Which is safer, eccentric hypertrophy or concentric hypertrophy?

Concentric Hypertrophy is More Dangerous Than Eccentric Hypertrophy

Concentric left ventricular hypertrophy carries significantly higher cardiovascular risk and worse outcomes compared to eccentric hypertrophy, primarily due to reduced myocardial efficiency, impaired coronary perfusion reserve, and greater propensity for diastolic dysfunction. 1

Key Pathophysiologic Differences

Concentric Hypertrophy (Pressure Overload)

• Develops from chronic pressure overload (hypertension, aortic stenosis) with sarcomeres added in parallel, causing increased wall thickness without chamber enlargement 2
• Associated with significantly reduced myocardial efficiency (13% ± 4%) compared to eccentric hypertrophy (18% ± 6%, p=0.04) 1
• Impaired coronary perfusion reserve despite similar absolute perfusion measurements as eccentric patterns 1
• Results in normal or small LV cavity size with uniformly increased wall thickness 2

Eccentric Hypertrophy (Volume Overload)

• Develops from volume overload (valvular regurgitation, high cardiac output states) with sarcomeres added in series, lengthening myocytes 2
• Maintains myocardial efficiency similar to normal hearts (18% ± 6% vs 16% ± 3% in controls, p=NS) 1
• Characterized by increased LV cavity size with normal wall thickness but elevated total LV mass 2
• Generally presents with low-normal or mildly impaired systolic function due to chronic volume overload 2

Clinical Outcomes and Mortality Risk

Concentric Pattern Outcomes

• Higher cardiovascular morbidity and mortality compared to eccentric patterns, likely explained by reduced myocardial efficiency 1
• In heart failure with reduced ejection fraction (HFrEF), patients with concentric hypertrophy demonstrate distinctly different biomarker patterns with tumor necrosis factor receptor 1 and inflammatory markers as central hubs 3
• May not benefit from standard HFrEF therapies the same way eccentric patterns do—beta-blocker up-titration showed mortality benefit in eccentric but not concentric hypertrophy (p-interaction ≤0.001) 3

Eccentric Pattern Outcomes

• In aortic stenosis specifically, eccentric hypertrophy paradoxically shows worse outcomes with increased all-cause mortality (HR=3.67-9.48 vs other geometries, p<0.001) 4
• This exception occurs because eccentric hypertrophy in AS indicates reduced LV contractility and possible transition toward heart failure with reduced ejection fraction 5, 4
• In heart failure with preserved ejection fraction (HFpEF), eccentric hypertrophy patients have lower LVEF and reduced contractility compared to concentric patterns 5

Critical Clinical Distinctions

Why Concentric is Generally More Dangerous

• Inappropriate or excessive hypertrophy (particularly in elderly women) leads to low systolic wall stress and high ejection fraction but is associated with high perioperative morbidity and mortality 2
• The hypertrophied heart exhibits reduced coronary blood flow per gram of muscle and limited coronary vasodilator reserve even without epicardial coronary disease 2
• Increased sensitivity to ischemic injury with larger infarcts and higher mortality rates than non-hypertrophied hearts 2
• Hemodynamic stress from exercise or tachycardia produces maldistribution of coronary blood flow and subendocardial ischemia 2

Context-Dependent Exceptions

• In aortic stenosis patients, eccentric hypertrophy becomes the more dangerous pattern because it signals decompensation with increased LV size, reduced ejection fraction, and progression toward systolic dysfunction 4
• Eccentric hypertrophy in AS predicts both greater heart failure readmissions (HR=2.66-3.28 vs other geometries) and all-cause mortality across moderate and severe stenosis 4

Practical Clinical Algorithm

For hypertensive patients or pressure overload states:

• Concentric hypertrophy represents the higher-risk pattern requiring aggressive blood pressure control and close monitoring for coronary ischemia 1, 2

For valvular disease (especially aortic stenosis):

• Eccentric hypertrophy signals decompensation and warrants consideration for earlier surgical intervention given the substantially elevated mortality risk 4

For heart failure management:

• Eccentric patterns respond better to standard HFrEF therapies (ACE inhibitors/ARBs and beta-blockers) 3
• Concentric patterns may require alternative therapeutic strategies given the lack of mortality benefit from beta-blocker up-titration 3

Common Pitfalls to Avoid

• Do not assume all eccentric hypertrophy is benign—in the context of aortic stenosis or HFpEF, it indicates advanced disease with worse prognosis 5, 4
• Do not apply HFrEF treatment algorithms uniformly—concentric hypertrophy patients show different biomarker profiles and treatment responses 3
• Do not overlook the coronary perfusion implications of concentric hypertrophy even in patients without obstructive coronary disease 2, 1