Publications (23)102.11 Total impact
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Article: Left Atrial Volume as Predictor of Valve Replacement and Cardiovascular Events in Patients with Asymptomatic Mild to Moderate Aortic Stenosis.
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ABSTRACT: BACKGROUND: Left atrial (LA) size is known to increase with chronically increased left ventricular (LV) filling pressure. We hypothesized that LA volume was predictive of aortic valve replacement (AVR) and cardiovascular events in a large cohort of patients with asymptomatic mild to moderate aortic valve stenosis. METHODS: Transthoracic echocardiography was performed in 1,758 patients in the Simvastatin and Ezetemibe in Aortic Stenosis study. LA volume was measured in the apical four-chamber view in 1,503 patients (85%). The relation of LA volume to AVR or a combined endpoint of cardiovascular events (AVR, congestive heart failure due to aortic stenosis or death from cardiovascular causes) was evaluated. RESULTS: AVR was performed in 415 (28%) patients, whereas 505 (34%) reached the combined endpoint. A significant but weak association of increased LA volume and risk of the combined endpoint was found (log-rank test: P = 0.02), but this relation did not reach any significance in a multivariate model adjusting for age, gender, aortic valve area index, LV ejection fraction, LV hypertrophy, hypertension, and mitral regurgitation. LA volume was not predictive of AVR (log-rank test: P = 0.3). CONCLUSION: In asymptomatic patients with mild to moderate Aortic valve stenosis (AS), LA volume was not predictive of the combined endpoint of Aortic valve replacement, development of heart failure or cardiac death. AVA and presence of LV hypertrophy were the only predictors of events in multivariate analysis.Echocardiography 04/2013; · 1.24 Impact Factor -
Article: Prognostic Value of Energy Loss Index in Asymptomatic Aortic Stenosis.
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ABSTRACT: BACKGROUND: Aortic valve area index adjusted for pressure recovery (energy loss index [ELI]) has been suggested as a more accurate measure of aortic stenosis (AS) severity, but its prognostic value has not been determined in a prospective study. METHODS AND RESULTS: The relation between baseline ELI and rate of aortic valve events and combined total mortality and hospitalization for heart failure due to progression of AS was assessed by multivariate Cox regression and reclassification analysis in 1563 patients with initial asymptomatic AS in the Simvastatin and Ezetimibe in Aortic Stenosis (SEAS) study. During 4.3 years follow-up, a total of 498 aortic valve events and 181 combined total mortality and hospitalizations for heart failure due to progression of AS events occurred. In Cox regression analyses, 1 cm(2)/m(2) lower baseline ELI predicted a 2-fold higher risk both for aortic valve events and for combined total mortality and hospitalization for heart failure independent of baseline peak aortic jet velocity or mean aortic gradient and independent of aortic root size (all p<0.05). In reclassification analysis, ELI improved prediction of aortic valve events by 13% (95% confidence interval 5 to 19%) while prediction of combined total mortality and hospitalization for heart failure due to progression of AS did not improve significantly. CONCLUSIONS: In asymptomatic AS patients without known atherosclerotic disease or diabetes, ELI provides independent and additional prognostic information to that derived from conventional measures of AS severity, suggesting that ELI should be measured in such patients. CLINICAL TRIAL REGISTRATION INFORMATION: http://ClinicalTrials.gov. Identifier: NCT00092677.Circulation 01/2013; · 14.74 Impact Factor -
Article: Global LV load in asymptomatic aortic stenosis: covariates and prognostic implication (the SEAS trial).
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ABSTRACT: INTRODUCTION: Valvuloarterial impedance (Zva) is a measure of global (combined valvular and arterial) load opposing left venticular (LV) ejection in aortic stenosis (AS). The present study identified covariates and tested the prognostic significance of global LV load in patients with asymptomatic AS. METHODS: 1418 patients with mild-moderate, asymptomatic AS in the Simvastatin Ezetimibe in Aortic Stenosis (SEAS) study were followed for a mean of 43+/-14 months during randomized, placebo-controlled treatment with combined simvastatin 40 mg and ezetimibe 10 mg daily. High global LV load was defined as Zva >5 mm Hg/ml/m2. The impact of baseline global LV load on rate of major cardiovascular (CV) events, aortic valve events and total mortality was assessed in Cox regression models reporting hazard ratio (HR) and 95% Confidence Intervals (CI). RESULTS: High global LV load was found in 18% (n=252) of patients and associated with female gender, higher age, hypertension, more severe AS and lower ejection fraction (all p<0.05). A total of 476 major CV events, 444 aortic valve events and 132 deaths occurred during follow-up. In multivariate Cox regression analyses, high global LV load predicted higher rate of major CV events (HR 1.35 [95% CI 1.08-1.71], P=0.010) and aortic valve events (HR 1.41[95% CI 1.12-1.79], P=0.004) independent of hypertension, LV ejection fraction, female gender, age, abnormal LV geometry and AS severity, but failed to predict mortality. CONCLUSION: In asymptomatic AS, assessment of global LV load adds complimentary information on prognosis to that provided by hypertension or established prognosticators like AS severity and LV ejection fraction.Cardiovascular Ultrasound 11/2012; 10(1):43. · 1.26 Impact Factor -
Article: Left Atrial Systolic Force and Outcome in Asymptomatic Mild to Moderate Aortic Stenosis.
