Arq Bras Cardiol abc Arquivos Brasileiros de Cardiologia Arq. Bras. Cardiol. 0066-782X 1678-4170 Sociedade Brasileira de Cardiologia - SBC hQQFprX46kT9Jjj5gfJ6VBr S0066-782X2020000100066 10.36660/abc.20190838 Short Editorial Do We Need to Know the Left Ventricular Geometry Patterns of the Brazilian Population? 0000-0002-2263-4261 Saraiva Roberto M. 1 Fundação Oswaldo Cruz Instituto Nacional de Infectologia Evandro Chagas Rio de Janeiro RJ Brazil Fundação Oswaldo Cruz - Instituto Nacional de Infectologia Evandro Chagas, Rio de Janeiro, RJ - Brazil Mailing Address: Roberto M. Saraiva, Av. Brasil, 4365. Postal Code 21040-360, Rio de Janeiro, RJ - Brazil. E-mail: roberto.saraiva@ini.fiocruz.br, robertomsaraiva@gmail.com 10 02 2020 01 2020 114 1 66 67 This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Keywords Heart Failure Hypertension Hypertrophy, Left Ventricular Ventricular Remodeling Heart Ventricles/cirurgia Echocardiography/métodos

In this issue of the Arquivos Brasileiros de Cardiologia, Almeida et al.1 describe the left ventricular (LV) remodeling patterns frequencies found in a Brazilian population followed at primary healthcare clinics in Niterói city, state of Rio de Janeiro. The authors found that a LV abnormal geometry was present in up to 33% of 636 studied individuals (mean age 59.5±10.3 years old; 62% women). Eccentric LV hypertrophy (LVH) was the most common abnormal LV geometry pattern (29%), followed by concentric LVH and concentric remodeling (2% each).

LV remodeling is no longer considered solely an adaptative mechanism but a response to several different stimuli that lead to gene activation, cellular hypertrophy, apoptosis, fibrosis, and, finally, LV remodeling with different degrees of LV function compromise and increase in cardiovascular risk.2 In fact, the relation between LVH diagnosed by electrocardiogram and mortality has been long recognized.3 LV mass is considered an independent risk factor for heart failure (HF),4,5 stroke,5 sudden cardiac death,6 supraventricular and ventricular tachycardia,7 and all-cause8 and cardiovascular mortality.9 Therefore, hypertension (HTN) is considered stage A HF and LVH is considered stage B HF on the American College of Cardiology/American Heart Association guidelines on HF management.10 Surprisingly, it was not up to the study of Almeida et al.1 that LV geometry patterns were studied in Brazilian population. We need to know exactly what are the frequency and value of LV geometry patterns in the Brazilian population and not only apply knowledge obtained with other populations.

Many different factors and stimuli influence LV geometry remodeling such as age, gender,11 severity, duration and treatment status of HTN,12 obesity,13,14 metabolic syndrome,15 and diabetes mellitus.16 Almeida et al.1 also showed an association between eccentric LVH and gender, age, level of education, HTN, and albumin/creatinine ratio. However, the frequencies of those factors may have a great variation between populations which shows the importance of specifically addressing the LV geometry patterns and their prognostic value in Brazilian population.

LV abnormal geometry is classified into concentric remodeling (normal LV mass with increased relative wall thickness), concentric LVH (increased LV mass and relative wall thickness), and eccentric LVH (increased LV mass and normal relative wall thickness)17 based on M-mode echocardiography. LV geometric abnormalities are usually found in the general population. However, the distribution of the kind of LV geometry abnormalities may vary between studies. In a study with 35,602 patients with normal LV ejection fraction referred for echocardiography, concentric remodeling was identified in 35%, concentric LVH in 6% and eccentric LVH in 5%.8 However, this prevalence increases with ageing. In elderly patients, concentric remodeling was found in 43%, concentric LVH in 8.5% and eccentric LVH in 7.4%.18 Those results are strikingly different from the data described in the Brazilian population by Almeida et al.1 with a higher prevalence of eccentric LVH. Such a difference may be related to the high prevalence of HTN and diabetes in the population studied by Almeida et al.1 In fact, the most common type of LVH in patients with HTN is eccentric and not concentric LVH.12 Nevertheless, such differences between studies underscore the importance of studies addressing the Brazilian population. For instance, eccentric hypertrophy was associated with the development of HF with reduced ejection fraction, while concentric LVH was associated with the development of HF with preserved ejection fraction.19

