Left ventricular hypertrophy explained

Left ventricular hypertrophy
Field:Cardiology
Complications:Hypertrophic cardiomyopathy, Heart failure[1]
Diagnosis:Echocardiography, cardiovascular MRI
Differential:Athletic heart syndrome

Left ventricular hypertrophy (LVH) is thickening of the heart muscle of the left ventricle of the heart, that is, left-sided ventricular hypertrophy and resulting increased left ventricular mass.

Causes

While ventricular hypertrophy occurs naturally as a reaction to aerobic exercise and strength training, it is most frequently referred to as a pathological reaction to cardiovascular disease, or high blood pressure.[2] It is one aspect of ventricular remodeling.

While LVH itself is not a disease, it is usually a marker for disease involving the heart.[3] Disease processes that can cause LVH include any disease that increases the afterload that the heart has to contract against, and some primary diseases of the muscle of the heart.Causes of increased afterload that can cause LVH include aortic stenosis, aortic insufficiency and hypertension. Primary disease of the muscle of the heart that cause LVH are known as hypertrophic cardiomyopathies, which can lead into heart failure.

Long-standing mitral insufficiency also leads to LVH as a compensatory mechanism.

LV mass increases with ageing.

Associated genes include OGN, osteoglycin.[4]

Diagnosis

The commonly used method to diagnose LVH is echocardiography, with which the thickness of the muscle of the heart can be measured. The electrocardiogram (ECG) often shows signs of increased voltage from the heart in individuals with LVH, so this is often used as a screening test to determine who should undergo further testing.

Echocardiography

Left ventricular hypertrophy grading
by posterior wall thickness[5]
Mild 12 to 13 mm
Moderate >13 to 17 mm
Severe >17 mm
Two dimensional echocardiography can produce images of the left ventricle. The thickness of the left ventricle as visualized on echocardiography correlates with its actual mass. Left ventricular mass can be further estimated based on geometric assumptions of ventricular shape using the measured wall thickness and internal diameter.[6] Average thickness of the left ventricle, with numbers given as 95% prediction interval for the short axis images at the mid-cavity level are:[7]

CT & MRI

CT and MRI-based measurement can be used to measure the left ventricle in three dimensions and calculate left ventricular mass directly. MRI based measurement is considered the “gold standard” for left ventricular mass,[8] though is usually not readily available for common practice. In older individuals, age related remodeling of the left ventricle's geometry can lead to a discordancy between CT and echocardiographic based measurements of left ventricular mass.[9]

ECG criteria

There are several sets of criteria used to diagnose LVH via electrocardiography.[10] None of them are perfect, though by using multiple criteria sets, the sensitivity and specificity are increased.

The Sokolow-Lyon index:[11] [12]

The Cornell voltage criteria[13] for the ECG diagnosis of LVH involve measurement of the sum of the R wave in lead aVL and the S wave in lead V3. The Cornell criteria for LVH are:

The Romhilt-Estes point score system ("diagnostic" >5 points; "probable" 4 points):

ECG CriteriaPoints
Voltage Criteria (any of):
  1. R or S in limb leads ≥20 mm
  2. S in V1 or V2 ≥30 mm
  3. R in V5 or V6 ≥30 mm
3
ST-T Abnormalities:
  • ST-T vector opposite to QRS without digitalis
  • ST-T vector opposite to QRS with digitalis
3
1
Negative terminal P mode in V1 1 mm in depth and 0.04 sec in duration (indicates left atrial enlargement)3
Left axis deviation (QRS of −30° or more)2
QRS duration ≥0.09 sec1
Delayed intrinsicoid deflection in V5 or V6 (>0.05 sec)1

Other voltage-based criteria for LVH include:

Diagnostic accuracy of electrocardiography in left ventricular hypertrophy can be enhanced with artificial intelligence analysis.[14]

Treatment

Treatment is typically focused on resolving the cause of the LVH with the enlargement not permanent in all cases. In some cases the growth can regress with the reduction of blood pressure.[15]

LVH may be a factor in determining treatment or diagnosis for other conditions, for example, LVH is used in the staging and risk stratification of Non-ischemic cardiomyopathies such as Fabry's Disease.[16] Patients with LVH may have to participate in more complicated and precise diagnostic procedures, such as Echocardiography or Cardiac MRI.[17]

