Left atrial size and strain in hypertensive children compared to age-, sex- and race/ethnicity- matched controls

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We evaluated LA volume and strain in pediatric cases with HTN compared to age-, sex- and race/ethnicity-matched controls. Methods: This was a retrospective matched case-control study of patients that presented to the HTN clinic at CHOP from 12/2011 to 9/2018. Coarctation of the aorta, cardiomyopathy or heart transplantation cases were excluded. HTN was defined by abnormal ambulatory blood pressure result. LA volume was measured by biplane area-length method and indexed to body surface area (BSA). LA strain and strain rate were measured using TOMTEC® software. Left ventricular mass index (LVMI) was measured by M-mode and the 5/6 area-length method indexed to height 2.7 . Measurements were compared using Chi-square, McNemar, or Wilcoxon signed rank tests. Results: We included 47 cases and 47 controls. There was no difference in LA volume z-scores (-1.9 vs. -0.9, p=0.068), LA strain (37.8% vs. 38.0%, p=0.735) or LA strain rate (1.4 vs. 1.5, p=0.852) in cases compared to controls. LVMI by M-mode and 5/6 area-length method was higher in cases compared to controls (40 vs. 33.7 g/m 2.7 , p<0.001 and 29.9 vs 24.4 g/m 2.7 , p=<0.001, respectively). Conclusion: There was no difference in LA volume or LA strain in cases compared to controls. LVMI was significantly elevated in our cases and may be the first response to HTN, prior to affecting LA size. left atrial size left atrial strain left ventricular mass index pediatrics obesity Figures Figure 1 Figure 2 Introduction Echocardiographic examination of left atrial peak longitudinal strain (LA strain) and LA volume has been used to prognosticate adult conditions, such as risk of stroke in atrial fibrillation and all-cause mortality in hypertension (HTN), coronary artery disease, and cardiomyopathy. 1 – 5 LA enlargement occurs when there is either elevated left ventricular (LV) pressure or increased LV volume. 6 , 7 LA performance as measured by LA strain using speckle tracking echocardiography analyzes the LA throughout the cardiac cycle as it changes from being a reservoir for pulmonary venous return to being a conduit and lastly to being a booster pump during late ventricular diastole and atrial contraction. 8 Although the utility of evaluating the size and strain of the LA has proven to be very useful in adults with various cardiac conditions, little is known about LA volume and strain in pediatric conditions. Just recently, centers have published normative values for LA volume and strain in the pediatric population. 9 – 11 Only a few studies have investigated LA volume and strain in Kawasaki disease, cardiomyopathy and diabetes in children. 12 , 13 LA dimensions have been previously described in a small group of hypertensive pediatric cases; but further analysis of LA volume, strain and LA emptying fraction have not been described. 14 We evaluated LA volume, emptying fraction, strain and strain rate as well as LV measurements, systolic and diastolic function in a cohort of pediatric cases with HTN, diagnosed by ambulatory blood pressure monitoring (ABPM), and compared them to age-, sex- and race/ethnicity-matched controls. We hypothesized that pediatric cases with HTN have elevated LA volumes and abnormal LA strain in comparison to controls. Methods and Materials Study design and patient population: This was a retrospective matched case-control study of patients that presented for initial evaluation to the HTN and Vascular Evaluation Program (HTN clinic) at the Children’s Hospital of Philadelphia (CHOP) from 12/2011 to 9/2018. Cases were matched by age, sex and race/ethnicity to controls. Cases were those that were confirmed to have HTN based on ambulatory blood pressure monitoring (ABPM). These cases had secondary HTN related to the following conditions: chronic kidney disease, renal artery stenosis, solid organ transplant (except heart transplant), diabetes and other endocrine disorders, systemic lupus erythematosus, sickle cell disease, and various forms of vasculitis. These cases were also referred for a cardiovascular risk factor (obesity or primary HTN). Cases with a diagnosis of congenital heart disease, cardiomyopathy, heart transplantation or active arrhythmia were excluded due to the potential confounding impact of underlying cardiac disease on atrial or ventricular measurements. Controls were matched by age, sex and race/ethnicity. These controls were all referred to the general cardiology clinic at CHOP for a murmur or family history of congenital heart disease or cardiomyopathy. They all had normal blood pressure on chart review and had normal echocardiograms during their cardiology visit. Cases and controls were excluded from the analysis if echocardiographic imaging was inadequate to measure LA volumes or LA strain. Controls were retrospectively analyzed, and all cases provided informed consent under a protocol approved by the CHOP Institutional Review Board for the Protection of Human Subjects. Definitions: Cases were identified as hypertensive if they had abnormal ambulatory blood pressure monitoring (ABPM) performed after the initial HTN clinic visit. 15 HTN by ABPM was defined as severe ambulatory, ambulatory, nocturnal or masked HTN. 16 Severe ambulatory HTN was defined as a clinic BP measurement > 95th percentile and an ABPM systolic BP load of ≥50%. Ambulatory HTN was defined as a clinic BP measurement > 95th percentile and an ABPM systolic BP load of ≥25%. Nocturnal HTN is a mean night-time ambulatory systolic or diastolic BP of ≥95th percentile on ABPM. Masked HTN was defined as a clinic BP 95th percentile with ≥ 25% systolic BP load. 16 Race/ethnicity was matched based on what was documented in the chart. Cases were matched as African American/non-Hispanic, Caucasian/non-Hispanic, Hispanic/African American or Hispanic/Caucasian. Echocardiographic measures: LV measurements were collected prospectively at the time of the echocardiogram. LA volumes and LA strain were measured retrospectively from offline images (two-and four-chamber views) obtained during the HTN clinic or general cardiology clinic visit (Figs. 1 & 2 ). Echocardiographic examinations were performed using a General Electric (GE) ultrasound system (Chicago, IL) with a transducer appropriate for the patient’s size. All studies were stored digitally on Syngo Dynamics image archive (Siemens Healthineers, USA). All echocardiographic images were obtained by one of two sonographers who adhered to the HTN clinic echocardiographic protocol. 15 LV internal dimensions in systole and diastole, posterior wall and interventricular septal thickness in diastole were measured using M-mode in the parasternal short-axis view at the level of the papillary muscles and z-scores were determined. Fractional shortening was calculated. LVMI was measured by 2 methods: 1) M-mode using the formula of Devereaux and indexed to height 2 . 7 , and 2) 5/6 area-length method indexed to height 2 . 7 . 17 , 18 The 95th percentile for LVMI was calculated as follows: a constant 95th percentile value of 40 g/m 2.7 (female), and 45 g/m 2.7 (male) was used for cases over 9 years old, otherwise percentile curves provided by Khoury et al were used. 19 Two-dimensional global deformation parameters were measured during the echocardiographic examination on the GE ultrasound machine. LV global longitudinal strain (LV strain) with speckle tracking was calculated using the highest frame rates possible. Since LV strain was measured during the time of the clinic study with the GE ultrasound machine, interobserver variability could not be performed off-line as we would have to use a different strain platform (TOMTEC). LV strain measurements are not standard in our laboratory on normal or screening echocardiograms. Therefore, our control group did not have LV strain measurements included. LA volumes were measured by biplane area-length method and indexed to BSA. 18 Two-dimensional peak longitudinal LA speckle-tracking echocardiographic analyses and emptying fraction were performed by an experienced sonographer or physician (YW, MK), measured offline on TOMTEC software (Munich, Germany). For speckle tracking analysis, we acquired apical four-chamber view images using conventional two-dimensional gray scale echocardiography. The LA endocardial border was traced in the apical four-chamber view, excluding the appendage and pulmonary veins from the LA cavity. The LA tracing for strain was terminated 0.5 cm above the atrioventricular junction, to avoid influence of mitral annular motion (Figs. 1 & 2 ). Then, LA strain and strain rate curves were generated throughout the cardiac cycle. LA strain was presented as % and strain rate is unitless. To be consistent with previous studies, LV end-diastole at the onset of the QRS complex was defined as the starting point of the atrial cardiac cycle. Accuracy of the automated border tracking was verified and manually adjusted if needed. 20 Interobserver variability for LA volume and strain was assessed in 10% of measurements chosen at random and was calculated as the ratio (expressed as a percentage) of the difference between the values obtained by each observer (expressed as an absolute value) divided by the mean of the two values 21 . LA volume z-scores were derived from the algorithm provided by Bhatla et al. 10 Pulsed-wave Doppler measurements of E and A waves of the mitral valve were obtained in the apical four-chamber view with the cursor positioned at the leaflet tips. Pulsed tissue Doppler was used to measure myocardial velocities at the medial mitral valve annulus in early (e′) diastole. The E/A and E/e′ ratios were then calculated as a measure of LV diastolic function. 