Tom tat LA bs dương tiêng anh: Nghiên cứu chỉ số tương hợp tâm thất – động mạch ở bệnh nhân tăng huyết áp nguyên phát

Nghiên cứu chỉ số tương hợp tâm thất – động mạch ở bệnh nhân tăng huyết áp nguyên phátNghiên cứu chỉ số tương hợp tâm thất – động mạch ở bệnh nhân tăng huyết áp nguyên phátNghiên cứu chỉ số tương hợp tâm thất – động mạch ở bệnh nhân tăng huyết áp nguyên phátNghiên cứu chỉ số tương hợp tâm thất – động mạch ở bệnh nhân tăng huyết áp nguyên phátNghiên cứu chỉ số tương hợp tâm thất – động mạch ở bệnh nhân tăng huyết áp nguyên phátNghiên cứu chỉ số tương hợp tâm thất – động mạch ở bệnh nhân tăng huyết áp nguyên phátNghiên cứu chỉ số tương hợp tâm thất – động mạch ở bệnh nhân tăng huyết áp nguyên phátNghiên cứu chỉ số tương hợp tâm thất – động mạch ở bệnh nhân tăng huyết áp nguyên phátPhụ lục VI INTRODUCTION 1 The urgency of the subject In recent studies, left ventricular function and left ventricular aortic coupling has been demonstrated to play a critical role in the pathophysiol.

MILITARY MEDICAL UNIVERSITY

BUI THUY DUONG

VENTRICULAR - ARTERIAL COUPLING

IN PRIMARY HYPERTENSIVE PATIENTS

Major: Internal medicine Code: 9720107

SUMMARY OF MEDICAL DOCTORAL THESIS

HA NOI - 2023

SUPERVISOR: Assoc.,Prof PhD NGUYEN OANH OANH

Reviewer 1: Assoc Prof PhD Pham Quoc Khanh

Reviewer 2: Assoc Prof PhD Luong Cong Thuc

Reviewer 3: Assoc Prof PhD Pham Nguyen Son

This thesis will be defended at School-level ThesisEvaluation Councial at Military Medical University at: … o’clock,

1 The urgency of the subject

In recent studies, left ventricular function and left aortic coupling has been demonstrated to play a critical role in thepathophysiology of cardiovascular disease such as hypertension,heart failure Chen C.H et al developed and tested a novel fullynoninvasive estimation method, that is, single-beat analysis andvalidated it against invasive measurement His study showed similarfindings between two methods the European Association ofCardiovascular Imaging (EACVI) and the American Society ofEchocardiography (ASE) reached a consensus to use Ea (arterialelastance), Ees (left ventricularend-systolic elastance) and theventricular-arterial coupling (VAC or Ea/Ees) for echocardiographicassessment, prognosis, and management of hypertension

ventricular-In Vietnam, there have been few reports on ventricular arterialcoupling in primary hypertensive patients since our initial researches

in 2010

2 Objectives of the thesis:

➀ To investigate value of ventricular arterial coupling (VAC) and

its components as well as its association with anthropometric features and cardiovascular disease risk factors among primary hypertensive patients.

➁ To identify the relationship of VAC and its components with morphology, left ventricular and arterial function among primary hypertensive individuals

3 Scientific and practical significance of the research

- Having determined the value of left ventricular arterial coupling(VAC) and its components (Ea, EaI, Ees, EesI) in primaryhypertensive patients, in which there were changes in ventricular andarterial elasticity compared with people with normal cardiovascularfunctions

- Having determined the value of Ea, EaI, Ees, EesI, and VAC and

its association with gender, age, BMI and cardiovascular disease risk factors in in primary hypertensive patients

- Having evaluated the relationship between Ea, EaI, Ees, EesI andVAC with echocardiographic characteristics and stages of heartfailure in primary hypertensive individuals This contributes toexplain some pathophysiology variations in hypertension, predict andearly detect the complications of this disease such as diastolic andsystolic dysfunctions

4 Thesis structure

- The thesis has 134 pages, including 2 pages of Introduction, 35pages of Overview, 24 pages of Subjects and Methods, 33 pages ofResults, 35 pages of Discussion, 2 pages of Conclusion, and 1 page

of Recommendation

- There are 37 tables, 15 figures with 135 references, including 10

in Vietnamese and 125 in English The published works related to thethesis, studying protocol and list of participating subjects are alsoincluded