See also

Notes and References

  1. Maron BJ, Maron MS . Hypertrophic cardiomyopathy . Lancet . 381 . 9862 . 242–255 . January 2013 . 22874472 . 10.1016/s0140-6736(12)60397-3 . Elsevier BV . 38333896 .
  2. Web site: Ask the doctor: Left Ventricular Hypertrophy . 2007-12-07 .
  3. Meijs MF, Bots ML, Vonken EJ, Cramer MJ, Melman PG, Velthuis BK, van der Graaf Y, Mali WP, Doevendans PA . 6 . Rationale and design of the SMART Heart study: A prediction model for left ventricular hypertrophy in hypertension . Netherlands Heart Journal . 15 . 9 . 295–298 . 2007 . 18030317 . 1995099 . 10.1007/BF03086003 .
  4. Petretto E, Sarwar R, Grieve I, Lu H, Kumaran MK, Muckett PJ, Mangion J, Schroen B, Benson M, Punjabi PP, Prasad SK, Pennell DJ, Kiesewetter C, Tasheva ES, Corpuz LM, Webb MD, Conrad GW, Kurtz TW, Kren V, Fischer J, Hubner N, Pinto YM, Pravenec M, Aitman TJ, Cook SA . 6 . Integrated genomic approaches implicate osteoglycin (Ogn) in the regulation of left ventricular mass . Nature Genetics . 40 . 5 . 546–552 . May 2008 . 18443592 . 2742198 . 10.1038/ng.134 .
  5. Goland S, Czer LS, Kass RM, Siegel RJ, Mirocha J, De Robertis MA, Lee J, Raissi S, Cheng W, Fontana G, Trento A . 6 . Use of cardiac allografts with mild and moderate left ventricular hypertrophy can be safely used in heart transplantation to expand the donor pool . Journal of the American College of Cardiology . 51 . 12 . 1214–1220 . March 2008 . 18355661 . 10.1016/j.jacc.2007.11.052 . 29478910 .
  6. Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, Flachskampf FA, Foster E, Goldstein SA, Kuznetsova T, Lancellotti P, Muraru D, Picard MH, Rietzschel ER, Rudski L, Spencer KT, Tsang W, Voigt JU . 6 . Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging . Journal of the American Society of Echocardiography . 28 . 1 . 1–39.e14 . January 2015 . 25559473 . 10.1016/j.echo.2014.10.003 . free . 1854/LU-5953422 . free .
  7. Kawel N, Turkbey EB, Carr JJ, Eng J, Gomes AS, Hundley WG, Johnson C, Masri SC, Prince MR, van der Geest RJ, Lima JA, Bluemke DA . 6 . Normal left ventricular myocardial thickness for middle-aged and older subjects with steady-state free precession cardiac magnetic resonance: the multi-ethnic study of atherosclerosis . Circulation. Cardiovascular Imaging . 5 . 4 . 500–508 . July 2012 . 22705587 . 3412148 . 10.1161/CIRCIMAGING.112.973560 . free .
  8. Myerson SG, Bellenger NG, Pennell DJ . Assessment of left ventricular mass by cardiovascular magnetic resonance . Hypertension . 39 . 3 . 750–755 . March 2002 . 11897757 . 10.1161/hy0302.104674 . 16598370 . free .
  9. Stokar J, Leibowitz D, Durst R, Shaham D, Zwas DR . Echocardiography overestimates LV mass in the elderly as compared to cardiac CT . PLOS ONE . 14 . 10 . e0224104 . 2019-10-24 . 31648248 . 6812823 . 10.1371/journal.pone.0224104 . free . 2019PLoSO..1424104S .
  10. Web site: Lesson VIII - Ventricular Hypertrophy . 2009-01-07.
  11. Sokolow M, Lyon TP . The ventricular complex in left ventricular hypertrophy as obtained by unipolar precordial and limb leads . American Heart Journal . 37 . 2 . 161–186 . February 1949 . 18107386 . 10.1016/0002-8703(49)90562-1 .
  12. Okin PM, Roman MJ, Devereux RB, Pickering TG, Borer JS, Kligfield P . Time-voltage QRS area of the 12-lead electrocardiogram: detection of left ventricular hypertrophy . Hypertension . 31 . 4 . 937–942 . April 1998 . 9535418 . 10.1161/01.HYP.31.4.937 . 2662286 . 10.1.1.503.8356 .
  13. Casale PN, Devereux RB, Alonso DR, Campo E, Kligfield P . Improved sex-specific criteria of left ventricular hypertrophy for clinical and computer interpretation of electrocardiograms: validation with autopsy findings . Circulation . 75 . 3 . 565–572 . March 1987 . 2949887 . 10.1161/01.CIR.75.3.565 . 25815927 .
  14. Martínez-Sellés . Manuel . Marina-Breysse . Manuel . Current and Future Use of Artificial Intelligence in Electrocardiography . Journal of Cardiovascular Development and Disease . 2023 . 10 . 4 . 175 . 10.3390/jcdd10040175 . free . 37103054 . 10145690 .
  15. Gradman AH, Alfayoumi F . From left ventricular hypertrophy to congestive heart failure: management of hypertensive heart disease . Progress in Cardiovascular Diseases . 48 . 5 . 326–341 . 2006 . 16627048 . 10.1016/j.pcad.2006.02.001 .
  16. Tower-Rader A, Jaber WA . Multimodality Imaging Assessment of Fabry Disease . Circulation. Cardiovascular Imaging . 12 . 11 . e009013 . November 2019 . 31718277 . 10.1161/CIRCIMAGING.119.009013 . free .
  17. Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B . 6 . ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine . Journal of the American College of Cardiology . 50 . 7 . e1–e157 . August 2007 . 17692738 . 10.1161/CIRCULATIONAHA.107.185752 .

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