Early Systolic Lengthening Is Associated with SYNTAX Score in Patients with Non-ST-Elevation Acute Coronary Syndrome.

BACKGROUND: Early systolic lengthening is a echocardiographic strain parameter previously used to determine the lesion severity in patients with stable coronary artery disease. In the present study, we aimed to evaluate the relationship between early systolic lengthening and anatomic SYNTAX score in troponin (-) and (+) groups among patients with non-ST-elevation acute coronary syndrome (ACS). METHODS: A total of 95 patients diagnosed with non-ST-elevation ACS were included in the prospective, non-randomized, single-center study. The patients were categorized into 2 groups as troponin (+) and troponin (-). The patients were evaluated in terms of echocardiographic, clinical, and angiographic parameters. RESULTS: The baseline characteristics, including age (58 ± 13 vs. 60 ± 10 respectively, P =.340), a history of hypertension (67.1% vs. 64%, respectively, P =.479), diabetes (28.6% vs. 32%, respectively, P =.467), global longitudinal strain (-14.37 ± 5.11 vs. -16.42 ± 3.93, respectively, P =.095), left ventricular ejection fraction (58.71 ± 8.73 vs. 57.20 ± 8.70, respectively, P =.263), and E/e' (8.44 ± 2.13 vs. 8.33 ± 1.99, respectively, P =.785), were similar between troponin (+) and troponin (-) groups. Left ventricle end-systolic diameter (3.2 ± 0.78; 3.50 ± 0.74 vs. 3.2 ± 0.78, respectively, P =.031), left ventricle end-systolic volume (55.57 ± 32.17 vs. 38.28 ± 13.63, respectively, P =.013), left ventricle end-diastolic volume (115.31 ± 49.54 vs. 91.23 ± 20.57, respectively, P =.042), the rate of early systolic lengthening (65.7% vs. 28%, respectively, P =.001), the duration of early systolic lengthening (24.02 ± 31 ms vs. 15.56 ± 30.19 ms, respectively, P =.009), and the SYNTAX score (16 ± 11 vs. 10 ± 10, respectively, P =.023) were higher in the troponin (+) group. Furthermore, a significant correlation was found between early systolic lengthening and SYNTAX score (r = 0.43, P <.001). CONCLUSION: The rate and duration of early systolic lengthening were higher in patients in the troponin (+) group. Early systolic lengthening is related to SYNTAX score in patients with non-ST-elevation ACS.

Left Atrial Dysfunction as Marker of Arrhythmic Events in Patients with Hypertrophic Cardiomyopathy.

BACKGROUND: In this study, we investigated whether left atrial functions evaluated by speckle tracking echocardiography , classic echocardiographic and clinic parameters predict appropriate Implantable Cardioverter Defibrillator (ICD) shock in patients who underwent ICD implantation for hypertrophic cardiomyopathy. METHODS: Totally 87 patients who received ICD implantation for primary or secondary prevention were included in the study. Patients' clinical, electrocardiographic, 2 dimen- sion classic, and speckle tracking echocardiographic data were collected. Left atrial functions were assessed by speckle tracking echocardiography. Left atrial strain just before mitral valve opening was taken as peak atrial longitudinal strain. Appropriate ICD therapy was defined as cardioversion or defibrillation due to ventricular tachycardia or fibrillation. Patients were divided into 2 groups as occurrence or absence of appropri- ate ICD therapy during follow-up (mean, 50.2 ± 9.3 months). Patients with an European Society of Cardiology (ESC) risk score >6% were considered high-risk patients. RESULTS: A total of 24 (27.5 %) patients were observed to have an appropriate ICD therapy. In patients on whom appropriate ICD therapy was performed, a higher Sudden Cardiac Death risk Score and decreased peak atrial longitudinal strain and global longitudinal peak strain were observed. In patients with high ESC risk score (> 6%), in Cox regres- sion analysis, peak atrial longitudinal strain (odds ratio: 0.806, P = .008), Sudden Cardiac Death risk score (odds ratio: 1.114, P = .03) and global longitudinal peak strain (odds ratio: 1.263, P = .02) were found to be independent predictors of occurrence of appropriate ICD therapy. CONCLUSION: Easily measurable peak atrial longitudinal strain may provide additional information in predicting ventricular arrhythmias or deciding on prophylactic medical treatment to prevent ventricular arrhythmias or reduce the frequency of appropriate shock in high-risk patients with ICD implanted.

