What are the implications of left ventricular hypertrophy (LVH)?

From the Guidelines

Left ventricular hypertrophy (LVH) detected by echo is a significant predictor of future cardiovascular events and should be managed aggressively to reduce morbidity, mortality, and improve quality of life. The condition is most commonly caused by chronic high blood pressure (hypertension), which forces the heart to work harder to pump blood, and can also be influenced by other factors such as obesity, diabetes, and renal impairment 1. Management of LVH primarily focuses on treating the underlying cause, especially controlling blood pressure with medications such as ACE inhibitors, ARBs, beta-blockers, or calcium channel blockers, with beta blockers being inferior to ARBs, ACE inhibitors, and CCBs in reducing LVH 1.

Key Considerations

• LVH is a secondary manifestation of hypertension and independently predicts future cardiovascular events 1
• BP lowering leads to a reduction in LV mass, with the long-acting diuretic chlorthalidone being slightly more effective in reducing LVH than other medications in some studies 1
• Assessment of LVH by means of echocardiography or MRI is most useful in adults who are young or have evidence of secondary hypertension, chronic uncontrolled hypertension, or history of symptoms of heart failure 1
• Lifestyle modifications, including reducing sodium intake, maintaining a healthy weight, regular exercise, limiting alcohol, and avoiding tobacco, are equally important in managing LVH

Monitoring and Treatment

• Regular follow-up echocardiograms are typically recommended to monitor the progression or regression of LVH in response to treatment
• The use of repeat imaging to document changes in left ventricular mass (LVM) has been difficult to incorporate into standard practice due to the inherent variability of LVM measurements with echocardiography, but can be improved with the enhancement and clinical use of 3DE 1
• Controlling blood pressure and reducing LVH through medication and lifestyle modifications is crucial to prevent complications like heart failure, arrhythmias, and sudden cardiac death.

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 Losartan Potassium Tablets is used: • To lower the chance of stroke in patients with high blood pressure and a heart problem called left ventricular hypertrophy Losartan Potassium Tablets may not help Black patients with this problem.

The main use of losartan in relation to left ventricular hypertrophy (LVH) is to reduce the risk of stroke in patients with hypertension and LVH. However, it is noted that this benefit may not apply to Black patients.

From the Research

Echocardiography in Left Ventricular Hypertrophy (LVH)

• Echocardiography is a primary imaging modality used for the clinical evaluation of left ventricular (LV) function, including the diagnosis of LVH 2.
• It can be used to estimate LV filling pressure, which is useful for evaluating patients with dyspnea of unknown etiology and those with heart failure with preserved ejection fraction 2.
• Echocardiographic estimation of LV filling pressure can also be used for clinical decision making on a day-to-day basis 2.

Comparison of ECG and Echocardiography in LVH

• Both electrocardiogram (ECG)-detected LVH and echocardiography (echo)-detected LVH are equally predictive of heart failure (HF) 3.
• The ability of the Framingham Heart Failure Risk Score (FHFRS) to predict HF is similar when ECG-LVH and echo-LVH are included in the model separately 3.

Use of Echocardiography in Adult Hypertension

• Echocardiography is recommended for the assessment of LV hypertrophy and LV systolic and diastolic function in adult hypertension 4.
• Recent developments in the assessment of LV hypertrophy and LV function have prompted the preparation of a consensus position on the use of echocardiography in this setting 4.

Efficacy of Echocardiography in Differential Diagnosis of LVH

• Echocardiography plays an important role in detecting LVH and underlying causes in current clinical practice 5.
• Speckle-tracking echocardiographic parameters, such as global longitudinal strain (GLS), are useful for the detection of early LV structural abnormalities and can be used for the prediction of outcomes for various cardiac diseases 5.

Treatment of Arterial Hypertension

• The 2018 ESH/ESC guidelines indicate that the first-choice therapy in the majority of hypertensive patients should be a fixed combination of a drug that blocks the renin-angiotensin-aldosterone system and a calcium antagonist or a diuretic 6.
• ACE inhibitors, such as ramipril, have been shown to outperform AT-1 antagonists in preventing myocardial infarction and total mortality, and the fixed combination of ramipril and amlodipine represents a first-choice therapy for hypertension 6.