ABSTRACTIntroduction: Uncontrolled hypertension increases the total peripheral vascular resistanceconsidered as a silent vascular disease, with metabolic disorders, affecting different organs,inducing pathological changes. Among them, heart damage, progressing from left ventricularhypertrophy to heart failure by altering the left ventricular ejection fraction.Objective: To determine the prevalence of left ventricular hypertrophy and left ventricularejection fraction by echocardiography in hypertensive patients in the area of Silver Spring, MDand Washington DC.Patients and methods: The study was descriptive, retrospective, transversal, and observationalvariables control, in patients requested echocardiography studies (n = 218) during the establishedperiod, 78.4% Latin American, 44% male. It was observed in the database of the IntegratedPrevention Unit.Results: It was presented 41.4% of left ventricular hypertrophy among hypertensive. Among thehypertensive patients of 70 years (94%) it was found 46.80% of left ventricular hypertrophy, allof 70 years without hypertension, did not present left ventricular hypertrophy, there wasprevalence of hypertension and left ventricular hypertrophy in the older women. The leftventricular ejection fraction of hypertensive patients was 97.6% normal, 1.6% slightly, 0.0%moderate and 0.8% severe.Conclusions: The prevalence of left ventricular hypertrophy in hypertensive patients was 41.4%,and normal left ventricular ejection fraction is prevalent in the elderly without hypertension.Keywords: Hypertension - Left Ventricular Hypertrophy - Ejection Fraction -Echocardiography.
INTRODUCTIONHigh blood pressure, known as the silent disease, is probably the most important public issue indeveloped countries, is common, asymptomatic and easily treated, but with lethal complicationsif not treated.1 Over 74 million Americans suffer from hypertension and at least 16 million ofthem do not even know. If we combine the data from developed and developing countries thehigh blood pressure (HTN) affects 25-35% of the adult population. This figure increases to 60-70% in those over 70 years.2, 3 The Framingham Heart Study revealed a significant increase inthe prevalence of left ventricular hypertrophy (LVH) in elderly patients with hypertension(HTN).4Systemic HTN is defined as the increase in pressures on the arterial walls by blood flow. In caseof pathological situations where there is increased afterload, the heart undergoes LVH to reducetension in the walls under the law of Laplace.5, 6Echocardiography has been the standard procedure for calculating LVH more than 25 years, 13provides information on the morphology, ventricular cavity, ventricular thickness, leftventricular ejection fraction (LVEF), contraction of different segments and, as consequence ofthis, of the global systolic function, an important factor in morbidity and mortality inhypertension patients. Clinical and epidemiological studies demonstrate the diagnostic andprognostic utility of echocardiography in hypertension, especially in the impact of LVH andLVEF detected by echocardiography.1, 7 The LVH determined mainly by the increased size ofmyocyte is the most common heart disease in hypertensive patients, and increases the risk ofpremature cardiovascular events or death.8, 15 LVH is an important prognostic marker, andmonitoring a hypertensive patient should be followed with the study ecocardiográfico.18
General ObjectiveDetermine the prevalence of LVH by echocardiography in hypertensive patients in the area ofSilver Spring, MD and Washington DC. End Points Observe the prevalence of LVH in hypertensive patients between 70 years or older and younger men and women. Compare the value of LVEF in hypertensive patients in relation to non-hypertensive patients assessed by echocardiogram during the study period.
