Arterial stiffness in hypertensive patients with nonsustained atrial tachycardia

doi:10.21203/rs.3.rs-1983939/v1

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Arterial stiffness in hypertensive patients with nonsustained atrial tachycardia

https://doi.org/10.21203/rs.3.rs-1983939/v1

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Objectives: The pathophysiological mechanisms of increased arterial stiffness, currently an independent risk factor for atrial fibrillation, remain poorly understood. This study investigated the association of arterial stiffness with the presence of nonsustained atrial tachycardia (NSAT) in hypertensive patients.

Methods: We included sixty participants from a single centre without evident cardiovascular disease who underwent extensive cardiovascular examination. Arterial stiffness was assessed by pulse wave velocity (PWV) and Augmentation Index corrected for a heart rate of 75 bpm (Aix@75). Speckle-tracking echocardiography assessed left atrial (LA) function. A 24-hour ECG was used to identify patients with NSAT.

Results: There was no statistically significant difference in arterial stiffness between groups. Compared to the control group, NSAT group was older (69.82 ± 6.92 vs. 63.32 ± 6.98, p value 0.001), with more men (43.3% vs. 16.7%, p=0.047), higher prevalence of interatrial block (43.3% vs. 16.7%, p=0.047), lower use of ACEIs/ARBs (73.3% vs. 96.7%, p=0.026) and higher proportion of patients with high BNP levels (31.0% vs. 0.0%, p< 0.001). There was no statistically significant difference for LA strain parameters.

Conclusion: In this small pilot study, in hypertensive individuals without major cardiovascular comorbidities arterial stiffness was not associated with an increased presence of NSAT on 24-hour ECG.

arterial stiffness

nonsustained atrial tachycardia

left atrial strain

Arterial stiffness is recognized as a marker for the development of cardiovascular disease [1–3] and can be assessed with noninvasive, reproducible, and inexpensive techniques such as pilse wave velocity (PWV), central pulse pressure, and augmentation index [1]. Several studies have shown that these noninvasive arterial stiffness tests were able to predict cardiovascular events and mortality [2, 3].

The current literature shows a strong association between arterial stiffness and the incidence of atrial fibrillation [4–6]. Left atrial (LA) enlargement is a strong and independent risk factor for the development of atrial fibrillation [7] and is partially reversible, due to interstitial fibrosis and changes in atrial myocytes [8]. Speckle-tracking echocardiography is a sensitive tool that allows the quantification and detection of subtle changes in left atrial function, particularly reservoir, conduit or contraction LA properties [9, 10]. LA dysfunction, especially reservoir and conduit dysfunction, precedes LA dilation [11, 12] and increases the risk of development [11, 13] and recurrence [14] of atrial fibrillation, independent of LA dilation.

Despite extensive publications describing the association between arterial stiffness and atrial fibrillation, there are currently no studies, to the best of our knowledge, on the association between arterial stiffness and earlier stages of atrial cardiomyopathy, before the clinical phenotype of atrial fibrillation itself.

The aim of this study was to study arterial stiffness in clinically controlled hypertensive patients, verify the existence of an association between greater arterial stiffness and the onset of episodes of nonsustained atrial tachycardia on 24 h holter monitoring and evaluate the atrial function of these patients through speckle-tracking echocardiography.

Patients with nonsustained atrial tachycardia (NSAT) were initially selected from the InCor-HCFMUSP Holter department. The exams carried out in November and December 2019 and those carried out in October 2020 were evaluated. After 2414 exams were analysed, 240 exams fulfilling the inclusion criteria (NSAT of 10 or more beats) were selected. After reviewing the medical records, 177 patients were excluded. Of the 63 eligible patients, 30 patients agreed to participate in the protocol (Fig. 1).

