What is the optimal blood pressure treatment for someone with hypertension and Left Ventricular Hypertrophy (LVH)?

From the Guidelines

For patients with hypertension and left ventricular hypertrophy (LVH), the optimal blood pressure target is generally below 130/80 mmHg, and treatment should be initiated with an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB) to promote regression of LVH and reduce cardiovascular risk. The most recent and highest quality study, 1, published in 2020, supports this recommendation, emphasizing the importance of treating hypertension to reduce the risk of incident heart failure and heart failure hospitalization.

Key Considerations

• ACE inhibitors, such as lisinopril, or ARBs, such as losartan, are recommended as first-line agents due to their ability to promote regression of LVH and reduce cardiac remodeling beyond their blood pressure-lowering effects 1.
• If the target blood pressure is not achieved with a single agent, adding a calcium channel blocker, such as amlodipine, or a thiazide diuretic, such as hydrochlorothiazide, is recommended 1.
• Beta-blockers may be added as a third agent if needed, particularly if the patient has coronary artery disease or heart failure 1.
• Lifestyle modifications, including sodium restriction, regular physical activity, weight management, and limiting alcohol consumption, are crucial components of the treatment plan 1.

Monitoring and Adjustments

• Regular monitoring of blood pressure, kidney function, and electrolytes is essential, especially during medication adjustments 1.
• Home blood pressure readings should be taken 1-2 times daily to ensure accurate monitoring and adjustment of treatment as needed.

Evidence-Based Recommendations

The 2020 International Society of Hypertension Global Hypertension Practice Guidelines 1 provide the most recent and comprehensive evidence-based recommendations for the management of hypertension in patients with LVH. These guidelines emphasize the importance of treating hypertension to reduce the risk of incident heart failure and heart failure hospitalization, and recommend a target blood pressure of <130/80 mmHg. The guidelines also support the use of ACE inhibitors, ARBs, and other agents, such as beta-blockers and mineralocorticoid receptor antagonists, in the treatment of patients with hypertension and heart failure.

From the FDA Drug Label

The LIFE study was a multinational, double-blind study comparing losartan and atenolol in 9193 hypertensive patients with ECG-documented left ventricular hypertrophy. Treatment with losartan resulted in a 13% reduction (p=0. 021) in risk of the primary endpoint compared to the atenolol group; this difference was primarily the result of an effect on fatal and nonfatal stroke. 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 optimal blood pressure treatment for someone with hypertension and Left Ventricular Hypertrophy (LVH) is losartan, as it has been shown to reduce the risk of stroke by 25% relative to atenolol 2.

• The recommended starting dose of losartan 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 12.5 mg daily should be added and/or the dose of losartan should be increased to 100 mg once daily based on blood pressure response 2. Key points:
• Losartan is effective in reducing blood pressure and the risk of stroke in patients with hypertension and LVH.
• The benefit of losartan in reducing the risk of stroke does not apply to Black patients 2.

From the Research

Optimal Blood Pressure Treatment for Hypertension and LVH

• The optimal blood pressure treatment for someone with hypertension and left ventricular hypertrophy (LVH) involves a combination of lifestyle modifications and pharmacologic therapy 3.
• First-line therapy for hypertension includes lifestyle modification, such as weight loss, healthy dietary pattern, physical activity, and moderation or elimination of alcohol consumption 3.
• The decision to initiate antihypertensive medication should be based on the level of blood pressure and the presence of high atherosclerotic cardiovascular disease risk 3.
• First-line drug therapy for hypertension consists of a thiazide or thiazide-like diuretic, an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, and a calcium channel blocker 3.

Blood Pressure Targets

• The standard blood pressure target is less than 140/90 mmHg for the general population of patients with elevated blood pressure 4.
• However, some studies suggest that lower blood pressure targets (less than or equal to 135/85 mmHg) may be associated with a reduction in mortality and morbidity, particularly in patients with high cardiovascular risk 4.
• A study found that patients who initiated combination therapy with an ACE inhibitor and a thiazide diuretic were more likely to achieve blood pressure goals compared to those who initiated monotherapy 5.

Combination Therapy

• Combination regimens consisting of a calcium channel blocker and an angiotensin II type 1 receptor blocker have been shown to be effective in managing hypertension 6.
• This combination has demonstrated better efficacy and is well tolerated, including in patients with stage 2 hypertension and the elderly 6.
• Another study found that angiotensin receptor blockers (ARBs) have equal outcome efficacy to angiotensin-converting enzyme (ACE) inhibitors, but with fewer adverse events 7.

Pharmacologic Therapy

• ACE inhibitors and ARBs are commonly used in the treatment of hypertension, but ARBs may be preferred due to their lower risk of adverse events 7.
• Calcium channel blockers, such as amlodipine, are also effective in managing hypertension and can be used in combination with other agents 6.
• Thiazide diuretics, such as hydrochlorothiazide, are another option for first-line therapy and can be used in combination with other agents 3.