Regression of Left Ventricular Hypertrophy and Improved Prognosis

Abstract

It has been well recognized that the presence of left ventricular hypertrophy (LVH) is an adverse feature in hypertension, with such patients having a substantially higher risk of cardiovascular events, including mortality and morbidity from heart failure, atrial fibrillation, and sudden death.1 Indeed, LVH is probably the most visible manifestation of hypertensive target organ damage. See p 1615 For many years, clinicians have been interested in finding the best drugs to regress LVH or improve other surrogate markers of hypertensive target organ damage (such as microproteinuria or endothelial dysfunction), without knowing whether or not such actions actually did any good in the long term. Furthermore, the scientific community has long been provided with data from LVH regression studies that have generally been suboptimal in design, with small numbers of subjects, unrepresentative populations, short study duration, lack of comparison between agents, unblinded echocardiographic readings, and inappropriate statistical methods.2 Using the criteria proposed by Devereaux and Dahlof,2 future studies that avoid the above limitations should be related to the question(s) that need to be answered. These could be categorized as follows: (1) relatively small studies (n=40 to 60) to investigate pathophysiology in detail or explore the effects of new agents; (2) medium-sized ones (n=300 to 400; duration ≥1 year) to determine definitively whether interagent differences in the reduction of left ventricular mass exist; and (3) large, long-term trials (n>1200; duration ≥4 years) to determine whether LVH reversal improves prognosis, over and above blood pressure reduction and the type of treatment used. One “strict” meta-analysis, including only double-blind, randomized, controlled clinical studies with parallel-group design (39 trials) found that more LVH regression occurred with greater blood pressure reduction and a longer duration of therapy.3 Specifically, LVH regression occurred in 13% of patients treated with the ACE inhibitors, 9% treated …