Prognostic impact of baseline and serial changes in electrocardiographic left ventricular hypertrophy in resistant hypertension

Gender Difference of Blood Pressure Control Rate and Clinical Prognosis in Patients With Resistant Hypertension: Real-World Observation Study

BACKGROUND

There are several differences in the clinical course of hypertension due to the biological and social differences between men and women. Resistant hypertension is an advanced disease state, and significant gender difference could be expected, but much has not been revealed yet. The purpose of this study was to compare gender differences on the current status of blood pressure (BP) control and clinical prognosis in patients with resistant hypertension.

METHODS

This is a multicenter, retrospective cohort study using common data model databases of 3 tertiary hospitals in Korea. Total 4,926 patients with resistant hypertension were selected from January 2017 to December 2018. Occurrence of dialysis, heart failure (HF) hospitalization, myocardial infarction, stroke, dementia or all-cause mortality was followed up for 3 years.

RESULTS

Male patients with resistant hypertension were younger but had a higher cardiovascular risk than female patients. Prevalence of left ventricular hypertrophy and proteinuria was higher in men than in women. On-treatment diastolic BP was lower in women than in men and target BP achievement rate was higher in women than in men. During 3 years, the incidence of dialysis and myocardial infarction was higher in men, and the incidence of stroke and dementia was higher in women. After adjustment, male sex was an independent risk factor for HF hospitalization, myocardial infarction, and all-cause death.

CONCLUSION

In resistant hypertension, men were younger than women, but end-organ damage was more common and the risk of cardiovascular event was higher. More intensive cardiovascular prevention strategies may be required in male patients with resistant hypertension.

Prediction of stroke with electrocardiographic left ventricular hypertrophy in hypertensive patients: A meta-analysis

BACKGROUND

Electrocardiographic left ventricular hypertrophy (LVH) has been used to predict adverse prognosis in hypertensive patients. This meta-analysis aimed to investigate the association between LVH using the different electrocardiographic criteria in patients with hypertension.

METHODS

A comprehensive literature search was performed PubMed and Embase databases up to September 1, 2019. Observational studies evaluating the association between electrocardiographic LVH (Cornell voltage, Cornell product or Sokolow-Lyon voltage) at baseline and risk of stroke among hypertensive patients were selected. The risk ratio (RR) with 95% confidence interval (CI) was pooled for patients with electrocardiographic LVH versus without LVH.

RESULTS

Seven studies enrolling 58,098 hypertensive patients were included. When compared those with or without LVH patients showed that the pooled RR of stroke was 1.63 (95% CI 1.38-1.93) for Cornell voltage criteria, 1.41 (95% CI 1.07-1.86) for Cornell product criteria, and 1.42 (95% CI 1.20-1.69) for Sokolow-Lyon voltage criteria, respectively. However, the predictive significance of Cornell product criteria was not reliable in the sensitivity analysis.

CONCLUSIONS

Baseline electrocardiographic LVH detecting by Sokolow-Lyon or Cornell voltage criteria can predict the development of stroke in hypertensive patients. Use of electrocardiographic LVH can improve stroke risk stratification in hypertensive patients.

Diagnostic performance of electrocardiographic criteria in echocardiographic diagnosis of different patterns of left ventricular hypertrophy

Background

Electrocardiogram (ECG) is considered the initial screening method for the detection of left ventricular hypertrophy (LVH) despite its low sensitivity. However, there are no data on how ECG criteria for LVH perform in patients with concentric (cLVH) and eccentric LVH (eLVH).

Methods

In the setting of the Corinthia cross‐sectional study, ECGs were analyzed in 1,570 participants of the study. Seven ECG LVH criteria were calculated (Sokolow–Lyon voltage, index, and product, sex‐specific Cornell voltage and product, Lewis voltage, and the Framingham), whereas LVH was defined, based on echocardiographic data, as left ventricular mass indexed for body surface area (BSA) of at least 125 g/m² in men and at least 110 g/m² in women.

Results

Regarding the frequency encountered for each ECG LVH criterion, there was no difference between eLVH and cLVH. However, when ECG criteria were compared as continuous variables between LVH groups, Cornell voltage and product were higher in cLVH individuals, with a value of Cornell voltage >13.95 mV having 61% sensitivity and 62% specificity to differentiate cLVH from eLVH (p = .05). Even after adjustment for age, sex, body mass index, and hypertension, the occurrence of Cornell voltage or product increased the odds of cLVH by 1.6 times (p = .001).