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ABSTRACT: Background and Aims: In patients with chronic pressure overload due to hypertension or aortic valve stenosis (AS), higher left atrial systolic force (LASF) is associated with a high-risk cardiovascular (CV) phenotype. We tested LASF as prognostic marker in patients with AS. Methods: We used baseline and outcome data from 1,566 patients recruited in the Simvastatin and Ezetimibe in AS (SEAS) study evaluating the effect of placebo-controlled simvastatin and ezetimibe treatment on CV events. The primary outcome was a composite of major CV events, including CV death, aortic valve replacement, nonfatal myocardial infarction, hospitalization for unstable angina, heart failure caused by progression of AS, coronary artery bypass grafting, percutaneous coronary intervention, and nonhemorrhagic stroke. LASF was calculated by Manning's method. High LASF was defined as >95th percentile (50 Kdynes/cm(2) ) of the distribution within the study population. Results: During 4.3 years of follow-up, a major CV event occurred in 38 of 78 patients with high LASF (49%) and in 513 of 1,488 (34%) with normal LASF (P = 0.01). In multivariate Cox regression analysis, high LASF predicted higher rate of major CV events (Hazard ratio 1.43 [95% confidence interval 1.01-2.03] independent of aortic valve area and LV mass index. A simple risk score including absence or presence of these three variables allowed risk stratification into low, intermediate, high and very high risk for major CV events during follow-up (22%, 28%, 38%, and 53%, respectively). Conclusions: Higher LASF provides additional prognostic information in patients with asymptomatic mild-to-moderate AS.Echocardiography 06/2012; 29(9):1038-1044. · 1.24 Impact Factor -
Article: Hypertension in aortic stenosis: implications for left ventricular structure and cardiovascular events.
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ABSTRACT: The impact of hypertension on left ventricular structure and outcome during progression of aortic valve stenosis has not been reported from a large prospective study. Data from 1616 patients with asymptomatic aortic stenosis randomized to placebo-controlled treatment with combined simvastatin and ezetimibe in the Simvastatin Ezetimibe in Aortic Stenosis Study were used. The primary study end point included combined cardiovascular death, aortic valve events, and ischemic cardiovascular events. Hypertension was defined as history of hypertension or elevated baseline blood pressure. Left ventricular hypertrophy was defined as left ventricular mass/height(2.7) ≥ 46.7 g/m(2.7) in women and ≥ 49.2 g/m(2.7) in men and concentric geometry as relative wall thickness ≥ 0.43. Baseline peak aortic jet velocity and aortic stenosis progression rate did not differ between hypertensive (n = 1340) and normotensive (n = 276) patients. During 4.3 years of follow-up, the prevalence of concentric left ventricular hypertrophy increased 3 times in both groups. Hypertension predicted 51% higher incidence of abnormal LV geometry at final study visit independent of other confounders (P<0.01). In time-varying Cox regression, hypertension did not predict increased rate of the primary study end point. However, hypertension was associated with a 56% higher rate of ischemic cardiovascular events and a 2-fold increased mortality (both P<0.01), independent of aortic stenosis severity, abnormal left ventricular geometry, in-treatment systolic blood pressure, and randomized study treatment. No impact on aortic valve replacement was found. In conclusion, among patients with initial asymptomatic mild-to-moderate aortic stenosis, hypertension was associated with more abnormal left ventricular structure and increased cardiovascular morbidity and mortality.Hypertension 05/2012; 60(1):90-7. · 6.21 Impact Factor -
Article: Inappropriately high left-ventricular mass in asymptomatic mild-moderate aortic stenosis.