Quantitative assessment of left atrial functions by speckle tracking echocardiography in hypertensive patients with and without retinopathy.

PURPOSE: The association between hypertensive retinopathy and left atrial (LA) impairment is unknown. Accordingly, it was aimed to investigate the possible relationship between hypertensive retinopathy and LA phasic functions by means of two-dimensional speckle-tracking echocardiography (2D-STE). METHODS: A total of 124 hypertensive patients and 27 control subjects were included in the study. LA reservoir strain (LAS-S ), LA conduit strain (LAS-E ), and LA booster strain (LAS-A ) parameters were used to evaluate LA myocardial functions. RESULTS: Hypertensive patients (with and without retinopathy) displayed an obvious reduction in the LA reservoir strain (LAS-S ), and LA conduit strain (LAS-E ). Moreover, further impairment in LA reservoir and conduit strain was found in patients with hypertensive retinopathy than in the isolated hypertensive patients. There were no significant differences in LA booster strain (LAS-A ) among the three groups. Impaired LAS-S (OR: 0.764, CI: 0.657-0.888, and p < 0.001), LAS-E (OR: 0.754, CI: 0.634-0.897, and p = 0.001), and hypertension (HT) duration (OR: 2.345, CI: 1.568-3.507, and p < 0.001) were shown to be independent predictors of hypertensive retinopathy. CONCLUSION: Impaired LA reservoir and conduit strain may be used to predict hypertensive patients at higher risk of developing hypertensive retinopathy, and to determine which patients should be followed more closely for hypertensive retinopathy.

Clinical Utility of Left Atrial Asynchrony and Mechanical Function in Patients with Hypertrophic Cardiomyopathy.

Background: The aim of this study was to examine whether left atrial dispersion and left atrial strain as measured by speckle tracking echocardiography and clinical parameters are predictors of the development of atrial fibrillation in patients with hypertrophic cardiomyopathy. Methods: A total of 151 patients (69% male, mean age 48.9 ± 14.2 years) with hypertrophic cardiomyopathy were included in the study. The patients' demographic, clinical, electrocardiographic, 2-dimensional classic and speckle tracking echocardiographic data were collected. Atrial fibrillation was identified by 12-lead electrocardiograms or 24-72 hours of Holter recordings during the follow-up period. Atrial dispersion was defined as the standard deviation of time to peak strain in 12 left atrial segments. Results: During the follow-up period, 40 patients (26%) developed atrial fibrillation. Peak atrial longitudinal strain (16.8 ± 6 vs. 22.1 ± 6.6, p ≤ 0.001) was significantly lower in the patients who developed atrial fibrillation than in those who did not. However, atrial dispersion was significantly higher in the group which developed atrial fibrillation (61 [46.7,78.6] vs. 41.3 [30.6-51], p ≤ 0.001). In multivariate Cox regression analysis, atrial dispersion (msn) (hazard ratio: 1.019, 95% confidence interval: 1.004-1.033, p = 0.01), peak atrial longitudinal strain, and age were found to be independent predictors of atrial fibrillation. Conclusions: In patients with hypertrophic cardiomyopathy, atrial dispersion, peak atrial longitudinal strain and age are predictive of the development of atrial fibrillation. Atrial dispersion measured by a speckle tracking-based method may provide further information on left atrial function in patients with hypertrophic cardiomyopathy or other disease states.

Myocardial early systolic lengthening predicts mid-term outcomes in patients with hypertrophic cardiomyopathy.

