J Cardiol 2007 Jun; 49（6）: 323 – 329

Influence of Abdominal Circumference on the Inappropriateness ofLeft Ventricular Mass and Diastolic
Function in Non-Obese Patients
Jinho SHIN, MD
Jae Ung LEE, MD
Kyung Soo KIM, MD
Soon Gil KIM, MD
Jeong Hyun KIM, MD
Heon Kil LIM, MD
Bang Hun LEE, MD
Abstract ─────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────
Background and Objectives. Adipose tissue may be one of the sources of the humoral factors increasing
left ventricular mass（LVM）via non-hemodynamic mechanisms. The involvement of visceral obesity inexcessive or inappropriate LVM has not been established. We investigated the effect of abdominal circumference on the inappropriateness of LVM in non-obese patients.
Methods. Echocardiographic parameters for LVM and the indices for diastolic function were analyzed
in 312 non-obese patients. Inappropriate LVM was defined as observed/predicted ratio（OPR）of LVM ＞
130%. Predicted LVM was calculated by the equation of 54.9 ＋ 7.62 × height（m2.7）＋ 0.67 × stroke work
−13.2 × sex（male ＝ 1, female ＝ 2）. Abdominal obesity was defined by abdominal circumference ＞ 80
cm in females and ＞ 90 cm in males.
Results. Multiple regression analysis showed abdominal circumference was a significant factor for OPR
of LVM（β＝ 0.256）which was independent of age（β＝ 0.215）, sex, systolic blood pressure（β＝−0.232）, body mass index（β＝ 0.232）, and fasting blood glucose（β＝ 0.146）. Odds ratio（OR）of, which was independent of age ＞
abdominal obesity for inappropriate LVM was 3.28
（1.72−6.28）− 55[OR :
2
22.5
kg/m
[OR
:
2.24
（
1.13−4.41）],
anddiabetes
mellitus[OR :2.17（1.11−4.25）], body mass index ＞−]. Age and sex adjusted abdominal circumference（86.4 ± 0.9 vs 82.1 ± 0.5）
, abdominal
2.27（1.06−4.85）
obesity（28.1% vs 54.1%）, and metabolic syndrome（19.4% vs 51.6%）were higher in the inappropriate
LVM group than the appropriate LVM group（p ＜ 0.001）.
Conclusions. Abdominal obesity or the presence of metabolic syndrome is an important factor to predict
the inappropriateness of LVM even in non-obese patients.
──────────────────────────────────────────────────────────────────────────────────────────────────────────────────────J Cardiol 2007 Jun; 49（6）: 323−329

Key Words■ Obesity（body mass index）■ Hypertrophy（left ventricular）

INTRODUCTION
Left ventricular hypertrophy（ LVH）is a wellknown prognostic factor for cardiovascular
events.1）Left ventricular mass（LVM）is known to

be influenced by hemodynamic factors such as
blood pressure and stroke work as well as constitutional factors such as body size and sex.2）Nonhemodynamic factors such as genetic traits,
humoral factors and local tissue factors other than──────────────────────────────────────────────
Cardiology Division, Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
Address for correspondence : LEE Bang Hun, MD, Cardiology Division, Department of Internal Medicine, Hanyang University
Medical Center, #17 Hangdang-dong Sungdong-Ku, Seoul, Korea 133−792 ; E-mail : leebh@hanyang.ac.kr
Manuscript received January 31, 2007 ; revised March 5, 2007 ; accepted March 8, 2007

