Concomitant hypertension in hypertrophic cardiomyopathy: cardiovascular magnetic resonance biomarkers to guide cardiovascular prevention

Background Although hypertension is present in 25–50% of patients with hypertrophic cardiomyopathy (HCM), its clinical characterization and prognostic implications in this population remain insufficiently investigated.(1) Purpose To describe the phenotype of hypertensive patients with HCM using cardiovascular magnetic resonance (CMR), to assess the association of hypertension with all-cause mortality, and to compare its prognostic value with that of CMR findings. Methods Between 2008 and 2024, all consecutive HCM patients from the HCM-LGE registry referred for CMR in three French centers were included. The primary outcome was all-cause mortality using the electronic French National Registry of Death. Clinical variables, cardiac volumes, mass, functions and tissue characterization with late gadolinium enhancement (LGE) were assessed in all patients. Propensity-score matching was performed using hypertension, documented in each patient’s medical record, as the exposure variable to adjust for baseline differences between hypertensive and non-hypertensive patients. The prognostic value of hypertension and CMR findings were assessed using Cox proportional hazard models, and survival probabilities were estimated using the Kaplan-Meier method and compared with the log-rank test. Results Among 2,873 patients with HCM (52±8 years, 56% males), 796 (28%) had hypertension. Determinants associated with hypertension were diabetes, dyslipidemia, body mass index, renal failure, stroke, left ventricular end-diastolic volume and LGE extent (Figure 1A). HCM patients with hypertension had greater LGE extent (1.1±1.8 vs 0.9±1.5, p<0.001), more LGE multiple locations (17% vs 11%, p<0.001), and more midwall LGE (35% vs 28%, p=0.001). After propensity score matching (1:1 with versus without hypertension), survival curves showed an increased risk of all-cause mortality for hypertensive versus non-hypertensive patients at a median of 9 year-follow up (HR: 1.32 [95% CI: 1.04-1.69]; log-rank p=0.024; Figure 1B). Left ventricular mass index (HR: 0.98 [95% CI: 0.97-0.99]; p=0.004) was independently associated with all-cause mortality only for hypertensive patients and indexed left ventricular end-diastolic volume (HR: 1.04 [95% CI: 1.01-1.06]; p=0.002) was independently associated with all-cause mortality only for HCM patients without hypertension. Conclusion In a large multicenter cohort of HCM patients, concomitant hypertension had a significant impact on long-term mortality and differential prognostic value of CMR biomarkers may help to guide cardiovascular prevention in this population.