To establish a control group without NSAT, 723 outpatients with hypertension were evaluated, from October 2020 to May 2022. After analysing the medical records, 115 patients were eligible. Of these, 30 patients underwent Holter monitoring and met the criteria for the control group, without having NSAT with 10 or more beats and with an atrial arrhythmia burden less than 1%. Figure 1 summarizes the flowchart of the study.

In 2020 and early 2021, patient selection was extremely impacted by the COVID-19 pandemic.

Table 1 presents the baseline characteristics according to the groups. Considering a 5% significance level, there was a difference between the groups for sex, age, ACEi/ARB use, interatrial block and elevated B-type natriuretic peptide (BNP). In the group of individuals with NSAT (group 1), there was a higher prevalence of men, high BNP levels and interatrial block. In addition, they are older patients and have a lower prevalence of ACEI/ARB use.

Table 1

Baseline characteristics of the study population
	Total	NSAT + Group 1	NSAT – Group 2	p value
Sex
Female	42/60 (70.0%)	17/30 (56.7%)	25/30 (83.3%)	0.047
Male	18/60 (30.0%)	13/30 (43.3%)	5/30 (16.7%)
Ethnicity
Afrobrazilian	22/60 (36.7%)	8/30 (26.7%)	14/30 (46.7%)	0.180
Caucasian	38/60 (63.3%)	22/30 (73.3%)	16/30 (53.3%)
Age (Years)	66.57 ± 7.63	69.82 ± 6.92	63.32 ± 6.98	0.001
Abdominal circumference (cm)	104.35 ± 14.10	105.13 ± 13.30	103.57 ± 15.05	0.671
BMI (kg/m²)	29.92 ± 5.66	29.44 ± 4.90	30.40 ± 6.38	0.518
Smoker
No	54/60 (90.0%)	27/30 (90.0%)	27/30 (90.0%)	1.000
Yes	6/60 (10.0%)	3/30 (10.0%)	3/30 (10.0%)
Former Smoker
No	52/60 (86.7%)	25/30 (83.3%)	27/30 (90.0%)	0.706
Yes	8/60 (13.3%)	5/30 (16.7%)	3/30 (10.0%)
ACEi/ARB
No	9/60 (15.0%)	8/30 (26.7%)	1/30 (3.3%)	0.026
Yes	51/60 (85.0%)	22/30 (73.3%)	29/30 (96.7%)
Beta-Blocker
No	26/60 (43.3%)	13/30 (43.3%)	13/30 (43.3%)	1.000
Yes	34/60 (56.7%)	17/30 (56.7%)	17/30 (56.7%)
CCB
No	30/60 (50.0%)	17/30 (56.7%)	13/30 (43.3%)	0.439