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ABSTRACT: In some patients with aortic stenosis left-ventricular hypertrophy exceeds what is needed to sustain the hemodynamic load imposed by the aortic stenosis, a condition named inappropriately high left-ventricular mass (iLVM). Although iLVM is associated with increased mortality after aortic valve replacement, prevalence and covariates of iLVM in asymptomatic aortic stenosis are unknown. We analyzed baseline data from 1614 patients (67 ± 10 years, 51% hypertensive) recruited in the Simvastatin Ezetimibe in Aortic Stenosis study evaluating placebo-controlled combined simvastatin and ezetimibe treatment in asymptomatic mild-moderate aortic stenosis. iLVM was diagnosed by Doppler echocardiography as LVM greater than 28% of the expected LVM predicted from height, sex and stroke work. iLVM was detected in 268 patients (16.6%), irrespective of concomitant hypertension. Patients with iLVM had higher body weight, LVM and relative wall thickness, higher prevalence of systolic dysfunction (88 vs. 15%) and lower left-ventricular afterload (all P < 0.01) than patients with appropriate LVM in spite of comparable aortic stenosis severity. In multivariate analysis, all these five variables were independently associated with iLVM. The simple coexistence of low stress-corrected midwall shortening and left-ventricular hypertrophy was the best clinical model describing iLVM phenotype (sensitivity 72%, specificity 96%, area under the receiver operating characteristic curve 0.954). iLVM is common in asymptomatic mild-moderate aortic stenosis and unrelated to severity of aortic stenosis or presence of hypertension. iLVM was associated with combined concentric geometry and reduced left-ventricular myocardial contractility, suggesting iLVM in asymptomatic aortic stenosis as a marker of more advanced myocardial disease.Journal of hypertension 12/2011; 30(2):421-8. · 4.02 Impact Factor -
Article: Left atrial systolic force in asymptomatic aortic stenosis.
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ABSTRACT: There is a limited knowledge about left atrial (LA) systolic force (LASF) and its key determinants in patients with asymptomatic mild-moderate aortic stenosis (AS). We used baseline clinic and echocardiographic data from 1,566 patients recruited in the simvastatin ezetimibe in aortic stenosis study evaluating the effect of placebo-controlled combined simvastatin and ezetimibe treatment in asymptomatic AS. The LASF was calculated by Manning's method. Low and high LASF were defined as <5th and >95th percentile of the distribution within the study population, respectively. Mean LASF in the total study population was 21±14 kdynes/cm2. The determinants of LASF were higher age, heart rate, body mass index, systolic blood pressure, left ventricular (LV) mass, mitral peak early velocity, maximal LA volume, and longer mitral deceleration time (multiple R2=0.37, P<0.01). High LASF (78 patients) was characterized by abnormal LV relaxation in 90% of the cases. Low LASF (82 patients) was associated with restrictive LV filling pattern, absence of abnormal relaxation pattern, smaller maximal LA volume, and lower body mass index. In 40% of the patients with low LASF, estimated LV filling pressures were normal and the reduced LA force was explainable by an intrinsic systolic LA dysfunction. In patients with asymptomatic AS, LASF was closely related to filling pressure. Higher LASF invariably signifies the maximal LA effort to keep near normal LV filling pressure; lower LASF belongs to a heterogeneous group of patients in which it is much more difficult to depict who have low LA preload or who have intrinsic systolic LA dysfunction.Echocardiography 08/2011; 28(9):968-77. · 1.24 Impact Factor -
Article: Aortic root geometry in aortic stenosis patients (a SEAS substudy).
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ABSTRACT: To report aortic root geometry by echocardiography in a large population of healthy, asymptomatic aortic stenosis (AS) patients in relation to current vendor-specified requirements for transcatheter aortic valve implantation (TAVI). Baseline data in 1481 patients with asymptomatic AS (mean age 67 years, 39% women) in the Simvastatin Ezetimibe in AS study were used. The inner aortic diameter was measured at four levels: annulus, sinus of Valsalva, sinotubular junction and supracoronary, and sinus height as the annulo-junctional distance. Analyses were based on vendor-specified requirements for the aortic root geometry for current available prostheses, CoreValve and Edwards-Sapien. The ratio of sinus of Valsalva height to sinus width was 1:2. In multivariate linear regression analysis, larger sinus of Valsalva height was associated with older age, larger sinus of Valsalva diameter, lower ejection fraction and smaller supracoronary diameter (multiple R(2) = 0.19, P< 0.01). The required annulus diameter for implantation of CoreValve was met in 61.9%, and for the Edwards-Sapien prosthesis in 66.9%. Overall, annular dimension feasible for TAVI using any available prosthesis was found in 78.2% of patients and in 77.7% of patients also the required minimum sinus of Valsalva height was found. Comparing the group of patients who met TAVI requirements to those who did not, the latter included more women and patients with lower body height and weight and significantly smaller aortic root diameters (all P < 0.05). Among AS patients in the SEAS study, 27% of women and 19% of men did not have aortic root geometry fulfilling current requirements for TAVI.European Heart Journal – Cardiovascular Imaging 04/2011; 12(8):585-90. · 2.32 Impact Factor -
Article: Prognostic effect of inappropriately high left ventricular mass in asymptomatic severe aortic stenosis.
