females, 28-63 years, mean 49±9 years).A control group was made up with 30 individuals (15 females, 36-56 years, mean 44±5 years).Etiologic diagnosis for PE was tuberculosis (2 patients), pulmonary adenocarcinoma (1 patient), hypothyroidism (1 patient), rheumatologic condition (3 patients), rheumatoid arthritis (2 patients), sclerodermy CREST syndrome (1 patient) and idiopathic (8 patients), and for CP was tuberculosis (2 patients), in all others, it was idiopathic.Patients were evaluated by standard transthoracic echocardiography and NT-proBNP levels detected by electrochemiluminescence.Results: PE NT-proBNP log mean of 2.24 pg/mL (CI 95%: 1.97-2.50log pg/ mL), CP log mean of 2.67 pg/mL (CI 95% 2.43-2.92log pg/mL), and EMF log mean of 2.91 pg/mL (CI 95% 2.70-3.12log pg/mL) were higher when compared to control group log mean of 1.45 pg/mL (CI 95% 1.32-1.60log pg/ mL) (p<0.05).No difference of NT-proBNP levels was reported between CP and EMF (p=0.149).All patients presented normal left ventricular ejection fraction.The NT-proBNP log mean was correlated to transmitral E-wave peak velocity (r=0.439;p=0.006).Conclusion: NT-proBNP levels are increased in patients with restrictive syndromes, but could not differentiate restrictive cardiomyopathy from pericardial diseases.Also, NT-proBNP levels increase in parallel with transmitral E-wave, reflecting diastolic dysfunction in restrictive syndromes.

Absolute or relative increases in intramyocardial fibrosis accompany hypertrophy development in human hypertension. Myocardial texture analysis of two-dimensional echocardiographic gray-level distribution has been shown to identify alterations attributed to abnormal collagen content in several conditions. Therefore, this echocardiographic tool might help to identify those hypertensive individuals with abnormal interstitial collagen deposition, a condition that may promote and/or aggravate morbidity in this group of people who are at high risk for cardiovascular events. We compared male essential hypertensive subjects who had marked cardiac hypertrophy (left ventricular mass index adjusted for height > 2 SD of mean of control group) (group 1) with normotensive elite veteran athletes who had comparable cardiac hypertrophy (group 2) and sedentary normotensive subjects as controls (group 3). The groups (n = 14 each) were matched for age (+/- 2 years) and sex. We analyzed echocardiographic digitized data quantitatively by means of a calibrated 256 gray level digitization system to calculate midseptal and midposterior end-diastolic and end-systolic mean gray levels and to derive the so-called cyclic variation index, ie, the percent mean gray level variation during the cardiac cycle. Echocardiographic parietal and septal thicknesses and masses were evaluated according to the Penn convention. Left ventricular mass index (adjusted for height) overlapped between groups 1 and 2 (187.1 +/- 17.5 and 181.3 +/- 19.3 g/m, respectively; P = NS), whereas it was obviously smaller in control subjects (93.1 +/- 18.6 g/m; P < .001 for both). According to inclusion criteria, both septal and posterior wall thicknesses were comparable in athletes and hypertensive subjects, and they were higher than in the control group (P < .0001). The hypertensive subjects showed a significantly lower cyclic variation index than the control and athlete groups for both the septum (P < .001) and posterior wall (P < .001); no statistical difference was found between athletes and control subjects for this parameter. In conclusion, abnormalities of two-dimensional echocardiographic gray-level distribution are present in hypertensive hypertrophied individuals but seem unrelated to the degree of echocardiographic hypertrophy as such. An altered collagen network distribution or a decrease in capillary distribution in severe myocardial hypertrophy, secondary to pressure-volume overload in hypertension with other yet unknown mechanisms, could help to explain our findings. Further work is needed to establish the prognostic, clinical, and therapeutic implications of these findings.

