Data from the SPRINT trial found that intensive blood pressure (BP) lowering, in comparison to conventional therapy, lowers incidence of malignant left ventricular hypertrophy (LVH) and may also cause regression of malignant LVH at 2 years. Simon B. Ascher, MD, MPH, of the University of California-San Francisco and the University of California-Davis, and colleagues reported these findings in a manuscript that was published online Monday and in the Oct. 18 issue of the Journal of the American College of Cardiology. Malignant LVH, marked by increased ventricular mass and elevated biomarkers, is a precursor to heart failure and has been associated with adverse clinical outcomes including death. Prior data from the SPRINT trial showed that intensive BP lowering (<120 mmHg systolic blood pressure [SBP]), in comparison to conventional care (< 140 mmHg SBP), lowers the incidence of acute decompensated heart failure (ADHF) and death. However, prior studies have not explored the effect of a lower SBP target on the incidence of malignant LVH or the potential to induce regression of malignant LVH. In the study by Ascher and colleagues, a post hoc analysis was performed on data from the SPRINT trial, which studied patients at elevated cardiovascular risk. The analysis included 8,820 patients. Patients were grouped according to presence of LVH and biomarker levels (high sensitivity cardiac troponin T >14 ng/L or N-terminal pro–B-type natriuretic peptide >125 pg/mL): 49% of the SPRINT cohort had no LVH and non-elevated biomarkers, 5.1% had malignant LVH, 43% had no LVH but elevated biomarkers, and 2.6% had “nonmalignant” LVH without either biomarker elevated. Outcomes analyzed include ADHF and death, as well as incidence or regression of malignant LVH (determined by a loss of electrocardiogram (ECG) criteria for LVH and resolution of biomarker elevation) The study found that relative reductions in ADHF or death were not different across groups; however, the absolute risk reduction in the malignant LVH over 4 years was 4.4% compared to 1.2% in the control group. SBP lowering also reduced the incidence of malignant LVH over 2 years (2.5% vs 1.1%). Finally, intensive BP lowering caused regression in 57.6% of patients with malignant LVH over 2 years. The authors acknowledge several limitations should be regarded when drawing conclusion from these data. Importantly, imaging was not used to determine cases of LVH, and the diagnosis relied on ECG criteria for LVH, though the authors commented that misclassification of LVH would have been non-differential across groups and would have biased results toward the null hypothesis rather than toward a significant difference. In an accompanying editorial, Christopher R. deFilippi, MD, of the Inova Heart and Vascular Institute, Falls Church, Virginia, and Stephen Seliger, MS, MS, of the University of Maryland School of Medicine, further contextualized the findings from the manuscript. The editorialists reviewed the prevalence of malignant LVH in prior trials and summarized the entity’s strong association with adverse outcomes, mainly incident heart failure. They also further expounded on the reversibility of malignant LVH. While biomarkers were previously thought to represent irreversible damage, the authors cited literature demonstrating new mechanisms for biomarker release that still allow a way for the disease to be reversed. “Although the SPRINT Investigators saw no treatment interaction between those with and without malignant LVH, the larger absolute risk reduction and resulting fewer number needed to treat in those with malignant LVH might focus efforts on these higher-risk stage B pre-[heart failure] patients,” deFilippi and Seliger wrote. Sources: Ascher SB, de Lemos JA, Lee M, et al. Intensive Blood Pressure Lowering in Patients With Malignant Left Ventricular Hypertrophy. J Am Coll Cardiol 2022;80:1516–1525. deFilippi CR, Seliger S. Malignant Left Ventricular Hypertrophy and Epidemiology 101. J Am Coll Cardiol 2022;80:1526–1528. Image Credit: Nejron Photo – stock.adobe.com