Definition and pathogenesis of left ventricular hypertrophy in hypertension
- Pamela S Douglas, MD
Pamela S Douglas, MD
- Ursula Geller Professor of Research in Cardiovascular Diseases
- Duke University Medical Center
- Norman M Kaplan, MD
Norman M Kaplan, MD
- Section Editor — Hypertension
- Clinical Professor of Internal Medicine
- University of Texas Southwestern Medical Center
- Section Editor
- George L Bakris, MD
George L Bakris, MD
- Section Editor — Hypertension
- Professor of Medicine
- The University of Chicago
- Deputy Editors
- John P Forman, MD, MSc
John P Forman, MD, MSc
- Deputy Editor — Nephrology
- Assistant Professor of Medicine
- Harvard Medical School
- Gordon M Saperia, MD, FACC
Gordon M Saperia, MD, FACC
- Senior Deputy Editor — UpToDate
- Deputy Editor — Cardiology
- Assistant Professor of Medicine
- Tufts University School of Medicine
Left ventricular hypertrophy (LVH) is a common finding in patients with fixed or borderline hypertension and can be diagnosed either by ECG or by echocardiography [1,2]. Echocardiography is the procedure of choice, since the sensitivity of the different ECG criteria may be as low as 7 to 35 percent with mild LVH and only 10 to 50 percent with moderate to severe disease . In a report from the Treatment of Mild Hypertension Study, for example, almost none of 844 patients had ECG criteria for LVH, while echocardiographic LVH (indexed by body surface area, see below) was present in 13 percent of men and 20 percent of women . Nevertheless, if echocardiography is unavailable or too expensive, appropriate ECG criteria can be used to detect increased LV mass [5,6]. (See "Electrocardiographic diagnosis of left ventricular hypertrophy".)
The definition and pathogenesis of LVH in hypertension will be reviewed here. The clinical implications of and effects of therapy on this complication and the indications for echocardiography in hypertensive patients are discussed separately. (See "Clinical implications and treatment of left ventricular hypertrophy in hypertension".)
Left ventricular hypertrophy is defined as an increase in the mass of the left ventricle, which can be secondary to an increase in wall thickness, an increase in cavity size, or both. LVH as a consequence of hypertension usually presents with an increase in wall thickness, with or without an increase in cavity size. This increase in mass predominantly results from a chronic increase in afterload of the LV caused by the hypertension, although there is also a genetic component. A significant increase in the number and /or size of sarcomeres within each myocardial cell is the pathologic mechanism.
The estimation of LV mass is commonly derived from LV measurements obtained by 2D echocardiography. The American Society of Echocardiography with the European Association of Echocardiography has issued the following criteria for LVH using modified Simpson's rule :
- Estimated LV mass of 201 to 227 g (103 to 116 g/m2) for men and 151 to 171 g (89 to 100 g/m2) for women is mildly abnormal
- Estimated LV mass of 228 to 254 g (117 to 130 g/m2) for men and 172 to 182 g (101 to 112 g/m2) for women is moderately abnormal
- Estimated LV mass >255 g (>131 g/m2) for men and >193 g (>113 g/m2) for women is severely abnormal
- Frohlich ED, Apstein C, Chobanian AV, et al. The heart in hypertension. N Engl J Med 1992; 327:998.
- Lorell BH, Carabello BA. Left ventricular hypertrophy: pathogenesis, detection, and prognosis. Circulation 2000; 102:470.
- Devereux RB. Is the electrocardiogram still useful for detection of left ventricular hypertrophy? Circulation 1990; 81:1144.
- Liebson PR, Grandits G, Prineas R, et al. Echocardiographic correlates of left ventricular structure among 844 mildly hypertensive men and women in the Treatment of Mild Hypertension Study (TOMHS). Circulation 1993; 87:476.
- de Vries SO, Heesen WF, Beltman FW, et al. Prediction of the left ventricular mass from the electrocardiogram in systemic hypertension. Am J Cardiol 1996; 77:974.
- Norman JE Jr, Levy D. Improved electrocardiographic detection of echocardiographic left ventricular hypertrophy: results of a correlated data base approach. J Am Coll Cardiol 1995; 26:1022.
- Lang RM, Bierig M, Devereux RB, et al. Recommendations for chamber quantification: a report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr 2005; 18:1440.
- Krumholz HM, Larson M, Levy D. Prognosis of left ventricular geometric patterns in the Framingham Heart Study. J Am Coll Cardiol 1995; 25:879.
- Verdecchia P, Schillaci G, Borgioni C, et al. Adverse prognostic significance of concentric remodeling of the left ventricle in hypertensive patients with normal left ventricular mass. J Am Coll Cardiol 1995; 25:871.
- van Hoeven KH, Factor SM. A comparison of the pathological spectrum of hypertensive, diabetic, and hypertensive-diabetic heart disease. Circulation 1990; 82:848.
- Jain A, Avendano G, Dharamsey S, et al. Left ventricular diastolic function in hypertension and role of plasma glucose and insulin. Comparison with diabetic heart. Circulation 1996; 93:1396.
- Okin PM, Devereux RB, Nieminen MS, et al. Electrocardiographic strain pattern and prediction of cardiovascular morbidity and mortality in hypertensive patients. Hypertension 2004; 44:48.
- Fragola PV, Colivicchi F, Fabrizi E, et al. Assessment of left ventricular hypertrophy in patients with essential hypertension. A rational basis for the electrocardiogram. Am J Hypertens 1993; 6:164.
- Okin PM, Devereux RB, Nieminen MS, et al. Relationship of the electrocardiographic strain pattern to left ventricular structure and function in hypertensive patients: the LIFE study. Losartan Intervention For End point. J Am Coll Cardiol 2001; 38:514.
