AJH 2007; 20:990 –996
Heart
Regression of Left-Ventricular Hypertrophy in
Children and Adolescents With Hypertension
During Ramipril Monotherapy
Tomáš Seeman, Jiřı́ Gilı́k, Karel Vondrák, Eva Šimková, Hana Flögelová,
Marie Hladı́ková, and Jan Janda
Background: Left-ventricular hypertrophy (LVH) is a
risk factor for cardiovascular morbidity. Antihypertensive
treatment with angiotensin-converting enzyme inhibitors
(ACEI) is able to induce the regression of LVH in adults.
However, there has been no study of the ability of ACEI
to induce the regression of LVH in children. Our aim was
to investigate the effect of ramipril on left-ventricular mass
and blood pressure (BP) in hypertensive children.
Methods: Twenty-one children (median age, 15 years)
with renal (76%) or primary (24%) hypertension were pro-
spectively treated with ramipril monotherapy for 6 months.
Blood pressure was evaluated using ambulatory BP monitor-
ing, with hypertension defined as mean BP ⱖ95th percentile.
Left-ventricular hypertrophy was defined either as left-ven-
tricular mass index (LVMI) ⬎38.6 g/m2.7 (pediatric defini-
tion) or as LVMI ⬎51.0 g/m2.7 (adult definition).
Results: Nineteen children completed the study. The
median LVMI decreased from 36.8 g/m2.7 (range, 18.9 to
eft-ventricular hypertrophy (LVH) is an important
L sequela of hypertension and an independent risk
factor for cardiovascular morbidity and mortality in
adult patients with hypertension.1,2 Regression of LVH is
associated with decreased cardiovascular risk.3,4 There-
fore, regression of LVH has become one of the goals of
antihypertensive therapy in adults.5 The regression of
LVH during antihypertensive therapy was well docu-
mented in adult hypertensive patients with primary and
renal hypertension.3,6,7 Ambulatory blood-pressure moni-
toring (ABPM) is superior to office blood pressure (BP) in
predicting the treatment-induced regression of LVH.8
Received December 4, 2006. First decision January 1, 2007. Accepted
March 11, 2007.
From the Department of Pediatrics, and Kardiocentrum and Center
for Cardiovascular Research, University Hospital Motol, Second School
of Medicine, Charles University, Prague, Czech Republic; Department of
Pediatrics, Palacky University, Olomouc, Czech Republic; and Department
of Medical Informatics, Charles University, Prague, Czech Republic.
0895-7061/07/$32.00
doi:10.1016/j.amjhyper.2007.03.009
55.8 g/m2.7) to 32.6 g/m2.7 (range, 19.0 to 52.1 g/m2.7; P ⬍
.05) after 6 months. The prevalence of LVH decreased
from 42% to 11% using the pediatric definition (P ⬍ .05)
and did not change using the adult definition (ie, it re-
mained at 5%). The median ambulatory BP decreased by
11, 7, 8, and 7 mm Hg for daytime systolic, daytime
diastolic, nighttime systolic, and nighttime diastolic BP
(P ⬍ .05), respectively. A positive correlation was found
between LVMI and nighttime systolic BP at the start of the
study (r ⫽ 0.46, P ⬍ .05).
Conclusions: Ramipril is an effective drug in chil-
dren with hypertension, for its ability to reduce not only
BP but also left-ventricular mass and induce regression
of LVH. Am J Hypertens 2007;20:990 –996 © 2007
American Journal of Hypertension, Ltd.
Key Words: Left-ventricular hypertrophy, regression,
ramipril, children, hypertension.
Left-ventricular hypertrophy is also a form of target-
organ damage frequently seen in hypertensive children; it
occurs in 8% to 41% of subjects.9 –12 Contrary to the case
with adults, there are no prospective studies showing that
antihypertensive therapy can induce regression of LVH in
children with hypertension. Only case reports showing that
regression of LVH is possible in hypertensive children
have been published.13
The aim of our prospective interventional study was to
investigate the effect of ramipril treatment on left-ventric-
ular mass and the prevalence of LVH in children with
primary and secondary hypertension.
