Left ventricular mass-to-strain ratio to predict treatment response and prognosis in hypertensive heart disease

Background Typical hypertensive heart disease (HHD) phenotype is the left ventricular hypertrophy (LVH) and dysfunction, measurable via LV global longitudinal strain. We aimed to evaluate the LV mass-to-strain ratio (LV-MSR) as a marker of HHD treatment response and prognosis. Methods We retrospectively analyzed consecutive patients who underwent echocardiography at hypertension diagnosis and 6–18-monthly intervals in tertiary centers from 2006–2021. Association between LV-MSR and LV geometry changes was assessed using receiver operating characteristic (ROC) analysis and multivariable logistic regression. Time-dependent ROC and Cox regression were performed to evaluate LV-MSR prognostic value for cardiovascular death and heart failure hospitalization. Results Among 1,600 patients (mean age, 65.1 years; 61.1% male), 23.4% had concentric LVH, and 21.5% eccentric LVH at baseline. LV-MSR had the highest predictive accuracy for LV geometry changes (area-under-the-curve 0.786; 95% confidence interval [CI] 0.759– 0.813). LV-MSR showed significant association with new-onset LVH among the non-LVH group (adjusted odds ratio, 1.125, 95%CI 1.054–1.200, P<0.001) and persistent LVH among LVH group (adjusted hazard ratio [aHR] 1.133, 95%CI 1.087–1.180, P<0.001) at baseline. Higher LV-MSR was an independent prognosticator, whether as a continuous (aHR 1.032 per +1 g/m 2 /%, 95%CI 1.015–1.049, P<0.001) or categorical variable (aHR 2.257 for LV-MSR ≥6.52 g/m 2 /%, 95%CI 1.463–3.480, P<0.001). The associations persisted in subgroup analyses according to the presence of LVH baseline. Conclusions LV-MSR independently predicts LV geometry changes and clinical outcomes in HHD, serving as a superior prognostic marker compared to LV mass index or LV-GLS alone. Clinical Perspective What is new? LV mass-to-strain ratio (LV-MSR) integrates LV geometry (LVH) and LV longitudinal function (LV-GLS), providing a more comprehensive assessment of hypertensive heart disease (HHD) than either parameter alone. What are the clinical implications? Higher LV-MSR predicts LVH progression, persistence, and worse clinical outcomes, making it a useful marker for risk stratification and treatment response assessment in hypertension. Research Perspective Further studies should validate LV-MSR across diverse populations, integrate it into standard echocardiographic protocols, and evaluate its role in clinical decision-making and antihypertensive treatment guidance to improve patient outcomes.