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(Hypertension. 1995;26:1190-1194.)
© 1995 American Heart Association, Inc.
Articles |
Role of Anthropometric Indexes and Blood Pressure as Determinants of Left Ventricular Mass and Geometry in Adolescents
The Rio de Janeiro Study
From the Department of Cardiology, State University of Rio de Janeiro (Brazil).
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Abstract |
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Abstract To evaluate left ventricular structural changes and their relationship to blood pressure and anthropometric indexes, we examined by echocardiography 108 adolescents aged 13 to 19 years. Subjects were divided into three groups according to blood pressure tracking during three moments of observation: group 1 (n=27),
95th percentile; group 2 (n=37), 
50th
percentile; and group 3 (n=44), blood pressure not stable in the
original percentile. Left ventricular mass index and the
prevalence of altered left ventricular geometry were
greater in group 1 (P<.05 and P<.02,
respectively). Of all the anthropometric indexes, body surface area
showed the best correlation with left ventricular mass
(P<.00001). Left ventricular mass also
correlated with systolic and diastolic pressures
(P<.00001 and P<.003, respectively).
Ventricular septal and posterior wall thicknesses and left
ventricular diastolic diameter showed good
correlations with body surface area (P<.00001). These
variables also correlated with systolic pressure
(P<.001). In a multiple regression model when body surface
area was controlled, systolic pressure did not correlate
significantly with left ventricular mass. In a similar
model systolic pressure maintained a significant correlation
with ventricular septal and posterior wall
(P<.00001) thicknesses but not with left
ventricular diastolic diameter
(P>.05). We conclude that left ventricular
structural changes can occur early after initial abnormalities of blood
pressure. Considering that body surface area and systolic
pressure were the best predictors of left ventricular
alterations in adolescents, the usual way of correcting left
ventricular mass by body surface area should be reviewed.
Key Words: anthropometry • blood pressure • heart ventricle • adolescents • echocardiography
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Introduction |
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In hypertensive patients and even in the general population, LVH is an important and independent predictor of adverse cardiovascular events and mortality.1 2 Recent data have suggested that this risk could be better stratified by consideration of left ventricular geometry pattern in addition to muscle mass.3 Human and animal studies have shown that elevated BP is one of the most important factors promoting LVH. Although controversial, other factors, such as overweight, age, sex, race, dietary sodium intake, insulin resistance, adrenergic stimulation, and the renin-angiotensin system, have already been correlated with LVM.4 5 6 7 8 9 Therefore, studies of these factors could help to characterize the subset of hypertensive patients who are prone to developing LVH and to identify potential mechanisms of cardiac hypertrophy.
Most antihypertensive drugs, when used for a sufficient period, will reduce LVM. Even though it is not clear whether this reduction carries a better prognosis,10 every method of LVH prevention should be tried.
Few studies evaluating early LVM modifications have been conducted in young patients with altered BP. In some of these studies, echocardiography has clearly showed LVH.5 11 12 13 14 15 The aim of the present study was to evaluate echocardiographic alterations in left ventricular structure and their relationship with age, anthropometric indexes, and systolic and diastolic BP in adolescents at different BP percentiles.
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Methods |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Subjects
A total of 3906 children and adolescents from 10 to 15 years of age have participated in a screening program for arterial BP in Rio de Janeiro since 1987. Normal BP curves were established according to age and sex, and this population was separated into two groups according to BP percentile: group 1 included 327 individuals with diastolic and/or systolic BP at or above the 95th percentile, and group 2 included 327 individuals randomly selected from those who had diastolic and systolic BP at or below the 50th percentile as a control group (phase 1). From these two groups, 206 individuals (106 from group 1 and 100 from group 2) were visited at their homes in 1989 and 1990 when their parents and siblings were also examined (phase 2). For evaluation of the possible effects of BP on target organs, 127 children and adolescents (70 from group 1 and 57 from group 2) who participated in phase 2 agreed to be examined at the hospital during 1991 and 1992 (phase 3). From this population 108 children and adolescents were evaluated by echocardiography. During phases 2 and 3 it was observed that 44 individuals (34 from group 1 and 10 from group 2) did not maintain BP at their original percentile. According to this finding, the sample of 108 children and adolescents analyzed in this study was restructured: Group 1 included 27 individuals (15 males and 12 females) who maintained BP at or above the 95th percentile; group 2 was formed by 37 individuals (20 males and 17 females) who maintained BP at or below the 50th percentile in all phases; and group 3 included 44 individuals (16 males and 28 females) who, in phases 2 and 3, did not maintain the same BP percentile observed in phase 1 (
95th or 50th percentile). All subjects agreed to participate in
the study and signed a consent form.
Anthropometric Indexes
The anthropometric indexes used were weight (kilograms), height
(meters), BMI16 (kilograms per meter squared), and
BSA17 (using the formula Weight0.425
[kg]xHeight0.725 [cm]x71.84/10 000 and expressed in
meters squared).
