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Target systolic blood pressure in patients with left ventricular hypertrophy
Sverre E Kjeldsen1, Brent Egan2, Giuseppe Mancia3
1Department of Cardiology, Oslo University Hospital, Ullevaal, and Institute for Clinical Medicine, University of Oslo, Building No. 3, Kirkeveien 166, Oslo N-0407, Norway.
Insights
Lowering systolic blood pressure below 130 mmHg in older hypertensive patients with left ventricular hypertrophy (LVH) may increase mortality. Caution is advised when setting blood pressure targets for these individuals.
Area of Science:
- Cardiology
- Hypertension Research
- Clinical Trials
Background:
- Left ventricular hypertrophy (LVH) is a common cardiac complication of hypertension, affecting up to 50% of patients.
- Existing hypertension guidelines offer limited specific guidance on managing blood pressure targets in patients with LVH.
- Previous outcome trials suggest potential safety concerns with intensive blood pressure lowering (<130 mmHg systolic) in middle-aged and older hypertensive populations.
Purpose of the Study:
- To review the potential risks associated with low systolic blood pressure targets in hypertensive patients with LVH.
- To analyze data from major clinical trials regarding mortality outcomes in hypertensive patients with ECG-defined LVH and varying blood pressure targets.
Main Methods:
- Analysis of data from the Losartan Intervention for Endpoint Reduction (LIFE) study (n=9,193) focusing on ECG-LVH.
- Examination of data from the Valsartan Antihypertensive Long-term Use Evaluation (VALUE) Trial (n=2,458) in patients with ECG-LVH.
- Time-varying analysis to assess the impact of achieving specific systolic blood pressure levels on mortality.
Main Results:
- In the LIFE trial, achieving systolic blood pressure ≤130 mmHg was associated with a 37% increase in all-cause mortality (p=0.005) compared to systolic blood pressure ≥142 mmHg.
- The VALUE trial indicated higher all-cause and cardiac mortality in patients with ECG-LVH who achieved average systolic blood pressure <130 mmHg.
- Both trials suggest an increased mortality risk when systolic blood pressure is lowered below 130 mmHg in patients aged 50 and older with ECG-LVH.
Conclusions:
- Lowering systolic blood pressure <130 mmHg in middle-aged and older hypertensive patients with ECG-LVH may be associated with increased mortality.
- Further research is necessary to establish optimal systolic blood pressure targets for hypertensive patients with LVH.
- Prudence is advised when considering systolic blood pressure targets below 130 mmHg in this patient cohort.
Abstract:
Left ventricular hypertrophy (LVH) is the most common hypertension-related cardiac disorder. Indeed, it is present in about 50% of patients with hypertension when examined by echocardiography and up to 20-30% when examined by electrocardiogram (ECG). The presence of LVH may be related to safety concerns when treating hypertension because data from large outcome trials in middle-aged and older patients have shown increased mortality if systolic blood pressure (BP) is lowered <130 mmHg. LVH is only briefly mentioned in the 2024 ESC Hypertension Guideline and in the 2025 AHA/ACC Hypertension Guideline. This review therefore discusses the potential consequences of a low target BP in hypertensive patients with LVH. The Losartan Intervention for Endpoint Reduction Study (LIFE) included 9,193 patients 55-80 years old with hypertension and ECG-LVH. A time-varying LIFE analysis showed that achieving systolic BP ≤130 mmHg led to a 37% increase in all-cause mortality (p=0.005) and a 32% increase in cardiovascular mortality (p=0.08) compared to patients who achieved systolic BP of ≥142 mmHg. In the Valsartan Antihypertensive Long-term Use Evaluation (VALUE) Trial, which included patients aged ≥50 years with concomitant cardiovascular risk factors, patients with ECG-LVH (n=2,458) who achieved average systolic BP <130 mmHg (n=305) through 4 years had higher all-cause and cardiac mortality than patients with systolic BP 130-139 mmHg (HR=1.74, 95% CIs 1.17-2.60) or systolic BP ≥140 mmHg (HR=1.98, CIs 1.06-3.70). LIFE and VALUE suggested an increased mortality when lowering systolic BP <130 mmHg in patients 50 years and older with ECG-LVH. While further research is needed to better define a target systolic BP in patients with hypertension and ECG-LVH, caution is warranted in lowering systolic BP <130 mmHg in middle-aged and older hypertensive patients with ECG-LVH.
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