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Early detection by non-invasive methods of predisposition to atrial remodeling in hypertension
Predisposição para remodelagem auricular na hipertensão arterial - deteção precoce por meios não invasivos
Luiz Menezes Falcão
Faculdade de Medicina de Lisboa, Hospital de Santa Maria/Centro Hospitalar Lisboa Norte, Lisboa, Portugal
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The pressure/volume overload and ventricular wall stretching seen in HF lead to upregulation of the ADM gene. The preprohormone undergoes cleavage, forming pro-ADM, which is further processed to ADM. ADM causes natriuresis, diuresis, and vasodilation. It is also associated with reduced hypertrophy, ventricular remodeling and fibrosis. The actions of ADM thus have a cardioprotective effect. Due to its in vitro instability, ADM levels cannot be measured directly, but cleavage of pro-ADM also produces mid-regional pro-adrenomedullin, a stable fragment that is easily measured and whose concentrations reflect those of ADM. ADM: adrenomedullin; MR-proADM: mid-regional pro-adrenomedullin.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Daniela Lopes, Luiz Menezes Falcão" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Daniela" "apellidos" => "Lopes" ] 1 => array:2 [ "nombre" => "Luiz" "apellidos" => "Menezes Falcão" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S0870255116302323" "doi" => "10.1016/j.repc.2016.11.009" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255116302323?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204917301745?idApp=UINPBA00004E" "url" => "/21742049/0000003600000006/v1_201707020042/S2174204917301745/v1_201707020042/en/main.assets" ] "itemAnterior" => array:20 [ "pii" => "S2174204917301733" "issn" => "21742049" "doi" => "10.1016/j.repce.2016.10.022" "estado" => "S300" "fechaPublicacion" => "2017-06-01" "aid" => "1005" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "fla" "cita" => "Rev Port Cardiol. 2017;36:453-9" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2793 "formatos" => array:3 [ "EPUB" => 146 "HTML" => 2295 "PDF" => 352 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>" "titulo" => "Early changes in atrial conduction times in hypertensive patients with elevated pulse pressure" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "453" "paginaFinal" => "459" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Alterações precoces nos tempos de condução auricular nos doentes hipertensos com pressão de pulso elevada" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 883 "Ancho" => 3332 "Tamanyo" => 198713 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Pearson's correlation analysis demonstrating the correlation between pulse pressure and atrial electromechanical delay. EMD: electromechanical delay.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Tolga Çimen, Hamza Sunman, Tolga Han Efe, Ahmet Akyel, Kadriye Yayla, Haluk Furkan Şahan, Murat Bilgin, Lale Dinç Asarcıklı, Ali Nallbani, Mehmet Doğan, Sadık Açıkel, Ekrem Yeter" "autores" => array:12 [ 0 => array:2 [ "nombre" => "Tolga" "apellidos" => "Çimen" ] 1 => array:2 [ "nombre" => "Hamza" "apellidos" => "Sunman" ] 2 => array:2 [ "nombre" => "Tolga Han" "apellidos" => "Efe" ] 3 => array:2 [ "nombre" => "Ahmet" "apellidos" => "Akyel" ] 4 => array:2 [ "nombre" => "Kadriye" "apellidos" => "Yayla" ] 5 => array:2 [ "nombre" => "Haluk Furkan" "apellidos" => "Şahan" ] 6 => array:2 [ "nombre" => "Murat" "apellidos" => "Bilgin" ] 7 => array:2 [ "nombre" => "Lale Dinç" "apellidos" => "Asarcıklı" ] 8 => array:2 [ "nombre" => "Ali" "apellidos" => "Nallbani" ] 9 => array:2 [ "nombre" => "Mehmet" "apellidos" => "Doğan" ] 10 => array:2 [ "nombre" => "Sadık" "apellidos" => "Açıkel" ] 11 => array:2 [ "nombre" => "Ekrem" "apellidos" => "Yeter" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S0870255117303475" "doi" => "10.1016/j.repc.2016.10.012" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255117303475?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204917301733?idApp=UINPBA00004E" "url" => "/21742049/0000003600000006/v1_201707020042/S2174204917301733/v1_201707020042/en/main.assets" ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial comment</span>" "titulo" => "Early detection by non-invasive methods of predisposition to atrial remodeling in hypertension" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "461" "paginaFinal" => "463" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Luiz Menezes Falcão" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Luiz" "apellidos" => "Menezes Falcão" "email" => array:1 [ 0 => "luizmfalcao@sapo.pt" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Faculdade de Medicina de Lisboa, Hospital de Santa Maria/Centro Hospitalar Lisboa Norte, Lisboa, Portugal" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Predisposição para remodelagem auricular na hipertensão arterial - deteção precoce por meios não invasivos" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Hypertension (persistently high blood pressure levels) is one of the main cardiovascular risk factors. It causes pressure overload that leads to the structural and electrical alterations known as atrial remodeling.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">1,2</span></a> The consequences are seen at various levels, especially in increased risk for atrial fibrillation (AF), which worsens with increasing age.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">3</span></a> AF has a significant impact on cardiac output and is associated with a 4-5-fold higher risk of cardioembolic ischemic stroke,<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">4,5</span></a> as well as a considerably higher risk of death.