1. Increased urinary albumin excretion is common in patients with essential hypertension and is at least to some extent correlated with prevailing blood pressure levels. However, the generalized vascular dysfunction present in advanced atherosclerotic disease may independently influence this parameter. 2. To evaluate this possibility, we assessed blood pressure, ultrasonographic carotid thickness, cardiac mass, minimum forearm vascular resistances, metabolic parameters and the angiotensin-converting enzyme genotype in patients with untreated essential hypertension and atherosclerotic peripheral vascular disease (n = 11). The results were compared with similar data obtained in matched groups of patients with uncomplicated hypertension and with normotensive control subjects (n = 11 per group). 3. Urinary albumin excretion was higher in hypertensive patients with atherosclerosis than in those without complications; carotid thickness was higher in atherosclerotic patients and a positive, statistically significant correlation existed between this parameter and urinary albumin excretion. In the same patient group, systolic blood pressure, fasting insulin and triacylglycerol levels were elevated and correlated with urinary albumin levels. However, differences in urinary albumin excretion persisted after taking into account the influence of those parameters by analysis of covariance. The distribution of angiotensin-converting enzyme genotype patterns and values of cardiac mass and minimum forearm vascular resistances did not differ significantly among the experimental groups. 4. The data suggest that vascular status may influence urinary albumin excretion in patients with essential hypertension, while confirming the importance of systolic blood pressure levels as a determinant of the raised urinary albumin excretion.

Quantitatively assessed ultrasonic backscatter is an index of ultrasonic tissue characterization directly related to morphometrically evaluated collagen content in human beings. Our objective was to assess myocardial reflectivity pattern in patients with severe left ventricular hypertrophy caused by either aortic stenosis (AS) or aortic regurgitation (AR). Ten patients with AS, 10 patients with AR, and 10 closely age- and gender-matched healthy controls were studied by two-dimensional Doppler echocardiography. By using an echocardiographic prototype, we performed a radiofrequency analysis to obtain quantitative operator-independent measurements of the integrated backscatter signal of the ventricular septum and the posterior wall (integrated backscatter index: IBI, expressed in percentage). All patients with stenosis or aortic insufficiency showed a normal regional and global resting systolic function (fractional shortening: AS = 36.0 +/- 6.6 versus AR = 40.3 +/- 6.2 versus control = 40.2 +/- 8.7; p = not significant [NS]). Left ventricular mass index (Devereux's formula) was markedly increased in patients with stenosis or aortic insufficiency (AS = 199.3 +/- 18 versus AR = 208.8 +/- 60 versus control = 97.3 +/- 11 g/m(2); p < 0.0001). Myocardial echo density was increased in patients with stenosis or aortic insufficiency in comparison with controls, both in the septum (IBI%: AR = 40.7 +/- 7.9 versus AS = 33.4 +/- 4.2 versus control = 23.0 +/- 6.2; p < 0.0001) and in the posterior wall (IBI%: AR = 27.1 +/- 4.3 versus AS = 23.0 +/- 2.6 versus control = 15.0 +/- 4.2; p < 0.0001). No significant correlations were found between septal and posterior wall IBI and their thickness. Abnormally increased myocardial echo density-possibly related to disproportionate collagen deposition-can be detected in patients with pressure or volume overload caused by aortic valve disease and without overt systolic dysfunction.

Aim of this study was to evaluate left ventricular function during exercise, in 10 male elite runners and in 10 sedentary males. End-diastolic (EDV) and end-systolic volume (ESV), left ventricular ejection fraction (EF), early peak transmitral flow velocity (peak E), time-velocity integral of mitral inflow (m-TVI); mitral cross sectional area (m-CSA); mitral stroke volume (SV), and cardiac output (CO) were measured by echo-Doppler. We simultaneously analyzed: VO2max by spirometric method, mean arterial blood pressure (MAP) by sphygmomanometer, and heart rate (HR) by ECG. The parameters were measured under basal conditions (level 1), at 50% of maximal aerobic capacity (level 2), at peak of exercise (level 3) and during recovery. Ejection fraction in athletes increased significantly at peak of exercise through Frank-Starling mechanism. Stroke volume and cardiac output increased significantly in athletes at peak of exercise. Left ventricular diastolic function was superior in athletes versus controls: in fact, higher peak E in athletes enhanced early diastolic ventricular filling. Therefore, the athletes showed complex cardiovascular adjustments induced by training, which allowed an higher peak working power, a greater cardiac output, and VO2max when compared with an untrained control population.