Yes	30/60 (50.0%)	13/30 (43.3%)	17/30 (56.7%)
Diuretic
No	22/60 (36.7%)	14/30 (46.7%)	8/30 (26.7%)	0.180
Yes	38/60 (63.3%)	16/30 (53.3%)	22/30 (73.3%)
Statins
No	17/60 (28.3%)	10/30 (33.3%)	7/30 (23.3%)	0.567
Yes	43/60 (71.7%)	20/30 (66.7%)	23/30 (76.7%)
Warfarin
No	59/60 (98.3%)	29/30 (96.7%)	30/30 (100.0%)	1.000
Yes	1/60 (1.7%)	1/30 (3.3%)	0/30 (0.0%)
Central Pulse Pressure (mmHg)	48.47 ± 17.03	47.40 ± 15.19	49.53 ± 18.89	0.632
PWV (m/s)	10.44 ± 2.41	10.74 ± 2.72	10.13 ± 2.04	0.328
Aix@75 (%)	30.03 ± 8.73	30.45 ± 9.22	29.63 ± 8.37	0.724
Interatrial Block
No	42/60 (70.0%)	17/30 (56.7%)	25/30 (83.3%)	0.047
Partial	18/60 (30.0%)	13/30 (43.3%)	5/30 (16.7%)
BNP elevated
No	50/59 (84.7%)	20/29 (69.0%)	30/30 (100.0%)	< 0.001
Yes	9/59 (15.3%)	9/29 (31.0%)	0/30 (0.0%)
Troponin > p99
No	57/58 (98.3%)	27/28 (96.4%)	30/30 (100.0%)	0.483
Yes	1/58 (1.7%)	1/28 (3.6%)	0/30 (0.0%)
GFR MDRD (ml/min/1.73m³)	76.56 ± 16.53	75.31 ± 16.41	77.82 ± 16.84	0.560
Triglycerides (mg/dL)	124.75 ± 58.87	126.03 ± 55.04	123.47 ± 63.39	0.868
HDL (mg/dL)	54.72 ± 13.75	51.43 ± 12.30	58.00 ± 14.53	0.064
LDL (mg/dL)	107.82 ± 36.02	102.90 ± 29.27	112.73 ± 41.63	0.295
HbA1c (%)	6.18 ± 0.90	6.01 ± 0.71	6.36 ± 1.04	0.140
Diabetes Mellitus
No	34/60 (56.7%)	19/30 (63.3%)	15/30 (50.0%)	0.435
Yes	26/60 (43.3%)	11/30 (36.7%)	15/30 (50.0%)
SBP (mmHg)	144.35 ± 19.12	141.53 ± 17.53	147.17 ± 20.49	0.257
DBP (mmHg)	84.83 ± 9.58	84.53 ± 8.60	85.13 ± 10.62	0.811
Heart Rate (bpm)	71.78 ± 16.00	69.70 ± 15.52	73.87 ± 16.46	0.317
LVEF (%)	67.00 [64.00; 69.00]	66.50 [63.50; 69.25]	67.50 [64.00; 69.00]	0.691
Diastolic Dysfunction above grade I
No	50/58 (86.2%)	22/28 (78.6%)	28/30 (93.3%)	0.138
Yes	8/58 (13.8%)	6/28 (21.4%)	2/30 (6.7%)
AIx@75: Augmentation Index set to a heart rate of 75bpm; BNP: Brain natriuretic peptide; DBP: Diastolic bloob pressure; GFR: Glomerular filtration rate; HbA1C: Glycated hemoglobin; LVEF: Left ventricule ejection fraction; PWV: Pulse wave velocity; SBP: Systolic blood pressure