Chapter 1 OVERVIEW 1.1 Hypertension

1.1.1 Definition

Hypertension is defined as office SBP values ≥140 mmHg and/ordiastolic BP (DBP) values ≥90 mmHg, and the diagnosis ofhypertension should be based on at least two BP measurements(ESC/ESH 2018)

1.2 Left ventricular arterial coupling

1.2.1 What is the left ventricular arterial coupling ?

1.2.1.1 End systolic elastance–Ees

The crossing points where the end-systolic pressure and volumeintersect each other on the the pressure–volume loop is called theend-systolic pressure-volume relationship - ESPVR This relationship

is reasonably linear, and independent of the arterial pressures The

LV end-systolic elastance (Ees or Elv) is quantified as the slope ofESPVR demonstrating the LV contractility

1.2.1.2 Arterial elastance - Ea

On the pressure–volume (PV) loop, Sunagawa and coworkerscharacterized a slope joining the end-diastolic volume (EDV) and theend-systolic pressure (ESP) points demonstrating the augmentation

of arteries to respond to the increase of left ventricle’s stroke volume.This slope is called the effective arterial elastance (Ea)

1.2.1.3 Ventricular-Arterial Coupling - VAC

VAC demonstrates the interaction between Ea and Ees by the ratio:

1.2.2 Calculating VAC and its components by non-invasive methods

1.2.2.1 End systolic elastance

Ees was calculated by the modified single-beat method by Chel.which was proved to be equavalent to other invasive methods Thefomular is:

in which : End(est) = 0.0275 − 0.165 × EF + 0.3656 × (Pd/Ps × 0.9) +0.515 × End(avg)

End(avg) = 0.35695 − 7.2266 × tNd + 74.249 × tNd2−307.39 × tNd3+ 684.54 × tNd4 – 856.92 × tNd5+ 571.95 × tNd6 − 159.1 × tNd7

P d : diastolic pressure; P s : systolic pressure obtained at the upper arm; t Nd : ratio of preejection period to total systolic period; SV: stroke volume measured by Simpson’s method The unit of Ees(sb) is

mmHg/ml,a nd its normal range is 2.3 ± 1.0 mmHg/ml

1.2.2.2 Arterial elastance

Due to Pes ≈ 0.9 x Ps, therefore

Pes: end systolic pressure; P s : systolic pressure obtained at the upper arm; t Nd : ratio of preejection period to total systolic period;

𝐄𝐞𝐬 (𝐬𝐛 ) =𝐏𝐝 − (𝐄𝐧𝐝 (𝐞𝐬𝐭 ) × 𝐏𝐬 × 𝟎.𝟗)

𝐄𝐧𝐝 (𝐞𝐬𝐭 ) × 𝐒𝐕

SV: stroke volume measured by Simpson’s method The unit of Ea is

mmHg/ml, and its normal range is 2.2 ± 0.8 mmHg/ml

Therapeutic options to improve VAC:

According to Martin Osranek (2008), after treatment, Ea and VACdeceased, Ees increased, which were early signs of left ventricularremodeling In a research by Lam CS (2013), lowering BP couldhelp to improve Ea, Ees, and Ea/Ees and thereby improving the leftventricular function and slowering the hyperstrophy Somemedications like angiotensin converting enzyme inhibitor,angiotensin receptor blockers and dihydropyridine (calcium channelblockers) might have some effects to this parameter

Chapter 2 SUBJECTS AND METHODS 2.1 Subjects

The subjects were 228 adults (over 18 years old ), divided into thecontrol and the hypertension group in 103 Military Hospital fromOctober 2014 to December 20120

159 primary hypertensive patients who were eligible for the criteria

by WHO – ISH (2013) and Vietnam Heart Association 2008 receivedinpatient treatment at Department of Internal Medicineand Cardiology, 103 Military Hospital

- Exclusion criteria

+ Secondary hypertension

+ Severe acute diseases or cancer

+ Left ventricular outflow tract obstruction, coarctation of the aorta,heart valvular stenosis, or having left ventricular assist device

2.2 Methods

2.2.1 Study design: A descriptive, cross-sectional study

2.2.2 Methods of measurements in the research

- Ea, Ees(sb) and VAC

+ Calculating Ees and EesI based on the modified single-beat method

by Chel;

+ EesI was derived from Ees ajusted by BSA: EesI = Ees/BSA

- Ea and EaI:

EaI = Ea/BSA

- VAC: VAC = Ea/Ees

2.2.3 Diagnotic criteria in the research

a WHO – ISH (2013) and Vietnam Heart Association (2008)

b NYHA classification of chronic heart failure

c 2013 ACCF/AHA classification of heart failure

- Heart failure with reduced EF (EF ≤ 40%)

