AJH 2003; 16:556 –563
Prevalence of Left Ventricular Hypertrophy in
Patients With Mild Hypertension in Primary
Care: Impact of Echocardiography on
Cardiovascular Risk Stratification
Marı́a A. Martinez, Teresa Sancho, Eduardo Armada, José M. Rubio,
José L. Antón, Alberto Torre, Javier Palau, Paloma Seguido, Jaime Gallo,
Isabel Saenz, Enrique Polo, Rosa Torres, José Oliver, and Juan G. Puig,
on behalf of the Vascular Risk Working Group “Grupo Monitorización
Ambulatoria de la Presión Arterial (MAPA)–Madrid”
Background: Left ventricular hypertrophy (LVH) is
an important predictor of cardiovascular risk, and its de-
tection contributes to risk stratification. The aims of the
present study were to estimate the prevalence of echocar-
diographic LVH and to evaluate the influence of echocar-
diography (ECHO) on cardiovascular risk stratification in
hypertensive patients presenting in primary care.
Methods: In this cross-sectional study, 250 patients
recently diagnosed with mild hypertension underwent
clinical evaluation including electrocardiography (ECG),
microalbuminuria measurement, 24-h blood pressure mon-
itoring and ECHO. Level of cardiovascular risk was strat-
ified, initially using routine procedures including ECG to
assess target organ damage and then again after detection
of LVH by ECHO.
Results: The frequency of echocardiographic LVH was
32%, substantially higher than that detected by ECG (9%).
Initial cardiovascular risk stratification yielded the follow-
ing results: 30% low risk, 49% medium risk, 16% high
L
eft ventricular hypertrophy (LVH) is a well known
independent predictor of cardiovascular morbidity
and mortality in hypertensive patients.1 Epidemio-
logic studies have shown that LVH is the most powerful
risk factor for sudden death, ventricular arrhythmias, myo-
cardial ischemia, coronary heart disease, and congestive
heart failure.2
Estimates of the prevalence of LVH in patients with
Received November 8, 2002. First decision December 20, 2002. Ac-
cepted February 27, 2003.
From the Primary Care and Hospital Research Unit, Hospital La Paz,
Universidad Autónoma de Madrid, Madrid, Spain.
This work was supported by research grants from Ministry of Health
0895-7061/03/$30.00
doi:10.1016/S0895-7061(03)00859-8
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risk, and 5% very high risk subjects. The detection of LVH
by ECHO provoked a significant change in the risk strata
distribution, particularly in those patients initially classi-
fied as being at medium risk. In this group, 40% of
subjects were reclassified as high risk subjects according
to ECHO information. The new classification was as fol-
lows: 23% low risk, 30% medium risk, 42% high risk, and
5% very high risk subjects.
Conclusions: A substantial proportion of mildly hy-
pertensive patients presenting in primary care have LVH
determined by ECHO. Our results suggest that this proce-
dure could significantly improve cardiovascular risk strat-
ification in those patients with multiple risk factors, but no
evidence of target organ damage by routine investigations.
Am J Hypertens 2003;16:556 –563 © 2003 American
Journal of Hypertension, Ltd.
Key Words: Mild hypertension, primary care, left ven-
tricular hypertrophy, echocardiography.
essential hypertension average 40% (range 12% to
70%),3–9 depending to a large degree on the measurement
technique used. Standard electrocardiography (ECG), for
example, has only a limited ability to detect the presence
of increased LVM,10 even if new, improved criteria are
applied.11 Original estimates of the prevalence of LVH
have therefore increased considerably with the advent of
the more sensitive echocardiography (ECHO).
(Project FIS 97/56:0 –12) and AstraZeneca Pharmaceuticals, Madrid.
Authors’ affiliations are included in the Appendix.
Address correspondence and reprint requests to Dr. Maria Angeles
Martı́nez, Avda del Llano Castellano 3. 5°B, Madrid 28034, Spain;
e-mail: jrvillagrasa@terra.es
© 2003 by the American Journal of Hypertension, Ltd.
