LVH and causes

[XFACTOR2009]

Hello
. In 2004  I had  an echo  that said  all was fine  no LVH  but  this  April  I now have an echo  report which says I have mild  LVH at 13mm.   All other parameters appear to be normal and the report describes my heart as  within normal limits in structure and function.  I have an ejection fraction of 74  per cent and  nothing is  dilated     I am not tall,  am male  aged  48.   about  68  KG   and  5  feet  6  inches.    I have various  diagnosis,  sometimes  they say it is white coat hypertension,  one  doctor  has  said  I am not  hypertensive and the  other  that I am borderline but need not  take medication.  Typical  ambulatory studies  have  produced  results  like  132/86     135.91  and I get averages around this on my home monitor, and low  readings as well like  115. 72   My BP is not  consistently raised     However  that was  all before  the  latest echo.  However, I have my ECG's  over the years,  and applying  voltage  criteria  I do not reach LVH   but all the relevant  waves  in the voltage  criteria  leads  are the same  height,  both before  and after  the  diagnosis of  LVH,   about  5  different  ECG,  all hospital and technician or nurse  arranged.  
1.  I  wonder  whether the echo  interpretation is  reliable, given that no  extra  voltage  has been required  to penetrate the myocardium over the years
2.    If  there is  LVH, my heavy  duty exercise  routine   of  fast  cycling, hill walks  and power  walking,   may be responsible  for 'physiological'  rather than  pathological  (hypertensive )  LVH      I have a  resting pulse  between  50  and 55,  a lower sternal  edge (I  think it was  called)  ejection murmur)    no  dilation on echo, normal  diastolic and systolic  function  and EF  of  74  per cent    my  'untreated '  BP  has  been like it is  since I was in my 20's  as  has  my  exercise routine    I am now  48



Andrew

[nilremo]

This depends on your age, nowadays ( February , 2014) the new guidelines on this matter suggest that the upper borderline for people 60 years plus  is up to 150/90 and below 60 years, up to 140/90. The more they push for a lower blood pressure for everyone, the more patients on anti hypertensive drugs ( with all their side effects) and the more money to the coffers of the pharmaceutical manufacturers ( which is the true mover behind this craziness).

[XFACTOR2009]

Have done a home  blood  pressure  study since  late afternoon yesterday  to include first  thing awakening and the  first hour of being awake   .  Total 35  readings  with a arm monitor a  few months  old  with fresh  batteries

averaged  by  totalling  each and dividing by the number of readings

It  came  to 116/86    

[XFACTOR2009]

I agree with you, but I am only suggesting  the ECG  voltage pattern in my ECG's  as a partial indicator  that the  echo  finding may be lacking dependability  given the physiological LVH features  I described in my  findings.  I  agree  with you about  ECG  voltages,  in fact
ECG  fails  to detect heart attack changes in a large number  of cases  even when it is happening !        BTW,  12mm LVS  as in your  case reaches  the LVH diagnostic  threshold but ECG  usually  misses 'mild'  levels of  LVH

I'm  hoping  a  doc  will review  this  thread and answer  my  questions and look   over  our  discussion to see what  clarification they can offer.

[tickertock]

You can't go by the ecg in diagnosing LVH, its usually wrong! When my IVS was 12mm , I had the minimal voltage criteria for LVH, when it measured 14mm, I had no voltage criteria at all for LVH, go figure!! Will be interesting to see the Doc response!

[XFACTOR2009]

Just measured the ECG's  again,   adding the S  wave in V1  and    the R wave in V5   I get a  total of  32mm  for the recent  ECG which  followed  my  echo  detecting  LVH     and   doing the same for the 2004   ECG,  which was  around the time I also had my echo  then which showed no LVH,  the voltage was in fact   34mm  then   and  it is 32 mm now.
This is on the  sokolow lyon  voltage  criteria.    On this basis the  ECG  evidence  suggests a reduction in left  ventricular thickness  over  time,  rather  than it having hypertrophied

Maybe if one of the  doctors  that  visit this forum and answer  questions  can also  indicate whether a  reduction in voltage produces  grounds  to  query an  echo  report of ventricular wall  thickening between  those  periods

[XFACTOR2009]

