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Weissler-Snir A, Rakowski H, Meyer M. Beta-blockers in non-obstructive hypertrophic cardiomyopathy: time to ease the heart rate restriction? Eur Heart J 2023; 44:3655-3657. [PMID: 37650505 DOI: 10.1093/eurheartj/ehad518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/01/2023] Open
Affiliation(s)
- Adaya Weissler-Snir
- Hartford HealthCare, Heart and Vascular Institute, 80 Seymour St, Hartford, CT 06106, USA
- Department of Medicine, University of Connecticut Farmington, CT, USA
| | - Harry Rakowski
- The Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto General Hospital, 585 University Ave, Toronto, ON M5G 2N2, Canada
| | - Markus Meyer
- Lillehei Heart Institute, Department of Medicine, University of Minnesota, 2231 6th Street SE, Minneapolis, MN 55455, USA
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2
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Prevalence and prognostic implications of hypertensive response to exercise in patients with hypertrophic cardiomyopathy. INTERNATIONAL JOURNAL OF CARDIOLOGY. CARDIOVASCULAR RISK AND PREVENTION 2023; 16:200166. [PMID: 36874040 PMCID: PMC9975236 DOI: 10.1016/j.ijcrp.2022.200166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 12/11/2022] [Accepted: 12/15/2022] [Indexed: 01/15/2023]
Abstract
Objective Hypertensive response to exercise (HRE) is observed in patients with hypertrophic cardiomyopathy (HCM) with normal resting blood pressure (BP). However, the prevalence or prognostic implications of HRE in HCM remain unclear. Methods In this study, normotensive HCM subjects were enrolled. HRE was defined as systolic BP > 210 mmHg in men or >190 mmHg in women, or diastolic BP > 90 mmHg, or an increase in diastolic BP > 10 mmHg during treadmill exercise. All participants were followed for subsequent development of hypertension, atrial fibrillation (AF), heart failure (HF), sustained ventricular tachycardia/fibrillation (VT/VF), and all-cause death. Six hundred and eighty HCM patients were screened. Results 347 patients had baseline hypertension, and 333 patients were baseline normotensive. 132 (40%) of the 333 patients had HRE. HRE was associated with female sex, lower body mass index and milder left ventricular outflow tract obstruction. Exercise duration and metabolic equivalents were similar between patients with or without HRE, but the HRE group had higher peak heart rate (HR), better chronotropic response and more rapid HR recovery. Conversely, non-HRE patients were more likely to exhibit chronotropic incompetence and hypotensive response to exercise. After a mean follow-up of 3.4 years, patients with and without HRE had similar risks of progression to hypertension, AF, HF, sustained VT/VF or death. Conclusion HRE is common in normotensive HCM patients during exercise. HRE did not carry higher risks of future hypertension or cardiovascular adverse outcomes. Conversely, the absence of HRE was associated with chronotropic incompetence and hypotensive response to exercise.
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3
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Nezamabadi K, Mayfield J, Li P, Greenland GV, Rodriguez S, Simsek B, Mousavi P, Shatkay H, Abraham MR. Toward ECG-based analysis of hypertrophic cardiomyopathy: a novel ECG segmentation method for handling abnormalities. J Am Med Inform Assoc 2022; 29:1879-1889. [PMID: 35923089 PMCID: PMC9552290 DOI: 10.1093/jamia/ocac122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 06/22/2022] [Accepted: 07/21/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Abnormalities in impulse propagation and cardiac repolarization are frequent in hypertrophic cardiomyopathy (HCM), leading to abnormalities in 12-lead electrocardiograms (ECGs). Computational ECG analysis can identify electrophysiological and structural remodeling and predict arrhythmias. This requires accurate ECG segmentation. It is unknown whether current segmentation methods developed using datasets containing annotations for mostly normal heartbeats perform well in HCM. Here, we present a segmentation method to effectively identify ECG waves across 12-lead HCM ECGs. METHODS We develop (1) a web-based tool that permits manual annotations of P, P', QRS, R', S', T, T', U, J, epsilon waves, QRS complex slurring, and atrial fibrillation by 3 experts and (2) an easy-to-implement segmentation method that effectively identifies ECG waves in normal and abnormal heartbeats. Our method was tested on 131 12-lead HCM ECGs and 2 public ECG sets to evaluate its performance in non-HCM ECGs. RESULTS Over the HCM dataset, our method obtained a sensitivity of 99.2% and 98.1% and a positive predictive value of 92% and 95.3% when detecting QRS complex and T-offset, respectively, significantly outperforming a state-of-the-art segmentation method previously employed for HCM analysis. Over public ECG sets, it significantly outperformed 3 state-of-the-art methods when detecting P-onset and peak, T-offset, and QRS-onset and peak regarding the positive predictive value and segmentation error. It performed at a level similar to other methods in other tasks. CONCLUSION Our method accurately identified ECG waves in the HCM dataset, outperforming a state-of-the-art method, and demonstrated similar good performance as other methods in normal/non-HCM ECG sets.
