65 LVIDd (cm) 4.58 ± 0.38 4.5 ± 0.45 0.3
RWT 0.35 ± 0.05 0.42 ± 0.21 0.02
Remarks There was no difference in age, sex, BMI, BSA, ejection fraction, left ventricular diastolic diameter between the hypertensive group and
the control group
Table 2 Systolic blood pressure levels by longitudinal-circumferential index and systolic index Systolic BP (mmHg) Longitudinal-circumferential p
Normal Reduction
127.93 ± 9.02 139.92 ± 12.51 <0.001 (95%CI 7.94 ± 16.04) Systolic BP (mmHg) Systolic index p
Normal Reduction
128.57 ± 8.1 141.96 ± 12.39 <0.001 (95%CI 10.05 ± 16.73)
Remarks Mean systolic BP in the group with lower longitudinal-circumferential index and systolic index is higher than that with normal index
Fig. 1 Ilustration of longitudinal strain and circumferential strain: a Longitudinal strain in the hypertensive group was lower than that of the
control group with p < 0.001. b Circumferential strain was lower in the hypertensive group than in the control group with p < 0.001
An Evaluation on Initial Deficiency of Left Ventricular … 593
4.4 Systolic Blood Pressure Level by Longitudinal-Circumferential Index and Systolic Index
In Table 2, we found that mean systolic blood pressure in the group with normal longitudinal-circumferential index and systolic index was <130 mmHg.
In fact, many authors also reported that in patients with hypertension, the rate of cardiovascular events increased with blood pressure [13]. According to SPRINT study, the mean systolic blood pressure was 121.4 mmHg in the intensive treatment group and 136.2 mm Hg in the standard-treatment group. The intervention was stopped early after a median follow-up of 3.26 years owing to a significantly lower rate of the primary composite outcome in the intensive-treatment group than in the standard-treatment group [14].
In addition, the American Heart Association, American Heart Association and other American associations agree
that the level of systolic blood pressure for reducing cardiovascular risk is <130/80 mmHg [15].
This paper indicated that Speckle tracking echocardiography could detect early sub-clinical left ventricular systolic
dysfunction in hypertensive group that could not be detected by conventional method, which is ventricular ejection fraction, by echocardiography. Nevertheless, no longitudinal
report was carried out to ratify whether clinical left ventricular systolic dysfunction truly established in this group. It
implies that we still don’t know the sensitivity and specificity of the existing technique. Thus, further longitudinal
studies are required. Recently, Three-dimensional (3D) speckle-tracking echocardiography (3DSTE) [16] 3DSTE has the prospective to overwhelm various inherent restraints of two-dimensional STE (2DSTE) in the evaluation of
complicated LV myocardial mechanism, proposing extra distortion parameters (such as area strain) and a
wide-ranging quantitation of LV geometry and work from a single 3D acquirement.
5 Conclusion
This study illustrated left ventricular systolic strain, such as longitudinal, circumferential and radial strain; longitudinal–
circumferential index, systolic index diminished in hypertensive sufferers with typical left ventricular ejection fraction
in contrast to control group. At the same time, the mean systolic blood pressure in the group with normal longitudinal–
circumferential index, systolic index was lower than
130 mmHg. Additional clinical assessment, novel technique, and vigorous substantiation with this method are required so as to enhance its clinical practice and to recognize its benefits in contrast with the traditional approaches. Therefore,
future longitudinal studies are required.
Confict of Interest The authors declare that they have no confict of interest.
Fig. 2 Radial strain: Mean radial strain was lower in the hypertensive group than in the control group with p < 0.001
Fig. 3 Comparison of longitudinal-circumferential indexes in
hypertensive patients and control groups: The longitudinalcircumferential index in patients with hypertension was lower than
controls
Fig. 4 Systolic index in hypertensive patients and control groups:
Systolic index in hypertensive patients is lower than control group 594 D. T. Nguyen et al.
