What is the treatment for left ventricular hypertrophy?

Treatment of Left Ventricular Hypertrophy

ARBs, particularly losartan, are the preferred first-line agents for treating left ventricular hypertrophy, with a starting dose of 50 mg once daily, titrated to 100 mg daily as needed for blood pressure control and LVH regression. 1, 2

First-Line Pharmacological Therapy

ARBs as Preferred Agents

• Losartan is specifically FDA-approved to reduce stroke risk in hypertensive patients with LVH and demonstrates superior efficacy compared to beta-blockers in reducing left ventricular mass and myocardial fibrosis 1, 2
• Start with 50 mg once daily and increase to 100 mg once daily based on blood pressure response 2
• For patients with LVH, add hydrochlorothiazide 12.5 mg daily if needed, then increase losartan to 100 mg daily, followed by increasing hydrochlorothiazide to 25 mg daily based on blood pressure response 2
• Important caveat: The stroke reduction benefit of losartan in LVH patients does not apply to Black patients 2

Alternative First-Line Options

• ACE inhibitors are equally effective as ARBs for LVH regression and should be used when ARBs are not tolerated 1, 3
• Calcium channel blockers (non-dihydropyridines like verapamil and diltiazem) demonstrate significant efficacy in LVH regression 1
• Aldosterone antagonists such as eplerenone show efficacy equal to ACE inhibitors, and combination therapy may be more effective than either agent alone 1

Treatment Algorithm Based on Etiology

For Hypertension-Related LVH

• Target blood pressure <130/80 mmHg for most patients 3
• Use ARBs (losartan preferred), ACE inhibitors, or non-dihydropyridine calcium channel blockers as first-line 1, 3
• Avoid non-dihydropyridine calcium channel blockers, alpha-blockers, potent direct-acting vasodilators (hydralazine, minoxidil), and NSAIDs in hypertension-related LVH 3, 4

For Obstructive Hypertrophic Cardiomyopathy (HCM)

• Non-vasodilating beta-blockers titrated to maximum tolerated dose are first-line therapy 1, 3
• Verapamil or diltiazem can be used if beta-blockers are not tolerated 1, 3
• For persistent symptoms despite beta-blockers or calcium channel blockers, add disopyramide or consider myosin inhibitors (adults only) or septal reduction therapy 1, 3
• If systolic dysfunction develops (LVEF <50%), discontinue cardiac myosin inhibitors and initiate guideline-directed medical therapy for heart failure with reduced ejection fraction 3

Comparative Drug Efficacy

Most Effective Agents for LVH Regression

• The LIFE study demonstrated losartan was significantly more effective than atenolol in reducing LVH and myocardial fibrosis 1
• Indapamide (thiazide-like diuretic) showed significant efficacy and was superior to enalapril in one study 1
• Combination therapy with perindopril-indapamide showed greater LV mass reduction than beta-blockers or ACE inhibitors alone, though this correlated with greater blood pressure reduction 1

Agents to Avoid

• Direct arterial vasodilators (hydralazine, minoxidil) have no effect on LVH despite lowering blood pressure due to strong sympathetic stimulation 4, 5
• Beta-blockers with intrinsic sympathomimetic activity are less effective 6

Non-Pharmacological Interventions

• Regular aerobic exercise, body weight control, and sodium restriction are recommended 3
• Weight loss of 5 pounds or greater is associated with approximately 40% reduction in cardiovascular risk 3

Monitoring and Expected Timeline

• LVH regression typically achieves maximum effect after 2-3 years of consistent treatment 1
• Blood pressure control remains the primary goal, as adequate BP reduction is essential for LVH regression 1, 3
• 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, 3

Special Populations

Hepatic Impairment

• Start losartan at 25 mg once daily in patients with mild-to-moderate hepatic impairment 2
• Losartan has not been studied in severe hepatic impairment 2

Pediatric Patients

• For children 6 years and older with hypertension, start losartan at 0.7 mg/kg once daily (up to 50 mg total) 2
• Not recommended in children under 6 years or with estimated GFR <30 mL/min/1.73 m² 2

Pregnancy

• Mavacamten (myosin inhibitor) is contraindicated in pregnant women due to teratogenic effects 3