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Affiliation(s)
- Kasra Nezamabadi
- Computational Biomedicine Lab, Computer and Information Sciences, University of Delaware, Newark, Delaware, USA
| | - Jacob Mayfield
- Division of Cardiology, Hypertrophic Cardiomyopathy Center of Excellence, University of California San Francisco, San Francisco, California, USA
| | - Pengyuan Li
- Computational Biomedicine Lab, Computer and Information Sciences, University of Delaware, Newark, Delaware, USA
| | - Gabriela V Greenland
- Division of Cardiology, Hypertrophic Cardiomyopathy Center of Excellence, University of California San Francisco, San Francisco, California, USA
| | - Sebastian Rodriguez
- Division of Cardiology, Hypertrophic Cardiomyopathy Center of Excellence, University of California San Francisco, San Francisco, California, USA
| | - Bahadir Simsek
- Division of Cardiology, Hypertrophic Cardiomyopathy Center of Excellence, University of California San Francisco, San Francisco, California, USA
| | - Parvin Mousavi
- School of Computing, Queen's University, Kingston, Ontario, Canada
| | - Hagit Shatkay
- Computational Biomedicine Lab, Computer and Information Sciences, University of Delaware, Newark, Delaware, USA
| | - M Roselle Abraham
- Hypertrophic Cardiomyopathy Center of Excellence, Division of Cardiology, University of California San Francisco, San Francisco, USA
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4
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Assessment of Exercise Function in Children and Young Adults with Hypertrophic Cardiomyopathy and Correlation with Transthoracic Echocardiographic Parameters. Pediatr Cardiol 2022; 43:1037-1045. [PMID: 35059780 DOI: 10.1007/s00246-022-02822-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 01/07/2022] [Indexed: 10/19/2022]
Abstract
Exercise function is well characterized in adults with hypertrophic cardiomyopathy (HCM); however, there is a paucity of data in children and young adults with HCM. Here we sought to characterize exercise function in young people with HCM, understand limitations in exercise function by correlating exercise function parameters with echocardiogram parameters and identify prognostic value of exercise parameters. We performed a retrospective, single-center cohort study characterizing exercise function in patients < 26 years old with HCM undergoing cardiopulmonary exercise testing (CPET). Patients with syndromic HCM or submaximal effort were excluded. We compared exercise function in this cohort to population normal values and measured changes in exercise function over time. We correlated exercise function parameters with echocardiographic parameters and investigated the relationship between exercise test parameters and a clinical composite outcome comprised of significant ventricular arrhythmia, death, or heart transplantation. We identified 229 CPETs performed by 117 patients (mean age at time of first CPET 15.6 ± 3.2 years). Mean %-predicted peak VO2, O2 pulse, and peak heart rate were statistically significantly depressed compared to population normal values and exercise function gradually worsened over time. Abnormal exercise testing correlated closely with echocardiographic indices of diastolic dysfunction. There was a trend toward increased incidence of poor clinical outcome in patients with abnormal exercise function. While adverse clinical outcomes were rare, normal exercise function appears to be a marker of low risk for adverse clinical outcomes in this population.
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Gossios T, Savvatis K, Zegkos T, Ntelios D, Rouskas P, Parcharidou D, Karvounis H, Efthimiadis GK. Deciphering hypertrophic cardiomyopathy with electrocardiography. Heart Fail Rev 2021; 27:1313-1323. [PMID: 34286451 DOI: 10.1007/s10741-021-10147-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/10/2021] [Indexed: 11/30/2022]
Abstract
The comprehensive assessment of patients with hypertrophic cardiomyopathy is a complex process, with each step concurrently focusing on confirmation of the diagnosis, differentiation between sarcomeric and non-sarcomeric disease (phenocopy), and prognostication. Novel modalities such as genetic testing and advanced imaging have allowed for substantial advancements in the understanding of this condition and facilitate patient management. However, their availability is at present not universal, and interpretation requires a high level of expertise. In this setting, electrocardiography, a fast and widely available method, still retains a significant role in everyday clinical assessment of this population. In our review, we follow a stepwise approach for the interpretation of each electrocardiographic segment, discussing clinical implications of electrocardiographic patterns in sarcomeric disease, their value in the differential diagnosis from phenocopies, and impact on patient management. Outlining the substantial amount of information to be obtained from a simple tracing, we exhibit how electrocardiography is likely to remain an integral diagnostic tool in the future as well.