22 , 23 Analyses: Controls were matched 1:1 on age, sex, and race/ethnicity. For the cases, demographic and anthropomorphic variables, reason for referral, clinical characteristics, and ABPM results for each first HTN clinic visit were reported as median/inter-quartile range or number/percentage where appropriate. LA and LV measurements were compared between cases and controls using Chi-square, McNemar, or Wilcoxon signed rank tests. LA and LV measurements were also compared among hypertensive ABPM subgroups (severe ambulatory, ambulatory, and nocturnal) using Chi-square, Fisher’s exact, or Kruskal Wallis tests. Results In total, 120 subjects were included based on demographics, but due to image quality and availability of data, analysis was performed on 47 cases and 47 matched controls. Among the cases, the median age was 14 years (IQR 12–17) and the median BMI was 22.7 kg/m 2 (IQR 17.6–28.3). In addition, 38.3% of cases were African American, 48.9% Caucasian and 10.6% Hispanic. There was no difference in BMI, age, sex or race/ethnicity between cases and controls (Table 1 ). Of the cases, 27.3% were referred for a cardiovascular risk factor; the second most common referral diagnosis was kidney transplant (20.4%). In 17.0% of cases there was severe ambulatory HTN and in 68.1%, ambulatory HTN. An additional 10.6% had nocturnal HTN and 4.3% had masked HTN. Comparisons of LA volume z-scores between cases and controls revealed no significant difference between the two groups (Table 2 ). There was no difference in LA strain (37.8% vs. 38.0%, p = 0.735) or strain rate (1.4 vs 1.5, p = 0.852) between cases and controls. LA emptying fraction was similar between cases and controls (70.1% vs. 69.9%, p = 0.871). There was excellent reproducibility of LA strain and stain rate measurements (interobserver variability < 10%). LVMI measured by M-mode was significantly higher in cases than controls (40.0 g/m 2.7 vs 33.7 g/m 2.7 , p < 0.001). LVMI measured by 5/6 area-length was also significantly higher in cases than controls (p = 0.001). All LV strain measurements were within normal limits for cases compared to published normative data in the pediatric population. 24 , 25 Diastolic markers were different between cases and controls. E/e’ was higher in cases than controls (8.2 vs. 7.0, p = 0.004), but still within the normal range. There was no difference in LA volume and strain among cases when differentiating between different types of HTN; severe ambulatory, ambulatory and nocturnal HTN (Table 3 ). Due to small numbers of cases with masked HTN (N = 2) they were not included in this subgroup analysis. Discussion To our knowledge, this is the first case-control study to evaluate LA volume, strain and emptying fraction in a group of pediatric patients with systemic HTN compared to age-, sex- and race/ethnicity matched controls. The diagnosis of HTN was determined by ABPM, the gold standard for diagnosing systemic HTN. 26 We found that LA volume, strain and emptying fraction were not significantly different between cases and controls in this pediatric population which included young teenagers; however, other diastolic markers including medial e’, E/e’ and E/A were different compared to controls. LVMI was also significantly higher in the cases compared to controls. 27 LA volume, peak longitudinal strain and emptying fraction have been studied extensively in adults and are reliable markers of elevated LV filling pressure and diastolic dysfunction. 6 , 7 In adult patients with HTN, increased LA volume has been found to be an early marker of elevated LV pressure, prior to development of LV hypertrophy. 28 In our study, which focused on a pediatric population, almost all cases had normal LA volumes, despite elevations in LVMI. This is in contrast to a study by Daniels et al., which showed that pediatric patients with systemic HTN had LA enlargement, which appeared worse in patients with LV hypertrophy. 14 However, in that study, only an LA linear measurement was made and LA volumes were not assessed. We also found no difference in LA peak longitudinal strain between cases and controls. This lack of difference may be attributed to the fact that we studied a relatively young population, and the duration of HTN was unknown, so it is possible that these patients had a recent onset of HTN and had not yet demonstrated changes in LV diastolic function, which may be a later finding. Our data conflicts with what is seen in adult patients, in whom LA strain predicts outcomes such as arrhythmia, risk of stroke and the odds of success of cardioversion. 3 , 29 LA strain and strain rate are also decreased in adult patients with advanced heart failure and in those with HTN, even prior to LA enlargment. 30 – 32 In the pediatric population, LA strain has been shown to be abnormal in heart transplantation recipients with elevated filling pressures and in patients with cardiomyopathy and concurrent diastolic dysfunction. 33 , 34 To our knowledge, This is the first study to examine LA peak longitudinal strain in pediatric patients with systemic HTN. LV mass has been shown to be elevated in pediatric patients with HTN in other studies. 35 – 37 We chose to evaluate LVMI two ways, by M-mode and 5/6 area-length, as it has been shown that the 5/6 area-length method may be a more accurate measure of LVMI. 38 Both methods demonstrated an elevated LVMI in cases compared to controls. Perhaps an elevated LVMI is an initial finding in systemic HTN in pediatric patients and as diastolic dysfunction occurs over the long-term, echocardiographic changes in LA volume and strain are seen more in adults. 39 – 41 Diastolic dysfunction has been demonstrated in hypertensive adults and may be related to adverse cardiac events, but little is known regarding diastolic dysfunction in pediatric patients with HTN. 42 In our study, some diastolic parameters were different in patients with HTN compared to controls, but these values were still within the normal limits. Further studies are needed to examine diastolic values in pediatrics, as normal values may be different compared to adults. 39 Abnormalities in diastolic markers may aid in risk stratification in those pediatric patients that do not have other findings such as elevated LA volume or abnormal LA strain. There are limitations to our study. This is a relatively small sample size from a single center; therefore, our findings may not reflect the general pediatric population with HTN. This was a negative study in regard to LA measurements with no abnormalities in LA size, function or peak longitudinal strain seen. Although our patient population was recruited through our HTN clinic, these patients had a variety of conditions, including kidney dysfunction, endocrine disorders, etc. which may have influenced our findings and the sample size did not allow us to adjust for each specific condition. Lastly, since we only obtained the appropriate echocardiographic views for LV strain during the time of the echocardiogram for cases but not for controls, we could only compare our cases to previously published normal values. In summary, LA volume and strain measurements were reproducible, but were not different between pediatric cases with HTN and controls. There was, however, a statistically significant difference in diastolic markers including E/e’. Elevated LVMI was also seen in pediatric cases compared to controls, suggesting that the first compensatory response to HTN may be LV hypertrophy and subtle diastolic dysfunction, prior to affecting LA size. We speculate that LA dilation and dysfunction may be later findings as diastolic function worsens. Longitudinal follow up of this pediatric population with HTN will elucidate whether HTN will influence LA volume and strain over time. Table 1 Clinic measurements and patient demographics Case (N = 47) Control (N = 47) Characteristics Median IQR Median IQR P value Age (years), n = 47 14.0 12.0, 17.0 14 12.0, 17.0 1.000 Weight, (kg) n = 47 52.7 39.5, 82.1 60.9 45.5, 68.8 0.453 Height (cm), n = 47 160.4 139.5, 168.2 163 152.0, 172.0 0.041 BMI (kg/m 2 ) n = 47 22.7 17.6, 28.3 21.5 18.7, 25.1 0.228 BMI percentile, n = 20 54.5 26.3, 84.8 94.6 60.0, 99.0 0.090 BSA (m 2 ), n = 47 1.5 1.2, 2.0 1.6 1.4, 1.8 0.527 n % n % Sex Male 23 48.9% 23 48.9% 0.884 Female 24 51.1% 24 51.1% Race/Ethnicity White 23 48.9% 22 46.8% Black 18 38.3% 19 40.4% Hispanic 5 10.6% 5 10.6% Other 1 2.1% 1 2.1% Primary diagnosis CVRF* 12 27.3% Kidney transplant 9 20.5% Chronic kidney disease/dialysis 6 13.6% Diabetes type II 5 11.4% Renal artery stenosis 5 11.4% Diabetes type I 5 11.4% Rheumatologic disease ‡ 1 2.3% Malignancy 1 2.3% Ambulatory blood pressure monitoring results Ambulatory 32 68.1% Severe ambulatory 8 17.0% Masked 2 4.3% Nocturnal 5 10.6% BMI, body mass index; IQR, interquartile range; blood pressure *CVRF, referral diagnosis for cardiovascular risk factor (includes HTN and/or obesity) ‡ Rheumatologic disease includes systemic lupus erythematous and Takayasu arteritis Table 2 Echocardiographic findings in hypertensive cases compared to matched controls Case Control Echocardiographic findings N Median IQR N Median IQR P value LV SF (%) 46 37.0 35.0, 41.0 46 36.1 33.3, 38.6 0.2461 LV EF (%) 32 63.0 59.0, 68.0 32 63.4 59.5, 65.7 0.9485 LVMI (g/m 2.7 ) 47 40.0 33.0, 49.0 47 33.7 28.7, 37.2 0.0002 LVMI > 95th 47 19/47 47 5/47 < 0.0001 LV MI by 5/6 area-length (g) 43 95.2 72.9, 133.7 43 90.8 65.3, 116.1 0.0155 LV MI by 5/6 area-length index (g/m 2.7 ) 43 29.9 24.2, 37.8 43 24.4 21.0, 29.6 0.0006 LV Strain (%) 42 -18.1 -20.3, -16.6 0 LV strain <-16 (% yes) 42 32/42 0 PWT (cm) 47 0.8 0.7, 1.0 47 0.8 0.7, 0.8 0.0154 IVSD (cm) 47 0.9 0.8, 1.1 47 0.8 0.7, 0.9 0.0001 IVSD z-score 43 0.3 -0.7, 1.0 43 -0.7 -1.4, -0.0 < 0.0001 LVIDd (cm) 47 4.5 4.1, 5.0 47 4.6 4.2, 4.8 0.9519 LVIDs (cm) 46 2.9 2.6, 3.1 46 3 2.7, 3.2 0.3218 LVIDd z-score 43 -0.8 -1.6, 0.6 43 -0.6 -1.3, -0.1 0.8813 LVIDs z-score 43 -0.9 -1.7, 0.1 43 -0.4 -1.2, -0.0 0.2884 LA ESV (ml) 46 36.9 25.5, 47.9 46 44.1 31.2, 50.3 0.1993 LA EDV (ml) 46 10.2 6.8, 14.3 46 12.4 10.2,16.9 0.1189 LA volume z-score 47 -1.9 -2.8, -0.5 47 -0.9 -2.3, -0.2 0.0676 LA volume biplane (ml) 47 36.9 27.0, 49.5 47 42.5 31.2, 53.0 0.2715 LA volume/BSA (ml/m 2 ) 47 22.2 19.0, 30.3 47 27.3 21.6, 31.0 0.1002 LA global strain (%) 46 37.8 29.9, 48.2 46 38 33.4, 46.0 0.7352 LA strain rate 46 1.4 1.1, 1.8 46 1.5 1.2, 1.7 0.8519 LA EF (%) 46 70.1 66.3, 75.8 46 69.9 64.9, 73.3 0.8711 Mitral valve inflow E/A 37 1.7 1.4, 2.3 37 2.1 1.8, 2.6 0.0083 E/A > 2 47 21/47 47 29/47 0.6860 Medial e' (mm) 40 1.2 1.1,1.5 40 1.1 1.0,1.3 0.0008 E/e' 42 8.2 6.8, 9.8 42 7.0 6.4, 8.8 0.0347 E/e' >15 47 4/47 47 3/47 < .0001 LV, left ventricle; SF, shortening fraction; LV EF, left ventricular ejection fraction; IQR, interquartile range; LVMI, left ventricular mass index; MV, mitral valve; PWT, posterior wall thickness; IVSD, interventricular septum thickness in diastole ; LVIDd, left ventricular internal diameter in diastole; LVIDs, left ventricular internal diameter is systole; LA, left atrium; LA EF, left atrium emptying fraction; ESV, end systolic volume; EDV, end diastolic volume BSA, body surface area *available data for each variable by matched cases and controls is reported in respective “n” columns Table 3 Echocardiographic findings based on ambulatory blood pressure monitoring results Echo variable Ambulatory blood pressure monitoring results Severe ambulatory (N = 8) ambulatory (N = 32) nocturnal (N = 5) P-value LA ESV (ml) 29.7 (24.8, 65.8) 40.7 (23.3, 47.4) 34.7 (32.0, 52.4) 0.8453 LA EDV (ml) 9.1 (7.4, 18.4) 10.7 (6.4, 13.8) 11.1 (8.4, 14.3) 0.8391 LA volume z score -0.9 (-2.0, 0.4) -1.9 (-3.0, -0.7) -1.9 (-2.5, -1.7) 0.3283 LA volume z score > 2 1/8 1/32 0/5 0.4990 LA volume biplane (ml) 30.9 (23.4, 69.9) 37.4 (26.6, 47.1) 39.2 (35.5, 49.6) 0.8395 LA volume/BSA (ml/m 2 ) 28.4 (20.2, 35.1) 21.2 (18.4, 29.9) 22.9 (20.9, 23.0) 