In this study, we investigated whether early systolic lengthening (ESL) which reflects subclinical ischemia and other echocardiographic and clinic parameters predict primary outcome [appropriate ICD shock, cardiovascular mortality and ventricular tachycardia (VT) or fibrillation] in patients with hypertrophic cardiomyopathy (HCM). 202 Patients with HCM (68% male, mean age 48 ± 13.9 years) were included in the study. Patients' clinical, electrocardiographic, 2D classic and speckle tracking echocardiography (STE) data were collected. ESL was defined as time from onset of the Q wave on ECG (onset of the R wave if the Q wave was absent) to maximum myocardial systolic lengthening. Patients were divided into two groups as occurrence or absence of primary outcome during 5 years follow up. During the follow-up period of 5 years (mean follow-up duration, 45.9 ± 10.8 months), 31 patients (15%) developed primary outcome [appropriate ICD shock 22 (11%), cardiovascular death 6 (3%), VT/VF 3(1.5%)]. Higher HCM Risk SCD score, longer ESL, and decreased global longitudinal peak strain (GLPS) were observed in patients with primary outcome. A Cox regression analysis, ESL, GLPS and HCM Risk SCD score were found to be independent predictors of occurrence of primary outcome. In ROC curve analysis, ESL > 53.5 msn could discriminate between groups with and without a primary outcome (AUC 0.768, 80% sensitivity and 60% specificity, CI 95% 0.666-0.871). ESL were found to be predictive for primary outcome in patients with HCM. Readily measurable ESL could be helpful to distinguish patients at high risk who could optimally benefit from ICD therapy.

A case of congenital partial absence of the left pericardium presenting with atypical chest pain.

Congenital absence of the pericardium (CAP) is a rare cardiac malformation and can be defined as the partial or total absence of the fibroelastic sac that surrounds the heart and great vessels. As the patients are often asymptomatic or have nonspecific symptoms, the diagnosis of this rare congenital anomaly is difficult. Therefore, it is usually diagnosed incidentally during imaging, intraoperatively, or during postmortem examinations. In this regard, it is important to keep specific images in mind during the examination and to suspect CAP to make an accurate diagnosis. In this report, we present a case of a 42-year-old male who presented with a complaint of atypical chest pain and was diagnosed with CAP using multimodality imaging.

Anxiety Disorder Associated with the COVID-19 Pandemic Causes Deterioration of Blood Pressure Control in Primary Hypertensive Patients.

OBJECTIVE: The new coronavirus disease (COVID-19) has spread rapidly all over the world and caused anxiety disorders. Recent studies have also shown that the prevalence of depression and anxiety increased during the COVID-19 outbreak. We aimed to evaluate the anxiety and depression levels during the pandemic and identify the effect of pandemic-related stress on blood pressure (BP) control in primary hypertensive patients. METHOD: A total of 142 patients with primary hypertension (HT) who continued to use the same antihypertensive drugs before and during the pandemic were included in the study. Twenty-four -hour Ambulatory Blood Pressure Monitoring (ABPM) and the Hospital Anxiety and Depression Scale (HADS) questionnaire were applied to patients. We retrospectively reviewed 24-h ABPM records of the same patients for the year before the pandemic. RESULTS: Daytime, nighttime and 24 -hour-systolic blood pressure (SBP) levels as well as daytime, nighttime, and 24- hour-diastolic blood pressure (DBP) levels , were significantly elevated during the COVID-19 outbreak compared to the pre-pandemic period (p<0.001). Higher HADS-A scores (HADS-A ≥7) were significantly associated with much greater increase in BP compared to the patients with lower HADS-A scores. CONCLUSION: Psychological stress due to the COVID-19 outbreak led to worsening of the regulation of BP in controlled hypertensive patients whose antihypertensive treatments did not change.

Crochetage sign may predict late atrial arrhythmias in patients with secundum atrial septal defect undergoing transcatheter closure.

BACKGROUND: Atrial arrhythmias are well-known complications of atrial septal defect (ASD), and associated with substantial morbidity. After ASD closure, right atrial and ventricular enlargement regresses, however, the risk of atrial arrhythmia development continues. In this study, we aimed to investigate the relationship between the Crochetage sign, which is a possible reflection of heterogeneous ventricular depolarization due to long-term hemodynamic overload, and the development of late atrial arrhythmia after ASD closure. METHODS: This retrospective study included a total of 314 patients (mean age: 39.5 (30-50) years; male: 115) who underwent percutaneous device closure for secundum ASD. The study population was divided into two groups according to the presence or absence of the Crochetage sign. The Crochetage sign was defined as an M-shaped or bifid pattern notch on the R wave in one or more inferior limb leads. Cox-regression analysis was performed to determine independent predictors of late atrial arrhythmia development. RESULT: Fifty-seven patients (18.1%) presented with late atrial arrhythmia. Of these 57 patients, 30 developed new-onset atrial fibrillation/atrial flutter (AF/AFL), and 27 patients with pre-procedure paroxysmal AF/AFL had a recurrence of AF/AFL during follow-up. History of paroxysmal AF/AFL before the procedure (HR: 4.78; 95% CI 2,52-9.05; p < 0.001), the presence of Crochetage sign (HR: 3.90; 95% CI 2.05-7.76; p < 0.001), and older age at the time of ASD closure (HR: 1.03; 95% CI 1.01-1.06; p = 0.002) were found as independent predictors for late atrial arrhythmia. CONCLUSION: The presence of Crochetage sign may be used to predict the risk of late atrial arrhythmia development after transcatheter ASD closure.

