Mitral Annulus Posterior Systolic Excursion Instead of Left Ventricular Ejection Fraction to Evaluate Left Ventricular Systolic Function Both During Urgent Hypertensive Crisis and After Blood Pressure Normalization


To the Editor:

Hypertensive crisis (HC) consists of a sudden increase in systolic-diastolic blood pressure. It may be divided into two categories: emergency and urgency HCs,1 depending on the impairment of target organs’ dysfunction or not. Both during emergency or urgency HC, the left ventricle is unable to perform its normal function.2 Left ventricular (LV) systolic function is usually assessed by percentage of LV ejection fraction (LVEF%), but the Mitral Annulus Posterior Systolic Excursion (MAPSE) may also be used.3 Specifically, MAPSE seems to reflect the contribution of the longitudinally oriented myocardial fibers in generating LV stroke volume.4 LVEF% decreased during urgent HC, for LV dysfunction because of sudden growth of afterload, depending on peripheral vasoconstriction, activation of the nervous system, and activation of the renin-angiotensin-aldosterone system.5 Alterations of salt/water balance are also responsible for this.6 But when afterload is reduced (for blood pressure lowering), LV systolic function increases again, with consequent increase in LVEF%. Several reports confirm that LV systolic function may be well evaluated by MAPSE.7,8 More recently, it was also demonstrated that at rest and after exercise, MAPSE was well correlated with LV function in patients with heart failure and preserved LVEF%.9 There is also evidence of a satisfactory correlation between MAPSE and LVEF% by magnetic resonance imaging.7,10 Bergenzaun and colleagues11 demonstrated that in critically ill patients, “eyeball” ejection fraction can be used instead of single-plane Simpson when assessing LVEF%. But, Emilsson and coworkers12 showed a higher correlation between LVEF% and longitudinal fractional shortening (l-FS) than between LVEF% and MAPSE, suggesting that l-FS (which includes a correction for ventricular length) may be a more suitable index of LV systolic function than MAPSE per se. Nevertheless, LVEF% may be replaced with MAPSE, because it more rapidly defines LV dysfunction during urgent HC in the emergency department. That was evidenced by the results obtained in our 35 hypertensive patients admitted to a first aid station for HC.

Some epidemiologic, clinical, and echocardiographic characteristics of these patients, with LVEF% and MAPSE values recorded during urgent HC and at blood pressure lowering, are reported in the Table.

Table Table.   Epidemiologic, Clinical, Metabolic, and Echocardiographic Findings in 35 Patients Evaluated During Urgent HC and at Blood Pressure Lowering
  1. Bold values indicate significance. Abbreviations: BMI, body mass index; EF, ejection fraction; HC, hypertensive crisis; HDL, high-density lipoprotein; IVS, interventricular septum; LDL, low-density lipoprotein; LV, left ventricular; MAPSE, mitral annular posterior systolic excursion; NS, not significant.

 During HCBlood Pressure LoweringP Value
Patients, No.35 (19 men and 16 women)
Mean age, y59±7
BMI, kg/m226.2±1.3
Blood pressure, mm Hg210/110130/85<.001
Heart rate, beats per min118±773±4<.01
Fasting blood glucose, mmol/L5.6±0.75.7±1.1NS
Total cholesterol, mmol/L5.76±0.85.8±0.9NS
LDL cholesterol, mmol/L3.2±0.43.1±0.3NS
HDL cholesterol, mmol/L1.42±0.51.41±0.3NS
Triglycerides, mmol/L2.8±0.52.7±1.2NS
LV diastolic diameter, mm6.2±0.750±1.1<.01
IVS thickness, mm13±0.511±0.8<.05
LV posterior wall thickness, mm11±0.710±0.66NS
MAPSE, mm11.4±1.515.7±1.2<.001