- Heart failure with preserved EF (EF ≥ 50%)

- Heart failure with preserved EF, borderline (EF 41 – 49%)

- Heart failure with preserved EF, improved (EF > 40%)

* In this study, all types of heart failure with EF > 40% were calledheart failure with preserved EF Therefore, the hypertension groupwas divided into 3 subgroups:

+ Without heart failure: 98/159 patients

+ Having heart failure with preserved EF (HFpEF):31/159 patients+ Having heart failure with reduced EF (HFrEF): 30/159 patients

2.2.4 Data analysis

Data is processed with SPSS 20.0 software: data is presented asaverages and percentages Compare the results by X-squared test, TTest, ANOVA test The difference is statistically significant whenp<0.05

Chapter 3 RESULTS 3.1 General characteristics

- In the hypertension group, concentric LVH was found in 33.33%, eccentric LVH in 25.16%, concentric remodeling in 18.87%, normal

LV structure in 22.64%

- In the hypertension group, non-heart failure individuals (non-HF)were responsible for 61.64%; hypertenstion patients with HFpEF(heart failure with preserved ejection fraction) and HFrEF(heart

failure with reduced ejection fraction) were observed in 19.50% and18.87%, respectively.

- Proportion of patients with NYHA classes II, III and IV were 15.09,15.7% and 7.55%, respectively

3.2 Value of VAC as well as its components and its association with anthropometric features, cardiovascular risk factors in patients with primary hypertension

3.2.1 Value of VAC as well as its components in patients with primary hypertension

Table 3.12 Value of VAC and its components

Parameters

Control (n=69)

( ± SD)

Hypertension (n=159)

Non HF hypertension (n=98)

(mmHg/mL.m2)

2.27 ±0.81

without heart failure) were higher than the control (p < 0.05), andVAC was still equivalent.

3.2.2 Association of VAC and its components with some pometric features in primary hypertensive patients

anthro-3.2.2.1 Association of VAC and its components with age and gender

- In the hypertensive patients, EaI, Ees and EesI were higher infemales than in males; meanwhile VAC was lower in females, p <0.05 Ea was equivalent in both genders

- By analyzing the age group of 40-49 years, 50-59 years, 60-69years and over 70 years, we realized:

+ Ea, EaI tends to increase with age in both groups (hypertension andcontrol groups) (p < 0.05)

+ Ees and EesI tends to increase with age in the hypertensive patientswithout heart failure and in the control group (p < 0.05), but showed

no difference between age groups in the hypertensive group (p >0.05)

+ VAC also did not differ with age in the hypertension, hypertensionwithout heart failure and control group

Table 3.20 Association of VAC with age

Parameters

Hypertension (n=159)

VAC (Ea/Ees) 0.196 <0.05 0.02 >0.05

- Ea, EaI, Ees and EesI were positively correlated with age but VAC was

not

Figure 3.10 Correlation of age with Ea, EaI in hypertensive

patients without heart failure

(Blue line: Female; Orange line: Male)

Ea, EaI were positively correlated with age among hypertensive females without HF, of which their correlations were demonstrated asfollows:

Ea = 0.0522 x age + 0.1068; R² = 0.2601, p < 0.001 in womenEaI = 0.0424 x age – 0.3846; R² = 0.338, p < 0.001 in women

Figure 3.11 Correlation between age and Ees, EesI in hypertensive patients without heart failure

(Blue line: Female; Orange line: Male)

- Ees and EesI were positively correlated with age amonghypertensive females without HF, of which their correlations weredemonstrated as follows:

Ees = 0.0898 x tuổi – 0.5608; với R² = 0.326; p < 0.001

EesI = 0.0725 x tuổi – 1.1285; với R² = 0.3943; p < 0.001

- No correlation between Ea, EaI, Ees and EesI was found amonghypertensive males whereas there was no association between VACand age in both genders

3.2.2.2 Association of VAC index and its components with BMI

- In both groups of hypertension and hypertension without heartfailure, there was a strong-to-moderate negative correlation of EaIand EesI with height, weight and BMI There was no or slightsignificant correlation between VAC and height, weight and BMI

3.3 Association of VAC and its components with left ventricular morphology and function and arterial function in primary hypertensive patients

