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(Hypertension. 1996;28:47-52.)
© 1996 American Heart Association, Inc.

Articles

Effect of Hypertension on Aortic Root Size and Prevalence of Aortic Regurgitation

Michael Kim; Mary J. Roman; M. Chiara Cavallini; Joseph E. Schwartz; Thomas G. Pickering; Richard B. Devereux

the Division of Cardiology, Department of Medicine, and the Hypertension Center, The New York Hospital-Cornell University Medical Center, New York.

	Abstract

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Although early reports suggested that hypertension predisposed to aortic root enlargement and consequent aortic regurgitation, more recent pathological and M-mode echocardiographic studies have not found an association between hypertension and aortic enlargement when age is considered. These discrepancies may partially reflect methodological shortcomings in the accuracy and reproducibility of aortic and blood pressure measurements. Therefore, we measured two-dimensional echocardiographic diameters of the aortic root at four locations and compared findings with ambulatory and resting blood pressures and measures of body size in 110 normotensive and 110 hypertensive men and women matched for age and sex. Aortic diameters at the anulus (2.41±0.29 versus 2.34±0.24 cm, P=.06) and sinuses (3.47±0.44 versus 3.37±0.36 cm, P=.08) were marginally higher, whereas diameters at the supra-aortic ridge (2.94±0.38 versus 2.81±0.32 cm, P<.01) and ascending aorta (3.26±0.45 versus 3.11±0.32 cm, P<.01) were significantly increased in hypertensive subjects. Aortic diameters increased with increasing quartiles of diastolic and systolic pressures, particularly at the supra-aortic ridge and ascending aorta. In multivariate analyses, blood pressure remained an independent determinant of distal aortic diameters after body size and age were considered. Aortic regurgitation was seen in 5 normotensive and 7 hypertensive subjects and did not differ in severity. Thus, hypertension is associated with a slight increase in aortic root size, most notably of the supra-aortic ridge and proximal ascending aorta. Although dilatation at the commissural attachment might be expected to predispose to an increase in aortic regurgitation, we did not detect such a difference in this population of healthy, asymptomatic individuals.

Key Words: aorta • aortic regurgitation • hypertension, arterial

	Introduction

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Dilatation of the aortic root is a major pathophysiological mechanism for aortic regurgitation in a variety of disorders, including the Marfan syndrome,¹ bicuspid aortic valve,² and a substantial percentage of patients with severe, pure aortic regurgitation in whom no valvular abnormality is apparent.³ The usual underlying histopathologic changes in aortic tissue associated with aortic dilatation are summarized as "cystic medial necrosis" and, although qualitatively similar, are variable in severity.^{4 5 6}

Although early case reports and pathological series suggest that hypertension might directly predispose to aortic regurgitation because of enlargement of the aortic root,^{7 8 9 10 11 12 13 14} more recent pathological^{6 15} and M-mode echocardiographic^{3 16 17} studies have not found an association between blood pressure and aortic root size when the confounding influence of aging is considered. Thus, aortic root diameter is strongly related to age,^{3 17 18 19 20 21 22 23 24} and senescence may result in cystic medial necrosis.^{4 5 6 15} In contrast, other M-mode echocardiographic studies have noted significant relations of aortic root diameter to systolic¹⁸ and diastolic^{19 25} pressures. Furthermore, severe aortic regurgitation due to idiopathic aortic root dilatation is associated with antecedent hypertension.³

Discrepancies in the existing literature regarding the effect of hypertension on aortic root enlargement may partially reflect methodological shortcomings in the accuracy and reproducibility of aortic and blood pressure measurements. Although M-mode echocardiography is reliable in assessing aortic root diameter,^{26 27} it results in systematic underestimation of aortic diameter at the sinuses of Valsalva due to cyclic cardiac translational changes¹⁷ and does not permit extensive assessment of the entire aortic root, including the supra-aortic ridge, which serves as the site of commissural insertion. Commissural support is of critical importance in the maintenance of normal geometry and hence leaflet coaptation.²⁸ In addition, clinical estimates of blood pressure may be less accurate in reflecting vascular load and thereby target-organ damage than are ambulatory blood pressure determinations.^{29 30} Hence, we designed the present study to assess the effect of blood pressure on aortic size by examining comprehensive two-dimensional echocardiographic measurements of aortic root diameters in age- and sex-matched normotensive and hypertensive subjects in comparison with age, body size, and both clinic and ambulatory blood pressure measurements.