Supported by Grants 0021620819 and 0006420301 from the Min-
istry of Education and Health of the Czech Republic VZ MŠMT and
VZMZ.
Address correspondence and reprint requests to Dr. Tomáš Seeman,
Department of Pediatrics, Second School of Medicine, Charles Univer-
sity, V Uvalu 84, 15006 Prague 5, Czech Republic; e-mail: tomas.
seeman@lfmotol.cuni.cz
© 2007 by the American Journal of Hypertension, Ltd.
Published by Elsevier Inc.
AJH–September 2007–VOL. 20, NO. 9
Methods
Study Population
Twenty-one children and adolescents (median age, 15
years; range, 3.3 to 17.8 years; 14 boys) who fulfilled the
inclusion criteria (primary or renal hypertension confirmed
by ABPM, echocardiography evaluation at the time of
ABPM, and no treatment with antihypertensive agents)
were included in this prospective study. They were se-
lected consecutively over a period of 4 years (2001 to
2004) in our two centers. The children were prospectively
treated for 6 months with ramipril monotherapy. No child
received any other treatment for primary renal disease
other than ramipril (no steroids and no immunosuppres-
sive drugs). Ten children had already been included and
evaluated in our previous study, which investigated the
effect of ramipril on ambulatory BP and proteinuria in
children with chronic kidney diseases.14 Four children had
primary hypertension, and 17 children had renal hyperten-
sion. Primary renal diseases included polycystic kidney
diseases (n ⫽ 8; autosomal-dominant polycystic kidney
disease in 5 children and autosomal-recessive polycys-
tic kidney disease in 3 children), reflux nephropathy
(n ⫽ 5), renal dysplasia (n ⫽ 2), residual renal abnor-
malities after hemolytic uremic syndrome (n ⫽ 1), and
IgA nephropathy (n ⫽ 1).
Ambulatory BP was measured by ABPM, using an oscil-
lometric device (SpaceLabs 90207 or 90217; SpaceLabs,
Redmond, WA). A cuff of an appropriate width for the arm
circumference was chosen. Blood pressure was automati-
cally recorded every 20 min during the day and every 30
min at night. A record of daily activities and sleep during
the night was obtained for each child. Hypertension was
defined as a mean ambulatory systolic or diastolic BP during
the daytime or nighttime period ⱖ95th percentile for healthy
mid-European children.15 The nocturnal BP dip was calcu-
lated as a percentage of mean nighttime BP decline compared
with mean daytime BP. The office BP was measured in the
renal clinic under standard recommended conditions, using a
mercury sphygmomanometer and an appropriate cuff.16
A standard two-dimensional echocardiogram (GE/
Wingmed System 5; Vivid 7, Horten, Norway) was per-
formed by one experienced pediatric cardiologist (JG) on
the same day as ABPM, according to the recommenda-
tions of the American Society of Echocardiography.17
Left-ventricular mass (LVM) was calculated according to
the formula of Devereux et al from the left-ventricular
internal dimension at end diastole, interventricular sep-
tal thickness, and left-ventricular posterior wall thick-
ness.18 Left-ventricular mass was indexed to height2.7
(left-ventricular mass index, LVMI) to account for body
size.19 Left-ventricular hypertrophy was defined either
as LVMI ⬎38.6 g/m2.7, which corresponds with the
95th percentile of normative pediatric LVMI data,19 or
as LVMI ⬎51.0 g/m2.7, which in adults was found to
correlate with a fourfold greater risk of cardiovascular
events.20
REGRESSION OF LVH IN CHILDREN WITH RAMIPRIL 991
The intraobserver reliability of echocardiographic mea-
surements was adequate, insofar as the difference of re-
peated measurements of LVM in the same patient under
similar conditions was 1.197 ⫾ SEM of 1.901 (89.595 on
the first measurement and 88.397 on the second measure-
ment). This difference was not statistically significant
(P ⫽ .53, 95% confidence interval for differences of
means, ⫺2.659 to 5.053).
