Seminars in Cardiology, 2003, Vol. 9, No.

ISSN 1648-7966

GLOBAL MYOCARDIAL PERFORMANCE INDEX IN

PATIENTS WITH ACUTE MYOCARDIAL INFARCTION:
SERIAL CHANGES AND PROGNOSTIC IMPLICATION
Virginija Grabauskiene 1 , Jelena elutkiene 1 , ivile Lileikiene 1 , Pranas erpytis 1 ,
ana Majorova 2 , Aleksandras Lauceviius 1
1

Clinic of Heart Diseases, Vilnius University; Center of Cardiology and Angiology,

Vilnius University Hospital Santarikiu Klinikos, Lithuania
2
Department of Statistics, Vilnius University, Lithuania
Received 27 October 2003; accepted 1 December 2003

Keywords: myocardial performance index, Doppler echocardiography, acute myocardial infarction.

Summary
Objectives: The purpose of the study was to investigate serial changes and prognostic value of a
Doppler-derived global myocardial performance index (MPI) in patients with acute myocardial infarction
(AMI).
Design and Methods: The Doppler-derived MPI was measured in 30 patients (22 men; mean age
62 13 years) with anterior AMI and left ventricular (LV) ejection fraction (EF) < 40%. The patients were
studied within 72 hours of arrival at the coronary care unit and in the follow-up period: 1030 days; 36 and
912 months after AMI.
Results: The MPI was significantly higher in patients with AMI on admission than during outcomes
(p < 0.05). The MPI (72 hours) was significantly correlated to peak creatine kinase-MB and LV EF (r =
0.32 [p < 0.01] and r = 0.51 [p < 0.001], respectively). During hospitalisation, a higher MPI, lower EF
and deceleration time (DcT) were observed in patients with an adverse outcome than in patients who
survived without developing of congestive heart failure (CHF). The MPI was significantly lower and EF was
significantly higher during follow-up in patients who received reperfusion therapy than in those who have
not. During 9.2 5.5 months of follow-up, 6 patients died, CHF developed in 6 patients, and reinfarction
and unstable angina occurred in 4 patients.
Conclusion: The Doppler-derived myocardial performance index reflects the severity of left ventricular
dysfunction and may be useful after acute myocardial infarction in predicting patients at high risk for cardiac
events in the follow-up period.
Seminars in Cardiology 2003; 9(4): 2127
Left ventricular (LV) dysfunction after acute myocardial infarction (AMI) has been related to an adverse outcome [1]. Two-dimensional and Doppler
echocardiography is a reliable and practical noninvasive method for diagnosing systolic and diastolic
dysfunction in cardiac disease and suitable for longitudinal follow-up studies [26]. LV systolic function
is usually described in terms of stroke volume, cardiac output and ejection fraction, whereas LV diastolic function is defined by Doppler measurements
of mitral inflow during early and late diastole and the
duration of the myocardial relaxation phase. A measurement of LV myocardial performance combining

systolic and diastolic function can be a useful parameter in the assessment of cardiac function and
may be a predictor of the outcome after acute myocardial infarction [7]. A relatively new Doppler index
of combined systolic and diastolic myocardial performance of the left ventricle was reported by Tei et al in
1995 [8,9]. This myocardial performance index (MPI)
is easily obtained, reproducible, has a narrow range
in normal subjects, does not depend on LV geometry, and correlates with invasively obtained measurements of systolic and diastolic cardiac function
[7,10]. The MPI has shown potential clinical application in dilated cardiomyopathy and cardiac amyloidosis [1113]. The present study describes changes
Corresponding address: Virginija Grabauskiene, Center in the MPI in patients with AMI during 1 year of
of Cardiology and Angiology, Vilnius University Hospital
follow-up and evaluates the prognostic significance
Santarikiu Klinikos, Santarikiu 2, 2021 Vilnius, Lithuania.
of the MPI in relation to the development of major
Tel.: +370 5 2365 123.
E-mail: virginija.grabauskiene@santa.lt.
cardiac events following AMI.

