Correlation of Left Ventricular Mass Index and Left Ventricular Diastolic Functions

Using Echocardiography in Patients with Hypertension

Running Head: Left Ventricular Mass Index and Left Ventricular Diastolic Function Using

Echocardiography

Fitri Rahmah1, Budi Susetyo Pikir1

1. Department of Cardiology and Vascular Medicine, Faculty of Medicine Universitas

Airlangga-Dr. Soetomo Teaching Hospital, Surabaya 60285

Corresponding Author : Budi Susetyo Pikir

Department of Cardiology and Vascular Medicine, Faculty of Medicine-Dr. Soetomo

Teaching Hopsital-Universitas Airlangga. Jalan Mayjen Prof. Dr. Moestopo 47, Surabaya.

Phone: (031) 5501604 / +6281232214354

Email: bspikir@gmail.com

Abstract

Background: Left ventricular hypertrophy might occur in patients with hypertension.

Diastolic dysfunction is the first manifestation occurs in patients with hypertension

Objective: To analyze the correlation between left ventricular mass index (LVMI) and

diastolic functions using echocardiography.

Methods: This study was conducted in 61 subjects that consisted of 38 female and 23 male

patients with hypertension who met the inclusion criteria. Echocardiography was then

conducted as well as the examination for left ventricular mass index and left ventricular

diastolic functions (ratio of E/A, E/e’ and E/Vp). The obtained data were entered and

processed using SPSS version 17.0 statistic software for Windows. The results were

presented in tables or graphics.

Results: We found that the mean of LVMI was 75.41±12.74 g/m2. The mean of E/A, E/e’

and E/Vp ratios were 1.07±0.39, 8.85±1.96 and 1.54±0.45 respectively. No correlation was

found between LVMI and diastolic functions (LVMI versus E/A ratio, r=0.074, p=0.537;

LVMI versus E/e’ ratio, r=0.181, p=0.162; LVMI versus E/Vp, r=0.038, p=0,769).

Discussion: The mean of systolic blood pressure and diastolic blood pressure of this study’s

respondents were 132.05±13.74 mmHg and 79.92±9.94 mmHg. The systolic and diastolic

blood pressures were within the target of blood pressure decrease in hypertension patients,

i.e. 140/90 mmHg. This might affect left ventricular diastolic function as shown by the results

of this study.

Conclusion: No correlation was found between LVMI and diastolic functions in this study.

Anti-hypertension therapy and controlled blood pressure could affect diastolic functions.

Keywords: hypertension, left ventricular mass index, diastolic functions, echocardiography.

Introduction

Hypertension is one of the most common diseases in daily practices. Hypertension is the risk

factor of cardiovascular whose prevalence keeps increasing. The number of hypertension

patients in around the world has reached 1 billion and approximately 7.1 million people die

from hypertension per year. Morbidity and vascular mortality increase along with the

increase of systolic and diastolic blood pressure (1, 2). The data from Basic Health Research

(Riskesdas) in 2007 reported that hypertension prevalence in patients aged of above 15 in

Indonesia is 29.8%. The provinces with higher prevalence rates than national rates are Riau,

Bangka Belitung, Central Java, Yogyakarta, East Java, Nusa Tenggara Barat, Central

Kalimantan, South Kalimantan, Central Sulawesi and West Sulawesi (3).

Uncontrolled hypertension is considered the most important cause of left ventricular

hypertrophy and this can be modified. Various studies showed that left ventricular

hypertrophy (LVH) is the most important risk factor for cardiovascular occurrence,

particulary myocardial infarct and heart failure (4).

Left ventricular development into heart failure in hypertension includes the

mechanism of abnormality occurrence in the structure (particularly myocardium fibrosis) and

geometrical changes in left ventricular, i.e. left ventricular concentric remodeling and LVH

with high ration of left ventricular mass/volume. This is one of prognostic indicators. The

abnormality is described as left ventricular diastolic dysfunction. The dysfunction diastolic

includes changes in relaxation or the filling prior to changes in left ventricular systolic

functions (5).

