A 52-year-old woman with chronic hypertension presents with left ventricular hypertrophy on echocardiography. Which of the following is NOT a characteristic feature of cardiac hypertrophy in chronic hypertension?

## Cardiac Hypertrophy in Chronic Hypertension ### Pathophysiology of Adaptive Hypertrophy **Key Point:** Hypertrophy is an adaptive response to increased hemodynamic load. In chronic hypertension, the left ventricle undergoes concentric hypertrophy with increased wall thickness and myocyte size. ### Characteristic Features of Compensatory Hypertrophy | Feature | Status in Adaptive Hypertrophy | Mechanism | |---------|--------------------------------|----------| | Cell size | Increased | Protein synthesis exceeds degradation | | Cell number | Preserved | No mitosis in mature cardiomyocytes | | Mitochondrial density | Increased | Enhanced ATP production for increased workload | | Fetal gene expression | Upregulated | ANP, BNP, β-MHC reactivation | | Sarcomeric organization | Maintained | Orderly, parallel arrangement | | Myofibrillar organization | Preserved | Normal Z-disc alignment | ### What IS NOT Seen in Adaptive Hypertrophy **High-Yield:** Decreased myofibrillar organization and sarcomeric disarray are hallmarks of **pathological hypertrophy** (decompensated, dilated cardiomyopathy) or infiltrative/genetic cardiomyopathies (hypertrophic cardiomyopathy). In compensatory hypertrophy from chronic hypertension, the myofibrils remain well-organized and parallel, maintaining contractile function. **Clinical Pearl:** Early compensatory hypertrophy maintains or even enhances contractility. Sarcomeric disarray and myofibrillar disorganization indicate transition to decompensation and systolic dysfunction — a hallmark of pathological remodeling, not adaptive hypertrophy. ### Progression from Adaptive to Pathological 1. **Compensatory phase:** Increased wall thickness, preserved ejection fraction, organized sarcomeres 2. **Decompensatory phase:** Chamber dilatation, systolic dysfunction, sarcomeric disarray, fibrosis **Warning:** Do not confuse adaptive concentric hypertrophy (preserved EF, organized structure) with hypertrophic cardiomyopathy or dilated cardiomyopathy (disorganized myofibrils, genetic or infiltrative causes).