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Affiliation(s)
- Thomas Gossios
- Cardiology Department, NHS Foundation Trust, Guy's and St Thomas Westminster Bridge Road, London, SE1 7EH, UK. .,Inherited Cardiac Conditions Unit, Barts Heart Centre, St Bartholomew's Hospital, London, UK. .,Cardiomyopathies Laboratory, 1st Aristotle University of Thessaloniki Cardiology Department, AHEPA University Hospital, Thessaloniki, Greece.
| | - Konstantinos Savvatis
- Inherited Cardiac Conditions Unit, Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - Thomas Zegkos
- Cardiomyopathies Laboratory, 1st Aristotle University of Thessaloniki Cardiology Department, AHEPA University Hospital, Thessaloniki, Greece
| | - Dimitrios Ntelios
- Cardiomyopathies Laboratory, 1st Aristotle University of Thessaloniki Cardiology Department, AHEPA University Hospital, Thessaloniki, Greece
| | - Pavlos Rouskas
- Cardiomyopathies Laboratory, 1st Aristotle University of Thessaloniki Cardiology Department, AHEPA University Hospital, Thessaloniki, Greece
| | - Despoina Parcharidou
- Cardiomyopathies Laboratory, 1st Aristotle University of Thessaloniki Cardiology Department, AHEPA University Hospital, Thessaloniki, Greece
| | - Haralambos Karvounis
- Cardiomyopathies Laboratory, 1st Aristotle University of Thessaloniki Cardiology Department, AHEPA University Hospital, Thessaloniki, Greece
| | - Georgios K Efthimiadis
- Cardiomyopathies Laboratory, 1st Aristotle University of Thessaloniki Cardiology Department, AHEPA University Hospital, Thessaloniki, Greece
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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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Prognostic Value of Reduced Heart Rate Reserve during Exercise in Hypertrophic Cardiomyopathy. J Clin Med 2021; 10:jcm10071347. [PMID: 33805111 PMCID: PMC8037369 DOI: 10.3390/jcm10071347] [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: 02/23/2021] [Revised: 03/15/2021] [Accepted: 03/18/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Sympathetic dysfunction can be evaluated by heart rate reserve (HRR) with exercise test. OBJECTIVES To determine the value of HRR in predicting outcome of patients with hypertrophic cardiomyopathy (HCM). METHODS We enrolled 917 HCM patients (age = 49 ± 15 years, 516 men) assessed with exercise stress echocardiography (ESE) in 11 centres. ESE modality was semi-supine bicycle in 51 patients (6%), upright bicycle in 476 (52%), and treadmill in 390 (42%). During ESE, we assessed left ventricular outflow tract obstruction (LVOTO), stress-induced new regional wall motion abnormalities (RWMA), and HRR (peak/rest heart rate, HR). By selection, all patients completed the follow-up. Mortality was the predetermined outcome measure Results: During ESE, RWMA occurred in 22 patients (2.4%) and LVOTO (≥50 mmHg) in 281 (30.4%). HRR was 1.90 ± 0.40 (lowest quartile ≤ 1.61, highest quartile > 2.13). Higher resting heart rate (odds ratio 1.027, 95% CI: 1.018-1.036, p < 0.001), older age (odds ratio 1.021, 95% CI: 1.009-1.033, p < 0.001), lower exercise tolerance (mets, odds ratio 0.761, 95% CI: 0.708-0.817, p < 0.001) and resting LVOTO (odds ratio 1.504, 95% CI: 1.043-2.170, p = 0.029) predicted a reduced HRR. During a median follow-up of 89 months (interquartile range: 36-145 months), 90 all-cause deaths occurred. At multivariable analysis, lowest quartile HRR (Hazard ratio 2.354, 95% CI 1.116-4.968 p = 0.025) and RWMA (Hazard ratio 3.279, 95% CI 1.441-7.461 p = 0.004) independently predicted death, in addition to age (Hazard ratio 1.064, 95% CI 1.043-1.085 p < 0.001) and maximal wall thickness (Hazard ratio 1.081, 95% CI 1.037-1.128, p < 0.001). CONCLUSIONS A blunted HRR during ESE predicts survival independently of RWMA in HCM patients.
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8
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Bhattacharya M, Lu DY, Ventoulis I, Greenland GV, Yalcin H, Guan Y, Marine JE, Olgin JE, Zimmerman SL, Abraham TP, Abraham MR, Shatkay H. Machine Learning Methods for Identifying Atrial Fibrillation Cases and Their Predictors in Patients With Hypertrophic Cardiomyopathy: The HCM-AF-Risk Model. CJC Open 2021; 3:801-813. [PMID: 34169259 PMCID: PMC8209373 DOI: 10.1016/j.cjco.2021.01.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 01/25/2021] [Indexed: 02/07/2023] Open
Abstract
Background Hypertrophic cardiomyopathy (HCM) patients have a high incidence of atrial fibrillation (AF) and increased stroke risk, even with low CHA2DS2-VASc (congestive heart failure, hypertension, age diabetes, previous stroke/transient ischemic attack) scores. Hence, there is a need to understand the pathophysiology of AF/stroke in HCM. In this retrospective study, we develop and apply a data-driven, machine learning–based method to identify AF cases, and clinical/imaging features associated with AF, using electronic health record data. Methods HCM patients with documented paroxysmal/persistent/permanent AF (n = 191) were considered AF cases, and the remaining patients in sinus rhythm (n = 640) were tagged as No-AF. We evaluated 93 clinical variables; the most informative variables useful for distinguishing AF from No-AF cases were selected based on the 2-sample t test and the information gain criterion. Results We identified 18 highly informative variables that are positively (n = 11) and negatively (n = 7) correlated with AF in HCM. Next, patient records were represented via these 18 variables. Data imbalance resulting from the relatively low number of AF cases was addressed via a combination of oversampling and undersampling strategies. We trained and tested multiple classifiers under this sampling approach, showing effective classification. Specifically, an ensemble of logistic regression and naïve Bayes classifiers, trained based on the 18 variables and corrected for data imbalance, proved most effective for separating AF from No-AF cases (sensitivity = 0.74, specificity = 0.70, C-index = 0.80). Conclusions Our model (HCM-AF-Risk Model) is the first machine learning–based method for identification of AF cases in HCM. This model demonstrates good performance, addresses data imbalance, and suggests that AF is associated with a more severe cardiac HCM phenotype.