Left ventricular diastolic dysfunction is heart disease manifestation that is firstly

found in hypertension patients. The prevalence of left ventricular diastolic dysfunction in

hypertension is estimated to be 46-68% in Caucasian populations. This rate increased within

the last 15 years, while the mortality rate due to this abnormality remained unchanged (5, 6).

Echocardiography examination can detect left ventricular diastolic dysfunction.

Pulsed Doppler transmitral echocardiography can detect the abnormality in left ventricular

filling (diastolic) in patients with hypertension even before any abnormality occurs either

clinically or in electrocardiogram. A comprehensive diastolic function examination does not

only include simple classification of diastolic dysfunction (DD), but also by estimating the

pressure of left ventricular filling which is the determiner of symptoms and heart failure

prognosis with normal fraction injection. One of the methods to carry this out is by assessing

E/e’ ratio that is considered easy to apply and is accurate. The more accurate left ventricular

diastolic functions assessment enables earlier and more accurate management for left

ventricular diastolic dysfunction in hypertension patients (5), Based on what has been

discussed above, the author is interested in analyzing the correlation between left vertical

mass index and left ventricular diastolic functions in patients with hypertention.

Methods

The subjects in this study were 61 patients with hypertension treated in cardiology outpatient

unit. Echocardiography examination was conducted in ecochardiography room of Cardiology

Department Dr. Soetomo General Hospital Surabaya during October-December 2012. The

sample was taken using simple random sampling technique in which the inclusion criteria

were male or female patients aged of 30-65 who were willing to be involved in research

procedure as confirmed by their signing informed consent. The exclusion criteria were

hypertension patients with severe arrhythmia, coronary heart disease, severe valve

abnormality, congenital heart defect, severe lung abnormality, chronic kidney disease,

diabetes mellitus and obesity.

This was an observational analytic study with cross-sectional approach. This study’s

procedure was approved by Ethics Committee of Dr. Soetomo Teaching Hospital Surabaya,

Indonesia. Statistical analysis in this study was performed using Pearson or Spearman

correlation test, depending on the data distribution, to determine the correlation between two

diameters. Kolgomorov-Smirnov test was used to test data distribution normality. Intra-

observer and inter-observer variability was evaluated using correlation test, Bland Altmant

test and variability percentage. The data of the analysis results were presented in figures. All

data analysis were processed using the SPSS computer program version 20 (SPSS, Inc.,

Chicago, IL)

Results

Respondents’ characteristics

The number of samples in this study was 38 female patients (62.3%) and 23 male patients

(37.7%) with ages ranged between 40-65 years old and the mean age of 56.36±6.62 years old.

The duration of hypertension in the respondents was between 2-15 years with the mean of

5.77±3.33 years. The mean of normal systolic blood pressure was 132.05±13.74 mmHg and

the mean of normal diastolic blood pressure was 79.92±9.94 mmHg. The mean of body mass

index was 24.19±3.47 kg/m2 (Table 1).

Respondents’ echocardiography basic characteristics

Left ventricular systolic functions using Teich method in echocardiography examination

results showed good ejection fraction with the mean of 68.59%±5.04% No left ventricular

hypertrophy was found in left ventricular mass index with the mean of 75.41±12.74 g/m2 and

RWT mean of 0.36±0.57 (Table 2).

Respondents’ left ventricular diastolic function characteristics

The mean of diastolic function based on E/A, E/e’ and E/Vp were 1.07±0.39, 8.85±1.96 and

1.54±0.45 respectively. If the score of the respondents’ left ventricular diastolic functions

was classified into normal diastolic function and diastolic dysfunction, the result obtained

was there were 31 respondents (50.8%) with diastolic dysfunction and 30 respondents

(49.2%) with normal diastolic functions (Table 3).

