Should we add screening for and treating left ventricular hypertrophy to the management of all patients needing secondary prevention of cardiovascular disease?

Patients with overt vascular disease (TIA, CVA, peripheral vascular disease, etc.) and patients with diabetes are both well known to be at exceptionally high risk of cardiac death, and are generally thought to need more intensive risk factor control, i.e. secondary prevention. Their high risk of cardiac death is generally attributed to coincidental coronary artery disease, leading to cardiac death due to fresh ischaemic events. While coronary disease is undoubtedly important, left ventricular abnormalities could also be a major contributor to cardiac death in these patients, causing ’arrhythmic’ as opposed to ’ischaemic’ deaths. These left ventricular abnormalities consist of both left ventricular hypertrophy (LVH) and LV systolic dysfunction (LVSD). In this article, we focus only on LVH, as LVSD has often been discussed elsewhere. That LVH is a risk factor is well established. In Framingham, the relative risk of cardiovascular mortality for every 50 g increment in echo LV mass was 1.73 in men and 2.12 in women, even after correction for risk factors such as blood pressure. Even in patients with established coronary artery disease, the extra risk for cardiac death due to LVH is 2.8, when adjusted for age, gender and hypertension. In patients with coronary disease, this extra risk due to echo LVH appears to be greater than that for multivessel coronary disease or to LV dysfunction: in one head-to-head comparison, the relative risks were 2.4, 1.6 and 2.0, respectively. Unfortunately, the simple ECG is a very insensitive way of assessing LVH.