Abstract
BackgroundLeft ventricular (LV) hypertrophy (LVH) in uncontrolled hypertension is an independent predictor of mortality, though its regression with treatment improves outcomes. Retrospective data suggest that early control of hypertension provides a prognostic advantage and this strategy is included in the 2018 European guidelines, which recommend treating grade II/III hypertension to target blood pressure (BP) within 3 months. The earliest LVH regression to date was demonstrated by echocardiography at 24 weeks. The effect of a rapid guideline-based treatment protocol on LV remodelling, with very early BP control by 18 weeks remains controversial and previously unreported. We aimed to determine whether such rapid hypertension treatment is associated with improvements in LV structure and function through paired cardiovascular magnetic resonance (CMR) scanning at baseline and 18 weeks, utilising CMR mass and feature tracking analysis.MethodsWe recruited participants with never-treated grade II/III hypertension, initiating a guideline-based treatment protocol which aimed to achieve BP control within 18 weeks. CMR and feature tracking were used to assess myocardial morphology and function immediately before and after treatment.ResultsWe acquired complete pre- and 18-week post-treatment data for 41 participants. During the interval, LV mass index reduced significantly (43.5 ± 9.8 to 37.6 ± 8.3 g/m2, p < 0.001) following treatment, accompanied by reductions in LV ejection fraction (65.6 ± 6.8 to 63.4 ± 7.1%, p = 0.03), global radial strain (46.1 ± 9.7 to 39.1 ± 10.9, p < 0.001), mid-circumferential strain (− 20.8 ± 4.9 to − 19.1 ± 3.7, p = 0.02), apical circumferential strain (− 26.0 ± 5.3 to − 23.4 ± 4.2, p = 0.003) and apical rotation (9.8 ± 5.0 to 7.5 ± 4.5, p = 0.003).ConclusionsLVH regresses following just 18 weeks of intensive antihypertensive treatment in subjects with newly-diagnosed grade II/III hypertension. This is accompanied by potentially advantageous functional changes within the myocardium and supports the hypothesis that rapid treatment of hypertension could improve clinical outcomes.Trial registration: ISRCTN registry number: 57475376 (assigned 25/06/2015).
Highlights
Left ventricular (LV) hypertrophy (LVH) in uncontrolled hypertension is an independent predictor of mortality, though its regression with treatment improves outcomes
When participants prescribed β-blockers were excluded from the analysis, changes in LV endsystolic volume (LVESV) and LVESV index were no longer significant, though the finding of significant reductions in LV end-diastolic volume (LVEDV), LVEDV index, LV ejection fraction (LVEF) and stroke volume persisted
The novel use of cardiovascular magnetic resonance (CMR) feature tracking in assessing all directional components of myocardial deformation in a longitudinal study before and after the introduction of antihypertensive agents has for the first time found that radial strain reduces with treatment, whilst confirming the previously described higher longitudinal strain, lower mid and apical circumferential strain and lower apical torsion in treated hypertension compared with untreated hypertension [8, 10, 15, 16]
Summary
Left ventricular (LV) hypertrophy (LVH) in uncontrolled hypertension is an independent predictor of mortality, though its regression with treatment improves outcomes. We aimed to determine whether such rapid hypertension treatment is associated with improvements in LV structure and function through paired cardiovascular magnetic resonance (CMR) scanning at baseline and 18 weeks, utilising CMR mass and feature tracking analysis. The association of treatment-induced LVM regression with favourable prognosis is independent of baseline LVM and degree of blood pressure (BP) reduction [5]. The timing of LVH regression is unclear, with the most rapid improvement demonstrated in a longitudinal study of 24 weeks’ duration using echocardiography to quantify LVM before and after treatment for patients enrolled with grade I or II hypertension (mean baseline office BP: 164/93mmHg) and receiving either standard BP management or intensive management within the study [8]
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