What is the management plan for a patient with mild concentric left ventricular hypertrophy, normal left ventricular systolic function, and mildly reduced Global Longitudinal Strain?

Management of Mild Concentric Left Ventricular Hypertrophy with Normal Systolic Function and Mildly Reduced Global Longitudinal Strain

The management of mild concentric left ventricular hypertrophy with normal ejection fraction but mildly reduced global longitudinal strain (-19.3%) should focus on identifying and treating the underlying cause, primarily hypertension, while monitoring for progression of cardiac dysfunction. 1, 2

Diagnostic Evaluation

Initial Assessment

• Blood pressure measurement: Essential to identify hypertension as the most common cause of concentric LVH 1
• Laboratory tests:
  • Complete metabolic panel (especially renal function) 3
  • Lipid profile
  • Fasting glucose/HbA1c
  • Thyroid function tests
  • Phosphate levels (associated with abnormal GLS) 3

Advanced Cardiac Assessment

• Comprehensive echocardiography:

  • Detailed assessment of diastolic function (E/A ratio, E/e' ratio, deceleration time) 1
  • Tissue Doppler imaging of septal and lateral mitral annulus 1
  • Pulmonary vein flow assessment 1
  • Repeat measurement of GLS to confirm finding 2

• Consider cardiac MRI if:

  • Suspicion of infiltrative cardiomyopathy
  • Need to differentiate between hypertensive heart disease and hypertrophic cardiomyopathy
  • Assessment of myocardial fibrosis 1

Risk Stratification

Favorable Prognostic Indicators

• Preserved ejection fraction (55-60%) 1
• Only mildly reduced GLS (-19.3% is close to normal range of ≤-18%) 2
• Normal LV filling pattern 1
• Normal right ventricular function 1

Concerning Features Requiring Closer Monitoring

• Mildly dilated left atrium (indicates chronic pressure overload) 1
• Reduced GLS (early marker of subclinical dysfunction) 4, 5
• Concentric pattern of hypertrophy (associated with increased cardiovascular risk) 1

Management Plan

Blood Pressure Control (if hypertensive)

• Target BP <130/80 mmHg 1
• First-line medications:
  • ACE inhibitors or ARBs (preferred for LVH regression)
  • Calcium channel blockers
  • Diuretics if volume overloaded

Lifestyle Modifications

• Sodium restriction (<2g/day)
• Regular aerobic exercise (30 minutes most days)
• Weight loss if overweight/obese
• Limit alcohol consumption
• Smoking cessation

Follow-up Monitoring

• Echocardiography: Repeat in 12 months to assess:

  • Changes in LV wall thickness
  • Progression of GLS abnormalities
  • Left atrial size
  • Diastolic function 1

• More frequent monitoring (6-month intervals) if:

  • GLS worsens to >-16% 5
  • Left atrial enlargement progresses
  • Symptoms develop (dyspnea, chest pain, palpitations)

Special Considerations

Differential Diagnosis to Consider

• Hypertensive heart disease: Most common cause of concentric LVH 1
• Early-stage hypertrophic cardiomyopathy: Consider if family history present 1
• Athlete's heart: Relevant if patient has history of endurance training 1
• Infiltrative cardiomyopathies: Consider if other systemic symptoms present 1

Pitfalls to Avoid

• Don't ignore mildly reduced GLS: Despite normal EF, reduced GLS is an early marker of myocardial dysfunction and predicts adverse outcomes 4, 5
• Don't overlook left atrial enlargement: This indicates chronically elevated filling pressures 1
• Don't focus solely on LVH: The combination of findings (LVH, LA enlargement, reduced GLS) provides more prognostic information than any single parameter 1, 5

When to Consider Referral to Cardiology

• If GLS worsens to >-16% despite treatment 5
• If LVH progresses despite adequate blood pressure control
• If symptoms develop (dyspnea, chest pain, palpitations)
• If there is a family history of cardiomyopathy or sudden cardiac death 1

The mildly reduced GLS (-19.3%) in the setting of normal EF represents early subclinical LV dysfunction that requires monitoring but is not yet severe enough to warrant aggressive intervention beyond treating the underlying cause.