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ABSTRACT: In patients with aortic stenosis (AS) left ventricular (LV) myocardial growth may exceed individual needs to compensate LV haemodynamic load leading to inappropriately high LV mass (iLVM), a condition at high risk of adverse cardiovascular events. The prognostic impact of iLVM was determined in 218 patients with asymptomatic severe AS. iLVM was recognised when the measured LV mass exceeded 10% of the expected value predicted from height, sex and stroke work (prognostic cut-off assessed by a specific ROC analysis). For assessment of outcome, the endpoint was defined as death from all causes, aortic valve replacement or hospital admission for non-fatal myocardial infarction and/or congestive heart failure. At the end of follow-up (22+13 months) complete clinical data were available for 209 participants (mean age 75+11 years). A clinical event occurred in 81 of 121 patients (67%) with iLVM and in 26 of 88 patients (30%) with appropriate LV mass (aLVM) (p<0.001). Event-free survival in patients with aLVM and iLVM was 78% vs 56% at 1-year, 68% vs 29% at 3-year and 56% vs 10% at 5-year follow-up, respectively (all p<0.01). Cox analysis identified iLVM as a strong predictor of adverse outcome (Exp β 3.08; CI 1.65 to 5.73) independent of diabetes, transaortic valve peak gradient and extent of valvular calcification. Among patients with LV hypertrophy, those with iLVM had a risk of adverse events 4.5-fold higher than counterparts with aLVM. iLVM is common in patients with asymptomatic severe AS and is associated with an increased rate of cardiovascular events independent of other prognostic covariates.Heart (British Cardiac Society) 02/2011; 97(4):301-7. · 4.22 Impact Factor -
Article: Impact of pressure recovery on echocardiographic assessment of asymptomatic aortic stenosis: a SEAS substudy.
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ABSTRACT: The aim of this analysis was to assess the diagnostic importance of pressure recovery in evaluation of aortic stenosis (AS) severity. Although pressure recovery has previously been demonstrated to be particularly important in assessment of AS severity in groups of patients with moderate AS or small aortic roots, it has never been evaluated in a large clinical patient cohort. Data from 1,563 patients in the SEAS (Simvastatin and Ezetimibe in Aortic Stenosis) study was used. Inner aortic diameter was measured at annulus, sinus, sinotubular junction, and supracoronary level. Aortic valve area index (AVAI) was calculated by continuity equation and pressure recovery and pressure recovery adjusted AVAI (energy loss index [ELI]), by validated equations. Primarily, sinotubular junction diameter was used to calculate pressure recovery and ELI, but pressure recovery and ELI calculated at different aortic root levels were compared. Severe AS was identified as AVAI and ELI < or =0.6 cm(2)/m(2). Patients were grouped into tertiles of peak transaortic velocity. Pressure recovery increased with increasing peak transaortic velocity. Overestimation of AS severity by unadjusted AVAI was largest in the lowest tertile and if pressure recovery was assessed at the sinotubular junction. In multivariate analysis, a larger difference between AVAI and ELI was associated with lower peak transaortic velocity (beta = 0.35) independent of higher left ventricular ejection fraction (beta = -0.049), male sex (beta = -0.075), younger age (beta = 0.093), and smaller aortic sinus diameter (beta = 0.233) (multiple R(2) = 0.18, p < 0.001). Overall, 47.5% of patients classified as having severe AS by AVAI were reclassified to nonsevere AS when pressure recovery was taken into account. For accurate assessment of AS severity, pressure recovery adjustment of AVA must be routinely performed. Estimation of pressure recovery at the sinotubular junction is suggested.JACC. Cardiovascular imaging 06/2010; 3(6):555-62. · 14.29 Impact Factor -
Article: Asymmetric septal hypertrophy - a marker of hypertension in aortic stenosis (a SEAS substudy).
