Vol 9 No 1 2021 (2).indd
International Journal of Integrated Health Sciences (IIJHS) 1
Correlation between MMP-9 Level and Diastolic Dysfunction in
Concentric Left Ventricular Hypertrophy Patients
Abstract
Objective: To establish the relationship between plasma matrix
metalloproteinase (MMP)-9 levels and diastolic functional abnormalities
using the E/e’ measurement in concentric type Hypertensive Heart
Disease (HHD) patients.
Methods: A cross-sectional study was conducted from November 2014
to January 2015 in population with hypertension and concentric Left
Ventricular Hypertrophy (LVH). Diastolic function was assessed with
E/e’ measurement using echocardiography. The relationship between
the two variables was analyzed using Spearman correlation.
Results: Thirty-nine subjects (14 males, 35.9%) with the average relative
wall thickness of 0.7(±0.15), average body weight of 63.45 (±12.97) kg,
average height of 155.51 (±7.12) cm, average body mass index of 26.23
(±5.08) kg/m2, and mean age of 55 (±10) years were fit to be included
in the analysis. The median systolic blood pressure was 140 (110–220)
mmHg while the median diastolic blood pressure and median left
ventricular mass index were 80 (70–110) mmHg and 119.24 (103.05-
205.69) g/m2, respectively. The median MMP-9 was measured at 108
(4–460) ng/mL and the median E/e’ was 10.99 (6.2-20.42). There was
a significant positive correlation between MMP-9 and E/e’ (r=0.416,
p=0.004).
Conclusion: There is a significant moderate positive correlation between
the MMP-9 level and diastolic dysfunction in concentric LVH patients.
Keywords: Diastolic dysfunction, hypertensive heart disease, left
ventricular hypertrophy, matrix metalloproteinase-9
Received:
October 18, 2020
Accepted:
March 30, 2021
Correspondence:
Miftah Pramudyo,
Department of Cardiology and Vascular Medicine,
Faculty of Medicine Universitas Padjadjaran-Dr. Hasan
Sadikin Hospital, Bandung, Indonesia,
e-mail: miftah.pramudyo@gmail.com
Original Article
Miftah Pramudyo, Ridho Jungjunan, Erwan Martanto, Chaerul Achmad
Department of Cardiology and Vascular Medicine, Faculty of Medicine Universitas Padjadjaran-Dr. Hasan
Sadikin Hospital, Bandung, Indonesia
pISSN: 2302-1381;
eISSN: 2338-4506;
http://doi.org/10.15850/
ijihs.v9n1.2175
IJIHS. 2021;9(1):1–6
Introduction
Hypertension is a major risk factor for
coronary artery disease (CAD), stroke, and
heart failure.1 The risk of heart failure in
hypertensive patients is threefold higher than
those without hypertension.2 Hypertension
is one of the most prevalent diseases in the
world. The prevalence of hypertension in
>25-year-old worldwide is 40.6% in men and
35.8% in women. The prevalence varies based
on geographical location as well. In Southeast
Asia, the prevalence of hypertension is
approximately 37.3% in men and 34.9% in
women.3 Based on the 2013 Indonesia Basic
Health Research (Riset Kesehatan Dasar/
RISKESDAS), the prevalence of hypertension
is 25.8%, with West Java sits on one of
the top four most prevalent province with
hypertension in Indonesia.4
Non-communicable diseases contributed
to 63% of mortality worldwide in 2008 (36
out of 57 million deaths), mostly caused by
cardiovascular diseases.5 Hypertension is One
of many major cardiovascular disease risk
factors. In Indonesia, hypertension related to
20-25% of all coronary artery disease cases
2 International Journal of Integrated Health Sciences (IIJHS)
Correlation between MMP-9 Level and Diastolic Dysfunction in Concentric Left Ventricular
Hypertrophy Patients
and 36-42% of all strokes.6
Prolonged hypertension may injure the
cardiovascular system, with secondary
damages to the brain, eyes, and kidneys.