A new classification for LVH was proposed based on LV dilation and concentricity:20 concentric non-dilated, concentric dilated, eccentric non-dilated and eccentric dilated. The importance of this new classification was demonstrated by the fact that eccentric non-dilated LVH is not associated with poor outcomes while all others had increased risk of all-cause and cardiovascular disease (CVD) mortality21 or increased risk of HF or CVD death compared to participants without LVH.22

Thus, I congratulate Almeida et al.1 for their very important research and I challenge them to pursue on their research and present the classification of LV geometry based on 4-tiered classification of LVH and, more importantly, the prognostic value of LV remodeling patterns in Brazilian population followed at primary healthcare.

Short Editorial related to the article: Left Ventricular Remodeling Patterns in Primary Healthcare

 References 1 Almeida RCM, Jorge AJL, Rosa MLG, Leite AR, Correia DMS, Mesquita ET et al. Padrões de Remodelamento Ventricular Esquerdo na Atenção Primária à Saúde. Arq Bras Cardiol. 2020; 114(1):59-65. Almeida RCM Jorge AJL Rosa MLG Leite AR Correia DMS Mesquita ET Padrões de Remodelamento Ventricular Esquerdo na Atenção Primária à Saúde Arq Bras Cardiol 2020 114 1 59 65 2 Oktay AA, Lavie CJ, Milani RV, Ventura HO, Gilliland YE, Shah S, et al. Current Perspectives on Left Ventricular Geometry in Systemic Hypertension. Prog Cardiovasc Dis . 2016;59(3):235-46. Oktay AA Lavie CJ Milani RV Ventura HO Gilliland YE Shah S Current Perspectives on Left Ventricular Geometry in Systemic Hypertension Prog Cardiovasc Dis 2016 59 3 235 246 3 Kannel WB, Gordon T, Offutt D. Left ventricular hypertrophy by electrocardiogram. Prevalence, incidence, and mortality in the Framingham study. Ann Intern Med.1969;71(1):89-105. Kannel WB Gordon T Offutt D Left ventricular hypertrophy by electrocardiogram. Prevalence, incidence, and mortality in the Framingham study Ann Intern Med 1969 71 1 89 105 4 Aurigemma GP, Gottdiener JS, Shemanski L, Gardin J, Kitzman D. Predictive value of systolic and diastolic function for incident congestive heart failure in the elderly: the cardiovascular health study. J Am Coll Cardiol. 2001;37(4):1042-8. Aurigemma GP Gottdiener JS Shemanski L Gardin J Kitzman D Predictive value of systolic and diastolic function for incident congestive heart failure in the elderly: the cardiovascular health study J Am Coll Cardiol 2001 37 4 1042 1048 5 Gardin JM, McClelland R, Kitzman D, Lima JA, Bommer W, Klopfenstein HS, et al. M-mode echocardiographic predictors of six- to seven-year incidence of coronary heart disease, stroke, congestive heart failure, and mortality in an elderly cohort (the Cardiovascular Health Study). Am J Cardiol. 2001;87(9):1051-7. Gardin JM McClelland R Kitzman D Lima JA Bommer W Klopfenstein HS M-mode echocardiographic predictors of six- to seven-year incidence of coronary heart disease, stroke, congestive heart failure, and mortality in an elderly cohort (the Cardiovascular Health Study) Am J Cardiol 2001 87 9 1051 1057 6 Aro AL, Reinier K, Phan D, Teodorescu C, Uy-Evanado A, Nichols GA, et al. Left-ventricular geometry and risk of sudden cardiac arrest in patients with preserved or moderately reduced left-ventricular ejection fraction. Europace. 