Conclusion

Cornell voltage and product criteria disclosed a superior discriminative ability for the detection of LVH via ECG. When further categorizing LVH as concentric and eccentric, Cornell product depicted the higher discriminative ability for cLVH.

Resistant and refractory hypertension: two sides of the same disease?

Refractory hypertension (RfH) is an extreme phenotype of resistant hypertension (RH), being considered an uncontrolled blood pressure besides the use of 5 or more antihypertensive medications, including a long-acting thiazide diuretic and a mineralocorticoid antagonist. RH is common, with 10-20% of the general hypertensives, and its associated with renin angiotensin aldosterone system hyperactivity and excess fluid retention. RfH comprises 5-8% of the RH and seems to be influenced by increased sympathetic activity. RH patients are older and more obese than general hypertensives. It is strongly associated with diabetes, obstructive sleep apnea, and hyperaldosteronism status. RfH is more frequent in women, younger patients and Afro-americans compared to RFs. Both are associated with increased albuminuria, left ventricular hypertrophy, chronic kidney diseases, stroke, and cardiovascular diseases. The magnitude of the white-coat effect seems to be higher among RH patients. Intensification of diuretic therapy is indicated in RH, while in RfH, therapy failure imposes new treatment alternatives such as the use of sympatholytic therapies. In conclusion, both RH and RfH constitute challenges in clinical practice and should be addressed as distinct clinical entities by trained professionals who are capable to identify comorbidities and provide specific, diversified, and individualized treatment.

Combining ECG Criteria for Left Ventricular Hypertrophy Improves Risk Prediction in Patients With Hypertension

BACKGROUND

Patients with hypertension with ECG left ventricular hypertrophy (LVH) have higher cardiovascular morbidity and mortality, but single ECG criteria may underestimate risk. Whether continued presence or new development of ECG LVH by 2 criteria can further concentrate risk during blood pressure lowering is unclear.

METHODS AND RESULTS

Incident stroke, myocardial infarction, cardiovascular death, the composite of these outcomes, and all-cause mortality were examined in relation to the presence of on-treatment ECG LVH by Cornell product and/or Sokolow-Lyon voltage during a mean of 4.8±0.9 years follow-up in 9193 patients with hypertension randomized to losartan- or atenolol-based regimens. Patients were categorized into 4 groups according to the presence or absence of ECG LVH by each criterion at baseline and yearly during the study. At baseline, LVH by both criteria was present in 960 patients (10.4%). Compared with the absence of ECG LVH by both criteria, persistence or development of ECG LVH by both criteria entered as a time-varying covariate was associated with >3-fold increased risks of events in multivariable Cox analyses adjusting for randomized treatment, baseline risk factors, and on-treatment heart rate and systolic and diastolic blood pressures. Patients with ECG LVH by either Cornell product or Sokolow-Lyon voltage had 45% to 140% higher risks of all end points.

CONCLUSIONS

Persistence or development of ECG LVH by both Cornell product and Sokolow-Lyon voltage criteria during antihypertensive therapy is associated with markedly increased risks of cardiovascular end points and all-cause mortality. Further study is indicated to determine whether additional therapy in these patients can reduce their risk.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00338260.

Cohort Study of ECG Left Ventricular Hypertrophy Trajectories: Ethnic Disparities, Associations With Cardiovascular Outcomes, and Clinical Utility

Background

ECG left ventricular hypertrophy (LVH) is a well‐known predictor of cardiovascular disease. However, no prior study has characterized patterns of presence/absence of ECG LVH (“ECG LVH trajectories”) across the adult lifespan in both sexes and across ethnicities. We examined: (1) correlates of ECG LVH trajectories; (2) the association of ECG LVH trajectories with incident coronary heart disease, transient ischemic attack, ischemic stroke, hemorrhagic stroke, and heart failure; and (3) reclassification of cardiovascular disease risk using ECG LVH trajectories.

Methods and Results

We performed a cohort study among 75 412 men and 107 954 women in the Northern California Kaiser Permanente Medical Care Program who had available longitudinal exposures of ECG LVH and covariates, followed for a median of 4.8 (range <1–9.3) years. ECG LVH was measured by Cornell voltage‐duration product. Adverse trajectories of ECG LVH (persistent, new development, or variable pattern) were more common among blacks and Native American men and were independently related to incident cardiovascular disease with hazard ratios ranging from 1.2 for ECG LVH variable pattern and transient ischemic attack in women to 2.8 for persistent ECG LVH and heart failure in men. ECG LVH trajectories reclassified 4% and 7% of men and women with intermediate coronary heart disease risk, respectively.

