American Journal of Hypertension Advance Access published August 12, 2015

Original Article

Myocardial Performance Index in Childhood Onset Essential

Hypertension and White Coat Hypertension
Monesha Gupta-Malhotra,1,2 Rabih K. Hamzeh,3 Tim Poffenbarger,2 Karen McNiece-Redwine,4 and
Syed Shahrukh Hashmi5

BACKGROUND demographic, anthropometric, laboratory tests, vascular ultra-

As a global measure of ventricular systolic and diastolic function, the sound, and conventional echocardiographic parameters were simi-
myocardial performance index (MPI) can be an early indicator of hyper- lar between the 2 groups. There was a very small difference in MPI

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tensive cardiomyopathy in children with essential hypertension (EH). between the EH and WCH children (0.28 SD: 0.07 vs. 0.31 SD: 0.08,
P = 0.045). However, in EH children, MPI increased by 0.14 units for
METHODS every 10 unit increase in mean ABPM systolic BP (95% confidence
Children with untreated newly diagnosed EH and white coat hyperten- interval: 0.03–0.25).
sion (WCH) by a 24-hour ambulatory blood pressure monitoring (ABPM),
both groups without any identifiable etiology for the hypertension, were CONCLUSIONS
enrolled for the study. Echocardiograms and vascular ultrasounds for We found the increasing MPI was associated with increasing 24-hour
carotid artery intimal medial thickness were performed on all children prior mean systolic BP in children with EH. Therefore, MPI may have utility as
to therapy. Diastolic function (peak E and A velocities, E/A ratio, isovolumic a single, quick, noninvasive method of detection and tracking of sub-
relaxation time, and deceleration times) and MPI were evaluated by simul- clinical hypertensive heart disease.
taneous transmitral and transaortic spectral Doppler flow velocities. Systolic
function was evaluated by shortening fraction and ejection fraction. Keywords: blood pressure; carotid intimal medial thickness; diastolic
function; echocardiogram; hypertension; left ventricular hypertrophy,
RESULTS systolic function, Tei index.
A cohort of 66 children (24 with EH, 42 with WCH, males 61%, median
age of 13 years, range 10–17 years) were enrolled in the study. The doi:10.1093/ajh/hpv123

Essential hypertension (EH) plays an important role in the damage and therapeutic approach differ between the 2
cardiovascular morbidity and mortality among humans. groups.5–10
Among children with EH, early recognition and manage- The myocardial performance index (MPI) has been found
ment of endorgan damage has the potential in altering to be among the most useful echocardiographic parameters
adverse cardiovascular outcomes in adult life. Similar to to detect early hypertensive cardiomyopathy in various pop-
adults, we have shown that children with EH have abnormal ulations, including pregnant women,11 children with renal
cardiovascular function with aortopathy,1 left ventricular transplant,12 and adults with EH.13,14 Using tissue Doppler,
hypertrophy (LVH),2 and early diastolic dysfunction3 at an the MPI has been shown to precede LVH in adults with EH15
early stage in their disease process. Although evaluation of and has been shown to correlate with ventricular hemody-
childhood hypertension is more laborious than adult hyper- namic measurements in both adult human16 and animal
tension, monitoring blood pressure (BP) in clinic as well as hearts.17 However, there is a paucity of data regarding MPI
by an ambulatory BP monitoring (ABPM) is important for among hypertensive children. We hypothesized that the
both populations in order to distinguish those with ambu- MPI, which is a noninvasive and global measure of ventricu-
latory hypertension vs. those with white coat hypertension lar systolic and diastolic function,18,19 may be an early indica-
(WCH).4 This differentiation is important since endorgan tor of hypertensive cardiomyopathy11,15,20,21 among children