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Affiliation(s)
- Moumita Bhattacharya
- Computational Biomedicine and Machine Learning Lab, Department of Computer and Information Sciences, University of Delaware, Newark, Delaware, USA
| | - Dai-Yin Lu
- Hypertrophic Cardiomyopathy Center of Excellence, Johns Hopkins University, Baltimore, Maryland, USA.,Division of General Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Public Health, National Yang-Ming University, Taipei, Taiwan.,Hypertrophic Cardiomyopathy Center of Excellence, Division of Cardiology, University of California San Francisco, San Francisco, California, USA
| | - Ioannis Ventoulis
- Hypertrophic Cardiomyopathy Center of Excellence, Johns Hopkins University, Baltimore, Maryland, USA
| | - Gabriela V Greenland
- Hypertrophic Cardiomyopathy Center of Excellence, Johns Hopkins University, Baltimore, Maryland, USA.,Hypertrophic Cardiomyopathy Center of Excellence, Division of Cardiology, University of California San Francisco, San Francisco, California, USA
| | - Hulya Yalcin
- Hypertrophic Cardiomyopathy Center of Excellence, Johns Hopkins University, Baltimore, Maryland, USA
| | - Yufan Guan
- Hypertrophic Cardiomyopathy Center of Excellence, Johns Hopkins University, Baltimore, Maryland, USA
| | - Joseph E Marine
- Hypertrophic Cardiomyopathy Center of Excellence, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jeffrey E Olgin
- Hypertrophic Cardiomyopathy Center of Excellence, Division of Cardiology, University of California San Francisco, San Francisco, California, USA
| | - Stefan L Zimmerman
- Department of Radiology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Theodore P Abraham
- Hypertrophic Cardiomyopathy Center of Excellence, Johns Hopkins University, Baltimore, Maryland, USA.,Hypertrophic Cardiomyopathy Center of Excellence, Division of Cardiology, University of California San Francisco, San Francisco, California, USA
| | - M Roselle Abraham
- Hypertrophic Cardiomyopathy Center of Excellence, Johns Hopkins University, Baltimore, Maryland, USA.,Hypertrophic Cardiomyopathy Center of Excellence, Division of Cardiology, University of California San Francisco, San Francisco, California, USA
| | - Hagit Shatkay
- Computational Biomedicine and Machine Learning Lab, Department of Computer and Information Sciences, University of Delaware, Newark, Delaware, USA
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9
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Lu DY, Yalçin H, Sivalokanathan S, Greenland GV, Vasquez N, Yalçin F, Zhao M, Valenta I, Ganz P, Pampaloni MH, Zimmerman S, Schindler TH, Abraham TP, Abraham MR. Higher incidence of vasodilator-induced left ventricular cavity dilation by PET when compared to treadmill exercise-ECHO in hypertrophic cardiomyopathy. J Nucl Cardiol 2020; 27:2031-2043. [PMID: 30456498 DOI: 10.1007/s12350-018-01521-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 10/26/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Vasodilator-induced transient left ventricular cavity dilation (LVCD) by positron emission tomography (PET) is associated with microvascular dysfunction in hypertrophic cardiomyopathy (HCM). Here we assessed whether HCM patients who develop LVCD by PET during vasodilator stress also develop LV cavity dilation by echocardiography (ECHO-LVCD) following exercise stress. METHODS A retrospective analysis of cardiac function and myocardial blood flow (MBF) was conducted in 108 HCM patients who underwent perfusion-PET and exercise-ECHO as part of their clinical evaluation. We performed a head-to-head comparison of LV volumes and ejection fraction (LVEF) at rest and stress (during vasodilator stress, post-exercise), in 108 HCM patients. A ratio > 1.13 of stress to rest LV volumes was used to define PET-LVCD, and a ratio > 1.17 of stress to rest LVESV was used to define ECHO-LVCD. Patients were divided into 2 groups based on the presence/absence of PET-LVCD. MBF and myocardial flow reserve were quantified by PET, and global longitudinal strain (GLS) was assessed by ECHO at rest/stress in the two groups. RESULTS PET-LVCD was observed in 51% (n = 55) of HCM patients, but only one patient had evidence of ECHO-LVCD (ratio = 1.36)-this patient also had evidence of PET-LVCD (ratio = 1.20). The PET-LVCD group had lower PET-LVEF during vasodilator stress, but ECHO-LVEF increased in both groups post-exercise. The PET-LVCD group demonstrated higher LV mass, worse GLS at rest/stress, and lower myocardial flow reserve. Incidence of ischemic ST-T changes was higher in the PET-LVCD group during vasodilator stress (42 vs 17%), but similar (30%) in the two groups during exercise. CONCLUSION PET-LVCD reflects greater degree of myopathy and microvascular dysfunction in HCM. Differences in the cardiac effects of exercise and vasodilators and timing of stress-image acquisition could underlie discordance in ischemic EKG changes and LVCD by ECHO and PET, in HCM.
