ABC | Volume 114, Nº1, January 2019

Original Article Almeida et al. Left ventricular remodeling in primary care Arq Bras Cardiol. 2020; 114(1):59-65 30 individuals for participation and 20 for replacement in case of negative response. The selected total population was 1050. Nine hundred forty-two individuals confirmed the presence and 666 individuals attended the scheduled visit. Inclusion criteria were age between 45 and 99 years old and informed consent. Five individuals who did not complete the questionnaire were excluded, 6 did not perform the tissue Doppler echocardiography (TDE), and 20 did not perform the measurement of B-type natriuretic peptide (BNP). At the end of the study, 636 patients completed the necessary requirements: structured questionnaire, physical examination, anthropometric data, BNP, electrocardiogram (ECG) at rest and TDE. Definitions All individuals selected for the study were subjected to an assessment carried out in a single day and consisting of the following elements: clinical evaluation, laboratory tests, including BNP levels, ECG, and TDE. TDE tests were performed according to the recommendations for the quantification of chambers of the American Society of Echocardiography and the European Association of Echocardiography . (LANG, 2015). Indexing was performed by body surface area. The left ventricular mass (LVM) was estimated by Devereux et al. (DEVEREUX, 1986) and relative wall thickness (RWT) by the formula where RWT is equal to twice the diastolic posterior wall divided by the diameter of the LV. RWT values ≥ 0.42 and indexed LV ≥ 115 g/m² for men and ≥ 95 g/m² for women were considered abnormal. The subjects were grouped into four remodeling models: normal geometry, concentric remodeling, concentric hypertrophy, and eccentric hypertrophy, according to the Guidelines of the American Society of Echocardiography. 10 Patients were classified in stages of chronic kidney disease (CKD) according to estimated glomerular filtration rate (eGFR) calculated by KDIGO formula (Kidney Disease: Improving Global Outcomes). Stage 1: eGFR >90 mL/min; stage 2: eGFR 60-89 mL/min; stage 3: eGFR 30-59 mL/min; stage 4: eGFR 15–29 mL/min; and stage 5: eGFR <15 mL/min. Individuals with BMI ≥ 30 kg / m2 were considered obese. Diabetic patients were defined by previous history of diabetes. The study classified as hypertensive individuals those who reported being hypertensive, were on medication to treat hypertension or had a mean systolic blood pressure (SBP) ≥ 140 mmHg or mean diastolic blood pressure (DBP) ≥ 90 mmHg. Statistical analysis Statistical analysis was performed using SPSS v 21.0 (Chicago, Illinois, USA). Continuous variables were expressed as median and interquartile range (50 %(25-75%)). Categorical variables were expressed in absolute numbers and/or percentages. For comparison between groups, the qui‑square test was employed. All continuous variables were tested for normality with the Shapiro-Wilk test with pos-hoc test and for all of them the Ho (null hypothesis) of equality was rejected, that is, none of them had normal distribution. To that extent, the difference between those variables and the phenotypes was tested with the Kruskall-Wallis test. We estimated crude and adjusted odds ratios by logistic regression. In all comparisons, bilateral tests were utilized, and p values < 5%were considered statistically significant. Ethical considerations This study was conducted in accordance with the principles set out in the Declaration of Helsinki revised in 2000 (Scotland, 2000). The study was previously approved by the Universidade Federal Fluminense under n° CAAE: 0077.0.258.000-10 , and informed written consent was provided by all participating patients. Results The study evaluated 636 individuals of 59.5 ± 10.3 years old (62% women, 63% non-whites). The subjects were classified according to the geometry of the LV: normal geometry in 423 (67%); eccentric hypertrophy in 186 (29%); concentric hypertrophy in 14 (2%); and concentric remodeling in 13 (2%). Demographic data of the subjects are listed in Table 1. The variables of age, gender, level of education, high blood pressure, pulse pressure, albumin/creatinine ratio, and the sodium/creatinine ratio in urine were statistically significant between the remodeling patterns. Hypertension and diabetes mellitus were the most prevalent comorbidities in patients with concentric hypertrophy, while coronary artery disease and obesity occurred more frequently in the group with concentric remodeling (Table 1). Table 2 lists the main echocardiographic changes. Table 3 presents the crude and adjusted odds ratio of eccentric hypertrophy versus normal geometry, the only remodeling pattern with sufficient prevalence to achieve adequate power for conducting a multiple analysis. The variables of gender, age, level of education and albumin/ creatinine ratio showed a relationship with the risk of eccentric hypertrophy even after adjustment. Figure 1 shows the distribution of the patterns of left ventricular remodeling in patients without changes in renal function (A); in patients with subclinical changes demonstrated by microalbuminuria (B); and in those with established kidney disease (C). Discussion In the present study, with individuals assisted in primary care aged 45 years or more, themain pattern of ventricular geometric changes was eccentric LVH. The change was more prevalent in women, older patients, patients with lower educational levels, and patients with hypertension and renal dysfunction. The differences observed in this study compared to other studies in Europe and the United States can be explained by reasons similar to those reported in the study by Schvartzman et al. 3 The stature of Brazilians is lower than that of Europeans and North American Caucasians, impacting the LV mass indexed by the body surface. 60