Conclusions

ECG LVH trajectories were significant indicators of coronary heart disease, stroke, and heart failure risk, independently of level and change in cardiovascular disease risk factors, and may have clinical utility.

[Left ventricular hypertrophy in black African subjects with artery hypertension: Results of a cross-sectional survey conducted in semi-rural area in Senegal]

OBJECTIVES

To assess the prevalence of left ventricular hypertrophy according to electrocardiographic and echocardiographic criteria among hypertensive patients living in semi-rural Senegalese area.

PATIENTS AND METHODS

According to the World Health Organization STEPSwise approach, we conducted, in November 2012, a cross-sectional and exhaustive study in the population aged at least 35 years old and living for at least six months in the semi-rural area of Guéoul. We researched electrocardiographic and echocardiographic left ventricular hypertrophy in hypertensive subjects. Data were analyzed with SPSS 18.0 software version. The significance level was agreed for a value of P<0.05.

RESULTS

We examined 1411 subjects aged on average of 48.5±12.7 years. In total, 654 subjects were hypertensive and screening of left ventricular hypertrophy (LVH) was effective in 515 of them. According to Sokolow-Lyon index, 86 subjects (16.7%) presented electrocardiographic LVH, more frequently in men (P=0.002). According to Cornell index and Cornell product, LVH was founded respectively in 66 (12.8%) and 52 subjects (10.1%), more frequently in female (P=0.0001; P=0.004). It was more common in grade 3 of hypertension however criteria. In echocardiography, prevalence of LVH was 2.2% (13 cases) according to the left ventricular mass, 9.3% (48 cases) according to the left ventricular mass indexed to body surface area and 8.2% (42 cases) according to the left ventricular mass indexed to height^2.7. LVH was significantly correlated with the electrocardiographic LVH according to Sokolow-Lyon index (P<0.0001) and the grade 3 of hypertension (P=0.003).

CONCLUSION

Although rare in hypertensive Senegalese living in semi-rural area, left ventricular hypertrophy is correlated with severity of grade of hypertension. Screening by electrocardiogram will allow better follow-up of these hypertensive subjects.

Does pregnancy-induced hypertension affect the electrophysiology of the heart?

Pregnancy-induced hypertension (PIHT) increases both maternal and neonatal mortality and morbidity in pregnant women. We sought to investigate the electrocardiographic findings in pregnant women with PIHT. Seventeen pregnant women (29.4 ± 5 years) with PIHT and 24 pregnant women (27.3 ± 6.1 years) with normal blood pressure (control group) were included in the study. A 12-lead surface electrocardiogram was used to evaluate the electrocardiographic parameters. Pregnant women with PIHT had higher blood pressure (p = 0.001). The Tp-e interval was longer in PIHT pregnant women at 83.5 ± 7.8 ms versus 75.8 ± 8.4 ms in the control group (p = 0.007). The Tp-e/QTc ratio was higher in pregnant women with PIHT than that in healthy controls (0.19 ± 0.02 vs. 0.18 ± 0.02, respectively). This study demonstrated that Pd, QTd and the P wave durations were similar in the PIHT pregnant women and control group, but the Tp-e and Tp-e/QTc ratio were higher in pregnant women with PIHT than in normotensive pregnant women.

Cardiovascular and renal complications in patients with resistant hypertension

With an increased prevalence, resistant hypertension is recognized as an entity with a high cardiovascular morbidity and mortality. In a large cohort of patients with resistant hypertension, the crude incidence rate of total cardiovascular events reached 4.32 per 100 patient-years of follow-up (19.6 %), with a cardiovascular mortality of 8.3 % (incidence rate of 1.72 per 100 patient-years). Cardiovascular event rates are significantly higher in resistant hypertensives compared with non-resistant (18.0 % versus 13.5 %). In the same way, the prevalence of established cardiovascular and renal disease, as the asymptomatic organ damage (represented by left ventricular hypertrophy, carotid wall thickening, arterial stiffness, and microalbuminuria) is higher in these patients. Many studies have demonstrated a strong association between damage to these organs with higher blood pressure levels, the diagnosis of true resistant hypertension, and refractory hypertension. All efforts should be employed in order to control blood pressure and also to regress and/or prevent subclinical cardiovascular and renal damage. The focus should be on prevention of cardiovascular and renal complications, improving the prognosis of resistant hypertension.

