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Hypertrophy represents an increase in cell size and with it an increase in the amount of functioning tissue mass (Fig. 5.2). It results from an increased workload imposed on an organ or body part and is commonly seen in cardiac and skeletal muscle tissue, which cannot adapt to an increase in workload through mitotic division and formation of more cells. Hypertrophy involves an increase in the functional components of the cell that allows it to achieve equilibrium between demand and functional capacity. For example, as muscle cells hypertrophy, additional actin and myosin filaments, cell enzymes, and adenosine triphosphate (ATP) are synthesized.

Hypertrophy may occur as the result of normal physiologic or abnormal pathologic conditions. The increase in muscle mass associated with exercise is an example of physiologic hypertrophy. Pathologic hypertrophy occurs as the result of disease conditions and may be adaptive or compensatory. Examples of adaptive hypertrophy are the thickening of the urinary bladder from longcontinued obstruction of urinary outflow and the myocardial hypertrophy that results from valvular heart disease or hypertension. Compensatory hypertrophy is the enlargement of a remaining organ or tissue after a portion has been surgically removed or rendered inactive. For instance, if one kidney is removed, the remaining kidney enlarges to compensate for the loss.
The initiating signals for hypertrophy appear to be complex and related to ATP depletion, mechanical forces such as stretching of the muscle fibers, activation of cell degradation products, and hormonal factors. In the case of the heart, initiating signals can be divided into two broad categories:
       Biomechanical and stretch-sensitive mechanisms
       Neurohumoral mechanisms that are associated with the release of hormones, growth factors, cytokines, and chemokines.
Internal stretch-sensitive receptors for the biochemical signals and an array of membrane-bound receptors for the specific neurohumoral ligands, such as IGF-1 and epidermal growth factor (EGF), activate specific signal transduction pathways. These pathways control myocardial growth by altering gene expression to increase protein synthesis and reduce protein degradation, thereby causing hypertrophic enlargement of the heart. A limit is eventually reached beyond which further enlargement of the tissue mass can no longer compensate for the increased work demands. The limiting factors for continued hypertrophy might be related to limitations in blood flow. In hypertension, for example, the increased workload required to pump blood against an elevated arterial pressure in the aorta results in a progressive increase in left ventricular muscle mass and need for coronary blood flow.
There continues to be interest in the signaling pathways that control the arrangement of contractile elements in myocardial hypertrophy. Research suggests that certain signal molecules can alter gene expression controlling the size and assembly of the contractile proteins in hypertrophied myocardial cells. For example, the hypertrophied myocardial cells of well-trained athletes have proportional increases in width and length. This is in contrast to the hypertrophy that develops in dilated cardiomyopathy, in which the hypertrophied cells have a relatively greater increase in length than width. In pressure overload, as occurs with hypertension, the hypertrophied cells have greater width than length. It is anticipated that further elucidation of the signal pathways that determine the adaptive and nonadaptive features of cardiac hypertrophy will lead to new targets for treatment.