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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

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left ventricular hypertrophy

Left Ventricular Hypertrophy

Detection, significance and treatment

pathophysiology of lvh
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
Methods of detecting LVH
  • Clinical examination
  • Chest radiography
  • Electrocardiography
  • Echocardiography
  • (CT, MRI)
definition of lvh
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
Risk factors for LVH
  • Age
  • Gender
  • Race
  • Genetic factors
  • Blood pressure
  • Obesity
  • Physical activity
clinic versus mean 24 hour systolic bp and lvmi
Clinic versus mean 24 hour systolic BP and LVMI

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

sensitivity and specificity of ecg criteria for lvh
Sensitivity and specificity of ECG criteria for LVH

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)

cardiothoracic ratio and chd mortality whitehall study
Cardiothoracic ratio and CHD mortality:Whitehall study

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

Hemingway et al. BMJ 1998; 316: 1353-4.

cardiovascular risk in subjects with ecg lvh framingham
Cardiovascular risk in subjects with ECG-LVH: Framingham

Age-adjusted risk-ratio

*P<0.0001

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

risks of x ray and ecg lvh framingham
Risks of X-ray and ECG LVH:Framingham

Age-adjusted biennial rate per 1000

Data include men and women, aged 35-94

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

echocardiography
Echocardiography
  • Advantages
    • sensitivity
    • improved correlation with morbidity & mortality
    • assessment of function (systolic and diastolic)
    • addition to individual’s risk profile
  • Disadvantages
    • skilled operator
    • time
    • cost
echocardiographic lvh and prognosis
Echocardiographic LVH and prognosis

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

penn convention for m mode measurements
Penn convention for M-mode measurements
  • Peak of QRS
  • Endocardium excluded from SWT and PWT
  • Endocardium included in LVID

LV mass = 1.04[(SWT+LVID+PWT)3 - (LVID)3 - 14g

Divide by body surface area to get LV mass index

Septum (SWT)

LV cavity (LVID)

Posterior wall (PWT)

Devereux & Reichek Circulation 1977;55:613-8

ase guidelines for m mode measurements
ASE guidelines for M-mode measurements
  • Start of QRS
  • Endocardium included in SWT and PWT
  • Endocardium excluded from LVID

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

Divide by body surface area to get LV mass index

Septum (SWT)

LV cavity (LVID)

Posterior wall (PWT)

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

area length method for calculation of lv mass
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
4-year age-adjusted incidence of cardiovascular disease according to LVMI

Age-adjusted incidence/ 100 subjects

LVMI (g/m2)

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

incidence of cardiovascular mortality according to presence or absence of lvh

4-year age-adjusted

cardiovascular mortality

Incidence of cardiovascular mortality according to presence or absence of LVH

P=ns

P<0.001

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

echocardiographic lvh and prognosis21
Echocardiographic LVH and prognosis

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

risks associated with lvm and geometry
Risks associated with LVM and geometry

Cardiovascular events†

Total mortality*

% patients

RWT

LVMI (g/m2)

LVMI (g/m2)

*P<0.001, †P=0.03

Koren et al. Ann Int Med 1991; 114: 345-352.

regression of lvh by drug treatment meta analysis of rcts
Regression of LVH by drug treatment:meta-analysis of RCTs

Mean %  in LVMI

Between treatment P<0.01

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

lvh regression live study
LVH regression: LIVE study

% from baseline

*

*P<0.05 for LVMI

Sheridan and Gosse 1998

prognostic significance of echo lvm regression
Prognostic significance of Echo LVM regression

Events/ 100 patient years

*

*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
Prognostic significance of ECG voltage changes: Framingham

*

OR for CV events (2 years)

*

*P<0.05

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

who to refer for echocardiography
Who to refer for echocardiography?
  • Patients with borderline BP:
    • LVH may influence decision to treat
  • Patient with multiple risk factors:
    • LVH may lead to other interventions e.g. lipid lowering therapy
  • Possible white coat hypertension
  • ? To stratify class of antihypertensive agent to be used (increasing data suggesting LVH regression should be a goal of treatment)