Published by Elsevier Inc.
AJH–July 2003–VOL. 16, NO. 7 LEFT VENTRICULAR HYPERTROPHY IN MILD HYPERTENSION
To date, most studies on the prevalence of LVH deter-
mined by ECHO and its influence on cardiovascular risk
stratification in hypertensive subjects have been performed in
hypertension clinics or academic settings where participating
patients had been referred for clinical evaluation.3–5,9,12,13
The population studied in these reports may not be represen-
tative of that seen in a primary care setting while patients are
receiving their usual medical care.
The aims of the present study were to estimate the
prevalence and determinants of echocardiographic LVH in
a population of mildly hypertensive subjects, and to eval-
uate the impact of ECHO on a more precise stratification
of absolute cardiovascular risk, compared with routine
evaluations.
Patients and Methods
Patients and Study Design
The study was conducted in 12 primary care centers in
Madrid, Spain. We examined all patients aged between 18
and 75 years with mild hypertension who spontaneously
and consecutively attended the primary care centers from
January 1999 to December 2001. The inclusion criteria
were all of the following: white ethnicity; grade I essential
hypertension (systolic blood pressure [BP] 140 to 159 mm
Hg or diastolic BP 90 to 99 mm Hg) diagnosed in the
previous 12 months, according to the definition of the
1999 World Health Organization/International Society of
Hypertension (WHO/ISH)14; and no previous drug treat-
ment for hypertension.
Patients included in the study underwent routine clini-
cal evaluation including ECG (detailed below), M-mode
ECHO, and 24-h ambulatory BP monitoring. In addition,
urinary albumin excretion (UAE) was determined in pa-
tients included in the study from January 1999 to January
2000 (n ⫽ 117). The data collected were then used to
estimate the prevalence of LVH, to examine the associa-
tion of LVH with several clinical and biochemical vari-
ables, and to assess the impact of ECHO on modifying the
level of absolute cardiovascular risk as estimated by rou-
tine evaluation of target organ damage. This study was
carried out in accordance with the Second Declaration of
Helsinki and was approved by our Primary Care and
Hospital Ethical Review Committee. All participants gave
their informed consent.
Routine Clinical Evaluation
The initial evaluation of all participants included a clinical
interview and a complete physical examination. Diagnosis
of mild hypertension was confirmed by a practitioner who
took at least two consecutive sitting BP measurements.
The mean value of the three “visit” BP measurements was
considered as the “clinic” BP.
Body weight and body mass index were measured
according to recommended principles. Laboratory screen-
ing included urinalysis and determination of serum levels
557
of urea nitrogen, creatinine, glucose, uric acid, cholesterol,
sodium, potassium, and calcium. Biochemical serum de-
terminations were performed using a Hitachi 747 autoana-
lyzer (Boehringer Mannheim, Mannheim, Germany).
To detect cardiac organ damage, an ECG was per-
formed on all patients. We used the sex-specific Cornell
criteria15 to define LVH: sum of amplitudes of the S wave
in V3 and the R wave in a VL ⬎28 mm in men and ⬎20
mm in women.
Echocardiography
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Echocardiography was performed in a university hospital
cardiology department, where ECHO recordings were
made with a Sonos 1.000 (Hewlett Packard, Andover,
MA) ultrasound imaging system equipped with 2.5-MHz
and 3.5-MHz transducers. The same echocardiographer,
who was unaware of the subjects’ characteristics, per-
formed all studies. Two-dimensionally guided M-mode
echocardiograms of the left ventricle (LV) were taken at
the cordal level, with the patient in the partial left decub-
itus position, and three to five measurements were aver-
aged. End-diastolic measurements of the interventricular
septal thickness, LV internal diameter, and posterior wall
thickness (PWT) were carried out in accordance with the
American Society of Echocardiography recommenda-
tions.16 The LVM was calculated by the formula intro-
duced by Devereux and Reicheck 17 and was indexed for
body surface area to obtain the LVM index (LVMI). Left
ventricular hypertrophy was diagnosed when LVMI was
⬎134 g/m2 in men and ⬎110 g/m2 in women.18 Only
frames with optimal visualization of interfaces and show-
ing the septum, left ventricular internal diameter, and
posterior wall simultaneously were used for reading.
