Four-Group Classification of Left Ventricular Hypertrophy Based on Ventricular Concentricity and Dilatation Identifies a Low-Risk Subset of Eccentric Hypertrophy in Hypertensive Patients

Abstract

L eft ventricular hypertrophy (LVH), as defined by increased LV mass (LVM) on echocardiography, predicts cardiovascular events in hypertensive patients as well as in the general population.1,2 LVH can occur through ventricular dilatation, wall thickening, or combinations thereof. To distinguish between these patterns of hypertrophy, LVH has been subclassified based on relative wall thickness (RWT; wall thickness/LV internal radius).3 If the ratio is high, the term concentric is applied; if not, the term eccentric hypertrophy is used. Recently, a new 4-group classification system derived by cardiac MRI reclassified participants with eccentric LVH with normal LV end-diastolic volume (EDV) into a subgroup with better LV function and, maybe, better outcome that is not captured with the conventional 2-group classification. 4 The new classification has not yet been related to clinical outcome in hypertensive patients. hypertensive patients with measurable LVM at baseline were randomized to a mean of 4.8 years of losartan-or atenololbased treatment. Patients with LVH (LVM/body surface area ≥116 and ≥96 g/m 2 in men and woman, respectively) were divided into 4 groups-concentric nondilated (increased M/EDV, normal EDV), eccentric dilated (increased EDV, normal M/EDV), concentric dilated (increased M/EDV and EDV), and eccentric nondilated (normal M/EDV and EDV)-and compared with patients with normal LVM. Time-varying LVH classes were tested for association with all-cause and cardiovascular mortality and a composite end point of myocardial infarction, stroke, heart failure, and cardiovascular death in multivariable Cox analyses. At baseline, the LVs were categorized as eccentric nondilated in 12%, eccentric dilated in 20%, concentric nondilated in 29%, concentric dilated in 14%, and normal LVM in 25%. Treatment changed the prevalence of 4 LVH groups to 23%, 4%, 5%, and 7%; 62% had normal LVM after 4 years. In time-varying Cox analyses, compared with normal LVM, those with eccentric dilated and both concentric nondilated and dilated LVH had increased risks of all-cause or cardiovascular mortality or the composite end point, whereas the eccentric nondilated group did not. Conclusions-Hypertensive patients with relatively mild LVH without either increased LV volume or concentricity have similar risk of all-cause mortality or cardiovascular events because hypertensive patients with normal LVM seem to be a low-risk group. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00338260.(Circ Cardiovasc Imaging. 2014;7:422-429.)

Effect of Left Ventricular Ejection Fraction on Postoperative Outcome in Patients With Severe Aortic Stenosis Undergoing Aortic Valve Replacement

“…A recent study in hypertensive patients has shown that nondilated eccentric LV remodeling is associated with better outcome compared with other types of remodeling. 20 Further supporting this, LV end-diastolic diameter increased across groups as LVEF decreased. Despite larger LV size, SVi was lower in patients with LVEF 50% to 59% compared with patients with LVEF≥60%, suggesting that LV systolic function is impaired in this subgroup of patients.…”

From Left Ventricular Hypertrophy to Dysfunction and Failure

“…Bang et al proved the prognostic validity of this classification in 939 hypertensive patients of the LIFE study (mean follow-up of 4 years), identifying a low-risk subset with eccentric non-dilated LVH and 3 subsets of LVH at high risk of developing LV dysfunction and HF. 33 Garg et al validated this classification using cardiac magnetic resonance in 2,458 subjects, demonstrating that the risk of HF and cardiovascular death was greater in those subject with either dilated hypertrophy or both thick and dilated hypertrophy. 34 In patients with concentric dilated LVH, diastolic LV dysfunction is a frequent finding and is the functional determinant predisposing to HFpEF.…”

Antihypertensive Treatment With β‐Blockade in Patients With Asymptomatic Aortic Stenosis and Association With Cardiovascular Events

“…First, among older patients with AS, hypertension is common, found in up to 78% of patients 7. Hypertension significantly modulates LV mass and geometry14 and is a well‐known predictor of increased cardiovascular morbidity and mortality in both the general and AS populations 15, 16. In hypertension, Bbl is known to not only lower the blood pressure but also regress LV mass and alter LV geometry, probably due to the decrease in LV load,17 which is associated with better survival in hypertensive patients 14.…”

“…Hypertension significantly modulates LV mass and geometry14 and is a well‐known predictor of increased cardiovascular morbidity and mortality in both the general and AS populations 15, 16. In hypertension, Bbl is known to not only lower the blood pressure but also regress LV mass and alter LV geometry, probably due to the decrease in LV load,17 which is associated with better survival in hypertensive patients 14. However, adjustment for in‐treatment systolic blood pressure did not change the observed lower rate of mortality, and we did not find interaction with hypertension in the present study.…”