Original Article
Does the metabolic syndrome impact left-ventricular mechanics? A two-dimensional speckle tracking study Marijana Tadic a, Cesare Cuspidi b, Anka Majstorovic a, Biljana Pencic a, Sladjana Backovic a, Branislava Ivanovic c,d, Radisav Scepanovic a,d, Jelena Martinov e, Vesna Kocijancic a, and Vera Celic a,d
Objective: To evaluate left-ventricular mechanics estimated by two-dimensional echocardiography (2DE) speckle tracking analyses in patients with the metabolic syndrome. Methods: This cross-sectional study included 95 untreated patients with metabolic syndrome and 65 controls similar by sex and age. Metabolic syndrome was defined by the presence of at least three ATP-AHA-NHLB criteria. All the patients underwent adequate laboratory analyses and complete 2DE examination. Results: 2DE global longitudinal and circumferential strain was significantly decreased in the metabolic syndrome group, whereas 2DE global radial strain was similar between the observed groups. The left-ventricular torsion was similar between the metabolic syndrome participants and the controls; whereas the left-ventricular untwisting rate was significantly increased in the metabolic syndrome group. The increasing number of the metabolic syndrome criteria induces progressive reduction of the left-ventricular longitudinal strain from the individuals with no metabolic syndrome risk factors to the individuals with five metabolic syndrome criteria. The same pattern was not noticed for left-ventricular circumferential and radial strain. The combination of increased blood pressure, abdominal obesity and increased fasting glucose level was associated with the higher level of left-ventricular mechanical impairment comparing with other clusters of the metabolic syndrome components. The multivariate analysis of the metabolic syndrome criteria showed that 24-h mean blood pressure, waist circumference and fasting glucose level were independently associated with 2DE global longitudinal and circumferential myocardial strain, and leftventricular untwisting rate. The interaction between sex and metabolic syndrome significantly impacts the leftventricular longitudinal strain and untwisting rate. Conclusion: Left-ventricular mechanics assessed by 2DE strain is significantly impaired in the metabolic syndrome patients. Among all metabolic syndrome components, blood pressure, waist circumference and fasting glucose level are the most responsible for damage of leftventricular deformation. Keywords: left ventricle, metabolic syndrome, twodimensional speckle tracking imaging
Abbreviations: 2DE, two-dimensional echocardiography; a’, late diastolic flow velocity across the septal segment of mitral annulus (tissue Doppler); Am, late diastolic mitral flow (pulse Doppler); BP, blood pressure; DysLip, hypertrygliceridemia and/or decreased HDL level; e0 , average of the peak early diastolic relaxation velocity (e0 ) of the septal and lateral mitral annulus (tissue Doppler); Em, early diastolic mitral flow (pulse Doppler); HDL, highdensity lipoprotein; LA, left atrium; LV, left ventricle; TGD, triglycerides
INTRODUCTION
T
he metabolic syndrome represents a cluster of common cardiovascular risk factors such as increased blood pressure (BP), abdominal obesity, dyslipidemia and hyperglycemia [1]. It is associated with increased risk of cardiovascular and cerebrovascular morbidity and mortality [2,3]. Considering the results of large studies which showed that metabolic syndrome prevalence is constantly increasing in the past decade, mostly due to epidemic of abdominal obesity [4], it is clear why this metabolic phenomenon is in focus of various investigations. Our study group has previously shown that the metabolic syndrome significantly impacts left-ventricular structure and function [5,6]. Recently, we have also demonstrated that the metabolic syndrome has unfavorable influence on right-ventricular function and mechanics [7]. However, the investigations which studied the left-ventricular deformation in the patients with metabolic syndrome are not common [8–10], and do not provide comprehensive
Journal of Hypertension 2014, 32:1870–1878 a University Clinical Hospital Center ‘Dr Dragisa Misovic’, Heroja Milana Tepica 1, Belgrade, Serbia, bUniversity of Milan-Bicocca and Istituto Auxologico Italiano, Clinical Research Unit, Viale della Resistenza 23, Meda, Italy, cClinical Centre of Serbia, Clinic of Cardiology, Koste Todorovic 8, dFaculty of Medicine, Doktora Subotica 6 and e Clinical Centre of Serbia, Clinic of Gastroenterology, Koste Todorovic 2, Belgrade, Serbia
Correspondence to Marijana Tadic, MD, PhD, University Clinical Hospital Center ‘Dr Dragisa Misovic’, Heroja Milana Tepica 1, 11000 Belgrade, Serbia. E-mail: marijana_ [email protected] Received 17 April 2014 Revised 5 May 2014 Accepted 5 May 2014 J Hypertens 32:1870–1878 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. DOI:10.1097/HJH.0000000000000257
1870
www.jhypertension.com
Volume 32 Number 9 September 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Metabolic syndrome and myocardial mechanics
information about the left-ventricular myocardial function in the patients with different numbers of metabolic syndrome components, or data regarding the influence of different combinations of metabolic syndrome risk factors on left-ventricular deformation. Crendal et al. evaluated cumulative effect of metabolic syndrome criteria on leftventricular longitudinal function, but did not show changes in left-ventricular circumferential and radial function or leftventricular twisting and untwisting [8]. Our aims were to: investigate left-ventricular function and mechanical deformation in the patients with the metabolic syndrome using two-dimensional echocardiography (2DE) speckle tracking imaging, evaluate the effect of the increasing number of metabolic syndromes on left-ventricular deformation, determine the influence of each metabolic syndrome factor on left-ventricular mechanics, define which cluster of metabolic syndrome criteria is associated with greater damage of left-ventricular mechanics, and research the influence of sex and interaction between sex and metabolic syndrome on left-ventricular myocardial function.