	Methods

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Subjects
The study population was drawn from 368 (207 normotensive and 161 essential hypertensive [blood pressure 140/90 mm Hg]) adult volunteers studied between 1990 and 1994. The subjects were members of either a healthy, employed normotensive and hypertensive population enrolled by defined recruitment schemes into an ongoing longitudinal study or a pool of untreated hypertensive subjects referred from the Hypertension Center at The New York Hospital-Cornell Medical Center.^{30 31} Detailed descriptions of the subject pool have been previously reported.³¹ All examinations were performed at The New York Hospital-Cornell Medical Center under protocols approved by the Committee on Human Rights in Research of Cornell University Medical Center.

Groups of 110 hypertensive patients (74 men and 36 women) and 110 normotensive subjects with adequate echocardiograms, in which the entire aortic root including the ascending aorta could be sufficiently visualized for reliable measurement, were matched for sex and age±2 years.

Echocardiography
All subjects underwent two-dimensional and Doppler echocardiography performed by an experienced research echocardiographer using commercially available echocardiographs equipped with 2.5- and 3.5-MHz transducers. The dimensions of the aortic root and ascending aorta were evaluated in detail by two-dimensional echocardiography. With a commercially available digitizing tablet and videocassette recorder with forward and reverse frame-by-frame review capacity, measurements at end diastole were made by the leading edge technique in the parasternal long-axis view at four locations¹⁷ : (1) aortic anulus, (2) maximal diameter of the sinuses of Valsalva, (3) supra-aortic ridge (sinotubular junction), and (4) maximal diameter of the proximal ascending aorta (Fig 1). Measurements were taken on up to four separate cycles and averaged. Pulsed and color Doppler examinations were performed for determination of the presence and severity of aortic regurgitation.^{32 33}

View larger version (23K): [in this window] [in a new window]   Figure 1. Diagram of the aortic root in the two-dimensional parasternal long-axis view. Measurements were obtained at the level of the aortic anulus (1), sinuses of Valsalva (2), supra-aortic ridge (3), and proximal ascending aorta (4). LV indicates left ventricle; LA, left atrium; and AO, aorta.

Blood Pressure Measurement
Supine casual brachial blood pressure was determined after the echocardiographic study by the research technician using a standard mercury sphygmomanometer. Forty-eight subject pairs additionally underwent 24-hour ambulatory blood pressure monitoring during a normal day using a SpaceLabs 90207 monitor. The monitor was placed on the nondominant arm and set to take blood pressure readings every 15 minutes during waking hours. Detailed descriptions of this procedure and its validation have been reported previously.³⁴

Data Analysis and Statistical Methods
Data were stored and analyzed by the Crunch 4 Statistical Package (Crunch Software Corp). Mean values are presented with SD as the index of dispersion. Differences between mean values of the two groups were tested with Student's t test. The strength of the relationship of each aortic root measurement with body size and blood pressure variables was evaluated by the Pearson correlation coefficient. Independence of association was tested in multivariate analyses. Significance of differences between blood pressure quartiles was evaluated by ANOVA. Significance of differences in populations was evaluated with the ² test. A value of P<.05 was considered statistically significant.

	Results

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Comparison of Age, Body Size, and Blood Pressure
Mean age (55±12 years) and age range (25 to 88 years old) were identical in the two groups, as might be expected from the matching. Although height (1.71±0.10 m in both groups) and body surface area (1.91±0.22 versus 1.88±0.22 m², P=NS) were similar in the two groups, the average weight of the hypertensive subjects was 3 kg more than that of normotensive subjects (79.3±15.5 versus 76.3±15.8 kg, P=NS), and body mass index, a measure of obesity, was slightly higher in the hypertensive group (27.1±3.9 versus 25.9±4.2 kg/m², P<.05). By definition, all blood pressure measurements were significantly increased in the hypertensive group (casual systolic, 157±19 versus 124±12 mm Hg; casual diastolic, 94±11 versus 74±8; ambulatory awake systolic, 146±17 versus 129±10; and ambulatory awake diastolic, 90±12 versus 81±9). Heart rate was slightly increased in the hypertensive group (70±13 versus 66±10 beats per minute, P<.05).

Comparison of Aortic Dimensions
Table 1 shows unadjusted and adjusted aortic root dimensions in the study subjects. Aortic root diameters at the anulus and sinuses of Valsalva tended to be higher in the hypertensive group, but the differences did not achieve statistical significance. Diameters at the supra-aortic ridge and proximal ascending aorta were significantly increased in the hypertensive subjects (P<.01 for both comparisons). Similar results were obtained when the diameters were indexed by height, whereas indexing by body surface area eliminated statistical significance of the differences.

View this table: [in this window] [in a new window]   Table 1. Comparison of Unadjusted and Adjusted Aortic Root Dimensions in Matched Normotensive and Hypertensive Subjects

When the entire population was divided by sex (148 men and 72 women), diameters remained significantly larger for hypertensive than normotensive men at the supra-aortic ridge and proximal ascending aorta (P<.005 for both comparisons); diameters tended to be higher for hypertensive women at all levels but did not achieve statistical significance as a consequence of the smaller sample size.