Blood Pressure
BP was measured with subjects in the supine position with the
use of a wall-mounted or table mercury-type sphygmomanometer in
the right arm in all phases. Cuff sizes were 9.5, 12, and 14 cm in
width and 36 and 53 cm in length, depending on the size of the arm.
Diastolic BP was determined at Korotkoff phase V.
Echocardiography
LVM was calculated from M-mode echocardiographic
measurements. M-mode echocardiograms were obtained with a Toshiba
apparatus (model SSH-6A), and measurements were made
according to the American Society of
Echocardiography.18 The formula used
for LVM19 20 was
1.05x(LVDD+VS+PW)3-(LVDD)3. LVM
index was calculated as LVM/BSA, and RWT was defined as PW/(LVDD/2).
Left ventricular geometry was classified as normal if the
LVM index was <124.21 g/m2 and RWT <0.45; concentric
remodeling if the LVM index was <124.21 g/m2 and RWT
0.45; eccentric hypertrophy if the LVM index was 124.21
g/m2 and RWT <0.45; and concentric hypertrophy
if the LVM index was 124.21 g/m2 and RWT 0.45. These
cutoff points corresponded to the 95th percentile of these values in
our population.
Descriptive data are presented as mean±SD. Statistical
analysis was performed with ANOVA (F), Kruskal-Wallis
one-way ANOVA by ranks (H), 
2 test, and
simple and multiple regression and correlation with stepwise
variables selection.21
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Results |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Age and sex were not different among the groups, which allowed us to study each group as a whole. Weight, BSA, and BMI were significantly higher in group 1 compared with the other two groups (Table 1).
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LVM and the LVM index were greater in group 1 (P<.004 and
P<.05, respectively), as shown in Table 1. Abnormalities in
ventricular pattern did not differ among the groups (6
subjects [22.2%] from group 1, 1 [2.7%] from group 2, and 6
[13.6%] from group 3 [2=5.7964,
P>.05]). However, statistical significance was found when
group 1 was compared with group 2 (2=6.1054,
P<.02). The observed alterations in left
ventricular geometry were 1 subject with concentric
hypertrophy, 3 with eccentric hypertrophy, and
2 with concentric remodeling in group 1; 1 subject with concentric
remodeling in group 2; and 2 subjects with eccentric
hypertrophy and 4 with concentric remodeling in group
3.
Table 2 summarizes the correlations between LVM and age, age according to sex, anthropometric indexes, and systolic and diastolic BP. There was no significant relation between LVM and either age or age according to sex. All the correlations between LVM and anthropometric indexes were positive and significant. LVM was also significantly correlated with systolic and diastolic BP. The variables used for calculation of LVM were positively correlated with all the anthropometric indexes and BP (Table 3).
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In a multiple regression model LVM was used as the dependent variable and systolic BP and BSA as independent variables. The partial correlation coefficients were .6256 (P<.00001) for BSA and .4717 (P=.07) for systolic BP. The final model, however, was statistically significant (R2=.3993, P<.00001).
In similar models when BSA was controlled, systolic BP maintained a significant and positive correlation with VS and PW but not with LVDD. When VS was used as the dependent variable, the partial correlation coefficients were .4850 (P=.002) for BSA and .4642 (P=.007) for systolic BP, and the final model was significant (R2=.2735, P<.00001). When the dependent variable was PW, BSA had a partial correlation coefficient of .4245 (P<.02) and systolic BP one of .4202 (P<.02). The final model had a determination coefficient (R2) of .2122 (P<.00001). When LVDD was used as the dependent variable, the partial correlation coefficients were .5239 (P<.00001) for BSA and .2882 (P=.86) for systolic BP; however, the final model reached statistical significance (R2=.2608, P<.00001).
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Few studies evaluating LVM in children and adolescents have been conducted in the last decade.5 11 12 13 14 15 The aim of these previous studies was the early identification of subjects who are prone to developing LVH and its prognostic implications. In this context the authors focused their attention on the possible factors that could determine LVH. The present study was carried out in a healthy population, attenuating the selection biases inherent to hospital-based studies.
The group of children and adolescents who maintained BP at or above the 95th percentile in all phases showed weight, BSA, and BMI values higher than those in the other two groups. This finding reinforces the concept that body size is strongly related to BP levels in children and adolescents.22 23 The Bogalusa Heart Study23 and Brandão et al,22 analyzing the correlation between different anthropometric indexes and BP, have emphasized that the strongest association was between systolic BP and weight.
