How to Evaluate LVH with

CMR in Hypertension

Calvin Chin MD PhD FSCMR FRCP

Clinician Scientist and Senior Consultant, National Heart Centre Singapore
Director of Cardiovascular MRI, National Heart Centre Singapore
Associate Professor, Duke NUS Medical School
May 11, 2023
• No disclosures
LVH in Hypertension: Adaptation to Decompensation

Neurohormonal
Sympathetic
Inflammatory
Transition Point ??

Systolic/diastolic Heart Failure Preserved EF

dysfunction Heart Failure Reduced EF
Prognosis of Hypertensive LVH
LVH = Increased left ventricular mass

• LVH diagnosed by ECG, echocardiogram and MRI is a strong

predictor of higher cardiovascular mortality and morbidity

• LV mass regression during anti-hypertensive treatment is

associated with lower rates of clinical end points
 Electrocardiogram
• Provide early clues for LVH, associated
structural/electrical abnormalities
• Lacks sensitivity and specificity
Echocardiogram
• First line imaging in assessing hypertensive
heart disease
• Assessing morphology and cardiac function
(systolic/diastolic)
• Linear measurements to estimate volumes
Assessment of LV Mass

Myocardial volume: epicardial – endocardial volume

• No geometric shape assumptions

• High reproducibility = important to monitor
disease progression and treatment response
Intra-observer reproducibility <5g*
Inter-observer reproducibility <10g*
Inter study reproducibility <10g*

*Hypertension 2002;39:750-755
Diagnosis of LVH

Le et al., JCMR 2016 Maceira et al., JCMR 2010

How much LVH = decompensation and increased risk?

Geometry as a Marker of Transition
Incremental prognostic value* of geometric
patterns beyond LVH is less certain

M/V 1.1 to 1.3

RWT 0.32 to 0.42

*all cause mortality

JACC 2011;58:1733 F1000 2019;8:1130

Approaches to Improve HTN LVH Risk Stratification

(16%) (26%) (39%) (19%)

Circulation: Cardiovascular Imaging. 2014;7:422–429

Eur Heart J Cardiovasc Imaging 2021; 22(6):670-679.
 LV function as a Marker of Transition

• Myocardial dysfunction is common in LVH, even in

asymptomatic patients
• LVEF may be exaggerated
• Mid-wall shortening (echo) may be more sensitive
• Reduced LV strain is an early marker of LV systolic dysfunction
• Hypertensive LVH is associated with increased diastolic filling
pressures
• E/e’ (echo)
• LA size
Myocardial Fibrosis as a Marker of Transition?
LV Dysfunction

Adaptation Increasing LV mass Heart Failure

Myocardial Fibrosis

Myocardial volume [mL] = myocardial mass [g]/1.05 [g/mL]

Interstitial volume = ECV x myocardial volume

Myocyte volume = Myocardial volume – Interstitial Volume

Myocardial
Non ischemic
ECV
LGE
Map
Myocardial Fibrosis a Marker of Adverse Prognosis in Patients with Hypertension

Non-ischemic fibrosis on CMR associated

with increased primary composite outcome

Hypertension 2022;79;1804
Is Myocardial Fibrosis Reversible?

NCT03553810

Entresto Valsartan

1 year study to investigate the potential role of medications to regress fibrosis on CMR
• Accurate assessment of LVH is crucial
for the diagnosis and progression of
hypertensive heart disease
• Identifying the transition point from
adaptation and decompensation
improves risk stratification and
targeted therapies
• LV Geometric Patterns
• LV function
• Myocardial fibrosis