Schmieder R E, Messerli F H
Department of Medicine, Universität Erlangen-Nürnberg, F.R.G.
J Cardiovasc Pharmacol. 1990;16 Suppl 6:S16-22.
It is controversial whether myocardial hypertrophy in essential hypertension represents an adaptive physiologic or pathological response to increased pressure load imposed on the heart. Cardiac structural adaptations in endurance athletes fulfill the criteria of physiologic hypertrophy: maintained cardiac performance and full reversibility of cardiac structural changes following cessation of endurance training. In contrast, there is some evidence that cardiac hypertrophy in arterial hypertension is a pathological process. Diastolic function of the left ventricle is impaired; systolic function, although maintained in the early stages of myocardial hypertrophy, becomes reduced beyond a critical mass; and cardiac structural changes are not fully reversible. An increasing number of prospective studies document that left ventricular hypertrophy in essential hypertension represents an independent risk factor for cardiovascular mortality and morbidity, in particular for sudden cardiac death. Ventricular arrhythmias were regarded as the pathophysiologic link between cardiac structural adaptation and the increased risk of sudden death due to left ventricular hypertrophy. Structural changes of the coronary circulation may represent one confounding factor in the relationship between left ventricular hypertrophy and its cardiovascular risk. As a consequence, optimal antihypertensive therapy should aim at reducing both arterial hypertension and left ventricular hypertrophy. Whether regression of myocardial hypertrophy indeed reduces cardiovascular risk cannot be definitively answered from the available data.
原发性高血压中的心肌肥厚究竟是对心脏所承受的压力负荷增加的适应性生理反应还是病理性反应，这一点存在争议。耐力运动员的心脏结构适应性符合生理性肥厚的标准：心脏功能得以维持，且在耐力训练停止后心脏结构变化可完全逆转。相比之下，有证据表明动脉高血压中的心脏肥厚是一个病理过程。左心室舒张功能受损；收缩功能虽在心肌肥厚早期得以维持，但超过一定程度后会降低；且心脏结构变化并非完全可逆。越来越多的前瞻性研究表明，原发性高血压中的左心室肥厚是心血管疾病死亡率和发病率的独立危险因素，尤其是心源性猝死的危险因素。室性心律失常被视为心脏结构适应性与左心室肥厚导致的猝死风险增加之间的病理生理联系。冠状动脉循环的结构变化可能是左心室肥厚与其心血管风险之间关系中的一个混杂因素。因此，最佳的抗高血压治疗应旨在降低动脉高血压和左心室肥厚。现有数据无法确切回答心肌肥厚的消退是否真的能降低心血管风险。
