Full text of DOI:10.1016/S0895-7061(99)00185-5

AJH 2000;13:226–230
Left Ventricular Geometry in
Pregnancy-Induced Hypertension
Manuel Va´zquez Blanco, Oscar Grosso, Claudio A. Bellido, Oscar R. Iav´ıcoli,
Clotilde S. Berensztein, Hilda Ruda Vega, and Jorge Lerman
The changes induced by transient hypertension
upon cardiac geometry (G) are unclear. Pregnancy-
induced hypertension (PIH) offers a natural and
spontaneous model of this condition. To assess
geometric changes according to two-dimensionally
guided M-mode echocardiography, we compared
patients with PIH with normal pregnant women
(NPW). Fifty-five women, aged 28.5 ؎ 7.5 years,
with PIH (defined as blood pressure >140/90 mm
and RWT was normal; and concentric remodeling
(CR) if LVMI was normal and RWT was elevated.
Comparisons were performed by the Student t test.
Patients with PIH had higher LVMI (106 ؎ 29.4 v
90.6 ؎ 19.8 g/m2; P < .05) and RWT (0.41 ؎ 0.07 v
0.38 ؎ 0.05; P < .05). Considering the mean ؎ 1
SD of NPW as the limit of normality the G pattern
was NG in 26 (47%) and abnormal in 29 (53%), of
which 14 (25.5%) had EH, 11 (20%) had CR, and
Hg in the third trimester of pregnancy and without four (7%) had CH. If we considered the mean ؎ 2
a history of hypertension) were compared with 57
NPW aged 30.7 ؎ 7.5 years.
SD, the G pattern was NG in 46 (84%) and
abnormal G in nine (16%), EH in four (7%), CR in
three (5%), and CH in 2 (4%). According to these
data, women with PIH had higher LVMI and RWT
compared with NPW. The most frequent abnormal
G patterns were EH and CR. Am J Hypertens
2000;13:226–230 © 2000 American Journal of
Hypertension, Ltd.
Left ventricular mass index (LVMI) (Devereux
formula) and relative wall thickness (RWT)
(Ganau formula) were calculated by means of
echocardiography done in the left lateral decubitus
2 to 4 days postpartum. Subjects were considered
to have: normal geometry (NG) if both LVMI and
RWT fell below the mean ؎ 1 SD or 2 SD;
concentric hypertrophy (CH) if both were elevated;
eccentric hypertrophy (EH) if LVMI was elevated
KEY WORDS: Pregnancy induced hypertension, left
ventricular geometry, ventricular geometry.
rterial hypertension represents, by itself, a sion of proto-oncogenes after its union to the mem-
fundamental stimulus for the develop- brane receptor, are perhaps the two most impor-
ment of left ventricular hypertrophy. The tant.1–3 However, left ventricular overload imposed by
mechanisms of both are well known and arterial hypertension is more complex than expected:
A
induction by angiotensin II, together with the expres- although, in some patients, left ventricular mass in-
creases, in others it remains within normal limits.
There is evidence that remodeling of the left ventricle
depends on the hemodynamic conditions of preload,
Received March 15, 1999. Accepted July 6, 1999.
afterload, left ventricular contractility state, and sever-
From the Division of Cardiology, Hospital de Cl´ınicas “Jose´ de
San Mart´ın”, University of Buenos Aires, Buenos Aires, Argentina. ity and duration of the process.4,5
Address correspondence and reprint requests to Manuel Va´zquez
Hypertrophy secondary to pressure overload has a
great impact on the cardiovascular system and may
develop with different patterns, generically called
Blanco, MD, Hospital de Cl´ınicas, Division Cardiologia, Av Corri-
entes 4667, piso 3, departamento 15, 1195 Buenos Aires, Argentina;
e-mail: bvazquez@intramed.net.ar
© 2000 by the American Journal of Hypertension, Ltd.
Published by Elsevier Science, Inc.
0895-7061/00/$20.00
PII S0895-7061(99)00185-5

AJH–MARCH 2000–VOL. 13, NO. 3, PART 1
CARDIAC GEOMETRY AND PREGNANCY-INDUCED HYPERTENSION 227
ventricular geometries. The latter depend on the rela- diastolic measurement as phase V of Korotkoff
tionship between wall thickness and ventricular cavity sounds. The average of three recordings in a sitting
size. In the type known as “concentric remodeling,” position within a 3-min interval among them were
wall thickness predominates over ventricular cavity
size; in “eccentric hypertrophy,” the opposite relation
takes place; and, finally, in “concentric hypertrophy,”
both are increased. Ventricular mass is normal in the
first type and increased in the other two. Arterial
hypertension is known as a long lasting chronic over-
load that induces important structural changes in the
ventricular myocardium. On the other hand, little is
known about the changes induced by acute pressure
overload, as is the case of pregnancy-induced hyper-
tension.
