From the Guidelines
The workup for a 27-year-old man with Left Ventricular Hypertrophy (LVH) on EKG should begin with a comprehensive 2D echocardiography to establish the diagnosis, determine hypertrophy pattern, and assess LV systolic and diastolic function, as recommended by the 2024 AHA/ACC/AMSSM/HRS/PACES/SCMR guideline 1.
Initial Evaluation
The initial evaluation should include a thorough history, physical examination, and targeted diagnostic testing to determine the underlying cause of LVH.
- A comprehensive medical history focusing on hypertension, family history of cardiac disease, athletic activity, and symptoms like chest pain, syncope, or dyspnea is essential.
- Blood pressure measurement is crucial, as hypertension is a common cause of LVH.
- Laboratory tests should include complete blood count, comprehensive metabolic panel, lipid profile, and thyroid function tests.
Diagnostic Testing
- Echocardiography is crucial to confirm LVH, assess ventricular function, and evaluate for specific cardiomyopathies, such as hypertrophic cardiomyopathy (HCM) 1.
- For this young patient, genetic testing should be considered to identify hereditary conditions like HCM.
- Additional tests may include cardiac MRI for tissue characterization, exercise stress testing to evaluate functional capacity, and 24-hour ambulatory blood pressure monitoring if hypertension is suspected.
- Referral to a cardiologist is appropriate for specialized evaluation and management.
Importance of Workup
The workup is important because LVH in a young adult may indicate serious underlying conditions that require specific treatment approaches, and early identification can prevent complications like heart failure, arrhythmias, or sudden cardiac death.
- The 2024 AHA/ACC/AMSSM/HRS/PACES/SCMR guideline recommends routine follow-up of patients with HCM, including serial TTE every 1 to 2 years, to assess for changes in LV systolic and diastolic function, wall thickness, chamber size, LVOTO, and concomitant valvular disease 1.
- The guideline also recommends the use of provocative maneuvers, such as sustained Valsalva or squat-to-stand maneuvers, to uncover the presence of LVOTO, which may inform the care of the individual 1.
From the Research
Workup for Left Ventricular Hypertrophy (LVH)
The workup for a 27-year-old man with Left Ventricular Hypertrophy (LVH) on Electrocardiogram (EKG) includes:
- Evaluation of blood pressure to assess for hypertension, as it is a major modifiable risk factor for cardiovascular disease morbidity and mortality 2
- Assessment of cardiovascular risk factors, such as family history, lifestyle, and other comorbidities
- Laboratory tests, including complete blood count, electrolyte panel, and renal function tests to evaluate for potential secondary causes of LVH
- Imaging studies, such as echocardiogram, to confirm the presence of LVH and assess left ventricular function 3
- Consideration of other diagnostic tests, such as ambulatory blood pressure monitoring, to assess for masked hypertension or white coat hypertension
Diagnostic Criteria
The diagnosis of LVH can be made using various criteria, including:
- Electrocardiographic (ECG) criteria, such as the Cornell voltage criteria 4
- Echocardiographic criteria, such as left ventricular wall thickness and left ventricular mass index 3
- Imaging criteria, such as cardiac magnetic resonance imaging (MRI) or computed tomography (CT) scan
Management
The management of LVH includes:
- Lifestyle modifications, such as weight loss, regular exercise, and dietary changes to reduce blood pressure and cardiovascular risk 5
- Pharmacological therapy, such as renin-angiotensinogen-aldosterone system inhibitors, calcium channel blockers, and non-hydrochlorothiazide diuretics to reduce blood pressure and induce LVH regression 5
- Close monitoring of blood pressure and cardiovascular risk factors to prevent progression of LVH and reduce the risk of cardiovascular events 6, 2