What is the approach to left ventricular hypertrophy (LVH)?

From the Guidelines

The approach to left ventricular hypertrophy (LVH) should focus on aggressive blood pressure control, targeting levels below 130/80 mmHg, using first-line medications such as ACE inhibitors or ARBs, and lifestyle modifications to reduce cardiovascular risk. The management of LVH involves identifying and treating the underlying cause, with hypertension being the most common cause. According to the 2013 ACCF/AHA guideline for the management of heart failure 1, ACE inhibitors and beta blockers are effective in preventing heart failure, and diuretic-based antihypertensive therapy has been shown to prevent heart failure in a wide range of target populations. Some key points to consider in the management of LVH include:

• Confirming LVH through electrocardiogram or echocardiography, and determining the etiology
• Using first-line medications such as ACE inhibitors (like lisinopril 10-40 mg daily) or ARBs (such as losartan 50-100 mg daily) to promote LVH regression beyond their blood pressure-lowering effects
• Adding a thiazide diuretic (hydrochlorothiazide 12.5-25 mg daily) or calcium channel blocker (amlodipine 5-10 mg daily) as needed for optimal control
• Implementing lifestyle modifications, including sodium restriction (<2.3g/day), regular aerobic exercise (150 minutes weekly), weight management, and limiting alcohol consumption
• Considering valve replacement for LVH due to aortic stenosis, or beta-blockers, calcium channel blockers, or surgical intervention for hypertrophic cardiomyopathy
• Regular monitoring with repeat imaging every 1-2 years to assess regression, as LVH regression is associated with reduced cardiovascular events 1. It is also important to note that LVH increases the risk of arrhythmias, heart failure, and sudden cardiac death by altering cardiac structure and electrical conduction, making aggressive management crucial to reduce morbidity and mortality.

From the FDA Drug Label

Losartan is indicated to reduce the risk of stroke in patients with hypertension and left ventricular hypertrophy, but there is evidence that this benefit does not apply to Black patients The usual starting dose of losartan is 50 mg once daily. The dosage can be increased to a maximum dose of 100 mg once daily as needed to control blood pressure The usual starting dose is 50 mg of losartan once daily. Hydrochlorothiazide 12. 5 mg daily should be added and/or the dose of losartan should be increased to 100 mg once daily followed by an increase in hydrochlorothiazide to 25 mg once daily based on blood pressure response

The approach to Left Ventricular Hypertrophy (LVH) involves the use of losartan to reduce the risk of stroke in patients with hypertension and LVH. The recommended starting dose is 50 mg once daily, which can be increased to a maximum dose of 100 mg once daily as needed to control blood pressure. Additionally, hydrochlorothiazide can be added to the treatment regimen, starting with a dose of 12.5 mg daily and increasing to 25 mg once daily based on blood pressure response 2 2.

• Key points:
  • Losartan is indicated to reduce the risk of stroke in patients with hypertension and LVH
  • The recommended starting dose is 50 mg once daily
  • The dose can be increased to a maximum of 100 mg once daily as needed to control blood pressure
  • Hydrochlorothiazide can be added to the treatment regimen, starting with a dose of 12.5 mg daily and increasing to 25 mg once daily based on blood pressure response

From the Research

Approach to Left Ventricular Hypertrophy (LVH)

The approach to LVH involves a combination of screening, diagnosis, prevention, and treatment.

• Screening and diagnostic tools for LVH include ECG and 2D echocardiography, with the potential for improved sensitivity through the implementation of machine learning in diagnostic modalities 3.
• Prevention and reversal of LV remodeling are crucial for cardiovascular risk reduction in patients with hypertension, and can be achieved through lifestyle modifications, blood pressure control with antihypertensive therapy, and management of comorbidities 3, 4.

Treatment of LVH

The treatment of LVH involves the use of antihypertensive agents that have been shown to promote regression of LVH, including:

• Diuretics, which are particularly effective in African-American and elderly patients 5.
• Beta-blockers, which should be considered in elderly patients with greatly thickened LV walls and small chamber sizes 5.
• Angiotensin-converting enzyme (ACE) inhibitors, which have been shown to reduce left ventricular mass and improve cardiovascular outcomes 5, 6, 7.
• Angiotensin II antagonists, which have been shown to be effective in reversing left ventricular hypertrophy in hypertensive patients 6, 7.
• Calcium channel blockers, which may be useful in patients with LVH who have normal systolic performance and diastolic compliance abnormalities 5.

Monitoring and Follow-up

Serial echocardiographic studies are necessary to ensure that LV geometry has not worsened and that function is unchanged or improved in patients being treated for hypertension 5.

• Considerable changes in estimated LV mass (>60 g on serial intrapatient evaluation) are needed before the clinician can conclude with confidence that LV mass has decreased 5.