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Jain V, Ghosh R, Gupta M, Saijo Y, Bansal A, Farwati M, Marcus R, Klein A, Xu B. Contemporary narrative review on left atrial strain mechanics in echocardiography: cardiomyopathy, valvular heart disease and beyond. Cardiovasc Diagn Ther 2021; 11:924-938. [PMID: 34295714 DOI: 10.21037/cdt-20-461] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 08/19/2020] [Indexed: 12/14/2022]
Abstract
Left atrial (LA) strain mechanics refer to the measurement of LA myocardial deformation expressed as a percentage, and have been gathering interest over the last decade with expanding research supporting their utility in multiple cardiovascular disorders. Measured through advanced dynamic imaging techniques which include tissue Doppler imaging (TDI) and two-dimensional (2D) speckle tracking echocardiography (STE), LA strain mechanics are affected by left ventricular diastolic dysfunction prior to the onset of functional and structural changes in the left ventricle (LV). There is a need for practising cardiologists to become more familiar with the clinical utility of LA strain mechanics. In this article, we begin by reviewing the physiologic function of the LA, using this as a basis for understanding LA strain mechanics. The focus of this review article is to provide a contemporary update on the utility of LA strain mechanics in a range of cardiovascular disorders, including atrial fibrillation (AF), hypertrophic cardiomyopathy (HCM), valvular pathologies, coronary artery disease (CAD) as well as systemic diseases, such as hypertension (HTN), obesity and diabetes mellitus (DM). This article also highlights the current limitations in more widespread clinical applications of LA strain mechanics, as well as outlining the future perspectives on the clinical applications of LA strain mechanics.
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Affiliation(s)
- Vardhmaan Jain
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Raktim Ghosh
- MedStar Heart and Vascular Institute at MedStar Union Memorial Hospital and MedStar Good Samaritan Hospital, Baltimore, MD, USA
| | - Manasvi Gupta
- Department of Internal Medicine, UConn Health, University of Connecticut, Farmington, CT, USA
| | - Yoshihito Saijo
- Section of Cardiovascular Imaging, Robert and Suzanne Tomsich, Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Agam Bansal
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Medhat Farwati
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Rachel Marcus
- MedStar Heart and Vascular Institute at MedStar Union Memorial Hospital and MedStar Good Samaritan Hospital, Baltimore, MD, USA
| | - Allan Klein
- Section of Cardiovascular Imaging, Robert and Suzanne Tomsich, Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Bo Xu
- Section of Cardiovascular Imaging, Robert and Suzanne Tomsich, Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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Bayonas-Ruiz A, Muñoz-Franco FM, Ferrer V, Pérez-Caballero C, Sabater-Molina M, Tomé-Esteban MT, Bonacasa B. Cardiopulmonary Exercise Test in Patients with Hypertrophic Cardiomyopathy: A Systematic Review and Meta-Analysis. J Clin Med 2021; 10:jcm10112312. [PMID: 34070695 PMCID: PMC8198116 DOI: 10.3390/jcm10112312] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 05/16/2021] [Accepted: 05/23/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Patients with chronic diseases frequently adapt their lifestyles to their functional limitations. Functional capacity in Hypertrophic Cardiomyopathy (HCM) can be assessed by stress testing. We aim to review and analyze the available data from the literature on the value of Cardiopulmonary Exercise Test (CPET) in HCM. Objective measurements from CPET are used for evaluation of patient response to traditional and new developing therapeutic measurements. METHODS A systematic review of the literature was conducted in PubMed, Web of Science and Cochrane in Mar-20. The original search yielded 2628 results. One hundred and two full texts were read after the first screening, of which, 69 were included for qualitative synthesis. Relevant variables to be included in the review were set and 17 were selected, including comorbidities, body mass index (BMI), cardiac-related symptoms, echocardiographic variables, medications and outcomes. RESULTS Study sample consisted of 69 research articles, including 11,672 patients (48 ± 14 years old, 65.9%/34.1% men/women). Treadmill was the most common instrument employed (n = 37 studies), followed by upright cycle-ergometer (n = 16 studies). Mean maximal oxygen consumption (VO2max) was 22.3 ± 3.8 mL·kg-1·min-1. The highest average values were observed in supine and upright cycle-ergometer (25.3 ± 6.5 and 24.8 ± 9.1 mL·kg-1·min-1; respectively). Oxygen