The glomerular filtration rate was classified according
to National Kidney Foundation guidelines.21 It was normal
(calculated creatinine clearance according to the formula
of Schwartz et al,22 ⱖ90 mL/min/1.73 m2) in all children
with primary hypertension and in 12 children with renal
hypertension, mildly reduced (creatinine clearance, 60 to
89 mL/min/1.73 m2) in 4 children, and moderately re-
duced (creatinine clearance, 30 to 59 mL/min/1.73 m2) in
1 child. Body mass index (BMI) was expressed in absolute
values (kg/m2) and in percentiles of the healthy Czech
child population.23 Overweight was defined as a BMI
⬎85th percentile (six children, 29%) and obesity as BMI
⬎95th percentile (four children, 19%).
Ramipril was given as a single daily oral dose in the
morning or in the evening (one child). The initial dose was
1.5 mg/m2/day. This dose was doubled if all mean BP
values were not ⬍95th percentile after 1 month of treat-
ment. The maximal dose was 6 mg/m2/day. Ramipril was
given for 6 months as monotherapy. The ABPM and blood
tests for serum creatinine, serum potassium, and blood
count (by standard methods) were performed 1 month
after the initiation of treatment, 1 month after each change
of ramipril dose, and at the end of the study. Echocardi-
ography was performed at the end of the study (at 6
months). Patients were monitored at every outpatient visit
for the presence of adverse effects of ramipril, such as
cough, abdominal pain, fatigue, dizziness, orthostasis,
edema, or rash. All parents gave informed consent for their
children to participate in the study, which was approved by
the local ethics committee.
Statistics
The data are expressed as medians and range. The Wil-
coxon signed rank test and McNemar test were used to
assess significant changes in follow-up. The correlations
between variables (ambulatory BP, office BP, LVMI,
BMI, and glomerular filtration rate) were assessed by
Spearman correlation analysis (univariate and multivariate
analysis). P ⬍ .05 was regarded as statistically significant.
Results
Patients
Nineteen children completed the 6-month study. The rea-
sons for the two dropouts were noncompliance with the
study medication (n ⫽ 1) and missing the echocardiogra-
phy evaluation at the end of the study (n ⫽ 1).
992 REGRESSION OF LVH IN CHILDREN WITH RAMIPRIL AJH–September 2007–VOL. 20, NO. 9

Table 1. Baseline characteristics of patients children. The median ramipril dose at the end of the study
was 2.9 mg/m2/day (range, 1.1 to 5.7 mg/m2/day). The
Median (range) or percentage of nighttime dip in systolic BP decreased by
Variable number of patients 2% (the systolic BP dip changed from 10% at the start of
Age (y) 15.0 (3.3–17.8) the study to 8% at the end of the study). The percentage of
Sex (male/female) 14/7 nighttime dip in diastolic BP decreased by 1% (the dia-
BMI, absolute (g/m2) 21 (14.8–30.5) stolic BP dip changed from 18% to 17%). These differ-
BMI, relative (percentile) 63 (15–99)
Renal hypertension 17
ences were not statistically significant.
Primary hypertension 4
Creatinine clearance
(mL/min/1.73m2) 113 (55–245)
Echocardiography
Serum potassium Left-ventricular hypertrophy was present at the start of the
(mmol/L) 4.4 (3.6–5.0)
study in 42% of the children (8 of 19 children), using the
BMI ⫽ body mass index. 95th percentile of normative pediatric LVMI data for our
definition, and in 5% (one child), using the adult defini-
tion. At the end of the 6-month study, the prevalence of
LVH decreased significantly to 11% of the children (2 of
Blood Pressure
19 children), using the 95th percentile of normative pedi-
After 6 months of ramipril treatment, the mean daytime atric LVMI data as our definition (P ⬍ .05), and did not
systolic as well as nighttime diastolic BP decreased in 17 change (5%, one child, other than at the start) using the
of 19 children, the mean nighttime systolic BP decreased adult definition. The data are summarized in Fig. 1.