Ambulatory BP Monitoring
Ambulatory BP was recorded using the SpaceLabs 90207
Unit (SpaceLabs, Redmond, WA). For each 1 h, the av-
erage BP was determined irrespective of the number of
recordings; these hourly averages were used for the deter-
mination of ambulatory BP to minimize the influence of
different sampling intervals and missing values. Daytime
ambulatory BP was defined as the mean of the hourly BP
between 10:00 AM and 8:00 PM, whereas nighttime ambu-
latory BP was the mean of the hourly BPs between mid-
night and 6:00 AM. Twenty-four-hour ambulatory BP was
determined as the mean of all hourly pressures during the
monitoring. Only those recordings with at least two valid
ambulatory BP readings per hour during the daytime and
one valid BP reading per hour during the nighttime were
included in the study.
In the absence of established limits for normal ambu-
latory BP recordings, white coat hypertension was defined
by the criteria suggested by the 2001 Consensus Confer-
ence on Ambulatory Blood Pressure Monitoring19: a clinic
BP ⱖ140/90 mm Hg with an average daytime ambulatory
BP ⬍135/85 mmHg for both sexes. These criteria agree
558 LEFT VENTRICULAR HYPERTROPHY IN MILD HYPERTENSION AJH–July 2003–VOL. 16, NO. 7

with those previously published by the Joint National Table 1. Demographic and clinic characteristics of
Committee (JNC).20 The remaining hypertensive subjects the study population
were considered to have sustained hypertension. Daytime
systolic BP and nighttime systolic BP loads were defined Men Women
Variable (n ⴝ 117) (n ⴝ 133)
as the percentage of daytime and night-time readings,
respectively, that exceeded 135 mm Hg. Similarly, day- Age (y) 47.4 ⫾ 12.1 50.8 ⫾ 11.3
time diastolic BP and nighttime diastolic BP loads were Systolic clinic BP
(mm Hg) 144.7 ⫾ 13.4 143.2 ⫾ 11.5
defined as the percentage of daytime and nighttime read- Diastolic clinic BP
ings, respectively, that exceeded 85 mm Hg. (mm Hg) 95.6 ⫾ 7.4 91.7 ⫾ 5.3
Body mass index
Urinary Albumin Excretion (kg/m2) 24.3 ⫾ 11.5 22.5 ⫾ 12.1
Serum glucose

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Patients collected urine from 11:00 PM to 7:00 AM during 3 (mmol/L) 5.3 ⫾ 0.6 5.0 ⫾ 0.5
consecutive days. Urinary albumin excretion (UAE) was Serum creatinine
(␮mol/L) 59.6 ⫾ 13.0 60.3 ⫾ 14.5
measured using two immunonephelometric assays (BNII, Total cholesterol
Dade Behring, Marburg, Germany; and Array 360 System, (mmol/L) 5.6 ⫾ 0.7 5.2 ⫾ 0.4
Beckman Instruments, La Brea, CA). The lower detection HDL cholesterol
limit was 2.0 ␮g/mL. The intra- and interserial variability (mmol/L) 1.5 ⫾ 0.2 1.3 ⫾ 0.1
of the method ranged from 2% to 5% and from 6% to 8%, Triglycerides
(mmol/L) 1.4 ⫾ 0.3 1.2 ⫾ 0.1
respectively. The mean ⫾ SD UAE rate in a healthy Uric acid (mmol/L) 0.41 ⫾ 0.04 0.36 ⫾ 0.03
normotensive population of the same age range was 4.9 ⫾ Left ventricular
2.2 ␮g/min. The UAE was reported as the median value of mass index (g/m2) 121.5 ⫾ 30.6 106.1 ⫾ 27.7
the three samples. Microalbuminuria was defined as UAE Urinary albumin
ⱖ20 and ⱕ200 ␮g/min. (␮g/min)* 7,6 (0.2–240.1) 6.0 (0.3–69.1)

BP ⫽ blood pressure.