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Design and Methods

Study population
We studied 30 patients (22 men and 8 women;
mean age 62 13 years) who were admitted to the
coronary care unit with anterior AMI and LV ejection fraction (EF) < 40%. AMI was defined by at
least 2 of the following criteria: (1) transient elevation of creatine kinase 195 IU/l and/or creatine
kinase-MB 25 IU/l, or (2) electrocardiographic evidence of AMI (ST elevation > 1 mm in contiguous
leads or subendocardial injury pattern) and (3) typical chest pain lasting >30 minutes. All the patients were in sinus rhythm and all echo images
and Doppler data of the patients were adequate to
accurately assess. The exclusion criteria were: left
bundle branch block, valvular heart disease and dilated cardiomyopathy. Major cardiac events were defined as cardiac death, heart failure, unstable angina
or recurrent AMI. The degree of hemodynamic derangement in patients with AMI was based on clinical evaluation according to the Killip classification.
Sixteen patients were treated with primary percutaneous transluminal coronary angioplasty (PTCA)
and 4 patients with thrombolysis. Heart failure
in the follow-up period was graded according to
NYHA class. Two-dimensional and pulsed Doppler
echocardiography was performed within 72 hours after arrival to the coronary care unit and repeated
after 1030 days, within 36 and 912 months after
AMI. The patients were divided retrospectively into
four groups according to: (1) either survivors without
the development of congestive heart failure (CHF)
and other major cardiac events (group 1, n = 14)
or the presence of major cardiac events (group 2,
n = 16) during the follow-up period; (2) the treatment
of AMI without reperfusion therapy (group 3, n = 10)
or with PTCA and thrombolysis (group 4, n = 20).
The study complied with Declaration of Helsinki.

ISSN 1648-7966

tained placing the sample volume in the outflow tract

below the aortic valve. Each Doppler measurement
was calculated from the average of three consecutive cardiac cycles. The following parameters were
measured: peak early (E) and late transmitral filling
velocities (A), E/A, and deceleration time (DcT) of
E wave. Doppler time intervals were measured from
mitral inflow and LV outflow velocity time intervals
(Figure 1). The time interval a from the cessation to
the onset of mitral inflow was equal to the sum of
isovolumic contraction time, ejection time and isovolumic relaxation time. LV ejection time b was the
duration of LV outflow velocity profile. Thus, the sum
of isovolumic contraction time and isovolumic relaxation time was obtained by subtracting b from a. The
myocardial performance index (MPI) of combined LV
systolic and diastolic function (the sum of isovolumic
contraction time and isovolumic relaxation time divided by ejection time) was calculated as (a b)/b.
The MPI 0.39 0.05 (mean SD) was defined as
normal [9]. IMP-EF was calculated from formula:
MPI-EF = 60 (34 MPI) as described by Lax [14].
Statistical analysis
All the results are expressed as mean SD.
Chi-square and t tests were used for comparisons
between groups. Changes in echocardiographic
variables over time were assessed by repeatedmeasures analysis of variance. Patients who died
or had reinfarction, unstable angina or worsening of
CHF during the first 12 months were included into
the analysis until the event occurred. A p value of
<0.05 was considered significant.
Results

Clinical baseline characteristics

Baseline characteristics are listed in Table 1. Patients with AMI received the following medical therEchocardiography
apy at arrival: aspirin 100%; alpha-blocking agents
Two-dimensional, pulsed Doppler, and colour 23%; long-acting nitrates 27%; calcium antagoflow Doppler echocardiographic examinations were nists 5%; diuretics 20%; angiotensin-converting
performed with a Hewlett-Packard SONOS 2500 enzyme inhibitors 100%; digoxin 10 %; heparin
cardiac ultrasound unit with a 2.5-MHz transducer. 88%; beta-blockers 74%.
Two-dimensional echocardiographic and pulsed
Follow-up and clinical outcome
Doppler data were recorded and stored on a videoPatients were followed up for 9.2 5.5 months.
tape for later analysis.
LV end-diastolic volume (EDV) and end-systolic During this period, 6 patients died (5 of them from
volume (ESV) and ejection fraction (EF) were ob- cardiac causes: 4 from sudden death syndrome
tained by the Simpsons biplane method. Ventricular and 1 from end-stage heart failure). Heart failure
volumes were corrected for body surface area as developed in 6 patients (in 5 patients during primary
EDVI and ESVI. LV end-diastolic diameter (LVEDD) hospitalisation and in 1 patient who was readmitted).
was measured from M-mode parasternal long axis Reinfarction and unstable angina occurred in 4 paview and corrected for body surface area as LVEDD tients (in 2 patients within the first 3 months and in
index. Pulsed Doppler recordings of mitral flow ve- 2 patients after 3 months). Three patients underlocities were obtained from the apical four-chamber went additional revascularization procedures (2 paview placing the sample volume between the tips of tients after 6 months and 1 patient after 9 months
the mitral leaflets, and LV outflow velocities were ob- of follow-up).