0.4540 LA global strain (%) 31.8 (29.1, 41.1) 40.6 (30.3, 48.5) 35.8 (25.4, 39.9) 0.2859 LA strain rate 1.3 (1.2, 1.6) 1.4 (1.1, 1.8) 1.4 (1.1, 1.4) 0.6935 LA EF (%) 70.4 (64.7, 72.0) 69.4 (66.0, 75.9) 73.6 (69.3, 73.7) 0.7278 Mitral valve inflow E/A 1.7 (1.0, 2.3) 1.8 (1.4, 2.3) 1.6 (1.5, 1.8) 0.4610 E/A > 2 3/8 16/32 1/5 0.5120 Medial e' (mm) 1.1 (0.9, 1.2) 1.1 (1.0, 1.3) 1.3 (1.2, 1.4) 0.1326 E/e' 8.2 (7.2, 10.7) 8.5 (7.1, 10.1) 5.4 (4.4, 7.5) 0.1286 E/e' >15 1/8 3/32 0/5 1.0000 LA, left atrium; ESV, end systolic volume; EDV, end diastolic volume BSA, body surface area; EF, emptying fraction; MV, mitral valve Declarations Author Contribution H.G helped with data analysisY.W aided in measurements, imagesL.M-R aided in study design, manuscript writingA.B aided in study design, manuscript writingM, D.Q aided in study design, manuscript writingS, S.N aided in study design, manuscript writingAll authors reviewed the manuscript References Rossi A et al (2002) Determinants and prognostic value of left atrial volume in patients with dilated cardiomyopathy. J Am Coll Cardiol 40:1425–1430 Gerdts E et al (2002) Correlates of Left Atrial Size in Hypertensive Patients With Left Ventricular Hypertrophy. Hypertension 39:739–743 Benjamin EJ, D’Agostino RB, Belanger AJ, Wolf PA, Levy D (1995) Left Atrial Size and the Risk of Stroke and Death. Circulation 92:835–841 Chinali M et al (2005) Left Atrial Systolic Force and Cardiovascular Outcome. The Strong Heart Study. Am J Hypertens 18:1570–1576 Leung DY, Boyd A, Ng AA, Chi C, Thomas L (2008) Echocardiographic evaluation of left atrial size and function: Current understanding, pathophysiologic correlates, and prognostic implications. Am Heart J 156:1056–1064 Hoit BD (2014) Left Atrial Size and Function: Role in Prognosis. J Am Coll Cardiol 63:493–505 Hawley RR, Dodge HT, Graham TP (1966) Left Atrial Volume and Its Changes in Heart Disease. Circulation 34:989–996 Donal E, Behagel A, Feneon D (2015) Value of left atrial strain: a highly promising field of investigation. Eur Heart J - Cardiovasc Imaging 16:356–357 Ghelani SJ et al (2018) Left Atrial Volumes and Strain in Healthy Children Measured by Three-Dimensional Echocardiography: Normal Values and Maturational Changes. J Am Soc Echocardiogr 31(2):187–193 Bhatla P et al (2012) Normal values of left atrial volume in pediatric age group using a validated allometric model. Circ Cardiovasc Imaging 5:791–796 Hope KD et al (2019) Left atrial mechanics in children: insights from new applications of strain imaging. Int J Cardiovasc Imaging 35:57–65 Kang SJ, Kwon YW, Hwang SJ, Kim HJ, Jin BK, Yon DK (2018) Clinical Utility of Left Atrial Strain in Children in the Acute Phase of Kawasaki Disease. J Am Soc Echocardiogr Mar 31(3):323–332 Marcovecchio ML et al (2016) Increased left atrial size in obese children and its association with insulin resistance: a pilot study. Eur J Pediatr 175:121–130 Daniels SR, Witt SA, Glascock B, Khoury PR, Kimball TR (2002) Left atrial size in children with hypertension: The influence of obesity, blood pressure, and left ventricular mass. J Pediatr 141:186–190 Kaplinski M et al (2020) Clinical Innovation: A Multidisciplinary Program for the Diagnosis and Treatment of Systemic Hypertension in Children and Adolescents. Clin Pediatr (Phila) Flynn JT et al (2014) Update: Ambulatory Blood Pressure Monitoring in Children and Adolescents: A Scientific Statement From the American Heart Association. Hypertension 63, 1116–1135 Devereux RB et al (1986) Echocardiographic assessment of left ventricular hypertrophy: Comparison to necropsy findings. Am J Cardiol 57:450–458 Lang RM et al (2015) 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 28:1–39 Khoury PR, Mitsnefes M, Daniels SR, Kimball TR (2009) Age-specific reference intervals for indexed left ventricular mass in children. J Am Soc Echocardiogr 22:709–714 Mor-Avi V et al (2011) Current and Evolving Echocardiographic Techniques for the Quantitative Evaluation of Cardiac Mechanics: ASE/EAE Consensus Statement on Methodology and Indications. J Am Soc Echocardiogr 24:277–313 Popović ZB, Thomas JD (2017) Assessing observer variability: a user’s guide. Cardiovasc Diagn Ther 7:317–324 Nishimura RA, Abel MD, Hatle LK, Tajik AJ (1989) Assessment of Diastolic Function of the Heart: Background and Current Applications of Doppler Echocardiography. Part II. Clinical Studies. Mayo Clinic Proceedings 64, 181–204 Nagueh SF et al (2016) Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 29:277–314 Levy PT et al (2016) Reference Ranges of Left Ventricular Strain Measures by Two-Dimensional Speckle-Tracking Echocardiography in Children: A Systematic Review and Meta-Analysis. J Am Soc Echocardiogr 29:209–225 Jashari H et al (2015) Normal ranges of left ventricular strain in children: a meta-analysis. Cardiovasc Ultrasound 13:37 Flynn JT et al (2017) Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics Kaplinski M et al (2021) Left Ventricular Measurements and Strain in Pediatric Patients Evaluated for Systemic Hypertension and the Effect of Adequate Anti-hypertensive Treatment. Pediatr Cardiol Frohlich ED, Tarazi RC, Dustan HP (1971) Clinical-Physiological Correlations in the Development of Hypertensive Heart Disease. Circulation 44:446–455 Di Salvo G et al (2005) Atrial Myocardial Deformation Properties Predict Maintenance of Sinus Rhythm After External Cardioversion of Recent-Onset Lone Atrial Fibrillation: A Color Doppler Myocardial Imaging and Transthoracic and Transesophageal Echocardiographic Study. Circulation 112:387–395 Morris DA et al (2015) Normal values and clinical relevance of left atrial myocardial function analysed by speckle-tracking echocardiography: multicentre study. Eur Heart J - Cardiovasc Imaging 16:364–372 Hennawy B, Kilany E, Galal W, H., Mamdouh A (2018) Role of speckle tracking echocardiography in detecting early left atrial dysfunction in hypertensive patients. Egypt Heart J 70:217–223 Cameli M (2015) Left atrial strain in patients with arterial hypertension. ICFJ 1:31 Sabatino J et al (2019) Left Atrial Strain to Identify Diastolic Dysfunction in Children with Cardiomyopathies. JCM 8:1243 Loar RW et al (2020) Left Atrial Strain Correlates with Elevated Filling Pressures in Pediatric Heart Transplantation Recipients. J Am Soc Echocardiogr 33:504–511 Daniels SR, Loggie JMH, Khoury P, Kimball TR (1998) Left Ventricular Geometry and Severe Left Ventricular Hypertrophy in Children and Adolescents With Essential Hypertension. Circulation 97:1907–1911 Hanevold C, Waller J, Daniels S, Portman R, Sorof J (2004) The Effects of Obesity, Gender, and Ethnic Group on Left Ventricular Hypertrophy and Geometry in Hypertensive Children: A Collaborative Study of the International Pediatric Hypertension Association. Pediatrics 113:328–333 Daniels SD, Meyer RA, Loggie JM (1990) Determinants of cardiac involvement in children and adolescents with essential hypertension. Circulation 82:1243–1248 Lopez L et al (2010) Recommendations for Quantification Methods During the Performance of a Pediatric Echocardiogram: A Report From the Pediatric Measurements Writing Group of the American Society of Echocardiography Pediatric and Congenital Heart Disease Council. J Am Soc Echocardiogr 23:465–495 Mawad W, Friedberg MK (2017) The continuing challenge of evaluating diastolic function by echocardiography in children: developing concepts and newer modalities. Curr Opin Cardiol 32:93–100 Matsuda M, Matsuda Y (1996) Mechanism of left a trial enlargement related to ventricular diastolic impairment in hypertension. Clin Cardiol 19:954–959 Cioffi G, Mureddu GF, Stefenelli C, de Simone G (2004) Relationship between left ventricular geometry and left atrial size and function in patients with systemic hypertension. J Hypertens 22:1589–1596 Dini FL et al (2018) Prevalence and determinants of left ventricular diastolic dysfunction in obese subjects and the role of left ventricular global longitudinal strain and mass normalized to height. Echocardiography 35:1124–1131 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 24 Nov, 2024 Read the published version in Pediatric Cardiology → Version 1 posted Editorial decision: Revision requested 27 Aug, 2024 Reviews received at journal 17 Aug, 2024 Reviewers agreed at journal 06 Aug, 2024 Reviewers agreed at journal 01 Aug, 2024 Reviews received at journal 24 Jul, 2024 Reviewers agreed at journal 17 Jul, 2024 Reviewers agreed at journal 16 Jul, 2024 Reviewers invited by journal 16 Jul, 2024 Editor assigned by journal 16 Jul, 2024 Submission checks completed at journal 16 Jul, 2024 First submitted to journal 15 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4743311","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":336917164,"identity":"60e2422f-50bc-43fe-8ba0-d1f0e81f13f6","order_by":0,"name":"Michelle Kaplinski","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+UlEQVRIie3RMWsCMRTA8XcE0iVy6zsKfgMh03VwuK8Sl7reZDuICMK5HM4Vv0S7OEcedLrTL+BwINwcEKRDFePRoYOmjh3yhzc8yI8QAuDz/ceEnUoCIGP6sod27Mr/IKohXIFF0fg+YgdByPtIJ6e6Uuk2iaZivzfDLYaP9A5mQDdJXGZPUsm6t2CtJerPGqPZcxq8rR1kAzEqSaptCWhOI1kIyVqZizwcLiRpM7Ez+kTYkKOLlHlzS7BgAnCV/ZDARYrixb6FevMJj7GcEUY5T1f5uu8g/WVlvinBDe3M64EwFOyj+hp0bxK4+gXadf468fl8Pt/vzqIeWLA0z0l+AAAAAElFTkSuQmCC","orcid":"","institution":"Children's Hospital of Philadelphia, University of Pennsylvania","correspondingAuthor":true,"prefix":"","firstName":"Michelle","middleName":"","lastName":"Kaplinski","suffix":""},{"id":336917166,"identity":"1daaabe7-8489-44e1-af44-61e57a337dfc","order_by":1,"name":"Heather Griffis","email":"","orcid":"","institution":"Children's Hospital of Philadelphia, University of Pennsylvania","correspondingAuthor":false,"prefix":"","firstName":"Heather","middleName":"","lastName":"Griffis","suffix":""},{"id":336917167,"identity":"3d85c211-2a30-4352-bb47-d8115d21138e","order_by":2,"name":"Yan Wang","email":"","orcid":"","institution":"Children's Hospital of Philadelphia, University of Pennsylvania","correspondingAuthor":false,"prefix":"","firstName":"Yan","middleName":"","lastName":"Wang","suffix":""},{"id":336917168,"identity":"90aab9dd-1f0f-430d-b925-0a814f0abdf3","order_by":3,"name":"Laura Mercer-Rosa","email":"","orcid":"","institution":"Children's Hospital of Philadelphia, University of Pennsylvania","correspondingAuthor":false,"prefix":"","firstName":"Laura","middleName":"","lastName":"Mercer-Rosa","suffix":""},{"id":336917169,"identity":"722fc2c7-217f-4044-98c7-4c1e2a4a8bee","order_by":4,"name":"Anirban Banerjee","email":"","orcid":"","institution":"Children's Hospital of Philadelphia, University of Pennsylvania","correspondingAuthor":false,"prefix":"","firstName":"Anirban","middleName":"","lastName":"Banerjee","suffix":""},{"id":336917170,"identity":"9ec04354-2f9e-40d1-ae1e-587b3c336180","order_by":5,"name":"Michael D. Quartermain","email":"","orcid":"","institution":"Children's