Stratification of Patients by Absolute Data are expressed as mean ⫾ SD.
* Values refer to 117 patients and are expressed as median and
Level of Cardiovascular Risk range.

Overall cardiovascular risk was defined according to the

criteria recommended by the 1999 WHO/ISH Guidelines
for the Management of Hypertension.12 Four categories of pendent variables included in the model were those that
absolute cardiovascular disease risk are defined: low, me- reached statistical significance (P ⬍ .05) in univariate
dium, high, and very high. In the present study, the detec- analysis. A value of P ⬍ .05 was used as the cut-off point
tion of target organ damage was accomplished by two
to assess the statistical significance of each regression
different approaches: 1) routine procedures recommended
coefficient. Data in the text are expressed as mean values
by the WHO guidelines (interview, physical examination,
⫾ SD unless otherwise stated. In two-tailed tests, values of
ECG, serum creatinine and urine analysis; and 2) standard
P ⬍ .05 were considered to be statistically significant.
procedures along with subsequent reassessment by using
data on LVM obtained by ECHO.

Statistical Analysis
Data were stored and analyzed using the SPSS for Win-
dows, version 10, statistical package (SPSS Inc., Chicago,
IL). For the study, it was calculated that it would be
necessary to recruit 246 patients to have a power of 95%
at the 5% significance level to estimate a prevalence of
LVH of 20%. This prevalence feature is similar to that
obtained in a Spanish series of untreated patients with mild
hypertension.21
Urinary albumin excretion data were analyzed as a
continuous variable with logarithmic transformation. Pear-
son’s correlations were used to study the linear relation-
ship between LVMI and other continuous variables. A
stepwise multivariate regression analysis was used to iden-
tify the clinical factors determining LVMI. Similarly, a
stepwise logistic analysis was used to identify the predic-
tive factors for LVH. In both types of analysis, the inde-
Results
Study Population
Out of 320 eligible patients, 290 agreed to participate in
the study. Of these 290 cases, 40 (13.8%) were excluded
from analysis because of insufficient visualization of the
cardiac structure on ECHO. Data from 250 patients (all of
white European ethnicity) were therefore evaluated in this
study. Table 1 shows the clinical and demographic char-
acteristics of the study population. The main demographic
characteristics (age, sex, and level of absolute cardiovas-
cular risk) of the 40 excluded patients were similar to
those of the patients included in the analysis.
Ambulatory BP recordings were excluded in seven
patients because of an insufficient number of BP readings.
Urinary albumin excretion measurement was not possible
in five patients because of deficiencies in urine sample
collection.
AJH–July 2003–VOL. 16, NO. 7 LEFT VENTRICULAR HYPERTROPHY IN MILD HYPERTENSION 559

Table 2. Echocardiographic measures of left ventricular structure

Men Women
Variable All (n ⴝ 117) (n ⴝ 133) P
LV mass index (g/m2) 119.4 ⫾ 22.4 126.1 ⫾ 26.4 103.3 ⫾ 19.5 .02
LV internal diameter (mm) 45.8 ⫾ 4.2 47.1 ⫾ 4.9 44.2 ⫾ 3.9 .07
PW thickness (mm) 9.9 ⫾ 1.5 10.9 ⫾ 1.9 9.3 ⫾ 1.4 .02
IV septal thickness (mm) 11.2 ⫾ 1.7 12.3 ⫾ 1.9 10.8 ⫾ 1.7 .4
Relative wall thickness 0.43 ⫾ 0.09 0.47 ⫾ 0.1 0.42 ⫾ 0.08 .08

IV ⫽ interventricular; LV ⫽ left ventricle; PW ⫽ parietal wall.

