Clinical Impact of Left Ventricular Hypertrophy and Implications for Regression

doi:10.1016/j.pcad.2009.05.002

Progress in Cardiovascular Diseases

Volume 52, Issue 2, September–October 2009, Pages 153-167

https://doi.org/10.1016/j.pcad.2009.05.002 Get rights and content

Abstract

Left ventricular hypertrophy (LVH) is an independent risk factor and predictor of cardiovascular (CV) events and all-cause mortality. Patients with LVH are at increased risk for stroke, congestive heart failure, coronary heart disease, and sudden cardiac death. Left ventricular hypertrophy represents both a manifestation of the effects of hypertension and other CV risk factors over time as well as an intrinsic condition causing pathologic changes in the CV structure and function. We review the risk factors for LVH and its consequences, concentric remodeling, and its prognostic significance, clinical benefits and supporting evidence for LVH regression, and its implications for management. We conclude our review summarizing the various pharmacological and nonpharmacological therapeutic options approved for the treatment of hypertension and LVH regression and the supporting clinical trial data for these therapeutic strategies.

Section snippets

Risk Factors

Epidemiologic studies have determined that age is a very important risk factor for the development of LVH.¹⁸ Because both elevated blood pressure (BP) and increased body weight, which by themselves are independent risk factors for the development of LVH, increase with age in most populations, it is not surprising that there is a very high prevalence of LVH in the elderly.1, 6, 7, 18 In fact, most studies suggest that age is an independent risk factor for LVH.3, 4, 5

Left ventricular hypertrophy

Consequences of LVH

For decades, it has been known that LVH is not benign but is accompanied by numerous adverse events including myocardial ischemia and MI, ventricular dysrhythmias, ventricular dysfunction, and increased CV and all-cause morbidity and mortality (Fig 2).2, 3, 9, 14, 15^,29, 30, 31 More than 3 decades ago, data from the Framingham cohort demonstrated that definite electrocardiographic (ECG) evidence of LVH was associated with an 8-fold increase in CV mortality and a 6-fold increase in CHD mortality.

Concentric Remodeling

HTN induces four distinct patterns of LV geometry based on the relationships between cavity size and wall thickness, including eccentric and concentric LVH as well as CR (Fig 4).⁶² Concentric remodeling, a subtle abnormal LV geometric pattern associated with increased CV risk, is defined as an increase in RWT with normal LVMI (RWT ≥0.45 and LVMI <125 g/m², although many studies utilize slightly different cut-points for RWT and LVH).

Alterations in LV geometry in the absence of LVH have not

Determination of LVH

The prevalence of LVH in patients with HTN varies by severity of HTN, age and the methods of detection. Rates of 20% to nearly 50% have been reported in populations with mild-to-moderate HTN.⁶⁸ Electrocardiogram and echocardiography are the 2 most widely used diagnostic tools for the detection of LVH: ECG is highly specific but not nearly as sensitive when compared with anatomically validated echocardiographic methods.⁶⁹

Quantitative echocardiography, which accurately estimates LVM, not only is

Impact of Obesity on LVH Determination

As we discussed above, obesity is one of the most powerful predictors of LVH. In fact, we have recently demonstrated that abnormal LV geometry, including CR as well as both eccentric and concentric LVH, occur more commonly in obese than leaner patients.63, 65, 72

Moreover, although we have identified an “obesity paradox” (obese have better prognosis than their leaner counterparts) among our echocardiographic cohorts with preserved LV systolic function, similar to the finding by our group and

Central Aortic Pressure

Findings of the Conduit Artery Function Evaluation study⁷⁴ showed that central aortic pressure might be a better predictor of CV outcomes compared to peripheral brachial BP. Central aortic BP is measured noninvasively by using applantation tonometer to record radial artery pulse waves, which are then transformed to derive a central arterial wave form and central aortic mean systolic and diastolic pressures. In this particular study, the calcium-channel blocker (CCB) amlodipine was proven to be

Regression of LVH

It is well known from both animal and human studies that antihypertensive therapy could cause regression of LVH.76, 77 In addition, regression of LVH is associated with lower CV risk, independent of BP lowering. As a result, prevention or reversal of hypertensive LVH is widely accepted as a desirable treatment goal.

