What is the management approach for a patient with Left Ventricular Hypertrophy (LVH)?

Management of Left Ventricular Hypertrophy

The management of LVH requires first determining whether it represents hypertrophic cardiomyopathy (HCM) versus secondary causes such as hypertension, aortic stenosis, or infiltrative diseases, as the treatment strategies differ fundamentally between these etiologies. 1

Initial Diagnostic Evaluation

Any LV wall thickness ≥15 mm in adults that is unexplained by loading conditions warrants systematic evaluation for the underlying etiology. 1 The diagnostic workup must exclude:

• Infiltrative diseases including amyloidosis, sarcoidosis, Fabry disease, and glycogen storage diseases 1
• Drug-induced causes such as chronic anabolic steroids, tacrolimus, and hydroxychloroquine 1
• Physiologic athlete's heart in those with intense athletic training 1
• Hypertensive cardiomyopathy from long-standing systemic hypertension 2
• Valvular disease, particularly aortic stenosis causing secondary LVH 2

For HCM diagnosis in adults, imaging with 2D echocardiography or CMR showing maximal end-diastolic wall thickness ≥15 mm anywhere in the left ventricle establishes the diagnosis when other causes are excluded. 2 More limited hypertrophy (13-14 mm) can be diagnostic when present in family members of HCM patients or with a positive genetic test. 2

Management of Hypertrophic Cardiomyopathy

Medical Therapy for Obstructive HCM

Beta-blockers are first-line therapy for obstructive HCM, titrated to maximum tolerated dose to reduce symptoms and achieve physiologic evidence of beta-blockade such as suppressed resting heart rate. 1, 3

Non-dihydropyridine calcium channel blockers (verapamil or diltiazem) are alternative therapy for patients intolerant or with contraindications to beta-blockers. 1, 3 However, use these cautiously due to their vasodilating properties. 3

Disopyramide should be added to beta-blockers if LVOT gradient ≥50 mm Hg persists with refractory symptoms. 1 This requires careful monitoring of QTc interval and must be combined with AV nodal blocking agents to prevent rapid ventricular response if atrial fibrillation develops. 3

Critical pitfall: Avoid vasodilators that worsen LVOTO including nitrates, ACE inhibitors, ARBs, and dihydropyridine calcium channel blockers. 3 Diuretics must be used cautiously to prevent symptomatic hypotension from excessive preload reduction. 1

Medical Therapy for Non-Obstructive HCM

For non-obstructive HCM, beta-blockers or non-dihydropyridine calcium channel blockers may improve dyspnea and chest pain. 1 However, do not use these agents in asymptomatic HCM patients without data showing benefit. 1

Advanced Pharmacological Options

Cardiac myosin inhibitors such as mavacamten may be considered for adults with obstructive HCM who have failed first-line therapy, improving LVOT gradients, symptoms, and functional capacity in 30-60% of patients. 3

Invasive Treatment Options

Extended septal myectomy via transaortic approach is the standard surgical procedure for patients with LVOT gradient ≥50 mm Hg and symptoms refractory to maximum medical therapy. 1

Septal alcohol ablation is an alternative to surgery in selected patients, but requires careful patient selection and experienced centers. 1

Management of Secondary LVH (Hypertensive Heart Disease)

For LVH secondary to hypertension, antihypertensive agents that promote regression of LVH include diuretics, beta-blockers (except those with intrinsic sympathomimetic activity), ACE inhibitors, calcium channel blockers, peripheral alpha-1 blockers, and central alpha-2 stimulators. 4

Avoid direct arterial vasodilators (hydralazine and minoxidil) which maintain LVH despite lowering blood pressure due to strong sympathetic stimulating properties. 4

Diuretics show excellent evidence of LVH regression and may particularly benefit African-American and elderly patients. 4 Beta-blockers should be considered in elderly patients with greatly thickened LV walls and small chamber sizes. 4

Reversal of LVH may take 18 to 24 months from initiation of therapy. 5

Management of Advanced Heart Failure in HCM

Guideline-directed medical therapy for heart failure with reduced ejection fraction is recommended for patients with HCM who develop systolic dysfunction with LVEF <50%. 1

Cardiopulmonary exercise testing should be performed to assess for heart transplant or mechanical circulatory support candidacy in patients with nonobstructive HCM and advanced heart failure. 1

Risk Factor Modification

Intensive management of cardiometabolic risk factors is essential, as obesity, hypertension, diabetes, and obstructive sleep apnea are highly prevalent in HCM patients and associated with poorer prognosis. 1, 3

Management of Atrial Fibrillation

Prompt restoration of sinus rhythm or appropriate rate control is essential in patients with new-onset or poorly controlled atrial fibrillation. 1

Prognostic Significance

LVH is an independent risk factor for stroke, congestive heart failure, coronary heart disease, sudden cardiac death, atrial arrhythmias, and ventricular arrhythmias. 6, 7 Timely and optimal management of the underlying cause results in improvement (regression) of LVH and its related complications. 7

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