Echocardiography provides good information about the structure of the left ventricle. The determination of VS and PW and the size of the left ventricular chamber by echocardiography have a good sensitivity for determination of LVM and the different ventricular geometric patterns.3 24 In adults, the Framingham Study defined the normal limits of LVM as 100 g/m2 for women and 131 g/m2 for men.19 Devereux et al,25 studying a more heterogeneous population, found 110 g/m2 for women and 134 g/m2 for men as the normal limits for LVM. Recently, Koren et al3 defined 125 g/m2 as a cutoff point for detection of LVH. This value corresponds to approximately the 95th percentile of LVM in two normal samples studied in their center. In young people the normal values of LVM should also derive from the LVM distribution curve. In our study the corresponding value to the 95th percentile for LVM index was 124.21 g/m2, which is almost the same value found by Koren et al.3
LVM and LVM index were greater in group 1 than in the other groups. Our results are in agreement with other investigators who found higher values of LVM and LVM index in adolescents with BP persistently above the 95th11 12 or even above the 90th percentile.15 Higher values of LVM index have also been demonstrated in Japanese boys aged 9 to 12 years tracking in the highest systolic BP quintile over a 3-year period.11 The Muscatine Study,14 evaluating students from 9 to 18 years of age, has shown greater values of LVM index in the group from the highest BP quintile. However, other investigators26 have failed to demonstrate significant differences in LVM comparing children with BP above the 95th percentile with those from the lower part of the BP distribution curve.
Some authors have shown high values of LVM and LVM index in normotensive offspring of hypertensive parents.27 28 According to Koren et al3 the prognostic value of LVM for morbid events was striking, but it could still be improved by more detailed consideration of ventricular geometry. In our population the cutoff point of RWT was 0.45, corresponding to the 95th percentile. From the 108 adolescents studied, only 13 had abnormal left ventricular patterns: 6 (22.2%) from group 1, 1 (2.7%) from group 2, and 6 (13.6%) from group 3. The finding of these low prevalences is a consequence of the essentially healthy population analyzed. However, our results reinforce the concept that quantitative and qualitative alterations may occur early, without established hypertension. Moreover, we observed that concentric remodeling and eccentric hypertrophy were more prevalent than the classic concentric hypertrophy, in agreement with Ganau et al29 and Verdecchia et al.30 However, it is worth noting that the only case of concentric hypertrophy was found in the group of adolescents who maintained BP at or above the 95th percentile.
This study extends the current knowledge about the relationship of BP and anthropometric indexes to LVM and left ventricular geometry. We found strong correlations between LVM and BP as well as all the anthropometric indexes. The increase in left ventricular wall thickness with age has been demonstrated in some studies.1 7 9 31 However, recent data from the Framingham Study31 suggest that the positive correlation of left ventricular wall thickness with age depends on the increase in weight and BP during a lifetime. The correlation between LVM and age or age according to sex was not significant, which could be due to the narrow age range of the studied subjects.
The majority of the studies that correlated LVM index to anthropometric indexes concluded that BMI is one of the most important determinants of LVM in hypertensive adults32 and children5 as well as in healthy individuals,8 especially if obesity is present.1 7 33 In the present study the best correlation was found between LVM and BSA, similar to the findings of Devereux et al.25 The usual way of correcting LVM by BSA (LVM index) could mask the possible effects of obesity on LVM. Moreover, the Framingham Study found a greater prevalence of LVH using the correction of LVM/height rather than LVM/BSA.19 Thus, if obesity is present the correction of LVM by BSA could lead to underrecognition of increasing LVM, with prognostic and therapeutic implications.
Our data concerning the association between LVM and BP, especially systolic levels, are consistent with this well-known association.1 6 14 34 35 36 The variables used in the LVM calculation also had good correlation to both BP and anthropometric indexes. On the basis of this finding we tested the correlations between systolic BP levels, controlled by BSA, and the variables that comprise the LVM formula. In this model, systolic BP maintained a positive correlation with VS and PW but not with LVDD.
These data suggest that increases in LVM related to BP elevations are due to ventricular wall thickening and those related to greater body size are due to enlargement of the ventricle cavity. The Bogalusa Heart Study13 showed that systolic BP was associated with left ventricular wall thickness but not with LVM. Verdecchia et al,37 comparing hypertensive patients with normal LVM with a control group, found a greater prevalence of asymmetrical septal thickening in hypertensive subjects than in the healthy group, despite both groups having similar anthropometric indexes.
We conclude that quantitative and qualitative LVM alterations can occur early after initial abnormalities of BP. Considering that isolated or combined actions of BSA and systolic BP were the best predictors of left ventricular alterations in adolescents, the usual way of correcting LVM by BSA should be reviewed. These observations suggest that intervention programs of BP and weight control may provide important ways to prevent the development of LVH.
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Selected Abbreviations and Acronyms |
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Acknowledgments |
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Thanks to Professor Célia Landman Szwarchwald for statistical review.
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Footnotes |
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Reprint requests to Andrea A. Brandão, Rua Abade Ramos, 107/101, Jardim Botânico, Rio de Janeiro, Brazil, CEP 22461-090.
Received June 20, 1995; first decision August 1, 1995; accepted August 18, 1995.
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