Hospital of Philadelphia, University of Pennsylvania","correspondingAuthor":false,"prefix":"","firstName":"Michael","middleName":"D.","lastName":"Quartermain","suffix":""},{"id":336917171,"identity":"509d99ee-e725-4305-8d8d-e5b70dceaef8","order_by":6,"name":"Shobha S. Natarajan","email":"","orcid":"","institution":"Children's Hospital of Philadelphia, University of Pennsylvania","correspondingAuthor":false,"prefix":"","firstName":"Shobha","middleName":"S.","lastName":"Natarajan","suffix":""}],"badges":[],"createdAt":"2024-07-15 13:45:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4743311/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4743311/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00246-024-03719-y","type":"published","date":"2024-11-24T15:57:11+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":62633043,"identity":"20746692-6b96-4b59-88e6-afbe0b0a2558","added_by":"auto","created_at":"2024-08-16 16:17:43","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1170215,"visible":true,"origin":"","legend":"\u003cp\u003eLA volume measurements\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4743311/v1/1c6e43260c9bc5b041bf1606.png"},{"id":62633044,"identity":"55baa9e3-67ba-4ad2-84bf-4d33f11d68e0","added_by":"auto","created_at":"2024-08-16 16:17:43","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":490375,"visible":true,"origin":"","legend":"\u003cp\u003eLA strain measurements\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4743311/v1/efb3109419953d2c4a62f9aa.jpeg"},{"id":69835109,"identity":"fe80a988-d9ea-4b0b-9dcf-fed87e69cb40","added_by":"auto","created_at":"2024-11-25 16:12:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2347070,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4743311/v1/58cba1bf-1a03-4770-be7b-ee359e3e7774.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Left atrial size and strain in hypertensive children compared to age-, sex- and race/ethnicity- matched controls","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEchocardiographic examination of left atrial peak longitudinal strain (LA strain) and LA volume has been used to prognosticate adult conditions, such as risk of stroke in atrial fibrillation and all-cause mortality in hypertension (HTN), coronary artery disease, and cardiomyopathy.\u003csup\u003e\u003cspan additionalcitationids=\"CR2 CR3 CR4\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e LA enlargement occurs when there is either elevated left ventricular (LV) pressure or increased LV volume.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e LA performance as measured by LA strain using speckle tracking echocardiography analyzes the LA throughout the cardiac cycle as it changes from being a reservoir for pulmonary venous return to being a conduit and lastly to being a booster pump during late ventricular diastole and atrial contraction.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Although the utility of evaluating the size and strain of the LA has proven to be very useful in adults with various cardiac conditions, little is known about LA volume and strain in pediatric conditions.\u003c/p\u003e \u003cp\u003eJust recently, centers have published normative values for LA volume and strain in the pediatric population.\u003csup\u003e\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e Only a few studies have investigated LA volume and strain in Kawasaki disease, cardiomyopathy and diabetes in children.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e LA dimensions have been previously described in a small group of hypertensive pediatric cases; but further analysis of LA volume, strain and LA emptying fraction have not been described.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e We evaluated LA volume, emptying fraction, strain and strain rate as well as LV measurements, systolic and diastolic function in a cohort of pediatric cases with HTN, diagnosed by ambulatory blood pressure monitoring (ABPM), and compared them to age-, sex- and race/ethnicity-matched controls. We hypothesized that pediatric cases with HTN have elevated LA volumes and abnormal LA strain in comparison to controls.\u003c/p\u003e"},{"header":"Methods and Materials","content":"\n\u003ch3\u003eStudy design and patient population:\u003c/h3\u003e\n\u003cp\u003eThis was a retrospective matched case-control study of patients that presented for initial evaluation to the HTN and Vascular Evaluation Program (HTN clinic) at the Children\u0026rsquo;s Hospital of Philadelphia (CHOP) from 12/2011 to 9/2018. Cases were matched by age, sex and race/ethnicity to controls. Cases were those that were confirmed to have HTN based on ambulatory blood pressure monitoring (ABPM). These cases had secondary HTN related to the following conditions: chronic kidney disease, renal artery stenosis, solid organ transplant (except heart transplant), diabetes and other endocrine disorders, systemic lupus erythematosus, sickle cell disease, and various forms of vasculitis. These cases were also referred for a cardiovascular risk factor (obesity or primary HTN). Cases with a diagnosis of congenital heart disease, cardiomyopathy, heart transplantation or active arrhythmia were excluded due to the potential confounding impact of underlying cardiac disease on atrial or ventricular measurements. Controls were matched by age, sex and race/ethnicity. These controls were all referred to the general cardiology clinic at CHOP for a murmur or family history of congenital heart disease or cardiomyopathy. They all had normal blood pressure on chart review and had normal echocardiograms during their cardiology visit. Cases and controls were excluded from the analysis if echocardiographic imaging was inadequate to measure LA volumes or LA strain. Controls were retrospectively analyzed, and all cases provided informed consent under a protocol approved by the CHOP Institutional Review Board for the Protection of Human Subjects.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDefinitions:\u003c/h2\u003e \u003cp\u003eCases were identified as hypertensive if they had abnormal ambulatory blood pressure monitoring (ABPM) performed after the initial HTN clinic visit.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e HTN by ABPM was defined as severe ambulatory, ambulatory, nocturnal or masked HTN.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e Severe ambulatory HTN was defined as a clinic BP measurement\u0026thinsp;\u0026gt;\u0026thinsp;95th percentile and an ABPM systolic BP load of \u0026ge;50%. Ambulatory HTN was defined as a clinic BP measurement\u0026thinsp;\u0026gt;\u0026thinsp;95th percentile and an ABPM systolic BP load of \u0026ge;25%. Nocturnal HTN is a mean night-time ambulatory systolic or diastolic BP of \u0026ge;95th percentile on ABPM. Masked HTN was defined as a clinic BP\u0026thinsp;\u0026lt;\u0026thinsp;95th percentile and ABPM mean ambulatory systolic BP\u0026thinsp;\u0026gt;\u0026thinsp;95th percentile with \u0026ge; 25% systolic BP load.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e Race/ethnicity was matched based on what was documented in the chart. Cases were matched as African American/non-Hispanic, Caucasian/non-Hispanic, Hispanic/African American or Hispanic/Caucasian.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEchocardiographic measures:\u003c/h3\u003e\n\u003cp\u003eLV measurements were collected prospectively at the time of the echocardiogram. LA volumes and LA strain were measured retrospectively from offline images (two-and four-chamber views) obtained during the HTN clinic or general cardiology clinic visit (Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u0026amp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Echocardiographic examinations were performed using a General Electric (GE) ultrasound system (Chicago, IL) with a transducer appropriate for the patient\u0026rsquo;s size. All studies were stored digitally on Syngo Dynamics image archive (Siemens Healthineers, USA).\u003c/p\u003e \u003cp\u003eAll echocardiographic images were obtained by one of two sonographers who adhered to the HTN clinic echocardiographic protocol.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e LV internal dimensions in systole and diastole, posterior wall and interventricular septal thickness in diastole were measured using M-mode in the parasternal short-axis view at the level of the papillary muscles and z-scores were determined. Fractional shortening was calculated. LVMI was measured by 2 methods: 1) M-mode using the formula of Devereaux and indexed to height\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e.\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e, and 2) 5/6 area-length method indexed to height\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e.\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e The 95th percentile for LVMI was calculated as follows: a constant 95th percentile value of 40 g/m\u003csup\u003e2.7\u003c/sup\u003e (female), and 45 g/m\u003csup\u003e2.7\u003c/sup\u003e (male) was used for cases over 9 years old, otherwise percentile curves provided by Khoury et al were used.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e Two-dimensional global deformation parameters were measured during the echocardiographic examination on the GE ultrasound machine. LV global longitudinal strain (LV strain) with speckle tracking was calculated using the highest frame rates possible. Since LV strain was measured during the time of the clinic study with the GE ultrasound machine, interobserver variability could not be performed off-line as we would have to use a different strain platform (TOMTEC). LV strain measurements are not standard in our laboratory on normal or screening echocardiograms. Therefore, our control group did not have LV strain measurements included.\u003c/p\u003e \u003cp\u003eLA volumes were measured by biplane area-length method and indexed to BSA.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e Two-dimensional peak longitudinal LA speckle-tracking echocardiographic analyses and emptying fraction were performed by an experienced sonographer or physician (YW, MK), measured offline on TOMTEC software (Munich, Germany). For speckle tracking analysis, we acquired apical four-chamber view images using conventional two-dimensional gray scale echocardiography. The LA endocardial border was traced in the apical four-chamber view, excluding the appendage and pulmonary veins from the LA cavity. The LA tracing for strain was terminated 0.5 cm above the atrioventricular junction, to avoid influence of mitral annular motion (Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u0026amp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Then, LA strain and strain rate curves were generated throughout the cardiac cycle. LA strain was presented as % and strain rate is unitless. To be consistent with previous studies, LV end-diastole at the onset of the QRS complex was defined as the starting point of the atrial cardiac cycle. Accuracy of the automated border tracking was verified and manually adjusted if needed.