During normal pregnancy a number of hemody-
namic changes take place, such as an increase in blood
and stroke volumes, together with heart rate, and a
decrease in peripheral resistance and blood pres-
sure.6,7
A number of reports on pregnancy-induced hyper-
tension have been published, with different results.
However, there is a consensus that in patients with
preeclampsia, peripheral resistance is increased, plas-
matic volume is decreased, and stroke volume may be
normal or decreased.8
The consequences of left ventricular overload on left
ventricle anatomy can be expressed in different ways:
1) normal geometric pattern, with normal left ventric-
ular mass and relative wall thickness; 2) eccentric re-
modeling, with normal mass and increased relative
wall thickness; 3) eccentric hypertrophy, with increase
in both parameters; and 4) eccentric hypertrophy, with
increased mass and normal relative wall thickness.
Although patients with chronic arterial hyperten-
sion are exposed to long lasting pressure overload
with enough time to develop changes in left ventric-
ular geometry,9 little is known about the changes pro-
duced by conditions of acute pressure overload, as in
the case of pregnancy induced hypertension.
considered. All of the measurements were done after a
10-min period of relaxation and the procedure was
repeated on two occasions.
Left ventricular mass was calculated from left ven-
tricular end diastolic cavity, and septal and posterior
wall thickness obtained by two-dimensional (2D) tar-
geted M-mode echocardiography performed in a left
lateral decubitus position. Echocardiographic studies
were performed with an Apogee ultrasound system
(Interspect Ambler, Philadelphia, Pennsylvania) using
a 2.25 and a 3.00-MHz transducer, and the operators
were blinded to the blood pressure of the patients.
Measurements of ventricular septum, posterior wall,
and left ventricular cavity were performed according
to the American Society of Echocardiography (ASE)
criteria.10 Left ventricular mass was calculated from
these data using the Penn convention and the ASE
guidelines.10–12 The left ventricular mass index was
determined as the ratio of left ventricular mass (in
grams) to the body surface area (in square meters).
The relative posterior wall thickness was measured at
end diastole as the ratio between the double of poste-
rior wall thickness to the left ventricular diastolic cav-
ity diameter. The ventricular geometries considered
were the four categories of left ventricular anatomic
remodeling, taking into account the relative posterior
wall thickness at end diastole and the left ventricular
mass index. Patients had a normal left geometry if the
relative posterior wall thickness at end diastole and
the left ventricular mass index were under the values
of those corresponding to normal pregnant women,
and had concentric hypertrophy when both were in-
creased. Left ventricular eccentric hypertrophy was
identified as an increase in mass index with a normal
relative posterior wall thickness at end diastole and
concentric remodeling was defined as an increase in
relative posterior wall thickness at end diastole with a
normal left ventricular mass index.
METHODS
Patients We studied 55 women with pregnancy in-
duced hypertension whose ages were between 16 and
33 years (mean 28.5 Ϯ 7.5 years). Arterial hypertension
was diagnosed when systolic or diastolic pressures
were Ͼ140/90 mm Hg in a resting/sitting position on
at least two occasions during the third trimester of
pregnancy. None of them had previous recordings or
a history of arterial hypertension, and the blood pres-
sure during the first and the second trimesters of the
pregnancy was normal. These results were compared
to the ones obtained in 57 normal pregnant women
with ages that ranged between 16 and 34 years (mean
Statistical Analysis Data were expressed as
means Ϯ SD. The statistical significance of the differ-
ence between the values of the four ventricular geo-
metric groups was tested with analysis of variance
and the ␹2 test with the Yates correction. Results were
considered significant at P Ͻ .05.
