Hypertensive heart disease & LV hypertrophy
LV mass and geometry, diastolic function and the left atrium — and the hypertrophy that is not hypertension.
Numbers to remember
- LV mass index above 115 g/m² (men) or 95 g/m² (women) is LVH [1]
- Relative wall thickness >0.42 separates concentric from eccentric geometry [1]
- Wall thickness ≥15 mm in hypertension should raise HCM, amyloid or Fabry [13,14,23]
- Effective antihypertensive treatment regresses LV mass, and regression lowers events [66,67]
Questions echo must answer
Hypertension remodels the left ventricle, stiffens it and enlarges the left atrium; echo stages that damage and looks for other causes of a thick heart [23,26].
- Is there LVH, and what geometry?LV mass index and relative wall thickness: normal, concentric remodelling, concentric or eccentric hypertrophy [1].
- Diastolic function and LA pressuree′, E/e′, TR velocity, LA volume [2].
- Systolic functionEF is often preserved; GLS is reduced earlier [16,108].
- Is it really hypertension?Asymmetric or very thick walls, low voltage, granular myocardium, valve thickening or a pericardial effusion suggest HCM or infiltration [13,14,30].
Acquisition protocol
- PLAXSeptum, posterior wall and LV diameter at end-diastole (2D-guided linear) for LV mass [1,41].
- PSAX papillary levelConfirm the hypertrophy is concentric; a PLAX septum can be oblique.
- A4C/A2CBiplane volumes and EF; GLS.
- Diastolic setMitral inflow, septal and lateral e′, TR velocity, LA volume index [2].
- AortaRoot and ascending aorta.
- Blood pressure at the time of the studyRecord it.
- LV mass index and RWT
- Geometry class
- EF and GLS
- Diastolic grade, LAVI
- Features of HCM or infiltration excluded
Diagnosis & severity
| Geometry | LV mass index | RWT |
|---|---|---|
| Normal | Normal | ≤0.42 |
| Concentric remodelling | Normal | >0.42 |
| Concentric hypertrophy | Increased | >0.42 |
| Eccentric hypertrophy | Increased | ≤0.42 |
Thresholds for increased mass: >115 g/m² men, >95 g/m² women [1].
Thresholds that change management
- LVH on echo is hypertension-mediated organ damage; it supports treating to target and is an indication for antihypertensive therapy in borderline cases [26].
- Wall ≥15 mm, asymmetric hypertrophy or SAM → evaluate for HCM [13,14].
- Red flags for amyloid (low voltage, granular myocardium, apical sparing, thick valves and septum) → amyloid pathway [30].
- Diastolic dysfunction with symptoms → HFpEF work-up [2,101].
Pitfalls & mimics
- Oblique PLAX Overestimates wall thickness; confirm in short axis.
- Including RV trabeculation or the moderator band in the septal measurement.
- Basal septal bulge A sigmoid septum of the elderly is not concentric LVH.
- Athlete's heart Mild symmetrical LVH with a large cavity and normal diastolic function [150].