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Seminars in Cardiology, 2003, Vol. 9, No. 4

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Figure 1. Schema for measurements of Doppler intervals. The a is an interval between cessation and the onset
of mitral inflow. It includes isovolumic contraction time (ICT), ejection time (ET) and isovolumic relaxation time
(IRT). LV ejection time b is the duration of LV outflow velocity profile. The sum of isovolumic contraction time and
isovolumic relaxation time was obtained by subtracting b from a. The index of combined LV systolic and diastolic
function (the sum of isovolumic contraction time and isovolumic relaxation time divided by ejection time) was
calculated as (a b)/b

Table 1. Patients baseline characteristics

Age (years)
Man/women
Diabetes mellitus
Hypertension
Smokers (included previous smokers)
Total serum cholesterol (mmol/l)
Q wave anterior wall AMI
EF at the time of inclusion into the study (%)
Thrombolysis
PTCA
Heart rate (bmp)
SBP (mmHg)
DBP (mmHg)
Myocardial infarction in history
PTCA in history
Coronary artery bypass surgery in history
Peak CK-MB (IU/l)

62 12.75
22/8
4 (13.3%)
13 (43.3%)
9 (30%)
5.60 1.19
26 (86%)
34.00 2.77
4 (13%)
16 (53%)
77 11
134 18
78 13
5 (16%)
3 (10%)
1 (3%)
322.10 234.91

AMI acute myocardial infarction; CK creatine kinase; DBP diastolic blood pressure; EF ejection fraction;
PTCA percutaneous transluminal coronary angioplasty; SBP systolic blood pressure
Mean values SD

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Seminars in Cardiology, 2003, Vol. 9, No. 4

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Serial changes in left ventricular function in

patients with acute myocardial infarction
Comparative echocardiographic features in 30
patients with AMI from the time of arrival (72 hours
after AMI) to 1 year of the follow-up period are summarized in Table 2. Patients with AMI were characterised by an initially higher value of the MPI comparing with 1 year follow-up, when MPI significantly decreased (0.54 0.12 vs 0.44 0.13, p = 0.05). This
is in accordance with changes in global LV systolic
function expressed by EF, which increased at oneyear follow-up period (0.34 0.03 vs 0.47 0.04,
p < 0.001). Whereas LV end-diastolic volume index and LV end-diastolic diameter index at one-year
follow-up period increased (60.5 15.38 vs 68.53
12.18, p < 0.01 and 2.7 0.72 vs 3.24 0.49, p <
0.05, respectively). This reflects the LV remodelling

after anterior AMI. The MPI (72 hours) was significantly correlated to peak creatine kinase-MB and LV
ejection fraction (r = 0.32, p < 0.01 and r = 0.51,
p < 0.001, respectively).
Comparison of left ventricular function in
survivors with or without congestive heart
failure or other major cardiac event
2D and Doppler echocardiographic measurements in survivors without heart failure and patients
with heart failure or those who died or had other major cardiac events during follow-up are summarized
in Table 3. The MPI was significantly higher in patients who developed heart failure or had other major
cardiac events (group 2) than in survivors without
heart failure during follow-up (group 1) (0.63 0.07
vs 0.54 0.14, p < 0.05). During hospitalisation,

Table 2. Serial echocardiographic measurements in patients with acute myocardial infarction