The usefulness of morphology-voltage-P wave duration ECG score for predicting early left atrial dysfunction in hypertensive patients.

OBJECTIVE: Left atrial (LA) function is an important predictor of adverse cardiovascular outcomes in patients with hypertension (HT). Therefore, recognition of subtle LA dysfunction in the early stages of HT is essential for controlling modifiable variables. Several electrocardiographic and echocardiographic parameters have been studied to show early LA dysfunction. The goal of this study was to investigate the relationship between newly defined morphology-voltage-P wave duration electrocardiography (MVP ECG) score and early LA dysfunction in hypertensive patients. MATERIALS AND METHODS: Eighty-nine hypertensive patients were included in this study. Based on speckle tracking echocardiography results, the patients were divided into two groups: 67 patients with normal LA function were included in Group 1, and 22 patients with abnormal LA function in Group 2. RESULTS: Age, diabetes mellitus history, duration of HT history, left ventricular mass index, E/Em, and MVP ECG score values were statistically significant between the two groups. Based on the results of the multivariate logistic regression test, duration of HT history, E/Em, and MVP ECG score were determined as independent predictive parameters for early LA dysfunction in hypertensive patients. CONCLUSION: In conclusion, MVP ECG score assessment could be a novel approach to detect early LA dysfunction in hypertensive patients.

Primary patency and amputation free survival after endovascular management of infrarenal aorta total occlusions.

OBJECTIVE: Endovascular therapy (EVT) has increasingly been used even after the development of new techniques and technologies. EVT has displayed durable early and mid-term outcomes for infrarenal aorta occlusions (IAO). Nonetheless, little is known regarding their long-term outcomes and predictors of restenosis. METHODS: A total of 55 consecutive patients (age, 58.8±6.97 years; 67.2% male; 42% critical limb ischemia) from a single-center database, undergoing EVT for IAO disease between January 2011 and March 2019 were retrospectively analyzed. The outcome measures were primary patency rate and amputation free survival calculated by the Kaplan-Meier method. Independent predictors of restenosis were assessed by Cox proportional hazard regression model. RESULTS: In 49 patients (89.1%), technical success was achieved. In total, 190 stents (65 self-expandable stents, 60 balloon-expandable stents) were implanted. During the follow up of 34.5±28 months, 7 patients experienced loss of patency. Primary patency rates were 96%, 82%, and 75% at 1, 3, and 5 years, respectively, and amputation free survival rates were 100%, 90%, and 82% at 1, 3, and 5 years, respectively. CONCLUSION: In this study, five-year outcomes of primary patency and amputation free survival for EVT of infrarenal aorta total occlusive lesions were favorable. None of the demographic, lesion, and device factors were independently associated with loss of primary patency.

Presence of fragmented QRS is associated with left ventricular systolic dysfunction after surgery in patients with severe aortic regurgitation.

BACKGROUND AND AIM OF THE STUDY: Chronic severe aortic regurgitation (AR) is associated with progressive accumulation of interstitial fibrosis and disruption of myocardial structure. After aortic valve replacement (AVR), the negative remodeling process reverses, and left ventricular ejection fraction (LVEF) improves but not in all patients. In this study, we aimed to investigate the association of fragmented QRS (F-QRS), which is a possible marker of myocardial fibrosis, with postoperative left ventricular (LV) systolic dysfunction. METHODS: A total of 147 consecutive patients with AVR were included in this study. F-QRS was identified by the presence of various RSR' patterns (QRS duration <120 ms) such as additional R wave (R prime)or notching of the R or S wave in at least two consecutive leads. Patients were compared in two groups based on the presence or absence of F-QRS. A logistic regression model was used to determine independent predictors of postoperative LV systolic dysfunction (LVEF <50%). RESULTS: Patients with F-QRS were associated with poor recovery of LV systolic function after AVR compared to the patients without F-QRS, regardless of preoperative LVEF (p = .008). F-QRS was found to be an independent predictor of postoperative LV systolic dysfunction (LVEF <50%). Lower preoperative LVEF and increased LV end diastolic diameter index were also found as independent risk factors for postoperative LV systolic dysfunction. CONCLUSIONS: As a possible marker of myocardial fibrosis, F-QRS was associated with postoperative LV systolic dysfunction. Therefore, as a simple and convenient clinical parameter, F-QRS may be used to predict poor recovery of LVEF after AVR.