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Interatrial electromechanical delay and prolonged total atrial activation time have been linked to a higher incidence of AF.<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">3,7,8</span></a> Increased atrial conduction time is an indication of structural and electrical remodeling, which left atrial (LA) size and LA volume index are not.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">1,9</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Increased left ventricular (LV) mass index is associated with prolonged interatrial conduction time and LA electromechanical coupling interval.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">1</span></a> The severity of LV hypertrophy appears to be one of the factors associated with the onset of AF.</p><p id="par0020" class="elsevierStylePara elsevierViewall">It has been demonstrated that pharmacological treatment that reduces blood pressure (BP) and hence LV mass makes AF less likely to occur.<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">10–12</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Data from the Framingham Heart Study show a relation between LA size as determined by echocardiography and systolic BP and pulse pressure (PP).<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">13</span></a> At the same time, there is evidence of a link between higher PP and increased incidence of AF in hypertension.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">14</span></a> PP has been shown to be a better predictor of AF risk than mean arterial pressure or aortic distensibility.<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">15,16</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">There is a good correlation between P-wave duration obtained in a single surface electrocardiographic (ECG) lead and the maximum duration of atrial electrograms; it also correlates with inter- and intra-atrial conduction times.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">17</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">P-wave dispersion, the difference between maximum and minimum P-wave duration recorded in multiple ECG leads in sinus rhythm, has been studied as an indicator of AF risk in populations with and without cardiovascular disease and in conditions including hypertension, ischemic heart disease, valve disease, congenital heart defects and heart failure.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">17</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In hypertensive patients, P-wave dispersion may help identify LV hypertrophy and LV diastolic dysfunction, both of which lead to morphological and hemodynamic alterations in the left atrium that increase the risk of AF. Raised intra-atrial pressures and ischemia promote atrial remodeling, with disorganization of myocardial fibers and fibrosis, dilatation and electrical instability.<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">17,18</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Among the factors tending to increase P-wave dispersion and atrial fibrosis is elevation of angiotensin II and catecholamines.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">18</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Treatment targeting the renin-angiotensin-aldosterone system (RAAS) with perindopril in hypertensives led to a decrease in P-wave dispersion,<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">17</span></a> an effect also seen in a similar study using quinapril.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">17</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In hypertensive patients, increased P-wave dispersion and maximum P-wave duration reflect instability and heterogeneity of atrial conduction, which may be a result of the morphological and hemodynamic alterations undergone by the left atrium as a consequence of hypertension.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">18</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Heart failure with reduced LV ejection fraction (LVEF) predisposes to the onset of AF. In a study of patients with non-ischemic dilated cardiomyopathy, P-wave dispersion was much higher than in the control group.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">19</span></a> This increased P-wave dispersion may be explained by hemodynamic variations resulting from LV dysfunction and associated neurohormonal activation affecting the left atrium.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Camsari et al. found a significant correlation between P-wave dispersion and LVEF in patients with heart failure. Both sympathetic activity and the RAAS are stimulated in heart failure, and this influences P-wave duration and dispersion, both of which were reduced following treatment with metoprolol in their study.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">20</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">For patients with symptomatic heart failure despite optimized drug treatment, in sinus rhythm and with LVEF ≤35%, QRS ≥130 ms and complete left bundle branch block, cardiac resynchronization therapy (CRT) improves LV function and reduces neurohormonal activation. It has also been shown to contribute to reverse atrial remodeling and thus to improvement in atrial function.<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">21,22</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">In a study of 46 patients with heart failure with reduced LVEF, after three months of CRT, maximum P-wave duration, P-wave dispersion and LA diameter were decreased and LVEF was increased.