The prevalence and correlates of echocardiographic left ventricular hypertrophy among employed patients with uncomplicated hypertension.

To determine the prevalence and correlates of echocardiographic left ventricular hypertrophy among subjects in a general population, we studied 621 employed subjects. Patients with uncomplicated essential hypertension in a worksite-based treatment program included 145 with borderline hypertension and 316 with sustained hypertension by World Health Organization criteria. Normotensive subjects were randomly selected from members of the same unions. M-mode echocardiographic left ventricular dimensions were used to calculate left ventricular mass and other indexes of left ventricular anatomy. The specificity of 13 echocardiographic criteria of left ventricular hypertrophy was determined in normotensive individuals, and the prevalence of left ventricular hypertrophy by each criterion was assessed in patients with borderline or sustained essential hypertension. The results suggest that the most suitable reference standard for detection of left ventricular hypertrophy in a heterogeneous urban population utilizes sex-specific cutoff values for left ventricular mass index of 110 g/m2 or greater for women and 134 g/m2 or greater for men. With 97% specificity, the prevalence of left ventricular hypertrophy by these criteria is approximately 12% among patients with borderline hypertension and 20% among patients with relatively mild, uncomplicated sustained essential hypertension. Wall thickness measurements performed slightly less well. At similar levels of blood pressure, black patients were more likely than white patients to exhibit concentric left ventricular hypertrophy, especially among borderline hypertensive patients. Left ventricular hypertrophy occurred in patients with sustained hypertension who also exhibited increased cardiac output, strongly associated with low plasma renin activity.

Relation between clinical features of the mitral prolapse syndrome and echocardiographically documented mitral valve prolapse.

Mitral valve prolapse, the most common inherited cardiovascular condition, has been associated with a variety of signs, symptoms and electrocardiographic abnormalities, but the true spectrum of the mitral prolapse syndrome remains in doubt because clinical findings often contribute to patient identification and their prevalence in patient groups may be overstated because of ascertainment bias. Accordingly, clinical findings in 88 patients with echocardiographic mitral prolapse were compared with those in 81 of their adult first degree relatives with mitral prolapse (a group free of ascertainment bias) and in two control groups without mitral prolapse: 172 first degree relatives and 60 spouses. Comparison of relatives with and without mitral prolapse demonstrated true associations between mitral prolapse and clicks or murmurs, or both (67 versus 9%, p less than 0.001), thoracic bony abnormalities (41 versus 16%, p less than 0.001), systolic blood pressure less than 120 mm Hg (53 versus 31%, p less than 0.001), body weight 90% or less of ideal (31 versus 14%, p less than 0.005) and palpitation (40 versus 24%, p less than 0.01). In contrast, relatives with mitral prolapse showed no significant increase over normal relatives or spouses without mitral prolapse in prevalence of chest pain, dyspnea, panic attacks, high anxiety or repolarization abnormalities, but these features were all more common in women than in men (p less than 0.01 to less than 0.001). Thus, the true spectrum of the mitral prolapse syndrome encompasses a midsystolic click and late systolic murmur, thoracic bony abnormalities, low body weight and blood pressure and palpitation. Other suggested clinical features, including nonanginal chest pain, dyspnea, panic attacks and electrocardiographic abnormalities, have appeared to be associated with mitral valve prolapse because of ascertainment bias and an erroneous classification of differences between men and women as being due to mitral valve prolapse.

Standardization of M-mode echocardiographic left ventricular anatomic measurements.