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ABSTRACT: Some patients with aortic stenosis develop asymmetric septal hypertrophy (ASH) that may influence the surgical approach and is associated with higher perioperative morbidity. The aim of this analysis was to characterize further this subtype of aortic stenosis patients. Baseline data in 1719 patients with asymptomatic aortic stenosis, participating in the Simvastatin Ezetimibe in Aortic Stenosis study evaluating the effect of combined treatment with simvastatin and ezetimibe on progression of aortic stenosis was used. The study population was divided according to presence of ASH (interventricular septal/posterior wall thickness ratio >1.5). Left ventricular (LV) hypertrophy was considered present if LV mass index > or =104 g/m(2) in women and > or =116 g/m(2) in men. ASH was present in 22% of patients and associated with higher LV mass index, total peripheral resistance and peak transaortic velocity and concomitant hypertension (all p<0.05). Thirty-four percent of patients with ASH had combined ASH and LV hypertrophy (asymmetric LV hypertrophy). These patients had higher systolic blood pressure, lower LV ejection fraction and larger left atrial diameter than patients with ASH only. In logistic regression analyses, hypertension was the most important predictor both for ASH (odds ratio, OR 1.38 [1.05-1.82]) and for asymmetric LV hypertrophy (OR 2.99 [1.71-5.25]), both p<0.05) independent of other covariates including severity of aortic stenosis. Hypertension is the main clinic characteristic of ASH and asymmetric LV hypertrophy in patients with asymptomatic aortic stenosis independent of severity of aortic stenosis.Blood pressure 06/2010; 19(3):140-4. · 1.26 Impact Factor -
Article: Severe obstructive sleep apnea elicits concentric left ventricular geometry.
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ABSTRACT: Obstructive sleep apnea (OSA) has several negative effects on the heart including increase in myocardial end-systolic stress, venous return and sympathetic activity, all potential stimuli of left ventricular (LV) hypertrophy. The impact of the severity of OSA on LV geometry is unknown. We hypothesized that OSA is related to concentric LV geometry. One hundred and fifty-seven patients with suspected OSA underwent echocardiography, ambulatory 24-h blood pressure and ECG monitoring. On the basis of the severity of OSA, patients were divided into controls, mild OSA and moderate/severe OSA (apnea-hypopnea index <5, 5-15 and >15/h, respectively). Patients with LV hypertrophy were defined as LV mass at least 49.2 g/m2.7 for men and at least 46.7 for women. Relative wall thickness of at least 0.43 identified patients with concentric LV geometry. Patients with moderate/severe OSA (n = 86) had a higher body mass index and a higher prevalence of paroxysmal atrial fibrillation than those (n = 51) with mild OSA and controls (n = 20). Prevalence of hypertension, diabetes, obesity, LV mass and blood pressure did not differ between the groups. Relative wall thickness was positively related to apnea-hypopnea index (r = 0.30; P = 0.003) and the prevalence of concentric LV geometry was 20% in controls, 12% in mild OSA and 58% in moderate/severe OSA (P < 0.001). In logistic regression analysis concentric LV geometry was associated with moderate/severe OSA [odds ratio (OR) 7.6, P < 0.001], low stress-corrected midwall shortening (OR 3.38, P = 0.004), and higher body mass index (OR 1.09, P = 0.03). Moderate/severe OSA is associated with high prevalence of concentric LV geometry. This increased prevalence may in part explain the increased rate of cardiovascular events in these patients.Journal of hypertension 05/2010; 28(5):1074-82. · 4.02 Impact Factor -
Article: Effect of obesity on left ventricular mass and systolic function in patients with asymptomatic aortic stenosis (a Simvastatin Ezetimibe in Aortic Stenosis [SEAS] substudy).
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ABSTRACT: Obesity and hypertension are associated with left ventricular (LV) hypertrophy. Whether an increased body mass index (BMI) affects LV hypertrophy in patients with asymptomatic aortic stenosis independent of hypertension is not known. We used the clinical blood pressure, BMI, and echocardiographic findings recorded at baseline of 1,703 patients with asymptomatic aortic stenosis (AS) participating in the Simvastatin Ezetimibe in Aortic Stenosis (SEAS) study. The patient population was divided into 3 BMI classes: normal BMI, 18.5 to 24.9 kg/m(2); overweight, BMI 25.0 to 29.9 kg/m(2); and obese, BMI > or =30.0 kg/m(2). For the total study population, the average blood pressure was 145/82 +/- 20/10 mm Hg, age 67 +/- 10 years, BMI 26.9 +/- 4.3 kg/m(2), and peak transaortic velocity 3.1 +/- 0.5 m/s. The prevalence of hypertension increased with increasing BMI class (43% vs 51% and 63%, p <0.01). The LV mass and prevalence of LV hypertrophy increased with an increasing BMI (22% in normal, 38% in overweight, and 54% in obese patients). The LV ejection fraction and stress-corrected mid-wall fractional shortening decreased (p <0.01 vs normal-weight group). On multiple logistic regression analysis, the presence of LV hypertrophy was associated with a greater BMI (odds ratio 1.15, 95% confidence interval 1.12 to 1.18), independent of a history of hypertension, the severity of AS, older age, systolic blood pressure, and lower LV ejection fraction (all p <0.05). Valve regurgitation and gender had no independent association with the presence of LV hypertrophy. In conclusion, a greater BMI was associated with the presence of LV hypertrophy in patients with asymptomatic AS, independent of AS severity and the presence of hypertension.The American journal of cardiology 05/2010; 105(10):1456-60. · 3.58 Impact Factor -
Article: Left atrial size and force in patients with systolic chronic heart failure: Comparison with healthy controls and different cardiac diseases.