Treatment of subclinical hyperthyroidism: effect on left ventricular mass and function of the heart using magnetic resonance imaging technique

PURPOSE

The aim of this study was to investigate structure and function of the heart in subclinical hyperthyroidism (SH) before and after obtaining euthyroidism by radioactive iodine treatment, using high precision and observer-independent magnetic resonance imaging (MRI) technology.

METHODS

Cardiac MRI was performed before and after euthyroidism was obtained by radioactive iodine treatment in 12 otherwise healthy patients (11 women and one man, mean age 59 years, range 44-71 years) with a nodular goiter and SH, and compared with eight healthy controls investigated at baseline. Cardiac data were expressed as an index, as per body surface area, except for heart rate (HR) and ejection fraction.

RESULTS

Post-treatment cardiac MRI was performed in median 139 days after a normalized serum TSH value had been recorded. During treatment, serum TSH increased from (median (range)) 0.01 (0.01-0.09) to 0.88 (0.27-3.99) mU/l. Patients with untreated SH had increased resting HR (P<0.01) as well as cardiac index (cardiac output as per body surface area) (P<0.01) compared with controls. Obtaining euthyroidism resulted in a significant decrease in left ventricular mass index (LVMI) of 2.7 g/m(2) (P=0.034), in HR of 8 bpm (P=0.001), and in cardiac index of 0.24 l/min per m(2) (P=0.017).

CONCLUSIONS

Normalization of thyroid function by radioactive iodine treatment of SH resulted in significant reductions in clinically important heart parameters such as LVMI, HR, and cardiac index. SH should be regarded as a condition in which aggressive treatment should be considered to protect cardiac function.

P-wave duration changes and dispersion in preeclampsia

OBJECTIVE

The purpose of this research was to study P wave parameters to determine the association between preeclampsia and future cardiovascular risk and to study the possible correlation between P waves and severity of preeclampsia.

STUDY DESIGN

In this case-control study 58 pregnant women with preeclampsia and 30 normal pregnant women were compared by measuring maximum and minimum P-wave durations and P-wave dispersion (Pd) in the late third trimester.

RESULTS

Minimum P wave values were lower and Pd values were higher, both significantly, in the preeclampsia groups than in the control group. In addition, the Pd values of the severe preeclampsia group were higher compared to that of the mild preeclampsia group.

CONCLUSION

Preeclampsia predisposes the patient to future cardiovascular complications including atrial or ventricular arrhythmias, but validated tools to assess the risks are yet not available. P-wave duration and Pd constitute a recent contribution to the field of noninvasive electrocardiology. Our data clearly demonstrated that minimum P wave and Pd values were significantly altered in preeclamptic pregnant women when compared to the controls. This important association can be used to screen women for increased risk in order to better target counseling regardinglifestyle modifications and to follow up and manage women with a history of preeclampsia more closely.

Tadalafil-induced improvement in left ventricular diastolic function in resistant hypertension

PURPOSE

Left ventricular hypertrophy and diastolic dysfunction (LVDD) remain highly frequent markers of cardiac damage and risk of progression to symptomatic heart failure, especially in resistant hypertension (RHTN). We have previously demonstrated that administration of sildenafil in hypertensive rats improves LVDD, restoring phosphodiesterase type 5 (PDE-5) inhibition in cardiac myocytes.

METHODS

We hypothesized that the long-acting PDE-5 inhibitor tadalafil may be clinically useful in improving LVDD in RHTN independently of blood pressure (BP) reduction. A single blinded, placebo-controlled, crossover study enrolled 19 patients with both RHTN and LVDD. Firstly, subjects received tadalafil (20 mg) for 14 days and after a 2-week washout period, they received placebo orally for 14 days. Patients were evaluated by office BP and ambulatory BP monitoring (ABPM), endothelial function (FMD), echocardiography, plasma brain natriuretic peptide (BNP-32), cyclic guanosine monophosphate (cGMP) and nitrite levels.

RESULTS

No significant differences were detected in BP measurements. Remarkably, at least four echocardiographic parameters related with diastolic function improved accompanied by decrease in BNP-32 in tadalafil use. Although increasing cGMP, tadalafil did not change endothelial function or nitrites. There were no changes in those parameters after placebo.