Data are expressed as mean ⫾ SD.

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Evaluation of LVH
and Ambulatory BP
More than half of the patients (58%) had LVMI values
between 90 and 129 g/m2. As expected, LVMI was higher
in men than in women (Table 2). According to our criteria,
79 patients (32%; 95% CI: 26% to 38%) had LVH. Prev-
alence of LVH was higher (38%; 95% CI: 32% to 42%)
when we used less restrictive criteria: LVMI ⱖ120 g/m2 in
men and ⱖ 100 g/m2 in women.22 Valid ambulatory BP
recordings were obtained in 243 subjects, 92 of whom
(38%) were diagnosed with white coat hypertension and
151 (62%) with sustained hypertension. It was found that
LVH was more frequent in patients with sustained hyper-
tension than in patients white coat hypertension (38% and
20%, respectively, P ⬍ .01).
The detection of LVH by ECHO elicited a significant
change in the initial risk strata distribution (Fig. 1), as only
15/80 (19%) patients with echocardiographic LVH had
been previously diagnosed with target organ damage by
ECG. By contrast, LVH was ruled out by ECHO in 5/20
subjects whose disease was previously diagnosed by ECG.
Thus, as a result of the ECHO examination, 23% of
patients were included in the low risk group, 30% re-
mained in the medium risk group, and as many as 42%
were classified as in the high risk group (P ⬍ .01). The
proportion of subjects in whom echocardiographic assess-
ment led to reclassification as at high risk was slightly
greater when less restrictive criteria were used for defini-
tion of LVH.22

Factors Associated
With Increased LVM Table 3. Pearson correlation coefficients between
clinical parameters and left ventricular mass index
Table 3 shows the correlation between LVMI and several
clinical variables. The strongest correlation was found for Variable r P
age (P ⫽ .27, P ⬍ .01). Other factors with significant Age (y) 0.27 ⬍.01
positive correlation were UAE (0.25, P ⬍ .01), and several Body mass index
ambulatory BP variables. In a multiple linear regression (g/m2) 0.04 NS
Log urinary albumin
model age, sex, and night time systolic BP load were
excretion (␮g/min) 0.25 ⬍.01
predictors of LVMI. This regression model could only Clinic systolic BP
explain 26.2% of LVMI variability. However, in a logistic (mm Hg) 0.17 ⬍.05
model, only age and daytime systolic BP load were inde- Clinic diastolic BP
pendently associated with LVH. (mm Hg) 0.11 NS
Daytime ambulatory
systolic BP (mm Hg) 0.15 ⬍.05
Influence of ECG and Daytime ambulatory
ECHO Evaluation on diastolic BP (mm Hg) 0.12 NS
Cardiovascular Risk Stratification 24-h Ambulatory systolic
BP (mm Hg) 0.17 ⬍.05
Initial evaluation of cardiovascular risk (which included 24-h Ambulatory diastolic
ECG assessment as part of the routine procedure) indi- BP (mm Hg) 0.23 ⬍.01
cated that only 74/250 (30%) patients had no cardiovas- Nighttime ambulatory systolic
cular risk factors (other than hypertension) or any target BP (mm Hg) 0.17 ⬍.05
Nighttime ambulatory diastolic
organ damage, and were therefore classified in the low risk BP (mm Hg) 0.22 ⬍.01
group, according to the 1999 WHO/ISH guidelines14 (Fig. Daytime systolic load (%) 0.14 ⬍.05
1). A further 123/250 subjects (49%) had concomitant risk Daytime diastolic load (%) 0.12 NS
factors, without evidence of target organ damage, and Nighttime systolic load (%) 0.10 NS
were classified in the medium risk group and the remain- Nighttime diastolic load (%) 0.17 ⬍.01
ing 53/250 patients (21%) were considered to be high risk NS ⫽ not significant; other abbreviation as in Table 1.