MATERIAL PATIENTS AND METHODS Scope, duration of the studyThe study was conducted over a period of seven months, from July 2010 until January 2011, inthe Francisco A. Matheus Clinic in Silver Spring, MD. Methodological DesignThe study was descriptive, retrospective, cross-temporal, and with control of observationalvariables. Study PopulationThe study samples were all hypertensive and non-hypertensive patients with echocardiographystudy done. The inclusion criterion of the group was the medical study diagnosticechocardiography of LVH and to have hypertension. Patients who did not wish to participate ofthe study were excluded. Sample IdentificationThe universe consisted of two hundred and eighteen (n = 218) echocardiography studies of sexes,78.4% Latin American and 44% male. Operationalization of variablesIt was recorded in a Microsoft Access table the patients who were studied withechocardiography, hypertensive patients were determined by mercury sphygmomanometer,
verified at the time they were in the clinic for consultation and the register of medical records.LVH it was based on male values and cardiac ultrasound criteria was based on the methods ofthe American Society of echocardiogram.16The LVEF has a normal value greater than 50%, mild between 45% - 54%, moderate 30% - 44%or severe less than 30% and the study was based on values masculino.15, 16The (Compare Guide Line) current classification of arterial pressure determines the stage of thecondition the patients blood pressure and the values used in this study were the level of bloodpressure (mmHg) Category Systolic Diastolic Normal <120 and <80. Pre-hypertension 120-139or 80-89. Hypertension Stage 1: 140-159 or 90-99. Stage 2: 160 or 100.19 Instruments and data collectionThe data were obtained with echocardiography study on the M-mode of the ultrasoundequipment Esaote Biosound model. The image of innovation; System type: MyLab 30CV; Serialnumber: 01812. Medical records of patients who had attended the clinic during the monthsindicated were also evaluated. Statistical proceduresThe following data were analyzed. In medical records: blood pressure, age, sex. The results ofcardiac ultrasound studies in patients request of echocardiography. Ethical AspectsAll the recollected information of the study was authorized by the patients with an informedconsent and by the administrative department of the clinic.
RESULTSOf all patients studied (n=218), 58.71% (n=128) had high blood pressure( ), among hypertensivepatients found, 41.4% (n=53) demonstrated LVH, as shown in Figure 1.Among patients of 70 years or older 2.29% (n = 50) it was found 94% (n = 47) with hypertensionand among hypertensive patients founded it was recorded 46.80% (n = 22) of LVH. Amongfemale patients of 70 years or older 15.59% (n = 34), all of them had high blood pressure 100%(n = 34) and among the hypertensive 47.05% (n = 16) demonstrated LVH.The males aged 70 and older 7.33% (n = 16), 81.25% (n = 13) presented HTN and among thosewith HTN, 46.15% (n = 6) demonstrated LVH. The number of patients can be seeing, based onthe total universe in Graphic 1.Among patients of 69 years or less 77.06% (n = 168), it was found 48.21% (n = 81) of HTN andamong those patients hypertensive, 56.79% (n = 46) demonstrated LVH. Among female patientsof 69 years or less it was presented 26.78% (n = 45) of HTN and among hypertensive femalepatients 69 years or less it was recorded 40% (n = 18) of LVH, Graphic 2.Of men of 69 years or less it was presented 21.42% (n = 36) of HTN and among hypertensivemen of 69 years or less there was 77.77% (n = 28) of LVH, as shown in Graphic 2.The patients with HTN presented LVEF of normal 97.6%, mild 1.6%, moderate 0.0% and severe0.8% in the period, based on male values, as shown in Graphic 3.