To improve standardization of echocardiographic left ventricular anatomic measurements, echographic left ventricular dimensions and mass were related to body size indexes, sex, age and blood pressure. Independent normal populations comprised 92 hospital-based subjects (64 women, 28 men) and 133 subjects from a population sample (55 women, 78 men). All measurements of chamber size, wall thickness and mass differed between men and women in both series (p less than 0.01 to p less than 0.001). Left ventricular mass was related most closely to body surface area among measurements of body size (r = 0.37, p less than 0.01 to r = 0.57, p less than 0.001) in all four groups. Indexation by body surface area eliminated sex differences in wall thicknesses and internal dimension, but a significant sex difference in left ventricular mass index persisted (89 +/- 21 g/m2 in men versus 69 + 19 g/m2 in women in the entire series, p less than 0.0001). The 97th percentile of left ventricular mass index was identical in both groups of men (136 and 132 g/m2) and women (112 and 109 g/m2). A highly significant difference in lean body mass, estimated from 24 hour urine creatine excretion, was observed between men and women (58 +/- 15 versus 40 +/- 13 kg, p less than 0.001) and no sex difference existed in left ventricular mass indexed by lean body mass (3.4 +/- 1.3 versus 3.5 +/- 1.5 g/kg). Weak correlations were observed between left ventricular mass/lean body mass and systolic or diastolic blood pressure (r = 0.25, p less than 0.05 and r = 0.28, p less than 0.01, respectively) but not age (18 to 72 years).(ABSTRACT TRUNCATED AT 250 WORDS)

Increased cardiac performance in mild essential hypertension. Left ventricular mechanics.

To analyze cardiovascular dynamics in essential hypertension, 81 subjects with untreated mild essential hypertension (mean blood pressure, 112 +/- 14 mm Hg) and 87 normotensive subjects from the same working population were studied by echocardiography and simultaneous blood pressure determination. Hypertensive subjects had significantly higher pulse pressure, stroke volume index, cardiac index, left ventricular internal dimension, end-systolic pressure/volume ratio, end-systolic stress, left ventricular mass index, and relative wall thickness than normotensive subjects. Among both normotensive and hypertensive subjects, cardiac performance was closely dependent on afterload, as indicated by close inverse linear relationships between left ventricular fractional shortening and log end-systolic stress (r = -0.83 and -0.78 respectively; both, p less than 0.001). However, 19 of 81 hypertensive patients (23%) fell above the 95% confidence limits of this relationship in normotensive subjects (p less than 0.001 compared with that in normotensive subjects), with a bimodal distribution of fractional shortening as a percent of predicted in relation to end-systolic stress among patients with essential hypertension. This subgroup of hypertensive subjects, with increased resting cardiac performance independent of afterload, was similar in age to the remaining hypertensive subjects but had higher fractional shortening (41 +/- 5% vs 35 +/- 7%; p less than 0.001) and cardiac index (4.3 +/- 1.3 L/min/m2 vs 3.4 +/- 1.0 L/min/m2; p less than 0.005) and lower total peripheral resistance (1257 +/- 502 dyn sec cm-5 vs 1582 +/- 584 dyn sec cm-5 p less than 0.05) and left ventricular relative wall thickness (0.34 +/- 0.06 vs 0.42 +/- 0.10; p less than 0.005). Thus, analysis of cardiac mechanics detected a subset of patients with essential hypertension in whom increased cardiac function cannot be attributed either to relative youth or to supercompensatory left ventricular hypertrophy.

Complications of mitral valve prolapse. Disproportionate occurrence in men and older patients.

To determine factors influencing the strength of association between mitral valve prolapse and mitral regurgitation, ruptured chordae tendineae, and infective endocarditis, the prevalence of mitral prolapse in patients with disease was compared with both clinical and population control groups. The prevalence of mitral valve prolapse was 4 percent among population and clinical control groups (eight of 196 and 84 of 2,146, respectively) and was significantly higher (p less than 0.001) in patients with endocarditis (11 of 67, 16 percent), mitral regurgitation (17 of 31, 55 percent, and ruptured chordae (27 of 43, 63 percent). Odds ratios for complications in persons with mitral valve prolapse ranged from 4.6 for endocarditis to 41.4 for ruptured chordae in overall analyses, and from 6.8 for endocarditis to 53.0 for ruptured chordae based on age- and sex-matched case-control triplets (p less than 0.001 for each). All complications occurred disproportionately in men with mitral valve prolapse, in whom odds ratios ranged from 2.5 to 7.4 compared with an additional control group of unselected subjects with mitral valve prolapse. Compared with this control group, patients with mitral valve prolapse and endocarditis were slightly more likely to have a previously known heart murmur (odds ratio 3.2, difference not significant) but significantly more likely to have murmurs at the time of evaluation (odds ratio 8.5, p less than 0.01). Patients with mitral valve prolapse and mitral regurgitation and ruptured chordae tendineae were also significantly older than the unselected subjects with mitral valve prolapse (48 +/- 14 and 55 +/- 16 versus 38 +/- 14 years, p less than 0.005 for both). The concentration of risk of endocarditis in men with mitral valve prolapse and patients with antecedent murmur suggests that antibiotic prophylaxis is warranted in these groups but not in women without a murmur of mitral regurgitation.