No
1
2
3
4
5
6
7
8
9

Parameters
HR
E/A
DcT
MPI
EF-MPI
EF
EDVI
ESVI
LVEDDI

72 hours
n = 30
77.44
0.91
189
0.54
41.75
0.34
60.5
39.3
2.7

10.71
0.42
47.6
0.12
4.0
0.03
15.38
9.57
0.72

1030 days
n = 11
74
0.90
210
0.52
41.89
0.41
68.71
40.64
2.82

16.97
0.40
42.43
0.15
5.13
0.06
11.26
9.73
0.12

36 months
n = 17
68.39
1.18
190
0.49
43.29
0.44
67.17
37.01
2.99

8.44
0.62
65.52
0.15
5.08
0.10
13.16
12.50
0.32

912 months
n = 16

p value

<0.01
<0.05
NS
<0.05
<0.05
<0.001
<0.01
NS
<0.05

69.67
1.17
210
0.44
45.17
0.47
68.53
35.89
3.24

8.71
0.66
80.57
0.13
4.36
0.04
12.18
6.71
0.49

DcT deceleration time; EDVI end diastolic volume index; EF ejection fraction; ESVI end systolic volume
index; HR heart rate; LVEDDI left ventricular end diastolic diameter index; MPI myocardial performance index
Mean values SD
Table 3. Comparison in echocardiographic measurements of patients free of congestive heart failure and major
cardiac events (group 1) with patients who developed congestive heart failure or had major cardiac events (group 2)
after acute myocardial infarction
No
1
2
3
4
5
6
7
8
9

Parameters
HR
E/A
DcT
MPI
EF-MPI
EF
EDVI
ESVI
LVEDDI

Group 1
(n = 14)
75.2
0.83
210
0.54
41.49
0.36
60.71
35.77
2.86

10.35
0.34
37.9
0.14
4.65
0.03
13.5
6
0.35

Group 2
(n = 16)

p value

NS
NS
<0.001
<0.05
<0.05
<0.01
NS
NS
NS

81.54
1.04
150
0.63
37.79
0.32
89.39
38.63
2.81

10.41
0.39
49.1
0.07
2.25
0.04
36.01
9.28
0.8

DcT deceleration time; EDVI end diastolic volume index; EF ejection fraction; ESVI end systolic volume
index; HR heart rate; LVEDDI left ventricular end diastolic diameter index; MPI myocardial performance index
Mean values SD

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Table 4. Serial changes in left ventricular function in patients treated without (group 3) and with (group 4) reperfusion therapy
Group 3 (n = 10)

Parameters
72 hours
HR
E/A
DcT
MPI
EF-MPI
EF
EDVI
ESVI
LVEDDI

76.7
0.72
214
0.51
42.75
0.35
61.08
39.23
2.96

10.8
0.2
49
0.15
5.06
0.03
13.56
8.91
0.39

912 months
69.5
0.96
206.25
0.47
43.16
0.32
63.92
42.01
3.16

7.56
0.61
69.06
0.08
4.13
0.08
17.76
9.79
0.47

Group 4 (n = 20)
p value
<0.05
NS
NS
NS
NS
NS
NS
NS
NS

72 hours
78.94
1.03
166
0.6
39.68
0.33
81.65
36.21
2.77

10.84
0.4
47.5
0.07
2.5
0.04
116.56
7.79
0.68

912 months

p value

<0.05
<0.05
NS
<0.001
<0.001
<0.001
NS
NS
NS

71.21
1.43
181.43
0.42
45.66
0.45
72.52
41.33
3.11

10.66
0.75
53.9
0.16
5.24
0.09
19.75
16.19
0.42

DcT deceleration time; EDVI end diastolic volume index; EF ejection fraction; ESVI end systolic volume
index; HR heart rate; LVEDDI left ventricular end diastolic diameter index; MPI myocardial performance index
Mean values SD