There was no difference between the groups for the measurement of Augmentation Index corrected for a heart rate of 75 bpm (AIx@75). Although there was a numerically higher value of PWV in subjects in group 1, this difference was not statistically significant.

Regarding the assessment of left atrial function, although larger 3D volumes were observed for the left atrium in those patients with NSAT, this difference was not statistically significant (Table 2).

Table 2

Assessment of left atrial function between groups
	Total (n = 56)	NSAT + Group 1 (n = 27)	NSAT – Group 2 (n = 29)	p value
Strain 3D Reservoir (Longitudinal)	20.80 ± 9.21	19.19 ± 12.04	22.31 ± 5.21	0.221
Strain 3D Conduit (Longitudinal)	-9.91 ± 5.61	-9.41 ± 6.55	-10.38 ± 4.65	0.528
Strain 3D Contraction (Longitudinal)	-10.96 ± 6.51	-10.00 ± 7.85	-11.86 ± 4.93	0.298
Strain 3D Reservoir (Circumferential)	30.20 ± 9.91	29.93 ± 11.06	30.45 ± 8.89	0.847
Strain 3D Conduit (Circumferential)	-11.36 ± 8.47	-12.67 ± 10.70	-10.14 ± 5.59	0.280
Strain 3D Contraction (Circumferential)	-18.79 ± 8.97	-17.26 ± 10.56	-20.21 ± 7.07	0.230
Strain 2D (2 Chambers) Reservoir	25.02 ± 6.61	24.33 ± 6.46	25.66 ± 6.79	0.459
Strain 2D (2 Chambers) Conduit	-11.32 ± 5.18	-10.48 ± 5.06	-12.10 ± 5.25	0.245
Strain 2D (2 Chambers) Contraction	-13.88 ± 4.42	-14.07 ± 4.27	-13.69 ± 4.63	0.748
Strain 2D (4 Chambers) Reservoir	24.50 ± 6.73	23.22 ± 6.97	25.69 ± 6.39	0.174
Strain 2D (4 Chambers) Conduit	-12.12 ± 5.65	-11.74 ± 6.12	-12.48 ± 5.26	0.630
Strain 2D (4 Chambers) Contraction	-12.46 ± 4.08	-11.63 ± 4.23	-13.24 ± 3.84	0.142
Strain 2D (Biplanar) Reservoir	24.82 ± 6.09	23.85 ± 6.31	25.72 ± 5.84	0.255
Strain 2D (Biplanar) Conduit	-11.62 ± 4.77	-11.07 ± 5.07	-12.14 ± 4.50	0.411
Strain 2D (Biplanar) Contraction	-13.14 ± 3.68	-12.85 ± 3.91	-13.41 ± 3.50	0.574
3D Max Volume (mL)	49.54 ± 16.69	53.74 ± 17.71	45.62 ± 14.93	0.070
3D Minimum Volume (mL)	24.84 ± 12.14	28.11 ± 14.62	21.79 ± 8.44	0.057
Pre-A 3D volume (mL)	38.04 ± 14.65	41.48 ± 17.05	34.83 ± 11.38	0.095
Total Atrial Emptying Fraction (%)	0.52 ± 0.10	0.50 ± 0.12	0.53 ± 0.08	0.371
Active Atrial Emptying Fraction (%)	0.36 ± 0.10	0.34 ± 0.11	0.38 ± 0.08	0.156
Passive Atrial Emptying Fraction (%)	0.24 ± 0.11	0.24 ± 0.13	0.23 ± 0.08	0.750
Left Atrial Distensibility Index	1.10 [0.85; 1.31]	1.07 [0.72; 1.31]	1.11 [0.94; 1.26]	0.456

Tables 3 and 4 show comparisons between groups in relation to PWV (m/s) and Alx@75. These comparisons were performed using a linear model considering the variables of age, smoking, statin use, interatrial block, DBP and SBP.

Table 3

Linear model results to compare groups in relation to PWV (m/s)
	Coefficient	Standard error	p value
Intercept	-7.24	4.25	0.094
NSAT +	0.18	0.60	0.761
Age	0.14	0.04	0.003
Smoker	0.36	0.85	0.677
Statins	1.49	0.58	0.013
Interatrial block	-0.26	0.61	0.678
DBP (mmHg)	0.01	0.03	0.705
SBP (mmHg)	0.04	0.02	0.008
DBP: Diastolic bloob pressure; NSAT: Nonsustained atrial tachycardia; SBP: Systolic blood pressure

Table 4

Linear model results to compare groups in relation to Aix@75 (%)
	Coefficient	Standard error	p value
Intercept	14.60	18.30	0.429
NSAT +	-0.33	2.55	0.899
Age	0.12	0.19	0.548
Smoker	5.82	3.62	0.114
Statins	-6.04	2.48	0.018
Interatrial block	1.26	2.66	0.637
DBP (mmHg)	-0.08	0.15	0.587
SBP (mmHg)	0.13	0.07	0.069
DBP: Diastolic bloob pressure; NSAT: Nonsustained atrial tachycardia; SBP: Systolic blood pressure

Table 3 shows a significant association between PWV and age. On average, there was a 0.14 m/s increase in PWV for each year of age, a 1.49 m/s increase in PWV for statin users compared to patients who did not, and 0.04 m/s for each one-unit increase in SBP.

For Alx, there was a significant association of this outcome with the use of statins. Patients who use statins have, on average, a 6.04% less Aix@75 than patients who do not use statins (Table 4).

