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Sakai C, Kawasaki T, Kawamata H, Harimoto K, Shiraishi H, Matoba S. Absent fourth heart sound as a marker of adverse events in hypertrophic cardiomyopathy with sinus rhythm. Ann Noninvasive Electrocardiol 2022; 27:e12932. [PMID: 35146850 PMCID: PMC9107087 DOI: 10.1111/anec.12932] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 12/09/2021] [Accepted: 12/21/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Patients with hypertrophic cardiomyopathy (HCM) in sinus rhythm commonly show the fourth heart sound (S4). The lack of S4 may be a marker of impaired atrial function in HCM patients with sinus rhythm. METHODS AND RESULTS This retrospective study consisted of 47 patients with HCM who had undergone phonocardiography and a cardiopulmonary exercise test. The primary outcome was a composite of cardiac death, stroke, hospitalization for worsening heart failure, and newly developed atrial fibrillation (AF). S4 was detected in 38 of 43 patients with sinus rhythm (88%). Peak oxygen consumption was the highest in 38 sinus rhythm patients with S4 (23.6 ± 5.6 mL/kg/min), middle in five sinus rhythm patients without S4 (19.3 ± 6.7 mL/kg/min), and lowest in four patients with AF (15.7 ± 3.3 mL/kg/min, p = 0.01). After a median of 40.5 months, the incidence of the primary outcome was higher in patients without S4 than in those with S4 (33% vs. 8%; hazard ratio, 6.17; 95% confidence interval, 1.02 - 37.4; p = .04) and higher in sinus rhythm patients without S4 than in those with S4 (60% vs. 8%; hazard ratio, 12.05; 95% confidence interval, 2.31 - 71.41; p = .007). CONCLUSIONS The absence of S4 on phonocardiography was associated with impaired exercise tolerance and adverse cardiac events in HCM patients with sinus rhythm.
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Affiliation(s)
- Chieko Sakai
- Department of Cardiology, Matsushita Memorial Hospital, Osaka, Japan
| | - Tatsuya Kawasaki
- Department of Cardiology, Matsushita Memorial Hospital, Osaka, Japan
| | - Hirofumi Kawamata
- Department of Cardiology, Matsushita Memorial Hospital, Osaka, Japan
| | - Kuniyasu Harimoto
- Department of Cardiology, Matsushita Memorial Hospital, Osaka, Japan
| | - Hirokazu Shiraishi
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satoaki Matoba
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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O'Brien AC, MacDermott R, Keane S, Ryan D, McVeigh N, Durand R, Ferre M, Murphy DJ, Teekakirikul P, Keane D, McDonald K, Ledwidge M, Dodd JD. Cardiac MRI e-prime Predicts Myocardial Late Gadolinium Enhancement and Diastolic Dysfunction in Hypertrophic Cardiomyopathy. Eur J Radiol 2022; 149:110192. [DOI: 10.1016/j.ejrad.2022.110192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/27/2022] [Accepted: 01/29/2022] [Indexed: 11/17/2022]
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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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Chen CYJ, Su MYM, Liao YC, Chang FL, Wu CK, Lin LY, Chen YS, Lin YH, Hwang JJ, Yu SL, Kao HL, Chen WJ, Lu TP, Shih CY, Yeh SFS, Yang DH, Lai LP, Juang JMJ. Long-term outcomes and left ventricular diastolic function of sarcomere mutation-positive and mutation-negative patients with hypertrophic cardiomyopathy: a prospective cohort study. Eur Heart J Cardiovasc Imaging 2020:jeaa317. [PMID: 33221870 DOI: 10.1093/ehjci/jeaa317] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 11/06/2020] [Indexed: 02/24/2024] Open
Abstract
AIMS Hypertrophic cardiomyopathy (HCM) is an inheritable disease that leads to sudden cardiac death and heart failure (HF). Sarcomere mutations (SMs) have been associated with HF. However, the differences in ventricular function between SM-positive and SM-negative HCM patients are poorly characterized. METHODS AND RESULTS Of the prospectively enrolled 374 unrelated HCM patients in Taiwan, 115 patients underwent both 91 cardiomyopathy-related gene screening and cardiovascular magnetic resonance (45.6 ± 10.6 years old, 76.5% were male). Forty pathogenic/likely pathogenic mutations were identified in 52 patients by next-generation sequencing. The SM-positive group were younger at first cardiovascular event (P = 0.04) and progression to diastolic HF (P = 0.02) with higher N-terminal pro-brain natriuretic peptide (NT-proBNP) [New York Heart Association (NYHA) Class III/IV symptoms with left ventricular ejection fraction > 55%] than the SM-negative group (P < 0.001). SM-positive patients had a greater extent of late gadolinium enhancement (P = 0.01), larger left atrial diameter (P = 0.03), higher normalized peak filling rate (PFR) and PFR ratio, and a greater reduction in global longitudinal strain than SM-negative patients (all P ≤ 0.01). During mean lifelong follow-up time (49.2 ± 15.6 years), SM-positive was a predictor of earlier HF (NYHA Class III/IV symptoms) after multivariate adjustment (hazard ratio 3.5; 95% confidence interval 1.3-9.7; P = 0.015). CONCLUSION SM-positive HCM patients had a higher extent of myocardial fibrosis and more severe ventricular diastolic dysfunction than those without, which may contribute to earlier onset of advanced HF, suggesting the importance of close surveillance and early treatment throughout life.
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Affiliation(s)
- Ching-Yu Julius Chen
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, No. 7, Chung Shan S. Rd, Zhongzheng Dist., Taipei 10002, Taiwan
| | - Mao-Yuan Marine Su
- Department of Medical Imaging, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Ying-Chieh Liao
- Department of Internal Medicine, Cardiovascular Center, Chang-Hua Christian Hospital, Changhua City, Taiwan
| | - Fu-Lan Chang
- Department of Nursing, Taichung Veterans General Hospital; School of Nursing, China Medical University, Taichung, Taiwan
| | - Cho-Kai Wu
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, No. 7, Chung Shan S. Rd, Zhongzheng Dist., Taipei 10002, Taiwan
| | - Lian-Yu Lin
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, No. 7, Chung Shan S. Rd, Zhongzheng Dist., Taipei 10002, Taiwan
| | - Yih-Shurng Chen
- Cardiovascular Center and Division of Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Yen-Hung Lin
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, No. 7, Chung Shan S. Rd, Zhongzheng Dist., Taipei 10002, Taiwan
| | - Juey-Jen Hwang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Yun-lin Branch, Taipei, Taiwan
| | - Sung-Liang Yu
- Department of Clinical Laboratory Sciences and Medical Biotechnology, National Taiwan University Hospital, College of Medicine, Taipei, Taiwan
| | - Hsien-Li Kao
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, No. 7, Chung Shan S. Rd, Zhongzheng Dist., Taipei 10002, Taiwan
| | - Wen-Jone Chen
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, No. 7, Chung Shan S. Rd, Zhongzheng Dist., Taipei 10002, Taiwan
| | - Tzu-Pin Lu
- Department of Public Health, Institute of Epidemiology and Preventative Medicine, National Taiwan University, Taipei, Taiwan
| | - Ching-Yu Shih
- Department of Public Health, Institute of Epidemiology and Preventative Medicine, National Taiwan University, Taipei, Taiwan
| | - Shih-Fan Sherri Yeh
- Department of Environmental and Occupational Medicine, National Taiwan University Hospital, Hsin-Chu Branch, Taipei, Taiwan
| | - Dun-Hui Yang
- Department of Radiology, Tainan Municipal Hospital, Tainan City, Taiwan
| | - Ling-Ping Lai
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, No. 7, Chung Shan S. Rd, Zhongzheng Dist., Taipei 10002, Taiwan
| | - Jyh-Ming Jimmy Juang
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, No. 7, Chung Shan S. Rd, Zhongzheng Dist., Taipei 10002, Taiwan
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Seferović PM, Polovina M, Bauersachs J, Arad M, Gal TB, Lund LH, Felix SB, Arbustini E, Caforio AL, Farmakis D, Filippatos GS, Gialafos E, Kanjuh V, Krljanac G, Limongelli G, Linhart A, Lyon AR, Maksimović R, Miličić D, Milinković I, Noutsias M, Oto A, Oto Ö, Pavlović SU, Piepoli MF, Ristić AD, Rosano GM, Seggewiss H, Ašanin M, Seferović JP, Ruschitzka F, Čelutkiene J, Jaarsma T, Mueller C, Moura B, Hill L, Volterrani M, Lopatin Y, Metra M, Backs J, Mullens W, Chioncel O, Boer RA, Anker S, Rapezzi C, Coats AJ, Tschöpe C. Heart failure in cardiomyopathies: a position paper from the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2019; 21:553-576. [DOI: 10.1002/ejhf.1461] [Citation(s) in RCA: 133] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 02/20/2019] [Accepted: 02/28/2019] [Indexed: 12/20/2022] Open
Affiliation(s)
- Petar M. Seferović
- University of Belgrade Faculty of Medicine Belgrade Serbia
- Serbian Academy of Sciences and Arts Belgrade Serbia
| | - Marija Polovina
- University of Belgrade Faculty of Medicine Belgrade Serbia
- Department of CardiologyClinical Center of Serbia Belgrade Serbia
| | - Johann Bauersachs
- Department of Cardiology and AngiologyMedical School Hannover Hannover Germany
| | - Michael Arad
- Cardiomyopathy Clinic and Heart Failure Institute, Leviev Heart Center, Sheba Medical Center and Sackler School of Medicine, Tel Aviv University Tel Aviv Israel
| | - Tuvia Ben Gal
- Department of CardiologyRabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University Tel Aviv Israel
| | - Lars H. Lund
- Department of MedicineKarolinska Institutet, and Heart and Vascular Theme, Karolinska University Hospital Stockholm Sweden
| | - Stephan B. Felix
- Department of Internal Medicine BUniversity Medicine Greifswald Greifswald Germany
| | - Eloisa Arbustini
- Centre for Inherited Cardiovascular Diseases, IRCCS Foundation, University Hospital Policlinico San Matteo Pavia Italy
| | - Alida L.P. Caforio
- Division of Cardiology, Department of Cardiological, Thoracic and Vascular SciencesUniversity of Padua Padua Italy
| | - Dimitrios Farmakis
- University of Cyprus Medical School, Nicosia, Cyprus; Heart Failure Unit, Department of CardiologyAthens University Hospital Attikon, National and Kapodistrian University of Athens Athens Greece
