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    Left Ventricular Hypertrophy: Detection, Significance and Treatment

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    Kudor Szabadi Zoltán
    Left ventricular hypertrophy (LVH) can be detected through various methods including electrocardiography, chest radiography and echocardiography. Echocardiography provides the most accurate assessment of LV structure and function. LVH is defined based on left ventricular mass indexed to body surface area compared to healthy reference populations. High blood pressure is a major risk factor for LVH development. Several studies have shown LVH is associated with increased risks of cardiovascular disease and mortality. Treatment aimed at reducing blood pressure and regressing LVH can lower cardiovascular risks. Echocardiography may help guide treatment decisions for patients at risk or with borderline hypertension.

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    Left Ventricular Hypertrophy: Detection, Significance and Treatment

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    Kudor Szabadi Zoltán
    119 views27 pages
    Left ventricular hypertrophy (LVH) can be detected through various methods including electrocardiography, chest radiography and echocardiography. Echocardiography provides the most accurate assessment of LV structure and function. LVH is defined based on left ventricular mass indexed to body surface area compared to healthy reference populations. High blood pressure is a major risk factor for LVH development. Several studies have shown LVH is associated with increased risks of cardiovascular disease and mortality. Treatment aimed at reducing blood pressure and regressing LVH can lower cardiovascular risks. Echocardiography may help guide treatment decisions for patients at risk or with borderline hypertension.

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    MEDICAL POINT OF VIEW

    Original Title

    LVH HYPERTROPHY

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    Left ventricular hypertrophy (LVH) can be detected through various methods including electrocardiography, chest radiography and echocardiography. Echocardiography provides the most accurate assessment of LV structure and function. LVH is defined based on left ventricular mass indexed to body surface area compared to healthy reference populations. High blood pressure is a major risk factor for LVH development. Several studies have shown LVH is associated with increased risks of cardiovascular disease and mortality. Treatment aimed at reducing blood pressure and regressing LVH can lower cardiovascular risks. Echocardiography may help guide treatment decisions for patients at risk or with borderline hypertension.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    119 views27 pages

    Left Ventricular Hypertrophy: Detection, Significance and Treatment

    Uploaded by

    Kudor Szabadi Zoltán
    Left ventricular hypertrophy (LVH) can be detected through various methods including electrocardiography, chest radiography and echocardiography. Echocardiography provides the most accurate assessment of LV structure and function. LVH is defined based on left ventricular mass indexed to body surface area compared to healthy reference populations. High blood pressure is a major risk factor for LVH development. Several studies have shown LVH is associated with increased risks of cardiovascular disease and mortality. Treatment aimed at reducing blood pressure and regressing LVH can lower cardiovascular risks. Echocardiography may help guide treatment decisions for patients at risk or with borderline hypertension.

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    of 27

    Left Ventricular Hypertrophy

    Detection, significance and treatment

    Pathophysiology of LVH

    High BP LV wall stress Wall stress 1/ wall thickness LV wall thickening wall stress Myocyte hypertrophy and collagen matrix Mediators:

    Mechanical: preload & afterload Neurohormonal: angiotensin II, sympathetic NS

    Methods of detecting LVH

    Clinical examination Chest radiography Electrocardiography Echocardiography (CT, MRI)

    Definition of LVH

    Healthy cohort of subjects No high BP, diabetes, CV disease, obesity LVH defined as LVMI > mean + 2SD

    Framingham Study LVMI > 131g/m2 males; > 100g/m2 females Cornell, New York LVMI > 134g/m2 males; > 110g/m2 females
    Levy et al. Am J Cardiol 1987;59:956-60. Devereux et al. JACC 1984;4:1222-30.

    Risk factors for LVH

    Age Gender Race Genetic factors Blood pressure Obesity Physical activity

    Clinic versus mean 24 hour systolic BP and LVMI


    Relationship between mean 24 hour SBP and LVMI

    Clinic SBP v. LVMI: (r=0.28, p<0.05)


    Clinic SBP (mmHg)
    200 150 100 50 0 0 100

    Linear (Relationship between mean 24 hour SBP and LVMI) Linear (Relationship between mean 24 hour SBP and LVMI)

    24 hour SBP (mmHg)

    250

    24 hour mean SBP v. LVMI (r=0.48, p<0.01)

    250 200 150 100 50 0 0 100 200 300

    LVMI (g/m2)

    200

    300

    LVMI (gm2)

    Mayet al et. J Cardiovasc Risk 1995;2:255-61.

    12-lead ECG showing LVH and strain

    Sensitivity and specificity of ECG criteria for LVH


    Sensitivity Specificity Sokolow-Lyon Cornell voltage Minnesota code 3-1 Framingham criteria 15-30 7-45 3-15 3-17 73-100 93-100 85-99 88-99 98-100

    Romhilt-Estes point score 6-50

    Devereux et al 1983, Murphy et al 1985, Levy et al 1990, Lee et al 1992, Devereux et al 1993, Schillaci et al 1994, Crow et al 1995, Norman et al 1995, Chapman et al (in press)

    Determinants of specificity of ECG criteria for LVH


    Age Race Sex Smoking Obesity

    Cardiothoracic ratio and CHD mortality: Whitehall study


    Cardiothoracic ratio Hazard ratio for CHD* <0.4 0.4-0.439 0.44-0.449 0.45-0.469 0.471.0 1.02 (0.61-1.73) 1.02 (0.60-1.74) 1.33 (0.81-2.20) 1.65 (1.01-2.70)
    Hemingway et al. BMJ 1998; 316: 1353-4.

