What is the management plan for a patient with mild concentric left ventricular hypertrophy, normal left ventricular systolic function, grade I diastolic dysfunction, and a discrepancy between resting and stress left ventricular ejection fraction (LVEF) of 62% and 48%, respectively?

Management Plan for Mild Concentric LV Hypertrophy with Stress-Induced Hypokinesis

The patient requires medical therapy with an ACE inhibitor or ARB, beta-blocker, and further cardiac evaluation due to the concerning drop in LVEF during stress testing, which indicates stress-induced myocardial dysfunction that requires investigation for coronary artery disease.

Assessment of Cardiac Findings

The patient presents with several significant cardiac abnormalities:

1. Mild concentric left ventricular hypertrophy (LVH)
2. Normal resting LV systolic function (LVEF 62%)
3. Grade I diastolic dysfunction (abnormal relaxation pattern)
4. Stress-induced diffuse hypokinesis with drop in LVEF to 48%
5. Reduced global longitudinal strain (-15.3%)
6. Mild to moderate aortic valve thickening without significant stenosis

Management Algorithm

Step 1: Address Underlying Etiology

• Evaluate for hypertension - Most common cause of concentric LVH
• Screen for other causes of LVH:
  • Aortic valve disease (already noted mild-moderate thickening)
  • Hypertrophic cardiomyopathy
  • Infiltrative diseases

Step 2: Investigate Stress-Induced Dysfunction

• Coronary angiography is indicated due to the significant drop in LVEF during stress (from 62% to 48%) with diffuse hypokinesis
• This finding suggests stress-induced myocardial ischemia that requires evaluation for coronary artery disease 1

Step 3: Medical Therapy

1. Antihypertensive therapy:

   • ACE inhibitor or ARB is recommended as first-line therapy for patients with LVH 2
   • Beta-blocker therapy is indicated for patients with evidence of ischemia and to improve diastolic filling 1

2. Lipid management:

   • High-intensity statin therapy is recommended, especially if coronary artery disease is confirmed 1
   • Target LDL-C goal <1.4 mmol/L (55 mg/dL) and ≥50% reduction from baseline 1

3. Management of diastolic dysfunction:

   • Diuretics should be used if there are symptoms of volume overload 1
   • Optimize blood pressure control to reduce LV afterload 1

Step 4: Follow-up Monitoring

• Serial echocardiography every 6-12 months to monitor:

  • LV hypertrophy progression
  • Systolic function (LVEF)
  • Diastolic function parameters
  • Global longitudinal strain

• Stress testing should be repeated in 12 months or sooner if symptoms develop

Rationale and Evidence Base

The management approach is guided by several key considerations:

1. Concentric LVH with diastolic dysfunction is associated with worse outcomes compared to eccentric LVH 3. Patients with concentric LVH have more severe diastolic dysfunction even with similar LV mass indices.

2. Stress-induced reduction in LVEF is a concerning finding that suggests:

   • Underlying coronary artery disease requiring evaluation 1
   • Potential for progression to systolic heart failure (13% of patients with concentric LVH and normal LVEF progress to systolic dysfunction within 3 years) 4

3. Grade I diastolic dysfunction requires treatment to prevent progression to heart failure with preserved ejection fraction (HFpEF) 5

4. Reduced global longitudinal strain (-15.3%, normal >-18%) indicates subclinical systolic dysfunction despite normal LVEF 6

Important Considerations and Pitfalls

• Don't focus only on the normal resting LVEF - The stress-induced drop in LVEF is a critical finding that requires investigation
• Don't overlook diastolic dysfunction - Grade I diastolic dysfunction can progress and contribute to heart failure symptoms
• Avoid misinterpreting reduced longitudinal strain - This finding suggests early systolic dysfunction despite normal LVEF
• Don't delay coronary evaluation - The stress-induced diffuse hypokinesis strongly suggests ischemia

Monitoring Response to Therapy

• Improvement in diastolic parameters on follow-up echocardiography
• Stabilization or regression of LVH
• Improvement in global longitudinal strain
• Resolution of stress-induced wall motion abnormalities after appropriate treatment

This comprehensive approach addresses both the structural abnormalities (LVH) and functional concerns (stress-induced systolic dysfunction and baseline diastolic dysfunction) to reduce morbidity and mortality risk.