323

324

Shin, Lee, Kim et albody size and sex may be involved in hypertrophyof the left ventricle.3）The trophic effects of growth
factors may be a cause of the inappropriateness of
LVM. Adipose tissue may be one of the sources of
the humoral factors related to LVH. Increased bodymass index and insulin resistance were reported to
be associated with LVH. 4,5）Appropriateness of
LVM may represented by the percentage ratio ofobserved LVM to predicted LVM based on height,
sex and stroke work. Inappropriateness of LVM is
an independent prognostic factor regardless of thepresence of LVH or not.6）However, the involvement of abdominal obesity or metabolic syndrome
in excessively or inappropriately increased LVM
has not been established.7）
This study was performed to investigate theeffect of abdominal obesity on the inappropriateness of LVM, especially in non-obese patients.
SUBJECTS AND METHODSThe echocardiography database of 2,515 consecutive patients from December 1, 2004 to August 31,
2005 in Hanyang University Hospital, Seoul, Korea
were analyzed in a cross-sectional design. During
the study period, height, weight, abdominal circumference, blood pressure, and heart rate were measured before echocardiography. Abdominal circumference was measured at the mid-level between theiliac crest and lower costal margin with a springloaded measuring tape in the sitting or standing
position. Duplicate measurements were made in all
patients, and the average was used for analysis
unless there was ＜ 3% difference between duplicates, in which case the measurement was not used
for analysis. The levels of total cholesterol, triglyceride, high-density lipoprotein（ HDL）, fastingblood glucose, and serum creatinine were gatheredfrom the medical records.
All patients with echocardiography findings ofwall motion abnormality, grade II or more valvular
regurgitation, any valvular stenosis, pericardial disease, and poor M-mode measurements includinginterrogation angle of 10 °or more were excluded.
Patients with clinical heart failure or known cardiac
disease history and hypertensive patients receiving
antihypertensive medication were excluded.
Patients with serum creatinine level greater than
1.5 mg/dl in males and 1.4 mg/dl in females were
excluded. Among the remaining 951 patients compatible with these criteria, 585 patients with body2
mass index ＞− 25 kg/m and 54 patients with incom-

plete laboratory data were excluded. Finally, 312
patients were included in this study. The study protocol was approved by the Institutional Review
Board of Hanyang University Medical Center.
Informed consent was acquired from each patient
regarding the process of examination and use of thedata.
Abdominal obesity is defined as abdominal circumference ＞ 80 cm in females and ＞ 90 cm inmales with the Asia-Pacific perspective. 8）
Metabolic syndrome was defined by Adult
Treatment Panel III guideline for the othercriteria.9）
Echocardiography
Two-dimensional and guided M-mode echocardiography were performed on each subject by a single expert sonographer with a commercially available machine（ IE-33, Philips）with a 1−5 MHz
transducer. Measurements for M-mode guided calculations of LVM were taken at or just below thetip of the mitral valve with a paper speed of
50 mm/sec. At the time of the R wave uptake onelectrocardiography minitoring, LV interventricularseptal wall thickness（IVSTd）, internal dimension（LVDd）and posterior wall thickness（PWTd）were
measured from leading edge to leading edge
according to the guidelines of the American Societyof Echocardiography. LVM was calculated by the3equation of 1.04 ×｛（IVSTd ＋ LVDd ＋ PWTd）
3
10）−LVDd ｝× 0.8 ＋ 0.6.
Doppler echocardiographic recordings were performed by pulsed-wave Doppler with the sample
volume at the tip of mitral valve in the apical fourchamber view and recorded at a paper speed of
100 mm/sec. Early（E）and late（A）diastolic filling
velocities, deceleration time（DT）and early to latevelocity（E/A）ratio were determined as previously
reported. 11）For patients below 55 years of age,
impaired relaxation was diagnosed if there was E/Aratio ＜ or DT ＞
− 240 msec. For older patients, both
E/A ratio ＜ 0.8 and DT ＞
− 240 msec were required
to diagnose impaired relaxation.12）
Appropriateness of LVM
Appropriateness of LVM was expressed as
observed/predicted ratio（OPR）of LVM. 3）Echocardiography data were obtained from 368 subjects（184 males, 184 females）with normal body mass
and with normal blood presindex（below 25 g/m2）
sure from the health screening program in a hospiJ Cardiol 2007 Jun; 49（6）: 323 – 329

Abdominal Obesity and Left Ventricular Mass

325

groups, age and sex were adjusted using leastsquare means by the general linear model. For multiple comparisons between groups, Sidak confidence interval adjustment was added. For thenumerical variables, the determinants of OPR wereanalyzed using a stepwise multiple linear regression model. The relationships of dichotomous categorical variables and inappropriate LVM wereexpressed as odds ratios with 95% confidence interval by stepwise multiple logistic regression analysis. All comparisons were 2-tailed, and p ＜ 0.05
was considered to be statistically significant.
RESULTS

Fig. 1 Proportion of left ventricular mass according to
the appropriateness and left ventricular hypertrophy
LVM ＝ left ventricular mass.

