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Evaluating and Managing Heart Failure with LVH
Am Fam Physician. 2001 Jan 15;63(2):345.
Left ventricular hypertrophy (LVH) is a common clinical problem, and the number of patients with LVH is increasing. The prevalence of LVH in the Framingham Study is 16 percent in women and 19 percent in men. Pathologic LVH may be associated with an absence of symptoms for many years before the development of congestive heart failure or sudden death. Patients with LVH tend to be older and more obese, have higher blood pressure and be more likely to have preexisting coronary artery disease and depressed left ventricular systolic function. The presence of LVH predicts an increased risk of cardiovascular morbidity and death. The diagnosis of LVH depends predominantly on echocardiographic measurements that are adjusted for sex, height and body mass. Echocardiographic LVH is more prevalent than LVH detected by electrocardiography, with overall rates of 17.4 versus 2.4 percent, respectively. Lorell and Carabello have provided a concise review for clinicians of the most salient points of this disease.
For patients with LVH and diastolic dysfunction, there is no evidence-based consensus as to optimal management. Current therapy is aimed at preserving sinus rhythm and suppressing tachycardia, reducing elevated left atrial and diastolic pressures without excessively reducing preload and depressing cardiac output, and preventing or treating the confounding condition of myocardial ischemia. These treatments are usually achieved by the cautious and combined use of several agents, including beta-adrenergic blockers, angiotensin-converting enzyme (ACE) inhibitors, low-dose diuretics, long-acting calcium-channel blockers and long-acting nitrates.
With respect to patients with LVH and systolic dysfunction (ejection fraction less than 40 percent), evidence-based trials have led to the development of consensus guidelines for the management of heart failure. The management of heart failure should include the use of ACE inhibitors, beta-adrenergic blockers, diuretics to relieve fluid overload and digoxin to relieve persistent symptoms. Spironolactone can be considered in patients with advanced heart failure.
Therapies to limit and reverse LVH are desirable even in the absence of heart failure. Regression of severe LVH can be achieved in some patients. This is particularly possible in those with valvular aortic stenosis after valve replacement. The magnitude of regression of LVH observed in pharmacologic trials in hypertensive patients is less impressive. However, it is likely that more aggressive management of hypertension will achieve improved results.
Lorell BH, Carabello BA. Left ventricular hypertrophy. Pathogenesis, detection, and prognosis. Circulation. July 25, 2000;102:470–9.
Copyright © 2001 by the American Academy of Family Physicians.
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