lower EF and deceleration time (DcT) were observed

in patients with an adverse outcome than in patients who survived without developing heart failure
(0.32 0.04 vs 0.36 0.03, p < 0.01 and 150 49.1
vs 210 37.9, p < 0.001, respectively).
Serial changes in left ventricular function in
patients treated without and with reperfusion
therapy
Serial changes of Doppler echocardiographic
measurements in patients treated without (group 3)
and with (group 4) reperfusion therapy are summarized in Table 4. The MPI and EF did not change
significantly during follow-up in patients of group 3,
whereas the MPI was significantly lower (0.6 0.07
vs 0.42 0.16, p < 0.001) and EF was significantly
higher (0.33 0.04 vs 0.45 0.09, p < 0.001) during
follow-up in patients who were treated with reperfusion therapy (group 4). Thus, MPI can be a marker
of successful reperfusion therapy after AMI in the
follow-up period.
Discussion
A number of clinical, biochemical, electrocardiographic, and hemodynamic variables have been
used to define subgroups of patients with AMI at
risk for major cardiac events [1518]. Measures of
LV global and segmental systolic performance have
been shown to be among the strongest short and
long-term prognostic predictors in patients with AMI
[1921]. In our study, EF, the most commonly used
index of LV function, also dierentiated patients with
and without a complicated follow-up clinical course.
However, when geometry is irregular, as it is typical
after AMI, the assessment of EF and volumes is less
accurate [22], requires a well-trained observer and is
time-consuming. Recent studies have demonstrated

that the MPI may have important clinical advantages

relative to other assessments of LV function, especially ejection fraction [8,9]. It is shown that the MPI
in patients with either idiopathic cardiomyopathy or
amyloidosis was more closely related to morbidity
and mortality than any other measurement of myocardial performance [11,13]. Because both LV systolic and diastolic functions are aected by AMI, and
the geometry of the left ventricle is distorted during
the LV remodelling process, the MPI may theoretically be an attractive alternative to standard measures of LV function after AMI.
The present study demonstrates that a Dopplerderived MPI and a non-geometric Doppler index
were useful as indicators of LV function and predictors of the outcome after AMI. The MPI is reproducible, quick, non-invasive, easily performed at a
bedside, and is not aected by LV geometry. Our observations detected by the MPI are in accordance
with previous findings in which LV systolic and diastolic dysfunction is present very early in AMI, and the
progression of impaired relaxation of the left ventricle due to the development of compensatory hypertrophy. Recent studies have demonstrated that the
presence of a restrictive LV filling pattern with shortened DcT is associated with elevated LV filling pressure, the development of LV dilatation, heart failure,
and a higher risk of cardiac death in patients with
AMI [23,24]. Heart failure after infarction is often due
to LV systolic and diastolic dysfunction. In this study,
the MPI was also found to be significantly higher in
patients who developed heart failure or other major
cardiac events than in survivors without heart failure
during follow-up. The MPI allowed good discrimination of patients with and without events, similar EF
and provided statistically significant additional information. Dierences in LV function detected by the

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Seminars in Cardiology, 2003, Vol. 9, No. 4

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MPI were supported by dierences in the more established indicators of systolic and diastolic function,
such as ejection fraction and deceleration time. Our
study suggests that MPI can be a marker of successful reperfusion therapy after AMI in the follow-up
period and can be use for the assessment of LV
remodelling and treatment monitoring in patients after AMI.
Recently, new echocardiographic parameters
have been shown to provide information about LV diastolic function. In the study of Yamamoto et al [25]
the ratio of mitral E velocity to annular E velocity (E/E ) measured with tissue Doppler imaging
technique was useful not only in detecting pseudonormal LV mitral filling patterns, but also was the
most powerful predictor of cardiac death or hospitalisation for worsening heart failure compared with
clinical, hemodynamic, and other echocardiographic
variables [26,27]. Studies should be designed to

compare the MPI index with the newer parameters

of LV diastolic function.
Conclusion
These data suggest that the Doppler-derived
myocardial performance index reflects the severity
of left ventricular function and may be useful after
acute myocardial infarction in predicting patients at
high risk for cardiac events in the follow-up period.
Study Limitations
Because the intervals between the onset and
end of mitral inflow and ejection time are measured
not simultaneously, the MPI is less reliable in the
presence of arrhythmias. However, in the present
study, only patients with sinus rhythm were included.
The study population was selected according to age,
which must be taken into account when interpreting
these data.

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