Echocardiographic assessment of left ventricular hypertrophy: comparison to necropsy findings.

To determine the accuracy of echocardiographic left ventricular (LV) dimension and mass measurements for detection and quantification of LV hypertrophy, results of blindly read antemortem echocardiograms were compared with LV mass measurements made at necropsy in 55 patients. LV mass was calculated using M-mode LV measurements by Penn and American Society of Echocardiography (ASE) conventions and cube function and volume correction formulas in 52 patients. Penn-cube LV mass correlated closely with necropsy LV mass (r = 0.92, p less than 0.001) and overestimated it by only 6%; sensitivity in 18 patients with LV hypertrophy (necropsy LV mass more than 215 g) was 100% (18 of 18 patients) and specificity was 86% (29 of 34 patients). ASE-cube LV mass correlated similarly to necropsy LV mass (r = 0.90, p less than 0.001), but systematically overestimated it (by a mean of 25%); the overestimation could be corrected by the equation: LV mass = 0.80 (ASE-cube LV mass) + 0.6 g. Use of ASE measurements in the volume correction formula systematically underestimated necropsy LV mass (by a mean of 30%). In a subset of 9 patients, 3 of whom had technically inadequate M-mode echocardiograms, 2-dimensional echocardiographic (echo) LV mass by 2 methods was also significantly related to necropsy LV mass (r = 0.68, p less than 0.05 and r = 0.82, p less than 0.01). Among other indexes of LV anatomy, only measurement of myocardial cross-sectional area was acceptably accurate for quantitation of LV mass (r = 0.80, p less than 0.001) or diagnosis of LV hypertrophy (sensitivity = 72%, specificity = 94%).(ABSTRACT TRUNCATED AT 250 WORDS)

Echocardiographic demonstration of right atrial rupture in a patient with right-sided cardiac tumor.

Two-dimensional echocardiographic evaluation of a young man with recent drainage of a hemorrhagic pericardial effusion revealed persistent fluid and a massive tumor involving the right atrium, tricuspid valve, and right ventricle. Echocardiographic demonstration of right atrial wall rupture was confirmed at surgery; pathologic analysis showed a spindle cell sarcoma.

Contrast in cardiac anatomy and function between black and white patients with hypertension.

To determine whether cardiac findings differ between blacks and whites with essential hypertension, members of a well-defined working population in New York City were examined. Hypertensives had diastolic blood pressure ≤95, or systolic blood pressure ≤160 mmHg, or both, sustained on three occasions over three weeks. Normotensives were selected to reflect the age, sex, and race distribution of the total working population. Of 207 employees, 75 hypertensives (40 percent blacks) and 132 normotensives (53 percent blacks) under-went M-mode echocardiography. Left ventricular (LV) measurements and simultaneous blood pressure by mercury manometer were used to calculate LV mass index (LVMI), relative wall thickness (RWTd), cardiac output (CO) and total peripheral resistance (TPR). There were no differences in any variable between black and white normotensives. Black and white hypertensives were similar in age (52 ± 10 and 54 ± 12 yr, respectively) and blood pressure (151/100 ± 15/11 and 153/99 ± 18/8 mmHg). Black hypertensives had significantly higher TPR (1.80 ± 0.74 vs 1.43 ± 0.46, P<.01), lower CO (6.0 ± 2.5 vs 7.2 ± 2.4 L/min, P<.01), and higher RWTd (0.43 ± 0.11 vs 0.37 ± 0.07, P<.05) than white hypertensives. Race, per se, cannot explain these differences since they did not occur among normotensives. Rather, these findings may reflect a differing patho-physiology of hypertension in blacks and whites with similar blood pressure elevation.

Formation of lipid inclusions in normal human leukocytes.