2017;19(7):1146-52. Aro AL Reinier K Phan D Teodorescu C Uy-Evanado A Nichols GA Left-ventricular geometry and risk of sudden cardiac arrest in patients with preserved or moderately reduced left-ventricular ejection fraction Europace 2017 19 7 1146 1152 7 Chatterjee S, Bavishi C, Sardar P, Agarwal V, Krishnamoorthy P, Grodzicki T, et al. Meta-analysis of left ventricular hypertrophy and sustained arrhythmias. Am J Cardiol. 2014;114(7):1049-52. Chatterjee S Bavishi C Sardar P Agarwal V Krishnamoorthy P Grodzicki T Meta-analysis of left ventricular hypertrophy and sustained arrhythmias Am J Cardiol 2014 114 7 1049 1052 8 Milani RV, Lavie CJ, Mehra MR, Ventura HO, Kurtz JD, Messerli FH. Left ventricular geometry and survival in patients with normal left ventricular ejection fraction. Am J Cardiol. 2006;97(7):959-63. Milani RV Lavie CJ Mehra MR Ventura HO Kurtz JD Messerli FH Left ventricular geometry and survival in patients with normal left ventricular ejection fraction Am J Cardiol 2006 97 7 959 963 9 Artham SM, Lavie CJ, Milani RV, Patel DA, Verma A, Ventura HO. Clinical impact of left ventricular hypertrophy and implications for regression. Prog Cardiovasc Dis. 2009;52(2):153-67. Artham SM Lavie CJ Milani RV Patel DA Verma A Ventura HO Clinical impact of left ventricular hypertrophy and implications for regression Prog Cardiovasc Dis 2009 52 2 153 167 10 Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Jr., Drazner MH, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2013;128(16):e240-e327. Yancy CW Jessup M Bozkurt B Butler J Casey DE Jr Drazner MH 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines Circulation 2013 128 16 e240 e327 11 Kuch B, Muscholl M, Luchner A, Doring A, Riegger GA, Schunkert H, et al. Gender specific differences in left ventricular adaptation to obesity and hypertension. J Hum Hypertens. 1998;12(10):685-91. Kuch B Muscholl M Luchner A Doring A Riegger GA Schunkert H Gender specific differences in left ventricular adaptation to obesity and hypertension J Hum Hypertens 1998 12 10 685 691 12 Cuspidi C, Sala C, Negri F, Mancia G, Morganti A. Prevalence of left-ventricular hypertrophy in hypertension: an updated review of echocardiographic studies. J Hum Hypertens. 2012;26(6):343-9. Cuspidi C Sala C Negri F Mancia G Morganti A Prevalence of left-ventricular hypertrophy in hypertension: an updated review of echocardiographic studies J Hum Hypertens 2012 26 6 343 349 13 Lavie CJ, Milani RV, Ventura HO, Cardenas GA, Mehra MR, Messerli FH. Disparate effects of left ventricular geometry and obesity on mortality in patients with preserved left ventricular ejection fraction. Am J Cardiol. 2007;100(9):1460-4. Lavie CJ Milani RV Ventura HO Cardenas GA Mehra MR Messerli FH Disparate effects of left ventricular geometry and obesity on mortality in patients with preserved left ventricular ejection fraction Am J Cardiol 2007 100 9 1460 1464 14 Santos M, Shah AM. Alterations in cardiac structure and function in hypertension. Curr Hypertens Rep. 2014;16(5):428. Santos M Shah AM Alterations in cardiac structure and function in hypertension Curr Hypertens Rep 2014 16 5 428 428 15 Cuspidi C, Sala C, Lonati L, Negri F, Rescaldani M, Re A, et al. Metabolic syndrome, left ventricular hypertrophy and carotid atherosclerosis in hypertension: a gender-based study. Blood Press. 2013;22(3):138-43. Cuspidi C Sala C Lonati L Negri F Rescaldani M Re A Metabolic syndrome, left ventricular hypertrophy and carotid atherosclerosis in hypertension: a gender-based study Blood Press 2013 22 3 138 143 16 Palmieri V, Bella JN, Arnett DK, Liu JE, Oberman A, Schuck MY, et al. Effect of type 2 diabetes mellitus on left ventricular geometry and systolic function in hypertensive subjects: Hypertension Genetic Epidemiology Network (HyperGEN) study. Circulation. 