(n ⫽ 40) or very high risk (n ⫽ 13) patients. Correlation was analyzed by the Pearson test.
560 LEFT VENTRICULAR HYPERTROPHY IN MILD HYPERTENSION
FIG. 1. Stratification of patients by absolute level of cardiovascular risk performed at baseline workup and after detection of left ventricular
hypertrophy by echocardiography.*P ⬍ .01 for difference between percentages of patients classified in each risk level at baseline and after
echocardiography. LVH was defined according to two types of criteria: 1) LVMI ⱖ 134 g/m2 in men and ⱖ 110 g/m2 in women[17] and 2) LVMI
ⱖ120 g/m2 in men and ⱖ 100 g/m2 in women.[22] LVMI ⫽ left ventricular mass index; LVH ⫽ left ventricular hypertrophy.
Discussion
This study shows that a considerable number of patients
recently diagnosed with mild hypertension have LVH de-
termined by ECHO (32%; 95% confidence interval ⫽ 26%
to 38%), the frequency of which is underestimated using
standard methods of detection, including ECG. Within this
population, the method used to detect cardiac organ dam-
age therefore markedly influences cardiovascular risk
stratification.
The prevalence of echocardiographic LVH is highly
dependent on the criteria used for diagnosis. Several cri-
teria, based on LV mass (indexed by weight, height, or
body surface area) have been proposed.23 We have used
sex-specific cut-off values of 134 g/m2 in men and 110
g/m2 in women because the prognostic value of these
figures has been clearly shown in previous reports.17 In
addition, these criteria have been widely used in epidemi-
ologic studies and are considered a suitable reference
standard for detection of LVH in a heterogeneous popu-
lation.7 The frequency of LVH found in our study was
higher than that reported by other authors for mild hyper-
tensive subjects.8, 10 The study by Armario et al,21 per-
formed in a series of 171 untreated mild hypertensive,
patients, reported a prevalence of LVH of 23% using 125
g/m2 as the LVMI cut-off point. In a large cross-sectional
study of 844 mild hypertensive patients, Liebson et al5
found an even lower prevalence (15%). Variations in
prevalence are most likely to be due to demographic
differences in the study population (mainly age) and to the
threshold values used to define LVH.
There is little published information about the fre-
quency of LVH in hypertensive patients attended in pri-
mary care settings. The Ventrı́culo Izquierdo Tensión
Arterial España (VITAE) study6 was designed to research
AJH–July 2003–VOL. 16, NO. 7
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the prevalence of echocardiographic LVH in a represen-
tative cohort of essential hypertensive patients attended by
general practitioners in Spain.6 The authors reported a
prevalence that ranged from 59% to 73%, depending on
the threshold values used. These prevalence figures are
approximately twice that found by our group. Possible
explanations for this difference include a shorter duration
of hypertension and lower clinic BP, age, and body mass
index in our series. In addition, a high percentage of our
study patients were diagnosed with white coat hyperten-
sion, a condition that is associated with less target organ
damage than is sustained hypertension.24, 25 In the former
group, 20% of subjects had LVH, a figure intermediate
between those found in two large cross-sectional sur-
veys.26, 27
We found that LVMI was associated with several clin-
ical factors: biological sex, age, UAE, and different mea-
surements provided by ambulatory BP monitoring. The
higher prevalence of LVH in women compared with men
observed in our sample is likely due to the use of body
surface area in the calculation of LVMI1,9 along with
sex-specific definition criteria. By contrast, studies using
weight usually report a higher prevalence in men.28 In
hypertensive populations, microalbuminuria has been
shown to be associated with several risk factors and the
presence of early signs of hypertensive organ damage such
as LVH.29 Furthermore, microalbuminuria, similar to
LVH, is a powerful, independent predictor of morbidity
and mortality.30 According to this evidence, routine mea-
surement of urinary albumin excretion could be a useful
tool for the stratification of cardiovascular risk in patients
recently diagnosed with mild hypertension.