DISCUSSIONThe prevalence of LVH in patients with HTN found in this study (41.4%) is higher comparedwith the results present in the Spanish journal of cardiology, showed 20.3%, 20 but the prevalenceof LVH presented in the Spanish journal of cardiology was taken by the electrocardiogram, ascompared with the results of Journal of the American Heart Association, 14.6% findings of LVHin hypertensive patients, 21 the results of this study are still prominent.In the town of Silver Spring, MD and D.C. is the prevalence of LVH in hypertensive patients andis consistent with the values of LVH according the work of Devereux, the same technique usedin M-mode ultrasound with values between 12-30% of LVH or up to 60% when comparedhypertensive population reference centers in the treatment of HTA.22Among patients 70 years or older found 94% with HTN and among those 69 years or less thevalue of HTN decreased nearly doubled to 48.21%. This tells us that the percentage of HTNpatients of 70 years or more it becomes almost double, making it equivalent to the FraminghamHeart Study revealed that the older the patient, the greater the risk of hypertensive patientspresenting HVI.4Among patients 69 years or so shows that LVH is high compared to the number of hypertensivepatients in the group of greater than or equal to 70 years, what makes us think (changing), andthat as hypertension is a silent disease, 1 lot patients do not know the severity of the disease,leaving a shortfall in the treatment of hypertension in the productive age male and femaleprofessional.The main limitation of this study is their cross-cutting, limited observational estimates of theprevalence of LVH in hypertensive patients, whereas pre-treatment variations as BP in
hypertensive patients. The variability of myocardial damage increase or decrease is not set andthe LVEF was not considered in relation to medication use of patients studied.The increased variability of blood pressure in elderly patients may be present for the decline inbaroreceptor reflex function associated with increased stiffness and decreased elasticity causedby old age and HTN.The study shows the prevalence of LVH present in patients with HTN and surprised with theabsence of LVH in all hypertensive patients 70 years or more (n = 3), confirming other studieson the high prevalence of LVH in patients greater than or equal to 70 years, 3 and the relationshipwith the existence of the HTA.5, 6Among all hypertensive patients studied, LVEF is expressed normally, which tells us that therelation of blood pressure is directly related to the contractility cardiaca.8We conclude that people who suffer from HTN and LVH caused by their lack of control,especially the group of patients of 69 years does not know their status and have access todiagnostic tools for proper monitoring and medical treatment because no satisfactorysocioeconomic factors and education level are not limiting so that patients could get moreinformation about the disease they suffer.It is recommended that local health professionals who insist on educating the population and putemphasis on home monitoring of blood pressure, as in patients 69 years or less have high bloodpressure and 56.79% (n = 46) of LVH among this hypertensive patients, these data areworrisome because if compared between patients over 70 with younger patients, the prevalenceof LVH is more prominent among younger hypertensive patients.It would help further studies for deeper correlation and pathogenesis of LVH associated withblood pressure and LVEF to better prevent the consequence of the chronic development of
hypertensive cardiomyopathy, which is to be as devastating as the advanced stage othercomplications of hypertension. CONCLUSIONAmong patients with HTN 58.71% (n = 128) there is a prevalence of LVH of 41.4% (n = 53).The prevalence of LVH found in patients with HTN for men and women aged 70 or olderprevailed in female patients (47.05%) compared to male patients (46.15%).Among patients of 70 years or older there are 94% with HTN and among those 69 years or lessthe value of HTN goes under nearly the double to 48.21%.The LVEF among hypertensive patient compared with non-hypertensive, there is apredominance of abnormal LVEF among patients with hypertension compared to non-hypertensive studied.
Figure 1: Comparison with hypertension and left ventricular hypertrophy. Patients of 70 years or more 47 50 45 40 34 35 30 22 25 20 16 13 15 10 6 5 0 Male Female TotalGraphic 1: Patients presenting more risc of LVH, blue color: HTN, red color: LVH and HTN,left axis: Number of patients.
Patients of 69 years or less 90 81 80 70 60 45 46 50 36 40 28 30 18 20 10 0 Male Female TotalGraphic 2: Patients presenting less risc of LVH, blue color: HTN, red color: LVH and HTN, leftaxis: Number of patients. Left Ventricular Ejection Fraction 100 100 97.6 90 80 70 60 50 40 30 20 10 0 0.8 0 0 0 1.6 0 Severe Moderate mild NormalGraphic 3: Percentual of LVEF presented in HTN patients (red color) and non-HTN patients(blue color) based on male values, left axis: Patients percentage (100%).
ACKNOWLEDGMENTSFrancisco A. Matheus, M.D., P.C., Gonzalo Alberto Rincón, M.D. and Theodros Dagnew, M.D.,for them professional medical education and professional support of diagnostic imaging. Myacknowledgments to the Medical Center located at 13018 Georgia Ave Silver Spring, MD 20906with their respective secretaries offices, Lizabeth Cardon De Pazos, Sandra Patricia Cea,Gabriela Tirado and Elizabeth Cindy Climaco.