2001;103(1):102-7. Palmieri V Bella JN Arnett DK Liu JE Oberman A Schuck MY Effect of type 2 diabetes mellitus on left ventricular geometry and systolic function in hypertensive subjects: Hypertension Genetic Epidemiology Network (HyperGEN) study Circulation 2001 103 1 102 107 17 Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2015;28(1):1-39. Lang RM Badano LP Mor-Avi V Afilalo J Armstrong A Ernande L Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging J Am Soc Echocardiogr 2015 28 1 1 39 18 Lavie CJ, Milani RV, Ventura HO, Messerli FH. Left ventricular geometry and mortality in patients >70 years of age with normal ejection fraction. Am J Cardiol. 2006;98(10):1396-9. Lavie CJ Milani RV Ventura HO Messerli FH Left ventricular geometry and mortality in patients >70 years of age with normal ejection fraction Am J Cardiol 2006 98 10 1396 1399 19 Velagaleti RS, Gona P, Pencina MJ, Aragam J, Wang TJ, Levy D, et al. Left ventricular hypertrophy patterns and incidence of heart failure with preserved versus reduced ejection fraction. Am J Cardiol. 2014;113(1):117-22. Velagaleti RS Gona P Pencina MJ Aragam J Wang TJ Levy D Left ventricular hypertrophy patterns and incidence of heart failure with preserved versus reduced ejection fraction Am J Cardiol 2014 113 1 117 122 20 Khouri MG, Peshock RM, Ayers CR, de Lemos JA, Drazner MH. A 4-tiered classification of left ventricular hypertrophy based on left ventricular geometry: the Dallas heart study. Circ Cardiovasc Imaging. 2010;3(2):164-71. Khouri MG Peshock RM Ayers CR de Lemos JA Drazner MH A 4-tiered classification of left ventricular hypertrophy based on left ventricular geometry: the Dallas heart study Circ Cardiovasc Imaging 2010 3 2 164 171 21 Bang CN, Gerdts E, Aurigemma GP, Boman K, de SG, Dahlof B, et al. Four-group classification of left ventricular hypertrophy based on ventricular concentricity and dilatation identifies a low-risk subset of eccentric hypertrophy in hypertensive patients. Circ Cardiovasc Imaging. 2014;7(3):422-9. Bang CN Gerdts E Aurigemma GP Boman K de SG Dahlof B Four-group classification of left ventricular hypertrophy based on ventricular concentricity and dilatation identifies a low-risk subset of eccentric hypertrophy in hypertensive patients Circ Cardiovasc Imaging 2014 7 3 422 429 22 Garg S, de Lemos JA, Ayers C, Khouri MG, Pandey A, Berry JD, et al. Association of a 4-Tiered Classification of LV Hypertrophy With Adverse CV Outcomes in the General Population. JACC Cardiovasc Imaging. 2015;8(9):1034-41. Garg S de Lemos JA Ayers C Khouri MG Pandey A Berry JD Association of a 4-Tiered Classification of LV Hypertrophy With Adverse CV Outcomes in the General Population JACC Cardiovasc Imaging 2015 8 9 1034 1041 Minieditorial Precisamos Conhecer os Padrões de Geometria do Ventrículo Esquerdo da População Brasileira? 0000-0002-2263-4261 Saraiva Roberto M. 1 Fundação Oswaldo Cruz - Instituto Nacional de Infectologia Evandro Chagas, Rio de Janeiro, RJ - Brasil Correspondência: Roberto M. Saraiva, Av. Brasil, 4365. CEP 21040-360, Rio de Janeiro, RJ - Brasil. E-mail: roberto.saraiva@ini.fiocruz.br, robertomsaraiva@gmail.com Palavras-chave Insuficiência Cardíaca Hipertensão Hipertrofia do Ventrículo Esquerdo Remodelação Ventricular Ventrículo Cardíaco/cirurgia Ecocardiografia/métodos

