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Should LVH Regression Be a Goal of Antihypertensive Treatment?

Regression of left ventricular hypertrophy during antihypertensive treatment was associated with improved outcomes, independent of blood-pressure reduction.

Left ventricular hypertrophy (LVH) is a common consequence of hypertension and an independent risk factor for cardiovascular morbidity and mortality. Treatment of hypertension can result in LVH regression and in reduced risk for adverse outcomes. But does LVH regression during antihypertensive treatment predict better cardiovascular outcomes independent of blood-pressure reduction?

In the LIFE study, 9193 patients with moderate hypertension (mean age, 67; mean BP, 174/98 mm Hg) and electrocardiographic (ECG) evidence of LVH were randomized to receive first-line antihypertensive therapy with the angiotensin-receptor blocker losartan or the ß-blocker atenolol. By a mean of 4.8 years, the losartan group had experienced significantly fewer adverse cardiovascular events (Journal Watch Apr 30 2002). All subjects underwent annual ECGs, and about 10% also had annual echocardiograms. LVH and LV mass index (LVMI) were defined by strict ECG and echocardiographic criteria, respectively.

Overall, mean LVH and LVMI decreased significantly throughout the study, although BP stabilized after 1 year. Lower on-treatment LVH and LVMI were associated strongly with reduced cardiovascular morbidity and mortality, independent of randomized treatment, severity of baseline LVH, and baseline and on-treatment BP. After adjustment for these variables, a 1-standard-deviation decrease in ECG-defined on-treatment LVH was associated with significant decreases in cardiovascular death, myocardial infarction, or stroke (by 29%); cardiovascular mortality (by 38%); MI (by 19%); and stroke (by 27%). A 1-SD decrease in LVMI was associated with comparable benefits.

Comment: These data show that LVH, measured by ECG or echocardiography, independently predicts adverse cardiovascular outcomes in patients being treated for moderate hypertension. Further studies are needed to determine whether antihypertensive treatment directed at LVH regression would be more cardioprotective than treatment directed at BP reduction alone.

— Bruce Soloway, MD

Published in Journal Watch General Medicine December 10, 2004

Citation(s):

Okin PM et al. Regression of electrocardiographic left ventricular hypertrophy during antihypertensive treatment and the prediction of major cardiovascular events. JAMA 2004 Nov 17; 292:2343-9.

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Devereux RB et al. Prognostic significance of left ventricular mass change during treatment of hypertension. JAMA 2004 Nov 17; 292:2350-6.

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