This document discusses left ventricular hypertrophy (LVH), which is an adaptive response of the heart to high blood pressure. Initially, LVH helps the heart maintain pump function with increased afterload, but over time it can lead to heart failure. The progression typically involves LVH developing due to hypertension, followed by LV remodeling and dysfunction that eventually results in diastolic or systolic heart failure if blood pressure is not controlled. The document outlines the pathophysiology, clinical presentation, investigations, and treatment of LVH.

1. LEFT VENTRICULAR HYPERTROPHY (LVH) NOOR HAFIZAH BINTI HASSAN 2007287236

2. INTRODUCTION Changes in the heart following uncontrolled HT: Myocardial structure Coronary vasculature Conduction system of the heart Increase BP change cardiac structure: ↑ afterload (directly) Neurohormonal & vascular changes (indirectly)

3. Progression From Hypertension to Heart Failure LVH, left ventricular hypertrophy; MI, myocardial infarction; CHF, chronic heart failure. Vasan RS and Levy D. Arch Intern Med. 1996;156:1789-1796. Hypertension Smoking Dyslipidemia Diabetes Obesity Diabetes MI LVH LVF Normal LV Structure and Function LV Remodeling Subclinical LV Dysfunction Overt Heart Failure Diastolic Dysfunction Systolic Dysfunction

4. 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

5. 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 Hypertension Douglas L. Mann, MD, James L. Pool, MD, and Addison A. Taylor, MD, PhD Hypertensiononline.org.

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

7. NEJM 15 MAY 2003

8. 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

9. INVESTIGATION ECG: Provide information on rhythm disturbance, hyperkalemia, PR interval, and QT interval Suggest a diagnosis or alteration of treatment ECHOCARDIOGRAPHY: LV wall thickness LA size LV function Wall motion abnormalities

10. 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

11. 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

12. 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, 3 rd ed, 2008

13. 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 + , Ca 2+ ,Mg 2+ , and fibre MOH CPG on Management of Hypertension, 3 rd ed 2008

14. Progression From Hypertension to Heart Failure LVH, left ventricular hypertrophy; MI, myocardial infarction; CHF, chronic heart failure. Vasan RS and Levy D. Arch Intern Med. 1996;156:1789-1796. Hypertension Smoking Dyslipidemia Diabetes Obesity Diabetes MI LVH CHF Normal LV Structure and Function LV Remodeling Subclinical LV Dysfunction Overt Heart Failure Diastolic Dysfunction Systolic Dysfunction