| | - Gerasimos S. Filippatos
- University of Cyprus Medical School, Nicosia, Cyprus; Heart Failure Unit, Department of CardiologyAthens University Hospital Attikon, National and Kapodistrian University of Athens Athens Greece
| | - Elias Gialafos
- Second Department of CardiologyHeart Failure and Preventive Cardiology Section, Henry Dunant Hospital Athens Greece
| | | | - Gordana Krljanac
- University of Belgrade Faculty of Medicine Belgrade Serbia
- Department of CardiologyClinical Center of Serbia Belgrade Serbia
| | - Giuseppe Limongelli
- Department of Cardiothoracic Sciences, Università della Campania ‘Luigi VanvitellI’Monaldi Hospital, AORN Colli, Centro di Ricerca Cardiovascolare, Ospedale Monaldi, AORN Colli, Naples, Italy, and UCL Institute of Cardiovascular Science London UK
| | - Aleš Linhart
- Second Department of Medicine, Department of Cardiovascular MedicineGeneral University Hospital, Charles University in Prague Prague Czech Republic
| | - Alexander R. Lyon
- National Heart and Lung Institute, Imperial College London and Royal Brompton Hospital London UK
| | - Ružica Maksimović
- University of Belgrade Faculty of Medicine Belgrade Serbia
- Centre for Radiology and Magnetic Resonance Imaging, Clinical Centre of Serbia Belgrade Serbia
| | - Davor Miličić
- Department of Cardiovascular DiseasesUniversity Hospital Center Zagreb, University of Zagreb Zagreb Croatia
| | - Ivan Milinković
- Department of CardiologyClinical Center of Serbia Belgrade Serbia
| | - Michel Noutsias
- Mid‐German Heart Center, Department of Internal Medicine III, Division of CardiologyAngiology and Intensive Medical Care, University Hospital Halle, Martin‐Luther‐University Halle Halle Germany
| | - Ali Oto
- Department of CardiologyHacettepe University Faculty of Medicine Ankara Turkey
| | - Öztekin Oto
- Department of Cardiovascular SurgeryDokuz Eylül University Faculty of Medicine İzmir Turkey
| | - Siniša U. Pavlović
- University of Belgrade Faculty of Medicine Belgrade Serbia
- Pacemaker Center, Clinical Center of Serbia Belgrade Serbia
| | | | - Arsen D. Ristić
- University of Belgrade Faculty of Medicine Belgrade Serbia
- Department of CardiologyClinical Center of Serbia Belgrade Serbia
| | - Giuseppe M.C. Rosano
- Centre for Clinical and Basic Research, Department of Medical SciencesIRCCS San Raffaele Pisana Rome Italy
| | - Hubert Seggewiss
- Medizinische Klinik, Kardiologie & Internistische Intensivmedizin, Klinikum Würzburg‐Mitte Würzburg Germany
| | - Milika Ašanin
- University of Belgrade Faculty of Medicine Belgrade Serbia
- Department of CardiologyClinical Center of Serbia Belgrade Serbia
| | - Jelena P. Seferović
- Cardiovascular DivisionBrigham and Women's Hospital, Harvard Medical School Boston MA USA
- Clinic for Endocrinology, Diabetes and Metabolic Disorders, Clinical Center Serbia and Faculty of MedicineUniversity of Belgrade Belgrade Serbia
| | - Frank Ruschitzka
- Department of CardiologyUniversity Heart Center Zürich Switzerland
| | - Jelena Čelutkiene
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of MedicineVilnius University Vilnius Lithuania
- State Research Institute Centre for Innovative Medicine Vilnius Lithuania
| | - Tiny Jaarsma
- Department of Social and Welfare Studies, Faculty of Health ScienceLinköping University Linköping Sweden
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of CardiologyUniversity Hospital Basel, University of Basel Basel Switzerland
| | - Brenda Moura
- Cardiology DepartmentCentro Hospitalar São João Porto Portugal
| | - Loreena Hill
- School of Nursing and Midwifery, Queen's University Belfast Belfast UK
| | | | - Yuri Lopatin
- Volgograd State Medical University, Regional Cardiology Centre Volgograd Volgograd Russia
| | - Marco Metra
- Cardiology, Department of Medical and Surgical SpecialtiesRadiological Sciences, and Public Health, University of Brescia Brescia Italy
| | - Johannes Backs
- Department of Molecular Cardiology and EpigeneticsUniversity of Heidelberg Heidelberg Germany
- DZHK (German Centre for Cardiovascular Research) partner site Heidelberg/Mannheim Heidelberg Germany
| | - Wilfried Mullens
- BIOMED ‐ Biomedical Research Institute, Faculty of Medicine and Life SciencesHasselt University Diepenbeek Belgium
- Department of CardiologyZiekenhuis Oost‐Limburg Genk Belgium
| | - Ovidiu Chioncel
- University of Medicine Carol Davila Bucharest Romania
- Emergency Institute for Cardiovascular Diseases, ‘Prof. C. C. Iliescu’ Bucharest Romania
| | - Rudolf A. Boer
- Department of CardiologyUniversity Medical Center Groningen, University of Groningen Groningen The Netherlands
| | - Stefan Anker
- Division of Cardiology and Metabolism, Department of Cardiology (CVK)Charité Berlin Germany
- Berlin‐Brandenburg Center for Regenerative Therapies (BCRT) Berlin Germany
- DZHK (German Centre for Cardiovascular Research) partner site Berlin, Charité Berlin Germany
| | - Claudio Rapezzi
- Cardiology, Department of ExperimentalDiagnostic and Specialty Medicine, Alma Mater Studiorum University of Bologna Bologna Italy
| | - Andrew J.S. Coats
- Monash University, Australia, and University of Warwick Coventry UK
- Pharmacology, Centre of Clinical and Experimental Medicine, IRCCS San Raffaele Pisana, Rome, Italy, and St George's University of London London UK
| | - Carsten Tschöpe
- Berlin‐Brandenburg Center for Regenerative Therapies, Deutsches Zentrum für Herz‐Kreislauf‐Forschung (DZHK) Berlin, Department of CardiologyCampus Virchow Klinikum, Charite ‐ Universitaetsmedizin Berlin Berlin Germany
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Shimada YJ, Hoeger CW, Latif F, Takayama H, Ginns J, Maurer MS. Myocardial Contraction Fraction Predicts Cardiovascular Events in Patients With Hypertrophic Cardiomyopathy and Normal Ejection Fraction. J Card Fail 2019; 25:450-456. [PMID: 30928539 DOI: 10.1016/j.cardfail.2019.03.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 12/10/2018] [Accepted: 03/21/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Myocardial contraction fraction (MCF), the ratio of left ventricular stroke volume to myocardial volume, is a novel parameter that can distinguish between pathologic and physiologic hypertrophy. However, its prognostic value in hypertrophic cardiomyopathy (HCM) has never been examined. The objective was to determine if MCF is associated with functional capacity and predicts adverse cardiovascular outcomes in patients with HCM and normal left ventricular ejection fraction (LVEF). METHODS AND RESULTS We conducted a prospective cohort study of 137 patients with HCM and LVEF ≥55%. Patients were followed for 2.7 ± 2.5 years. We examined association of MCF with New York Heart Association (NYHA) functional class and a composite outcome of embolic stroke, heart transplantation, and cardiac death. We performed time-to-event analysis with the use of Cox proportional hazards modeling and stepwise elimination. The average age was 52 ± 18 years. The average MCF was 26 ± 11%. MCF was inversely correlated with NYHA functional class (P = .001). A total of 20 subjects experienced an outcome event with an event rate of 5.6% per patient-year. MCF independently predicted the outcome (adjusted hazard ratio 0.50 per 10% increase, 95% confidence interval 0.28-0.90, adjusted P = .02). CONCLUSIONS In patients with HCM and normal LVEF, MCF is associated with functional capacity and independently predicts adverse cardiovascular outcomes.
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Affiliation(s)
- Yuichi J Shimada
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York; Cardiology Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
| | - Christopher W Hoeger
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Farhana Latif
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Hiroo Takayama
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Jonathan Ginns
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Mathew S Maurer
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
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7
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Çetin S, Vural M, Akdemir R, Fırat H. Left atrial remodelling may predict exercise capacity in obstructive sleep apnoea patients. Acta Cardiol 2018; 73:471-478. [PMID: 29235925 DOI: 10.1080/00015385.2017.1414730] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Left atrial volume (LAV) and LA deformation has been proposed as a good marker of exercise performance in patients with diastolic dysfunction (DD). As DD is more prevalent in obstructive sleep apnoea (OSA) we aimed to evaluate the influence of LAV and LA deformation parameters on exercise performance in varying severity of OSA. MATERIALS AND METHODS OSA was diagnosed after polysomnography. Fifty-five OSA patients were enrolled in the study. OSA patients were divided into two groups with apnoea-hypopna-index (AHI) > 30 and <30. LAV was calculated. LA strain and LA strain rates were assessed with speckle tracking echocardiography (STE). Exercise capacity was evaluated by treadmill exercise test. RESULTS MET values were lower in group II compared to group I (p < .05). Echocardiographic findings: Comparison within groups: In both groups E/E', LA stain, LA strain rate S and LA strain rate E were higher after exercise than before (p < .05). In group I LA strain rate A was higher after exercise than before (p < .05). Comparison between groups: LA strain, LA strain rate S, LA strain rate E and LA strain rate A were lower and E/E' and LAVI were higher in group II compared to group I before and after exercise (p < .05). Correlation with METs: AHI, LVEDV, E/E' and LAVI were negatively and LA strain was positively correlated with METs (p < .05). CONCLUSIONS Left ventricular diastolic dysfunction is more prevalent in severe OSA and is associated with impaired exercise performance. Additionally, LA remodelling may predict exercise capacity in this subgroup of patients.