tal（n ＝ 184）and a rural community（n ＝ 184）
according to the previously described methods.2）
LVMs indexed by body surface area were 93.1 ±17.2 g/m 2 for males and 84.3 ± 14.5 g/m 2 forfemales. In this study, we adopted LVM indexed byheight to highlight the effect of weight and thetransformation of the height in meters to the powerof 2.7 was most approximate to the linearity. LVMs
indexed by height（m2.7）were 38.9 ± 7.8 g/m2.7 formale and 38.1 ± 7.5 g/m2.7 for female. In a multiple
regression model including stroke volume, sex, andheight2.7, LVM was predicted by the equation of
54.9 ＋ 7.62 × height（m2.7）＋ 0.67 × stroke work
（g-m/beat）−13.2 × sex（ male ＝ 1, female ＝ 2）
（constant ＝ 54.9 ± 14.7 g, adjusted R 2 ＝ 0.576,
SEE ＝ 21.67, p ＝ 0.001）. Age of the subject was
52.1 ± 16.2. The observed/predicted LVM was
99.9 ± 14.9% for males and 100.2 ± 15.2% forfemales.13）
We set the cut-off value（mean ± 2SD）for LVH
as 54 g/m 2.7 for both sexes. The cut-off value
between inappropriate LVM group and appropriate
LVM group was 130% or higher for both sexes.
Statistical analysis
Data are expressed as mean ± SD. For the simple analysis of general characteristics and the sex
difference, chi-square test and independent t-test
were performed. Comparing the means between
J Cardiol 2007 Jun; 49（6）: 323 – 329

General characteristics of the subjects
Age of the subjects was 54.9 ± 13.0 yea rs（range : 19−86 years）. The female ratio was
159/312（50.9%）. Seventeen patients（5.4%）had
hypertension, 46（14.7%）had diabetes mellitus, 82（26.2%）
had metabolic syndromes, and 107（34.3%）
had abdominal obesity. Increased fasting blood glucose levels（ ＞were observed in 65− 110 mg/dl）（20.8%）patients. Increased triglyceride levels（＞− 150 m g/dl）were observed in 73（23.6%）
patients. HDL level was less than 40 mg/dl（inmales）or 50 mg/dl（in females）in 196（ 62.8%）
patients. Blood pressures were 130/85 mmHg or
higher in 78（24.8%）
patients.
In 223 patients（71.4%）, LV was normal regarding both the LVM index and the appropriateness.
Among patients with apparently normal LVM
index, 38（12.2%）
patients had inappropriate LVM.
Among 51 LVH patients, 18 patients（5.8%）had
appropriate LVH and 33（10.6%）
patients had inappropriate LVH（Fig. 1）.
Abdominal obesity and inappropriate LVM weremore frequent in females（15.9% vs 52.1%, 16.0%
vs 29.3%, respectively ; Table 1）.
Factors determining OPR of LVM
In a simple correlation analysis, abdominal circumference had a significant correlation with OPR
of LVM（r ＝ 0.376, p ＜ 0.001 ; Fig. 2）. Regarding
OPR of LVM, Pearson correlation coefficients ofage（r ＝ 0.296）, female sex（r ＝ 0.202）, body massindex（ r ＝ 0.351）, systolic blood pressure（r ＝−0.159）, fasting blood glucose（r ＝ 0.236）,
and triglyceride（r ＝ 0.167）were also significant.
Correlations between OPR of LVM and other parameters such as diastolic blood pressure（r ＝−0.079）, heart rate（ r ＝−0.053）, serum326