RESULTS
Left ventricular mass index of patients with PIH was
106 Ϯ 29.4 g/m2, 95% confidence interval (CI) 98.24–
113.76, versus 90.6 Ϯ 19.8 g/m2, 95% CI 85.46–95.74
30.7 Ϯ 7.5 years). Serial blood pressure measurements g/m2 in NPW (P Ͻ .05). Relative wall thickness in
were obtained with a mercury sphygmomanometer PIH patients was 0.41 Ϯ 0.07, (95% CI 039–0.43) ver-
with systolic blood pressure defined as phase I and sus 0.38 Ϯ 0.05, 95% (CI 0.37–0.39) in NPW, a differ-

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228 VAZQUEZ BLANCO ET AL
AJH–MARCH 2000–VOL. 13, NO. 3, PART 1
ence that was statistically significant (P Ͻ .05) (Table history of hypertension or any other condition that
could increase it. Recently, Degli Esposti et al16 pub-
1).
lished data about preeclamptic patients who had in-
Ventricular Geometric Patterns If we consider the
mean Ϯ 1 SD as the upper normal limit of LVMI and
RWT of NPW (110.4 g/m2 and 0.43, respectively), we
obtained normal geometric values in 26 patients with
PIH (47%), eccentric hypertrophy in 14 (25%), concen-
tric remodeling in 11 (20%), and concentric hypertro-
phy in four (7%), versus 39 (68.4%), eight (14%), eight
(14%), and two (3.5%), respectively, in NPW. However
if we consider the mean Ϯ 2 SD of the LVMI and RWT
as the upper normal limit (130.2 g/m2 and 0.48, re-
spectively), we found a normal geometric pattern in 46
patients (84%), eccentric hypertrophy in four (7%),
concentric remodeling in three (5%), and concentric
hypertrophy in two (4%), versus normal geometric
values in 53 (93%), concentric remodeling in three
(5%), and eccentric hypertrophy in one (2%) in NPW
(Fig. 1). The data for PIH patients compared to data for
NPW were significantly different (P Ͻ .02), and the
risk of having an abnormal geometric pattern was
more than twice as high in PIH patients compared as
in NPW (odds ratio 2.62, CI 1.13–6.16).
creased left ventricular mass, together with systolic
and diastolic dysfunction, in comparison with normal
pregnant women.
Ventricular Geometry In our study, normal preg-
nant women had an average left ventricular mass
index of 90.6 Ϯ 19.8 g/m2 together with a relative wall
thickness of 0.38 Ϯ 0.05. These results differ from
those reported by Ganau et al,9 who consider 106
g/m2 as the normal upper limit for left ventricular
mass. This figure corresponds to the mean value plus
two standard deviations of normal women. Likewise,
for these authors, the normal upper value of relative
wall thickness was 0.44, which corresponds to the 95th
percentile.
These different results may be due to differences in
the population, because the pregnant patients studied
by us had other hemodynamic modifications that can
produce different changes in the structure and func-
tion of the left ventricle.
Having these limitations in mind, we found that if
the mean value plus one standard deviation of normal
pregnant women is considered as a normal limit, we
obtained normal geometric values in 26 of our patients
(47.3%), and abnormal in 29 (52.7%). In 14 hyperten-
sive women (25.4%) eccentric hypertrophy developed,
in 11 (20%) concentric remodeling developed, and in
the last four (7.3%) concentric hypertrophy was ob-
served. But when we considered the mean value plus
two standard deviations as the normal upper limit in
normal pregnant women, we obtained normal geo-
metric values in 46 patients (83.6%), eccentric hyper-
trophy in four (7.3%), concentric remodeling in three
(5.5%), and concentric hypertrophy in two (3.6%). The
data found in our group of patients with pregnancy-
induced hypertension, compared to those in normal
pregnant women, were significantly different.
Ganau et al reported normal geometric values in
52% of patients when considering 106 g/m2 as the
normal upper limit for left ventricular mass and 0.44
as the normal upper limit for relative wall thickness.
These authors found eccentric hypertrophy in 27%,
concentric remodeling in 20%, and concentric hyper-
trophy in 8%.9 These results are similar to ours; how-
ever, despite this, the cause of structural abnormalities
of the left ventricle is different in both situations.
Pregnancy-induced hypertension appears within a
short time, is short lasting, and affects a healthy car-
diovascular system free of previous pathological in-
fluences. Consequently the organism has not enough
time to adapt itself to this pressure overload. On the
other hand, in essential hypertension, the process de-
DISCUSSION
During normal pregnancy a number of hemodynamic
changes take place, such as an increase in blood and
stroke volumes together with heart rate, and a decrease
in peripheral resistance and mean blood pressure.6,7
These changes may be responsible for structural remod-
eling of the left ventricle by themselves13,14
Pregnancy-induced hypertension represents an ad-
equate model to evaluate the consequences of acute
pressure overload on the myocardium during a short
period of time. These patients differ from normal
pregnant women in the fact that peripheral resistance
is increased, and plasma volume may be normal or
decreased.8 The heart must adapt its wall thickness to
this increase in pressure load, to decrease parietal
stress despite the short lasting overload.
