How should I interpret an echocardiogram showing a normal-sized left ventricle with concentric remodeling, no increased left ventricular mass, normal systolic function, and an ejection fraction of 67%?

Interpreting Concentric LV Remodeling with Normal Mass

This echocardiogram shows concentric remodeling—a pattern where the LV walls are thickened relative to chamber size, but total LV mass remains normal—which represents an early adaptive response to increased afterload (typically hypertension) and carries intermediate cardiovascular risk between normal geometry and frank LV hypertrophy.

Understanding the Terminology

According to the 2019 ACC/AHA/ASE guidelines, concentric remodeling is specifically defined as increased wall thickness with normal left ventricular mass 1. This distinguishes it from:

• Normal geometry: Normal wall thickness AND normal LV mass
• Concentric hypertrophy: Increased wall thickness AND increased LV mass (with normal or reduced chamber size)
• Eccentric hypertrophy: Increased chamber size AND increased LV mass

The key differentiator is the relative wall thickness (RWT), calculated as (2 × posterior wall thickness)/(LV internal diameter at end-diastole). Concentric remodeling shows RWT > 0.42 but normal LV mass index 2.

Clinical Significance

Systolic Function Assessment

The reported EF of 67% is supranormal and typical of concentric remodeling patterns. However, this is misleading:

• The elevated EF reflects geometric advantage, not enhanced contractility—the thicker walls and smaller cavity artificially boost the ejection fraction calculation
• Research demonstrates that longitudinal systolic dysfunction occurs even with preserved EF in these patients, detectable by global longitudinal strain (GLS) or MAPSE 3
• You should specifically request or measure GLS if available—values less negative than -20% indicate subclinical dysfunction despite the normal EF 4

Diastolic Function Concerns

Concentric remodeling is associated with progressive diastolic dysfunction 5, 6:

• Studies show a stepwise worsening of E/E' ratio from normal geometry → concentric remodeling → hypertrophy patterns
• The normalized peak filling rate (NPFR) may still be preserved in isolated concentric remodeling, unlike in frank hypertrophy where it decreases significantly 6
• Check for elevated E/E' ratio (>14), enlarged left atrial volume index, and TR velocity to assess diastolic dysfunction severity

Prognostic Implications

Concentric remodeling carries increased cardiovascular risk despite normal LV mass 7:

• It represents an intermediate risk state between normal geometry and LV hypertrophy
• The pattern indicates chronic pressure overload (usually uncontrolled hypertension)
• Risk of progression to concentric hypertrophy and heart failure is substantial if the underlying cause is not addressed 8, 9

Systematic Review Approach

1. Verify the Measurements

• Confirm LV mass calculation method (linear vs 2D)—upper normal limits differ: 95 g/m² (women) or 115 g/m² (men) for linear method; 88 g/m² (women) or 102 g/m² (men) for 2D method 2
• Calculate RWT yourself: should be ≥0.42 for concentric remodeling
• Check that septal and posterior wall thickness are increased (typically 0.9-1.2 cm) but not meeting hypertrophy criteria

2. Assess for Underlying Causes

The primary driver is almost always hypertension—review:

• Blood pressure control history and current readings
• Medication compliance with antihypertensive therapy
• Secondary hypertension workup if indicated (young age, resistant hypertension)

Less common causes include:

• Aortic stenosis (check valve gradients)
• Athletic heart (but this typically shows eccentric patterns)

3. Evaluate Functional Consequences

Request or review these parameters if not already reported:

• Diastolic function assessment: E/A ratio, E/E' ratio, LA volume index, TR velocity
• Strain imaging: GLS to detect subclinical longitudinal dysfunction (expect values around -18 to -19% vs normal >-20%) 3
• Right heart function: Concentric remodeling can lead to elevated filling pressures affecting the RV

4. Look for Associated Findings

• Left atrial enlargement: Common with concentric remodeling due to elevated filling pressures 5
• Reduced LV end-diastolic volume: The hallmark of concentric remodeling—smaller cavity despite normal mass 6
• Stroke volume: May be reduced due to smaller cavity size, contributing to symptoms 8

Clinical Action Points

The finding of concentric remodeling mandates aggressive blood pressure control to prevent progression to LV hypertrophy and heart failure:

• Target BP <130/80 mmHg (or lower if tolerated)
• ACE inhibitors or ARBs are preferred as they promote reverse remodeling
• Consider adding mineralocorticoid receptor antagonists if BP remains uncontrolled
• Serial echocardiography every 1-2 years to monitor for progression to hypertrophy

Common Pitfalls to Avoid

1. Don't be reassured by the "normal" EF of 67%—this is geometrically enhanced and masks underlying dysfunction
2. Don't dismiss this as "normal" because LV mass is normal—concentric remodeling carries independent cardiovascular risk 7
3. Don't forget to index measurements to BSA—failure to do so may misclassify patients at extremes of body size 2
4. Don't overlook diastolic dysfunction assessment—this is where the pathology manifests clinically 5

When to Escalate Evaluation

Consider advanced imaging or cardiology referral if:

• Symptoms of heart failure despite preserved EF
• Evidence of significant diastolic dysfunction (E/E' >14, enlarged LA)
• GLS significantly reduced (<-16%)
• Progression to LV hypertrophy on serial imaging
• Uncertain etiology (no hypertension history)