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Affiliation(s)
- Süha Çetin
- Department of Cardiology, Okan University Hospital , Istanbul , Turkey
| | - Mustafa Vural
- Department of Cardiology, Sakarya University School of Medicine , Sakarya , Turkey
| | - Ramazan Akdemir
- Department of Cardiology, Sakarya University School of Medicine , Sakarya , Turkey
| | - Hikmet Fırat
- Pulmonology Clinic, Ministery of Health Dışkapı Yıldırım Beyazıt Research and Educational Hospital , Ankara , Turkey
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9
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Dissecting functional impairment in hypertrophic cardiomyopathy by dynamic assessment of diastolic reserve and outflow obstruction: A combined cardiopulmonary-echocardiographic study. Int J Cardiol 2017; 227:743-750. [DOI: 10.1016/j.ijcard.2016.10.067] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 10/22/2016] [Accepted: 10/26/2016] [Indexed: 11/20/2022]
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10
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Axelsson A, Iversen K, Vejlstrup N, Ho CY, Havndrup O, Kofoed KF, Norsk J, Jensen M, Bundgaard H. Functional effects of losartan in hypertrophic cardiomyopathy-a randomised clinical trial. Heart 2015; 102:285-91. [PMID: 26661322 DOI: 10.1136/heartjnl-2015-308343] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 11/16/2015] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE There is a lack of disease-modifying treatments in hypertrophic cardiomyopathy (HCM). The aim of this randomised, placebo-controlled study was to assess if losartan could improve or ameliorate deterioration of cardiac function and exercise capacity. METHODS Echocardiography, exercise test and MRI or CT were performed at baseline and after 12 months in 133 patients (52±13 years, 35% female) randomly allocated to losartan (100 mg/day) or placebo. RESULTS Losartan had no effect on systolic function compared with placebo (mean difference for left ventricular ejection fraction (LVEF) 0% (95% CI -3% to 4%), p=0.84 or global longitudinal strain 0.7% (95% CI -0.2% to 1.6%), p=0.13). Neither Doppler measures of diastolic function, left atrial volume (mean difference 2 mL/m(2) (95% CI -4 to 8 mL/m(2)) p=0.53) nor exercise capacity (mean difference -0.3 metabolic equivalents (METS) (95% CI -1.0 to 0.3 METS), p=0.28) differed between the treatment groups. At follow-up, there was further progression of disease, with the most prominent impairment being an increase in left atrial volume of 6 mL/m(2) (95% CI 3 to 9 mL/m(2), p<0.0001) in both groups combined. LVEF decreased (mean change -2%, (95% CI -3% to -1%), p=0.037) and 4% of patients had end-stage HCM with a LVEF of less than 50% at the end of the study. CONCLUSION Treatment with losartan had no effect on cardiac function or exercise capacity compared with placebo. Losartan fail to improve myocardial performance and failed to alter the progression of the disease. These findings do not support the use of angiotensin II receptor blockers as disease modifiers in adult patients with overt HCM. TRIAL REGISTRATION NUMBER NCT01447654-results.
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Affiliation(s)
- Anna Axelsson
- Unit for Inherited Cardiac Diseases, Department of Cardiology, The Heart Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Kasper Iversen
- Department of Cardiology, Copenhagen University Hospital Herlev Hospital, Herlev, Denmark
| | - Niels Vejlstrup
- Unit for Inherited Cardiac Diseases, Department of Cardiology, The Heart Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Carolyn Y Ho
- Cardiovascular Division, Brigham and Women's Hospital, Boston, USA
| | - Ole Havndrup
- Department of Cardiology, Roskilde Hospital, Roskilde, Denmark
| | - Klaus F Kofoed
- Unit for Inherited Cardiac Diseases, Department of Cardiology, The Heart Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jakob Norsk
- Unit for Inherited Cardiac Diseases, Department of Cardiology, The Heart Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Morten Jensen
- Unit for Inherited Cardiac Diseases, Department of Cardiology, The Heart Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Henning Bundgaard
- Unit for Inherited Cardiac Diseases, Department of Cardiology, The Heart Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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11
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Geske JB, Allison TG, Gersh BJ. Cardiopulmonary Limitation in Hypertrophic Cardiomyopathy: Unscrambling the Rubik's Cube. JACC. HEART FAILURE 2015; 3:419-421. [PMID: 25863971 DOI: 10.1016/j.jchf.2014.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 11/21/2014] [Indexed: 06/04/2023]
Affiliation(s)
- Jeffrey B Geske
- Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Thomas G Allison
- Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Bernard J Gersh
- Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, Minnesota.
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12
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Ma G, Xu M, Gao W, Li Z, Li W, Chen B, Feng J, Wang H, Ma W, Chen H, Shen A, Feng X, Zhang Y. Left ventricular filling pressure assessed by exercise TDI was correlated with early HFNEF in patients with non-obstructive hypertrophic cardiomyopathy. BMC Cardiovasc Disord 2014; 14:194. [PMID: 25524147 PMCID: PMC4289563 DOI: 10.1186/1471-2261-14-194] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 06/23/2014] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Hypertrophic cardiomyopathy (HCM) patients are more susceptible to suffer from heart failure with normal ejection fraction (HFNEF). Therefore, it is critical to evaluate the relationship between left ventricular filling pressure (LVFP) and HFNEF, even if a large proportion of HCM patients have normal LVFP at rest. The objective was to assess the correlation between exercise tissue Doppler imaging (TDI) and early HFNEF in HCM patients by treadmill exercise echocardiography combined with cardiopulmonary exercise test (CPET). METHOD Twenty-seven non-obstructive HCM patients and 31 age- and gender-matched healthy volunteers were enrolled in this study. All subjects underwent treadmill exercise echocardiography combined with CPET. N-terminal pro-brain natriuretic peptide (NT-proBNP) levels were analyzed before and after exercise. RESULT Five HCM patients had normal LVFP at rest and increased after exercise. For this subgroup, the relationship between minute ventilation and carbon dioxide production (VE/VCO2 slope) and NT-proBNP levels were higher compared with controls and the subgroup with normal resting and stress LVFP, but was similar to the subgroup with elevated LVFP both at rest and after exercise. CONCLUSION Elevated LVFP after exercise suggested the occurrence of early HFNEF in patients with non-obstructive HCM.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Xinheng Feng
- Department of Cardiology, Peking University Third Hospital, 100191 Beijing, China.
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13
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Avegliano G, Costabel JP, Huguet M, Thierer J, Trivi M, Catalina TG, Petit M, Bijnens B, Frangi A, Ronderos R. Influence of dynamic obstruction and hypertrophy location on diastolic function in hypertrophic cardiomyopathy. J Cardiovasc Med (Hagerstown) 2014; 15:207-13. [PMID: 24662413 DOI: 10.2459/jcm.0b013e3283638093] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Hypertrophic cardiomyopathy (HCM) is a disease with marked genetic and phenotypic heterogeneity. It is well known that obstructive septal forms of this disease entail worse clinical outcome compared with nonobstructive septal and apical forms. The objective of this study was to analyze the differences in left ventricular diastolic function in different subgroups of HCMs and to assess the influence of the location of myocardial hypertrophy and the presence of dynamic obstruction on impairment of diastolic function and its correlation with the clinical status. METHODS We studied 86 patients with HCM; 27 with the obstructive asymmetric septal type (OAS), 37 with the nonobstructive asymmetric septal type (NOAS) and 22 with apical hypertrophic cardiomyopathy (ApHCM). Patients underwent conventional and tissue Doppler echocardiography and were assessed applying the latest recommendations regarding diastolic dysfunction. Cardiac magnetic resonance was used to study the various morphologic subtypes and quantify left ventricular mass (LVM). RESULTS The early diastolic annular velocity (e') was significantly lower in OAS with a median of 5 cm/s compared with NOAS with 7 cm/s and ApHCM with 7.5 cm/s (P = 0.0002), and the E/e' ratio was 8.5 in ApHCM, 10 in NOAS and 14 in OAS (P = 0.0001); no significant differences were found in LVM or maximal wall thickness. CONCLUSION In HCM, the location of left ventricular hypertrophy and the presence of dynamic obstruction affect the degree of diastolic dysfunction; impairment is greater in patients with the OAS type, and markedly less in patients with apical involvement.
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Affiliation(s)
- Gustavo Avegliano
- aCardiac Imaging Department, Instituto Cardiovascular de Buenos Aires, Buenos Aires, Argentina bCenter for Computational Imaging and Simulation Technologies in Biomedicine, Universitat Pompeu Fabra cCetir Sant Jordi dCentro Cardiovascular Sant Jordi eInstitució Catalana de Recerca i Estudis Avançats, Barcelona, Spain
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14
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Magrì D, Agostoni P, Cauti FM, Musumeci B, Egidy Assenza G, De Cecco CN, Muscogiuri G, Maruotti A, Ricotta A, Pagannone E, Marino L, Santini D, Proietti G, Serdoz A, Paneni F, Volpe M, Autore C. Determinants of peak oxygen uptake in patients with hypertrophic cardiomyopathy: a single-center study. Intern Emerg Med 2014; 9:293-302. [PMID: 23054411 DOI: 10.1007/s11739-012-0866-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2012] [Accepted: 09/22/2012] [Indexed: 10/27/2022]
Abstract
Most patients with hypertrophic cardiomyopathy (HCM) usually complain of a reduced exercise capacity, and several factors have been advocated as possible causes of this clinical feature. The present single-center study was designed to investigate exercise capacity and its main clinical determinants in HCM patients. One hundred ninety seven patients of 223 evaluated underwent a complete clinical assessment, including Doppler echocardiography, cardiopulmonary exercise test (CPET) and, in most cases, cardiac magnetic resonance. The HCM population (male 75 %; age 47 ± 16 years; NYHA class I or II 95 %; left ventricular ejection fraction 61 ± 3 %; resting left ventricular outflow tract gradient ≥30 mmHg 22 %; late gadolinium enhancement presence 58 %) showed slightly reduced mean peak oxygen uptake values (pVO2 75 ± 15 %, 23.2 ± 6.7 ml/kg/min) with a significant reduction of the achieved percentage of peak heart rate reserve (%pHRR 65 ± 20 %). Adopting a pVO2 <80 % cut-off value, 59 % of HCM patients showed a reduced exercise capacity. Age, male gender, left atrial size, chronotropic and systolic blood pressure response, ventilatory efficiency, late gadolinium enhancement presence and β-blocker therapy were independently associated with pVO2 (R (2)-adjusted index 0.738). A %pHRR cut-off value of 74 % appeared to most accurately predict an impaired exercise capacity (area under curve 0.90). A great prevalence of reduced exercise capacity is present in NYHA class I-II HCM patients. Notwithstanding its multifactorial genesis, few parameters might be adopted in identifying this feature. In this context, %pHRR value might represent a reliable and easy-to-obtain tool for the clinical evaluation of HCM patients.
