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Racial Differences in Malignant LV Hypertrophy
Study Questions:
Does malignant left ventricular hypertrophy (LVH) contribute to racial disparities in heart failure (HF) risk?
Methods:
Participants from three population-based, racially diverse cohort studies were pooled. Participants with prevalent cardiac disease, end-stage kidney disease, and nonwhite nonblack ethnicity were excluded. LVH was defined by the Sokolow-Lyon electrocardiographic (ECG) criteria. Participants with malignant LVH were identified based on abnormal levels of high-sensitivity cardiac troponin T (hs-cTnT) or N-terminal pro–B-type natriuretic peptide (NT-proBNP). Incidence of HF was assessed among patients without LVH, LVH with normal biomarkers, and malignant LVH.
Results:
A total of 15,710 participants were included, with a median age of 57 years (56% female and 32% black). Overall, 9% had LVH with 53% of LVH participants having malignant LVH. Those with malignant LVH were more likely to be older, male, diabetic, and hypertensive, and had more pathological remodeling on magnetic resonance imaging than those with LVH and normal biomarkers. Malignant LVH was 3 times more prevalent among black men versus white men, and black women versus white women due to higher overall rates of LVH. Incident HF over 10 years was more common in those with malignant LVH (13.6%) versus those with LVH and normal biomarkers (2.7%). This association persisted after race/sex adjustment. However, risk for incident HF was similar in those with LVH and normal biomarkers compared to those with no LVH and normal biomarkers. Abnormal levels of both hs-cTnT and NT-proBNP were associated with the highest risk for incident HF. These associations persisted across body mass index categories. In mediation analysis, survival free from HF was 13% lower in black men and 15% lower in black women with malignant LVH mediating 33% of the association of race with HF in men and 11% of the effect in women.
Conclusions:
LVH with elevated biomarker is more prevalent in blacks and represents a malignant phenotype associated with a higher risk for incident HF, whereas LVH with normal biomarkers was relatively benign. Among individuals free of cardiovascular disease at baseline, risk of incident HF was higher in blacks with LVH compared to whites with LVH.
Perspective:
These findings suggest that LVH on ECG or cardiac imaging should prompt measuring hs-cTnT and NT-proBNP for risk stratification, as those with elevated levels represent a high-risk group. Aggressive risk factor control may be warranted in this group with malignant LVH. Normal biomarkers may help distinguish physiological versus pathological LVH among athletes as well. Major limitations of this study include lack of standardization in definition of HF. Risk factors were only assessed at the time of presentation and not at follow-up. Hence, influence of differences in risk factor burden and control over the lifespan on observed racial differences in prevalence of malignant LVH could not be determined. Additional research is needed to identify interventions that prevent progression to malignant LVH and effectively treat it to reduce risk for HF.
Clinical Topics: Anticoagulation Management, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Prevention, Acute Heart Failure, Heart Failure and Cardiac Biomarkers, Magnetic Resonance Imaging, Hypertension
Keywords: African Americans, Biomarkers, Diabetes Mellitus, Electrocardiography, Heart Failure, Hypertension, Hypertrophy, Left Ventricular, Magnetic Resonance Imaging, Natriuretic Peptide, Brain, Peptide Fragments, Phenotype, Risk Assessment, Risk Factors, Secondary Prevention, Troponin T
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