Pulsation of catheter during coronary angiography: Is it a sign of severe aortic regurgitation?

A 48-year-old male patient was admitted to our outpatient clinic with complaints of shortness of breath. He also had a holo-diastolic murmur at the right sternal border and an apical impulse being displaced laterally and inferiorly. Transthoracic echocardiography showed a severe aortic regurgitation without aortic valve stenosis and a mildly dilated left ventricle accompanied by an ejection fraction of 55%. The aortic regurgitation jet was eccentric and there were significant holodiastolic flow reversals in the descending thoracic aorta. Surgical management was advised for this patient because of symptomatic severe aortic regurgitation. Then, the patient underwent preoperative coronary angiography through the right femoral artery route. The left coronary ostium could be engaged with a 6 Fr Judkins left diagnostic catheter; however, the catheter jumped through the ascending aorta. Afterwards, the catheter was engaged and again jumped through the ascending aorta. Engagement and jumping cycles observed between successive systole to diastole. In our opinion, this catheter movement is explained by wide pulse pressure, like the severe characteristic physical findings of severe aortic regurgitation. Further studies are needed to understand whether this catheter movement is angiographically evidence of severe aortic regurgitation.

The association of left ventricular end-diastolic pressure with global longitudinal strain and scintigraphic infarct size in ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention.

Left ventricular end-diastolic pressure (LVEDP) is an independent predictor for prognosis in ST-elevation myocardial infarction (STEMI) patients. We aimed to investigate the relationship of admission LVEDP measured after a successful primary percutaneous coronary intervention (pPCI) with scintigraphic infarct size (IS) and global longitudinal strain (GLS), a strong predictor of IS, in STEMI patients. A total of 62 consecutive patients with STEMI were enrolled in the study. LVEDP measurements were performed after pPCI in patients who had TIMI-3 flow. Echocardiography was performed 24 h after pPCI and repeated 3 months later. GLS was calculated as an average peak strain from the 3 apical projections. IS was evaluated at the third month by technetium 99m sestamibi. The mean age was 56 ± 8 years in the study population. The mean LVEDP was found 19.4 ± 4.4 mmHg. Median IS was 4% (0-11.7 IQR).The mean GLS at the 24th hour and the third month were found to be - 15.4 ± 2.8 and - 16.7 ± 2.5 respectively. There was a moderate negative correlation between LVEDP and GLS (24th-hour p < 0.001 r = - 0.485 and third-month p < 0.001 r = - 0.489). LVEDP had a moderate positive correlation with scintigraphic IS (p < 0.001 r = 0.545). In the multivariable model, we found that LVEDP was significantly associated with scintigraphic IS (ß coefficient = 0.570, p = 0.008) but was not associated with the 24th hour (ß coefficient = 0.092, p = 0.171) and third month GLS (ß coefficient = 0.037, p = 0.531). This study demonstrated that there was a statistically significant relationship between LVEDP and scintigraphic IS, and IS was increased with high LVEDP values. However, there was not a relationship between LVEDP and GLS.

Serum lactate level may predict the development of acute kidney injury in acute decompensated heart failure.

OBJECTIVE: Acute decompensated heart failure (ADHF) is a life-threatening medical condition and more than 30% of patients hospitalized for ADHF develop acute kidney injury (AKI), which increases the rate of both mortality and morbidity. Previous research has indicated that several biomar- kers may help to predict the development of AKI. The aim of this study was to investigate the relationship between lactate level at the time of admission and AKI in ADHF patients. METHODS: A total of 154 consecutive ADHF patients were prospectively enrolled from June 2018 to December 2018, and after applying the exclusion criteria, a total of 91 patients were included in the study. The patients were divided into 2 groups: those with and without AKI. RESULTS: There were 63 patients in the group without AKI and 28 patients in the group with AKI. The AKI group had a higher percentage of a history of chronic kidney disease (CKD), a higher creatinine level, lower glomerular filtration rate level, lower bicarbonate level, higher lactate level, and a lower left ventricular ejection fraction compared with the non-AKI group (p<0.05 for all parameters). Multiple logistic regression analysis determined that CKD history (odds ratio [OR]: 4.003, 95% confidence interval [CI]: 1.295-12.371; p=0.016) and lactate level (OR: 1.545, 95% CI: 1.222-1.954; p<0.001) were independent predictive parameters for developing AKI. CONCLUSION: An elevated lactate level may help to make an early diagnosis of AKI, an important concern in ADHF.

