What is the recommended management for left ventricular hypertrophy, including identification and treatment of underlying causes, blood pressure targets, and first‑line antihypertensive therapy?

Management of Left Ventricular Hypertrophy

Identify and Treat the Underlying Cause

Start by determining whether LVH is due to hypertension, hypertrophic cardiomyopathy (HCM), infiltrative disease, or physiologic adaptation, as management differs fundamentally based on etiology. 1

• Any LV wall thickness ≥15 mm in adults unexplained by loading conditions requires systematic evaluation to exclude infiltrative diseases (amyloidosis, sarcoidosis, Fabry disease, glycogen storage diseases), drug-induced causes (anabolic steroids, tacrolimus, hydroxychloroquine), and physiologic athlete's heart 2
• Hypertensive LVH must be distinguished from HCM, particularly in younger patients or when asymmetric septal hypertrophy is present 1
• Transthoracic echocardiography is more sensitive than ECG for detecting LVH and should assess interventricular septal thickness, posterior wall thickness, end-diastolic diameter, and calculate left ventricular mass 1

First-Line Pharmacologic Therapy for Hypertensive LVH

ARBs, particularly losartan 50-100 mg daily, are the preferred first-line agents for hypertension-induced LVH due to superior efficacy in reducing left ventricular mass and myocardial fibrosis compared to beta-blockers. 1, 3

• ACE inhibitors are equally effective as ARBs in reducing LVH and should be used when ARBs are not tolerated 1, 3
• Non-dihydropyridine calcium channel blockers (verapamil, diltiazem) demonstrate significant efficacy in LVH regression 1, 3
• Aldosterone antagonists (eplerenone) have efficacy equal to ACE inhibitors, and combination therapy may be more effective than either agent alone 1
• Thiazide-type diuretics should not be used as monotherapy in patients with metabolic syndrome; they are effective only when combined with renin-angiotensin system blockade 1

Blood Pressure Targets

Blood pressure control remains the primary goal of therapy, as adequate BP reduction is essential for LVH regression. 1

• The combination of an ACE inhibitor with a diuretic (perindopril-indapamide) has shown greater reduction of LV mass than beta-blockers or ACE inhibitors alone, though this was associated with greater blood pressure reduction 1
• During medication titration, review patients every 2-4 weeks to adjust doses and monitor adverse effects; once target blood pressure is achieved, extend follow-up intervals while maintaining strict blood pressure surveillance 1

Management of Hypertrophic Cardiomyopathy

For obstructive HCM (LVOT gradient ≥50 mm Hg), non-vasodilating beta-blockers titrated to maximum tolerated dose are first-line therapy. 1, 2

• Verapamil or diltiazem can be used in patients intolerant to beta-blockers 1, 2
• Disopyramide should be added to beta-blockers if LVOT gradient ≥50 mm Hg persists with refractory symptoms 1, 2
• For non-obstructive HCM, beta-blockers or non-dihydropyridine calcium channel blockers may improve dyspnea and chest pain 2
• Do not use beta-blockers or calcium channel blockers in asymptomatic HCM patients without data showing benefit 2
• Extended septal myectomy is the standard surgical procedure for patients with LVOT gradient ≥50 mm Hg and symptoms refractory to maximum medical therapy 2

Non-Pharmacologic Management

Weight loss of at least 5 pounds is associated with ~40% reduction in cardiovascular risk. 3

• Sodium restriction and regular aerobic exercise are essential, though competitive sports should be avoided in HCM patients 3
• Aggressively manage cardiometabolic risk factors including obesity, hypertension, diabetes, and obstructive sleep apnea, which are highly prevalent and associated with poorer prognosis 2, 3

Monitoring and Expected Outcomes

Echocardiographic reassessment is recommended at 12-month intervals after initiating therapy because measurable reductions in left-ventricular mass generally do not appear before one year. 1

• Maximum effect of treatment on LVH regression is typically achieved after 2-3 years of consistent treatment 1, 3
• Treatment-induced reduction in left ventricular mass is significantly and independently associated with reduction in major cardiovascular events, stroke, and cardiovascular and all-cause mortality 1, 3

Special Populations and Pitfalls

In hypertensive patients with LVH and atrial fibrillation, ARBs reduce the recurrence of atrial fibrillation and should be prioritized. 1

• Prompt restoration of sinus rhythm or appropriate rate control is essential in patients with new-onset or poorly controlled atrial fibrillation, as they have greater dependency on atrial systole for ventricular filling 3
• For patients with systolic dysfunction (LVEF <50%), initiate guideline-directed medical therapy for heart failure with reduced ejection fraction 2, 3
• Diuretics must be used cautiously in HCM to prevent symptomatic hypotension from excessive preload reduction 2
• Avoid using dobutamine to identify latent LVOTO due to lack of specificity 2