METHODOLOGY The observational cross-sectional study included 95 untreated patients with the metabolic syndrome, between 30 and 65 years of age, and 65 patients without the metabolic syndrome, who were sent from primary care to our outpatient clinic as part of the screening program for primary prevention of cardiovascular diseases. The investigation was performed at the University Clinical Hospital Centre ‘Dragisa Misovic’ from July 2011 to April 2013. Patients with clinical or laboratory signs of heart failure, coronary artery disease, previous cerebrovascular event, atrial fibrillation, congenital heart disease, moderate or severe valvular heart disease, severe obesity (BMI 35 kg/m2), secondary hypertension or other chronic diseases such as obstructive pulmonary disease, pulmonary hypertension, connective tissue disorders, neoplastic disease, cirrhosis of the liver, kidney failure, sleeping disorders, or endocrinological diseases (including type 2 diabetes mellitus) were excluded from the study. The study was approved by the local Ethics Committee, and informed consent was obtained from all the participants. The anthropometric measures (height, weight) were taken from all the participants included in the study in order to calculate the BMI and body surface area (BSA), as well as the waist circumference. Regarding laboratory analyses, we used the level of fasting glucose, uric acid, total cholesterol, low and highdensity lipoprotein cholesterol (HDL, LDL), triglycerides and serum creatinine. The metabolic syndrome was defined by the presence of three or more criteria of the American Heart Association (AHA)/National Heart, Lung, and Blood Institute (NHLB) definition [1]: abdominal obesity (waist circumference 102 cm in men and 88 cm in women), increased fasting triglycerides (1.7 mmol/l), decreased HDL cholesterol (
Does the metabolic syndrome impact left-ventricular mechanics? A two-dimensional speckle tracking study Marijana Tadic a, Cesare Cuspidi b, Anka Majstorovic a, Biljana Pencic a, Sladjana Backovic a, Branislava Ivanovic c,d, Radisav Scepanovic a,d, Jelena Martinov e, Vesna Kocijancic a, and Vera Celic a,d
Objective: To evaluate left-ventricular mechanics estimated by two-dimensional echocardiography (2DE) speckle tracking analyses in patients with the metabolic syndrome. Methods: This cross-sectional study included 95 untreated patients with metabolic syndrome and 65 controls similar by sex and age. Metabolic syndrome was defined by the presence of at least three ATP-AHA-NHLB criteria. All the patients underwent adequate laboratory analyses and complete 2DE examination. Results: 2DE global longitudinal and circumferential strain was significantly decreased in the metabolic syndrome group, whereas 2DE global radial strain was similar between the observed groups. The left-ventricular torsion was similar between the metabolic syndrome participants and the controls; whereas the left-ventricular untwisting rate was significantly increased in the metabolic syndrome group. The increasing number of the metabolic syndrome criteria induces progressive reduction of the left-ventricular longitudinal strain from the individuals with no metabolic syndrome risk factors to the individuals with five metabolic syndrome criteria. The same pattern was not noticed for left-ventricular circumferential and radial strain. The combination of increased blood pressure, abdominal obesity and increased fasting glucose level was associated with the higher level of left-ventricular mechanical impairment comparing with other clusters of the metabolic syndrome components. The multivariate analysis of the metabolic syndrome criteria showed that 24-h mean blood pressure, waist circumference and fasting glucose level were independently associated with 2DE global longitudinal and circumferential myocardial strain, and leftventricular untwisting rate. The interaction between sex and metabolic syndrome significantly impacts the leftventricular longitudinal strain and untwisting rate. Conclusion: Left-ventricular mechanics assessed by 2DE strain is significantly impaired in the metabolic syndrome patients. Among all metabolic syndrome components, blood pressure, waist circumference and fasting glucose level are the most responsible for damage of leftventricular deformation. Keywords: left ventricle, metabolic syndrome, twodimensional speckle tracking imaging
Abbreviations: 2DE, two-dimensional echocardiography; a’, late diastolic flow velocity across the septal segment of mitral annulus (tissue Doppler); Am, late diastolic mitral flow (pulse Doppler); BP, blood pressure; DysLip, hypertrygliceridemia and/or decreased HDL level; e0 , average of the peak early diastolic relaxation velocity (e0 ) of the septal and lateral mitral annulus (tissue Doppler); Em, early diastolic mitral flow (pulse Doppler); HDL, highdensity lipoprotein; LA, left atrium; LV, left ventricle; TGD, triglycerides
INTRODUCTION
T