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ABSTRACT: Left atrial (LA) systolic force (LASF) is significantly increased in chronic heart failure (CHF), arterial hypertension (HT) and aortic stenosis (AS). The increase is proportional to the degree of left ventricular hypertrophy and diastolic dysfunction. To assess the magnitude of changes in maximal LA volume (LAV(max)) and LASF in systolic CHF compared with other cardiac diseases, and to assess whether the left atrium remodels differently and works in response to specific conditions affecting diastolic function and to individual factors associated with LA alterations. LAV(max) and LASF were measured and evaluated by two-dimensional Doppler echocardiography in 94 patients with systolic CHF and normal left ventricular filling pressure, 100 control patients, 181 patients with HT, 40 patients with idiopathic hypertrophic cardiomyopathy (HCMP) and 85 patients with AS. The prevalence of LA dilation and supernormal LASF (defined as values of LAV(max) and LASF exceeding two SDs of the mean of controls) was measured in all groups. LAV(max) and LASF were 7.1±2 mL/m(3) and 7.8±4 kdynes in controls, and 11.0±4 mL/m(3) and 19.7±11 kdynes in systolic CHF patients, respectively (both P<0.001). These values were significantly higher than in patients with HT, but similar to those with AS and HCMP. LA dilation and supernormal LASF were detected in 13% and 11% of patients with HT, 32% and 59% of patients with AS, 26% and 43% of patients with HCMP, and 41% and 56% of patients with systolic CHF, respectively (all P<0.01). In multiple logistic analysis, systolic CHF represented the strongest predictor of supernormal LASF. It was not independently associated with LA dilation, which was mainly related to indexes of volume load. LAV(max) and LASF were markedly increased in patients with systolic CHF, with a magnitude that was significantly higher than that of HT patients, but similar to that measured in HCMP and AS patients. In the present community population with various cardiac diseases, systolic CHF represented the most powerful stimulus for increasing LASF and was not related to LA dilation.Experimental and clinical cardiology 01/2010; 15(3):e45-51. · 0.58 Impact Factor -
Article: Impact of hypertension on left ventricular structure in patients with asymptomatic aortic valve stenosis (a SEAS substudy).
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ABSTRACT: Both hypertension and aortic valve stenosis induce left ventricular hypertrophy. However, less is known about the influence of concomitant hypertension on left ventricular structure in patients with aortic valve stenosis. Baseline Doppler echocardiography was performed in 1720 patients with asymptomatic aortic valve stenosis (peak transaortic velocity >or=2.5 m/s and <or=4.0 m/s) recruited in the Simvastatin and Ezetimibe in Aortic Stenosis study at 173 centers in seven European countries. Patients were grouped as normotensive (n = 482) or hypertensive (n = 1238) according to history of hypertension or clinic blood pressure greater than 140 mmHg systolic or greater than 90 mmHg diastolic at baseline visits. Hypertensive patients were older, more obese, and included more women (all P < 0.05). Furthermore, the hypertensive group had higher wall thicknesses and left ventricular mass and higher prevalence of left ventricular hypertrophy (40 vs. 25%) and increased relative wall thickness (21 vs. 14%, both P < 0.01). On the basis of aortic valve area and energy loss the degree of aortic valve stenosis did not differ between the groups. In multivariate analysis, hypertension predicted higher left ventricular mass independent of other well known confounders including male sex, circumferential end-systolic stress, body mass index, aortic regurgitation, left ventricular ejection fraction and severity of aortic stenosis (multiple R = 0.30, P < 0.001). In patients with asymptomatic aortic stenosis, concomitant hypertension significantly influences left ventricular geometry and is associated with higher left ventricular mass, relative wall thickness and higher prevalence of left ventricular hypertrophy.Journal of hypertension 10/2009; 28(2):377-83. · 4.02 Impact Factor -
Article: Myocardial deformation in aortic valve stenosis: relation to left ventricular geometry.