consumption in the anaerobic threshold (ATVO2) was reported in 18 publications. Left ventricular outflow tract gradient (LVOT) > 30 mmHg was present at baseline in 31.4% of cases. It increased to 49% during exercise. Proportion of abnormal blood pressure response (ABPRE) was higher in severe (>20 mm) vs. mild hypertrophy groups (17.9% vs. 13.6%, p < 0.001). Mean VO2max was not significantly different between severe vs. milder hypertrophy, or for obstructive vs. non-obstructive groups. Occurrence of arrhythmias during functional assessment was higher among younger adults (5.42% vs. 1.69% in older adults, p < 0.001). Twenty-three publications (9145 patients) evaluated the prognostic value of exercise capacity. There were 8.5% total deaths, 6.7% cardiovascular deaths, 3.0% sudden cardiac deaths (SCD), 1.2% heart failure death, 0.6% resuscitated cardiac arrests, 1.1% transplants, 2.6% implantable cardioverter defibrillator (ICD) therapies and 1.2 strokes (mean follow-up: 3.81 ± 2.77 years). VO2max, ATVO2, METs, % of age-gender predicted VO2max, % of age-gender predicted METs, ABPRE and ventricular arrhythmias were significantly associated with major outcomes individually. Mean VO2max was reduced in patients who reached the combined cardiovascular death outcome compared to those who survived (-6.20 mL·kg-1·min-1; CI 95%: -7.95, -4.46; p < 0.01). CONCLUSIONS CPET is a valuable tool and can safely perform for assessment of physical functional capacity in patients with HCM. VO2max is the most common performance measurement evaluated in functional studies, showing higher values in those based on cycle-ergometer compared to treadmill. Subgroup analysis shows that exercise intolerance seems to be more related to age, medication and comorbidities than HCM phenotype itself. Lower VO2max is consistently seen in HCM patients at major cardiovascular risk.
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Affiliation(s)
- Adrián Bayonas-Ruiz
- Human Physiology Area, Faculty of Sport Sciences, University of Murcia, Santiago de la Ribera-San Javier, 30720 Murcia, Spain
| | | | - Vicente Ferrer
- Physiotherapy Department, Faculty of Medicine, Campus of Espinardo, University of Murcia, 30100 Murcia, Spain
| | - Carlos Pérez-Caballero
- Sports Activities Service, Campus of Espinardo, University of Murcia, 30100 Murcia, Spain
| | - María Sabater-Molina
- Inherited Cardiopathies Unit, Virgen de la Arrixaca University Hospital, El Palmar, 30120 Murcia, Spain
| | - María Teresa Tomé-Esteban
- Cardiovascular Clinical Academic Group, Inherited Cardiovascular Disease Unit, St George's Hospital NHS Foundation Trust, St George's University of London, London SW17 0QT, UK
| | - Bárbara Bonacasa
- Human Physiology Area, Faculty of Sport Sciences, University of Murcia, Santiago de la Ribera-San Javier, 30720 Murcia, Spain
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Lander BS, Phelan DM, Martinez MW, Dineen EH. Hypertrophic Cardiomyopathy: Updates Through the Lens of Sports Cardiology. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021; 23:53. [PMID: 34054288 PMCID: PMC8144867 DOI: 10.1007/s11936-021-00934-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/28/2021] [Indexed: 11/25/2022]
Abstract
Purpose of review This review will summarize the distinction between hypertrophic cardiomyopathy (HCM) and exercise-induced cardiac remodeling (EICR), describe treatments of particular relevance to athletes with HCM, and highlight the evolution of recommendations for exercise and competitive sport participation relevant to individuals with HCM. Recent findings Whereas prior guidelines have excluded individuals with HCM from more than mild-intensity exercise, recent data show that moderate-intensity exercise improves functional capacity and indices of cardiac function and continuation of competitive sports may not be associated with worse outcomes. Moreover, recent studies of athletes with implantable cardioverter defibrillators (ICDs) demonstrated a safer profile than previously understood. In this context, the updated American Heart Association/American College of Cardiology (AHA/ACC) and European Society of Cardiology (ESC) HCM guidelines have increased focus on shared decision-making and liberalized restrictions on exercise and sport participation among individuals with HCM. Summary New data demonstrating the safety of exercise in individuals with HCM and in athletes with ICDs, in addition to a focus on shared decision-making, have led to the most updated guidelines easing restrictions on exercise and competitive athletics in this population. Further athlete-specific studies of HCM, especially in the context of emerging therapies such as mavacamten, are important to inform accurate risk stratification and eligibility recommendations.