Correlation between left ventricular mass index and left ventricular diastolic functions

Kolgomorov-Smirnov test was used since the number of samples was >50. The analysis

results showed that the sample group was not normally distributed (p>0.05) and thus

Spearman correlation test was performed. The test result showed no significant correlation

between the score of E/A, E/e’ and E/Vp ratios and LVMI (Table 4 and 5).

Intra-observer and inter-observer variability

Bland Altman method was used to evaluate intra-observer and inter-observer variability for

LVMI, E/A, E/e’ and E/Vp. In 15 patients as the samples, a quite good agreement was

obtained with most of them having significant correlation between intra-observer and inter-

observer and intra-observer as well as inter-observer variability of <5 (Table 6).

Discussion

Hypertension is the risk factor that most frequently causes heart failure. In hypertension, left

ventricular would turn into heart failure which involved heart structure abnormalities

(particularly fibrosis and myocardium) and geometrical changes of left ventricular in the form

of left ventricular concentric remodeling and left ventricular hypertrophy. Those changes

occurred along with the impairment in left ventricular which was commonly known as left

ventricular dysfunction. The diastolic dysfunction included changes in relaxation phases and

left ventricular filling prior to changes in left ventricular systolic functions and it caused the

symptoms of heart failure although the fraction ejection was still normal. Left ventricular

hypertrophy occurred as pathological responses toward hypertension which caused diastolic

dysfunction and coronary flow reserve decrease (5, 7).

Old age and the gender female correlated with stiffness increase of ventricular systolic

and diastolic as well as blood vessel even though no cardiovascular disease occurred.

Hypertension and aging had significant contribution in heart morphology and bad output (8).

In epidemiology study and clinical test, heart failure patients with normal fraction ejection

tended to be older, female, having higher body mass index and mostly suffered from

hypertension and atrial fibrillation (9).

2D-echocardiography was a highly beneficial tool for evaluating heart structure and

function. Epidemiological data in Framingham study defined left ventricular hypertrophy in

echocardiography examination as the left ventricular mass in its correlation with the total

width of body surface >131 g/m2 for male and >100 g/m2 for female. Meanwhile, according

to European Society of Hypertension, for the index score of left ventricular mass the

threshold value was 125 g/m2 for male and 110 g/m2 for female. There were various

measurement methods for left ventricular mass. Left ventricular mass index measurement

with two-dimensional guided M-mode using ASE criteria and modified Deveraux formula

would give the estimation of left ventricular mass with higher accuracy level (10).

This study involved 61 respondents, 38 (62.3%) were female and 23 (37.7%) were

male. The mean of the respondents’ age was 56.36±6.62 years old and the mean of

hypertension duration was 5.77±3.33 years old. Echocardiography examination results

showed that left ventricular mass index was good in all respondents, either female or male.

Based on E/A, E/e’ and E/Vp ratios, it was obtained that 31 respondents had left ventricular

diastolic dysfunction and the other 30 had normal left ventricular diastolic functions.

In this study, coronary heart disease was the exclusion criteria and therefore left

ventricular diastolic function changes with normal left ventricular mass index occurred as the

consequence of hypertension. Obesitas also became the exclusion factor due to its

independent correlation with left ventricular hypertrophy, particularly in populations with

hypertension and other metabolic risk factors (11-13).

It was found that left ventricular diastolic function impairment occurred despite the

left ventricular mass index being normal. This was in accordance with the previous studies

reporting that left ventricular diastolic function impairment might occur in hypertension

patients despite the absence of changes in left ventricular mass. The respondents’

characteristics in which the number of female subjects was higher than male ones also

possibly affected the left ventricular diastolic function impairment. Respondents’ ages could

also be considered as one of the factors correlated with left ventricular diastolic function.