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Affiliation(s)
- Damiano Magrì
- Cardiology Unit, Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
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15
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Parisi V, Losi MA, Contaldi C, Chiacchio E, Pastore F, Scatteia A, Giamundo A, di Nardo C, Lombardi R, Betocchi S. Speckle-tracking analysis based on 2D echocardiography does not reliably measure left ventricular torsion. Clin Physiol Funct Imaging 2012; 33:117-21. [PMID: 23383689 DOI: 10.1111/cpf.12002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Accepted: 08/30/2012] [Indexed: 11/27/2022]
Abstract
PURPOSE Worldwide left ventricular (LV) twist is measured by 2D speckle tracking acquiring apical short axis at a LV level where papillary muscles are no longer visible; however, we hypothesized that this methodological recommendation is not enough accurate to obtain a reliable measurement of apical rotation. METHODS We measured twist and untwist rate in 30 healthy subjects by following the earlier method. By 3D echocardiography, we identified two LV apex levels: (i) 3D Apex, defined as the last apical slice at which LV cavity was visible; (ii) 2D Apex, defined as the level where diameters are equal to those of apical LV short axis used for twist analysis in the same subject. The ratio between the distance of 2D Apex and 3D Apex from LV base was calculated and expressed as percentage (2D Apex/3D Apex). RESULTS 2D Apex/3D Apex was strongly related to the magnitude of twist and untwisting rate (r = 0·82, P<0·001; r = -0·46, P = 0·015, respectively). The only determinant of twist was 2D Apex/3D Apex (r(2) = 0·68; r = 0·82; F ratio: 52·6, P<0·001); whereas untwisting rate was influenced by 2D Apex/3D Apex and age (r(2) = 0·42; r = 0·65; F ratio: 7·7; P = 0·003 for 2D Apex/3D Apex; and P = 0·011 for age). CONCLUSIONS Left ventricular apical level acquisition, even when recorded in a standard manner, determines variability of twist mechanics measurements. Thus, current anatomical markers used to identify LV apex for twist analysis are not reliable and need different standardization. 3D echocardiography may help in such standardization.
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Affiliation(s)
- Valentina Parisi
- Department of Clinical Medicine, Cardiovascular and Immunological Sciences, University of Naples Federico II, Naples, Italy
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16
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Aljaroudi WA, Desai MY, Alraies MC, Thamilarasan M, Menon V, Rodriguez LL, Smedira N, Grimm RA, Lever HM, Jaber WA. Relationship between baseline resting diastolic function and exercise capacity in patients with hypertrophic cardiomyopathy undergoing treadmill stress echocardiography: a cohort study. BMJ Open 2012; 2:bmjopen-2012-002104. [PMID: 23242244 PMCID: PMC3533067 DOI: 10.1136/bmjopen-2012-002104] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE Diastolic dysfunction (DD) is often incriminated in the symptomatology of patients with hypertrophic cardiomyopathy (HCM), but with limited supporting data. This study sought to assess the relationship between baseline diastolic function and exercise capacity in patients with HCM. DESIGN Retrospective study. SETTING Tertiary referral centre from Cleveland, Ohio, USA. PARTICIPANTS 695 consecutive patients with a diagnosis of HCM who underwent exercise stress echocardiography between 1996 and 2011. PRIMARY AND SECONDARY OUTCOME MEASURES Diastolic function was reassessed from the resting echocardiograms by two blinded board-certified cardiologists. Maximal metabolic equivalents (MET) were extracted from the records. Multivariate regression analysis was performed to determine independent predictors of METs achieved. RESULTS Of 695 patients, 130 were excluded because of inability to assess diastolic function. There was no significant difference in maximal METs achieved between those excluded and included in the analysis (p=0.80). There were 495 remaining patients with a mean age (SD) of 50 (15) years, and 32% women among whom 102 (21%) had normal diastolic function, 243 (49%) stage 1 DD; 131 (26%) stage 2 DD and 19 (4%) stage 3 DD. Patients with advanced DD had lower maximal METs achieved compared with those with normal diastolic function (OR 3.18(1.96 to 5.14) for stage 1 versus normal, and 3.21(1.89 to 5.43) for stage ≥2 versus normal, p<0.0001 for both). After adjustment for demographics, comorbidities, echocardiographic parameters and haemodynamics, baseline DD was not an independent predictor of maximal METs achieved. CONCLUSIONS Although baseline DD is common in patients with HCM, it does not predict maximal METs achieved beyond traditional risk factors.
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Affiliation(s)
- Wael A Aljaroudi
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
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17
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Sinning D, Kasner M, Westermann D, Schulze K, Schultheiss HP, Tschöpe C. Increased left ventricular stiffness impairs exercise capacity in patients with heart failure symptoms despite normal left ventricular ejection fraction. Cardiol Res Pract 2011; 2011:692862. [PMID: 21403885 PMCID: PMC3051202 DOI: 10.4061/2011/692862] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2010] [Accepted: 01/08/2011] [Indexed: 01/08/2023] Open
Abstract
Aims. Several mechanisms can be involved in the development of exercise intolerance in patients with heart failure despite normal left ventricular ejection fraction (HFNEF) and may include impairment of left ventricular (LV) stiffness. We therefore investigated the influence of LV stiffness, determined by pressure-volume loop analysis obtained by conductance catheterization, on exercise capacity in HFNEF. Methods and Results. 27 HFNEF patients who showed LV diastolic dysfunction in pressure-volume (PV) loop analysis performed symptom-limited cardiopulmonary exercise testing (CPET) and were compared with 12 patients who did not show diastolic dysfunction in PV loop analysis. HFNEF patients revealed a lower peak performance (P = .046), breathing reserve (P = .006), and ventilation equivalent for carbon dioxide production at rest (P = .002). LV stiffness correlated with peak oxygen uptake (r = -0.636, P < .001), peak oxygen uptake at ventilatory threshold (r = -0.500, P = .009), and ventilation equivalent for carbon dioxide production at ventilatory threshold (r = 0.529, P = .005). Conclusions. CPET parameters such as peak oxygen uptake, peak oxygen uptake at ventilatory threshold, and ventilation equivalent for carbon dioxide production at ventilatory threshold correlate with LV stiffness. Increased LV stiffness impairs exercise capacity in HFNEF.
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Affiliation(s)
- David Sinning
- Department of Cardiology and Pulmonology, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany
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18
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Roşca M, Popescu BA, Beladan CC, Călin A, Muraru D, Popa EC, Lancellotti P, Enache R, Coman IM, Jurcuţ R, Ghionea M, Ginghină C. Left Atrial Dysfunction as a Correlate of Heart Failure Symptoms in Hypertrophic Cardiomyopathy. J Am Soc Echocardiogr 2010; 23:1090-8. [DOI: 10.1016/j.echo.2010.07.016] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2010] [Indexed: 11/25/2022]
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19
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Losi MA, Nistri S, Galderisi M, Betocchi S, Cecchi F, Olivotto I, Agricola E, Ballo P, Buralli S, D'Andrea A, D'Errico A, Mele D, Sciomer S, Mondillo S. Echocardiography in patients with hypertrophic cardiomyopathy: usefulness of old and new techniques in the diagnosis and pathophysiological assessment. Cardiovasc Ultrasound 2010; 8:7. [PMID: 20236538 PMCID: PMC2848131 DOI: 10.1186/1476-7120-8-7] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2010] [Accepted: 03/17/2010] [Indexed: 01/16/2023] Open
Abstract
Hypertrophic cardiomyopathy (HCM) is one of the most common inherited cardiomyopathy. The identification of patients with HCM is sometimes still a challenge. Moreover, the pathophysiology of the disease is complex because of left ventricular hyper-contractile state, diastolic dysfunction, ischemia and obstruction which can be coexistent in the same patient. In this review, we discuss the current and emerging echocardiographic methodology that can help physicians in the correct diagnostic and pathophysiological assessment of patients with HCM.
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Affiliation(s)
- Maria-Angela Losi
- Department of Clinical Medicine, Cardiovascular and Immunological Sciences, University Federico II, Naples, Italy.
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20
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Losi MA, Memoli B, Contaldi C, Barbati G, Del Prete M, Betocchi S, Cavallaro M, Carpinella G, Fundaliotis A, Parrella LS, Parisi V, Guida B, Chiariello M. Myocardial fibrosis and diastolic dysfunction in patients on chronic haemodialysis. Nephrol Dial Transplant 2010; 25:1950-4. [PMID: 20075436 DOI: 10.1093/ndt/gfp747] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Left ventricular (LV) diastolic dysfunction is linked to myocardial collagen content in many cardiac diseases. There are no data regarding such relationship in patients with end-stage renal disease (ESRD) undergoing haemodialysis. METHODS Twenty-five patients with ESRD undergoing haemodialysis were studied by echocardiography. LV diastolic function was investigated by Doppler echocardiography, by analysing LV filling velocities at rest and during loading manoeuvres, which represent an estimate of LV filling pressure. According to the Doppler pattern, LV filling pressure in a given patient was judged to be normal or slightly increased or to be moderately or severely increased. The presence of myocardial fibrosis was estimated by ultrasound tissue characterization with integrated backscatter, which in diastole correlates with the collagen content of the myocardium. RESULTS Integrated backscatter was higher in patients with moderate or severely increased than in patients with normal or slightly increased LV filling pressure (integrated backscatter: 51.0 +/- 9.8 vs 41.6 +/- 5.6%; P = 0.008). Integrated backscatter was a strong and independent determinant of diastolic dysfunction (odds ratio = 1.212; P = 0.040). CONCLUSION Our data support the hypothesis that, in a selected population of patients with ESRD undergoing haemodialysis, myocardial fibrosis is associated with LV diastolic myocardial properties.