Shin, Lee, Kim et al

Table 1 General characteristics of the subjects
Male

Female（n＝153） （n＝159）
Age（yr）

54.3±13.6

55.5±13.3

Height（cm）

169.0±5.9＊155.4±6.1

63.4±7.6＊

53.8±6.1

Body mass index（kg/m ）

22.2±2.2

22.3±2.1

Abdominal circumference（cm）

84.4±6.4＊

82.0±9.1

Systolic blood pressure（mmHg）

122.3±14.5＊ 118.2±14.6

Diastolic blood pressure（mmHg）

78.6±9.676.8±12.1

Heart rate（beats/min）

70.1±13.3

70.3±12.1

Total cholesterol（mg/dl）

178.6±39.0＊ 193.5±39.8

Fasting blood glucose（mg/dl）

106.7±33.0

Creatinine（mg/dl）

1.09±0.18＊

0.82±0.17

Triglyceride（mg/dl）

127.7±66.0

122.1±73.7

High-density lipoprotein（mg/dl）

39.5±12.9＊46.2±13.6

Metabolic syndrome

21.7%

30.6%

Abdominal obesity

15.9%＊

52.1%＞110 mg/dl） 26.0%＊
Fasting blood glucose（−

15.9%＞150 mg/dl）
Triglyceride（−

28.0%＊

19.1%

High-density lipoprotein（＜40/50 mg/dl in male/female）

60.7%

65.0%

Weight（kg）
2

103.5±37.8

30.8%＊
19.2%
41.9±10.8 43.8±12.7
LVM index（g/m ）＞ 54 g/m2.7
13.3%
LVM index−
18.5%
Observed/predicted ratio of LVM（%）110.4±19.1＊ 118.8±21.8＞130%16.0%＊OPR of LVM −
29.3%
12.1%
Impaired relaxation
15.6%＞ 130/85 mmHg
Blood pressure −2.7

Continuous values are mean±SD.＊p＜0.05 vs female.
OPR＝observed/predicted ratio. Other abbreviation as in Fig. 1.

creatinine level（ r ＝ 0.02）, total cholesterol（r ＝−0.003）, and HDL（r ＝−0.072）were notsignificant. Partial correlation coefficient between
abdominal circumference and OPR of LVM adjusted for age, sex, body mass index, fasting blood glucose level, systolic blood pressure, and triglyceride
level was also significant（adjusted r ＝ 0.223, p ＜0.001）.
In multiple linear regression analysis, abdominal
circumference was a significant factor for OPR ofLVM（β＝ 0.256, p ＜ 0.001）which was independent of age（β＝ 0.215, p ＜ 0.001）, female sex（β＝ 0.206, p ＜ 0.001 ）, systolic blood pressure（β＝ − 0.232, p ＜ 0.001）, body mass index（β＝0.232, p ＜ 0.001）, and fasting blood glucose（β＝0.146, p ＝ 0.004）.
In multiple logistic regression analysis, odds
ratio（OR）of abdominal obesity for inappropriate

LVM was 3.28（1.72−6.28）, which was indepen［OR : 2.17（1.11−4.25）］, bodydent of age ＞− 55
2
mass index ＞
22.5
kg/m［OR: 2.24（1.13−4.41）］,−and the presence of diabetes mellitus［OR : 2.27
. Sex difference was not a significant（1.06−4.85）］
factor for inappropriate LVM.
Comparison between appropriate LVM group vsinappropriate LVM group
Appropriate LVM was found in 77.2%（n ＝ 241）of patients and inappropriate LVM in 22.8%（n ＝71）. Patients with inappropriate LVM were older（53.1 ± 13.4 vs 62.3 ± 10.9 yr, p ＜ 0.001）, more
likely to be female, i.e. the proportion of female
was 46.4% in the appropriate LVM group and67.2% in the inappropriate LVM group（p ＜0.01）.
Age adjusted abdominal circumferences werehigher in the inappropriate LVM group than appropriate LVM group in both males（83.7 ± 8.6 vs 87.8
± 5.9 cm, p ＝ 0.004）and females（80.9 ± 7.4 vs84.2 ± 7.5 cm, p ＝ 0.04 ; Fig. 3）.
When adjusted for age and sex, abdominal obesity（ 28.1% vs 54.1%, p ＜ 0.001）and metabolic
syndrome（19.4% vs 51.6%, p ＜ 0.001）were more
frequent in the inappropriate LVM group than theappropriate LVM group. Adjusted fasting blood
glucose（102.4 ± 25.9 vs 114.0 ± 58.8 mg/dl, p ＝0.02）and triglyceride（119.6 ± 59.3 vs 142.3 ±99.6 mg/dl, p ＝ 0.02）levels were higher in the
inappropriate LVM group than the appropriate
LVM group. In subjects with inappropriate LVM,
transmitral E/A was lower and impaired relaxationof LV was more frequent（Table 2）.
DISCUSSION
In this study, we observed that abdominal obesity
is a determinant of inappropriate increase of LVM
even in patients regarded as non-obese by the criterion of body mass index, i.e. body mass index ＜ 25
g/m2. Moreover, its association with OPR of LVM
is independent of body mass index. The presence of
metabolic syndrome is also associated with inappropriate LVM. A previous study showed that
increased body mass index and metabolic abnormality were associated with inappropriately
increased LVM in hypertensive patients. 5）
Abdominal obesity or insulin resistance was also
demonstrated in hypertensive patients with LVH.14）
In our study, the frequency of metabolic syndrome
paralleled the frequency of abdominal obesity in
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327

Abdominal Obesity and Left Ventricular Mass

Fig. 2 Simple correlation between abdominal circumference and observed/
predicted ratio of left ventricularmass
Abbreviations as in Fig. 1, Table 1.