1Division of Pediatric Cardiology, Department of Pediatrics, Children’s

Correspondence: Monesha Gupta-Malhotra (moneshagupta@gmail.
com). Memorial Hermann Hospital, The University of Texas Health Science
Center, Houston, Texas, USA; 2Division of Pediatric Nephrology,
Initially submitted March 23, 2015; date of first revision April 27, 2015; Department of Pediatrics, Children’s Memorial Hermann Hospital, The
accepted for publication July 3, 2015. University of Texas Health Science Center, Houston, Texas, USA; 3Division
of Pediatric Cardiology, Texas Tech University, El Paso, Texas, USA;
4Division of Pediatric Nephrology, Department of Pediatrics, Children’s

Hospital of Arkansas, University of Arkansas for Medical Sciences,

Little Rock, Arkansas, USA; 5Pediatric Research Center, Department of
Pediatrics, The University of Texas Health Science Center, Texas, USA.
© American Journal of Hypertension, Ltd 2015. All rights reserved.
For Permissions, please email: [email protected]

American Journal of Hypertension  1

Gupta-Malhotra et al.

with EH. Therefore, the primary objective of this study was echocardiogram in the same manner as study children.
to determine MPI among children with EH and compare it Demographic and anthropometric data were collected on all
to those in children with WCH as determined by 24-hour subjects at study entry.
ABPM. Secondary objectives were to compare conventional
echocardiographic parameters of both systolic and diastolic Blood pressure protocol
function between the 2 groups.
Children with untreated newly diagnosed EH and WCH,
both groups without any identifiable etiology for the hyper-
METHODS tension, were enrolled for the study. The BP was reported as
Institutional approval the patients BP factored by their age, gender, height-specific
95th percentile (BP index). The hypertension status was eval-
The study was approved by the institutional Committee uated by both clinic and ABPM for 24 hours in all children
for the Protection of Human Subjects at the University of as follows: Clinic hypertensive status was confirmed in all
Texas Health Science Center and Children’s Memorial subjects at the first visit to the hypertension clinic by averag-
Hermann Hospital, Texas Medical Center in Houston, Texas. ing the last 3 of 4 BP measurements performed by Critikon