Arterial stiffness plays a key role in the pathophysiology of cardiovascular disease and is an independent predictor of cardiovascular mortality [4–6]. Recently, greater importance has been given to the association between increased arterial stiffness and atrial fibrillation [4–6]. Chen et al. [5] identified an increase in PWV as an independent predictor of a new episode of atrial fibrillation. Shaikh et al. [6] also demonstrated that higher Augmentation Index (Aix) was independently associated with the development of atrial fibrillation in 5,797 Framingham study participants during a median follow-up of 7 years. The increase in LA volume is another robust and independent predictor of a new episode of atrial fibrillation [7].

In our work, although the NSAT group had higher LA volumes, this difference was not statistically significant, possibly due to the low number of individuals, and there was no power to demonstrate such a difference. Interestingly, we were able to demonstrate that individuals with NSAT have a higher prevalence of interatrial block, which may mean that electrocardiographic changes may precede changes in atrial function assessed on echocardiography. In addition, the elevation of BNP in individuals with NSAT may represent an important finding in clinical practise to identify hypertensive patients who may benefit from Holter monitoring, to investigate nonsustained atrial tachycardia, which may progress to atrial fibrillation in the follow-up.

In our study, evaluating hypertensive patients without significant cardiovascular comorbidities, at a stage before the development of clinical atrial fibrillation, we were unable to verify the association of arterial stiffness parameters with the presence of nonsustained atrial tachycardia on 24-h Holter monitoring. However, it was possible to verify that such patients are older, which makes sense, since atrial fibrillation also affects older individuals more frequently [15].

A similar finding occurs with the higher prevalence of men in the group with nonsustained atrial tachycardia. The incidence of AF differs by sex and increasing age. In a European cohort of 79,793 individuals, after the age of 50 years, the incidence of AF in men increases markedly, while in women this increase occurs after the age of 60 years. Both curves converge at age 90. The incidence of AF is very low before the age of 50 years [15]. As the NSAT may may represent a phase prior to the development of atrial fibrillation, in the age group between 60–70 years we expected to find more men with this condition, since the incidence curves only converge at 90 years of age.

We were also able to demonstrate that there was a lower prevalence of ACEi/ARB use in the NSAT group, which may indicate some protective role of these drug classes, as has been demonstrated for atrial fibrillation in other studies [16, 17]. Blockers of the renin-angiotensin-aldosterone system, such as angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs), can prevent AF by affecting epicardial fat accumulation, representing a useful therapeutic strategy for preventing AF [16].

An interesting finding was that statin use was associated with a lower AIx, after adjusting for linear regression. Statin therapy may be a pharmacological strategy to improve arterial elasticity. The positive benefits of statin therapy in cardiovascular disease have been shown to be attributable not only to its lipid-lowering ability, but also to various pleiotropic effects such as anti-inflammatory, antiproliferative, antioxidant, and antithrombotic properties [18,19].

Interestingly, in this sample, we had an increase in pulse wave velocity, in the linear regression adjusted for statin use, such that statin use was associated with a 1.49 m/s increase in PWV. The divergent behaviour of these two arterial stiffness indices highlights the fact that diseases can have opposite effects on the central and peripheral arterial systems and that, therefore, multiple assessments must be performed along the vascular tree. It is possible that the use of a statin may have increased aortic calcification in the plaque stabilization process, which increased PWV [18,19].

Clinical implications

Our findings do not support that increased arterial stiffness may be associated with the finding of nonsustained atrial tachycardia on Holter monitoring. Despite having a numerically higher PWV in the NSAT group, this difference was not statistically significant. The groups also did not show significant differences with regard to echocardiographic functional assessment.

However, the increase in BNP levels and the presence of interatrial block on the ECG may alert us to the greater chance of a hypertensive individual having nonsustained atrial tachycardia and, therefore, make us more vigilant during follow-up, given that this patient may develop long-term atrial fibrillation.