CONCLUSION

The current findings suggest that tadalafil improves LV relaxation through direct effects PDE-5-mediated in the cardiomyocytes with potential benefit as an adjunct to treat symptomatic subjects with LVDD such as RHTN patients.

Resistant hypertension and target organ damage

Cardiovascular (CV) complications such as myocardial infarction, heart failure, stroke and renal failure are related to both the degree and the duration of blood pressure (BP) increase. Resistant hypertension (RH) is associated with a higher risk of CV complications and a higher prevalence of target organ damage (TOD). The relationship between CV disease and TOD can be bidirectional. Elevated BP in RH may cause CV structural and functional alterations, and the development or persistence of left ventricular hypertrophy, aortic stiffness, atherosclerotic plaques, microvascular disease and renal dysfunction, may render hypertension more difficult to control. Specifically, RH is related to several conditions, including obesity, sleep apnea, diabetes, metabolic syndrome and hyperaldosteronism, characterized by an overexpression of humoral and hormonal factors that are involved in the development and maintenance of TOD. Optimal therapeutic strategies, including pharmacological treatment and innovative invasive methodologies, have been shown to achieve adequate BP control and induce the regression of TOD, thereby potentially improving patient prognosis.

Prevalence of electrocardiographic left ventricular hypertrophy in human hypertension: an updated review

AIM

Left ventricular hypertrophy (LVH) is a strong predictor of cardiovascular events in different clinical settings. We reviewed recent studies on the prevalence of hypertensive LVH, as assessed by ECG, in order to update our knowledge about this marker of cardiac organ damage in human hypertension.

DESIGN

A MEDLINE search using the key words ' LVH ', 'hypertension', 'ECG', 'cardiac organ damage' and 'cardiac hypertrophy' was performed in order to identify relevant articles. Full articles published in English language in the last decade (1 January 2000 to 31 December 2010) reporting studies in adult or elderly individuals, were considered.

RESULTS

A total of 26 studies, including 40 444 untreated and treated individuals (85% whites, 47% men, 32% obese, 28% diabetics and 22% patients with cardiovascular disease) were considered. LVH was defined by 15 criteria (seven studies used two or more criteria, range 2-7); LVH prevalence consistently varied among studies (0.6-40.0%) with an average of 18% in the pooled population. A sex-based analysis in five out of 26 studies (12 084 patients) showed an average prevalence of LVH of 24% in men and 16% in women (odds ratio 1.38, 95% CI 0.91-2.09, P  =  0.11).

CONCLUSION

Our analysis shows that LVH, as assessed by ECG, is present in a relevant fraction of the hypertensive population; these data highlight the role of ECG as a first-line examination for identifying subclinical organ damage and optimizing blood pressure control in hypertensive patients.

Prognostic factors in resistant hypertension: implications for cardiovascular risk stratification and therapeutic management

Resistant hypertension (RH) is defined as uncontrolled office blood pressure (BP) in spite of the use of at least three antihypertensive medications. Although its condition has a high prevalence, it is still understudied, and its prognosis is not well established. Some prospective studies evaluated the prognostic value of ambulatory BP monitoring, ECG and renal parameters. They pointed out that ambulatory BPs are important predictors of cardiovascular morbidity and mortality, whereas office BP has no prognostic value. The diagnosis of true RH and the nondipping pattern are also valuable predictors of cardiovascular outcomes. Moreover, several ECG (prolonged ventricular repolarization, serial changes in the strain pattern and left ventricular hypertrophy) and renal parameters (albuminuria and reduced glomerular filtration rate) are also powerful cardiovascular risk markers in RH. These markers and others yet unexplored, such as arterial stiffness and serum biomarkers, may improve cardiovascular risk stratification in these very high-risk patients.

The white coat effect is not associated with additional increase of target organ damage in true resistant hypertension

BACKGROUND AND OBJECTIVE

White coat effect (WCE) (i.e., the difference between office blood pressure [OBP] and awake ambulatory blood pressure monitoring [ABPM]) may be present in hypertensive individuals. The relationship between occurrence of WCE and target organ damage (TOD) has not yet been assessed in true resistant hypertension (RHTN).

PATIENTS AND METHODS

RHTN patients were divided into two groups: RHTN with WCE (WCE, n=66) and RHTN without WCE (non-WCE, n=61). All patients were submitted to OBP measurement, ABPM, echocardiography and renal function evaluation in three visits.