The presence of target organ damage can
also impact therapeutic strategies, targeted
blood pressure, and specific recommended
medications.1,7 Chronic hypertension may lead
to remodeling of the heart. Cardiac remodeling
involves changes in genomic, cellular, and
interstitial levels that can be clinically
evaluated as alterations of the heart’s shape,
size, and function.8 Concentric hypertrophy
is the most common pattern of hypertrophy
found in hypertension.8 Cardiac remodeling
may also affect the heart physiology and is
manifested as diastolic dysfunction. Gold
standard assessment of diastolic function
involves invasive measurement, but recently
has been replaced by non-invasive techniques,
with one of the methods is echocardiography.9
The method for assessing diastolic dysfunction
recommended by the European Society of
Cardiology (ESC) is the examination of the
ratio between trans mitral inflow Doppler and
Tissue Doppler Imaging (TDI) early diastolic
velocity (E/e ‘). E/e ratio of ≥13 was related
to increased risk of cardiovascular event and
was independent of left ventricular mass
and relative wall thickness in hypertensive
patients.7,10
Plasma matrix metalloproteinase (MMP)-9
is one of the collagen turnover markers that
is widely used as an indicator of ventricular
remodeling in cases of heart failure.11-13 There
is a lot of studies done about MMP-9 and
ventricular remodeling, both in pre-clinical
studies and clinical studies. However, there
are not many studies on the relationship of
diastolic dysfunction with MMP-9 and these
studies have had different results in terms of
the relationship between MMP-9 levels and
diastolic function abnormalities. This study
aims to analyze the relationship between MMP-
9 levels and diastolic function abnormalities.
Methods
A cross-sectional study was conducted in
Bandung from November 2014 to January
2015 with ethical clearance from dr. Hasan
Sadikin General Hospital. The subjects in this
study included patients clinically diagnosed
with concentric-type left ventricular
hypertrophy HHD, age >18 years old in
Out-Patient Department dr. Hasan Sadikin
General Hospital. Consecutive sampling was
used. The sample size (n) in this correlation
analysis study was determined by the sample
and power calculation program with the
calculation of the test for one correlation.
The minimum number of samples that must
be obtained is 30 samples. Exclusion criteria
include patients with atrial fibrillation, aortic
stenosis, CAD, diabetes mellitus (DM), cancer,
hypertrophic obstructive cardiomyopathy,
mitral stenosis, coarctation of the aorta,
chronic kidney disease (CKD) stage ≥3, and
septic shock.
The independent variable of this study is
the MMP-9 plasma level, while the dependent
variable is diastolic dysfunction (E/e’). MMP-
9 levels were assessed from peripheral
venous blood sampling on the same day of
echocardiography examination. The blood was
drawn and put into a tube containing Ethylene-
Diamino-Tetraacetic Acid (EDTA) and then
centrifuged at 4°C. Plasma component was
isolated and kept frozen at -70°C for further
storage. MMP-9 plasma levels were examined
using Enzyme-Linked Immunosorbent Assay
(ELISA), expressed in ng/mL units.14 Diastolic
dysfunction was assessed by echocardiography
using a Vivid 7 echocardiography machine.
Parameters were measured using the mitral
inflow ratio to tissue Doppler imaging method
or the E/e’ ratio. E/e’ values parameter is
obtained from the mean values of E/e’ septal
and E/e’ lateral.7,10
A standard echocardiographic examination
is performed by a technician. The results were
then confirmed by a cardiologist specialized in
echocardiography. Blood samples were drawn
after echocardiographic examinations on the
same day by trained nurses using a tourniquet
and 3cc syringes. All samples were stored
collectively at the Hasan Sadikin Hospital
Clinical Pathology Laboratory and MMP-9
levels were assessed together on February 15,
2015.
For statistical analysis, we do a normality
test using the Saphiro-Wilks or Kolmogorov
Smirnov test, followed by descriptive statistics
and correlation test analysis between plasma
MMP-9 levels and the degree of diastolic
dysfunction using Pearson product-moment
correlation analysis if data is normally
distributed, or with Rank Spearman if the
data is not normally distributed. Confounding
variables that cannot be excluded will be
analyzed through multivariate analysis.