- Daniels SD, Meyer RA, Loggie JM. Determinants of cardiac involvement in children and adolescents with essential hypertension. Circulation 1990; 82:1243.
- Schnall PL, Pieper C, Schwartz JE, et al. The relationship between 'job strain,' workplace diastolic blood pressure, and left ventricular mass index. Results of a case-control study. JAMA 1990; 263:1929.
- Devereux RB, Pickering TG, Harshfield GA, et al. Left ventricular hypertrophy in patients with hypertension: importance of blood pressure response to regularly recurring stress. Circulation 1983; 68:470.
- Post WS, Larson MG, Levy D. Impact of left ventricular structure on the incidence of hypertension. The Framingham Heart Study. Circulation 1994; 90:179.
- Greenwood JP, Scott EM, Stoker JB, Mary DA. Hypertensive left ventricular hypertrophy: relation to peripheral sympathetic drive. J Am Coll Cardiol 2001; 38:1711.
- Schlaich MP, Kaye DM, Lambert E, et al. Relation between cardiac sympathetic activity and hypertensive left ventricular hypertrophy. Circulation 2003; 108:560.
- Re RN. Intracellular renin and the nature of intracrine enzymes. Hypertension 2003; 42:117.
- Dzau VJ. Tissue renin-angiotensin system in myocardial hypertrophy and failure. Arch Intern Med 1993; 153:937.
- Sadoshima J, Xu Y, Slayter HS, Izumo S. Autocrine release of angiotensin II mediates stretch-induced hypertrophy of cardiac myocytes in vitro. Cell 1993; 75:977.
- Mazzolai L, Nussberger J, Aubert JF, et al. Blood pressure-independent cardiac hypertrophy induced by locally activated renin-angiotensin system. Hypertension 1998; 31:1324.
- Cuspidi C, Ciulla M, Zanchetti A. Hypertensive myocardial fibrosis. Nephrol Dial Transplant 2006; 21:20.
- Danser AH, van Kats JP, Admiraal PJ, et al. Cardiac renin and angiotensins. Uptake from plasma versus in situ synthesis. Hypertension 1994; 24:37.
- Harada K, Komuro I, Shiojima I, et al. Pressure overload induces cardiac hypertrophy in angiotensin II type 1A receptor knockout mice. Circulation 1998; 97:1952.
- Harrap SB, Dominiczak AF, Fraser R, et al. Plasma angiotensin II, predisposition to hypertension, and left ventricular size in healthy young adults. Circulation 1996; 93:1148.
- Klingbeil AU, Schneider M, Martus P, et al. A meta-analysis of the effects of treatment on left ventricular mass in essential hypertension. Am J Med 2003; 115:41.
- Wright JR, Shurrab AE, Cooper A, et al. Left ventricular morphology and function in patients with atherosclerotic renovascular disease. J Am Soc Nephrol 2005; 16:2746.
- Masaki T, Kimura S, Yanagisawa M, Goto K. Molecular and cellular mechanism of endothelin regulation. Implications for vascular function. Circulation 1991; 84:1457.
- Ichikawa KI, Hidai C, Okuda C, et al. Endogenous endothelin-1 mediates cardiac hypertrophy and switching of myosin heavy chain gene expression in rat ventricular myocardium. J Am Coll Cardiol 1996; 27:1286.
- Akhter SA, Luttrell LM, Rockman HA, et al. Targeting the receptor-Gq interface to inhibit in vivo pressure overload myocardial hypertrophy. Science 1998; 280:574.
- Schunkert H, Hense HW, Holmer SR, et al. Association between a deletion polymorphism of the angiotensin-converting-enzyme gene and left ventricular hypertrophy. N Engl J Med 1994; 330:1634.
- Hernández D, Lacalzada J, Rufino M, et al. Prediction of left ventricular mass changes after renal transplantation by polymorphism of the angiotensin-converting-enzyme gene. Kidney Int 1997; 51:1205.
- Brull D, Dhamrait S, Myerson S, et al. Bradykinin B2BKR receptor polymorphism and left-ventricular growth response. Lancet 2001; 358:1155.
- Bowman JC, Steinberg SF, Jiang T, et al. Expression of protein kinase C beta in the heart causes hypertrophy in adult mice and sudden death in neonates. J Clin Invest 1997; 100:2189.
- Kizer JR, Arnett DK, Bella JN, et al. Differences in left ventricular structure between black and white hypertensive adults: the Hypertension Genetic Epidemiology Network study. Hypertension 2004; 43:1182.
- Drazner MH, Dries DL, Peshock RM, et al. Left ventricular hypertrophy is more prevalent in blacks than whites in the general population: the Dallas Heart Study. Hypertension 2005; 46:124.
- Liao Y, Cooper RS, McGee DL, et al. The relative effects of left ventricular hypertrophy, coronary artery disease, and ventricular dysfunction on survival among black adults. JAMA 1995; 273:1592.
- Levy D, Garrison RJ, Savage DD, et al. Left ventricular mass and incidence of coronary heart disease in an elderly cohort. The Framingham Heart Study. Ann Intern Med 1989; 110:101.
- Koide M, Nagatsu M, Zile MR, et al. Premorbid determinants of left ventricular dysfunction in a novel model of gradually induced pressure overload in the adult canine. Circulation 1997; 95:1601.
- Innes BA, McLaughlin MG, Kapuscinski MK, et al. Independent genetic susceptibility to cardiac hypertrophy in inherited hypertension. Hypertension 1998; 31:741.
- Zabalgoitia M, Berning J, Koren MJ, et al. Impact of coronary artery disease on left ventricular systolic function and geometry in hypertensive patients with left ventricular hypertrophy (the LIFE study). Am J Cardiol 2001; 88:646.