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All participants and parents gave informed assent and con- oscillometric monitor (Tampa, FL) after 5 minutes of rest and
sent, respectively, for this study. We were careful in main- confirmed by manual auscultation with a mercury sphyg-
taining full patient confidentiality, safeguarding the rights momanometer by trained personnel using methods recom-
and welfare of human subjects, and informing subjects, in a mended by the Fourth Report.4 Hypertension was diagnosed
confidential manner, of the results obtained from the study. when 3 separate measurements of systolic and/or diastolic
BP were recorded >95th percentile for post-conceptual age,
adjusted for height, age, and gender per Fourth Report4 were
Patient population
documented in the medical record. All children who were
This was a single center, cross-sectional study of chil- above the age of 5 years except those admitted with a hyper-
dren who were diagnosed with elevated BP prior to antihy- tensive emergency underwent an ambulatory BP monitoring
pertensive therapy. We prospectively enrolled participants (ABPM) using Spacelabs oscillometric monitors (Spacelabs,
from those referred to our tertiary pediatric hypertension Redmond, WA). The children along with their families were
clinic. The children were seen in our clinic from 2 sources: instructed on avoidance of caffeinated beverages or supple-
(i) Referral Study Population: These patients were referred ments, any medications, herbal or over the counter products,
to the clinic after detection of elevated BP from either an smoking and alcohol for 24 hours prior to and during the
ambulatory setting by a primary care provider or an inpa- ABPM. While on ABPM, the BP was automatically measured
tient setting. (ii) Recruited Study Population: Children who every 20 minutes for 24 hours. Subjects with 24-hour systolic
were identified by systematic school-based screening for BP or diastolic BP greater than the pediatric 95th percentile
hypertension in urban Houston public schools. These chil- or BP load (percentage of BP values exceeding the 95th per-
dren recruited by screening comprised a small proportion of centile for the 24-hour period) greater than 25% were con-
patients in our clinic and were students aged 11–18 years in sidered to have ambulatory hypertension.23 Both BP and BP
Houston area public schools. Parents are notified in advance load will be used to define the severity of ambulatory hyper-
by a letter sent from each school regarding the screening pro- tension. Specifically, more severe ambulatory hypertension
gram. Forms were provided for parents to sign and return if was defined as mean systolic or diastolic BP greater than
they did not wish their child to participate. At each screen- the 95th percentile and BP load greater than 50%. Subjects
ing, 3 seated BP measurements were made at least 1-minute with casual hypertension but with 24-hour systolic BP and
apart using oscillometric monitors. Students found to have diastolic BP less than the pediatric 95th percentile and BP
an average BP above the gender, age, and height-percentile load less than 25% were considered to have WCH. Control
specific 95th percentile per the Fourth Report4 underwent population for this study comprised of children who were
a second set of BP measurements 1–2 weeks later. Students referred for elevated BP by their primary care providers but
found to have BP above the 95th percentile at the 2nd screen- on further evaluation in the hypertension clinic had WCH.
ing underwent a 3rd set of BP measurements an additional
1–2 weeks later. Students with elevated BP on all 3 occasions Diagnosis of essential hypertension
were considered to be hypertensive. Families of hyperten-
sive children were informed of the persistent BP elevation Once hypertension was confirmed to have ambulatory
and invited for a clinic-based evaluation, either to our clinic hypertension using ABPM, all children underwent further
or with their primary care physician. Patients recruited evaluation for secondary hypertension per recommen-
by these 2 methods, i.e., school screening or referral as dations by the Fourth Working Group.4 The diagnosis of
described above, have been reported to be similar in a prior primary hypertension or EH was made by extensive evalu-
publication22; this was confirmed in our dataset during our ation per recommendations by the Fourth Working Group4
analysis. All enrolled children underwent further evaluation including a urinary evaluation, blood tests, renal ultrasound,
including ambulatory BP monitoring (ABPM) as described and echocardiogram in all children. Thus, the criteria for the
further below. Control population included those children diagnosis of EH were: (i) clinic BP elevation above the 95th
who had a normal measures by ABPM and they underwent percentile on 3 previous occasions, (ii) positive 24-hour
laboratory testing, vascular ultrasound, and a transthoracic ABPM, (iii) absence of secondary causes of hypertension,

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 Myocardial Performance Index in Hypertensive Children

and (iv) no concurrent medication with the potential to raise global function was determined at 0.33 in 1 study33 and 0.35
BP (e.g., steroids, central stimulants). in another study.34 In adults and children, an MPI value of
less than 0.40 is considered normal for the left ventricular
Echocardiography and vascular ultrasound protocol global function with higher values indicating left ventricu-
lar dysfunction and we used this value to define normal vs.
All children underwent a transthoracic echocardiogram abnormal. Simultaneous electrocardiogram tracings were
and a vascular ultrasound. The reproducibility of measure- obtained along with the Doppler tracing and an average of 5
ments for both echocardiogram and vascular ultrasound consecutive heart beats or cardiac cycles were used to deter-
were determined for repeat assessments for 10 values by the mine the mean values.
same sonographer and by 2 sonographers independently Carotid artery duplex ultrasound was performed by pro-
yielding kappa values of greater than 0.8. The echocardio- tocol to measure carotid intimal medial thickness by expe-
graphic studies were performed on all participants using rienced vascular sonographers in a standard manner35 who
an Acuson Sequoia 512 ultrasound machine (Siemens, PA). were unaware of the ABPM or echocardiography results.
The heart was imaged by trained pediatric sonographers The thickest carotid intimal medial thickness complex of
via a complete transthoracic echocardiographic examina-

