Key result
Lowering systolic BP ≤130 mmHg is linked to ~37% higher mortality in hypertensive ECG-LVH patients.
Why the study?
Lowering systolic BP below 130 mmHg in hypertension trials showed increased mortality in patients with LVH, yet LVH is only briefly addressed in recent guidelines.
Does lowering systolic blood pressure to <130 mmHg increase mortality in middle-aged and older hypertensive patients with ECG-LVH?
Does lowering systolic blood pressure to <130 mmHg increase mortality in middle-aged and older hypertensive patients with ECG-LVH?
Answers are grounded in this paper and cite their sources.
Caution is warranted when lowering systolic blood pressure to <130 mmHg in middle-aged and older hypertensive patients with ECG-LVH, as it may be associated with increased all-cause and cardiovascular mortality.
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.
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Kjeldsen et al. (2026) conducted a review in Hypertensive patients aged 55-80 years with ECG-detected left ventricular hypertrophy (n=9,193). Lowering systolic blood pressure to ≤130 mmHg vs. Systolic blood pressure ≥142 mmHg was evaluated on All-cause mortality (HR 1.37 for all-cause mortality (37% increase) in LIFE; HR 1.74 and 1.98 for all-cause and cardiac mortality in VALUE for systolic BP <130 mmHg vs 130-139 or ≥140 mmHg, 95% CI VALUE HR for 130-139 mmHg: 1.17-2.60; for ≥140 mmHg: 1.06-3.70, p=0.005 for all-cause mortality LIFE; 0.08 for cardiovascular mortality LIFE). Lowering systolic blood pressure to ≤130 mmHg increased all-cause mortality by 37% (p=0.005) and cardiovascular mortality by 32% in hypertensive patients aged 55-80 with ECG-LVH in the LIFE study.
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