No significant correlation was found between left ventricular mass index and the

observed parameters of diastolic functions, i.e. E/A, E/e’ and E/Vp ratio values. This might

because the patients in this study had been given anti-hypertension medications although the

mean of the respondents’ hypertension duration was more than two years. The mean of

systolic blood pressure and diastolic blood pressure of this study’s respondents were

132.05±13.74 mmHg and 79.92±9.94 mmHg respectively. The systolic and diastolic blood

pressures were within the target of blood pressure decrease in patients with hypertension, i.e.

blood pressure of less than 140/90 mmHg. This might also affect left ventricular diastolic

function in this study. In VALIDD study, it was found that the control of blood pressure

using valsartan or other medications that did not affect rennin system was the key

determinant in diastolic function repair (9). Other studies found that good blood pressure

control (with candesartan of 16 mg or bendroflumethiazide of 2.5 mg) resulted in left

ventricular systolic function repair with the increase of e’ velocity in just three months.

Losartan Intervention for Endpoint study reported (14-17).

We also found normal left ventricular mass index score, i.e. 75.41±12.74 g/m2. Left

ventricular hypertrophy occurred if the left ventricular index mass was 12.5 g/m2 for male

and 110 g/m2 for female (2, 18). The previous study reported that both left ventricular

hypertrophy and left ventricular concentric remodeling had prognosis score in heart failure

occurrence and were correlated with diastolic function (19-21). Left ventricular hypertrophy

due to hypertension could also be reversible in which if long-term blood pressure decrease

occurred it then would correlated with left ventricular mass decrease (22). In addition to

controlling blood pressure, limitation in sodium intake and independent body mass decrease

could also facilitate left ventricular hypertrophy regression (23, 24).

The result of intra-observer and inter-observer variability examination results showed

a good agreement with p of <0.05. The measurement of left ventricular mass index using

ASE criteria showed a bit better reproducibility level than when using Penn-convention. M-

mode intra-observer measurement might vary up to 5% in various echocardiography study,

while the inter-observer variability could reach 15% (21). Diastolic function evaluation with

echocardiography using transmitral inflow, tissue Doppler imaging or velocity propagation

was quite easy to conduct. The use of transmitral inflow with Valsava maneuver showed a

quite feasibility score, i.e. 60% and therefore was not applied in this study (5). Doppler

echocardiography evaluation of diastolic functions could give various results in one same

individual, and it might be different each day along with the changes in preload, afterload and

tonus simpatic (25, 26).

Conclusion

The ages of the respondents ranged between 40-65 years old. The number of female

respondents was higher than the female ones. The mean of hypertension duration was

5.77±3.33 years. In hypertension patients, the left ventricular mass index was still within the

normal range, both in male and female respondents. It is also obtained that the mean of left

ventricular diastolic functions with the ratios E/A, E/e’ and E/Vp were 1.07±0.39, 8.85±1.96

and 1.54±0.45 consecutively. No significant correlation was found between left ventricular

mass index and the score of E/A. E/e’ and E/Vp ratio scores.

References

1. WHO. International Society if Hypertension (ISH) statement on Management of Hypertension. Journal of hypertension. 2003;21:1983-92.

2. Balitbangkes S. urvey Kesehatan Rumah Tangga 1995 (SKRT 1995). Jakarta: Departemen Kesehatan RI, 1995.

3. Rahajeng E, Tuminah S. Prevalensi hipertensi dan determinannya di Indonesia. Majalah Kedokteran Indonesia 2009;59:580-7.

4. Rosendroff C, Go O, Schmeidler J, Silverman JM, Beeri MS. Correlation of arterial blood pressure and compliance with left ventricular structure and function in the very elderly. Journal of the American Society of Hypertension : JASH. 2012;6(1):48-55.

5. Galderisi M. Diagnosis and management of left ventricular diastolic dysfunction in the hypertensive patient. American journal of hypertension. 2011;24(5):507-17.

6. Ike SO, Ikeh VO. The prevalence of diastolic dysfunction in adult hypertensive Nigerians. Ghana Medical Journal. 2006;40(2):55-60.