he metabolic syndrome represents a cluster of common cardiovascular risk factors such as increased blood pressure (BP), abdominal obesity, dyslipidemia and hyperglycemia [1]. It is associated with increased risk of cardiovascular and cerebrovascular morbidity and mortality [2,3]. Considering the results of large studies which showed that metabolic syndrome prevalence is constantly increasing in the past decade, mostly due to epidemic of abdominal obesity [4], it is clear why this metabolic phenomenon is in focus of various investigations. Our study group has previously shown that the metabolic syndrome significantly impacts left-ventricular structure and function [5,6]. Recently, we have also demonstrated that the metabolic syndrome has unfavorable influence on right-ventricular function and mechanics [7]. However, the investigations which studied the left-ventricular deformation in the patients with metabolic syndrome are not common [8–10], and do not provide comprehensive
Journal of Hypertension 2014, 32:1870–1878 a University Clinical Hospital Center ‘Dr Dragisa Misovic’, Heroja Milana Tepica 1, Belgrade, Serbia, bUniversity of Milan-Bicocca and Istituto Auxologico Italiano, Clinical Research Unit, Viale della Resistenza 23, Meda, Italy, cClinical Centre of Serbia, Clinic of Cardiology, Koste Todorovic 8, dFaculty of Medicine, Doktora Subotica 6 and e Clinical Centre of Serbia, Clinic of Gastroenterology, Koste Todorovic 2, Belgrade, Serbia
Correspondence to Marijana Tadic, MD, PhD, University Clinical Hospital Center ‘Dr Dragisa Misovic’, Heroja Milana Tepica 1, 11000 Belgrade, Serbia. E-mail: marijana_ [email protected] Received 17 April 2014 Revised 5 May 2014 Accepted 5 May 2014 J Hypertens 32:1870–1878 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. DOI:10.1097/HJH.0000000000000257
1870
www.jhypertension.com
Volume 32 Number 9 September 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Metabolic syndrome and myocardial mechanics
information about the left-ventricular myocardial function in the patients with different numbers of metabolic syndrome components, or data regarding the influence of different combinations of metabolic syndrome risk factors on left-ventricular deformation. Crendal et al. evaluated cumulative effect of metabolic syndrome criteria on leftventricular longitudinal function, but did not show changes in left-ventricular circumferential and radial function or leftventricular twisting and untwisting [8]. Our aims were to: investigate left-ventricular function and mechanical deformation in the patients with the metabolic syndrome using two-dimensional echocardiography (2DE) speckle tracking imaging, evaluate the effect of the increasing number of metabolic syndromes on left-ventricular deformation, determine the influence of each metabolic syndrome factor on left-ventricular mechanics, define which cluster of metabolic syndrome criteria is associated with greater damage of left-ventricular mechanics, and research the influence of sex and interaction between sex and metabolic syndrome on left-ventricular myocardial function.
METHODOLOGY The observational cross-sectional study included 95 untreated patients with the metabolic syndrome, between 30 and 65 years of age, and 65 patients without the metabolic syndrome, who were sent from primary care to our outpatient clinic as part of the screening program for primary prevention of cardiovascular diseases. The investigation was performed at the University Clinical Hospital Centre ‘Dragisa Misovic’ from July 2011 to April 2013. Patients with clinical or laboratory signs of heart failure, coronary artery disease, previous cerebrovascular event, atrial fibrillation, congenital heart disease, moderate or severe valvular heart disease, severe obesity (BMI 35 kg/m2), secondary hypertension or other chronic diseases such as obstructive pulmonary disease, pulmonary hypertension, connective tissue disorders, neoplastic disease, cirrhosis of the liver, kidney failure, sleeping disorders, or endocrinological diseases (including type 2 diabetes mellitus) were excluded from the study. The study was approved by the local Ethics Committee, and informed consent was obtained from all the participants. The anthropometric measures (height, weight) were taken from all the participants included in the study in order to calculate the BMI and body surface area (BSA), as well as the waist circumference. Regarding laboratory analyses, we used the level of fasting glucose, uric acid, total cholesterol, low and highdensity lipoprotein cholesterol (HDL, LDL), triglycerides and serum creatinine. The metabolic syndrome was defined by the presence of three or more criteria of the American Heart Association (AHA)/National Heart, Lung, and Blood Institute (NHLB) definition [1]: abdominal obesity (waist circumference 102 cm in men and 88 cm in women), increased fasting triglycerides (1.7 mmol/l), decreased HDL cholesterol (