OBJECTIVE:To test the hypothesis that quantitative analysis of two-dimensional echocardiographic gray-level distributions could allow one to detect the early changes in acoustic properties of human diabetes myocardium differentiating it from normal myocardium.METHODS:We evaluated, by two-dimensional echocardiography, 28 asymptomatic type 1 insulin-dependent diabetic patients with normal ventricular function (group A) and 15 age- and sex-matched healthy controls (group B). By selection, all of the diabetics were normotensive and had a negative maximal exercise stress. Echocardiographic images were digitized by using a calibrated digitization system. Quantitative texture analysis was accomplished on data from the septum and posterior wall both at end-diastole and at end-systole. The following parameters were obtained: the mean gray level of the regions of interest, and its absolute SD, skewness, kurtosis, and cyclic variation index.RESULTS:The main result of this study was that the cyclic variation indices of the echo amplitudes of the septum and posterior wall in the diabetic group were significantly lower than those in controls (P < 0.001 and P < 0.002, respectively). Furthermore, the diabetic group had a significantly higher mean gray level of the septum [group A 54.3 +/- 22.5 (mean +/- SD) versus group B 39.7 +/- 9.8, P < 0.03] at end-diastole. The mean gray-level of the posterior wall was similar in the two groups, both at end-diastole and at end-systole.CONCLUSION:Alterations of cyclic echo amplitude (possibly related to collagen deposition) can be detected in asymptomatic diabetic patients with normal resting function. Theoretically, this finding might be considered an early preclinical alteration, potentially related to subsequent development of "diabetic cardiomyopathy'.

OBJECTIVES:We sought to characterize myocardial echodensity in asymptomatic patients with insulin-dependent diabetes and normal conventional two-dimensional echocardiographic findings to determine whether ultrasound tissue characterization can detect ultrastructural changes in myocardium, such as an increase in collagen content. BACKGROUND:Fibrosis alters the acoustic properties of the heart in animals and humans, and these changes are detectable by cardiac tissue characterization with ultrasound. Early changes detected in the diabetic heart include increased interstitial collagen deposition. METHODS:Using two-dimensional echocardiography, we evaluated 26 asymptomatic patients with insulin-dependent diabetes with normal regional and global rest function, and 17 age- and gender-matched control subjects. By selection, all diabetic patients were normotensive and had negative maximal exercise stress test results to avoid the confounding effects of hypertension and coronary artery disease. Using an echocardiographic instrument implemented at the Institute of Clinical Physiology, we performed an on-line radiofrequency analysis to obtain quantitative operator-independent measurements of the integrated back-scatter signal of the ventricular septum and posterior wall. The integrated values of the radiofrequency signal from the myocardial wall were normalized for those from the pericardial interface and were expressed as percentages (integrated backscatter index). RESULTS:Diabetic patients showed a significant increase in myocardial echodensity both in the septum ([mean +/- SD] 36.6 +/- 8.1 vs. 23.6 +/- 4.4, p < 0.0001) and posterior wall (21.2 +/- 5.3 vs. 18.4 +/- 3.7, p < 0.001). By individual patient analysis, 17 patients exceeded the 95% confidence limits for normal myocardial echocardiographic reflectivity found in normal subjects, and only 3 had a relatively abnormal transmitral Doppler filling pattern (E/A ratio), mainly consisting of an abnormally increased late peak flow velocity (65% vs. 11%, p < 0.001). The increased myocardial intensity was similar in patients with (n = 16) and without (n = 10) noncardiac complications, such as retinopathy or nephropathy (37.5 +/- 7.9% vs. 35.0 +/- 8.3%, p = 0.35). CONCLUSIONS:Abnormally increased myocardial echodensity, possibly related to collagen deposition, can be detected in asymptomatic diabetic patients with normal rest function. Theoretically, this finding might be considered a very early preclinical alteration potentially related to subsequent development of diabetic cardiomyopathy.

