What is the treatment for left ventricular hypertrophy (LVH)?

Treatment of Left Ventricular Hypertrophy

The most effective treatment for left ventricular hypertrophy (LVH) is aggressive management of the underlying cause, with ACE inhibitors or ARBs as first-line pharmacological therapy for LVH regression, particularly in hypertensive patients with LVH. 1

Underlying Causes and Initial Approach

LVH can result from various causes that require specific management:

• Hypertension: The most common cause of LVH

  • First-line: ACE inhibitors or ARBs (e.g., losartan) 1, 2
  • Target BP: 120-130/80 mmHg 3
  • Losartan is specifically FDA-approved for hypertensive patients with LVH 2

• Hypertrophic Cardiomyopathy (HCM): When LVH is due to genetic sarcomere mutations

  • First-line: Non-vasodilating beta-blockers titrated to maximum tolerated dose 4
  • Second-line (for beta-blocker intolerant patients): Verapamil 4
  • Third-line: Disopyramide (can be added to beta-blocker or verapamil) 4

• Other causes requiring specific management:

  • Valvular disease: Valve repair/replacement
  • Infiltrative diseases: Disease-specific therapy
  • Athletic heart: Deconditioning period

Pharmacological Treatment Algorithm

1. For hypertensive LVH:

   • Start with losartan 50 mg daily (can increase to 100 mg daily) 2
   • Add hydrochlorothiazide 12.5 mg if needed (can increase to 25 mg) 2
   • Consider adding aldosterone antagonists for resistant hypertension 1

2. For HCM with LVOT obstruction:

   • Beta-blockers (maximum tolerated dose) 4
   • If beta-blockers ineffective/contraindicated: Verapamil (starting 40 mg TID, max 480 mg daily) 4
   • If symptoms persist: Add disopyramide 4
   • Low-dose loop or thiazide diuretics may be used cautiously for dyspnea 4

3. For acute management of severe provocable LVOT obstruction with hypotension/pulmonary edema:

   • IV beta-blockers and vasoconstrictors (phenylephrine, metaraminol, norepinephrine) 4
   • Avoid vasodilators and positive inotropes as they can be life-threatening 4

Monitoring and Follow-up

• Echocardiography every 6-12 months to assess LVH regression 1
• Regular blood pressure monitoring, including home BP monitoring 1
• ECG monitoring for progression of electrical abnormalities 1
• Laboratory monitoring: electrolytes, renal function, BNP/NT-proBNP 1

Lifestyle Modifications

• Regular physical activity (30 minutes daily) 1
• DASH diet for weight loss and BP reduction 1
• Weight reduction for overweight/obese patients 1
• Smoking cessation 1
• Sodium restriction 1
• Moderate alcohol intake 1

Surgical/Interventional Options

For HCM with refractory symptoms:

• Septal myectomy (creates a trough in the basal septum) 4, 1
• Alcohol septal ablation 1
• ICD placement for high-risk patients 1

Important Considerations and Pitfalls

• Avoid direct arterial vasodilators (hydralazine, minoxidil) as they can maintain LVH despite lowering BP 5
• Avoid dihydropyridine calcium channel blockers (e.g., nifedipine) in HCM with LVOT obstruction 4
• Avoid hypovolemia in HCM patients as it can worsen LVOT obstruction 4
• Continue beta-blockers and calcium channel blockers without interruption in the perioperative period for HCM patients 4
• Losartan's benefit for stroke reduction in hypertensive LVH patients may not apply to Black patients 2
• Regression of LVH decreases subsequent cardiovascular morbidity and mortality 6, 7

By addressing the underlying cause and implementing appropriate pharmacological therapy, LVH can be effectively managed and potentially reversed, leading to improved cardiovascular outcomes.