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Affiliation(s)
- Maria Angela Losi
- Department of Clinical Medicine, Cardiovascular & Immunological Sciences, Federico II University School of Medicine, Naples, Italy.
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21
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Shim CY, Ha JW, Choi EY, Lee HJ, Moon SH, Kim JM, Rim SJ, Chung N. Relationship between serum biochemical markers of myocardial fibrosis and diastolic function at rest and with exercise in hypertrophic cardiomyopathy. Korean Circ J 2009; 39:519-24. [PMID: 20049137 PMCID: PMC2801459 DOI: 10.4070/kcj.2009.39.12.519] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2009] [Revised: 05/06/2009] [Accepted: 05/19/2009] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Recent studies have demonstrated the usefulness of biochemical markers of collagen turnover as markers of myocardial fibrosis in various diseases. In this study, we hypothesized that increased collagen markers in patients with hypertrophic cardiomyopathy (HCM) were correlated with diastolic function at rest and diastolic functional reserve during exercise. SUBJECTS AND METHODS Thirty-six patients with HCM and 21 controls with normal left ventricular thickness were studied. Mitral septal annular velocities and mitral inflow velocities were measured at rest and during graded supine bicycle exercise (25 W, 3-minute increments) for the assessment of diastolic function at rest and during exercise. By radioimmunoassay, a byproduct of collagen III synthesis (PIIINP) and peptides resulting from collagen I synthesis (PINP) and degradation (ICTP) were measured. The patients with HCM were divided into two groups according to the median value of the PINP/ICTP ratio in the group. RESULTS At rest, the mitral annular early diastolic velocity (E') was lower and the E/E' was higher in the patients with HCM with high a PINP/ICTP ratio compared with patients with HCM with a low PINP/ICTP ratio and controls (p<0.001, p=0.012). With exercise, the Doppler parameters were increased in all groups, but there was no significant difference in the change in E' and E/E' during exercise according to collagen turnover markers. CONCLUSION A higher PINP/ICTP ratio was associated with resting diastolic dysfunction in patients with HCM; however, there was no relationship with augmented diastolic dysfunction during exercise. We suggest that the type I collagen synthesis-to-degradation ratio is a useful marker of resting diastolic function in patients with HCM.
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Affiliation(s)
- Chi Young Shim
- Division of Cardiology, Cardiovascular Center, Yonsei University College of Medicine, Seoul, Korea
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22
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Daniel KR, Wells G, Stewart K, Moore B, Kitzman DW. Effect of aldosterone antagonism on exercise tolerance, Doppler diastolic function, and quality of life in older women with diastolic heart failure. ACTA ACUST UNITED AC 2009; 15:68-74. [PMID: 19379452 DOI: 10.1111/j.1751-7133.2009.00056.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Optimal therapy for diastolic heart failure (DHF), the most common form of heart failure in older persons, is unclear. To determine the effect of aldosterone antagonism in DHF, the authors conducted an open-label preliminary trial of spironolactone 25 mg/d in 11 women with DHF. Cardiopulmonary exercise testing, Doppler echocardiography, and a quality-of-life survey were administered at baseline and after 4 months. Peak exercise VO(2) increased by 8.3% (P=.001), the ratio of Doppler diastolic early filling velocity to mitral annulus velocity decreased by 25% (P=.02), quality-of-life score improved by 21% (P=.16 for trend), and median New York Heart Association class improved from class III to class II (P=.004). Findings from this preliminary study confirm the role of aldosterone in the pathophysiology of DHF and suggest that aldosterone antagonism may benefit such patients. These hypotheses are currently being tested in two separated National Institutes of Health-funded, randomized trials, the Spironolactone for Failure in the Elderly (SPIFFIE) and the Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist (TOPCAT) trials.
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Affiliation(s)
- Kurt R Daniel
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27157-1045, USA
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23
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Utility of tissue Doppler imaging to predict exercise capacity in hypertrophic cardiomyopathy: Comparison with B-type natriuretic peptide. J Cardiol 2009; 53:361-7. [DOI: 10.1016/j.jjcc.2008.12.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2008] [Revised: 12/13/2008] [Accepted: 12/16/2008] [Indexed: 11/19/2022]
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Plehn G, Vormbrock J, Meissner A, Trappe HJ. Effects of exercise on the duration of diastole and on interventricular phase differences in patients with hypertrophic cardiomyopathy: relationship to cardiac output reserve. J Nucl Cardiol 2009; 16:233-43. [PMID: 19159996 DOI: 10.1007/s12350-008-9031-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2008] [Revised: 10/31/2008] [Accepted: 11/04/2008] [Indexed: 11/30/2022]
Abstract
BACKGROUND Our study sought to characterize the effect of exercise on the duration of left ventricular (LV) diastole and interventricular dyssynchrony in patients with hypertrophic cardiomyopathy (HCM). We hypothesized that an abnormally shortened diastolic time may adversely affect cardiac performance. METHODS We studied 49 symptomatic patients with HCM during incremental exercise. Twenty-nine patients had obstructive disease (HOCM) and 20 no resting or provocable gradient (HNCM). Right heart catheterization and high temporal resolution radionuclide angiography were simultaneously performed. The loss of diastolic time per beat (LDT(RR)) was quantified using a regression equation obtained from a healthy control group (n = 30). RESULTS During rest and peak exercise, a significant shortening of the relative duration of LV diastole (35.6 +/- 5 vs. 38.0 +/- 3 s/min and 29.3 +/- 6 vs. 32.4 +/- 3 s/min; P < or = .02) and an increased interventricular phase delay were evident in patients with HOCM compared to controls. Baseline and peak exercise LDT(RR) values were inversely related to cardiac output reserve and exercise duration. In multivariate analysis, LDT(RR) at peak exercise was identified as an independent predictor of cardiac output reserve. CONCLUSIONS In HOCM, baseline abnormalities of the relative duration of LV systolic and diastolic time aggravate during exercise. The disproportionate shortening of diastolic time may significantly impair cardiac efficiency by restricting diastolic filling.
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Affiliation(s)
- Gunnar Plehn
- Department of Cardiology and Angiology, Marienhospital Herne, University of Bochum, Hölkeskampring 40, 44625, Herne, Germany.
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25
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Menon SC, Ackerman MJ, Cetta F, O'Leary PW, Eidem BW. Significance of left atrial volume in patients < 20 years of age with hypertrophic cardiomyopathy. Am J Cardiol 2008; 102:1390-3. [PMID: 18993161 DOI: 10.1016/j.amjcard.2008.07.027] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2008] [Revised: 07/02/2008] [Accepted: 07/02/2008] [Indexed: 10/21/2022]
Abstract
Left atrial (LA) enlargement is an indicator of chronic elevation in left ventricular (LV) end-diastolic pressure as well as diastolic dysfunction. There is a lack of data on the significance of LA volume in the pediatric population. The objective of this study was to elucidate the relation between LA volume and diastolic dysfunction, clinical symptoms, and exercise capacity in young patients with hypertrophic cardiomyopathy. All patients aged <20 years with obstructive hypertrophic cardiomyopathy who underwent evaluation at the Mayo Clinic from 2002 to 2006 were retrospectively identified. Reviews of the LA volume index and other traditional diastolic Doppler echocardiographic parameters, as well as clinical data, were performed. A total of 88 patients (66 male) were studied. The median age at evaluation was 14 years. The mean LA volume index was 39 +/- 19 ml/m(2). Additional echocardiographic parameters included a mean LV outflow gradient of 55 +/- 51 mm Hg, a mean E/E' ratio of 14.0 +/- 7.6, and a mean maximal septal wall thickness of 23 +/- 9 mm. On univariate linear regression analysis, LA volume index had an excellent correlation with diastolic dysfunction grade (p <0.001, r(2) = 0.6), LV outflow tract gradient, mitral E/E', and the degree of mitral regurgitation. LA volume index was also positively associated with symptom score (p = 0.005) and maximal oxygen consumption on exercise test (n = 22; p = 0.01). On multivariate analysis, LA volume index was related to diastolic dysfunction grade (p <0.001) and mean mitral regurgitation grade (p = 0.05). In conclusion, this study demonstrates the potential clinical importance of LA volume index in pediatric hypertrophic cardiomyopathy as a marker of the severity of underlying diastolic dysfunction, symptom score, and decreased exercise capacity. LA volume index has significant diagnostic and prognostic value in these patients.
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Motoyasu M, Kurita T, Onishi K, Uemura S, Tanigawa T, Okinaka T, Takeda K, Nakano T, Ito M, Sakuma H. Correlation between late gadolinium enhancement and diastolic function in hypertrophic cardiomyopathy assessed by magnetic resonance imaging. Circ J 2008; 72:378-83. [PMID: 18296832 DOI: 10.1253/circj.72.378] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Diastolic dysfunction is common in patients with overt hypertrophic cardiomyopathy (HCM). Steady-state cine magnetic resonance imaging (MRI) enables measurement of the diastolic function of the left ventricle (LV), and late gadolinium enhanced MRI can delineate the presence and extent of fibrosis in HCM. The purpose of this study was to determine the relationship between the extent of myocardial fibrosis demonstrated by late gadolinium-enhanced MRI and diastolic dysfunction. METHODS AND RESULTS Seventeen patients (13 men, mean age 57.7+/-9.8 years) with HCM were studied. The severity index of late gadolinium enhancement was determined by scoring the extent of enhanced tissue in 30 myocardial segments. The peak filling rate (PFR), LV ejection fraction and LV mass were determined by cine MRI. Contrast-enhanced MRI demonstrated late gadolinium enhancement in 97 of 510 segments (19%) and 13 of the 17 patients (77%). The severity index of late gadolinium enhancement demonstrated a significant negative correlation with PFR (r= -0.86, p<0.01) and with the LV ejection fraction (r= -0.59, p<0.05). No significant correlation was observed between the severity index of late gadolinium enhancement and LV mass (r=0.23, p=0.30). CONCLUSION The extent of myocardial fibrosis revealed by late gadolinium-enhanced MRI has a strong relationship to diastolic dysfunction in patients with HCM.