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Affiliation(s)
- Dai-Yin Lu
- Hypertrophic Cardiomyopathy Center of Excellence, Johns Hopkins University, Baltimore, MD, USA
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Public Health, National Yang-Ming University, Taipei, Taiwan
| | - Hulya Yalçin
- Hypertrophic Cardiomyopathy Center of Excellence, Johns Hopkins University, Baltimore, MD, USA
| | - Sanjay Sivalokanathan
- Hypertrophic Cardiomyopathy Center of Excellence, Johns Hopkins University, Baltimore, MD, USA
| | - Gabriela V Greenland
- Hypertrophic Cardiomyopathy Center of Excellence, Johns Hopkins University, Baltimore, MD, USA
- Division of Cardiology, University of California San Francisco, 555 Mission Bay Blvd South, Smith Cardiovascular Research Building, 452K, San Francisco, CA, 94158, USA
| | - Nestor Vasquez
- Hypertrophic Cardiomyopathy Center of Excellence, Johns Hopkins University, Baltimore, MD, USA
| | - Fatih Yalçin
- Hypertrophic Cardiomyopathy Center of Excellence, Johns Hopkins University, Baltimore, MD, USA
| | - Min Zhao
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Ines Valenta
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Peter Ganz
- Division of Cardiology, University of California San Francisco, 555 Mission Bay Blvd South, Smith Cardiovascular Research Building, 452K, San Francisco, CA, 94158, USA
| | - Miguel Hernandez Pampaloni
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, USA
| | - Stefan Zimmerman
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Thomas H Schindler
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Theodore P Abraham
- Hypertrophic Cardiomyopathy Center of Excellence, Johns Hopkins University, Baltimore, MD, USA
- Division of Cardiology, University of California San Francisco, 555 Mission Bay Blvd South, Smith Cardiovascular Research Building, 452K, San Francisco, CA, 94158, USA
| | - M Roselle Abraham
- Hypertrophic Cardiomyopathy Center of Excellence, Johns Hopkins University, Baltimore, MD, USA.
- Division of Cardiology, University of California San Francisco, 555 Mission Bay Blvd South, Smith Cardiovascular Research Building, 452K, San Francisco, CA, 94158, USA.
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10
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Rigopoulos AG, Panou F, Sakadakis E, Frogoudaki A, Papadopoulou K, Triantafyllidi H, Ali M, Iliodromitis E, Rizos I, Noutsias M. Cardiopulmonary Exercise Test Parameters at Three Months After Alcohol Septal Ablation in Hypertrophic Obstructive Cardiomyopathy Are Associated With Late Clinical Outcome. Heart Lung Circ 2020; 29:202-210. [DOI: 10.1016/j.hlc.2018.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 09/27/2018] [Accepted: 12/15/2018] [Indexed: 11/27/2022]
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11
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Bhattacharya M, Lu DY, Kudchadkar SM, Greenland GV, Lingamaneni P, Corona-Villalobos CP, Guan Y, Marine JE, Olgin JE, Zimmerman S, Abraham TP, Shatkay H, Abraham MR. Identifying Ventricular Arrhythmias and Their Predictors by Applying Machine Learning Methods to Electronic Health Records in Patients With Hypertrophic Cardiomyopathy (HCM-VAr-Risk Model). Am J Cardiol 2019; 123:1681-1689. [PMID: 30952382 DOI: 10.1016/j.amjcard.2019.02.022] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 02/06/2019] [Accepted: 02/11/2019] [Indexed: 01/19/2023]
Abstract
Clinical risk stratification for sudden cardiac death (SCD) in hypertrophic cardiomyopathy (HC) employs rules derived from American College of Cardiology Foundation/American Heart Association (ACCF/AHA) guidelines or the HCM Risk-SCD model (C-index ∼0.69), which utilize a few clinical variables. We assessed whether data-driven machine learning methods that consider a wider range of variables can effectively identify HC patients with ventricular arrhythmias (VAr) that lead to SCD. We scanned the electronic health records of 711 HC patients for sustained ventricular tachycardia or ventricular fibrillation. Patients with ventricular tachycardia or ventricular fibrillation (n = 61) were tagged as VAr cases and the remaining (n = 650) as non-VAr. The 2-sample ttest and information gain criterion were used to identify the most informative clinical variables that distinguish VAr from non-VAr; patient records were reduced to include only these variables. Data imbalance stemming from low number of VAr cases was addressed by applying a combination of over- and undersampling strategies. We trained and tested multiple classifiers under this sampling approach, showing effective classification. We evaluated 93 clinical variables, of which 22 proved predictive of VAr. The ensemble of logistic regression and naïve Bayes classifiers, trained based on these 22 variables and corrected for data imbalance, was most effective in separating VAr from non-VAr cases (sensitivity = 0.73, specificity = 0.76, C-index = 0.83). Our method (HCM-VAr-Risk Model) identified 12 new predictors of VAr, in addition to 10 established SCD predictors. In conclusion, this is the first application of machine learning for identifying HC patients with VAr, using clinical attributes. Our model demonstrates good performance (C-index) compared with currently employed SCD prediction algorithms, while addressing imbalance inherent in clinical data.