It is evident from numerous studies that prevention and/or regression of ECG-LVH is associated with a reduced risk of CV morbidity and mortality.78, 79, 80 Fouad et al⁸¹ first

Pharmacologic Interventions

The above data suggest that antihypertensive treatment should be directed both towards BP reduction and LVH regression. With the exception of minoxidil and hydralazine, other classes of hypertensive drugs have been shown to produce some reduction in LVH.¹⁰⁶ Because of the heterogeneity of the trials and inconsistent data, clear recommendations in favor of one group of medications are not yet available. However, overall evidence is in favor of ACE inhibitors and angiotensin receptor blockers

Conclusions

These results in hypertensive subjects show that a reduction in LVM is associated with a reduction in major CV morbidity and mortality exceeding that achieved by BP control alone, strongly suggesting that emphasis is needed not only on BP lowering but also on reducing LVH. Evidence suggests that RAAS inhibition with either an ACE inhibitor or an ARB should be primary choice, as these agents appear to lower LVM to a greater extent compared to other antihypertensive agents. In view of recent

Statement of Conflict of Interest

All authors declare that there are no conflicts of interest.

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: Statement of Conflict of Interest: see page 164.

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Clinical Impact of Left Ventricular Hypertrophy and Implications for Regression

Abstract

Section snippets

Risk Factors

Consequences of LVH

Concentric Remodeling

Determination of LVH

Impact of Obesity on LVH Determination

Central Aortic Pressure

Regression of LVH

Pharmacologic Interventions

Conclusions

Statement of Conflict of Interest

Am J Med

Lancet

Chest

Clin Geriatr Med

Am J Cardiol

Am J Cardiol

Am J Cardiol

Am J Med

Am Heart J

Am J Cardiol

Am Heart J

Am J Cardiol

Am J Cardiol

Am J Med

Am J Cardiol

Am J Med

J Am Coll Cardiol

Chest

Am J Hypertens

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am J Hypertens

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

Am Heart J

J Electrocardiol

Am J Cardiol

Lancet

Am J Med

Am J Cardiol

Regression of increased left ventricular mass by antihypertensives

Drugs

Left ventricular hypertrophy. Its relationship to obesity and hypertension

Postgrad Med

Left ventricular hypertrophy in the elderly

Cardiol Elderly

Impact of left ventricular geometry on prognosis-A review of Ochsner studies

Ochsner J

Cardiomyopathy of overload: a major determinant of prognosis in congestive heart failure

N Engl J Med

Double blind control study of antihypertensive agents. III. Chlorothiazide alone and in combination with other agents; preliminary results

Arch Intern Med

Prognostic implications of echocardiographically determined left ventricular mass in the Framingham Heart Study

N Engl J Med

Relation of left ventricular mass and geometry to morbidity and mortality in uncomplicated essential hypertension

Ann Intern Med

Value of echocardiographic measurement of left ventricular mass in predicting cardiovascular morbid events in hypertensive men

Ann Intern Med

Hypertension and left ventricular hypertrophy in the elderly

Cardiopathy of obesity

Int Med Spec

Metabolic risk factors and left ventricular hypertrophy

Nutr Metab Cardiovac Dis

Association of left ventricular hypertrophy with metabolic risk factors: the HyperGEN study

J Hypertens

Electrocardiographic left ventricular hypertrophy and risk of coronary heart disease: the Framingham study

Ann Intern Med

The relationship of left ventricular geometry and hypertrophy to left ventricular function in valvular heart disease

J Heart Valve Dis

Left ventricular hypertrophy is more prevalent in blacks than whites in the general population: the Dallas Heart Study

Hypertension

Hepatocyte growth factor and left ventricular geometry in end-stage renal disease

Hypertension