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Affiliation(s)
- Munenobu Motoyasu
- Department of Cardiology, Mie University Graduate School of Medicine, Tsu, Japan
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27
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Choi EY, Ha JW, Rim SJ, Kim SA, Yoon SJ, Shim CY, Kim JM, Jang Y, Chung N, Cho SY. Incremental Value of Left Ventricular Diastolic Function Reserve Index for Predicting Exercise Capacity in Patients with Hypertrophic Cardiomyopathy. J Am Soc Echocardiogr 2008; 21:487-92. [PMID: 17904804 DOI: 10.1016/j.echo.2007.08.041] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2007] [Indexed: 11/15/2022]
Abstract
The changes of left ventricular diastolic function during exercise are heterogeneous in patients with hypertrophic cardiomyopathy (HCM). We sought to investigate whether exertional changes of mitral annular velocities and plasma N-terminal-pro-B-type natriuretic peptide (BNP) concentration are associated with exercise capacity in patients with HCM. After a comprehensive echocardiographic study, 32 patients with HCM performed symptom-limited graded supine bicycle exercise. Echocardiographic Doppler parameters were measured at each stage of exercise. Blood samples were collected at rest and immediately after exercise to determine the concentration of pro-BNP. Resting pro-BNP (r = -0.620, P < .001), E'(base) (r = 0.414, P = .018), and DeltaE'(50W) (change of E' from base to 50 W of exercise) (r = 0.367, P = .039) were significantly correlated with exercise duration. Left ventricular longitudinal diastolic function reserve index, defined as DeltaE' x E'(base), significantly correlated with exercise duration (at 50 W, r = 0.540, P = .001) independent of age, sex, body mass index, and resting pro-BNP level. When combining DeltaE' x E'(50W) (<5.85 cm(2)/s(2)) and resting pro-BNP (>740 mg/dL), the predictive accuracy for exercise capacity could be improved (for <500 seconds, global chi(2) = 5.84 in pro-BNP vs 8.10 in pro-BNP + DeltaE' x E'(50W), P = .023). The assessment of left ventricular longitudinal diastolic function reserve can provide incremental information to pro-BNP for the prediction of exercise capacity in patients with HCM.
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Affiliation(s)
- Eui-Young Choi
- Cardiology Division, Yonsei Cardiovascular Center and Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, South Korea
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28
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Bayrak F, Kahveci G, Degertekin M, Mutlu B. Echocardiographic predictors of severe heart failure symptoms in hypertrophic cardiomyopathy patients with sinus rhythm. Trials 2008; 9:11. [PMID: 18312670 PMCID: PMC2292134 DOI: 10.1186/1745-6215-9-11] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2007] [Accepted: 02/29/2008] [Indexed: 02/07/2023] Open
Abstract
Background Symptoms in hypertrophic cardiomyopathy (HC) appear to be caused by diastolic dysfunction, myocardial ischemia, left ventricle (LV) outflow obstruction, and atrial fibrillation. However, clinical deterioration and severe heart failure symptoms can be observed in patients without any of these factors. Thus, the aim of this study is to determine the echocardiographic predictors of severe heart failure symptoms in patients with HC. Methods and results 86 HC patients were compared according to symptomatic status. Patients with severe heart failure symptoms were older, preponderantly female, had more often LV outflow obstruction and mitral regurgitation, longer E wave deceleration time (EDt), higher E/Ea ratios and lower LV tissue Doppler (TD) velocities when compared to rest of the patients. LV outflow obstruction (r = 0.43, R2 = 0.19, p < 0.0001), LV lateral mitral annular systolic TD velocity (LMSa) (r = 0.51, R2 = 0.26, p < 0.006) and EDt (r = 0.55, R2 = 0.30, p < 0.027) were found to be the independent predictors for severe heart failure symptoms in forward stepwise regression. Conclusion In HCM patients with sinus rhythm and normal LV systolic function, LMSa, EDt and LV outflow obstruction are independent predictors of heart failure symptoms. Diastolic dysfunction determined with EDt, occult systolic dysfunction which is detected with TD analysis, and afterload increase as result of LV outflow obstruction seem to be the main echocardiographic factors affecting symptomatic status in HCM patients with sinus rhythm and normal systolic function.
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Affiliation(s)
- Fatih Bayrak
- Yeditepe University Hospital, Department of Cardiology, Istanbul, Turkey.
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29
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Efthimiadis GK, Hitoglou-Makedou A, Giannakoulas G, Mitakidou A, Karamitsos T, Karvounis H, Mochlas S, Styliadis I, Stefanidis H, Parcharidis G, Louridas G. Clinical significance of N-terminal-probrain natriuretic peptide in hypertrophic cardiomyopathy. Heart Vessels 2007; 22:322-7. [PMID: 17879024 DOI: 10.1007/s00380-007-0976-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2006] [Accepted: 01/27/2007] [Indexed: 10/22/2022]
Abstract
N-Terminal-probrain natriuretic peptide (NT-proBNP) plasma levels are elevated in patients with congestive heart failure. Published data concerning the utility of NT-proBNP in hypertrophic cardiomyopathy (HCM) are lacking. Our aim was to evaluate the clinical significance of NT-proBNP in patients with HCM. A blood sample was collected for plasma NT-proBNP measurement from 43 consecutive patients with documented HCM. NT-proBNP was measured using a chemiluminescent immunoassay kit (Roche Diagnostics) on an Elecsys 2010 analyzer. Median value of NT-proBNP was 219 pg/ml (range 8-3 045 pg/ml) in NYHA class I patients, 698 pg/ml (125-2 463 pg/ml) in NYHA class II patients, and 2 683 pg/ml (131-11 542 pg/ml) in NYHA class III and IV patients. NT-proBNP plasma levels were significantly higher across the severity of functional limitation (i.e., NYHA class classification) (P = 0.002). NT-proBNP levels were significantly higher in female than male (P = 0.034), in referral vs nonreferral patients (P = 0.004), in symptomatic vs asymptomatic patients (P = 0.020), in patients with basal subaortic gradient >or=30 mmHg (P = 0.001) and in the patients who were on cardioactive medication (P = 0.010). In univariate analysis NT-proBNP was significantly correlated with age (P < 0.001), left ventricular maximum wall thickness (P = 0.001), left atrial size (P = 0.019), and subaortic gradient >or=30 mmHg (P < 0.001). In multivariate regression analysis, age (P < 0.001), maximum wall thickness (P = 0.007), and gradient >or=30 mmHg (P = 0.027) were independently associated with NT-proBNP levels. Our data support the idea that measurement of plasma NT-proBNP levels in HCM patients is useful to assess their clinical status, especially the severity of hypertrophy and the presence of obstruction, although age must be taken into account.
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Affiliation(s)
- Georgios K Efthimiadis
- First Cardiology Department, AHEPA Hospital, Aristotle University, Thessaloniki, Greece.
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30
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Arruda ALM, Pellikka PA, Olson TP, Johnson BD. Exercise Capacity, Breathing Pattern, and Gas Exchange During Exercise for Patients with Isolated Diastolic Dysfunction. J Am Soc Echocardiogr 2007; 20:838-46. [PMID: 17617310 DOI: 10.1016/j.echo.2006.12.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND Left ventricular diastolic dysfunction (DiaD) is as common as left ventricular systolic dysfunction. Whether these causes of heart failure lead to similar breathing pattern and gas exchange responses to exercise remains unclear. METHODS Participants (control subjects [n = 47], systolic dysfunction [n = 46], and DiaD [n = 40]) underwent resting echocardiograms and cardiopulmonary exercise testing. RESULTS Patients demonstrated lower peak oxygen consumption and tidal volume than control subjects (P < .05). Ventilation tended to be highest in DiaD. The submaximal ventilatory equivalent for carbon dioxide was highest in DiaD. Left atrial volume (all groups) was correlated with peak oxygen consumption (r = -0.38) whereas the ratio of early mitral inflow velocity to early mitral annular velocity was related to peak oxygen consumption (r = -0.36) and treadmill time (r = -0.35). CONCLUSION Isolated DiaD is associated with altered breathing pattern and gas exchange similar to systolic dysfunction. Elevated left atrial volume, higher early mitral inflow velocity to early mitral annular velocity ratio, or both are predictive of exercise capacity and elevated ventilatory responses in patients with DiaD suggesting a role for dysfunctional ventricular relaxation.
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Affiliation(s)
- Ana Lucia M Arruda
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA
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31
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Araujo AQ, Arteaga E, Ianni BM, Fernandes F, Ramires FJ, Buck PC, Salemi VMC, Nastari L, Mady C. Relationship between outflow obstruction and left ventricular functional impairment in hypertrophic cardiomyopathy: a Doppler echocardiographic study. Echocardiography 2007; 23:734-40. [PMID: 16999691 DOI: 10.1111/j.1540-8175.2006.00303.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Left ventricular outflow tract (LVOT) obstruction is predictive of a worse outcome in hypertrophic cardiomyopathy (HCM). In a detailed Doppler echocardiographic study of 178 selected HCM patients, the group of patients (n = 73) with the obstructive form (resting peak gradient > or = 30 mmHg) presented more hypertrophy and poorer systolic and diastolic left ventricular (LV) functions than the HCM group (n = 105) without obstruction. LVOT peak gradient was positively correlated with hypertrophy (P < 0.0001) and negatively to tissue Doppler mitral annulus systolic (P = 0.0001) and early diastolic (P < 0.0001) velocities. The gradient significantly correlated with E/Ea ratio (r = 0.67; P < 0.0001). By multiple regression, LVOT gradient was related to E/Ea, LV maximal thickness and left atrial size. In comparison with patients without obstruction, patients with obstruction presented greater hypertrophy (P < 0.0001), lower systolic and early diastolic mitral annulus velocities (both P < 0.0001), higher E/Ea ratio (P < 0.0001) and higher global function index (P < 0.0001). In HCM, beyond the effects on hypertrophy, LVOT obstruction is an independent determinant of LV functional abnormalities.
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Affiliation(s)
- Aloir Q Araujo
- Cardiomyopathies Division-Heart Institute (InCor), University of São Paulo Medical School, Av. Eneas Carvalho Aguiar 44, 05403-900 São Paulo, SP, Brazil.