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e Interobserver variability for LA volume and strain was assessed in 10% of measurements chosen at random and was calculated as the ratio (expressed as a percentage) of the difference between the values obtained by each observer (expressed as an absolute value) divided by the mean of the two values\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. LA volume z-scores were derived from the algorithm provided by Bhatla et al.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003ePulsed-wave Doppler measurements of E and A waves of the mitral valve were obtained in the apical four-chamber view with the cursor positioned at the leaflet tips. Pulsed tissue Doppler was used to measure myocardial velocities at the medial mitral valve annulus in early (e\u0026prime;) diastole. The E/A and E/e\u0026prime; ratios were then calculated as a measure of LV diastolic function.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eAnalyses:\u003c/h2\u003e \u003cp\u003eControls were matched 1:1 on age, sex, and race/ethnicity. For the cases, demographic and anthropomorphic variables, reason for referral, clinical characteristics, and ABPM results for each first HTN clinic visit were reported as median/inter-quartile range or number/percentage where appropriate. LA and LV measurements were compared between cases and controls using Chi-square, McNemar, or Wilcoxon signed rank tests. LA and LV measurements were also compared among hypertensive ABPM subgroups (severe ambulatory, ambulatory, and nocturnal) using Chi-square, Fisher\u0026rsquo;s exact, or Kruskal Wallis tests.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eIn total, 120 subjects were included based on demographics, but due to image quality and availability of data, analysis was performed on 47 cases and 47 matched controls. Among the cases, the median age was 14 years (IQR 12\u0026ndash;17) and the median BMI was 22.7 kg/m\u003csup\u003e2\u003c/sup\u003e (IQR 17.6\u0026ndash;28.3). In addition, 38.3% of cases were African American, 48.9% Caucasian and 10.6% Hispanic.\u003c/p\u003e \u003cp\u003eThere was no difference in BMI, age, sex or race/ethnicity between cases and controls (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Of the cases, 27.3% were referred for a cardiovascular risk factor; the second most common referral diagnosis was kidney transplant (20.4%). In 17.0% of cases there was severe ambulatory HTN and in 68.1%, ambulatory HTN. An additional 10.6% had nocturnal HTN and 4.3% had masked HTN.\u003c/p\u003e \u003cp\u003eComparisons of LA volume z-scores between cases and controls revealed no significant difference between the two groups (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). There was no difference in LA strain (37.8% vs. 38.0%, p\u0026thinsp;=\u0026thinsp;0.735) or strain rate (1.4 vs 1.5, p\u0026thinsp;=\u0026thinsp;0.852) between cases and controls. LA emptying fraction was similar between cases and controls (70.1% vs. 69.9%, p\u0026thinsp;=\u0026thinsp;0.871). There was excellent reproducibility of LA strain and stain rate measurements (interobserver variability\u0026thinsp;\u0026lt;\u0026thinsp;10%).\u003c/p\u003e \u003cp\u003eLVMI measured by M-mode was significantly higher in cases than controls (40.0 g/m\u003csup\u003e2.7\u003c/sup\u003e vs 33.7 g/m\u003csup\u003e2.7\u003c/sup\u003e, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). LVMI measured by 5/6 area-length was also significantly higher in cases than controls (p\u0026thinsp;=\u0026thinsp;0.001). All LV strain measurements were within normal limits for cases compared to published normative data in the pediatric population.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e Diastolic markers were different between cases and controls. E/e\u0026rsquo; was higher in cases than controls (8.2 vs. 7.0, p\u0026thinsp;=\u0026thinsp;0.004), but still within the normal range.\u003c/p\u003e \u003cp\u003eThere was no difference in LA volume and strain among cases when differentiating between different types of HTN; severe ambulatory, ambulatory and nocturnal HTN (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Due to small numbers of cases with masked HTN (N\u0026thinsp;=\u0026thinsp;2) they were not included in this subgroup analysis.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo our knowledge, this is the first case-control study to evaluate LA volume, strain and emptying fraction in a group of pediatric patients with systemic HTN compared to age-, sex- and race/ethnicity matched controls. The diagnosis of HTN was determined by ABPM, the gold standard for diagnosing systemic HTN.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e We found that LA volume, strain and emptying fraction were not significantly different between cases and controls in this pediatric population which included young teenagers; however, other diastolic markers including medial e\u0026rsquo;, E/e\u0026rsquo; and E/A were different compared to controls. LVMI was also significantly higher in the cases compared to controls.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eLA volume, peak longitudinal strain and emptying fraction have been studied extensively in adults and are reliable markers of elevated LV filling pressure and diastolic dysfunction.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e In adult patients with HTN, increased LA volume has been found to be an early marker of elevated LV pressure, prior to development of LV hypertrophy.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e In our study, which focused on a pediatric population, almost all cases had normal LA volumes, despite elevations in LVMI. This is in contrast to a study by Daniels et al., which showed that pediatric patients with systemic HTN had LA enlargement, which appeared worse in patients with LV hypertrophy. \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e However, in that study, only an LA linear measurement was made and LA volumes were not assessed.\u003c/p\u003e \u003cp\u003eWe also found no difference in LA peak longitudinal strain between cases and controls. This lack of difference may be attributed to the fact that we studied a relatively young population, and the duration of HTN was unknown, so it is possible that these patients had a recent onset of HTN and had not yet demonstrated changes in LV diastolic function, which may be a later finding. Our data conflicts with what is seen in adult patients, in whom LA strain predicts outcomes such as arrhythmia, risk of stroke and the odds of success of cardioversion.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e LA strain and strain rate are also decreased in adult patients with advanced heart failure and in those with HTN, even prior to LA enlargment.\u003csup\u003e\u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e In the pediatric population, LA strain has been shown to be abnormal in heart transplantation recipients with elevated filling pressures and in patients with cardiomyopathy and concurrent diastolic dysfunction.\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e,\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e To our knowledge, This is the first study to examine LA peak longitudinal strain in pediatric patients with systemic HTN.\u003c/p\u003e \u003cp\u003eLV mass has been shown to be elevated in pediatric patients with HTN in other studies.\u003csup\u003e\u003cspan additionalcitationids=\"CR36\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e We chose to evaluate LVMI two ways, by M-mode and 5/6 area-length, as it has been shown that the 5/6 area-length method may be a more accurate measure of LVMI.\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e Both methods demonstrated an elevated LVMI in cases compared to controls. Perhaps an elevated LVMI is an initial finding in systemic HTN in pediatric patients and as diastolic dysfunction occurs over the long-term, echocardiographic changes in LA volume and strain are seen more in adults. \u003csup\u003e\u003cspan additionalcitationids=\"CR40\" citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eDiastolic dysfunction has been demonstrated in hypertensive adults and may be related to adverse cardiac events, but little is known regarding diastolic dysfunction in pediatric patients with HTN.\u003csup\u003e\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e In our study, some diastolic parameters were different in patients with HTN compared to controls, but these values were still within the normal limits. Further studies are needed to examine diastolic values in pediatrics, as normal values may be different compared to adults.\u003csup\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e Abnormalities in diastolic markers may aid in risk stratification in those pediatric patients that do not have other findings such as elevated LA volume or abnormal LA strain.\u003c/p\u003e \u003cp\u003eThere are limitations to our study. This is a relatively small sample size from a single center; therefore, our findings may not reflect the general pediatric population with HTN. This was a negative study in regard to LA measurements with no abnormalities in LA size, function or peak longitudinal strain seen. Although our patient population was recruited through our HTN clinic, these patients had a variety of conditions, including kidney dysfunction, endocrine disorders, etc. which may have influenced our findings and the sample size did not allow us to adjust for each specific condition. Lastly, since we only obtained the appropriate echocardiographic views for LV strain during the time of the echocardiogram for cases but not for controls, we could only compare our cases to previously published normal values.\u003c/p\u003e \u003cp\u003eIn summary, LA volume and strain measurements were reproducible, but were not different between pediatric cases with HTN and controls. There was, however, a statistically significant difference in diastolic markers including E/e\u0026rsquo;. Elevated LVMI was also seen in pediatric cases compared to controls, suggesting that the first compensatory response to HTN may be LV hypertrophy and subtle diastolic dysfunction, prior to affecting LA size. We speculate that LA dilation and dysfunction may be later findings as diastolic function worsens. Longitudinal follow up of this pediatric population with HTN will elucidate whether HTN will influence LA volume and strain over time.