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the far wall of the distal common carotid artery was meas-
tion for cross-sectional two-dimensional grayscale images, ured in longitudinal B-mode section using a high-resolu-
Doppler, and M-mode imaging using a standard protocol tion 8 MHz transducer. The right and left carotid intimal
to evaluate congenital cardiac disease24 and hypertensive medial thicknesses were averaged for the purpose of this
cardiomyopathy.25,26 Those children with congenital cardiac study.
disease were excluded from this study. The echocardio-
grams measurements were made in a manner blinded the
Statistical analysis
BP status of the child. Estimates of left ventricular pump
function included rate-corrected velocity of circumfer- The cases with ambulatory hypertension (EH) and WCH
ential fiber shortening, shortening fraction, and ejection were compared to one another. Data from the medical
fraction. Estimates of left ventricular afterload was deter- records was abstracted and tabulated. Continuous variables
mined by end systolic wall stress, both meridional along were compared between groups using parametric (t-tests,
long axis from apex to the base of the heart and circum- analysis of variance with post hoc Tukey) and nonparamet-
ferential along short axis. Estimates of left ventricular ric (Mann–Whitney, Kruskal Wallis) tests depending on the
relaxation included mitral valve inflow velocities and time distribution of the variable. Chi-square tests were used to
intervals. Quantification of left ventricular mass (LVM) compare categorical variables across groups. Multivariable
was made from 2-dimensionally guided M-mode measure- linear regression analyses were performed separately to
ments made during diastole of the left ventricular internal assess the independent effects of EH (compared to WCH)
dimension, interventricular septal thickness, and posterior and the independent effect of ABPM parameters. Both of
wall thickness according to methods established by the these involved regression models that adjusted for vari-
American Society of Echocardiography.25,26 The LVM was ous demographic, anthropometric, BP, laboratory, vascular
calculated using the equation reported by Devereux et al.27 ultrasound, and echocardiographic parameters. Regression
The LVM index (LVMI2.7) was calculated by dividing LVM models were run with and without inclusion of interaction
by height in meters to the 2.7th power to minimize the terms to assess independent and interaction effects. All anal-
effect of age, gender, ethnicity, and overweight status.28,29 yses were performed in STATA (v.10, College Station, TX).
The LVH was defined as LVMI 38.6 g/m2.7, a value reported Statistical significance was assumed at a type I error rate of
to represent the pediatric 95th percentile of LVMI2.7 in 0.05.
normotensive healthy children.28,29 The measurements of
diastolic function (peak E and A velocities, E/A ratio, iso-
volumic relaxation time, and deceleration times) were RESULTS
made by simultaneous transmitral and transaortic spectral
Doppler flow velocities.25 The left ventricular endocardial A total of 66 children (24 with EH, 42 with WCH, males
shortening fraction, ejection fraction,24–26 velocity of cir- 61%, median age of 13  years, range 10–17  years) were
cumferential fiber shortening corrected for the heart rate, enrolled in the study. The demographic, anthropometric,
circumferential end systolic wall stress,30,31 and meridional vascular ultrasound, and laboratory parameters were simi-
end systolic wall stress31,32 were evaluated in the standard lar between the EH and WCH groups (Table 1). The aver-
manner using M-Mode. The MPI or the Tei index was age systolic BP in the clinic were elevated in both groups
assessed in the standard manner described by Tei et al.19 by (Table 2). However, the systolic BP was significantly higher
sequential recording of the mitral valve inflow at the tip of among those with EH vs. WCH (mean: 139 mm Hg, SD:
the mitral leaflets in diastole and the left ventricular outflow 12 mm Hg vs. 131 mm Hg, SD 10 mm Hg, respectively;
just below the aortic valve in systole via spectral pulse wave P = 0.01). Table 3 compares the echocardiogram parameters
Doppler in the apical 4 chambered and 5-chambered view between the 2 groups. Overall, LVH was seen in 36% of chil-
respectively. The MPI was defined as the sum of isovolumic dren whereby the left ventricular geometry was as follows:
contraction time and isovolumic relaxation time divided by eccentric hypertrophy in 11 (26%) of the WCH children and
the left ventricular ejection time.18 In normal children aged in 8 (33%) of the EH children and concentric hypertrophy in
3 years and older, the average MPI value for left ventricular 1 (2%) WCH children and in 4 (17%) EH children.

