Puzzle: Increased LVEF Seen in Elevated

SBP, No Hypertrophy
MILAN, ITALY In a small study of patients free of hypertension symptoms or left
ventricular (LV) hypertrophy, those with a high systolic blood-pressure reading in a clinic
measurement had a higher LV ejection fraction (LVEF) than those with a normal systolic
blood-pressure reading[1].
"We hadn't expected to find this relationship . . . and to our knowledge this is novel," said
coauthor Dr David Collier (William Harvey Research Institute, London, UK), presenting the
study at a late-breaking session here at the European Society of Hypertension (ESH) 2015
Scientific Sessions.
Dr Mohammed Y Khanji (Queen Mary University of London, UK) and colleagues examined
data from 96 participants in the Heart Attack Prevention Programme for You (HAPPY)
London (HAPPYLondon) study who had no symptoms of hypertension and had cardiac MRI
scans.
The results "have implications for the way we look at ejection fraction," Collier said. For
example, a small difference in LVEF might determine whether a patient is a candidate for an
implantable cardiac defibrillator.
Moreover, it appears that this increased LVEF may "settle" with improved blood-pressure
control, Khanji and colleagues note. Thus, "it is possible that we may need to consider an
ejection-fraction correction factor based on blood pressure," they conclude.
Session cochair Dr Christopher J Bulpitt (Imperial College London, UK) wondered whether
the study participants had white-coat hypertension, and Collier clarified that they did not
determine home or ambulatory blood pressure. In reply to a question from the audience,
Collier said that they used standard cardiac MRI to determine the LVEF.
Implications for ICD Patient Selection
The participants visited a clinic and blood pressure was determined (based on two consistent
readings, measured from their left arm when they were seated). The participants also
underwent cardiac MRI at 1.5 T within 2 weeks of the clinic visit.
The researchers divided the participants into two groups based on their blood pressure,
regardless of whether they were taking antihypertensives:

31 participants were hypertensive (BP >140/90 mm Hg; mean BP 150/86).

65 participants were normotensive (BP <140/90 mm Hg; mean BP 127/77 mm Hg).

In both groups, patients had an average age of 64.5 years and 74% were males, and about half
were taking antihypertensives.
The mean LVEF was significantly higher in the hypertensive participants compared with the
normotensive participants (68% vs 64%, P<0.05), which was not explained by a difference in
left ventricular myocardial mass.
However, systolic blood pressure was significantly correlated with LVEF (correlation
coefficient 0.26, P=0.010).
Further, a multiple regression model showed that systolic blood pressure and blood-pressure
treatment predicted LVEF, but age, diastolic blood pressure, LV myocardial mass, and heart
rate did not (P<0.001).
The relationship between LVEF and blood-pressure control can be important for patients who
may be potential candidates for device implants.
For example, imagine a 62-year-old patient with uncontrolled blood pressure of 166/94 mm
Hg and LVEF of 58%, Collier said. On a subsequent occasion, the patient's LVEF is 53%,
which might be considered less optimal. "But does that actually mean there has been a
change in that person's heart?" he asked.
"This might be particularly significant given the [imprecise nature] of [LVEF]
measurements," he added. "If the cutoff LVEF for implanting a device is 35%, then a
difference of 5% might make a big difference."
The study might help explain how uncontrolled blood pressure can lead to hypertrophy and
heart failure. "Sustained hyperdynamic circulation may be a contributory mechanism for
future hypertrophy, heart failure, and other long-term complications," Khanji and colleagues
suggest.
However, this was a relatively small cohort, so further research is needed to verify the
findings, Collier cautioned.