    *Adjusted for age, BP, HR, cholesterol, smoking, angina and ECG ischaemia

    Cardiovascular risk in subjects with ECG-LVH: Framingham


    Age-adjusted risk-ratio

    Cardiovascular outcome Coronary heart disease Stroke Peripheral arterial disaese Cardiac failure
    *P<0.0001

    Men 3.0* 5.8* 2.7 15.0*

    Women 4.6* 6.2* 5.3* 12.8*

    Kannel. Eur Heart J 1992; 13 (suppl D): 82-88

    Risks of X-ray and ECG LVH: Framingham


    Age-adjusted biennial rate per 1000
    No X-ray enlargement X-ray enlargement No ECG-LVH ECG-LVH 171 669 253 1072

    Data include men and women, aged 35-94


    Kannel. Eur Heart J 1992; 13 (suppl D): 82-88

    Echocardiography

    Advantages

    sensitivity improved correlation with morbidity & mortality assessment of function (systolic and diastolic) addition to individuals risk profile
    skilled operator time cost

    Disadvantages

    Echocardiographic LVH and prognosis


    Ref. Levy et al 1990 Levy et al 1989 Population N General General Follow-up End-points RR with LVH CAD CVD All death Casale et al 1986 HTN Koren et al 1991 HTN 140 280 4.8y 10.2y CVD Men: 1.67 Women 1.60 Men 1.49 Women 1.57 Men 1.73 Women 2.12 Men 3.83 1911 4y 3220 4y

    CVD All 2.17 CVD death All 14.0 All death All 3.5

    Sheps and Frohlich. Hypertension 1997; 29: 560-563.

    M-mode echocardiograms

    LVH

    Normal

    Penn convention for M-mode measurements

    Septum (SWT)

    Peak of QRS Endocardium excluded from SWT and PWT Endocardium included in LVID

    LV cavity (LVID)
    LV mass = 1.04[(SWT+LVID+PWT)3 - (LVID)3 - 14g Divide by body surface area to get LV mass index

    Posterior wall (PWT)

    Devereux & Reichek Circulation 1977;55:613-8

    ASE guidelines for M-mode measurements

    Septum (SWT)

    Start of QRS Endocardium included in SWT and PWT Endocardium excluded from LVID

    LV cavity (LVID)
    LVM = 0.8{1.04[ (SWT+LVID+PWT)3 - (LVID)3]} + 0.6 g

    Posterior wall (PWT)


    Divide by body surface area to get LV mass index

    Devereux et al. Am J Cardiol 1986;57:450-8

    Area-length method for calculation of LV mass


    LVmass=1.05[5/6(A1xL1)-5/6(A2xL2)] Divide by body surface area to get LV mass index

    Reichek et al. Circulation 1983;67:348-52

    4-year age-adjusted incidence of cardiovascular disease according to LVMI


    18 16 14 12 10 8 6 4 2 0 <75 75-94 95-116 117Males Females

    LVMI (g/m2)

    Redrawn from Levy et al; NEJM 1990; 322: 1561-6.

    Incidence of cardiovascular mortality according to presence or absence of LVH


    5 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 Men Women

    No LVH LVH

    P<0.001

    P=ns
    Redrawn from Levy et al, NEJM 1990; 322: 1561-6.

    Echocardiographic LVH and prognosis


    Ref. Levy et al 1990 Levy et al 1989 Population N General General Follow-up End-points RR with LVH CAD CVD All death Casale et al 1986 HTN Koren et al 1991 HTN 140 280 4.8y 10.2y CVD Men: 1.67 Women 1.60 Men 1.49 Women 1.57 Men 1.73 Women 2.12 Men 3.83 1911 4y 3220 4y

    CVD All 2.17 CVD death All 14.0 All death All 3.5

    Sheps and Frohlich. Hypertension 1997; 29: 560-563.

    Risks associated with LVM and geometry


    Total mortality*
    40

    Cardiovascular events

    % patients

    30 20 10 0 >125 <125 >125 <125 >0.45 <0.45

    RWT

    LVMI (g/m2) *P<0.001, P=0.03

    LVMI (g/m2)
    Koren et al. Ann Int Med 1991; 114: 345-352.

    Regression of LVH by drug treatment: meta-analysis of RCTs


    0 -2 -4 -6 -8 -10 -12 -14 Diuretics B-blockers CCB's ACE-I

    Between treatment P<0.01


    Schmieder et al. JAMA 1996; 275: 1507-1513

    LVH regression: LIVE study


    1 0

    % from baseline

    -1 -2 -3 -4 -5 -6 PWT IVST LVID LVMI


    Sheridan and Gosse 1998

    Indapamide SR Enalapril

    *P<0.05 for LVMI

    Prognostic significance of Echo LVM regression


    Events/ 100 patient years
    7 6 5 4 3 2 1 0 All Regressors LVH Non-regressors

    *P=0.04, P=0.0004 after adjustment for age.


    Verdecchia et al. Circulation 1998; 97: 48-54

    Prognostic significance of ECG voltage changes: Framingham


    OR for CV events (2 years)
    2 1.5 1 0.5 0 Decreased voltage Males Increased voltage Females

    *P<0.05

    Levy et al. Circulation 1994; 90: 1786-1793

    Who to refer for echocardiography?

    Patients with borderline BP:

    LVH may influence decision to treat


    LVH may lead to other interventions e.g. lipid lowering therapy

    Patient with multiple risk factors:

    Possible white coat hypertension ? To stratify class of antihypertensive agent to be used (increasing data suggesting LVH regression should be a goal of treatment)

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