REFERENCES1. Harrison. 2005. Principles of Internal Medicine; 16th Ed. United States of America, McGraw-Hill. Pag. 1320-23 and 1463-67.2. Texas Heart Institute. 2010. St. Luke’s Episcopal Hospital, Houston, Texas. Education Department. (http://www.texasheartinstitute.org/HIC/Topics_Esp/Cond/hbp_span.cfm. Consultado el: 19 de agosto de 2010).3. Heart Disease. 2001. Textbook of Cardiovascular Medicine; 6th Ed. Philadelphia, W. B. Sauders Company. Pag. 160-228.4. American Journal of Public Health. 1988, Vol. 78, Numero 6s. Framinghan Study.5. Farreras y Rozman, 2004. Medicina Interna; 15th Ed. Madrid, España, Elsevier. Vol. I, pag. 587-611.6. William F. Ganong. 1992. Fisiología Medica; 13th Ed. México, DF, Manual Moderno. Pag. 578-9.7. Fuster; O’rourke; Walsh; Poole-Wilson. 2008. Hurst’s The Heart; 12th Ed. China. McGrawHill Medical. Pag. 389-91, 811-15. Volumen I8. Robbins. 2007. Basic Pathology; 8 Ed. Philadelphia, PA, Sauders Elsevier. Pag. 3-4, 410- 12 and 353-7.9. Robert Berkow. 1999. The Merck Manual of Medical Information. Home Ed. 4 Printing. United States of America. Merck Research Laboratories. Pag. 12010. R. Devereux. 1995. Hypertensive Cardiac Hypertrophy. Pathophysiology and Clinical Characteristics. In Hypertension Pathophysiology, Diagnosis and Management. 2th Ed. Laragh, Brenner. Pag. 298-355.11. American Heart Association. 2003. New Guidelines issued for Treating Resistant Hypertension. Dallas, Texas. 42; 1206-1252.12. Journal of the American Medical Association (JAMA), November 17, 2004—Vol 292, No. 19.13. Devereux RB, Liebson PR, Horan MJ. Recommendations concerning the use of echocardiography in hypertension and general population research. Hypertension. 1987;9(suppl II):II-97-II-104.14. Levy D.; Garrison RJ.; Savage D.D.; Kannel B.B.; Castelli W. P. Prognostic implications od echocardiographically determined left ventricular mass in the Framingham Heart Study. New England Journal of Medicine 1990; 322:1561-6.15. LIBBY; BONOW; MANN; ZIPES. 2008. Braunwald’s Heart Disease. 8th Ed. Philadelphia, P.A. Sauders Elsevier. Volumen I. Pag. 247-8, 571-3 and 611-39.16. Journal of the American Society of Echocardiography (JASE), 2005; 18: 1440-1463.
17. David A. Warrell; Timothy M. Cox; John D. Firthr. 2003. Oxford Texlbook of Medicine. 4 Ed. New York. Oxford University Press. Volume II. Pag. 1153-9.18. William N. Kelly. 1997. Textbook of Internal Medicine. 3th Ed. Philadelphia, P.A. Lippincott-Raven. Volume I. Pag. 175-183.19. U. S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, National Institutes of Health, National Heart, Lung, and Blood, Institute National, High Blood Pressure Education Program N I H, Publication No. 03 - 5233. December 2003. Site: (http://www.nhlbi.nih.gov/guidelines/hypertension) Consultado el: 29 de noviembre de 2010. Seventh Report of the Joint National Committee on Prevention Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7).20. Revista Española de Cardiología. 2006; 59(2):136-42.21. Journal of the American Heart Association Vol. 81, No 2, February 1990.22. Hammond IW, Devereux RB, Alderman MH,et al. The prevalence and correlates of echocardiographic left ventricular hypertrophy among employed patients with uncomplicated hypertension. J Am Coll Cardiol. 1986; 7: 639-650.