In a previous study, Thomson et al15 did not find
significant changes in mass index between normal
pregnant control subjects and pregnancy-induced hy-
pertensive women. The absence of significant differ-
ences between both groups could be explained by the
low number of patients in this study.
On the contrary, in our study, patients with preg-
nancy-induced hypertension had a significant increase
in left ventricular mass, a situation that especially
reflects an increase in septal and posterior wall thick-
ness without changes in left ventricular diastolic di-
ameter. We did not know the left ventricular mass
before the pregnancy; however, it can be assumed that
it was previously normal, because the patients had no velops progressively and the myocardium adapts it-

AJH–MARCH 2000–VOL. 13, NO. 3, PART 1
CARDIAC GEOMETRY AND PREGNANCY-INDUCED HYPERTENSION 229
TABLE 1. ECHOCARDIOGRAPHIC DATA
NPW
PIH
P Value
LVDD (mm)
LVSD (mm)
IVST (mm)
LPWT (mm)
SF (%)
46.4 Ϯ 4.6
28.8 Ϯ 3.9
8.9 Ϯ 1.4
47.2 Ϯ 4.5
29.5 Ϯ 4.5
10 Ϯ 1.5
ns
ns
0.001
0.03
ns
0.02
0.004
ns
8.7 Ϯ 1.3
9.3 Ϯ 1.6
37.9 Ϯ 5.6
0.38 Ϯ 0.05
90.6 Ϯ 19.8
67.4 Ϯ 13.7
1.58 Ϯ 6.6
1.68 Ϯ 6.6
37.7 Ϯ 5.7
0.41 Ϯ 0.07
106 Ϯ 29.4
71.1 Ϯ 12.1
1.59 Ϯ 6.9
1.59 Ϯ 6.9
RWT
LVMI (g/m2)
WEIGHT (kg)
HEIGHT (m)
BSA (m2)
ns
ns
FIGURE 1. Distribution of hypertensive pregnant women ac-
cording to their geometric patterns of ventricular hypertrophy,
considering the mean Ϯ 1 SD and the mean Ϯ 2 SD.
LVDD, left ventricular diastolic dimension; LVMI, left ventricular mass
index; LVSD, left ventricular systolic dimension; IVST, interventricular
septal thickness; LPWT, left posterior wall thickness; NPW, normal preg-
nant women; PIH, pregnancy-induced hypertension; RWT, relative wall
thickness; SF, shortening fraction; BSA, body surface area.
self to decrease its wall stress. Concentric remodeling
is the first step in the geometric changes that affect the
myocardium. Several published reports discussed the
different ways by which the left ventricle adapts to
arterial hypertension. Acording to some reports,5,17
left ventricular concentric hypertrophy is the most
common observation, but there are exceptions to this
rule. In a previous work,18 we have observed that
concentric and eccentric patterns appear with a similar
frequency. Others9 have remarked that eccentric hy-
pertrophy and concentric remodeling are more com-
mon than concentric hypertrophy.
increase in afterload. However, it has been the less
frequently observed in our series, and this may be
explained by the fact that pregnancy-induced hyper-
tension is a short lasting phenomenon.
Normal Geometry The majority of chronic hyper-
tensive patients, even those with a relatively pro-
longed form of the disease, and those with pregnancy-
induced hypertension show a normal geometric
pattern. It may be possible that other issues, such as
the contractile state of the myocardium, and even
genetic causes can explain the lack of structural
changes seen in patients with essential hypertension,
as well as in patients with pregnancy-induced hyper-
tension. Finally, we conclude that, although a normal
pattern is the most common ventricular geometry
found in patients with pregnancy-induced hyperten-
sion, this short lasting pressure overload is capable of
inducing changes in the structure of the left ventricle.
Eccentric Hypertrophy This change has been con-
sidered as a form of left ventricular failure due to
pressure overload.9 In normal pregnancy, changes in
the left ventricular morphology may be found. During
the second and third trimesters of pregnancy, there is
a tendency for the left ventricular cavity and mass
index to increase, but these disappear in a period of
approximately 6 months after delivery.14 The fact that
pregnancy imposes a volume overload on the circula-
tory system represents a physiological explanation for
this trend and for the greater incidence of eccentric
hypertrophy, as we observed in our series. In the
present study, no patient had overt cardiac failure,
although we cannot rule out the possibility that this
type of geometric remodeling may hide a latent form
of contractile failure.
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