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Affiliation(s)
- Moumita Bhattacharya
- Department of Computer and Information Sciences, Computational Biomedicine Lab, University of Delaware, Newark, Delaware
| | - Dai-Yin Lu
- Hypertrophic Cardiomyopathy Center of Excellence, Johns Hopkins University, Baltimore, Maryland; Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Public Health, National Yang-Ming University, Taipei, Taiwan
| | - Shibani M Kudchadkar
- Hypertrophic Cardiomyopathy Center of Excellence, Johns Hopkins University, Baltimore, Maryland
| | - Gabriela Villarreal Greenland
- Hypertrophic Cardiomyopathy Center of Excellence, Johns Hopkins University, Baltimore, Maryland; Division of Cardiology, Hypertrophic Cardiomyopathy Center of Excellence, University of California San Francisco, San Francisco, California
| | - Prasanth Lingamaneni
- Hypertrophic Cardiomyopathy Center of Excellence, Johns Hopkins University, Baltimore, Maryland
| | - Celia P Corona-Villalobos
- Hypertrophic Cardiomyopathy Center of Excellence, Johns Hopkins University, Baltimore, Maryland; Department of Radiology, Johns Hopkins University, Baltimore, Maryland
| | - Yufan Guan
- Hypertrophic Cardiomyopathy Center of Excellence, Johns Hopkins University, Baltimore, Maryland
| | - Joseph E Marine
- Hypertrophic Cardiomyopathy Center of Excellence, Johns Hopkins University, Baltimore, Maryland
| | - Jeffrey E Olgin
- Division of Cardiology, Hypertrophic Cardiomyopathy Center of Excellence, University of California San Francisco, San Francisco, California
| | - Stefan Zimmerman
- Department of Radiology, Johns Hopkins University, Baltimore, Maryland
| | - Theodore P Abraham
- Hypertrophic Cardiomyopathy Center of Excellence, Johns Hopkins University, Baltimore, Maryland; Division of Cardiology, Hypertrophic Cardiomyopathy Center of Excellence, University of California San Francisco, San Francisco, California
| | - Hagit Shatkay
- Department of Computer and Information Sciences, Computational Biomedicine Lab, University of Delaware, Newark, Delaware; Hypertrophic Cardiomyopathy Center of Excellence, Johns Hopkins University, Baltimore, Maryland.
| | - Maria Roselle Abraham
- Hypertrophic Cardiomyopathy Center of Excellence, Johns Hopkins University, Baltimore, Maryland; Division of Cardiology, Hypertrophic Cardiomyopathy Center of Excellence, University of California San Francisco, San Francisco, California.
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12
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Coats CJ. The vital role of exercise testing in hypertrophic cardiomyopathy. Int J Cardiol 2018; 271:200-201. [DOI: 10.1016/j.ijcard.2018.06.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 06/06/2018] [Indexed: 11/25/2022]
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13
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Magri D, Agostoni P, Sinagra G, Re F, Correale M, Limongelli G, Zachara E, Mastromarino V, Santolamazza C, Casenghi M, Pacileo G, Valente F, Morosin M, Musumeci B, Pagannone E, Maruotti A, Uguccioni M, Volpe M, Autore C. Clinical and prognostic impact of chronotropic incompetence in patients with hypertrophic cardiomyopathy. Int J Cardiol 2018; 271:125-131. [PMID: 30087038 DOI: 10.1016/j.ijcard.2018.04.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 03/23/2018] [Accepted: 04/05/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND A blunted heart rate (HR) response is associated with an impaired peak oxygen uptake (pVO2), a powerful outcome predictor in hypertrophic cardiomyopathy (HCM). The present multicenter study sought to determine the prognostic role for exercise-induced HR response in HCM. METHODS A total of 681 consecutive HCM outpatients on optimized treatment were recruited. The heart failure (HF) end-point was death due to HF, cardiac transplantation, NYHA III-IV class progression, HF worsening leading to hospitalization and severe functional deterioration leading to septal reduction. The sudden cardiac death (SCD) end-point included SCD, aborted SCD and appropriate implantable cardioverter defibrillator discharges. RESULTS During a median follow-up of 4.2 years (25-75th centile: 3.9-5.2), 81 patients reached the HF and 23 the SCD end-point. Covariates with independent effects on the HF end-point were left atrial diameter, left ventricular ejection fraction, maximal left ventricular outflow tract gradient and exercise cardiac power (ECP = pVO2∗systolic blood pressure) (C-Index = 0.807) whereas the HCM Risk-SCD score and the ECP remained associated with the SCD end-point (C-Index = 0.674). When the VO2-derived variables were not pursued, peak HR (pHR) re-entered in the multivariate HF model (C-Index = 0.777) and, marginally, in the SCD model (C-index = 0.656). A pHR = 70% of the maximum predicted resulted as the best cut-off value in predicting the HF-related events. CONCLUSIONS The cardiopulmonary exercise test is pivotal in the HCM management, however the pHR remains a meaningful alternative parameter. A pHR < 70% identified a HCM population at high risk of HF-related events, thus calling for a reappraisal of the chronotropic incompetence threshold in HCM.