In agreement with previous results by our group and
others, ambulatory BP was related to LVMI more closely
AJH–July 2003–VOL. 16, NO. 7 LEFT VENTRICULAR HYPERTROPHY IN MILD HYPERTENSION
than was clinic BP.24,31 Nighttime ambulatory BP showed
a higher correlation with LVMI than daytime BP. This
finding, also observed for microalbuminuria in previous
studies,32 could be related to the fact that nighttime am-
bulatory BP values are usually more reproducible than
daytime values33 because of the limited physical activity
during that period.
In a stepwise multiple linear regression model, with
LVMI as the dependent variable, age, sex, and nighttime
diastolic BP load were predictors of LVMI. The associa-
tion with urinary albumin excretion that was found in the
univariate analysis did not remain after taking these fac-
tors into account. This regression model could explain
only 26.2% of LVMI variability, a slightly lower figure
than that described by other authors.10,34 Obviously, LVM
is influenced by other factors that were not considered in
our study, such as those of genetics, metabolism, and
lifestyle.4 In a logistic regression model with LVH as the
dependent variable, only age and daytime systolic load
were predictive factors, after controlling for several po-
tential confounding factors.
The question of whether and when to use ECHO in
hypertensive patients has been the subject of considerable
controversy.35–37 The WHO/ISH14 and the JNC20 guide-
lines stress the importance of basing decisions about the
management of hypertensive patients not only on BP
levels, but also on the presence of other risk factors and
target organ damage, such as ECG evidence of LVH.
Although ECHO is more sensitive and specific for identi-
fying LVH than ECG, it is presently not recommended in
the baseline workup of hypertensive patients.
In our primary-care series, most patients (79%) were
initially classified as having low to medium cardiovascular
risk by routine investigations. The detection of LVH by
ECHO changed the risk category in 40% of subjects who
were initially classified as being at medium risk. By con-
trast, shifts from one to another risk level were very few in
the remaining categories. As a whole, our data therefore
suggest that ECHO evaluation might be particularly useful
in the initial work-up of mildly hypertensive subjects
classified as medium risk by routine evaluation, that is,
those patients with several cardiovascular risk factors but
no evidence of target organ disease. Within this group,
LVH will be diagnosed by ECHO in approximately 40%
of cases. This information will probably lead to the deci-
sion to start treatment with antihypertensive drugs, in
accordance with the WHO/ISH guidelines. By contrast,
ECHO information might be less useful in patients as-
signed to a very low or high risk category.
Two recent articles12,13 have investigated the impact of
echocardiography in hypertensive patients judged to be at
relatively low risk on the basis of traditional clinical
evaluation. These studies, performed in hospital clinics,
showed that 29% to 50% of individuals would be reclas-
sified as being at high cardiovascular risk after detection of
LVH. Our results extend those findings to a primary care
setting, where most hypertensive patients receive their
561
medical care and which therefore is the context in which
the first therapeutic decision is usually made.
The present study has two potential limitations. First,
our routine procedures to detect target organ damage did
not include funduscopic examination, a procedure recom-
mended by international guidelines (WHO/ISH and JNC).
Interestingly, previous studies on hypertensive patients
showed significant correlations between retinal vascular
changes and LVM38,39 and a low incidence of retinopathy
in subjects with no LVH.38 According to this evidence, we
could hypothesize that funduscopic findings would not
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have significantly influenced our results on cardiovascular
risk stratification. Second, our additional evaluation of
organ damage did not include carotid ultrasonography. It
is likely that this assessment had increased the proportion
of patients reclassified as being at high risk by echocardi-
ography. In the Assessment of Prognostic Risk Observa-
tional Survey (APROS) study,12 the carotid evaluation led
to another 16% of patients being reclassified.
In conclusion, patients in primary care diagnosed with
mild hypertension have a substantial frequency of echo-
cardiographically detected LVH. Our results suggest that
ECHO could be particularly useful for improving cardio-
vascular risk stratification in those patients with multiple
risk factors but no evidence of target organ damage using
routine evaluations. Prospective primary care– based stud-
ies are needed to determine the efficacy and cost of this
approach for identifying high risk patients.