The fact that the ACEi and ARB classes can provide protection for the development of nonsustained atrial tachycardia may represent a preferred strategy in these individuals, especially in those with high BNP and interatrial block.

Study limitations

Ideally, the echocardiogram and pulse wave velocity measurement should be performed at the same time. However, as the echocardiogram image acquisition technique does not allow the simultaneous measurement of pulse wave velocity, the exams could not be performed simultaneously. Despite this, blood pressure was measured before each exam and no significant differences were observed between groups in the baseline table.

The low sample size is because our hospital is a tertiary referral centre, with a lower proportion of patients with arterial hypertension without other major decompensated comorbidities, since these patients are receiving primary care.

Another limitation is the difference in the proportion between men and women in the analysed samples, possibly due to the greater demand for health services by the female population and perhaps due to a higher prevalence of atrial cardiomyopathy in men in the sample.

Finally, it is important to point out that this is an observational study, which only generates a hypothesis, and a cause-and-effect relationship cannot be established, mainly due to the number of patients observed.

In this small pilot study, in hypertensive individuals without major cardiovascular comorbidities, arterial stiffness was not associated with an increased presence of NSAT on 24 h Holter monitoring. NSAT was significantly associated with BNP elevation, interatrial block on electrocardiogram, men and elderly individuals.

Arterial stiffness is possibly associated with a higher density of atrial arrhythmias in hypertensive patients, which we were unable to demonstrate given the small number of patients in our study. Larger studies with this patient profile are needed to answer this question in the future.

Study Population

The study population was selected from the outpatient unit of Instituto do Coraçao (InCor), Hospital das Clinicas-HCFMUSP, Faculdade de Medicina da Universidade de Sao Paulo. Patients with NSAT were selected using the InCor Holter service data. The patients in the control group were selected from the InCor Hypertension outpatient clinic. Patients with a diagnosis of hypertension and aged over 50 were eligible to participate in the study. No sample size calculation was performed because it was a pilot study.

Patients were excluded for the following reasons: atrial fibrillation; secondary arterial hypertension; diabetes mellitus with HbA1C ≥ 9%; chronic kidney disease with GFR < 45 ml/min (MDRD); uncontrolled thyroid disorders; SBP ≥ 160 mmHg and/or DBP ≥ 100 mmHg, not considering the isolated office measure; Canadian Cardiovascular Stable Coronary Artery Disease Society (CCS) classes II, III or IV; acute coronary syndrome for less than 1 year; heart failure with LVEF ≤ 40% (measured by echocardiogram – Simpson); alcoholism and drug use; presence of a pacemaker, implantable cardioverter defibrillator or cardiac resynchronization therapy (CRT); presence of residual congenital heart disease residual; previous stroke; clinical history of severe obstructive sleep apnoea syndrome (OSA); severe left ventricular hypertrophy: septum or posterior wall LV ≥ 16 mm for women and ≥ 17 mm for men (American Society of Echocardiography) or presence of electrolyte disturbances of potassium, calcium and magnesium.

After selection, such patients underwent a 24-h Holter ECG monitoring, they were divided into 2 groups as follows: those with nonsustained atrial tachycardia for more than 10 beats (NSAT group or group 1), and those in whom such finding was not observed (control group or group 2).

The study was conducted in accord with to the Declaration of Helsinki and was approved by the Scientific Committee of the InCor/HCFMUSP and by the Ethics Committee for the Analysis of Projects of Research (CAPPesq) of the Clinical Board of HCFMUSP (SDC 4839/19/058) in November 2019, under number 3.689.322. All participating individuals signed the terms of free and informed consent form, in which they agreed to conduct the exams listed in the project.

24-hour ECG recording (Holter monitoring)

The exam was performed using a 3-channel Digital Recorder – CardioLight (Cardios®), with analysis performed in CardioNet Client Software.