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Affiliation(s)
- Damiano Magri
- Dpt Clinical and Molecular Medicine, Sapienza University, Rome, Italy.
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milano, Italy; Dpt of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Gianfranco Sinagra
- Cardiovascular Dpt "Ospedali Riuniti" Trieste and Postgraduate School Cardiovascular Sciences, University of Trieste Cardiology Division, Italy
| | - Federica Re
- Cardiac Arrhythmia Center and Cardiomyopathies Unit, San Camillo-Forlanini Hospital, Roma, Italy
| | | | | | - Elisabetta Zachara
- Cardiac Arrhythmia Center and Cardiomyopathies Unit, San Camillo-Forlanini Hospital, Roma, Italy
| | | | | | - Matteo Casenghi
- Dpt Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Giuseppe Pacileo
- Cardiologia SUN, Monaldi Hospital, II University of Naples, Naples, Italy
| | - Fabio Valente
- Cardiologia SUN, Monaldi Hospital, II University of Naples, Naples, Italy
| | - Marco Morosin
- Cardiovascular Dpt "Ospedali Riuniti" Trieste and Postgraduate School Cardiovascular Sciences, University of Trieste Cardiology Division, Italy
| | - Beatrice Musumeci
- Dpt Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Erika Pagannone
- Dpt Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Antonello Maruotti
- Dpt of Scienze economiche, politiche e delle lingue moderne - Libera Università SS Maria Assunta, Rome, Italy; Centre for innovation and leadership in health sciences, University of Southampton, Southampton, UK
| | - Massimo Uguccioni
- Cardiac Arrhythmia Center and Cardiomyopathies Unit, San Camillo-Forlanini Hospital, Roma, Italy
| | - Massimo Volpe
- Dpt Clinical and Molecular Medicine, Sapienza University, Rome, Italy; IRCCS - Neuromed, Pozzilli, IS, Italy
| | - Camillo Autore
- Dpt Clinical and Molecular Medicine, Sapienza University, Rome, Italy
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14
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Abstract
Understanding the functional limitation in hypertrophic cardiomyopathy, the most common inherited heart disease, is challenging. In addition to the occurrence of disease-related complications, several factors are potential determinants of exercise limitation, including left ventricular hypertrophy, myocardial fiber disarray, left ventricular outflow tract obstruction, microvascular ischemia, and interstitial fibrosis. Furthermore, drugs commonly used in the daily management of these patients may interfere with exercise capacity, especially those with a negative chronotropic effect. Cardiopulmonary exercise testing can safely and objectively evaluate the functional capacity of these patients and help the physician in understanding the mechanisms that underlie this limitation. Features that reduce exercise capacity may predict progression to heart failure in these patients and even the risk of sudden cardiac death.
