Target systolic blood pressure in patients with left ventricular hypertrophy

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.