Assessment of Target Organ Damage:Established and Novel Methods

Christian Delles

BHF Glasgow Cardiovascular Research CentreInstitute of Cardiovascular and Medical SciencesUniversity of Glasgow

Joint British Societies

Cardiovascular Risk

2013 ESH/ESC Guidelines. J Hypertens 2013

Organ Damage and Cardiovascular Risk

Dzau V et al. Circulation 2006

The Cardiovascular Continuum

ESH Taskforce Document. J Hypertens 2009

Subclinical Organ Damage and CV Risk

Study

TsioufisMihaniCASE-J trialCV Health StudyELSALaurentFowkesDe BuyzereKorenTsioufisHOTINSIGHTJensen

Condition

HypertensionOutpatientsHypertensionElderlyHypertensionHypertensionOutpatientsOutpatientsHypertensionHypertensionHypertensionHypertensionHypertension

10 yr CVD ≥ 20%

YesYesYesYesYesYes

Yes (men)Yes (men)

YesYesYesYes

Yes (CHD)

Organ damage

LVH (echo)LVH (echo)LVH (echo) Ca IMT (highest quintile) Ca IMT (2 highest quintiles)PWV (highest quintile) Ankle / brachial ratio Ankle / brachial ratioLVH (echo)Low eGFRLow eGFR or high SCR (≥ 1.5 mg/dl)Low eGFR or high SCR (≥ 1.5 mg/dl)MA

Heart

Schmieder RE. Dtsch Arztebl Int 2010

ECG: Indices of Left Ventricular Hypertrophy

Sokolow-Lyon Index:

SV1 + RV5/6

≥ 3.8 mV (3.5 mV)

Cornell Voltage Product:

Men:(RaVL + SV3) × QRS> 244 mV msec

Women:(RaVL + SV3 +0.8) × QRS> 244 mV msec

e-cardiogram.com

ECG: Sokolow-Lyon Index

ECG Voltage Criteria and CV Events

Levy D at al. Circulation 1994

Echocardiography

Echocardiography

2013 ESH/ESC Guidelines. J Hypertens 2013

Left Ventricular Mass and CV Events

Schillaci G et al. Hypertension 2000

The ECG is valuable [for detection of LVH], at least in patients over 55

years of age. Electrocardiography can also be used to detect patterns of

ventricular overload or ‘strain’, which indicates more severe risk,

ischaemia, conduction abnormalities, left atrial dilatation and arrhythmias,

including atrial fibrillation.

2013 ESH/ESC Guidelines. J Hypertens 2013

Cardiac Damage

Echocardiography should be considered in hypertensive patients in

different clinical contexts and with different purposes:

• in hypertensive patients at moderate total CV risk, it may refine the risk

evaluation by detecting LVH undetected by ECG

• in hypertensive patients with ECG evidence of LVH it may more

precisely assess the hypertrophy quantitatively and define its geometry

and risk

• in hypertensive patients with cardiac symptoms, it may help to diagnose

underlying disease.

2013 ESH/ESC Guidelines. J Hypertens 2013

Cardiac Damage

Blood Vessels

Dzau V et al. Circulation 2006

The Cardiovascular Continuum

Endothelial Function: Flow-mediated Dilatation

Vascular Stiffness and CV Events

Willum-Hansen T et al. Circulation 2006

Blood Pressure Determines CV Risk

Prospective Studies Collaboration. Lancet 2002

Pulse Pressure Refines CV Risk

Franklin SS et al. Circulation 1999

Atherosclerosis and Vascular Stiffness

Ng et al. Am J Physiol Renal Physiol 2011Wikipedia.org

Vascular Stiffness: Pulse Wave Velocity

Vascular Stiffness and Mortality

Relative Risk of Cardiovascular Mortality According to PWV and Cardiovascular Risk Factors: Univariate Analysis

Parameters OR Lower 95% CI Higher 95% CI P

PWV, 5 m/s 2.35 1.76 3.14 <0.0001

Previous CVD, yes/no 14.81 7.98 27.47 <0.0001

Age, 10 y 2.32 1.78 3.01 <0.0001

PP, 10 mm Hg 1.53 1.31 1.80 <0.0001

SBP, 10 mm Hg 1.26 1.12 1.42 <0.001

Diabetes, yes/no 4.23 1.96 9.15 <0.001

Laurent S et al. Hypertension 2001

Carotid Intima-Media Thickness

Barth JD. Am J Cardiol 2002

Healthy subject Patient with arterial hypertension and hypercholesterolaemia