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15
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Hussain N, Chaudhry W, Ahlberg AW, Amara RS, Elfar A, Parker MW, Savino JA, Titano R, Henzlova MJ, Duvall WL. An assessment of the safety, hemodynamic response, and diagnostic accuracy of commonly used vasodilator stressors in patients with severe aortic stenosis. J Nucl Cardiol 2017; 24:1200-1213. [PMID: 26979307 DOI: 10.1007/s12350-016-0427-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 01/21/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND Increasing numbers of patients are undergoing transcatheter aortic valve replacement, which often involves assessment of coronary artery disease ischemic burden. The safety and diagnostic accuracy of vasodilator stress agents in patients with severe aortic stenosis (AS) undergoing SPECT myocardial perfusion imaging (MPI) has not been established. METHODS Patients with severe AS (valve area <1 cm2) on echocardiography who underwent vasodilator stress SPECT MPI at two centers were identified. Patients with aortic valve intervention prior to MPI or who underwent concurrent exercise during stress testing were excluded. AS patients were matched to controls without AS based on age, gender, BMI, ejection fraction, and stress agent. Symptoms, serious adverse events, hemodynamic response, and correlation to invasive angiography were assessed. RESULTS A total of 95 cases were identified with 45% undergoing regadenoson, 31% dipyridamole, and 24% adenosine stress. A significant change in systolic blood pressure (BP), cases vs controls, was observed with adenosine [-17.9 ± 20.1 vs -2.6 ± 24.9 P = .03)], with a trend toward significance with regadenoson [-16.8 ± 20.3 vs -9.4 ± 17.9 (P = .08)] and dipyridamole [-17.8 ± 20.6 vs -9.0 ± 12.1 (P = .05)]. The change in heart rate was significantly different only for adenosine [5.3 ± 16.8 vs 14.2 ± 10.8 (P = .04)]. Overall, 45% of cases vs 24% of controls (P = .004) had a >20 mmHg decrease in systolic BP. Age, BMI, and resting systolic BP were related to a >20 mmHg decrease in systolic BP on univariate analysis, although only higher resting systolic BP was a predictor on multivariate analysis. In 33 patients who underwent angiography, the sensitivity, specificity, and diagnostic accuracy of vasodilator stress MPI was 77%, 69%, and 73%, respectively. No serious adverse events occurred in the severe AS patients. CONCLUSION Severe AS patients are more likely to have a hemodynamically significant decrease in systolic BP with vasodilator stress. There were no serious adverse events in this severe AS cohort with good diagnostic performance of MPI compared to angiography.
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Affiliation(s)
- Nasir Hussain
- Division of Cardiology, Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA
| | - Waseem Chaudhry
- Division of Cardiology, Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA
| | - Alan W Ahlberg
- Division of Cardiology, Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA
| | - Richard S Amara
- Department of Medicine, Mount Sinai Hospital, New York, NY, USA
| | - Ahmed Elfar
- Division of Cardiology, Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA
| | - Matthew W Parker
- Division of Cardiovascular Medicine, University of Massachusetts Medical Center, Worcester, MA, USA
| | - John A Savino
- Mount Sinai Heart, Mount Sinai Hospital, New York, NY, USA
| | - Ruwanthi Titano
- Department of Medicine, Mount Sinai Hospital, New York, NY, USA
| | | | - William L Duvall
- Division of Cardiology, Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA.
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16
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Kalyva A, Marketou ME, Parthenakis FI, Pontikoglou C, Kontaraki JE, Maragkoudakis S, Petousis S, Chlouverakis G, Papadaki HA, Vardas PE. Endothelial progenitor cells as markers of severity in hypertrophic cardiomyopathy. Eur J Heart Fail 2015; 18:179-84. [PMID: 26696595 DOI: 10.1002/ejhf.436] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 10/05/2015] [Accepted: 10/06/2015] [Indexed: 01/05/2023] Open
Abstract
AIMS Endothelial progenitor cells (EPCs) are bone marrow-derived cells that are mobilized into the circulation to migrate and differentiate into mature endothelial cells contributing to post-natal physiological and pathological neovascularization. In this study, we evaluated circulating EPCs in patients with hypertrophic cardiomyopathy (HCM) and examined a potential association with clinical parameters of the disease. METHODS AND RESULTS We included 40 HCM patients and 23 healthy individuals. Using flow cytometry we measured EPCs in peripheral blood as two subpopulations of CD45-/CD34+/VEGFR2+ and CD45-/CD34+/CD133+ cells. Circulating CD45-/CD34+/VEGFR2+ cells were significantly increased in HCM patients in comparison with the controls (0.000238 ± 0.0003136 vs. 0.000057 ± 0.0001316, respectively, P = 0.002). However, there was no significant difference in the number of circulating CD45-/CD34+/CD133+ cells (0.003079 ± 0.0033288 vs. 0.002065 ± 0.0022173, respectively, P = 0.153). The CD45-/CD34+/VEGFR2+ subpopulation revealed a moderate correlation with LV mass index (r = 0.35, P = 0.026), while both EPC subpopulation levels showed strong positive correlations with th E/e' ratio (r = 0.423, P = 0.007 for CD45-/CD34+/VEGFR2+ and r = 0.572, P < 0.001 for CD45-/CD34+/CD133+). CONCLUSION HCM patients showed an increased mobilization of EPCs compared with healthy individuals that correlated with diastolic dysfunction. Our findings may open up new dimensions in the pathophysiology, prognostication, and treatment of HCM.
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Affiliation(s)
- Athanasia Kalyva
- Molecular Cardiology Laboratory, School of Medicine, University of Crete, Greece
| | - Maria E Marketou
- Department of Cardiology, Heraklion University Hospital, Crete, Greece
| | | | | | - Joanna E Kontaraki
- Molecular Cardiology Laboratory, School of Medicine, University of Crete, Greece
| | | | | | | | - Helen A Papadaki
- Department of Haematology, Heraklion University Hospital, Crete, Greece
| | - Panos E Vardas
- Department of Cardiology, Heraklion University Hospital, Crete, Greece
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