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: [email protected]
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.
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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