in all children, and the mean daytime diastolic BP de- The median LVMI decreased significantly after 6
creased in 14 children. The changes in ambulatory and months of ramipril treatment (data given in Table 2).
office BP after ramipril treatment are shown in Table 1. Individual values of LVMI before and at the end of the
Hypertension normalized (ie, all mean ambulatory BP study are given in Fig. 2.
values ⬍95th percentile) in 53% of children. The initial Using univariate analysis, there was no significant cor-
dose of ramipril had to be increased during the study in 12 relation between LVMI and daytime or nighttime systolic

FIG. 1. Effect of ramipril on the prevalence of hypertension (HT) and left-ventricular hypertrophy (LVH), using 95th percentile of normative
pediatric left-ventricular mass index (LVMI) data for definition of LVH.
AJH–September 2007–VOL. 20, NO. 9 REGRESSION OF LVH IN CHILDREN WITH RAMIPRIL 993

Table 2. Change in left-ventricular dimensions and blood pressure in ramipril-treated patients*

P
Variable Baseline After 6 months value
Mean ambulatory daytime
systolic BP (mm Hg) 133.0 (112–154) 124.4 (110–142) ⬍.001
Mean ambulatory daytime
diastolic BP (mm Hg) 80.0 (67–109) 74.3 (65–90) ⬍.01
Mean ambulatory nighttime
systolic BP (mm Hg) 120.0 (109–138) 111.0 (97–125) ⬍.001
Mean ambulatory nighttime
diastolic BP (mm Hg) 69.0 (53–89) 61.0 (51–72) ⬍.001
Mean ambulatory 24-h systolic
BP (mm Hg) 125.5 (112–146) 115.5 (106–134) ⬍.001
Mean ambulatory 24-hr diastolic
BP (mm Hg) 74.5 (64–99) 66.5 (60–81) ⬍.001
Office systolic BP (mm Hg) 135.0 (110–160) 130.0 (102–160) NS
Office diastolic BP (mm Hg) 86.0 (70–110) 85.0 (60–100) NS
LVMI (g/m2.7) 37.4 (18.8–55.8), 36.2 ⫾ 8.6 32.5 (19.0–52.1), 33.1 ⫾ 7.2 ⬍.05
IVS thickness (cm) 0.72 (0.39–1.08) 0.68 (0.54–1.08) NS
LVPW thickness (cm) 0.78 (0.57–1.04) 0.78 (0.55–0.96) NS
LVID (cm) 4.82 (3.16–5.58) 4.75 (2.69–5.77) NS
RWT 0.31 (0.21–0.41) 0.30 (0.21–0.46) NS

BP ⫽ blood pressure; IVS ⫽ interventricular septum; LVID ⫽ left-ventricular internal dimension; LVMI ⫽ left-ventricular mass index; LVPW
⫽ left-ventricular posterior wall; NS ⫽ not significant; RWT ⫽ relative wall thickness.
* Values are median (range), if not given as mean ⫾ SD.

or diastolic BP. No significant correlation was found be- changes in daytime or nighttime systolic or diastolic BP,
tween LVMI and renal function or BMI. No significant changes in renal function, or changes in BMI during the
correlation was found between changes in LVMI and study. The correlations with a trend toward a significant

FIG. 2. Effect of ramipril on left-ventricular mass index (LVMI) in individual patients.