This study has been approved by Dr. Hasan
Sadikin Bandung hospital’s Health Research
Ethic Committee number LB.04.01/A05/
EC/019/I/2015.
International Journal of Integrated Health Sciences (IIJHS) 3
Miftah Pramudyo, Ridho Jungjunan, et al.
Results
Forty-six subjects met the inclusion criteria,
and seven subjects were excluded with the
following causes: 1 have incomplete data
(no lateral E/e’ data); 1 has CAD and DM;
4 have DM; 1 has CKD stage 3. The total
number of research subjects was 39 people
who were involved in the data processing.
In Table 1, there are 39 samples
included in the study. The normality test
done on numerical data was Shapiro-
Wilk test because n ≤50. Normality tests
show that the data on variables relative
wall thickness, age, weight, height, and
body mass index are normally distributed,
whereas left ventricular mass, systolic
blood pressure, and diastolic blood
pressure were not normally distributed.
There are 14 male subjects in this study
(35.9%) with 25 females (64.1%). The
average age of the subjects was 55 (± 10)
year, the average weight was 63.45 (±12.97)
kg, mean height was 155.51 (±7.12) cm,
mean body mass index 26.23 (± 5.08) kg/
m2, and average wall thickness was 0.7
(±0.15). Median systolic blood pressure
was 140 (110-220) mmHg, median diastolic
blood pressure was 80 (70-110) mmHg,
and the median left ventricular mass index
was 119.24 (103.05-205.69) g/m2.
The median value of plasma MMP-9
levels in this study was 108 (4–460) ng/mL
Fig. 1 Process Flow of Obtaining Research
Samples
Table 1 Basic Characteristics of HHD Patients
Characteristics Mean (±SD) Median (min-max)
n (%)
(n = 39)
Age (years) 55 (±10)
Sex (male) 14 (35.9)
Weight (kg) 63.45 (±12.97)
Height (cm) 155.51 (±7.12)
Body mass index (kg/m2) 26.23 (±5.08)
Systolic blood pressure (mmHg) 140 (110–220)
Diastolic blood pressure (mmHg) 80 (70–110)
Left Ventricle mass index (g/m2) 119.24 (103.05–205.69)
Male 117.5 (115.03–146.9)
Female 122.03 (103.05–205.69)
Relative wall thickness 0.7 (±0.15)
Left Ventricular Ejection Fraction 72.62 (±8.537) 73 (56–88)
SD: Standard Deviation
4 International Journal of Integrated Health Sciences (IIJHS)
is smaller than a similar study conducted
by Ahmed et al.15 (162±6 g/m2), but greater
than that of Tayebjee et al.16 The difference
between this study and those studies may be
due to the differences of inclusion criteria and
the criteria for left ventricular hypertrophy
used. This study used left ventricular
hypertrophy criteria based on ASE and EAE
guidelines, which are 115 g/m2 for males and
95 g/m2 for females for left ventricular mass
index.10
Plasma MMP-9 median level in this study
was 108 (4–460) ng/mL. Other studies
have had differing MMP-9 levels and these
differences may occur due to differences in
the testing technique used.
This study revealed MMP-9 plasma
levels were positively correlated with E/e‘,
which means that the higher the plasma
levels of MMP-9, the higher the E/e’ value.
This concludes that MMP-9 plasma levels
are positively correlated with diastolic
dysfunction in concentric HHD patients.
The association of MMP-9 level with
left ventricular function has been under
extensive studies. MMP-9 level relationship
with left ventricular systolic function in
post-myocardial infarction patients and low
ejection fraction-heart failure have been
widely investigated, but few studies have
looked at the association of MMP-9 with
diastolic function.
In previous studies done on this topic, the
relationship between MMP-9 plasma levels
and diastolic function is still controversial.
and the median value of E/e’ was 10.99 (6.2-
20.42) (Table 2).