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ABSTRACT: To assess left ventricular (LV) strain and displacement and their relations to LV geometry in patients with aortic stenosis (AS). Cross-sectional echocardiographic study in patients with AS. Peak circumferential, radial and longitudinal strain, and radial, longitudinal and transverse displacement were measured by 2D speckle tracking. Severity of AS was assessed from energy loss index (ELI). LV hypertrophy was present if LV mass/height(2.7) > or =46.7/49.2 g/m(2.7) in women/men and concentric LV geometry if relative wall thickness > or =0.43. LV geometry was assessed from LV mass/height(2.7) and relative wall thickness in combination. Setting Department of Heart Disease, Haukeland University Hospital, Bergen, Norway. 70 patients with AS (mean age 73+/-10 years, 54% women). None. Main outcome measures Association of regional and average LV myocardial strain and displacement with LV geometric pattern and degree of AS. Average longitudinal strain was lower in the hypertrophy groups and correlated with higher LV mass index and relative wall thickness, lower stress-corrected mid-wall shortening and smaller ELI (all p<0.05). Average strain and displacement in other directions did not differ between geometric groups. In multivariate regression analysis, lower average longitudinal strain was associated with higher relative wall thickness (beta=0.15), lower ejection fraction (beta=-0.16), systolic blood pressure (beta=-0.16) and energy loss index (beta=-0.20) (all p<0.05) (R(2)=0.72). When relative wall thickness was replaced with LV mass, lower longitudinal strain was also associated with higher LV mass (beta=0.21, p<0.05) (R(2)=0.73). In patients with AS, lower average longitudinal strain is related to higher LV mass, concentric geometry and more severe AS.Heart (British Cardiac Society) 09/2009; 96(2):106-12. · 4.22 Impact Factor -
Article: Low-flow aortic stenosis in asymptomatic patients: valvular-arterial impedance and systolic function from the SEAS Substudy.
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ABSTRACT: This study sought to assess the impact of valvuloarterial impedance on left ventricular (LV) myocardial systolic function in asymptomatic aortic valve stenosis (AS). In atherosclerotic AS, LV global load consists of combined valvular and arterial resistance to LV ejection. Global load significantly impacts LV ejection fraction (EF) in symptomatic AS, but less is known about its effect on LV myocardial function in asymptomatic AS. Echocardiograms in 1,591 patients with asymptomatic AS (67 +/- 10 years, 51% hypertensive) at baseline in the SEAS (Simvastatin Ezetimibe in Aortic Stenosis) study evaluating placebo-controlled combined simvastatin and ezetimibe treatment in AS were used to assess LV global load as valvuloarterial impedance and LV myocardial function as stress-corrected midwall shortening. The study population was divided into tertiles of global load. Stress-corrected midwall shortening was considered low if <87% in men and <90% in women. Low-flow AS was defined as stroke volume index <22 ml/m(2.04). Energy loss index decreased (0.85 cm(2)/m(2) vs. 0.77 and 0.75 cm(2)/m(2)) and the prevalence of low stress-corrected midwall shortening increased (10% vs. 26% and 63%) with increasing LV global load (all p < 0.001). The EF was low in only 2% of patients. Patients with low-flow AS had higher LV global load and more often low midwall shortening than those with normal-flow AS (9.66 +/- 2.23 mm Hg/ml.m(2.04) and 77%, vs. 6.38 +/- 2.04 mm Hg/ml.m(2.04) and 30%, respectively, p < 0.001). In logistic regression analysis, LV global load was a main predictor of low stress-corrected midwall shortening independent of male sex, concentric LV geometry, LV hypertrophy (all p < 0.001), concomitant hypertension, and aortic regurgitation. LV global load impacts LV myocardial function in asymptomatic AS independent of other main covariates of LV systolic function. LV myocardial systolic dysfunction is common in asymptomatic AS in particular in patients with low-flow AS and increased valvuloarterial afterload, whereas EF is generally preserved. (An Investigational Drug on Clinical Outcomes in Patients With Aortic Stenosis [Narrowing of the Major Blood Vessel of the Heart]; NCT00092677).JACC. Cardiovascular imaging 05/2009; 2(4):390-9. · 14.29 Impact Factor -
Article: Impact of left ventricular geometry on prognosis in hypertensive patients with left ventricular hypertrophy (the LIFE study).
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ABSTRACT: Less is known about the relation between in-treatment left ventricular (LV) geometry and risk of cardiovascular events. We assessed LV geometric patterns on baseline and annual echocardiograms as time-varying predictors of the primary composite endpoint (cardiovascular death, stroke, and myocardial infarction) in 937 hypertensive patients with LV hypertrophy during 4.8 years losartan- or atenolol-based treatment in the Losartan Intervention for Endpoint reduction in hypertension (LIFE) echocardiography substudy. LV geometry was determined from LV mass/body surface area and relative wall thickness in combination. At end of the study, 52% of patients with initial LV hypertrophy had normal geometry (P < 0.001). In particular, concentric remodelling was reduced by 82% and concentric LV hypertrophy by 84%. Development of LV hypertrophy was seen in <5%. In Cox regression analyses including LV geometric patterns as time-varying variables and adjusting for treatment, Framingham risk score, race, and time-varying systolic blood pressure, the patterns independently predicted higher risk of primary composite endpoints [HR 2.99 (1.16-7.71) for concentric remodelling, HR 1.79 (1.17-2.73) for eccentric hypertrophy, and HR 2.71 (1.13-6.45) for concentric hypertrophy; all P < 0.05]. In hypertensive patients with ECG LV hypertrophy, in-treatment LV geometry by echocardiography adds information on risk of cardiovascular events.European Heart Journal – Cardiovascular Imaging 05/2008; 9(6):809-15. · 2.32 Impact Factor -
Article: Left atrial volume in patients with asymptomatic aortic valve stenosis (the Simvastatin and Ezetimibe in Aortic Stenosis study).