Normal peripheral blood leukocytes left standing at room temperature develop large inclusions which increase in number and size with time of incubation. The formation and nature of these inclusions were investigated. At 0 hour the structures were present in only 1% of the cells, whereas at 48 hr, they were in virtually all neutrophils and monocytes. Ultrastructurally, the globules measured 0.5-1.5 mu in diameter and they were usually not membrane bound. Histochemical analysis indicated that they were lipid in nature. The inclusions were separated on a sucrose density gradient and their isolation was confirmed by electron microscopy. Thin-layer chromatography of the isolated globules suggested that they consisted predominantly of triglycerides. Since it is known that the cells synthesize triglycerides at rest, it was postulated that the structures may represent the storage form for free fatty acids which may be utilized for membrane synthesis during phagocytosis.

Relation between the presence of echocardiographic vegetations and the complication rate in infective endocarditis.

M-mode and two-dimensional echocardiograms of 77 patients with infective endocarditis were examined to determine if presence and/or size of vegetations on echocardiogram were predictive of morbidity and mortality. Patients with (n = 43) or without (n = 34) vegetations on echocardiogram did not differ significantly in the proportions developing congestive heart failure (23 of 43 or 53% vs 12 of 34 or 35%) or emboli (11 of 43 or 24% vs 6 of 34 or 18%), whereas a slightly lower proportion of those with vegetations required surgery (5 of 43 or 12% vs 7 of 34 or 21%) or died (3 of 43 or 7% vs 4 of 34 or 12%). No significant relationship was found between vegetation size and the frequency of complications, the need for surgery, or death. In contrast, patients whose echocardiograms demonstrated premature mitral valve closure or chordal or cusp rupture had a significantly higher incidence of heart failure (10 of 13 or 77% vs 22 of 60 or 37%, p less than 0.003) and surgery (3 of 13 or 23% vs 7 of 60 or 12%, p less than 0.05). We conclude that: the presence of vegetation on the initial echocardiogram is not predictive of the clinical course in infective endocarditis; vegetation size does not predict complications, need for surgery, or death; but valve cusp or chordal rupture and/or premature mitral valve closure are associated with congestive heart failure and the need for surgery.

Mitral valve prolapse and hyperthyroidism: effect of patient selection.

Patients with mitral valve prolapse and hyperthyroidism have common symptoms; the most outstanding symptom is palpitation. To determine whether or not common symptoms contributed to the reported association of these conditions, we evaluated 220 patients with symptomatic mitral valve prolapse and 216 first-degree relatives in 72 families; 65 relatives with mitral valve prolapse and 151 relatives without mitral valve prolapse, all greater than or equal to 16 years of age. Thirty subjects, aged 49 +/- 13 years (p less than 0.025 vs entire study group), had thyroid disease (23 subjects had definite thyroid disease, seven subjects had probable); 27 of 30 subjects with thyroid disease (90%) were female (p less than 0.005). The age- and sex-adjusted prevalence of hyperthyroidism was significantly higher in probands with mitral valve prolapse than in family members without mitral valve prolapse (3.5% vs 0%, p = 0.03), while an intermediate prevalence of hyperthyroidism (2.2%) was observed in family members with mitral valve prolapse. Thus, the prevalence of hyperthyroidism is increased among symptomatic patients with mitral valve prolapse as compared to family members without mitral valve prolapse, but the prevalence of thyroid conditions is similar among family members with or without this condition. These findings are explained by the effect of common symptoms on clinical detection of both mitral valve prolapse and hyperthyroidism.

Association of mitral-valve prolapse with low body-weight and low blood pressure.

Subjects with mitral-valve prolapse (MVP) have been observed to have an asthenic body build. To determine whether body-weight differed between individuals with inherited MVP and normal subjects, 177 relatives of 45 patients with MVP were studied, 35 female and 19 male relatives had MVP, and 51 female and 72 male relatives did not. There was no difference in mean height between relatives with and without MVP, but those with MVP weighed significantly less. Blood pressure was also significantly lower in relatives with MVP than in normal relatives. It is suggested that the lower blood pressure and the possible beneficial effects of lower weight on other cardiovascular risk factors may provide a selective advantage to carriers of the MVP gene, explaining its high prevalence in the general population. These findings may provide the first example of a common inherited condition which is systematically associated with changes in body-weight and blood pressure.