How is left ventricular hypertrophy managed?

Management of Left Ventricular Hypertrophy

The management of left ventricular hypertrophy (LVH) should focus on treating the underlying cause, with beta-blockers and non-dihydropyridine calcium channel blockers as first-line pharmacological therapy for symptomatic patients, particularly those with hypertrophic cardiomyopathy. 1

Pharmacological Management

First-Line Medications

• Beta-blockers:

  • First-line therapy for symptomatic LVH, especially in hypertrophic cardiomyopathy
  • Mechanism: Slow heart rate, improve diastolic function, reduce LV filling pressures, decrease myocardial oxygen demand
  • Should be titrated to maximum tolerated dose
  • Preferred in neonates and children with LVH 1

• Non-dihydropyridine calcium channel blockers (verapamil, diltiazem):

  • Alternative first-line agents
  • Particularly effective for chest pain and improving exercise capacity
  • May improve stress myocardial perfusion defects
  • Verapamil starting dose: 40 mg TID (maximum 480 mg daily)
  • Should be used cautiously in patients >6 months of age 1, 2

Second-Line Medications

• Diuretics:

  • Loop or thiazide diuretics for dyspnea and volume overload
  • Aldosterone antagonists may be beneficial in some patients
  • Require cautious use, typically as intermittent dosing or chronic low-dose therapy
  • Monitor for symptomatic hypotension and hypovolemia 1

• Disopyramide:

  • Can be added to beta-blockers or calcium channel blockers for persistent symptoms
  • Titrated to maximum tolerated dose (usually 400-600 mg/day)
  • Monitor QTc interval during dose titration (reduce if >480 ms)
  • Avoid in patients with glaucoma, prostatism, or taking other QT-prolonging drugs 1, 2

Medications for Hypertension-Induced LVH

• Angiotensin Receptor Blockers (ARBs):

  • Losartan indicated for hypertensive patients with LVH at 50 mg daily, can be increased to 100 mg daily
  • May add hydrochlorothiazide 12.5 mg daily and increase to 25 mg daily based on blood pressure response 3
  • However, a 12-month placebo-controlled trial showed no benefit of losartan on LV mass, fibrosis, or functional class in HCM patients 1

• ACE inhibitors:

  • May be beneficial for regression of LVH
  • Can be used for other indications if needed 4, 5

Non-Pharmacological Management

Lifestyle Modifications

• Weight loss in obese patients
• Sodium restriction
• Regular moderate-intensity exercise with appropriate precautions
• Avoid dehydration and excess alcohol consumption 1, 2

Invasive Procedures

• For obstructive hypertrophic cardiomyopathy with LVOT gradient ≥50 mm Hg:

  • Surgical myectomy
  • Alcohol septal ablation
  • Pacing 1

• For extensive apical hypertrophy with small LV cavity:

  • Transapical myectomy may be considered for severely symptomatic patients with small LV cavity (LV end-diastolic volume <50 mL/m² and LV stroke volume <30 mL/m²)
  • Should be performed only at centers of excellence with extensive surgical experience 1

Special Considerations

Medications to Avoid

• Arterial and venous dilators, including nitrates and phosphodiesterase inhibitors, in patients with LVOTO 1
• Digoxin in patients with LVOTO as it can worsen obstruction 1, 2
• Direct arterial vasodilators (e.g., hydralazine, minoxidil) which may maintain LVH despite lowering blood pressure 5

Management of Arrhythmias

• Restore sinus rhythm or achieve appropriate rate control in patients with atrial fibrillation 1
• Consider ICD placement for high-risk patients 2

Monitoring and Follow-up

• Regular assessment of symptom status
• Periodic echocardiography to evaluate ventricular function
• ECG monitoring for arrhythmias
• Assessment of medication side effects and tolerance 2

Common Pitfalls and Caveats

• Iatrogenic chronotropic incompetence may occur with beta-blockers and calcium channel blockers
• When beta-blockers and calcium channel blockers are used in combination, monitor for bradycardia and atrioventricular conduction block
• Significant changes in LV mass (>60g) are needed on serial echocardiograms before concluding that LV mass has decreased 5
• Treatment should be maintained long-term, as regression of LVH may take 18-24 months from initiation of therapy 6