American Journal of Hypertension  3

Gupta-Malhotra et al.

Table 1.  Demographic, anthropometric, laboratory, and vascular ultrasonography profiles of children with white coat hypertension and
essential hypertension

White coat Essential

Parameter hypertension hypertension P-value

Number (n) 42 24
Age, years 13.5 (1.7) 13.5 (1.8) 0.84
Male, n (%) 27 (64) 13 (54) 0.42
Ethnicity, n (%)
 NHW 13 (31) 8 (33.3) 0.89
 Black 15 (36) 8 (33.3)
 Hispanic 13 (31) 8 (33.3)

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 Asian 1 (2) 0 (0)
Weight, kg 72.7 (19.6) 71 (21.1) 0.74
Height, m 1.6 (0.1) 1.6 (0.1) 0.61
BMI, kg/m2 27 (6.5) 26.9 (8.7) 0.99
BMI z-score 1.4 (0.9) 1.30 (0.9) 0.56
Obese, n (%) 13 (28) 5 (19) 0.35
Total cholesterol, mg/dl 171.7 (37.2) 167.5 (30.9) 0.70
High density lipoprotein, mg/dl 36.1 (8.3) 39.4 (10) 0.27
Low density lipoprotein, mg/dl 109.7 (30) 105.3 (37.6) 0.68
Triglycerides, mg/dl 117.7 (84.1) 110.8 (97.2) 0.80
Fasting glucose, mg/dl 89.2 (8.5) 86.7 (12.8) 0.42
Urine albumin/creatinine, median (IQR) 0.03 (0.02–0.05) 0.04 (0.02–0.06) 0.60
Carotid intimal medial thickness, mm 0.60 (0.11) 0.56 (0.08) 0.19

All values shown are mean (with SD) unless specified.

Abbreviations: BMI, body mass index; IQR, interquartile range.

The echocardiographic left ventricular diastolic param- DISCUSSION

eters and systolic parameters were similar between the 2
groups (Table 3). However, MPI was higher among EH chil- Although the prevalence of EH among children is much
dren compared to WCH (0.28 SD: 0.07 vs. 0.31 SD: 0.08, lower than in adults, the recent trends amongst adolescents
P = 0.04). Overall, 5 (20%) children with EH had MPI values in The United States of America have shown a “disconcert-
greater than 0.4. Three of these children were overweight, ingly high” abnormal cardiovascular health behaviors and
while 2 of them had eccentric LVH. Comparatively, only risk factors, including hypertension.36 The status of child-
3 (7%) of the children with WCH had MPI values greater hood cardiovascular health is a strong predictor of cardio-
than 0.4; 2 of these 3 children in the WCH group were over- vascular health in adulthood37 and hence early detection
weight and 1 of them also had eccentric LVH. Although and treatment of childhood onset EH has implications into
a significant difference was observed in MPI between the later life.
EH and WCH patients, this was not apparent upon multi- MPI evaluates both systolic and diastolic dysfunction as
variable linear regression analysis when adjusted for gen- a single measure and has been used extensively for longitu-
der, ethnicity, heart rate, carotid intimal medial thickness, dinal tracking and prognostication in various forms of car-
and LVH. MPI correlated with the mean systolic (r = 0.63, diomyopathy in adults. Several studies have shown similar
P < 0.01) and diastolic (r = 0.50, P = 0.01) BP obtained from results with MPI being among the earliest and the strong-
24-hour ABPM in EH children (Figure 1A,B, respectively). est predictor of left ventricular disease18,38–41 and adverse
This correlation was not observed in those with normal cardiovascular outcomes in adults.42,43 The MPI can detect
ABPM or WCH. early left ventricular diastolic function and has been found
Upon multivariable linear regression analysis of only to correlate with hemodynamic parameters of diastolic dys-
the children with EH, for every 10 unit increase in 24-hour function or impaired relaxation.17 Furthermore, as the left
mean systolic BP, the MPI value increased by 0.14 units ventricular systolic function reduces, the MPI increases. This
(P  <  0.01) (Table  4). Other than the mean systolic BP as increase in MPI is inversely correlated to a decreasing ejec-
obtained via ABPM, the multivariable linear regression tion fraction.17 Thus, the Doppler-derived MPI is a powerful
analysis did not yield any other significant associations quantitative measure of global left ventricular function. MPI
with MPI. has been found to be the strongest independent predictor of