RESULTS

No differences were observed between the WCE and non-WCE groups regarding age, body mass index or gender. OBP were 169.8±15.8/95.1±14.0 (WCE) and 161.9±9.0/90.1±10.4mmHg (non-WCE), ABPM=143.0±12.8/86.1±9.9 (WCE) and 146.1±13.6/85.1±14.9mmHg (non-WCE). No statistical differences were observed between WCE and non-WCE subgroups with respect to left ventricular mass index (LVMI) (WCE=131±4.7; non-WCE=125±2.9g/m(2)), creatinine clearance (WCE=78±4.7; non-WCE=80±3.6ml/min/m(2)) and microalbuminuria (MA) (WCE=44±8.4; non-WCE=49±6.8mg/g Cr).

CONCLUSIONS

This finding may suggest that WCE is not associated with additional increase of TOD in true RHTN subjects.

Renal sympathetic denervation reduces left ventricular hypertrophy and improves cardiac function in patients with resistant hypertension

OBJECTIVES

This study investigated the effect of catheter-based renal sympathetic denervation (RD) on left ventricular hypertrophy (LVH) and systolic and diastolic function in patients with resistant hypertension.

BACKGROUND

LVH and diastolic dysfunction are associated with elevated sympathetic activity and increased morbidity and mortality. The effect of RD on LVH and LV function is unclear.

METHODS

Forty-six patients underwent bilateral RD, and 18 patients served as controls. Transthoracic echocardiography was performed at baseline, and after 1 month and 6 months.

RESULTS

Besides reduction of systolic and diastolic blood pressure (-22.5/-7.2 mm Hg at 1 month and -27.8/-8.8 mm Hg at 6 months, p < 0.001 at each time point), RD significantly reduced mean interventricular septum thickness from 14.1 ± 1.9 mm to 13.4 ± 2.1 mm and 12.5 ± 1.4 mm (p = 0.007), and LV mass index from 53.9 ± 15.6 g/m(2.7) (112.4 ± 33.9 g/m(2)) to 47.0 ± 14.2 g/m(2.7) (103.6 ± 30.5 g/m(2)) and 44.7 ± 14.9 g/m(2.7) (94.9 ± 29.8 g/m(2)) (p < 0.001) at 1 month and 6 months, respectively. The mitral valve lateral E/E' decreased after RD from 9.9 ± 4.0 to 7.9 ± 2.2 at 1 month and 7.4 ± 2.7 at 6 months (p < 0.001), indicating reduction of LV filling pressures. Isovolumic relaxation time shortened (baseline 109.1 ± 21.7 ms vs. 85.6 ± 24.4 ms at 6 months, p = 0.006), whereas ejection fraction significantly increased after RD (baseline: 63.1 ± 8.1% vs. 70.1 ± 11.5% at 6 months, p < 0.001). No significant changes were obtained in control patients.

CONCLUSIONS

Besides the known effect on blood pressure, our study showed for the first time that RD significantly reduces LV mass and improves diastolic function, which might have important prognostic implications in patients with resistant hypertension at high cardiovascular risk.

Resistant hypertension and left ventricular hypertrophy: an overview

Available data on subclinical cardiac damage in resistant hypertension (RH) are rather scanty. Thus, we sought to review the literature focusing on the association between RH and left ventricular hypertrophy (LVH). A MEDLINE search was performed to identify relevant articles using the key words "resistant hypertension, " "refractory hypertension," "left ventricular hypertrophy," "cardiac damage," and "left ventricular dysfunction." Full articles published in the English language in the last two decades (December 1, 1989, to July 31, 2010) reporting studies in adult or elderly individuals, were considered. Checks of the reference lists of selected articles complemented the electronic search. A total of 11 cross-sectional and longitudinal studies, including 3325 patients attending outpatient hypertension clinics, were considered. Prevalence rates of echocardiographic LVH, as assessed by updated criteria, ranged from 55% to 75% of patients with RH, peaking to 91% in the subgroup with concomitant electrocardiographic (ECG) LV strain. Reduction in ECG-LVH induced by treatment showed a relevant beneficial impact on cardiovascular prognosis. These data support the view that initial and on-treatment assessment of LVH in patients with RH is important for cardiovascular risk monitoring and therapeutic strategies decision-making.