994 REGRESSION OF LVH IN CHILDREN WITH RAMIPRIL
FIG. 3. Correlation between left-ventricular blood pressure (LVMI) and nighttime systolic blood pressure. BP ⫽ blood pressure; LVH ⫽
left-ventricular hypertrophy. On the x axis, nighttime systolic BP in mmHg in relation to 95th percentile (0 ⫽ 95th percentile, according to
Soergel et al15).
relationship were correlations between LVMI and night-
time systolic BP (r ⫽ 0.42, P ⫽ .07), BMI in percentiles
(r ⫽ 0.43, P ⫽ .06), daytime systolic BP (r ⫽ 0.37, P ⫽
.12), and 24-h systolic BP at the start of the study (r ⫽
0.32, P ⫽ .17), and between the change in LVMI and
the change in daytime systolic BP during the study (r ⫽
0.39, P ⫽ .10). Using multivariate analysis, there was a
significant correlation only between LVMI and night-
time systolic BP at the start of the study (r ⫽ 0.46, P ⫽
.048, Fig. 3).
Renal Function, BMI, and Side Effects
At the end of the study, the glomerular filtration rate did
not change significantly. The median glomerular filtration
rate decreased from 113 mL/min/1.73 m2 (range, 55 to 245
mL/min/1.73 m2) to 107 mL/min/1.73 m2 (range, 54 to
195 mL/min/1.73 m2). Body mass index did not change
significantly: the median relative BMI increased from the
63rd percentile (range, 16th to 99th percentile) to the 67th
percentile (range, 6th to 98th percentile); the median ab-
solute BMI was 21.0 kg/m2 (range, 14.8 to 30.5 kg/m2) at
the start of the study and 21.2 kg/m2 (range, 14.8 to 30.1
kg/m2) at the end of the study. Ramipril was well tolerated
by the children; no child complained of a cough. The
median serum potassium level did not change significantly
(a decrease by 0.1 mmol/L). However, two children de-
AJH–September 2007–VOL. 20, NO. 9
veloped mild hyperkalemia (5.3 and 5.6 mmol/L) at the
final outpatient check at 6 months, which normalized by
adding a diuretic after completing the 6-month study pro-
tocol. One child who developed hyperkalemia had mod-
erately decreased renal function (55 mL/min/1.73 m2), and
the second already had a high-normal potassium level at
baseline (4.7 mmol/L). No significant change in hemoglo-
bin level was noted (a decrease by 1 g/L).
Discussion
In our previous study, we showed that ramipril is a safe
and effective drug for the treatment of hypertension and
proteinuria in children with chronic kidney diseases.14 Our
current study is the first prospective, interventional trial on
the effects of ramipril on LVM and the prevalence of LVH
in children with primary and renal hypertension. We were
able to demonstrate that 6-month ramipril monotherapy
can induce a significant reduction of LVM and a regres-
sion of LVH in three-quarters of the hypertensive children
treated.
Left-ventricular hypertrophy is an independent predic-
tor of cardiovascular morbidity and mortality in adults.1,2
Moreover, regression of LVH is associated with fewer
cardiovascular events.24 Therefore, LVH is becoming an
important treatment goal for hypertensive patients.5,25 All
classes of antihypertensive drugs are able to reduce LVH.
AJH–September 2007–VOL. 20, NO. 9
However, drugs blocking the renin-angiotensin systems,
such as angiotensin-converting enzyme (ACE) inhibitors
or angiotensin receptor blockers (ARBs) (eg, as used in the
HOPE and LIFE trials), seem to have some benefits be-
yond the BP-lowering effects on regression of LVH in
comparison to other antihypertensive agents.24
In children, LVH is also a prevalent cardiovascular
consequence of hypertension, affecting 8% to 41% of
hypertensive children,9 –12,26,27 and 33% to 75% of chil-
dren with chronic renal insufficiency, and children on
dialysis or after renal transplantation.28 –30 Because most
of the children in our study had renal hypertension, it must
be emphasized that children with renal hypertension have
a higher prevalence of LVH than children with primary
hypertension. Therefore, the relatively high LVH preva-
lence of 42% in our study is due to the great majority of
children having chronic kidney disease. Blood pressure
and BMI are the most important determinants of LVH in
children.31 We found a correlation between nighttime sys-
tolic BP and LVMI using multivariate analysis. In con-
trast, we could not find any correlation between diastolic
BP, daytime systolic BP, or BMI and LVMI, which is in
accordance with other cross-sectional studies28 but in con-
trast to other studies showing a correlation between am-
bulatory BP and LVMI.27 However, a nonsignificant trend
for a relationship between daytime and 24-h systolic BP
and BMI and LVMI was noted in our study, suggesting
that systolic BP and body composition influence LVM in
hypertension children.
