LEFT VENTRICULAR HYPERTROPHY

(LVH)NOOR HAFIZAH BINTI HASSAN

2007287236

INTRODUCTION

Changes in the heart following uncontrolled HT:Myocardial structureCoronary vasculatureConduction system of the heart

Increase BP change cardiac structure:↑ afterload (directly)Neurohormonal & vascular changes (indirectly)

LVH, left ventricular hypertrophy; MI, myocardial infarction; CHF, chronic heart failure.Vasan RS and Levy D. Arch Intern Med. 1996;156:1789-1796.

Progression From Hypertensionto Heart Failure

Hypertension

Smoking

Dyslipidemia

Diabetes

Obesity

Diabetes

MI

LVH

LVF

Normal LV Structure

and Function

LV Remodeling

Subclinical LV Dysfunction

Overt Heart Failure

DiastolicDysfunction

Systolic Dysfunction

Adaptive response to maintain pump performance in the ↑ of afterload

↓Concentric hypertrophy: thickening of intraventricular

septum & free wall of LV

Cardiac myocyte hypertrophy

Deposition of extracellular matrix

PATHOPHYSIOLOGY OF LVH IN HT

Continue..

Cardiac myocyte hypertrophy↓

Frank-Starling’s law↓

Hypertrophy can no longer compensate for ↑ afterload

↓LV dilatation (eccentric LVH)

Deposition of ECM around the hypertrophied myocyte

↓Inhibit the heart from

contracting and relaxing normally

The Normal Heart, Left Ventricular Hypertrophy in Hypertension, and Heart Failure in HypertensionDouglas L. Mann, MD, James L. Pool, MD, and Addison A. Taylor, MD, PhDHypertensiononline.org.

Harrison’s Principle of Internal Medicine 16th ed, page 1369

NEJM 15 MAY 2003

CLINICAL PRESENTATION• ASYMPTOMATIC UNTIL THEY DEVELOP LV DIASTOLIC

DYSFUNCTION AND HEART FAILURE

• PHYSICAL SIGNS:

– Abnormal apical impulse: sustained + diffuse (>3 cm

diameter) + displaced from

midclavicular line

– S4 gallop: best heard with the bell of stethoscope in left

lateral position. Palpable occasionally.

: decrease elasticity of the hypertrophied

ventricle during late diastole

INVESTIGATION

1. ECG:– Provide information on rhythm disturbance,

hyperkalemia, PR interval, and QT interval – Suggest a diagnosis or alteration of treatment

2. ECHOCARDIOGRAPHY: – LV wall thickness– LA size– LV function– Wall motion abnormalities

• LA enlargement is the earliest changes seen in hypertensive heart disease

• Terminal portion of P wave has a duration of 0.04 sec, and depth of 1 mm or more

• LVH with ‘strain pattern’• Framingham study: LVH with strain pattern carries a poor prognosis

OTHER MODALITIES• CARDIAC MRI

• CT

• ABPM – White coat HT– Resistant HT (140/90 mmHg) on more than 3 anti-HT

regimens, one of which is diuretics– Evaluation of suspected hypotension s/sx– Establishing the D.O.A of new drugs in clinical trial

PHARMACOLOGICAL MX

• Treatment of HT will lead to regression of LVH, improvement of LV function and reduction of cardiovascular morbidity.

• All classes of antihypertensive agents have been shown to cause regression of LVH.

MOH CPG on Management of Hypertension, 3rd ed, 2008

NON PHARMALOGICAL MX• ↓ weight• ↓ sodium intake• Avoidance of alcohol intake• Regular physical exercise• Healthy eating• Cessation of smoking• Others: stress mx, micronutrient

alteration, supplementation with fish oil, K+, Ca2+,Mg2+, and fibre

MOH CPG on Management of Hypertension, 3rd ed 2008

LVH, left ventricular hypertrophy; MI, myocardial infarction; CHF, chronic heart failure.Vasan RS and Levy D. Arch Intern Med. 1996;156:1789-1796.

Progression From Hypertensionto Heart Failure

Hypertension

Smoking

Dyslipidemia

Diabetes

Obesity

Diabetes

MI

LVH

CHF

Normal LV Structure

and Function

LV Remodeling

Subclinical LV Dysfunction

Overt Heart Failure

DiastolicDysfunction

Systolic Dysfunction