Left
ventricular hypertrophy: targeting the hypertensive patient
Graham Jackson
Consultant Cardiologist, Guy’s & St. Thomas Hospitals, London,
UK
Correspondence: Dr Grahm Jackson, London Bridge Hospital, Suite
301, Emblem House, 27 Tooley Street, London SE2 2PF, UK. Fax:
+44 171 357 7408
Hypertension is one of the “big three” modifiable
risk factors- – the others being cigarette smoking and hyperlipidemia.
It is always important not to view risk factors in isolation because
it is the cumulative risk that determines morbidity and mortality.
Hypertension can lead to significant target organ damage, clinical
cardiovascular disease, and frequently both.
In their review Spencer and Lip provide a succinct yet comprehensive
review of target organ effects and their adverse influence on
prognosis. Left ventricular hypertrophy (LVH) is a well-known
marker for an adverse prognosis but it is only recently that we
have seen evidence that treatment aimed at regressing LVH can
impact on morbidity and mortality. Given its adverse effect on
prognosis it is important to accurately detect the presence of
LVH.
It is now recognised that echocardiography is significantly superior
to electrocardiography and should routinely be used for the detection
of LVH. Takeda and Chambers provide us with a useful practical
guide to the use of echocardiography and, though enthusiasts,
clearly help us to understand its limitations. Magnetic resonance
imaging (MRI,) whilste being more accurate than echocardiography
in assessing LVH, is limited by cost, which precludes its use
for serial measurement in clinical practice. In the research setting,
MRI is the most accurate means of monitoring regression of LVH,
with two-dimensional echocardiography an acceptable, less expensive
alternative.
The metabolic consequences of LVH and their detrimental effect
on contractile function are reviewed by Montessuit and colleagues,
who pose a challenging cause and effect question. This interesting
and thoughtful overview opens the door to the concept of metabolic
manipulation by agents such as trimetazidine, which would, from
the paper by Sabouret, appear to address the metabolic abnormalities.
Specific studies in this area are not yet available but the concept
of adding a metabolic agent when hypertension is controlled and
LVH is present may be worthy of prospective evaluation.
Translating basic concepts and research protocols into clinical
practice is the ultimate end -point of any study aimed at improving
patient care. As Brilla says:, “The question arises whether pharmacologically
mediated regression of LVH would improve patients’ morbidity and
mortality”. His article presents a well-balanced case for antihypertensive
therapy not only benefitting the patient by good blood pressure
control but also by regressing LVH. The question to which we do
not yet have a clear answer to is whether the regression is due
to the blood pressure control itself (no matter what agents are
used) or whether certain agents achieve a preferential benefit
(e.g. angiotensin converting enzyme inhibitors or angiotensin
II antagonists.). It could also be a combination of means of action
and time, with blood pressure control the common denominator.
Thus certain drugs may regress LVH inside 12 months whereas, in
the presence of equal blood pressure control, others may take
18-–24 months.
The "take home message" from this issue of Heart and Metabolism
is that LVH is bad news. Its detection is clearly important and
routine echocardiography is superior to electrocardiography and
in addition offers the opportunity for serial non-invasive monitoring
of the response to antihypertensive therapy. Controlling blood
pressure leads to regression of LVH and reduced morbidity and
mortality –- we have a target and a benefit but we still need
to make progress with our understanding and treatment of LVH.
Graham Jackson
Consultant Cardiologist
FURTHER READING
Lorell BH, Carabello BA Left ventricular hypertrophy: pathogenesis,
detection and prognosis. Circulation 2000;201: 470–479.
-
Left ventricular hypertrophy: pathogenesis,
detection, and prognosis.
Lorell BH, Carabello BA.
Department of Medicine, Beth Israel Deaconess Medical Center
and Harvard Medical School, Boston, Mass 02215, USA.
Publication Types:
PMID: 10908222 [PubMed - indexed for MEDLINE]
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