The correlation analysis between plasma
levels of MMP-9 and E/e’ was shown in Table
3 and Fig. 2, presented in a scatter plot.
Based on the data elaborated above, we
can conclude that the MMP-9 plasma level
is moderate-positively correlated with E/e’
parameter, with r value=0.416 and p=0.004
(<0.05).
Discussion
The median left ventricular mass index in this
study was 119.24 (103.05-205.69) g/m2, which
Table 2 Median Value of Plasma MMP-9
and E/e’
Parameters Median (min.-max.)
Plasma MMP-9 level
(ng/mL)
108 (4–460)
E/e’ 10,99 (6.2–20.42)
Table 3 Correlation between plasma MMP-
9 level and E/e’
Parameter Coefficient correlation (r) P-value
MMP-9 — E/e’ 0.416 0.004
Note: Correlation analysis uses Rank Spearman
correlation analysis, significant if P<0.05
Fig. 2 Correlation between Plasma MMP-9 Levels and Diastolic Dysfunction as Measured by
the E/e’ test
Correlation between MMP-9 Level and Diastolic Dysfunction in Concentric Left Ventricular
Hypertrophy Patients
International Journal of Integrated Health Sciences (IIJHS) 5
This study result is supported by Ahmed et
al.15 and Martos et al.17 studies, with the result
of a significant relationship between MMP-9
levels and diastolic dysfunction. This study
is not supported by the result of the study
conducted by Tayebjee et al.16 who stated that
there was no significant relationship between
MMP-9 levels and diastolic dysfunction.
The coefficient correlation (r) between
MMP-9 and E/e’ in Tayebjee, et al16 was
-0.115, which did not statistically significant
(p=0.349). Unfortunately, studies conducted
by Ahmed et al.15 and Martos et al.17 did not
mention the coefficient correlation between
MMP-9 and E/e’.
The difference of results in the study by
Tayebjee et al.16 and this study may be caused
by the differences in the study population.
The study of Tayebjee et al.16 compared all
hypertensive patients with or without left
ventricular hypertrophy, whereas in this
study, the population is patients with a more
specific left ventricular hypertrophy, which
is the concentric type of left ventricular
hypertrophy.
A process that may explain the increase in
plasma MMP-9 levels in patients with HHD
with diastolic dysfunction is described by
Martos et al17. Matrix Metalloproteinase-9
has collagen and extracellular matrix (ECM)
turnover activity. Changes in cardiac ECM
have an extensive role in terms of ventricular
contraction function, both systolic and diastolic.
High levels of MMP-9 cause a high turnover of
collagen which is the main component of ECM.
Among these collagens, there is elastin which
functions to maintain the flexibility of the
heart muscle. One of the activities of MMP-9 is
to activate elastase which causes an increase
in elastin degradation. The loss of elastin in the
heart muscle and blood vessels causes stiffness
of the heart and blood vessels that contribute
to an increase in the degree of diastolic
dysfunction. Matrix Metalloproteinase-9 also
has a profibrotic effect, which means that the
increasing levels of MMP-9 will increase the
occurrence of fibrosis processes which will
also increase the stiffness of the heart muscle
and blood vessels, thus worsening the degree
of diastolic dysfunction.17
The limitation of this study is that most of
the exclusion criterias were obtained from
the patient’s history with only a small part of
the study sample had the results of diagnostic
examinations, thus allowing for information
bias.
In conclusion, there is a moderate positive
correlation between plasma MMP-9 levels and
diastolic function abnormalities as measured
by E/e’ examination in concentric HHD
patients. Further study is needed to compare
the normal population and the population with
diastolic dysfunction to determine the cut-off
value of MMP-9 levels in diastolic dysfunction.
Miftah Pramudyo, Ridho Jungjunan, et al.
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Correlation between MMP-9 Level and Diastolic Dysfunction in Concentric Left Ventricular
Hypertrophy Patients