Nesta edição dos Arquivos Brasileiros de Cardiologia, Almeida et al.1 descrevem as frequências dos padrões de remodelação do ventrículo esquerdo (VE) encontradas em uma população brasileira acompanhada em clínicas de atenção primária à saúde da cidade de Niterói, estado do Rio de Janeiro. Os autores descobriram que uma geometria anormal do VE estava presente em até 33% dos 636 indivíduos estudados (média de idade de 59,5 ± 10,3 anos; 62% de mulheres). A hipertrofia do VE (HVE) excêntrica foi o padrão de geometria anormal mais comum (29%), seguido por HVE concêntrica e remodelação concêntrica (2% cada).

A remodelação do VE não é mais considerada apenas um mecanismo adaptativo, mas uma resposta a vários estímulos diferentes que levam à ativação gênica, hipertrofia celular, apoptose, fibrose e, finalmente, à remodelação do VE com diferentes graus de comprometimento da função do VE e aumento do risco cardiovascular.2 De fato, a relação entre HVE diagnosticada por eletrocardiograma e mortalidade foi reconhecida há muito tempo.3 A massa do VE é considerada um fator de risco independente para insuficiência cardíaca (IC),4,5 acidente vascular cerebral,5 morte súbita cardíaca,6 taquicardia supraventricular e ventricular,7 e mortalidade por todas as causas8 e cardiovascular.9 Portanto, a hipertensão arterial sistêmica (HAS) é considerada estágio A da IC e a HVE é considerada estágio B da IC nas diretrizes do American College of Cardiology/American Heart Association no manejo da IC.10 Surpreendentemente, foi somente com o estudo Almeida et al.1 que os padrões de geometria do VE foram estudados na população brasileira. Precisamos saber exatamente qual é a frequência e o valor dos padrões de geometria do VE na população brasileira e não apenas aplicar o conhecimento obtido com outras populações.

Muitos fatores e estímulos diferentes influenciam a remodelação da geometria do VE, como idade, sexo,11 gravidade, duração e status do tratamento da HAS,12 obesidade,13,14 síndrome metabólica15 e diabetes mellitus.16 Almeida et al.1 também mostraram uma associação entre HVE excêntrica e sexo, idade, nível de escolaridade, HAS e razão albumina/creatinina. Entretanto, as frequências desses fatores podem apresentar uma grande variação entre as populações, o que mostra a importância de abordar especificamente os padrões geométricos do VE e seu valor prognóstico na população brasileira.

A geometria anormal do VE é classificada como remodelação concêntrica (massa normal do VE com aumento da espessura relativa da parede), HVE concêntrica (massa do VE e espessura relativa da parede aumentadas) e HVE excêntrica (massa aumentada do VE e espessura relativa da parede normal)17 com base na ecocardiografia modo M. Anormalidades geométricas do VE são geralmente encontradas na população em geral. Entretanto, a distribuição do tipo de anormalidades na geometria do VE pode variar entre os estudos. Em um estudo com 35.602 pacientes com fração de ejeção normal do VE encaminhados para ecocardiografia, a remodelação concêntrica foi identificada em 35%, a HVE concêntrica em 6% e a HVE excêntrica em 5%.8 No entanto, essa prevalência aumenta com o envelhecimento. Em pacientes idosos, a remodelação concêntrica foi encontrada em 43%, a HVE concêntrica em 8,5% e a HVE excêntrica em 7,4%.18 Esses resultados são notavelmente diferentes dos dados descritos na população brasileira por Almeida et al.,1 com maior prevalência de HVE excêntrica. Essa diferença pode estar relacionada à alta prevalência de HAS e diabetes na população estudada por Almeida et al.1 De fato, o tipo mais comum de HVE em pacientes com HAS é a HVE excêntrica e não a concêntrica.12 De qualquer maneira, essas diferenças entre os estudos ressaltam a importância de estudos voltados à população brasileira. Por exemplo, a hipertrofia excêntrica foi associada ao desenvolvimento de IC com fração de ejeção reduzida, enquanto a HVE concêntrica foi associada ao desenvolvimento de IC com fração de ejeção preservada.19

Uma nova classificação para a HVE foi proposta com base na dilatação e concentricidade do VE:20 concêntrica não dilatada, concêntrica dilatada, excêntrica não dilatada e excêntrica dilatada. A importância dessa nova classificação foi demonstrada pelo fato de que a HVE excêntrica não dilatada não está associada a desfechos ruins, enquanto todos as outras apresentaram risco aumentado de mortalidade por todas as causas e por doenças cardiovasculares (DCV)21 ou risco aumentado de morte por IC ou DCV em comparação com participantes sem HVE.22

Assim, parabenizo Almeida et al.1 por suas pesquisas muito importantes e os desafio a prosseguir em suas pesquisas e a apresentar a classificação da geometria do VE com base na classificação em quatro níveis da HVE e, mais importante, o valor prognóstico dos padrões de remodelação do VE na população brasileira acompanhada na atenção básica.

Minieditorial referente ao artigo: Padrões de Remodelamento Ventricular Esquerdo na Atenção Primária à Saúde