Relation of Aortic Root Dimensions to Age, Body Size, and Hemodynamic Variables
As demonstrated in Table 2, age did not bear a significant univariate relation to aortic diameter in this age-matched population. Aortic root diameters at all levels were significantly related to height, weight, and body surface area. Aortic diameters at all levels were also significantly related to casual systolic and diastolic pressures when the entire population was considered. Use of ambulatory blood pressures eliminated the statistical significance of relations at the anulus and sinuses of Valsalva (primarily as a consequence of smaller sample size because correlation coefficients were not substantially different), whereas ambulatory blood pressure remained strongly related to aortic diameter at the supra-aortic ridge and ascending aorta. As indicated in Table 3, among normotensive subjects, aortic diameters were more strongly related to casual systolic pressure than to ambulatory pressure, whereas among hypertensive subjects, aortic diameters were most strongly related to ambulatory diastolic pressure, particularly in the more distal segments of the aortic root.

View this table: [in this window] [in a new window]   Table 2. Relation of Aortic Dimensions to Age, Body Habitus, and Blood Pressure: Univariate Analyses

View this table: [in this window] [in a new window]   Table 3. Relation of Aortic Dimensions to Blood Pressure in Normotensive and Hypertensive Adults: Univariate Analyses

In multiple regression analysis (Table 4) involving the entire study population with height (the anthropometric variable resulting in the best model), age, and casual systolic pressure entered as variables, height was the strongest predictor of aortic diameter at all levels (P<.00005 for all). Age was also an independent determinant of all aortic diameters. Systolic pressure also entered the model for each diameter except at the sinuses of Valsalva.

View this table: [in this window] [in a new window]   Table 4. Relation of Aortic Root Dimensions to Age, Body Habitus, and Blood Pressure: Multivariate Analyses

Comparison of Aortic Measurements by Severity of Pressure Load
Fig 2 shows aortic root diameters compared by quartiles of hemodynamic load. When the combined normotensive and hypertensive study population was divided into quartiles of casual systolic pressure (first quartile, <122 mm Hg; second quartile, 122 and <140; third quartile, 140 and <157; fourth quartile, 157), progressive enlargement was found only at the supra-aortic ridge (P<.005) and ascending aorta (P<.05). When the entire study population was divided into quartiles of casual diastolic pressure (first quartile, <78 mm Hg; second quartile, 78 and <84; third quartile, 84 and <92; and fourth quartile, 92), all aortic diameters were found to significantly increase with increasing blood pressure, with the most significant increases occurring in the more distal segments.

View larger version (144K): [in this window] [in a new window]   Figure 2. Aortic root diameters in the entire population compared by quartiles of hemodynamic load. Top, Aortic root dimensions in relation to quartiles of systolic pressure; bottom, in relation to diastolic pressure.

Aortic Regurgitation
Aortic regurgitation of any severity was found in 4.5% of the normotensive subjects and 6.4% of the hypertensive subjects. Aortic regurgitation was mild in two and moderate in three normotensive subjects, and mild in three and moderate in four hypertensive subjects.

	Discussion

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In the present study, we detected a small but significant enlargement of the aortic root when comparing age- and sex-matched populations of hypertensive and normotensive subjects of a similar body size. Differences were found most consistently in the distal segments of the aortic root (the supra-aortic ridge and ascending aorta). The effect of blood pressure was most evident when the severity of blood pressure was taken into account by comparing groups divided by quartiles of blood pressure (most notably, diastolic). Interestingly, ambulatory blood pressure measurements were less strongly correlated to aortic diameters than casual blood pressure in the normotensive group, whereas ambulatory blood pressure was more correlated to aortic size in the hypertensive group. Although it is unclear whether this difference is of physiological significance, the finding may suggest greater blood pressure reactivity in the hypertensive cohort, rendering the ambulatory blood pressure more representative than a casual, albeit standardized, blood pressure determination. Although the greatest differences in aortic root diameter were found in the distal segments, including the level of commissural support to the aortic valve, the prevalence of aortic regurgitation was low in our population and did not significantly differ between the normotensive and hypertensive groups.