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Affiliation(s)
- Bradley S Lander
- Division of Cardiology, Columbia University Irving Medical Center, New York, NY 10032 USA
| | - Dermot M Phelan
- Sanger Heart & Vascular Institute, Atrium Health, Charlotte, NC 28203 USA
| | - Matthew W Martinez
- Department of Cardiovascular Medicine, Atlantic Health, Morristown Medical Center, Morristown, NJ 07960 USA.,Sports Cardiology and Hypertrophic Cardiomyopathy, 111 S Madison Ave, Suite 300, Morristown, NJ 07960 USA
| | - Elizabeth H Dineen
- Division of Cardiology, University of California Irvine, 333 City Blvd W, Suite 400, Orange, CA 92868 USA
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Basu J, Malhotra A, Papadakis M. Exercise and hypertrophic cardiomyopathy: Two incompatible entities? Clin Cardiol 2020; 43:889-896. [PMID: 32048747 PMCID: PMC7403677 DOI: 10.1002/clc.23343] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 01/27/2020] [Accepted: 01/27/2020] [Indexed: 01/02/2023] Open
Abstract
A greater understanding of the pathogenic mechanisms underpinning hypertrophic cardiomyopathy (HCM) has translated to improved medical care and better survival of affected individuals. Historically these patients were considered to be at high risk of sudden cardiac death (SCD) during exercise; therefore, exercise recommendations were highly conservative and promoted a sedentary life style. There is emerging evidence that suggests that exercise in HCM has a favorable effect on cardiovascular remodeling and moderate exercise programs have not raised any safety concerns. Furthermore, individuals with HCM have a similar burden of atherosclerotic risk factors as the general population in whom exercise has been associated with a reduction in myocardial infarction, stroke, and heart failure, especially among those with a high-risk burden. Small studies revealed that athletes who choose to continue with regular competition do not demonstrate adverse outcomes when compared to those who discontinue sport, and active individuals implanted with an implantable cardioverter defibrillator do not have an increased risk of appropriate shocks or other adverse events. The recently published exercise recommendations from the European Association for Preventative Cardiology account for more contemporary evidence and adopt a more liberal stance regarding competitive and high intensity sport in individuals with low-risk HCM. This review addresses the issue of exercise in individuals with HCM, and explores current evidence supporting safety of exercise in HCM, potential caveats, and areas of further research.
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Affiliation(s)
- Joyee Basu
- Cardiac Risk in the Young Clinical Research Fellow, Cardiology Clinical Academic GroupSt George's University of LondonLondonUK
| | - Aneil Malhotra
- Cardiac Risk in the Young Clinical Research Fellow, Cardiology Clinical Academic GroupSt George's University of LondonLondonUK
- Division of Cardiovascular SciencesThe University of ManchesterManchesterUK
| | - Michael Papadakis
- Cardiac Risk in the Young Clinical Research Fellow, Cardiology Clinical Academic GroupSt George's University of LondonLondonUK
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Fujimoto K, Inoue K, Saito M, Higashi H, Kono T, Uetani T, Aono J, Nagai T, Nishimura K, Suzuki J, Okura T, Ikeda S, Nakatani S, Higaki J. Incremental value of left atrial active function measured by speckle tracking echocardiography in patients with hypertrophic cardiomyopathy. Echocardiography 2018; 35:1138-1148. [PMID: 29648690 DOI: 10.1111/echo.13886] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
PURPOSE Hypertrophic cardiomyopathy (HCM) impairs left ventricular (LV) diastolic function leading to left atrial (LA) dilatation. Because Doppler echocardiography cannot accurately assess LV diastolic function in hearts with heterogeneous hypertrophy, assessment of LA function might be useful for risk stratification of patients with HCM. This study aimed to elucidate the impact of LA function on outcome in patients with patients. METHODS Seventy-six patients with HCM who underwent echocardiographic and cardiac magnetic resonance imaging were retrospectively enrolled. Twenty-six control subjects were also included. Using speckle tracking echocardiography, LA function was divided into active and passive strain indices based on the timing of the second positive peak of LA strain rate that occurred during LV systole. RESULTS Left atrial strain indices of active and passive function were significantly impaired concomitantly with increased LA volume index in HCM patients compared with controls. During follow-up (2.6 ± 1.7 years), 14 patients with HCM developed cardiac events (heart failure hospitalization or atrial fibrillation). The association of LA active strain with cardiac events was independent of and incremental to clinical and echocardiographic parameters (age, gender, E/e', LV global longitudinal strain, and LA volume index) in sequential models. Cardiac events were more frequent in HCM patients with LA active strain <20.3% than with active strain ≥20.3% (P = .01). CONCLUSION Loss of LA active function was associated with increased cardiac events in patients with HCM.
