MADRID — Antihypertensive therapy with candesartan was shown to reverse left ventricular hypertrophy in a study reported by Dr. Vivencio Barrios at the annual meeting of the European Society of Hypertension.
Regression of electrocardiographic left ventricular hypertrophy (LVH) has been shown to improve the prognosis of hypertensive patients in several recently published controlled randomized trials, “but information on LVH regression in clinical practice has been very scarce,” said Dr. Barrios of the cardiology institute at Ramon y Cajal Hospital, Madrid.
Dr. Barrios conducted an open-label, 12-month study evaluating the impact of candesartan, an angiotensin-1 receptor blocker, on LVH in a real-world practice setting. The study involved 276 patients with uncontrolled essential hypertension. The mean blood pressure at baseline was 164/92 mm Hg. The patients' average age was 62 years, and 18% had diabetes.
The investigators assessed LVH via electrocardiography, using the Cornell voltage duration product (VDP) measurement, as well as QRS-segment duration. The baseline and posttreatment ECG tracings were assessed by a single lab, by a blinded investigator. At the outset of the study, 24% of the patients had LVH.
Patients were treated with candesartan 8 mg/day or 16 mg/day, with the objective of reaching pressures below 140/90 mm Hg for nondiabetics or 130/80 for diabetic patients. The investigators had the option of adding on other antihypertensive medications if the pressure values did not drop into the target ranges after several months.
At 12 months, the angiotensin-1 receptor blocker produced the expected degree of pressure reduction, decreasing the baseline mean values of 164/92 mm Hg to 143/84 mm Hg. It also produced a significant decrease in the prevalence of LVH. By the end of the study, 20% of the study population had ECG evidence of LVH, down from 24% at the outset. Dr. Barrios noted that 19% of those with LVH showed observable LVH regressions.
On average, the VDP was significantly reduced by 132.88 mm × msec, and the QRS interval was reduced by 2.95 msec; both indicate a trend away from LVH.
The Spanish investigators found that the VDP changes were larger in older patients, and in those with higher baseline VDP values, suggesting that candesartan offers the greatest potential benefit in those patients with the most advanced LVH.
Earlier detection and reversal of LVH has become a burning concern among hypertension specialists who hope that primary care physicians will join them in their efforts to prevent heart failure, for which advanced age and presence of LVH are the two most important risk factors.
“We have data from the 1970s showing that if you do a standard ECG and there are signs of LVH, the risk [of heart failure] is two- to fivefold greater. You really need to do the ECGs, look for LVH, and treat much more intensively,” said Dr. Thomas Kahan of the cardiology section at Karolinska Institutet, Stockholm, who chaired a session on heart failure prevention.
“There's a stepwise progression from hypertension to LVH to heart failure. My impression is that we have a lot of risk markers, but we tend not to use them in clinical practice.” He insisted that physicians increase their level of scrutiny for LVH whenever they do ECGs or echocardiograms.