Hypertension and left ventricular geometry: Diagnosis, prognosis, and management

Hypertension remains one of the most prevalent and consequential cardiovascular risk factors worldwide and is a leading cause of heart disease. Hypertensive heart disease may manifest in alterations in left ventricular (LV) geometry, including concentric remodeling, concentric hypertrophy, and eccentric hypertrophy, representing adaptive responses to chronic pressure or volume overload that may progress to maladaptive remodeling and heart failure. LV geometric patterns, defined by LV mass and relative wall thickness, carry important diagnostic and prognostic implications independent of blood pressure levels. This review provides a comprehensive and contemporary overview of the relationship between hypertension and LV geometry. We summarize key determinants of hypertensive LV remodeling, including cumulative blood pressure exposure, sex differences, metabolic comorbidities, obesity, pericardial adiposity, and obstructive sleep apnea. We discuss current approaches to screening and diagnosis, highlighting the strengths and limitations of electrocardiography, echocardiography, and cardiac magnetic resonance imaging. We review emerging applications of artificial intelligence in electrocardiographic and echocardiographic assessment, with particular attention to their potential to improve detection, phenotypic differentiation, and prognostication. We further examine the prognostic significance of LV remodeling in hypertension and review evidence supporting regression of LV hypertrophy through intensive blood pressure control, management of comorbidities, and lifestyle interventions. Early identification and reversal of hypertensive LV remodeling may offer a critical opportunity to prevent progression to heart failure and reduce long-term cardiovascular morbidity and mortality. See also the graphical abstract(Fig. 1).