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinic measurements and patient demographics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eCase (N\u0026thinsp;=\u0026thinsp;47)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eControl (N\u0026thinsp;=\u0026thinsp;47)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIQR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIQR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years), n\u0026thinsp;=\u0026thinsp;47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.0, 17.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12.0, 17.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight, (kg) n\u0026thinsp;=\u0026thinsp;47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.5, 82.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e60.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e45.5, 68.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.453\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeight (cm), n\u0026thinsp;=\u0026thinsp;47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e160.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e139.5, 168.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e163\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e152.0, 172.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.041\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e) n\u0026thinsp;=\u0026thinsp;47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.6, 28.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18.7, 25.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.228\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI percentile, n\u0026thinsp;=\u0026thinsp;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.3, 84.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e94.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e60.0, 99.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.090\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBSA (m\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e), n\u0026thinsp;=\u0026thinsp;47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.2, 2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.4, 1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.527\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003en\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e48.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.884\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e51.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRace/Ethnicity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e46.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlack\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e40.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHispanic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePrimary diagnosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCVRF*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKidney transplant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic kidney disease/dialysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes type II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRenal artery stenosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes type I\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRheumatologic disease \u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMalignancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAmbulatory blood pressure monitoring results\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAmbulatory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere ambulatory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMasked\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNocturnal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eBMI, body mass index; IQR, interquartile range; blood pressure\u003c/p\u003e \u003cp\u003e*CVRF, referral diagnosis for cardiovascular risk factor (includes HTN and/or obesity)\u003c/p\u003e \u003cp\u003e\u0026Dagger; Rheumatologic disease includes systemic lupus erythematous and Takayasu arteritis\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEchocardiographic findings in hypertensive cases compared to matched controls\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eCase\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEchocardiographic findings\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIQR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIQR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLV SF (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e35.0, 41.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e36.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e33.3, 38.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.2461\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLV EF (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e63.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e59.0, 68.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e63.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e59.5, 65.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.9485\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVMI (g/m\u003csup\u003e2.7\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e33.0, 49.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e33.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e28.7, 37.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.0002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVMI\u0026thinsp;\u0026gt;\u0026thinsp;95th\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19/47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5/47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLV MI by 5/6 area-length (g)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e72.9, 133.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e90.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e65.3, 116.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.0155\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLV MI by 5/6 area-length index (g/m\u003csup\u003e2.7\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e24.2, 37.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e24.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e21.0, 29.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.0006\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLV Strain (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-18.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-20.3, -16.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLV strain \u0026lt;-16 (% yes)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32/42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePWT (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.7, 1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.7, 0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.0154\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIVSD (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.8, 1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.7, 0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIVSD z-score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.7, 1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e-1.4, -0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVIDd (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.1, 5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e4.2, 4.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.9519\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVIDs (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.6, 3.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e2.7, 3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.3218\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVIDd z-score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-1.6, 0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e-1.3, -0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.8813\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVIDs z-score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-1.7, 0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e-1.2, -0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.2884\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLA ESV (ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e25.5, 47.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e44.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e31.2, 50.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.1993\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLA EDV (ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6.8, 14.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e12.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e10.2,16.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.1189\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLA volume z-score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-1.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-2.8, -0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e-2.3, -0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.0676\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLA volume biplane (ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e27.0, 49.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e42.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e31.2, 53.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.2715\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLA volume/BSA (ml/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e19.0, 30.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e27.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e21.6, 31.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.1002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLA global strain (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e29.9, 48.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e33.4, 46.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.7352\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLA strain rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.1, 1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1.2, 1.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.8519\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLA EF (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e70.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e66.3, 75.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e69.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e64.9, 73.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.8711\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMitral valve inflow E/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.4, 2.