Hypertensive Heart Disease and Left Ventricular Hypertrophy
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Direct answer
Hypertensive heart disease is the structural and functional change in the heart caused by long-standing high blood pressure, most importantly concentric left ventricular hypertrophy. The wall thickens to normalise wall stress, but at the cost of stiffness that later causes diastolic dysfunction and heart failure with preserved ejection fraction. ECG voltage criteria and the echocardiographic left ventricular mass index detect the hypertrophy, and blood pressure control can partly reverse it.
What you must remember
- Mechanism: pressure overload drives concentric hypertrophy, which normalises wall stress at the cost of stiffness and impaired relaxation.
- Echo criteria: left ventricular mass index above about 115 g/m2 in men and 95 g/m2 in women defines hypertrophy, and relative wall thickness above 0.42 suggests concentric geometry.
- ECG voltage: Sokolow-Lyon index of 35 mm or more, S wave in V1 plus R wave in V5 or V6, and Cornell voltage above 28 mm in men and 20 mm in women.
- Strain pattern: asymmetric ST depression and T wave inversion in leads I, aVL, V5 and V6 indicate advanced hypertrophy and a worse prognosis.
- Complications: diastolic dysfunction, heart failure with preserved ejection fraction, atrial fibrillation, ventricular arrhythmias and sudden death.
- Regression: blood pressure control reduces left ventricular mass, and renin-angiotensin blockers are particularly favoured for regression.
- Mimics: hypertrophic cardiomyopathy, aortic stenosis, athlete's heart and cardiac amyloidosis, where low voltage despite hypertrophy is the clue.
- Ischaemia: hypertrophy raises myocardial oxygen demand and causes microvascular ischaemia, even without obstructive coronary disease.
From hypertension to a hypertrophy diagnosis
A 60-year-old man with 15 years of uncontrolled hypertension presents with exertional breathlessness, and his ECG shows voltage criteria for hypertrophy with lateral strain. The workup separates a pressure-driven pattern from other causes.
- Confirm the pressure load. Ambulatory or home blood pressure monitoring establishes sustained hypertension and rules out white-coat effects.
- Measure the hypertrophy. Echocardiography quantifies left ventricular mass index and wall thickness, then classifies the geometry as concentric hypertrophy, eccentric hypertrophy, concentric remodelling or normal.
- Assess diastolic function. Mitral inflow, tissue Doppler and left atrial size show whether relaxation is impaired, which points towards heart failure with preserved ejection fraction.
- Exclude the mimics. Septal hypertrophy with a family history suggests hypertrophic cardiomyopathy, while low voltage with hypertrophy raises the possibility of amyloidosis.
- Treat the pressure. An ACE inhibitor or ARB combined with a calcium channel blocker or thiazide-like diuretic brings blood pressure to target.
- Document regression. A repeat echocardiogram after sustained control shows whether left ventricular mass has fallen, while atrial fibrillation, kidney function and coronary risk are screened.
Where the exam tries to catch you
Hypertrophy questions usually turn on which test is reliable and which mimic is present.
- Trap: accepting ECG voltage as proof of hypertrophy in every patient Correct: voltage depends on chest wall thickness, obesity and lead placement, so echocardiography is the more reliable test.
- Trap: labelling every hypertrophied heart as hypertensive Correct: low voltage with hypertrophy points to amyloidosis, and septal hypertrophy with a family history points to hypertrophic cardiomyopathy.
- Trap: assuming hypertrophy is harmless once blood pressure is normal Correct: left ventricular hypertrophy is an independent predictor of events, so regression and atrial fibrillation are followed up.
Frequently asked questions
What ECG criteria indicate left ventricular hypertrophy?
The commonly used ECG criteria are the Sokolow-Lyon index, the Cornell voltage and the Romhilt-Estes score. ECG criteria are specific but insensitive, so echocardiography is preferred when the diagnosis matters.
What is the difference between concentric and eccentric hypertrophy?
Concentric hypertrophy has thick walls with a small cavity and typically results from pressure overload, such as hypertension or aortic stenosis. Eccentric hypertrophy has a dilated cavity with proportionate thickening, typical of volume overload from valvular regurgitation.
Which drugs regress left ventricular hypertrophy?
ACE inhibitors, ARBs and calcium channel blockers regress left ventricular hypertrophy over time, mainly through the blood pressure lowering they provide. Renin-angiotensin blockade is particularly favoured, and regression is confirmed on serial echocardiography.
Why is left ventricular hypertrophy with low ECG voltage suspicious for amyloidosis?
Hypertrophy with low ECG voltage is suspicious for cardiac amyloidosis because infiltrated myocardium thickens without producing proportionate electrical forces. Further workup, including serum and urine protein electrophoresis with free light chain testing and tissue confirmation, separates amyloid from hypertensive hypertrophy.