References
1. Son, P.T., Quang, N.N., Viet, N.L., Khai, P.G., Wall, S., et al.:
Prevalence, awareness, treatment and control of hypertension in Vietnam -results from a national survey. J. Human Hypertens. 1–
13 (2011)
2. Carluccio, E., Biagioli, P., Alunni, G., Murrone, A., et al.:
Advantages of deformation indices over systolic velocities in assessment of longitudinal systolic function in patients with heart failure and normal ejection fraction. Eur. J. Heart Fail. 13, 292–
302 (2011)
3. Altiok, E., Neizel, M., Tiemann, S., Krass, V., et al.: Quantitative analysis of endocardial and epicardial left ventricular myocardial deformation-comparison of strain-encoded cardiac magnetic resonance imaging with two-dimensional speckle-tracking echocardiography.
J. Am. Soc. Echocardiogr. 25, 1179–1188 (2012)
4. Imbalzano, E., Zito, C., Carerj, S., et al.: Left ventricular function in hypertension: new insight by speckle tracking echocardiography.
Echocardiography 28, 649–657 (2011)
5. Viet Nam Heart association: Guideline on diagnosis and treatment of systemic hypertension (2015)
6. Phan, T.T., Shivu, G.N., Abozguia, K., Gnanadevan, M., et al.:
Left ventricular torsion and strain patterns in heart failure with normal ejection fraction are similar to age-related changes. Eur.J Echocardiogr. 10, 793–800 (2009)
7. Kosmala, W., Plaksej, R., Strotmann, J.M., et al.: Progression of left ventricular function abnormalities in hypertension patients with heart failure: an ultrasonic two dimensional speckle tracking study. J. Am. Soc. Echocardiogr. 21, 1309–1317 (2008)
8. Sengupta, S.P., Caracciolo, G., Thompson, C.: Early impairment of left ventricular function in patients with systemic hypertension:
new insights with 2- dimensional speckle tracking echocardiography.
Indian Heart J. 65, 48–52 (2013)
9. Galderisi, M., Lomoriello, V.S., Santoro, A., et al.: Differences of myocardial systolic deformation and correlates of diastolic function in competitive rowers and young hypertensives: a speckletracking echocardiography study. J. Am. Soc. Echocardiogr. 23,
1190–1198 (2010)
10. Di Bello, V., Talini, E., Dell’Omo, G., et al.: Early left ventricular
mechanics abnormalities in prehypertension: a two- dimensional strain echocardiography study. Am. J. Hypertens. 23, 405–412 (2010)
11. Mizuguchi, Y., Oishi, Y., Miyoshi, H., et al.: Possible mechanism of left ventricular torsion evaluated with hypertension. Eur.
J. Echocardiogr. 11, 690–697 (2010)
12. Morris, D.A., Boldt, L.-H., Eichstadt, H., et al.: Myocardial systolic and Diastolic performance derived by 2-Dimensional speckle tracking echocardiography in heart failure with normal left ventricular ejection fraction clinical perspective. Circ. Heart Fail.
5, 610–620 (2012)
13. Kuroda, K., Kato, T.S., Amano, A.: Hypertensive cardiomyopathy:
a clinical approach and literature review. World J. Hypertens.
5(2), 41–52 (2015)
14. Wright, J.T., Williamson, J.D., Whelton, P.K., et al.: A randomized trial of intensive versus standard blood-pressure control,
https://doi.org/10.1056/nejmoa1511939 (2015)
15. Whelton, P.K., Carey, R.M., Carey, R.M.: ACC/AHA/AAPA/
ABC/ACPM/APhA, Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults.
https://doi.org/10.1016/j.jacc.2017.11.006 (2017)
16. Mararu, D., et al.: Three-dimensional speckle-tracking echocardiography:
benefits and limitations of integrating myocardial
mechanics with three-dimensional imaging. Cardiovasc. Diagn.
Ther. 8(1), 101–117 (2018