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1.8, 2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.0083\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eE/A\u0026thinsp;\u0026gt;\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21/47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e29/47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.6860\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedial e' (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.1,1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1.0,1.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.0008\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eE/e'\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6.8, 9.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e6.4, 8.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.0347\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eE/e' \u0026gt;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4/47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3/47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eLV, left ventricle; SF, shortening fraction; LV EF, left ventricular ejection fraction; IQR, interquartile range; LVMI, left ventricular mass index; MV, mitral valve; PWT, posterior wall thickness; IVSD, interventricular septum thickness in diastole ; LVIDd, left ventricular internal diameter in diastole; LVIDs, left ventricular internal diameter is systole; LA, left atrium; LA EF, left atrium emptying fraction; ESV, end systolic volume; EDV, end diastolic volume BSA, body surface area\u003c/p\u003e \u003cp\u003e*available data for each variable by matched cases and controls is reported in respective \u0026ldquo;n\u0026rdquo; columns\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEchocardiographic findings based on ambulatory blood pressure monitoring results\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEcho variable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003eAmbulatory blood pressure monitoring results\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSevere ambulatory (N\u0026thinsp;=\u0026thinsp;8)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eambulatory (N\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003enocturnal (N\u0026thinsp;=\u0026thinsp;5)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLA ESV (ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29.7 (24.8, 65.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40.7 (23.3, 47.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34.7 (32.0, 52.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.8453\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLA EDV (ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.1 (7.4, 18.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.7 (6.4, 13.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.1 (8.4, 14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.8391\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLA volume z score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.9 (-2.0, 0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-1.9 (-3.0, -0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-1.9 (-2.5, -1.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.3283\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLA volume z score\u0026thinsp;\u0026gt;\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1/8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1/32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0/5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.4990\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLA volume biplane (ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.9 (23.4, 69.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.4 (26.6, 47.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39.2 (35.5, 49.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.8395\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLA volume/BSA (ml/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28.4 (20.2, 35.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.2 (18.4, 29.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.9 (20.9, 23.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.4540\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLA global strain (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31.8 (29.1, 41.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40.6 (30.3, 48.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35.8 (25.4, 39.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.2859\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLA strain rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.3 (1.2, 1.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.4 (1.1, 1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.4 (1.1, 1.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.6935\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLA EF (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70.4 (64.7, 72.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e69.4 (66.0, 75.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e73.6 (69.3, 73.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.7278\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMitral valve inflow E/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.7 (1.0, 2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.8 (1.4, 2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.6 (1.5, 1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.4610\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eE/A\u0026thinsp;\u0026gt;\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3/8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16/32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1/5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.5120\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedial e' (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.1 (0.9, 1.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.1 (1.0, 1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.3 (1.2, 1.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.1326\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eE/e'\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.2 (7.2, 10.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.5 (7.1, 10.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.4 (4.4, 7.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.1286\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eE/e' \u0026gt;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1/8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3/32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0/5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.0000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eLA, left atrium; ESV, end systolic volume; EDV, end diastolic volume BSA, body surface area; EF, emptying fraction; MV, mitral valve\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eH.G helped with data analysisY.W aided in measurements, imagesL.M-R aided in study design, manuscript writingA.B aided in study design, manuscript writingM, D.Q aided in study design, manuscript writingS, S.N aided in study design, manuscript writingAll authors reviewed the manuscript\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRossi A et al (2002) Determinants and prognostic value of left atrial volume in patients with dilated cardiomyopathy. J Am Coll Cardiol 40:1425\u0026ndash;1430\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGerdts E et al (2002) Correlates of Left Atrial Size in Hypertensive Patients With Left Ventricular Hypertrophy. Hypertension 39:739\u0026ndash;743\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBenjamin EJ, D\u0026rsquo;Agostino RB, Belanger AJ, Wolf PA, Levy D (1995) Left Atrial Size and the Risk of Stroke and Death. Circulation 92:835\u0026ndash;841\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChinali M et al (2005) Left Atrial Systolic Force and Cardiovascular Outcome. The Strong Heart Study. Am J Hypertens 18:1570\u0026ndash;1576\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLeung DY, Boyd A, Ng AA, Chi C, Thomas L (2008) Echocardiographic evaluation of left atrial size and function: Current understanding, pathophysiologic correlates, and prognostic implications. Am Heart J 156:1056\u0026ndash;1064\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHoit BD (2014) Left Atrial Size and Function: Role in Prognosis. J Am Coll Cardiol 63:493\u0026ndash;505\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHawley RR, Dodge HT, Graham TP (1966) Left Atrial Volume and Its Changes in Heart Disease. Circulation 34:989\u0026ndash;996\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDonal E, Behagel A, Feneon D (2015) Value of left atrial strain: a highly promising field of investigation. Eur Heart J - Cardiovasc Imaging 16:356\u0026ndash;357\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGhelani SJ et al (2018) Left Atrial Volumes and Strain in Healthy Children Measured by Three-Dimensional Echocardiography: Normal Values and Maturational Changes. J Am Soc Echocardiogr 31(2):187\u0026ndash;193\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBhatla P et al (2012) Normal values of left atrial volume in pediatric age group using a validated allometric model. Circ Cardiovasc Imaging 5:791\u0026ndash;796\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHope KD et al (2019) Left atrial mechanics in children: insights from new applications of strain imaging. Int J Cardiovasc Imaging 35:57\u0026ndash;65\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKang SJ, Kwon YW, Hwang SJ, Kim HJ, Jin BK, Yon DK (2018) Clinical Utility of Left Atrial Strain in Children in the Acute Phase of Kawasaki Disease. J Am Soc Echocardiogr Mar 31(3):323\u0026ndash;332\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarcovecchio ML et al (2016) Increased left atrial size in obese children and its association with insulin resistance: a pilot study. Eur J Pediatr 175:121\u0026ndash;130\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDaniels SR, Witt SA, Glascock B, Khoury PR, Kimball TR (2002) Left atrial size in children with hypertension: The influence of obesity, blood pressure, and left ventricular mass. J Pediatr 141:186\u0026ndash;190\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaplinski M et al (2020) Clinical Innovation: A Multidisciplinary Program for the Diagnosis and Treatment of Systemic Hypertension in Children and Adolescents. Clin Pediatr (Phila)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFlynn JT et al (2014) Update: Ambulatory Blood Pressure Monitoring in Children and Adolescents: A Scientific Statement From the American Heart Association. \u003cem\u003eHypertension\u003c/em\u003e 63, 1116\u0026ndash;1135\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDevereux RB et al (1986) Echocardiographic assessment of left ventricular hypertrophy: Comparison to necropsy findings. Am J Cardiol 57:450\u0026ndash;458\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLang RM et al (2015) 