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ABSTRACT: Left atrial (LA) size is known to increase with persistently increased left ventricular (LV) filling pressure. We therefore hypothesized that LA volume might reflect the severity of aortic valve stenosis (AS). Transthoracic echocardiography was performed in 1,758 patients with asymptomatic AS (transaortic Doppler velocity > or =2.5 and < or =4 m/s) in the Simvastatin and Ezetimibe in Aortic Stenosis (SEAS) study. LA volume was measured in end-systole in the apical 4-chamber view in 1,503 patients (85%), and aortic valve area (AVA) was estimated by the continuity equation and indexed by body surface area. Mean values for age and AVA were 67 +/- 10 years and 1.27 +/- 0.5 cm2, respectively, and 574 were women (38%). Mean value for LA volume indexed (LAVI) was 36 +/- 13 ml/m2. Enlargement of LA volume (> or =32 ml/m2) was found in 57% of patients. AVA indexed was significantly correlated to LAVI (r = -0.1, p = 0.0002). Multivariate analysis showed that LAVI was significantly related to AVA indexed (beta = -4.1, p = 0.007) in a model that also included mitral regurgitation (beta = 2.8, p <0.0001), history of hypertension (beta = 2.2, p = 0.002), LV end-diastolic volume (beta = 0.05, p <0.0001), presence of LV hypertrophy (beta = 3.4, p <0.0001), and restrictive LV filling pattern (beta = 3.5, p = 0.01). Gender and LV ejection fraction were eliminated from the final model. In conclusion, LA volume is often enlarged in asymptomatic patients with AS. Furthermore, LA volume is related to AVA even when adjusting for other known risk factors for increased LA volume including of measurements of diastolic function.The American Journal of Cardiology 04/2008; 101(7):1030-4. · 3.37 Impact Factor -
Article: Gender differences in left ventricular structure and function during antihypertensive treatment: the Losartan Intervention for Endpoint Reduction in Hypertension Study.
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ABSTRACT: In hypertensive patients with left ventricular hypertrophy, antihypertensive treatment induces changes in left ventricular structure and function. However, less is known about gender differences in this response. Baseline and annual echocardiograms until the end of study or a primary end point occurred were assessed in 863 hypertensive patients with electrocardiographic left ventricular hypertrophy aged 55 to 80 years (mean: 66 years) during 4.8 years of randomized losartan- or atenolol-based treatment in the Losartan Intervention for Endpoint Reduction in Hypertension Echocardiography substudy. Left ventricular hypertrophy was diagnosed as left ventricular mass divided by height(2.7) >or=46.7 g/m(2.7) and 49.2 g/m(2.7) in women and men, respectively, and systolic function as ejection fraction and stress-corrected midwall fractional shortening. Women included more patients with obesity, isolated systolic hypertension, and mitral regurgitation (all P<0.01). Ejection fraction, stress-corrected midwall shortening, and prevalence of left ventricular hypertrophy were higher in women at baseline and at the end of study (all P<0.01). In particular, more women had residual eccentric hypertrophy (47% versus 32%; P<0.01) in spite of similar in-treatment reduction in mean blood pressure. In logistic regression, left ventricular hypertrophy at study end was more common in women (odds ratio: 1.61; 95% CI: 1.16 to 2.26; P<0.01) independent of other significant covariates. In linear regression analyses, female gender also predicted 2% higher mean in-treatment ejection fraction and 2% higher mean stress-corrected midwall shortening (both beta=0.07; P<0.01). Hypertensive women in this study retained higher left ventricular ejection fraction and stress-corrected midwall shortening in spite of less hypertrophy regression during long-term antihypertensive treatment.Hypertension 04/2008; 51(4):1109-14. · 6.21 Impact Factor
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Institutions
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2006–2012
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University of Bergen
- Institute of Medicine
Bergen, Hordaland Fylke, Norway
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2009–2010
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Haukeland University Hospital
- Department of Heart Disease
Bergen, Hordaland Fylke, Norway
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