Acknowledgments
We thank Rosario Madero for statistical advice and As-
traZeneca Pharmaceuticals for supporting the MAPA-Ma-
drid Working Group for the last 10 years. On the 10th
anniversary of the MAPA-Madrid Working Group, this
paper is dedicated to all primary-care physicians who have
collaborated with Hospital La Paz investigators to increase
our knowledge of cardiovascular risk.
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Appendix:
The members of the Monitorización Ambulatoria de la Pre-
sión Arterial (MAPA)–Madrid Working Group that partici-
pated in this study were: Hospital La Paz, Unidad de
Investigación: Rosario Madero; Servicio de Medicina In-
terna: Juan G Puig, Teresa Sancho, José I Bernardino; Ser-
vicio de Nefrologia: Alberto Torre; Servicio de Urgencias:
Maria A Martinez; Servicio de Bioquimica: Teresa Ramos,
Rosa Torres; Servicio de Cardiologı́a: J. Oliver, E Armada.
Ambulatorio de Fuencarral: José L Martinez, José L Antón,
Milagros Quesada, Mercedes Gutiérrez, Angeles Acedo,
Marta Hernáinz, Fernando de la Cuadra-Salcedo, F Miguel A
Alvaro, Juan B Herrero, José L Manzanares; Centro de Salud
(CS) Aguileñas: Gonzalo Esteban; CS Bustarviejo: Isabel
Laguna, Isabel Sáenz, Monserrat Aza, Yolanda Hidalgo,
Mercedes Martinez, Alejandra Rabanal, Carmen Villar; Ger-
ardo Antón; CS El Escorial: Francisco J Palau, Josefa
Pechero, Aurora Barbera, Isabel Hernández, Raúl Nieto, Juan
C de la Fuente, Elena Navarro; CS Espronceda: Armando
563
Nevado, Roberto Cabrera, Alberto Galgo; CS Chopera: Al-
varo Aguirre, Paloma Seguido, Luisa Pascual, Antonio
González, Jaime Gallo, Juan J González, Luis Zorita-Viota,
Mariano Ferrer, Concepción Miranda, Carmen Villar,
Amparo de la Cuesta, Concepción Seco, Marı́a J Gómez;
Ana B Garcia; CS Paracuellos: José M Rubio, Monserrat
Blas, Carmen Conles, Sonia Puerta, Matilde del Castillo,
Rosario Paramio, Elena Aymerich, Carlos del Valle, Javier
Salas, Ignacio Valverde; CS Dr Tamames (Coslada): José L
Antón, Gema Herranz, Luis F Gimbel, José Sanz, Marı́a J
Gomera, Sol Blesa, Eva Cruz, Raquel Martı́nez, Teresa
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Sánchez-Villares, Marı́a J Jarabo, Victorina de Blas, Salva-
dor, A Rodriguez, Clara Martinez, Angeles Francisco, Ana
M Minguez, Pilar F Sánchez, Gema Rodrı́guez, Antonia
Palomino, Luisa Revuelta, Begofia Guantes, Teresa Mijares,
Pelayo, J Sánchez; CS Sánchez Morate: Elisa M Rodriguez,
Mercedes Segovia; CS Sector III: Jesús Neri, Enrique Polo;
CS Potes: Javier González, Javier Castellanos, Juan L
González, Francisco J San Andrés, Eva M Medrano. CS
Jazmin: Jose Suero, Clemente Aguila, Carmen Morrión, Ali-
cia Sánchez, Inmaculada Peya, A Rey. CS Mar Báltico:
Teresa Mantilla, Javier Rosado, Esmeralda Alonso, Dolores
Sánchez, Victoria Martinez, Pilar Garcia, Silvia Lafuente.
Consultorio de Guadalix: Pascual O’Dhogerty, Isabel Izqui-
erdo.