Aim of this work was to study in a group of elite cyclists, undergoing laboratory testing, the trend of the left ventricular systolic and diastolic function, echocardiographically and Doppler derived, simultaneously with the evaluation of ergospirometric parameters during maximal exercise. We studied a group of male subjects, consisting of 10 professional elite bicyclists (mean age: 25.1 +/- 3.2 years) during competitive activity (VO2/kg max: 78.5 +/- 7.7 ml.kg.min-1). The maximal exercise test, conducted with Wind Loaded Simulator for optimisation of ergometric capacity, showed, at the end of exercise, at a speed of 49.2 +/- 2.4 km/h, a VO2max of 5365 +/- 543.4 ml/min, with a calculated Cardiac Output (CO) of 19.3 +/- 3.7 l/min. A linear regression relationship was found between VO2max and CO (r = 0.84; p < 0.0001) as well as between VO2max and maximal reached speed (r = 0.97; p < 0.0001). During the aerobic period a slight but significant increase in End Diastolic Volume (EDV) was observed due to the greater venous return from exercising muscles. At stop, in anaerobic period, the EDV remained substantially constant. Ejection Fraction (EF) also increased during exercise through the Frank-Starling mechanism activation. The slight, but not significant, increase in EF at stop level may be explained by an activation of homeometric control of contractility with a sympathetic modulation on myocardial fibres. The early diastolic mitral flow velocity (Peak E) increased significantly during exercise, in comparison with basal upright values. The left ventricular diastolic compliance observed in athletes permits a good left ventricular filling, particularly in early diastolic phase; this allows an excellent left ventricular systolic performance. Based on echocardiography and pulsed Doppler measurements, calculated cardiac output is underestimated by approximately 20%.

BACKGROUND:The development of a reduced forearm blood flow reserve and an increased carotid intima media thickness is a well known consequence of the structural adaptation of arterioles and large arteries in response to hypertension. It is unknown, however, how those two processes relate to each other in the individual hypertensive patient.METHODS:Minimal forearm vascular resistances (Rmin, the ratio of mean blood pressure to postischemic plethysmographic peak forearm blood flow), common carotid intima media thickness (IMT, high-resolution ultrasonography), blood pressure (indirect method), left ventricular mass, posterior wall and septum thickness (by echocardiography) and lipids were measured in 15 men with mild-to-moderate essential hypertension without evidence of atherosclerotic involvement of the carotid arteries, and in 14 normotensive controls with a similar age range.RESULTS:Rmin and IMT were greater in hypertensives, and a statistically significant positive correlation existed between the two variables. Both Rmin and IMT correlated with left ventricular structure indices and blood pressure. Age showed a positive correlation with IMT, while lipids were unrelated to either parameter.CONCLUSIONS:The micro- and macrovascular segments of the hypertensive circulation readapt in parallel in response to elevated blood pressure, possibly through the commensurate development of medial hypertrophy.

Microalbuminuria (urinary albumin excretion between 20 and 200 micrograms/min) and abnormalities of red blood cell sodium-hydrogen exchange coexist in essential hypertensive patients. To evaluate how the two phenomena relate, we recruited 10 untreated microalbuminuric male essential hypertensive patients without diabetes to be compared with an equal number of matched essential hypertensive patients excreting albumin in normal amounts as well as 10 healthy control subjects. Sodium-hydrogen exchange values were increased to a comparable extent in microalbuminuric and normoalbuminuric hypertensive patients. Systolic and mean blood pressures were higher in microalbuminuric patients. Fasting insulin was greater and high-density lipoprotein cholesterol lower in patients than control subjects. Urinary albumin excretion correlated positively with both mean blood pressure and left ventricular mass values in the absence of a relationship with circulating lipid and insulin levels. In contrast with microalbuminuria, sodium-hydrogen exchange covaried only with high-density lipoprotein cholesterol and insulin levels. Thus, microalbuminuria and an abnormal sodium-hydrogen exchange are unrelated phenomena in essential hypertensive patients. Microalbuminuria appears to be a hemodynamically driven biological variable, while an accelerated sodium-hydrogen exchange seems primarily conditioned by the metabolic abnormalities of hypertension, possibly in the context of an insulin-resistant syndrome.