In children with chronic renal failure (ie, those with
predialysis, dialysis, and transplants), several studies dem-
onstrated that the regression of LVH is possible through
strict BP treatment and by achieving correct dry weight
and avoiding hyperhydration.32,33 However, for children
with primary or renal hypertension without chronic renal
failure, there are no studies investigating the effects of
antihypertensive therapy on LVM and on the prevalence
of LVH. Our study clearly demonstrates that BP reduction
by ramipril also leads to a reduction of LVH after 6
months in most children with primary hypertension and
renal hypertension without chronic renal failure. It must be
stated that the regression of LVH in patients with chronic
kidney diseases may be equally due to treatment of the
primary renal disease. However, in our study, no child
received any treatment for primary renal disease other than
ramipril (ie, no steroids or immunosuppressive drugs).
Several adult studies such as the HOPE and LIFE trials
showed that agents blocking the renin-angiotensin-aldo-
sterone system, such as ACE inhibitors or ARBs, are
better than other antihypertensive drugs to induce a regres-
sion of LVH.25 The authors hypothesized that ACE inhib-
itors or ARBs may have more effects on the heart than do
drugs that merely lower BP (eg, effects on interstitial
fibrous tissue). In agreement with these large studies, we
did not find any correlation between the change in BP
during the 6-month period of ramipril therapy and the
change in LVMI. However, a trend toward a relationship
REGRESSION OF LVH IN CHILDREN WITH RAMIPRIL 995
between change in daytime systolic BP and change in
LVMI was noted. Furthermore, since no significant corre-
lation with BP was found with other determinants of
LVM, such as BMI, renal function, or hemoglobin level,
we can speculate that a part of the regression of LVH may
be caused by BP-independent mechanisms because of
ACE inhibition.34
Despite the beneficial effect on the prevalence of LVH
(reduction from 42% to 11%), almost half of the children
remained hypertensive at the end of the 6-month period of
ramipril monotherapy. To achieve better BP control, about
half of the hypertensive children will require a combina-
tion of antihypertensive agents. Further studies are war-
ranted to test whether tighter BP control by combination
therapy will result in further regression of LVH.
Ramipril was very well tolerated by the children in our
study. We did not observe cough in any child. Mild
hyperkalemia was detected in only two children: one of
them had moderately decreased renal function, which is a
known risk factor for the development of hyperkalemia
during therapy with ACE inhibitors, and the second child
already had a high-normal potassium level at the start of
the study. Therefore, children with decreased renal func-
tion or high-normal potassium levels should be checked
frequently for hyperkalemia during treatment with ACE
inhibitors. The hyperkalemia normalized after adding
diuretics at the end of the 6-month study period. No
significant effects on renal function or hemoglobin level
were observed.
The limitations of our study were mainly its uncon-
trolled and nonblind design and the lack of a comparison
drug. However, our study was not designed to compare
different drugs but to demonstrate that regression of LVH
by antihypertensive therapy with an ACE inhibitor is
possible in children with primary hypertension and renal
hypertension without chronic renal failure. A further lim-
itation of our study is the small number of patients, which
makes the study insufficiently powered to detect differ-
ences in several variables. Despite these limitations, this
study provides the first prospective, interventional pediat-
ric trial on the effects of ramipril on LVM.
In conclusion, ramipril is an effective and safe drug in
children with hypertension that is able to reduce LVM and
induce regression of LVH.
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