A 52-year-old woman presents with progressive dyspnea and chest discomfort. Echocardiography reveals left ventricular hypertrophy with an ejection fraction of 45% secondary to chronic hypertension. Which drug is the first-line choice to induce regression of left ventricular hypertrophy and improve outcomes?

Explanation

## Left Ventricular Hypertrophy (LVH) Regression **Key Point:** ACE inhibitors (particularly lisinopril) are the gold-standard agents for inducing regression of left ventricular hypertrophy in hypertensive patients, independent of their blood pressure-lowering effect. ### Mechanism of LVH Regression with ACE Inhibitors 1. **Angiotensin II blockade** — reduces cardiac fibroblast proliferation and collagen deposition 2. **Reduced afterload** — decreases wall stress and hypertrophic stimulus 3. **Anti-inflammatory and anti-fibrotic effects** — inhibit TGF-β and other growth factors 4. **Improved diastolic function** — reduces myocardial stiffness ### Comparative Efficacy for LVH Regression | Drug Class | LVH Regression | Mechanism | Evidence | | --- | --- | --- | --- | | **ACE Inhibitors (Lisinopril)** | ★★★★★ | Direct RAAS blockade + anti-fibrotic | Gold standard; multiple RCTs | | **ARBs (Losartan)** | ★★★★★ | AT1 receptor blockade | Equivalent to ACE-I | | **Calcium channel blockers** | ★★★☆☆ | Vasodilation + reduced afterload | Modest effect; less than ACE-I | | **Beta-blockers** | ★★☆☆☆ | Reduced heart rate + contractility | Minimal regression | | **Vasodilators (Hydralazine)** | ★☆☆☆☆ | Afterload reduction only | Reflex tachycardia; no anti-fibrotic | **High-Yield:** ACE inhibitors and ARBs are superior to other antihypertensive classes for LVH regression because they block the renin-angiotensin-aldosterone system (RAAS), which directly drives cardiac hypertrophy and fibrosis. Calcium channel blockers have modest effects; beta-blockers and vasodilators are inferior. **Clinical Pearl:** In a hypertensive patient with LVH and reduced ejection fraction (HFrEF), ACE inhibitors are not only the drug of choice for LVH regression but also reduce mortality and hospitalization rates. **Tip:** When a question asks about "regression of LVH" or "reversal of cardiac hypertrophy," think ACE inhibitor or ARB first. These are the only classes with proven structural benefit beyond blood pressure reduction.