In response to hypertension, arterioles remodel their structure, the heart develops myocardial hypertrophy, and the kidney reduces creatinine clearance and increases albuminuria. To better understand the interrelations among the target organs involved in hypertension, we evaluated minimal forearm vascular resistances--a hemodynamic index of arteriolar structure derived from mean blood pressure and maximal postischemic forearm blood flow--the echocardiographic indexes of cardiac structure, and urinary albumin excretion and creatinine clearance in 29 male mild to moderate non-macroalbuminuric essential hypertensive patients on no drugs and 11 age- and sex-matched normotensive control subjects. Minimal forearm resistances were elevated in hypertensive patients and correlated with left ventricular mass, wall thickness, and mean arterial pressure. Patients with abnormal minimal forearm resistances (2 SD above normal) were characterized by higher pressure, greater wall thickness, lower creatinine clearance, and higher albumin excretion, suggesting that maximal forearm flow capacity does relate to the hemodynamic load exerted on both the kidney and heart. However, the correlation with cardiac structure and mean arterial pressure explained only part of the variability of minimal forearm resistances. Furthermore, no correlation among these parameters was found when hypertensive patients were evaluated separately from normotensive subjects, possibly because of heterogeneous factors active on arteriolar structure and unrelated to the pressor load. Overall, the data suggest that the development of abnormal minimal forearm resistances in the course of the hypertensive process is related to the pressor load, but its details need further understanding.

Microalbuminuria (urinary albumin excretion between 20 and 200 mu g/min) and endothelial dysfunction coexist in patients with essential hypertension. To evaluate whether the two phenomena are related and the determinants of that association, we recruited 10 untreated males with essential hypertension and microalbuminuria without diabetes to be compared with an equal number of matched patients with essential hypertension excreting albumin in normal amounts and 10 normal controls.The status of endothelial function was inferred from circulating von Willebrand Factor antigen (vWF), a glycoprotein secreted in greater amounts when the vascular endothelium is damaged. vWF concentrations were higher in hypertensive patients with microalbuminuria than in hypertensive patients without and controls. Individual vWF and urine albumin-excretion values were correlated (r = 0.55, p < 0.002). Blood pressure correlated with both urinary albumin excretion and vWF. Left ventricular mass index and minimal forearm vascular resistances were comparable in patients with hypertension and higher than in controls; total and low-density lipoprotein cholesterol, triglycerides, lipoprotein-a, Factor VII, and plasminogen activator inhibitor-1 did not differ. Fibrinogen was higher and creatinine clearance lower in microalbuminurics.Albuminuria in essential hypertension may reflect systemic dysfunction of the vascular endothelium, a structure intimately involved in permeability, haemostasis, fibrinolysis, and blood pressure control. This abnormality may have important physiopathological implications and expose these patients to increased cardiovascular risk.

Young elite athletes often show left ventricular hypertrophy, but normal values of quantitatively evaluated myocardial wall reflectivity. The aim of this study is to assess the acoustic pattern of ventricular wall reflectivity, as well as of systolic and diastolic function, in older endurance runners with increased left ventricular mass. For this purpose, 12 elite, senior isotonic athletes in full training and 11 normal, age-matched controls with sedentary life styles were studied. The following parameters were measured with a commercially available 2D echo-Doppler machine: end-diastolic diameter, diastolic septum thickness, left ventricular mass index, ejection fraction (by Teicholtz rule); peak E, peak A, E/A ratio, acceleration and deceleration time of mitral inflow velocity and isovolumic relaxation time. On-line radio frequency analysis was also performed to obtain quantitative operator-independent measurements of the integrated backscatter signal of the ventricular septum and the posterior wall. The integrated values of the radiofrequency signals were normalized for the pericardial interface and expressed in percent (% 2D-IB). In spite of the greater left ventricular mass in athletes versus normal controls (319 +/- 81 vs 225 +/- 63 g.m-2, P < 0.0005), there were no significant intergroup differences as regards end-diastolic diameter (50.7 +/- 5.1 vs 48.1 +/- 5.2 mm, P = ns), ejection fraction (75.5 +/- 9.3 vs 71.8 +/- 9.1%, P = ns), and 2D-IB of septum (22.2 +/- 6.9 vs 22.4 +/- 7.0, P = ns) and posterior wall (12.5 +/- 5.6 vs 13.1 +/- 2.8, P = ns).(ABSTRACT TRUNCATED AT 250 WORDS)