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32
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Dumont CA, Monserrat L, Peteiro J, Soler R, Rodriguez E, Bouzas A, Fernández X, Pérez R, Bouzas B, Castro-Beiras A. Relation of left ventricular chamber stiffness at rest to exercise capacity in hypertrophic cardiomyopathy. Am J Cardiol 2007; 99:1454-7. [PMID: 17493479 DOI: 10.1016/j.amjcard.2006.12.077] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2006] [Revised: 12/21/2006] [Accepted: 12/21/2006] [Indexed: 11/20/2022]
Abstract
The degree of exercise capacity is poorly predicted by conventional markers of disease severity in patients with hypertrophic cardiomyopathy (HC). The principal mechanism of exercise intolerance in patients with HC is the failure of stroke volume augmentation due to left ventricular (LV) diastolic dysfunction. The role of LV chamber stiffness, assessed noninvasively, as a determinant of exercise tolerance is unknown. Sixty-four patients with HC were studied with Doppler echocardiography, exercise testing, and gadolinium cardiac magnetic resonance. The LV chamber stiffness index was determined as the ratio of pulmonary capillary wedge pressure (derived from the E/Ea ratio) to LV end-diastolic volume (assessed by cardiac magnetic resonance). Maximal exercise tolerance was defined as achieved METs. There were inverse correlations between METs achieved and age (r = -0.38, p = 0.003), heart rate deficit (r = -0.39, p = 0.002), LV outflow tract gradient (r = -0.33, p = 0.009), the E/Ea ratio (r = -0.4, p = 0.001), mean LV wall thickness (r = -0.26, p = 0.04), and LV stiffness (r = -0.56, p <0.001) and a positive correlation between METs achieved and LV end-diastolic volume (r = 0.33, p = 0.01). On multivariate analysis, only LV chamber stiffness was associated with exercise capacity. A LV stiffness level of 0.18 mm Hg/ml had 100% sensitivity and 75% specificity (area under the curve 0.84) for predicting < or =7 METs achieved. In conclusion, LV diastolic dysfunction at rest, as manifested by increased LV chamber stiffness, is a major determinant of maximal exercise capacity in patients with HC.
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MESH Headings
- Adolescent
- Adult
- Age Factors
- Aged
- Analysis of Variance
- Cardiomyopathy, Hypertrophic/diagnosis
- Cardiomyopathy, Hypertrophic/etiology
- Cardiomyopathy, Hypertrophic/physiopathology
- Contrast Media
- Echocardiography, Doppler, Color
- Exercise Test
- Exercise Tolerance
- Female
- Gadolinium DTPA
- Heart Rate
- Humans
- Hypertrophy, Left Ventricular/complications
- Hypertrophy, Left Ventricular/diagnosis
- Hypertrophy, Left Ventricular/physiopathology
- Magnetic Resonance Imaging, Cine
- Male
- Middle Aged
- Pulmonary Wedge Pressure
- Regression Analysis
- Research Design
- Rest
- Sensitivity and Specificity
- Severity of Illness Index
- Stroke Volume
- Vascular Resistance
- Ventricular Dysfunction, Left/complications
- Ventricular Dysfunction, Left/diagnosis
- Ventricular Dysfunction, Left/physiopathology
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33
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Varol E, Ozaydin M, Altinbas A, Aslan SM, Dogan A, Dede O. Elevated carbohydrate antigen 125 levels in hypertrophic cardiomyopathy patients with heart failure. Heart Vessels 2007; 22:30-3. [PMID: 17285443 DOI: 10.1007/s00380-006-0938-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2006] [Accepted: 07/12/2006] [Indexed: 10/23/2022]
Abstract
Carbohydrate antigen 125 (CA 125), known as a tumor marker for ovarian cancer, has been reported to increase and relate to severity in heart failure patients with systolic dysfunction. Hypertrophic cardiomyopathy (HCM) has a wide clinical spectrum that often includes heart failure symptoms. The aim of this study was to evaluate the role of CA 125 in HCM patients, its relation to severity of symptoms, and degree of diastolic dysfunction. CA 125 blood levels were determined in 32 HCM patients (21 male; age 51.3 +/- 18.4 years) and in 30 healthy volunteers (19 male; age 49.6 +/- 16.1 years). Echocardiographic examinations were performed in all patients. The results were grouped according to clinical status (New York Heart Association class) of the patients. The mean serum level of CA 125 was 14.6 +/- 23.8 U/ml in the study group and 7.6 +/- 4.8 U/ml in the control group. There was no significant difference between the groups (P = 0.12). CA 125 levels increased as the New York Heart Association functional class increased (class I/II: 6.2 +/- 2.4 U/ml; class III: 30.6 +/- 36.4 U/ml; P < 0.001). The mean CA 125 level in functional class III patients (30.6 +/- 36.4 U/ml) was significantly higher than that of the control group (7.6 +/- 4.8 U/ml) (P < 0.001) and the functional class I/II group (6.2 +/- 2.4 U/ml) (P < 0.001). There was a significant difference over all three diastolic dysfunction groups with respect to CA 125 levels (4.9 +/- 1.3 U/ml in impaired relaxation group, 11.8 +/- 6.9 U/ml in pseudonormal group, and 52.6 +/- 45.6 U/ml in restrictive filling group; P < 0.0001). Serum CA 125 is related to the clinical severity of HCM. Whether CA 125 has a specific biological role in HCM requires further investigation.
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Affiliation(s)
- Ercan Varol
- Department of Cardiology, Isparta State Hospital, Isparta, Turkey.
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34
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Thaman R, Esteban MT, Barnes S, Gimeno JR, Mist B, Murphy R, Collinson PO, McKenna WJ, Elliott PM. Usefulness of N-terminal pro-B-type natriuretic peptide levels to predict exercise capacity in hypertrophic cardiomyopathy. Am J Cardiol 2006; 98:515-9. [PMID: 16893708 DOI: 10.1016/j.amjcard.2006.02.057] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2005] [Revised: 02/16/2006] [Accepted: 02/16/2006] [Indexed: 11/27/2022]
Abstract
Most patients with hypertrophic cardiomyopathy (HC) have reduced maximal oxygen consumption (VO2max) during exercise. The degree of impairment is poorly predicted by the magnitude of hypertrophy, left ventricular (LV) outflow tract obstruction, and other conventional markers of disease severity. The aim of this study was to determine the usefulness of N-terminal-pro-B-type natriuretic peptide (NT-pro-BNP) as a marker of exercise performance in HC. Plasma NT-pro-BNP was measured in 171 consecutive patients (mean age 46 +/- 18 years) who underwent echocardiography and cardiopulmonary exercise testing. The mean log NT-pro-BNP was 2.79 +/- 0.5; log NT-pro-BNP levels were higher in women patients (p = 0.001) and patients with chest pain (p = 0.010), in New York Heart Association class > or = II (p = 0.009), with atrial fibrillation (p < 0.001), with systolic impairment (p = 0.025), and with LV outflow tract obstructions (p < 0.0001). NT-pro-BNP levels were also correlated with maximal wall thickness (r = 0.335, p < 0.0001), left atrial size (r = 0.206, p = 0.007), and the mitral Doppler E/A ratio (r = 0.197, p = 0.012). The mean percent VO2max achieved was 73.8 +/- 22.6%; percent VO2max was smaller in patients with systolic impairment (p = 0.044) and LV outflow tract obstructions (p = 0.025). There were inverse correlations between percent VO2max and NT-pro-BNP (r = -0.352, p = 0.001), LV end-systolic cavity size (r = -0.182, p = 0.031), and left atrial size (r = -0.251, p = 0.003). On multivariate analysis, only NT-pro-BNP was correlated with percent VO2max. A NT-pro-BNP level of 316 ng/L had 78% sensitivity and 44% specificity (area under the curve 0.616) for predicting percent VO2max < 80%. In conclusion, NT-pro-BNP levels correlate with peak oxygen consumption in HC and are more predictive of functional impairment than other conventional markers of disease severity.
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Affiliation(s)
- Rajesh Thaman
- The Heart Hospital, University College London, London, United Kingdom
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35
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Palmieri V, Russo C, Palmieri EA, Arezzi E, Pezzullo S, Minichiello S, Martino S, Migliaresi P, Celentano A. Isolated left ventricular diastolic dysfunction: implications for exercise left ventricular performance in patients without congestive heart failure. J Am Soc Echocardiogr 2006; 19:491-8. [PMID: 16644431 DOI: 10.1016/j.echo.2005.12.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2005] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Clinical relevance of left ventricular (LV) diastolic dysfunction in the absence of congestive heart failure (CHF) and LV systolic dysfunction is not fully established. METHODS Asymptomatic outpatients, sedentary, with cardiovascular risk factors but no history of cardiovascular events, underwent echocardiographic evaluation of LV structure and function by standard Doppler, color M-mode, and Doppler tissue methods, and exercise testing with simultaneous noninvasive assessment of LV stroke index and cardiac index. LV ejection fraction less than 50% and significant valvular disease or stress test suggestive of coronary disease were additional exclusion criteria. RESULTS In 70 patients selected (40 +/- 10 years old, 63% men, 34% hypertensive, 34% diabetic, 4% diabetic and hypertensive, 11% with LV hypertrophy), LV diastolic dysfunction was detected in 26%, which was associated with hypertension, higher LV mass index, lower systolic function, lower peak exercise heart rate, and chronotropic reserve (all P < .05), and with lower peak exercise stroke index and cardiac index (both covariates adjusted P < .05), but not with lower peak exercise metabolic equivalents (P > .5). Abnormal LV relaxation was independently correlated with lower peak exercise cardiac index and stroke index (both P < .05). Peak exercise systolic and cardiac indices were comparable between patients with CHF risk factors (74%) versus those without. CONCLUSIONS Isolated LV diastolic dysfunction was independently associated with lower peak exercise LV systolic performance in patients without CHF. Its diagnosis may provide a target for aggressive CHF risk management.
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Affiliation(s)
- Vittorio Palmieri
- Department of Clinical and Experimental Medicine, Federico II University of Naples, Naples, Italy.