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 Myocardial Performance Index in Hypertensive Children

Table 2.  Blood pressure profile of children with white coat hypertension and essential hypertension

Systolic Diastolic

White coat Essential White coat Essential

Parameter hypertension hypertension P-value hypertension hypertension P-value

Clinic BPa (mm Hg) 131 (10) 139 (12) 0.01 76 (10) 78 (12) 0.47
Clinic BP Index 1.0 (0.1) 1.1 (0.1) <0.01 0.9 (0.1) 0.9 (0.1) 0.40
Ambulatory BP (mm Hg)
 Total 117 (5) 131 (6) <0.01 67 (5) 72 (8) <0.01
 Waking 124 (5) 137 (6) <0.01 72 (6) 77 (10) 0.01
 Sleeping 107 (7) 119 (9) <0.01 58 (6) 62 (7) 0.02
Ambulatory BP index

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 Total 0.93 (0.04) 1.05 (0.04) <0.01 0.87 (0.11) 0.94 (0.11) <0.01
 Waking 0.93 (0.04) 1.04 (0.04) <0.01 0.85 (0.07) 0.91 (0.12) 0.01
 Sleeping 0.92 (0.06) 1.03 (0.08) <<0.01 0.86 (0.09) 0.92 (0.11) 0.02
Ambulatory BP load (%)
 Total 21 (12) 65 (17) <0.01 15 (12) 30 (24) <0.01
 Waking 22 (15) 64 (18) <0.01 14 (13) 30 (24) <0.001
 Sleeping 17 (16) 57 (29) <0.01 14 (14) 30 (29) <0.01
Ambulatory BP dip (%) 13 (5) 13 (6) 0.90 20 (9) 20 (8) 0.90

All values shown are mean (SD). 

Abbreviation: BP, blood pressure. 
aClinic BP are average of 3 measurements.

Table 3.  Echocardiographic profile of children with white coat hypertension and essential hypertension

Parameter White coat hypertension Essential hypertension P-value

Heart rate, beats/min 73.2 (12.7) 73.6 (13.4) 0.90

Left ventricular mass, g 136.4 (39.5) 138.4 (42.5) 0.85
Left ventricular mass index, g/BSA 74.7 (14.8) 77.9 (19.3) 0.45
Left ventricular mass index 2.7, g/cm2.7 35.6 (8) 36.7 (8.2) 0.62
Relative wall thickness 0.34 (0.04) 0.37 (0.05) 0.05
Left ventricular hypertrophy, n (%) 12 (29) 12 (50) 0.08
Shortening fraction, % 43.5 (13) 43.4 (9) 0.97
Ejection fraction, % 0.80 (0.1) 0.80 (0.1) 0.63
Meridional end systolic wall stress, g/cm2 30.7 (3.6) 30.7 (3.1) 0.96
Circumferential end systolic wall stress, g/cm2 75.4 (27.9) 78.1 (33.8) 0.73
Mitral valve E wave, cm/s 101 (18.3) 95.3 (20) 0.24
Mitral valve A wave, cm/s 53.3 (13.1) 52.9 (14.6) 0.90
Velocity of circumferential fiber shortening, circ/s 1.06 (0.34) 1.06 (0.24) 0.95
Mitral valve E/A 1.97 (0.46) 1.88 (0.48) 0.46
Mitral valve deceleration time, ms 182.8 (30.6) 170.6 (37.1) 0.16
Mitral valve acceleration time, ms 91.6 (20.5) 94.1 (16.4) 0.61
Isovolumic relaxation time, ms 73.0 (14.2) 74.5 (11.6) 0.67
Left ventricular ejection time, m 294.8 (21.6) 293 (24.1) 0.76
Myocardial performance index (MPI) 0.28 (0.07) 0.31 (0.08) 0.04

Values are mean (with SD) for all except as noted.

