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

Treatment for Severe Concentric Left Ventricular Hypertrophy

The first-line treatment for severe concentric left ventricular hypertrophy (LVH) should be angiotensin receptor blockers (ARBs), particularly losartan, due to their superior efficacy in reducing left ventricular mass and myocardial fibrosis compared to other antihypertensive medications. 1

Pharmacological Management Based on Etiology

Hypertension-Induced LVH

• ARBs (particularly losartan) are preferred first-line agents for LVH regression due to superior efficacy in reducing left ventricular mass and myocardial fibrosis 1
• ACE inhibitors are equally effective as ARBs in reducing LVH and can be considered as alternative first-line agents when ARBs are not tolerated 1, 2
• Calcium channel antagonists, particularly non-dihydropyridines like verapamil and diltiazem, have demonstrated significant efficacy in LVH regression 1, 3
• Aldosterone antagonists, such as eplerenone, have shown efficacy equal to ACE inhibitors in reducing LVH 1
• The LIFE study demonstrated that losartan was significantly more effective than atenolol in reducing LVH and decreasing myocardial fibrosis 2, 1
• Thiazide or thiazide-like diuretics can be added for blood pressure control and have shown efficacy in LVH regression 2, 4

Hypertrophic Cardiomyopathy (HCM) with LVH

• For obstructive HCM, non-vasodilating beta-blockers titrated to maximum tolerated dose are recommended as first-line therapy 1, 2
• Verapamil or diltiazem can be used in patients with obstructive HCM who are intolerant to beta-blockers 2, 1
• Disopyramide can be added to beta-blockers or calcium channel blockers for symptom improvement in patients with obstructive HCM 2, 1
• For patients with obstructive HCM who have persistent symptoms despite beta-blockers or calcium channel blockers, adding a myosin inhibitor (adults only), disopyramide, or septal reduction therapy is recommended 2
• For nonobstructive HCM with preserved ejection fraction, beta blockers and non-dihydropyridine calcium channel blockers are used to reduce symptoms by lowering LV diastolic pressures and improving LV filling 2

Blood Pressure Targets and Monitoring

• Target blood pressure of <130/80 mmHg for most patients with LVH 4
• Blood pressure control should remain the primary goal of therapy, as adequate BP reduction is essential for LVH regression 1
• LVH regression is typically maintained over time but achieves maximum effect after 2-3 years of consistent treatment 1
• Regular monitoring with echocardiography is recommended to assess LVH regression 2, 5

Non-Pharmacological Interventions

• Regular aerobic exercise, body weight control, and dietary modifications are recommended 4
• Sodium restriction is advised as part of dietary modifications 4
• Weight loss of 5 pounds or greater has been associated with reductions in cardiovascular risk of about 40% 2
• Physical activity of at least 30 minutes per day, most days of the week, is recommended 2

Medications to Avoid

• Non-dihydropyridine calcium channel blockers, alpha-blockers, potent direct-acting vasodilators, and nonsteroidal anti-inflammatory agents should be avoided in patients with LVH due to hypertension 4
• In pregnant women, mavacamten (a myosin inhibitor) is contraindicated due to potential teratogenic effects 2

Clinical Benefits of LVH Regression

• Treatment-induced reduction in left ventricular mass is significantly and independently associated with reduction in major cardiovascular events, stroke, and cardiovascular and all-cause mortality 1, 6
• LVH regression reduces the risk of ventricular arrhythmias and sudden cardiac death 5, 7
• Timely and optimal management of the underlying cause of LVH results in improvement (regression) of LVH and its related complications 5

Important Considerations

• Cardiac MRI is the gold standard in diagnosis and assessment of response to therapy for LVH 5
• Patients with LVH are at increased risk for stroke, congestive heart failure, coronary heart disease, and sudden cardiac death 6, 8
• For patients who develop systolic dysfunction with LVEF <50%, guideline-directed medical therapy for heart failure with reduced ejection fraction is recommended 2
• If a patient with HCM develops persistent systolic dysfunction (LVEF <50%), cardiac myosin inhibitors should be discontinued 2