Reversal of Left Ventricular Hypertrophy in Essential Hypertension

A systematic review 1 included 39 studies with a total of 1 394 subjects. Left ventricular mass index was reduced significantly in the antihypertensive treatment arms compared with placebo (p<0.04). The greater the pre-treatment left ventricular mass index the more marked was the decline in the index associated with antihypertensive drug therapy (p<0.001). Left ventricular mass decreased 13% (95% CI 9.9% to 16.8%) with ACE inhibitors, 9% (95% CI 5.5% to 13.1%) with calcium channel blockers, 6% (95% CI 2.3% to 8.6%) with beta-blockers, and by 7% (95% CI 3.0% to 10.7%) with diuretics. ACE inhibitors tended to reduce left ventricular mass more than beta-blockers and diuretics.

Another systematic review 2 included 50 RCTs with a total of 1 715 patients. According to the review, decrease in systolic blood pressure, duration of antihypertensive therapy and antihypertensive drug class determined the reduction of lef ventricular hypertrophy. ACE inhibitors and calcium channel blockers were more potent in reducing left ventricular mass than beta-blockers, with diuretics in the intermediate range.

A meta-analysis 3 included 80 studies with 146 active treatment arms (n=3 767) and 17 placebo arms (n=346). Adjusted for treatment duration and change in diastolic blood pressure, there was a significant difference (p=0.004) among medication classes: left ventricular mass index decreased by 13% with angiotensin II receptor antagonists (95% CI 8% to 18%), by 11% with calcium antagonists (95% CI 9% to 13%), by 10% with ACE inhibitors (95% CI 8% to 12%), by 8% with diuretics (95% CI 5% to 10%), and by 6% with beta-blockers (95% CI 3% to 8%). In pairwise comparisons, angiotensin II receptor antagonists, calcium antagonists, and ACE inhibitors were more effective at reducing left ventricular mass than were beta-blockers (all p<0.05 with Bonferroni correction).

A meta-analysis 4 included 78 studies (84 randomized pairwise comparisons) with a total of 6 001 subjects. The effects of diuretics, beta-blockers, calcium channel blockers, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers on left ventricular mass (LVM) regression were compared in patients with hypertension. Overall, LVM was reduced by 10.3±0.88% (P<0.001) from a baseline value of 248±4.4 g and LVM index by 11.0±0.60% (P<0.001) from a baseline value of 132±1.6 g/m² . Regression of LVM was significantly less with beta-blockers than with angiotensin receptor blockers (9.8% vs. 12.5%; P=0.01), but none of the other analyzable pairwise comparisons between drug classes revealed significant differences. Beta-blockers showed less regression than the other 4 classes combined (P<0.01), and regression was more pronounced with angiotensin receptor blockers versus the others (P<0.01).

Comment: The relationship of left ventricula mass reduction by drug therapy and patient-important outcomes is unclear.

References

• Schmieder RE, Martus P, Klingbeil A. Reversal of left ventricular hypertrophy in essential hypertension. A meta-analysis of randomized double-blind studies. JAMA 1996 May 15;275(19):1507-13. [PubMed]
• Schmieder RE, Schlaich MP, Klingbeil AU, Martus P. Update on reversal of left ventricular hypertrophy in essential hypertension ( a meta-analysis of all randomized double-blind studies until December 1996). Nephrology, Dialysis, Transplantation 1998;13:564-569.
• Klingbeil AU, Schneider M, Martus P et al. A meta-analysis of the effects of treatment on left ventricular mass in essential hypertension. Am J Med 2003;115(1):41-6. [PubMed]
• Fagard RH, Celis H, Thijs L ym. Regression of left ventricular mass by antihypertensive treatment: a meta-analysis of randomized comparative studies. Hypertension 2009;54(5):1084-91. [PubMed]