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Gupta-Malhotra et al.

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Figure 1.  Correlation of the myocardial performance index with 24-hour ambulatory systolic (A) and diastolic (B) blood pressure among children with
white coat hypertension and essential hypertension.

the development of congestive heart failure from left ven- MPI values in both groups were mostly within normal limits
tricular dysfunction after myocardial infarction in adults.41 and the difference in the MPI values between the WCH and
Furthermore, MPI can also be utilized as a longitudinal EH groups was very small at 0.03. Additionally, we failed to
marker to evaluate any improvement in left ventricular func- identify a significant difference in an adjusted model. This
tion in adults with ischemic heart disease during therapy lack of an association may be due to the fact that our control
with renin–angiotensin inhibitors.44 population comprised of higher-risk children with obesity
We evaluated a group of well-phenotyped, multiethnic, and WCH. Furthermore, a higher number of children with
untreated childhood onset EH by utilizing several stand- EH had abnormal MPI values greater than 0.4 compared to
ard diastolic (transmitral Doppler flow velocities and inter- the children with WCH (20% vs. 7%); 2 of these 3 children
vals) and systolic (endocardial shortening fraction, ejection in the WCH group were overweight and 1 of them also had
fraction, velocity of circumferential fiber shortening, end eccentric LVH. It is also important to note that the classifica-
systolic wall stress) echocardiographic parameters. In our tion of WCH or EH was based on the continuous variables
study, these conventional measurements did not reveal any obtained from the ABPM. Stratification of a continuous
difference in left ventricular systolic and/or diastolic func- variables (such as mean systolic BP) into a categorical vari-
tion between children with EH compared to children with able (such as EH) results in loss of information, decreased
WCH. However, the global measure of left ventricular sys- power and underestimation of the magnitude of variabil-
tolic and diastolic function, as assessed by the MPI19 showed ity in the outcome.45 These issues are more problematic in
detectable differences between the same 2 groups in our smaller sample sizes. It should be noted that the children in
patient population upon univariable analysis. The average our study, most probably represent patients in early stages

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 Myocardial Performance Index in Hypertensive Children

Table 4.  Change in myocardial performance index with changes in selected parameters among children with essential hypertension

Crude Adjusted

Parameter Coefficient, β 95% CI Coefficient, β 95% CI

Mean SBPa 0.082 0.040 to 0.125 0.137 0.028 to 0.246

Mean DBPa 0.054 0.015 to 0.092 −0.012 −0.091 to 0.066
Age −0.003 −0.021 to 0.016 0.012 −0.029 to 0.053
Male −0.016 −0.083 to 0.050 −0.019 −0.108 to 0.07
Ethnicity
 White Referent Referent
 Black −0.005 −0.09 to 0.080 0.037 −0.004 to 0.006
 Hispanic −0.024 −0.109 to 0.061 −0.040 −0.003 to 0.004

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BMI 0.001 −0.003 to 0.005 0.001 −0.004 to 0.006
Heart rate 0.001 −0.001 to 0.004 0.001 −0.003 to 0.004
CIMT −0.028 −0.517 to 0.460 −0.182 −0.981 to 0.616
LVH −0.015 −0.081 to 0.051 −0.008 −0.089 to 0.073

Abbreviations: BMI, body mass index; CI, confidence interval; CIMT, carotid intimal medial thickness; DBP, diastolic blood pressure; LVH, left
ventricular hypertrophy; SBP, systolic blood pressure.
aMean blood pressures are in 10 unit increments.