3.3.1 Association of VAC and its components with left ventricular morphology in primary hypertensive patients

Table 3.26 Association of VAC and its components with

left ventricular hypertrophy

Parameters

hypertrophic

- EesI was lower, and VAC was higher in the hypertensive groupwith left ventricular hypertrophy (LVH) than in the hypertensivegroup without LVH

Table 3.27 Association of VAC and its components with left

ventricular end-diastolic diameter

- Compared to hypertensive subjects with LVDd ≤ 50mm, those withLVDd > 50mm had lower Ees, EesI and higher VAC, p < 0.05

Table 3.28 Correlation coefficient of VAC and its components

with Dd, EDV, EDVi

Parameters

Dd (n = 159)

EDV (n = 159)

EDVi (n = 159)

Ea (mmHg/ml) -0.076 >0.05 -0.414 <0.05 -0.418 <0.05 EaI (mmHg/ml.m2) -0.174 <0.05 -0.459 <0.05 -0.375 <0.05 Ees (mmHg/ml) -0.369 <0.05 -0.591 <0.05 -0.575 <0.05 EesI(mmHg/ml.m2) -0.437 <0.05 -0.615 <0.05 -0.521 <0.05 VAC (Ea/Ees) 0.307 <0.05 0.291 <0.05 0.273 <0.05

- There was a negative correlation between Ea, EaI and EDV, EDVi;between Ees, EesI and Dd, EDV và EDVi (p < 0.05) whereas VACslightly correlated with Dd, EDV, EDVi

Table 3.29 Correlation coefficient of VAC and its components

with RWT, LVM, LVMI

Parameters

RWT (n = 159)

LVM (n = 159)

LVMI (n = 159)

Ea (mmHg/ml) -0.047 >0.05 -0.074 >0.05 -0.025 >0.05

EaI (mmHg/ml.m2) -0.010 >0.05 -0.179 <0.05 -0.071 >0.05 Ees (mmHg/ml) 0.121 >0.05 -0.327 <0.05 -0.298 <0.05 EesI (mmHg/ml.m2) 0.144 >0.05 -0.404 <0.05 -0.320 <0.05 VAC (Ea/Ees) -0.143 >0.05 0.286 <0.05 0.293 <0.05

- Ees, EesI decreased in accordance with the increase of LVM andLVMi (p < 0.05)

3.3.2 Association of VAC and its components with alteration of LV function in primary hypertensive patients

3.3.2.1 Association of VAC and its components with indices of left ventricular diastolic and systolic function.

- For diastolic function: There was no or weak correlation between

Ea, EaI, Ees , EesI, VAC and e’, E/e’, left atrial volume/BSA

- For systolic function: Fs was positively correlated with Ees and

EesI but negatively associated with VAC

Ea, EaI, Ees , EesI and VAC were positively correlated with CO and

CI, p < 0.05

- For natriuretic peptide: Wheareas a moderate positivecorrelation was obtained between VAC and BNP (r = 0.396, p <0.05) but didn’t occur to Ea, EaI, Ees and EesI (p > 0.05)

3.3.2.2 Association of VAC and its components with heart failure severity

Table 3.33 Association of VAC and its components with heart failure classified by the 2013 ACCF Guideline

Parameters

(1) Control (n=69)

Hypertension

p (2)

Non-HF (n=98)

(3) HFpEF (n=31)

(3) HFrEF (n=30) Ea

in the control

- VAC was highest in the patients with HFrEF (p<0.05)

Table 3.35 Association of VAC and its components heart failure

(3) NYHA III (n=25)

(4) NYHA IV (n=12)

- Ees in NYHA IV was significantly lower than in NYHA II, III andreduced compared to the controls

- VAC in NYHA IV was equivalent to NYHA III, which was 1.4 and1.6 times higher than that in NYHA II and the control group,respectively (p<0.05)

3.3.2.3 Diagnostic value of VAC for heart failure

- In predicting the severity of heart failure, the area under the curve(AUC) of VAC was 0.769, that of BNP was 0.872 (p < 0.05) Withthe cut-point value of 0.921, VAC had the sensitivity of 63.2%, andspecificity of 88.4% which were equivalent to that of BNP at cut-point of 107.60 pg/ml and sensitivity of 91.2%, specificity of 98.6%

3.3.3 Association of VAC and its components with arterial function primary hypertensive patients

3.3.3.1 Association of VAC and its components with SVRi

- Ea, EaI, Ees and EesI showed positive correlation with SVRi, but

VAC did not

3.3.3.2 Association of LV end-systolic elastance with arterial elastance

Figure 3.15: Correlation between Ees and Ea