Previous studies evaluating the relation of aortic root size to blood pressure have yielded conflicting results. Recently, Vasan et al,¹⁹ using two-dimensionally guided M-mode measurement of the sinuses of Valsalva in the Framingham Heart Study, found that diastolic pressure was directly related to aortic diameter, whereas both systolic and pulse pressures were inversely related to aortic diameter after adjustment for age, height, and weight. In an earlier study³ involving 102 patients with severe aortic regurgitation, we found similar mean M-mode aortic diameters in normotensive and hypertensive groups. Age (P<.0005) and diastolic pressure (P<.05) were multivariate correlates of aortic diameter in the normotensive group, whereas only age (P<.005) predicted aortic diameter in the hypertensive group. Tell et al²⁵ in the Cardiovascular Health Study found a relation between diastolic but not systolic pressure and M-mode echocardiographic dimensions when the entire elderly cohort was analyzed; however, when the "healthier" subgroup (no coronary heart disease or antihypertensive therapy) was examined, aortic diameter was not associated with blood pressure. Other researchers have shown either no relation of blood pressure to M-mode aortic measurements or relationships only to systolic pressure.¹⁸

In the present study, using a more thorough and accurate measurement of the entire aortic root, we found significant differences between normotensive and hypertensive subjects in aortic root diameter, primarily at the supra-aortic ridge and proximal ascending aorta. Failure to find a statistically significant difference at the sinuses of Valsalva and aortic anulus (the areas usually measured by M-mode echocardiography) may explain the relatively weak and inconsistent relations of blood pressure to aortic root diameter in previous studies and may reconcile discrepant findings in earlier pathological studies of hypertensive patients succumbing to aortic regurgitation in which higher segments of the aorta may have been examined.^{9 10 11}

Although use of ambulatory blood pressure monitoring to eliminate individuals with white coat hypertension and to theoretically provide a more accurate measurement of blood pressure load might be predicted to strengthen any relation of blood pressure to aortic size, such an effect was noted only in the hypertensive group in the present study. Optimal measurement of pressure load might have been achieved by noninvasive estimation of central arterial pressure and vascular compliance³⁵ or by quantitative analysis of the arterial pressure waveform.³⁶ Despite similar mean pressures, systolic and diastolic pressures may vary considerably³⁷ with the degree of wave amplification, being maximal in the young, normotensive individual with a compliant vasculature.³⁸ To the extent that brachial blood pressure may overestimate central pressure in our normotensive population, the correlation between arterial pressure and aortic diameter may have been understated.

When aortic root diameter increases, aortic valve cusps are unable to expand in area, and the degree of cusp overlap is reduced, eventually leading to aortic regurgitation.^{12 39 40} Since the point of commissural attachment is at the supra-aortic ridge, increases in this diameter are more likely to be of greater pathophysiological significance.²⁸ Thus, dilatation in the more distal segment of the aortic root has been shown to be associated with more-severe left ventricular structural and functional abnormalities in patients with severe aortic regurgitation due to idiopathic root dilatation in comparison with patients with severe aortic regurgitation due to valvular disease³ and to be associated with an increased likelihood of aortic complications in the Marfan syndrome.¹ Therefore, the greatest hemodynamic effects of root dilatation appear to be when it occurs at the distal portions of the aortic root. Although hypertension was associated with larger measurements in the distal aortic root in the present study, there was no significant difference in the prevalence of aortic regurgitation between the normotensive and hypertensive subjects, perhaps because of their relatively young age, mild degree of hypertension, and otherwise healthy status. In fact, in a previous analysis limited to individuals with severe aortic regurgitation, antecedent hypertension was strongly associated with the presence of idiopathic aortic root dilatation as the cause of aortic regurgitation.³

Relationships of body size to aortic size have been uniformly noted in previous populations^{17 19 41} and were confirmed in the present study. Indexation of the aortic diameters for body surface area eliminated differences in aortic size between normotensive and hypertensive subjects, whereas indexation for height marginally amplified differences. Previous authors have suggested that the use of body surface area as a means of adjustment for differences in body size is mathematically incorrect and that indexation of aortic diameter for height is a more linear and mathematically sound way of comparing measurements.⁴¹

In conclusion, aortic root diameters at the supra-aortic ridge and proximal ascending aorta are significantly greater in hypertensive patients compared with an age- and sex-matched normotensive population. These findings may be of pathophysiological importance in the development of aortic regurgitation in hypertensive individuals.

	Acknowledgments

 
This study was supported in part by grants HL-18323 and HL-47540 from the National Heart, Lung, and Blood Institute, Bethesda, Md.

	Footnotes

 
Reprint requests to Mary J. Roman, MD, Division of Cardiology, The New York Hospital-Cornell University Medical Center, 525 E 68th St, New York, NY 10021. E-mail mroman@mail.med.cornell.edu.

Received January 15, 1996; first decision February 29, 1996;

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				V. Palmieri, G. de Simone, M. J. Roman, J. E. Schwartz, T. G. Pickering, and R. B. Devereux Ambulatory Blood Pressure and M;etabolic Abnormalities in Hypertensive Subjects With Inappropriately High Left Ventricular Mass Hypertension, November 1, 1999; 34(5): 1032 - 1040. [Abstract] [Full Text] [PDF]

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