The definition of nonsustained atrial tachycardia that was included in the protocol was arbitrarily instituted as any episode with 10 or more beats since it is a frequent arrhythmia in hypertensive individuals and the inclusion of any NSAT could decrease the specificity of the study.

Laboratory measurements

The biochemical tests (electrolytes and biomarkers) were collected at the laboratory of the InCor-HCFMUSP, on the same day as the PWV. The following methods were used for measuring electrolyte levels: potassium method: ion-selective electrode potentiometry (reference: 3.5 to 5.0 mEq/L). calcium method: ion-selective electrode potentiometry (reference: 1.15 to 1.29 mMol/L) and magnesium method: colorimetric analysis (reference: 1.8 to 2.4 mg/dL). The following methods were used for measuring biomarkers levels: troponin I method: chemiluminescence (reference: Up to 0.04 ng/mL) and BNP method: chemiluminescence (Reference: Less than 100 pg/mL).

Risk factor assessment

Risk factors were checked directly from the patient's medical record and through an interview conducted by a trained researcher on the day of the tests. Hypertension was defined as SBP at least 140 mmHg or DBP at least 90 mmHg, or the use of antihypertensive medications. Diabetes mellitus was defined by a fasting blood glucose level of at least 126 mg/dL or the current use of insulin or oral hypoglycaemic agents. Body mass index was calculated as weight (kg) divided by height squared (m²). A current smoker was defined as having smoked more than 100 cigarettes in one's lifetime and having smoked at least one cigarette daily at the time of the interview. A former smoker was someone who had smoked more than 100 cigarettes in their lifetime but reported that they had quit smoking. The glomerular filtration rate was estimated using the MDRD equation.

On ECG, partial interatrial block was defined as P wave duration ≥ 120 ms. Advanced interatrial block was defined as P wave duration ≥ 120 ms and biphasic or “positive-negative” P wave morphology in inferior leads. Two blinded observers (JGBL and LAB) had to validate this criterion. In case of discordance, a third blinded observer (FCCD) had to validate one of the options.

Measurement of PWV

PWV was assessed in the carotid-femoral arterial segment using the Complior® device (Colson, Gonesse, France). The measurement was made by means of simultaneous positioning of two mechanographic sensors in the carotid and femoral arteries located at a known distance. These sensors contain membranes that are successively deformed by the shock of the pulse wave and this deformation is initially transformed into an electrical signal and later transmitted to a calculation computer program.

The PWV test was performed with the patient in the supine position, after 10 minutes of rest, in a quiet, temperature-controlled environment. The distance between the carotid artery and the femoral artery was measured using a tape measure, at the points where the transducers were placed. This information has been entered directly into the software.

Each pulse wave appears in real time on the computer screen and the device determines the initial ascending phase of the wave and the beginning of the wave at two different points, deducting the speed as a function of the known and previously entered distance. After 10 curves followed by analysis, the mean value was recorded.

Echocardiographic examination

Two-dimensional echocardiography

Transthoracic echocardiogram exams were scheduled for all patients and GE® (Vivid 7 and Vivid IQ) or Philips® (Epic 9 and CX50) echocardiography service devices were used, with a multifrequency transducer and resources to obtain the modalities of M-mode, two-dimensional, conventional Doppler echocardiography. pulsatile and continuous, as well as colour Doppler.

The examination was performed in the left lateral decubitus position, under continuous electrocardiographic monitoring. The images were obtained from the parasternal (long and short axes), apical (two, three, four and five chambers) and subcostal projections, using two-dimensional (2D), M-mode and Doppler techniques. American Society of Echocardiography (ASE) guidelines were followed for image acquisition and analysis. For each echocardiographic variable, at least 3 cardiac cycles were analysed.