of their hypertensive disease process, with relatively minor group includes children with WCH. We found that children
changes in their MPI values. with EH had a significantly higher systolic BP in the clinic
In this study we demonstrated that sustained hyperten- in comparison to children with WCH, while their diastolic
sion was associated with MPI elevation in children with BP were similar. We also found that MPI had poor correla-
EH. Although there are no trends of changes in the WCH tions with BP measurements in clinic but strong correlations
children, higher MPI values were associated with increasing ambulatory measurements on an ABPM. These findings in
mean systolic BP in the EH children. MPI correlated with our study underscore the fact that children with WCH are
the mean systolic and diastolic BP obtained from 24-hour not the same as those with EH. Therefore, appropriate diag-
ABPM in EH children (Figure 1). We found the mean sys- nosis of EH with ABPM should be considered. Or else, MPI
tolic BP as ascertained by 24-hour ABPM correlated signifi- may serve as an alternative to an ABPM in evaluating a child
cantly with MPI only in children with EH. Thus, in these with elevated BP in clinic, where the ABPM is unavailable to
children, for every 10 unit increase in 24-hour mean systolic determine the severity of hypertension or exclude children
BP, the MPI value increased by 0.14 units. In other studies, with WCH. Where periodic ABPM measures are not pos-
the MPI has been found to correlate with invasive measure- sible in all children due to various reasons, MPI may serve
ments16 and has the advantage of being largely independent as a surrogate measurement to follow-up prospectively on
of heart rate and ventricular geometry.19,46,47 Our study had the cardiovascular changes due to sustained hypertension.
similar findings where MPI was independent of heart rate Future studies should evaluate the prospective prognostic
and ventricular geometry. Unlike LVH, MPI values were not value of this measurement.
found to be affected by body mass index in our study and
hence MPI may be more reflective of endorgan damage in Limitations
hypertensive cardiomyopathy. Thus the MPI can serve as a
single, quick, noninvasive, reproducible, and easy method The study evaluated a small number of children from a
of detection of subclinical hypertensive heart disease18,19 single tertiary care medical center, thus limiting the power
even in the young. This simple echocardiographic parameter and generalizability of the study. The lack of any observable
may be useful for tracking and determining the severity of significant association between demographic, BP, and echo-
the disease, although this needs to be established by future cardiographic parameters and MPI during multivariable
research. The MPI may be helpful in longitudinal tracking analysis may be due to the relatively small sample size in our
for progression of disease in the same child and thus help study. We recommend a larger study to confirm our findings.
with therapeutic decision making. It is also possible that the MPI distribution in these children
In the current study, we performed a 24-hour ABPM on is independent on these parameters and is a function of
all children and differentiated those with EH and WCH. unmeasured variables such as clinical outcomes. Finally, we
Due to barriers in obtaining ABPM on all children with did not evaluate the children by serum biomarkers such as
elevated BP, the appropriate diagnosis may not be made in brain natriuretic peptide levels, by imaging modalities such
some children, thereby mislabeling children with WCH as as cardiac magnetic resonance imaging, or by echocardio-
having EH. Majority of pediatricians do no utilize an ABPM graphic techniques such as tissue Doppler imaging, strain
for the diagnosis of EH in children and hence their EH imaging, or speckle tracking.
American Journal of Hypertension  7
Gupta-Malhotra et al.

We found the increasing MPI was associated with increas- 8. Stabouli S, Kotsis V, Toumanidis S, Papamichael C, Constantopoulos A,
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ACKNOWLEDGMENTS 12. Kim GB, Kwon BS, Kang HG, Ha JW, Ha IS, Noh CI, Choi JY, Kim
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Heart, Lung, and Blood Institute. The content is solely the
Yukiiri K, Nishiyama A, Kohno M, Goda F. Comparison of central
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American Journal of Hypertension  9