The reason I  wonder  about  whether  the exercise as a cause  is  that I read  an article  in Maedica,  an online   clinical  journal,  in fact a paper about differentiating between physiological and pathological LVH, as well as  some other materials I have read.    Apparently,  it cannot be assumed  that LVH in a hypertensive is pathological,  though often it is.  If  there is an intensive  engagement in exercise it can have  the same result of  LVH  developing.  However,  it is suggested that  where  there is no  dilation, normal  atrium  etc  and a low pulse  rate as well as a certain type of ejection murmur,   and normal  systolic  and diastolic  function  then these  are  findings  more likely to be associated with physiologic  LVH than hypertensive.   The article  suggests  that  tissue  doppler  imaging is a technique with potential to differentiate  pathological  from physiological  and  this is a technique feasible on most  commercially  available echo  machines.   Its hard for me to accept I have pathological LVH  given my  other  echo  findings and the fact that in the ecg leads  relevant  for LVH  voltage  criteria the voltages  have not increased  between my   no  LVH  ech in 2004  and my  LVH  echo in 2011  and yet the percentage vof  echo 'increase '  in ventricular  wall  thickening was not  marginal between those  times      I  am told it has  gone from below  12  to 13  .    My blood pressure has it seems  been  about the same for  over  20 years

Why  should one be concerned to know if  it is  pathological or physiological

Each  carries a  different risk  and approach     borderline   hypertension and   'physiological ' LVH  carries   little  risk  compared to pathological hypertension.   physiological

That said  I do not fully understand  all  dimensions of my  echo  report, in particular  the haemodynamic parameters.   The doctor wouldn''t  expand on these  as he said it was  too complicated

The  echo  btw,  took only 10 minutes.   My  first one  7  years  ago  took almost  half  an hour.  

[XFACTOR2009]

Hi Tickertock,   Thanks  again.  I'm still hoping that a  doc on here  can have a look at my original post,  however, I am  going to list all the findings of my echo.
LVS  thickness   13mm
LVID (d)  45.9mm
LVID (s)   26.1mm
posterior wall thickness  13.1 mm
LVEF (2D)   74  per cent
Left atrium   diam  PLAX   33.1mm
Right Ventricle  TAPSE 20mm
Aorta  31.9mm
Aortic  Valve   122.cm/s
Max LV  aorta gradient  6mm/hg
Pulmonary valve  111cm/s
Max RV-PA gradient  5mm/hg
Haemodynamic
E  65 cm/s
A  50 cm/s
E  12cm/s
mitral  DTE  202 ms

The  echo report  also says

Left Ventricle   Normal wall motion, non dilated  LV,  mild  symmetric LVH, MAPSE  13mm   Turbulent blood  flow  seen  in LVOT
Left atrium    non  dilated
Non dilated  right ventricle, normal  systolic  function
no  aortic  dilation,  normal;  aortic calve, no  stenosis or  regurtitation
normal mitral  valve, no stenosis  physiologic  MR  grade  0  to 1]

Tricuspic  normal ,  Physiologic  TR  grade  0  to  1
same  for pulmonary vavle
and no pericardial effusion

As  for my ECG taken the same day,   it was  said to be noral.  

[tickertock]

Forgot to mention people with high end ejection fraction such as yours is often to a mid systolic murmur due to the high volume ejected, once again I think you can be reassured not worry ,just keep your BP under control , of course I'm no doctor just been down a similiar and worried myself silly

[tickertock]

Of course your exercise routine could be the cause of your mild LVH,  on the other hand it probably isn't , its probably due to your mild hypertension over the years that is clearly now recognized as not desirable, some people get away with it some don't, that s what happened to me, it could also be a readers error, if in doubt get an another echo within 6months -1 year in the meantime , keep your BP controlled on the low side once you don't get symptoms, just my opinion of course!

[XFACTOR2009]

Thanks for the reassurance,  however,  your  reply  isn't  so useful  for me because  my  questions are technical and really needs a doctors  response,  which I hope  will  arise.  
BTW,  120/80  is  normotensive  in the UK and EU     Obviously though I agree   lower is  generally  better

[tickertock]

I wouldn't be alarmed about this, but you should try keep your BP around 110/70 to 115/75, anything > 120/80 is considered borderline