The exams were evaluated by the same experienced echocardiographer. Systolic function was assessed by the left ventricular shortening fraction and left ventricular ejection fraction (using the Simpson method). Left atrium measurements were obtained by the two-dimensional method as follows: anteroposterior linear measurement (parasternal projection, long axis) and by the disc method (atrial volume). LA volume was calculated from the apical four-chamber and two-chamber views using the biplane Simpson’s method. LV mass and LA volume were then indexed for body surface area. LA enlargement was defined as an LA volume index greater than 34 ml/m².

Diastolic function was evaluated accordingly, based on American Society of Echocardiography (ASE) guidelines. Diastolic function was then categorized into four groups: grade I, grade II, grade III and indeterminate grade, taking into account the early–late ventricular filling velocities (E/A) ratio, E/e′ ratio, tricuspid regurgitation velocity, and LA volume index (LAVI). In patients with indeterminate grade of diastolic dysfunction and depressed LV ejection fraction (LVEF), the systolic/diastolic pulmonary venous flow velocity ratio was used.

Speckle-tracking echocardiography

LA function was evaluated by means of two-dimensional strain measurements obtained by speckle-tracking echocardiography (STE). The following steps were performed using EchoPAC software (GE Healthcare, Horten, Norway): (1) marking the systolic event (opening and closure of the aortic valve) by an aortic flow pulsatile Doppler, (2) manual tracing of the LA endocardial border and (3) evaluating proper approval and tracing of the six segments. If two or more segments were not approved, step 2 was performed again. Otherwise, the analysis was approved, and the software generated a strain average curve. (4) Using the strain average curve, built from the beginning of the QRS complex, we obtained the left atrial strain reservoir (LASR) and left atrial strain contraction (LASCT), representing the LA reservoir and contraction functions, respectively. The conduit function (LASCD) was calculated by the difference between these two values. (5) This procedure was performed in LA-focused four-chamber and two-chamber apical windows. Care was taken to ensure good electrocardiogram visualization, especially regarding the P wave, which was used to determine atrial booster function. The following variables were obtained by calculating the average strain values in the four and two-chamber apical windows: global LASR, global LASCD and global LASCT.

Statistical analysis

The calculations were performed using R 4.0.5 software (R Core Team, 2021). For quantitative variables with normal distribution, the results are presented in terms of means ± standard deviations and comparisons between groups were performed with the t test. For measurements that did not show a normal distribution, the median [interquartile range] and the Wilcoxon test were considered. To verify the assumption of normality of continuous data, the Kolmogorov-Smirnov test was used. For qualitative variables, absolute and relative frequencies were considered, and the comparison was performed using the chi-square test. To compare the groups in terms of PWV (m/s) and Alx@75, a linear regression model was used adjusted for age, smoking, statin use, type of atrial block, diastolic blood pressure (DBP) and systolic blood pressure (SBP).

AUTHOR CONTRIBUTIONS STATEMENT

JGBL, LAB, DTH, LS, JBSA, WM, MIS and FCCD conceived and designed the research, took part in the acquisition, statistical analysis, analysis and interpretation of the data, writing and critical revision of the manuscript.

ALB, RGSV, GDP, DCSLB, TCW, SCPB, EWRR, CJG and SAB collaborated in the analysis and interpretation of data; all the authors critically revised the manuscript for significant intellectual content.

DATA AVAILABILITY STATEMENT

The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.

FUNDING

This study was funded and granted by Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP), Protocol # 19/16297-9.

COMPETING INTERESTS STATEMENT

There are no conflicts of interest.

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No competing interests reported.

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Arterial stiffness in hypertensive patients with nonsustained atrial tachycardia

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Abstract

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Introduction

Results

Discussion

Clinical implications

Study limitations

Conclusion

Methods

Study Population

24-hour ECG recording (Holter monitoring)

Laboratory measurements

Risk factor assessment

Measurement of PWV

Echocardiographic examination

Two-dimensional echocardiography

Speckle-tracking echocardiography

Statistical analysis

Declarations

References

Additional Declarations

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