Does Concentric LV Remodeling Occur in Ischemic Heart Disease?
Yes, concentric left ventricular remodeling is directly associated with ischemic heart disease and represents a late-stage response to myocardial infarction and coronary artery disease. 1
Definition and Pathophysiology
Concentric LV remodeling is characterized by:
- Normal or small LV cavity size 1
- Increased LV wall thickness 1
- Normal left ventricular mass (LVM ≤115 g/m² in men or ≤95 g/m² in women) 2
- Relative wall thickness (RWT) ≥0.42 2
This geometric pattern can be caused by chronic pressure overload, volume overload, or myocardial infarction, and is most commonly associated with coronary artery disease. 1
Evidence Linking Concentric Remodeling to Ischemic Disease
Direct Association with CAD
The European Association of Cardiovascular Imaging guidelines explicitly state that concentric remodeling is most commonly associated with coronary artery disease, though it also occurs with longstanding hypertension. 1 This pattern represents local LV remodeling with apical and posterior displacement of papillary muscles in ischemic disease. 1
Quantitative Relationship
Patients with more extensive coronary plaque burden (>4 segments) demonstrate significantly higher LVM and are twice as likely to have concentric remodeling compared to those without CAD. 3 Specifically:
- Each 20g increase in LVM correlates with 0.27-0.29 additional segments of coronary plaque 3
- Concentric remodeling patients have 1.1-1.3 more segments of plaque than those with normal geometry 3
Mechanism in Ischemic Heart Disease
In chronic ischemic disease, concentric remodeling develops through local LV remodeling that leads to:
- Excess valvular tenting 1
- Loss of systolic annular contraction 1
- Papillary muscle displacement with leaflet tethering 1
This process is distinct from the pressure-overload mechanism seen in hypertension. 1
Clinical Implications and Prognosis
Prognostic Significance
The prognostic implications differ based on whether left ventricular hypertrophy is present:
In patients with stable coronary artery disease without LVH, concentric remodeling alone does not independently predict adverse cardiovascular events, heart failure hospitalization, or cardiovascular death. 4 This contrasts with concentric and eccentric LVH, which do predict worse outcomes. 4, 5
However, when concentric LVH is present in patients with CAD, it confers the highest risk of both all-cause and cardiac mortality. 5
Distinction from Hypertensive Remodeling
While concentric remodeling is also associated with longstanding hypertension, the mechanism differs from ischemic disease. 1 In hypertension, it represents a response to chronic pressure overload, whereas in ischemic disease it results from post-infarction remodeling and papillary muscle displacement. 1
Common Pitfalls and Caveats
Do not assume all concentric remodeling in CAD patients carries the same prognosis as concentric LVH—the presence or absence of increased LV mass is the critical distinguishing factor for risk stratification. 4, 5
The conventional concept that hypertension leads to concentric hypertrophy followed by chamber dilation has been challenged—concentric hypertrophy is actually less common than eccentric hypertrophy even in hypertensive subjects. 6
When evaluating patients with both CAD and concentric remodeling, assess for ischemic mitral regurgitation, as the geometric changes predispose to valvular dysfunction through papillary muscle displacement. 1