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 28:1\u0026ndash;39\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhoury PR, Mitsnefes M, Daniels SR, Kimball TR (2009) Age-specific reference intervals for indexed left ventricular mass in children. J Am Soc Echocardiogr 22:709\u0026ndash;714\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMor-Avi V et al (2011) Current and Evolving Echocardiographic Techniques for the Quantitative Evaluation of Cardiac Mechanics: ASE/EAE Consensus Statement on Methodology and Indications. J Am Soc Echocardiogr 24:277\u0026ndash;313\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePopović ZB, Thomas JD (2017) Assessing observer variability: a user\u0026rsquo;s guide. Cardiovasc Diagn Ther 7:317\u0026ndash;324\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNishimura RA, Abel MD, Hatle LK, Tajik AJ (1989) Assessment of Diastolic Function of the Heart: Background and Current Applications of Doppler Echocardiography. Part II. Clinical Studies. \u003cem\u003eMayo Clinic Proceedings\u003c/em\u003e 64, 181\u0026ndash;204\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNagueh SF et al (2016) Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 29:277\u0026ndash;314\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLevy PT et al (2016) Reference Ranges of Left Ventricular Strain Measures by Two-Dimensional Speckle-Tracking Echocardiography in Children: A Systematic Review and Meta-Analysis. J Am Soc Echocardiogr 29:209\u0026ndash;225\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJashari H et al (2015) Normal ranges of left ventricular strain in children: a meta-analysis. Cardiovasc Ultrasound 13:37\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFlynn JT et al (2017) Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaplinski M et al (2021) Left Ventricular Measurements and Strain in Pediatric Patients Evaluated for Systemic Hypertension and the Effect of Adequate Anti-hypertensive Treatment. Pediatr Cardiol\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFrohlich ED, Tarazi RC, Dustan HP (1971) Clinical-Physiological Correlations in the Development of Hypertensive Heart Disease. Circulation 44:446\u0026ndash;455\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDi Salvo G et al (2005) Atrial Myocardial Deformation Properties Predict Maintenance of Sinus Rhythm After External Cardioversion of Recent-Onset Lone Atrial Fibrillation: A Color Doppler Myocardial Imaging and Transthoracic and Transesophageal Echocardiographic Study. Circulation 112:387\u0026ndash;395\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorris DA et al (2015) Normal values and clinical relevance of left atrial myocardial function analysed by speckle-tracking echocardiography: multicentre study. Eur Heart J - Cardiovasc Imaging 16:364\u0026ndash;372\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHennawy B, Kilany E, Galal W, H., Mamdouh A (2018) Role of speckle tracking echocardiography in detecting early left atrial dysfunction in hypertensive patients. Egypt Heart J 70:217\u0026ndash;223\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCameli M (2015) Left atrial strain in patients with arterial hypertension. ICFJ 1:31\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSabatino J et al (2019) Left Atrial Strain to Identify Diastolic Dysfunction in Children with Cardiomyopathies. JCM 8:1243\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLoar RW et al (2020) Left Atrial Strain Correlates with Elevated Filling Pressures in Pediatric Heart Transplantation Recipients. J Am Soc Echocardiogr 33:504\u0026ndash;511\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDaniels SR, Loggie JMH, Khoury P, Kimball TR (1998) Left Ventricular Geometry and Severe Left Ventricular Hypertrophy in Children and Adolescents With Essential Hypertension. Circulation 97:1907\u0026ndash;1911\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHanevold C, Waller J, Daniels S, Portman R, Sorof J (2004) The Effects of Obesity, Gender, and Ethnic Group on Left Ventricular Hypertrophy and Geometry in Hypertensive Children: A Collaborative Study of the International Pediatric Hypertension Association. Pediatrics 113:328\u0026ndash;333\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDaniels SD, Meyer RA, Loggie JM (1990) Determinants of cardiac involvement in children and adolescents with essential hypertension. Circulation 82:1243\u0026ndash;1248\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLopez L et al (2010) Recommendations for Quantification Methods During the Performance of a Pediatric Echocardiogram: A Report From the Pediatric Measurements Writing Group of the American Society of Echocardiography Pediatric and Congenital Heart Disease Council. J Am Soc Echocardiogr 23:465\u0026ndash;495\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMawad W, Friedberg MK (2017) The continuing challenge of evaluating diastolic function by echocardiography in children: developing concepts and newer modalities. Curr Opin Cardiol 32:93\u0026ndash;100\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMatsuda M, Matsuda Y (1996) Mechanism of left a trial enlargement related to ventricular diastolic impairment in hypertension. Clin Cardiol 19:954\u0026ndash;959\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCioffi G, Mureddu GF, Stefenelli C, de Simone G (2004) Relationship between left ventricular geometry and left atrial size and function in patients with systemic hypertension. J Hypertens 22:1589\u0026ndash;1596\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDini FL et al (2018) Prevalence and determinants of left ventricular diastolic dysfunction in obese subjects and the role of left ventricular global longitudinal strain and mass normalized to height. Echocardiography 35:1124\u0026ndash;1131\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"pediatric-cardiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pedc","sideBox":"Learn more about [Pediatric Cardiology](http://link.springer.com/journal/246)","snPcode":"246","submissionUrl":"https://submission.nature.com/new-submission/246/3","title":"Pediatric Cardiology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"left atrial size, left atrial strain, left ventricular mass index, pediatrics, obesity","lastPublishedDoi":"10.21203/rs.3.rs-4743311/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4743311/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIntroduction:\u003c/p\u003e\n\u003cp\u003eLeft atrial (LA) volume and peak longitudinal strain (LA strain) are indicators of left ventricular (LV) diastolic function in adults, but little is known about LA volume and strain in pediatric patients with hypertension (HTN). We evaluated LA volume and strain in pediatric cases with HTN compared to age-, sex- and race/ethnicity-matched controls.\u003c/p\u003e\n\u003cp\u003eMethods:\u003c/p\u003e\n\u003cp\u003eThis was a retrospective matched case-control study of patients that presented to the HTN clinic at CHOP from 12/2011 to 9/2018. Coarctation of the aorta, cardiomyopathy or heart transplantation cases were excluded. HTN was defined by abnormal ambulatory blood pressure result. LA volume was measured by biplane area-length method and indexed to body surface area (BSA). LA strain and strain rate were measured using TOMTEC® software. Left ventricular mass index (LVMI) was measured by M-mode and the 5/6 area-length method indexed to height\u003csup\u003e2.7\u003c/sup\u003e. Measurements were compared using Chi-square, McNemar, or Wilcoxon signed rank tests.\u003c/p\u003e\n\u003cp\u003eResults:\u003c/p\u003e\n\u003cp\u003eWe included 47 cases and 47 controls.\u0026nbsp; There was no difference in LA volume z-scores (-1.9 vs. -0.9, p=0.068), LA strain (37.8% vs. 38.0%, p=0.735) or LA strain rate (1.4 vs. 1.5, p=0.852) in cases compared to controls.\u0026nbsp; LVMI by M-mode and 5/6 area-length method was higher in cases compared to controls (40 vs. 33.7 g/m\u003csup\u003e2.7\u003c/sup\u003e, p\u0026lt;0.001 and 29.9 vs 24.4 g/m\u003csup\u003e2.7\u003c/sup\u003e,\u003csup\u003e \u003c/sup\u003ep=\u0026lt;0.001, respectively).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConclusion:\u003c/p\u003e\n\u003cp\u003eThere was no difference in LA volume or LA strain in cases compared to controls.\u0026nbsp; LVMI was significantly elevated in our cases and may be the first response to HTN, prior to affecting LA size.\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Left atrial size and strain in hypertensive children compared to age-, sex- and race/ethnicity- matched controls","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-16 16:17:39","doi":"10.21203/rs.3.rs-4743311/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-08-27T17:30:50+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-17T12:04:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"187214888138709237261730063204741401968","date":"2024-08-07T00:27:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"239705821967620104831337201187355142223","date":"2024-08-01T21:56:05+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-24T16:27:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"261048171571956772838083773159125865069","date":"2024-07-18T01:19:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"201800343907160548017031041711909270165","date":"2024-07-17T00:20:57+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-16T21:40:22+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-16T05:55:58+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-16T05:55:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"Pediatric Cardiology","date":"2024-07-15T13:43:58+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"pediatric-cardiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pedc","sideBox":"Learn more about [Pediatric Cardiology](http://link.springer.com/journal/246)","snPcode":"246","submissionUrl":"https://submission.nature.com/new-submission/246/3","title":"Pediatric Cardiology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"b1f0d735-ed59-4139-9fe8-0f094f864465","owner":[],"postedDate":"August 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-11-25T16:05:41+00:00","versionOfRecord":{"articleIdentity":"rs-4743311","link":"https://doi.org/10.1007/s00246-024-03719-y","journal":{"identity":"pediatric-cardiology","isVorOnly":false,"title":"Pediatric Cardiology"},"publishedOn":"2024-11-24 15:57:11","publishedOnDateReadable":"November 24th, 2024"},"versionCreatedAt":"2024-08-16 16:17:39","video":"","vorDoi":"10.1007/s00246-024-03719-y","vorDoiUrl":"https://doi.org/10.1007/s00246-024-03719-y","workflowStages":[]},"version":"v1","identity":"rs-4743311","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4743311","identity":"rs-4743311","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}