Table 2 Comparison between groups with appropriate
LVM vs inappropriate LVM

Age（yr）
Female23.1±2.1

82.1±7.6＊

86.4±7.9

Heart rate（beats /min）

J Cardiol 2007 Jun; 49（6）: 323 – 329＊
115（46.4%）
43（67.2%）

Abdominal circumference（cm）

Diastolic blood pressure（mmHg）

the two groups.
The clinical significance of OPR of LVM may be
explained by patients with inappropriate LVM withnormal LVM index. In our study, the proportion ofthese patients was 53.5%（n ＝ 38）among thepatients with 71 inappropriate LVM.
These patients may be regarded as normal if we
don t have the concept of appropriateness.
Considering the fact that our study was done forrelatively low risk subjects, the relationshipbetween abdominal obesity and the inappropriately
high LVM might be extended to apparently healthy
subjects with normal body mass index.
For this study, treated hypertensive patients were
excluded because the classes of antihypertensive

53.1±13.4＊ 62.3±10.9
21.9±2.1＊

Systolic blood pressure（mmHg）

aLVM ＝ appropriate left ventricular mass ; iLVM ＝
inappropriate left ventricular mass.

iLVM（n＝71）

Body mass index（kg/m2）
Abdominal obesity（＞90/80 cm in male/female）

Fig. 3 Abdominal circumferences adjusted for age inappropriate LVM vs inappropriate LVM
groups according to sex

aLVM（n＝241）

Total cholesterol（mg/dl）
Fasting blood glucose（mg/dl）
Creatinine（mg/dl）＊
42（54.1%）64（28.1%）

120.5±14.2 118.7±16.7
78.1±10.9 76.1±11.4
69.9±12.7 70.8±12.3
186.2±38.1 186.3±47.2
102.4±25.9＊ 114.0±58.8

Triglyceride（mg/dl）

0.89±0.19 0.91±0.21119.6±59.3＊ 142.3±99.6

High-density lipoprotein（mg/dl）

43.5±13.6

40.6±13.6

62.4%

64.3%

High-density lipoprotein（＜40/50 mg/dl in male/female）
Metabolic syndrome criteria number
Metabolic sydrome（%）
LVM index（g/m2.7）
Impaired relaxation（%）
E/A
Deceleration time（msec）
Isovolumic relaxation time（msec）

1.59±1.1＊

2.04±1.4＊

48（19.4%） 33（51.6%）39.3±19.1＊ 52.8±28.7＊29（11.7%）
38（59.4%）
1.20±0.38 ＊ 1.07±0.29

203.1±39.7 203.8±46.4
76.2 ±7.6
78.3±8.1

Continuous values are mean±SD. ＊p＜0.05 vs iLVM.
Abbreviations as in Figs. 1, 3.

328

Shin, Lee, Kim et al

medication may have differential effects on bloodpressure lowering and regression of LVM.15）The
effects of antihypertensive drugs on the appropriateness of LVM have not been reported.
Impaired relaxation was more frequent in the
inappropriate LVM group in our study. These
results are comparable to the previous study donein hypertensive patients.16）We used different criteria for the categorization of the transmitral flow
parameters since it is greatly influenced by the
aging process.
The inappropriate LVM group was older in ourstudy. Age is not an independent determinant of
LVM.2）Abdominal obesity increases with aging,which suggests that the relationship of abdominal
obesity and inappropriate LVM is usually compounded by age. After adjustment for age, we
found that the relationship of abdominal obesity
and inappropriate LVM was consistent and independent of the effect of age. Regarding the age factor, there is also another possibility that measurement errors may be exaggerated in the elderly.
Abdominal obesity is a stronger predictor of insulin
resistance than physical fitness in the elderly.17）

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