7. Campbell NR, Poirier L, Tremblay G, Lindsay P, Reid D, Tobe SW, et al. Canadian Hypertension Education Program: the science supporting New 2011 CHEP recommendations with an emphasis on health advocacy and knowledge translation. The Canadian journal of cardiology. 2011;27(4):407-14.

8. Verma A, Solomon SD. Diastolic Dysfunction as a link Between Hypertension and Heart Failure. Med Clin N Am. 2009;93:647-64.

9. Redfiled SJ, Jacobsen, Borluag BA, al. e. Age- and gender relatedventricular-vascular stiffening: a community-based study. Circulation. 2005;112:2254-62.

10. Lip GYH, Felmeden AC, lee jhFL, Beevers DG. Hypertensive heart disease, a complex syndrome or hypertensive cardiomyopathy. European heart journal. 2000;21(20):1653-65.

11. Kuch B, Hense HW, Gneiting B, Doring A, Muscholl M, Brockel U, et al. Body composition and prevalence of left ventricular hypertrophy. Circulation. 2000;102(4):405-10.

12. Kuperstein R, Hanly P, Niroumand M, Sasson Z. The importance of age and obesity on the relation between diabetes and left ventricular mass. J Am Coll Cardiol. 2001;37(7):1957-62.

13. de Simone G, Kitzman DW, Palmieri V, Liu JE, Oberman A, Hopkins PN, et al. Association of inappropriate left ventricular mass with systolic and diastolic dysfunction: the HyperGEN study. American journal of hypertension. 2004;17(9):828-33.

14. Almuntaser I, Mahmud A, Brown A, Murphy R, King G, Crean P, et al. Blood pressure control determines improvement in diastolic dysfunction in early hypertension. American journal of hypertension. 2009;22(11):1227-31.

15. Owan TE, Hodge DO, Herges RM, Jacobsen SJ, Roger VL, Redfield MM. Trends in prevalence and outcome of heart failure with preserved ejection fraction. N Engl J Med. 2006;355(3):251-9.

16. Katholi RE, Couri DM. Left ventricular hypertrophy: major risk factor in patients with hypertension: update and practical clinical applications. International journal of hypertension. 2011;2011:495349.

17. Solomon SD, Janardhanan R, Verma A, Bourgoun M, Daley WL, Purkayastha D, et al. Effect of angiotensin receptor blockade and antihypertensive drugs on diastolic function in patients with hypertension and diastolic dysfunction: a randomised trial. Lancet. 2007;369(9579):2079-87.

18. Gardin JM, Arnold A, Gottdiener JS, Wong ND, Fried LP, Klopfenstein HS, et al. Left ventricular mass in the elderly. The Cardiovascular Health Study. Hypertension. 1997;29(5):1095-103.

19. Wachtell K, Bella JN, Rokkedal J, Palmieri V, Papademetriou V, Dahlof B, et al. Change in diastolic left ventricular filling after one year of antihypertensive treatment: The Losartan Intervention For Endpoint Reduction in Hypertension (LIFE) Study. Circulation. 2002;105(9):1071-6.

20. Levy D, Garrison RJ, Savage DD, Kannel WB, Castelli WP. Prognostic implications of echocardiographically determined left ventricular mass in the Framingham Heart Study. N Engl J Med. 1990;322(22):1561-6.

21. Koren MJ, Devereux RB, Casale PN, Savage DD, Laragh JH. Relation of left ventricular mass and geometry to morbidity and mortality in uncomplicated essential hypertension. Annals of internal medicine. 1991;114(5):345-52.

22. Verdecchia P, Schillaci G, Borgioni C, Ciucci A, Battistelli M, Bartoccini C, et al. Adverse prognostic significance of concentricremodeling of the left ventricle in hypertensive patients with normal left ventricular mass. J Am Coll Cardiol. 1995;25:871–8.