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Affiliation(s)
- Kaori Fujimoto
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Katsuji Inoue
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Makoto Saito
- Department of Cardiology, Kitaishikai Hospital, Ozu, Japan
| | - Haruhiko Higashi
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Tamami Kono
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Teruyoshi Uetani
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Jun Aono
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Takayuki Nagai
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Kazuhisa Nishimura
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Jun Suzuki
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Takafumi Okura
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Shuntaro Ikeda
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Satoshi Nakatani
- Division of Functional Diagnostics, Department of Health Sciences, Osaka University Graduate School of Medicine, Suita, Japan
| | - Jitsuo Higaki
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
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Exercise stress echocardiography in hypertrophic cardiomyopathy. J Echocardiogr 2017; 15:110-117. [PMID: 28501918 DOI: 10.1007/s12574-017-0338-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 04/19/2017] [Accepted: 04/28/2017] [Indexed: 01/06/2023]
Abstract
In this review, we make a comprehensive summary of exercise stress echocardiography in hypertrophic cardiomyopathy (HCM) and practical tips used in our hospital. The main objective of performing exercise stress echocardiography in patients with HCM is to evaluate left ventricular outflow tract obstruction, mitral regurgitation, left ventricular asynergy, and diastolic function during exercise. There are limitations to the explanations that can be provided for exertional symptoms when resting echocardiography is performed in patients with HCM. In contrast, exercise stress echocardiography causes the manifestation of findings that are latent at rest, which possibly provides the elucidation of symptom etiology. In this article, we focus on the usefulness of exercise stress echocardiography in HCM.
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Izumo M, Akashi YJ. Exercise echocardiography for structural heart disease. J Echocardiogr 2016; 14:21-9. [PMID: 26758899 DOI: 10.1007/s12574-016-0274-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 12/25/2015] [Accepted: 12/28/2015] [Indexed: 11/24/2022]
Abstract
Since the introduction of transcatheter structural heart intervention, the term "structural heart disease" has been widely used in the field of cardiology. Structural heart disease refers to congenital heart disease, valvular heart disease, and cardiomyopathy. In structural heart disease, valvular heart disease is frequently identified in the elderly. Of note, the number of patients who suffer from aortic stenosis (AS) and mitral regurgitation (MR) is increasing in developed countries because of the aging of the populations. Transcatheter aortic valve replacement and percutaneous mitral valve repair has been widely used for AS and MR, individually. Echocardiography is the gold standard modality for initial diagnosis and subsequent evaluation of AS and MR, although the difficulties in assessing patients with these diseases still remain. Here, we review the clinical usefulness and prognostic impact of exercise echocardiography on structural heart disease, particularly on AS and MR.
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Affiliation(s)
- Masaki Izumo
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan.
| | - Yoshihiro J Akashi
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
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Nagata Y, Takeuchi M, Mizukoshi K, Wu VCC, Lin FC, Negishi K, Nakatani S, Otsuji Y. Intervendor Variability of Two-Dimensional Strain Using Vendor-Specific and Vendor-Independent Software. J Am Soc Echocardiogr 2015; 28:630-41. [DOI: 10.1016/j.echo.2015.01.021] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Indexed: 10/23/2022]
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Otsuji Y. Journal of Echocardiography Award for the Year 2013. J Echocardiogr 2014. [DOI: 10.1007/s12574-014-0217-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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