What should be evaluated in an echocardiogram (echo) for a young patient with hypertension?

Echocardiographic Evaluation in Young Hypertensive Patients

In young hypertensive patients, echocardiography should primarily assess left ventricular mass (to detect LVH), left ventricular geometry (to distinguish concentric from eccentric patterns), left ventricular systolic and diastolic function, and left atrial size, as these parameters directly predict cardiovascular morbidity and mortality. 1

Primary Parameters to Evaluate

Left Ventricular Mass and Hypertrophy

• Measure LV mass indexed to height: LVH is defined as LV mass >51 g/m^2.7 for both males and females in adolescents/young adults >8 years old 1
• Alternative indexing to body surface area can be used: >115 g/BSA for males and >95 g/BSA for females 1
• LVH is present in approximately 61% of asymptomatic hypertensive patients when properly assessed by echocardiography, despite normal ECG findings in most cases 2

Left Ventricular Geometry Pattern

• Calculate relative wall thickness (RWT): abnormal when >0.42, which distinguishes concentric from eccentric hypertrophy 1
• Concentric LVH carries significantly worse prognosis and requires repeat echocardiography at 6-12 month intervals 1
• Approximately 4% of hypertensive patients demonstrate disproportionate septal thickening (septal-to-free wall ratio ≥1.3) 2

Systolic and Diastolic Function

• Assess left ventricular ejection fraction, as reduced systolic function is found in approximately 15% of asymptomatic hypertensive patients 2
• Evaluate diastolic function parameters, as impaired diastolic function is a common early manifestation of hypertensive heart disease 1, 3
• Mitral valve E-F slope should be measured, as decreased closing velocity indicates diastolic dysfunction 2

Left Atrial Assessment

• Measure left atrial size, as enlargement (present in 5-7% of hypertensive patients) indicates chronic diastolic dysfunction and increased cardiovascular risk 1, 2
• Left atrial function assessment provides prognostic information 3

Additional Hemodynamic Considerations

Cardiac Output and Resistance Patterns

• Assess cardiac output and total peripheral resistance patterns to guide medication selection 1
• High output-low resistance patterns favor beta-blockers or diuretics 1
• High resistance patterns favor vasodilators 1

Valvular Assessment

• Evaluate for aortic stenosis, as hypertension and stenotic valves act as serial resistors affecting symptom status and prognosis 1

When to Order Echocardiography

Echocardiography should be performed in young hypertensive patients when: 1

• Considering initiation of pharmacologic treatment
• ECG shows LVH or other abnormalities (though ECG has extremely low sensitivity for detecting LVH) 1
• Patient has cardiac symptoms (dyspnea, chest pain, palpitations)
• Stage 2 hypertension is present
• Secondary hypertension is suspected
• Chronic stage 1 hypertension remains incompletely treated

Follow-Up Imaging Schedule

Repeat echocardiography at 6-12 month intervals is indicated when: 1

• Persistent hypertension despite treatment
• Concentric LVH is detected
• Reduced ejection fraction is present

Critical Pitfalls to Avoid

• Do not rely on ECG alone for detecting LVH in young hypertensive patients, as it has extremely low sensitivity (less than 10% abnormal despite 61% having cardiac abnormalities on echo) 1, 2
• Do not limit evaluation to LV mass alone—a complete assessment must include geometry, systolic function, diastolic function, and left atrial size 1
• Chest X-ray is similarly insensitive, with less than 10% showing abnormalities despite high prevalence of cardiac changes 2
• Echocardiography detects cardiac abnormalities before they become clinically apparent through other modalities 2