23. Gardin JM, Brunner D, Schreiner PJ, Xie X, Reid CL, Ruth K, et al. Demographics and correlates of five-year change in echocardiographic left ventricular mass in young black and white adult men and women: the Coronary Artery Risk Development in Young Adults (CARDIA) study. J Am Coll Cardiol. 2002;40(3):529-35.

24. Ferrara LA, de Simone G, Pasanisi F, Mancini M, Mancini M. Left ventricular mass reduction during salt depletion in arterial hypertension. Hypertension. 1984;6(5):755-9.

25. Guideline c. European Society of Hypertension – European Society of Cardiology guidelines for the management of arterial hypertension. Journal of hypertension. 2003;21:1011-53.

26. Foppa M, Duncan BB, Rohde LE. Echocardiography-based left ventricular mass estimation. How should we define hypertrophy? Cardiovascular ultrasound. 2005;3:17.

Tables

Table 1 . Respondents’ basic characteristicsN = 61 Mean+SD Median

Age (year) 56.36+6.62 57

Hypertension duration (year) 5.77+3.33 5 . 0

BSA (m2) 1.61+0.15 1 . 61

BMI (kg/m2) 24.19+3.47 23 . 8

Body Height (cm) 157.11+8.9 156

Body Weight (kg) 59.8+9.07 61

Systolic Blood Pressure (mmHg) 132.05+13.74 130

Diastolic Blood Pressure (mmHg) 79.92+9.94 80

Table 2. Respondents’ echocardiography characteristicsN=61 Mean+SD Median Minimum Maximum

IVSd 0.77+0.09 0.8 0.6 1 . 0

LVIDd 4.56+0.29 4.70 3.9 5 . 1

LVPWd 0.99+1.05 0.80 0.5 9 . 0

EF by Teich 68.59+5.04 69.0 59 83

LVMI (g/m2) 75.41+12.74 74.97 49.44 97 . 92

RWT 0.36+0.57 0.36 0.23 0 . 48

E 0.77+0.25 0.86 0.41 1 . 12

A 0.75+0.15 0.71 1.25 1 . 25

e’ 8.58+2.17 8.0 6 14

Vp 50.56+9.25 50.0 30 71

Table 3. Respondents’ left ventricular diastolic function characteristicsParameter Mean Median Minimum Maximum

E/A 1.07+0.39 1.17 0.36 1 . 61

E/e’ 8.85+1.96 1.55 6.28 12 . 45

E/Vp 1.54+0.45 1.55 0.8 2 . 68

Table 4. Normality test for LVMI, E/A, E/e dan E/Vp scoresKolmogorov-Smirnova Shapiro-Wilk

Statistic Df Sig. Statistic df Sig.

LVMI

E/A

E/E'

E/Vp

.133

.171

.148

.101

61

61

61

61

.009

.000

.002

.192

.960

.883

.908

.967

61

61

61

61

.045

.000

.000

.098

a. Lilliefors Significance Correction

Table 5. Correlation analysis between the parameters of echocardiography diastolic functions and left ventricular mass index (LVMI)

N = 61 Nilai r Nilai p

E/A↔LVMI 0.074 0.537

E/e’↔LVMI -0.181 0.162

E/Vp↔LVMI 0.038 0.769

Table 6. Intra-observer and inter-observer variabiltyParameter Intra-observer %

VariabilityInter-observer % Variability

r-value Mean diff

(SD)

Intra-observer

r-value Mean diff

( SD )

Inter-observer

LVMI 0.92 0.55 (4.73) p=0.660

0.72+2.39 0.96 0.56

(3.28) p=0.520

0.73+1 . 66

E/A 0.98 0.04 4.44+0.04 0.99 0.03 3.37+0 . 02

(0.72) p=0.051

(0.05) p=0.051

E/e’ 0.71 0.02(1.43) p=0.970

0.24+0.70 0.99 0.05

(0.35) p=0.551

0.62+0 . 18

Vp 0.99 0.27(0.88) p=0.260

0.59+0.45 0.98 0.67

(1.72) p=0.160

1.48+0 . 86