Presence of ear lobe crease may predict intermediate and high-risk patients with acute non-ST elevation acute coronary syndrome.

Introduction: Ear lobe crease (ELC) was first described in 1973 as a physical examination finding indicating significant coronary artery disease (CAD). Several studies have been carried out in relation to this finding, and it has been shown that it is a marker of intima-media thickness, carotid artery disease, and CAD. We aimed to investigate the relationship between earlobe crease, which is a simple physical examination finding, and GRACE score as a risk estimation index in acute coronary syndromes without ST-segment elevation (NSTE-ACS) patients. Methods: 360 patients (mean age 62.2 years, 70% male) were included in our study. Patients were divided into two groups of GRACE scores ≤ 109 and >109, 167 patients were enrolled in group 1, and193 cases in group 2. Results: The group 2 patients were older, had higher systolic blood pressure (SBP) levels, a higher rate of hypertension, higher glucose levels, lower creatinine clearance levels, higher initial and peak troponin levels, lower hemoglobin levels, lower left ventricular ejection fraction (LVEF) and higher Gensini scores than the patients in group 1. The higher GRACE score group had markedly increased frequencies of ELC compared to the lower GRACE score group (80.8% vs. 24.5%, respectively, P < 0.001). Conclusion: The presence of ELC may predict moderate to high risk group of patients with NSTEACS.

Compression of the Left Atrium and Pulmonary Veins Due to Ascending and Descending Aortic Aneurysms.

An 89-year-old female patient presented to our cardiology outpatient clinic complaining of shortness of breath and back pain. Chest X-ray demonstrated a widened mediastinum. Transthoracic echocardiography showed an ascending aortic aneurysm and the modified apical 5-chamber view showed that left atrium was compressed between the ascending and descending aortas. Color Doppler turbulence was also seen in the compressed area. A contrast-enhanced chest computed tomography scan in axial and coronal planes showed that left atrium and pulmonary veins were compressed by ascending and descending aortic aneurysms. Herein, we illustrated this rare condition diagnosed by transthoracic echocardiography in combination with computed tomography.

The relationship between presystolic wave and nondipper hypertension.

BACKGROUND: A presystolic wave (PSW) is commonly seen on Doppler examination of the left ventricular outflow tract (LVOT), and the possible mechanism for PSW is considered to be left ventricular stiffness and impaired LV compliance. We aimed to compare the relationship between PSW and dipper, nondipper hypertension. PATIENTS AND METHODS: A total of 83 patients were included in the study. The participating patients were divided into two groups as 42 patients with dipper hypertension and 41 patients with nondipper hypertension based on the results of ambulatory blood pressure monitoring. RESULTS: Left ventricular mass index (91.6 ± 12.9 vs. 106.1 ± 7.9, P < 0.001) and E/Em (7.4 [6.6-8.3] vs. 10 [8-12], P < 0.001) were significantly higher, and Em (9.9 ± 2.7 vs. 7.9 ± 3.4, P = 0.004) was significantly lower in the nondipper group compared with dipper group. And also, the PSW was found to be higher in the nondipper group. The nondipper group had markedly increased frequencies of PSW compared with the dipper group (68 vs. 38%, respectively, P = 0.008). In the multivariate logistic regression test, E/Em [odds ratio (OR) 1.464, 95% confidence interval (CI): 1.113-1.926, P = 0.006] and the presence of PSW (OR 3.115, 95% CI: 1.061-9.143, P = 0.039) were determined as independent predictive parameters for nondipper hypertension. CONCLUSION: The presence of PSW on transthoracic echocardiography suggests that we may come across nondipper hypertension and a high risk of end-organ damage. PSW may be used as a useful parameter in risk stratification in hypertensive patients.