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">22</span></a> Maximum P-wave duration and P-wave dispersion were positively correlated with reduction in LA diameter and negatively correlated with improvement in LVEF.</p><p id="par0080" class="elsevierStylePara elsevierViewall">P-wave terminal force in lead V1 (PTFV1) is the product of the amplitude and duration of the terminal negative phase of the P wave in lead V1 in mm×ms. It is a marker of cardiovascular prognosis and there is evidence that when increased it indicates increased risk of AF.<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">23,24</span></a> Abnormal PTFV1, defined as ≥40 mm×ms, was shown to be an independent predictor of cardiac death or hospitalization for heart failure in patients with prior myocardial infarction,<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">23</span></a> while another study, in patients with increased LV mass, showed that PTFV1 ≥40 mm×ms was associated with increased risk for ischemic stroke.<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">25</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">In their study published in this issue of the <span class="elsevierStyleItalic">Journal</span>, Çimen et al. examine early changes in atrial conduction times and P-wave dispersion in 157 patients with essential hypertension, no significant cardiac structural alterations, and elevated PP (≥60 mmHg).<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">26</span></a> Atrial electromechanical delay (EMD) was assessed by tissue Doppler echocardiography and P-wave dispersion by electrocardiography. The authors show that elevated PP was associated with increased atrial EMD and P-wave dispersion.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Detection of early alterations, by non-invasive and easily accessible means, that could help prevent structural and electrical remodeling and thus reduce the risk of AF is of the utmost importance. The study by Çimen et al. in this issue is another contribution to this goal.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0095" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Menezes Falcão L. Predisposição para remodelagem auricular na hipertensão arterial - deteção precoce por meios não invasivos. Rev Port Cardiol. 2017;36:461–463.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:26 [ 0 => array:3 [ "identificador" => "bib0135" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Early changes in atrial electromechanical coupling in patients with hypertension: assessment by tissue Doppler imaging" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "B.K. Avci" 1 => "O. Gulmez" 2 => "G. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 5 | 12 |
| 2024 October | 34 | 33 | 67 |
| 2024 September | 39 | 21 | 60 |
| 2024 August | 50 | 23 | 73 |
| 2024 July | 32 | 29 | 61 |
| 2024 June | 29 | 17 | 46 |
| 2024 May | 29 | 17 | 46 |
| 2024 April | 31 | 27 | 58 |
| 2024 March | 21 | 16 | 37 |
| 2024 February | 21 | 23 | 44 |
| 2024 January | 25 | 22 | 47 |
| 2023 December | 30 | 22 | 52 |
| 2023 November | 27 | 21 | 48 |
| 2023 October | 24 | 17 | 41 |
| 2023 September | 14 | 16 | 30 |
| 2023 August | 14 | 15 | 29 |
| 2023 July | 11 | 10 | 21 |
| 2023 June | 24 | 14 | 38 |
| 2023 May | 25 | 21 | 46 |
| 2023 April | 16 | 3 | 19 |
| 2023 March | 25 | 18 | 43 |
| 2023 February | 19 | 14 | 33 |
| 2023 January | 13 | 18 | 31 |
| 2022 December | 35 | 18 | 53 |
| 2022 November | 32 | 23 | 55 |
| 2022 October | 28 | 16 | 44 |
| 2022 September | 14 | 24 | 38 |
| 2022 August | 17 | 27 | 44 |
| 2022 July | 31 | 35 | 66 |
| 2022 June | 16 | 28 | 44 |
| 2022 May | 14 | 32 | 46 |
| 2022 April | 29 | 22 | 51 |
| 2022 March | 24 | 38 | 62 |
| 2022 February | 21 | 21 | 42 |
| 2022 January | 22 | 23 | 45 |
| 2021 December | 18 | 31 | 49 |
| 2021 November | 29 | 27 | 56 |
| 2021 October | 29 | 36 | 65 |
| 2021 September | 14 | 25 | 39 |
| 2021 August | 26 | 30 | 56 |
| 2021 July | 10 | 19 | 29 |
| 2021 June | 15 | 14 | 29 |
| 2021 May | 32 | 32 | 64 |
| 2021 April | 35 | 57 | 92 |
| 2021 March | 64 | 17 | 81 |
| 2021 February | 51 | 15 | 66 |
| 2021 January | 27 | 12 | 39 |
| 2020 December | 36 | 8 | 44 |
| 2020 November | 34 | 20 | 54 |
| 2020 October | 21 | 14 | 35 |
| 2020 September | 53 | 10 | 63 |
| 2020 August | 34 | 14 | 48 |
| 2020 July | 37 | 6 | 43 |
| 2020 June | 22 | 7 | 29 |
| 2020 May | 32 | 11 | 43 |
| 2020 April | 25 | 7 | 32 |
| 2020 March | 40 | 8 | 48 |
| 2020 February | 33 | 18 | 51 |
| 2020 January | 31 | 3 | 34 |
| 2019 December | 26 | 6 | 32 |
| 2019 November | 41 | 6 | 47 |
| 2019 October | 22 | 6 | 28 |
| 2019 September | 16 | 7 | 23 |
| 2019 August | 31 | 7 | 38 |
| 2019 July | 22 | 9 | 31 |
| 2019 June | 20 | 11 | 31 |
| 2019 May | 34 | 13 | 47 |
| 2019 April | 16 | 15 | 31 |
| 2019 March | 78 | 9 | 87 |
| 2019 February | 74 | 9 | 83 |
| 2019 January | 85 | 6 | 91 |
| 2018 December | 91 | 10 | 101 |
| 2018 November | 110 | 8 | 118 |
| 2018 October | 361 | 14 | 375 |
| 2018 September | 63 | 14 | 77 |
| 2018 August | 37 | 10 | 47 |
| 2018 July | 17 | 5 | 22 |
| 2018 June | 36 | 4 | 40 |
| 2018 May | 63 | 13 | 76 |
| 2018 April | 70 | 5 | 75 |
| 2018 March | 81 | 13 | 94 |
| 2018 February | 55 | 12 | 67 |
| 2018 January | 73 | 8 | 81 |
| 2017 December | 130 | 16 | 146 |
| 2017 November | 56 | 16 | 72 |
| 2017 October | 39 | 13 | 52 |
| 2017 September | 38 | 13 | 51 |
| 2017 August | 58 | 20 | 78 |
| 2017 July | 80 | 30 | 110 |
| 2017 June | 19 | 5 | 24 |
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