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 based on blood pressure response. 1, 2

First-Line Pharmacological Approach

ARBs as Primary Therapy

• Losartan is specifically FDA-indicated to reduce stroke risk in hypertensive patients with LVH and demonstrates superior efficacy in reducing left ventricular mass and myocardial fibrosis compared to beta-blockers. 1, 2
• Start losartan at 50 mg once daily, with dose escalation to 100 mg daily as needed for blood pressure control. 2
• Consider adding hydrochlorothiazide 12.5 mg daily if blood pressure targets are not met with losartan monotherapy, increasing to 25 mg daily if needed. 2
• Important caveat: The stroke reduction benefit of losartan in LVH does not apply to Black patients, requiring alternative first-line consideration in this population. 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
• Non-dihydropyridine calcium channel blockers (verapamil or diltiazem) demonstrate significant efficacy in LVH regression and are appropriate first-line alternatives. 1
• Aldosterone antagonists like eplerenone show efficacy equal to ACE inhibitors, with combination therapy potentially more effective than either agent alone. 1

Treatment Algorithm Based on LVH Etiology

For Hypertrophic Cardiomyopathy (HCM)

• Non-vasodilating beta-blockers titrated to maximum tolerated dose are first-line therapy for obstructive HCM. 1, 3
• Use verapamil or diltiazem in patients intolerant to beta-blockers. 1, 3
• Add disopyramide to beta-blockers or calcium channel blockers for persistent symptoms. 1
• Consider myosin inhibitors (adults only) or septal reduction therapy for refractory cases despite optimal medical therapy. 3

For Hypertension-Induced LVH

• Target blood pressure <130/80 mmHg for most patients. 3
• Avoid non-dihydropyridine calcium channel blockers, alpha-blockers, potent direct-acting vasodilators (hydralazine, minoxidil), and NSAIDs in hypertension-related LVH. 3, 4, 5
• Thiazide-like diuretics, particularly indapamide, show significant LVH regression efficacy and may be superior to some ACE inhibitors. 1

Comparative Drug Efficacy

Most Effective Agents

• The LIFE study demonstrated losartan's superiority over atenolol in reducing LVH and myocardial fibrosis. 1
• Combination therapy with ACE inhibitor plus diuretic (perindopril-indapamide) produces greater LV mass reduction than beta-blockers or ACE inhibitors alone, though this correlates with greater blood pressure reduction. 1
• Beta-blockers are as effective as ACE inhibitors specifically for decreasing LV wall thickness. 4

Agents to Avoid

• Direct arterial vasodilators (hydralazine, minoxidil) maintain LVH despite lowering blood pressure due to strong sympathetic stimulation and should be avoided. 6, 5
• Beta-blockers with intrinsic sympathomimetic activity are less effective for LVH regression. 6

Non-Pharmacological Interventions

• Regular aerobic exercise, body weight control, and sodium restriction are recommended adjuncts. 3
• Weight loss of ≥5 pounds associates with approximately 40% reduction in cardiovascular risk. 3

Monitoring and Expected Outcomes

Timeline for Response

• LVH regression achieves maximum effect after 2-3 years of consistent treatment and is typically maintained over time. 1
• Reversal may require 18-24 months from therapy initiation. 5
• Significant changes in LV mass (>60 g on serial echocardiography) are needed to confirm meaningful regression. 6

Clinical Benefits

• Treatment-induced LV mass reduction independently associates with decreased major cardiovascular events, stroke, cardiovascular mortality, and all-cause mortality. 1, 3
• Blood pressure control remains the primary therapeutic goal, as adequate BP reduction is essential for LVH regression. 1, 3

Special Considerations

Dosage Modifications

• Start losartan at 25 mg once daily in patients with possible intravascular depletion (e.g., on diuretic therapy) or mild-to-moderate hepatic impairment. 2
• Losartan is not recommended in pediatric patients <6 years or with eGFR <30 mL/min/1.73 m². 2

Heart Failure Development

• If systolic dysfunction develops (LVEF <50%), transition to guideline-directed medical therapy for heart failure with reduced ejection fraction. 3
• Discontinue cardiac myosin inhibitors if persistent systolic dysfunction occurs in HCM patients. 3

Pregnancy

• Mavacamten (myosin inhibitor) is contraindicated in pregnancy due to teratogenic effects. 3