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36
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Araujo AQ, Arteaga E, Ianni BM, Salemi VMC, Ramires FJA, Matsumoto AY, Fernandes F, Mady C. Usefulness of a New Proposed Tissue Doppler Imaging Global Function Index in Hypertrophic Cardiomyopathy. Echocardiography 2006; 23:197-201. [PMID: 16524389 DOI: 10.1111/j.1540-8175.2006.00198.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND A global function index (GFI) derived from tissue Doppler imaging (TDI) has been proposed to improve the diagnosis of hypertrophic cardiomyopathy (HCM). We aimed to evaluate the usefulness of this index in a large selected HCM population. METHODS GFI =[E/Ea]/Sa, was calculated at mitral annulus lateral and septal borders in 164 HCM patients and in 40 healthy volunteers. Group comparisons and correlations between GFI and other variables were performed. RESULTS Of the 164 patients, 69 (42%) had a peak gradient >30 mmHg in the left ventricle outflow tract (LVOT). GFI (lateral or septal) was not normally distributed. There were differences among controls, obstructive HCM, and nonobstructive HCM (P < 0.0001), but significant overlap of GFI values were observed between groups. GFI was correlated to septal thickness (r = 0.44; P < 0.0001), left atrial diameter (r = 0.52; P < 0.0001), and LVOT gradient (r = 0.58; P < 0.0001). CONCLUSION In a selected HCM population, GFI was limited by its asymmetrical distribution and significant overlap of values between groups. Further studies are necessary to verify the reliability of GFI in the clinical practice and its position among other tissue Doppler indices.
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Affiliation(s)
- Aloir Q Araujo
- Heart Institute (INCOR), University of São Paulo Medical School, São Paulo, Brazil.
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37
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Kitaoka H, Kubo T, Okawa M, Hitomi N, Furuno T, Doi YL. Left Ventricular Remodeling of Hypertrophic Cardiomyopathy Longitudinal Observation in a Rural Community. Circ J 2006; 70:1543-9. [PMID: 17127796 DOI: 10.1253/circj.70.1543] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The purpose of the present study was to assess the clinical long-term course of hypertrophic cardiomyopathy (HCM) in a rural Japanese cohort. METHODS AND RESULTS A total of 137 consecutive HCM patients (mean age at diagnosis: 52+/-13 years) were enrolled. During a follow-up period of 11.4+/-5.7 years, 28 patients died of HCM-related causes. Eleven patients died suddenly, 10 died of progressive heart failure, 6 died of stroke associated with atrial fibrillation and 1 died of a postoperative complication of alcohol septal ablation. For the overall study group, 5-, 10- and 15-year cumulative survival rates were 91%, 88% and 79%, respectively. Although sudden death was the predominant cause of HCM-related death during the follow-up period of <10 years, heart failure death increased after follow-up period of >10 years. Fifteen (13%) of 114 patients who had follow-up echocardiography became ;end-stage' HCM and 8 patients died of severe and refractory heart failure. They already showed minimally dilated left ventricular (LV) dimension and lower LV fractional shortening at initial evaluation. CONCLUSIONS Although HCM patients in a Japanese rural community showed relatively benign clinical course (the same as cohorts in the developed world), heart failure death because of LV remodeling became equally important to sudden death when they were followed for more than 10 years.
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Affiliation(s)
- Hiroaki Kitaoka
- Cardiology Division, Department of Medicine and Geriatrics, Kochi Medical School, Nankoku-shi, Kochi, Japan
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38
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Arteaga E, Araujo AQ, Buck P, Ianni BM, Rabello R, Mady C. Plasma amino-terminal pro-B-type natriuretic peptide quantification in hypertrophic cardiomyopathy. Am Heart J 2005; 150:1228-32. [PMID: 16338263 DOI: 10.1016/j.ahj.2005.02.045] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2004] [Accepted: 02/20/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Plasma B-type natriuretic peptide (BNP) is a sensitive functional marker in heart disease including hypertrophic cardiomyopathy (HCM). The utility of plasma amino-terminal pro-BNP (NT-proBNP) quantification in heart disease has been investigated, but there are no published data regarding this test in HCM. METHODS Plasma NT-proBNP was assessed in 71 patients with HCM and in 40 healthy subjects. Symptomatic status was assessed according to the New York Heart Association classification. M-mode and Doppler echocardiographic data were obtained in all patients and healthy subjects to study their correlations and comparisons (Spearman and Mann-Whitney tests). RESULTS Median NT-proBNP was 848 pg/mL in patients and 28 pg/mL in the control group (P < .0001). Patients in New York Heart Association functional class I/II had a median NT-proBNP of 669 pg/mL as compared with 3357 pg/mL for patients in class III/IV (P < .0001). Amino-terminal pro-BNP levels correlated positively with left atrial diameter (r = 0.40, P = .0005), septal thickness (r = 0.35, P = .002), and mitral flow velocity/mitral annulus velocity (E/Ea) ratio (r = 0.42, P < .0001). There was a weak correlation with obstruction (r = 0.23, P = .05), and a significant difference in the medians was observed between obstructive (1651 pg/mL) and nonobstructive (669 pg/mL) HCM groups (P = .01). Patients with Doppler E/Ea ratios > or = 10 had higher NT-proBNP levels than patients with E/Ea < 10 (P < .0001). Multivariate analysis showed that NT-proBNP correlated independently with left atrial diameter (P < .01), hypertrophy (P < .01), and E/Ea (P < .01). CONCLUSIONS In HCM, plasma NT-proBNP levels are elevated and correlate positively with symptoms of heart failure, hypertrophy severity, and Doppler echocardiographic signs of left ventricular diastolic dysfunction. Further studies are necessary to assess the usefulness of the test in clinical practice and its role as a prognostic marker.
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Affiliation(s)
- Edmundo Arteaga
- Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil.
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Kjaergaard J, Johnson BD, Pellikka PA, Cha SS, Oh JK, Ommen SR. Left Atrial Index Is a Predictor of Exercise Capacity in Patients with Hypertrophic Cardiomyopathy. J Am Soc Echocardiogr 2005; 18:1373-80. [PMID: 16376769 DOI: 10.1016/j.echo.2005.05.020] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2005] [Indexed: 11/30/2022]
Abstract
BACKGROUND Left atrial (LA) enlargement is related to diastolic dysfunction and mitral regurgitation (MR), both of which are common in patients with hypertrophic cardiomyopathy (HCM). This study investigates the association between LA size and exercise capacity in patients with HCM. METHODS All HCM patients who underwent a treadmill test with direct measurement of oxygen consumption (VO2) and a standard transthoracic echocardiography within 30 days in the years 2001-2003 were identified. Patients with significant comorbidities were excluded. Exercise capacity was defined as percentage of predicted peak VO2. Clinical and echocardiographic parameters were compared with those of a group of normal subjects. RESULTS Compared with normal subjects, HCM patients had increased left atrial (LA) volume index (36 vs 21 mL/m2; P < .0001) and mitral E/e' ratio (14 vs 9; P < .0001); 27% of the patients had at least moderate MR. LA volume index demonstrated borderline correlation with exercise capacity (r = -.20; P = .06) but was an independent predictor of exercise capacity in a multivariate linear analysis, together with body mass index, heart rate at rest, and left ventricular end-systolic diameter. Including the parameters E/e' ratio or moderate or severe MR did not add incremental value to the model. CONCLUSION LA volume index, reflecting the combined influences of MR and diastolic dysfunction, was independently associated with objective measures of exercise capacity in patients with isolated HCM.
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Affiliation(s)
- Jesper Kjaergaard
- Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA
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Ha JW, Cho JR, Kim JM, Ahn JA, Choi EY, Kang SM, Rim SJ, Chung N. Tissue Doppler-Derived Indices Predict Exercise Capacity in Patients With Apical Hypertrophic Cardiomyopathy. Chest 2005; 128:3428-33. [PMID: 16304295 DOI: 10.1378/chest.128.5.3428] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Although impaired left ventricular (LV) diastolic function is a prominent feature of hypertrophic cardiomyopathy (HCM), diastolic function and its relation to exercise capacity in apical HCM (ApHCM) has not been explored previously. This study was sought to determine the relationship between diastolic mitral annular velocities combined with conventional Doppler indexes and exercise capacity in patients with ApHCM. PATIENTS Twenty-nine patients with ApHCM (24 men; mean age +/- SD, 57 +/- 10 years) underwent supine bicycle exercise with simultaneous respiratory gas analysis and two-dimensional and Doppler echocardiographic study. RESULTS The mitral inflow velocities (early filling [E], late filling, and deceleration time) were traced and measured. Early diastolic mitral annular velocity (E') was measured at the septal corner of mitral annulus by Doppler tissue imaging (DTI) from the apical four-chamber view. Pro-brain natriuretic peptide (proBNP) was measured at the time of echocardiography using a quantitative electrochemiluminescence immunoassay. E/E' ratio correlated inversely with maximal oxygen uptake (Vo(2)max) [r = - 0.47, p = 0.0106]. There was a significant positive correlation between E' and Vo(2)max (r = 0.41, p = 0.024). However, no correlation was found between conventional two-dimensional, Doppler indices, and proBNP and Vo(2)max). Of all the echocardiographic and clinical parameters assessed, E/E' ratio had the best correlation with exercise capacity (r - 0.47) and was the strongest independent predictor of Vo(2)max by multivariate analysis (p = 0.0106). CONCLUSIONS DTI-derived indexes (E', E/E' ratio), an estimate of myocardial relaxation and LV filling pressures, correlate with exercise capacity in patients with ApHCM, suggesting that abnormal diastolic function may be a factor limiting exercise capacity.
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Affiliation(s)
- Jong-Won Ha
- Cardiology Division, Yonsei University College of Medicine, Seoul, Korea.
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Shizukuda Y, Sachdev V, Fananapazir L, Tripodi D, Mohiddin SA, Arai AE, Waclawiw MA, Plehn JF. Is Functional Capacity Related to Left Atrial Contractile Function in Nonobstructive Hypertrophic Cardiomyopathy? ACTA ACUST UNITED AC 2005; 11:234-40. [PMID: 16230864 DOI: 10.1111/j.1527-5299.2005.04457.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The mechanisms underlying reduced exercise capacity in patients with nonobstructive hypertrophic cardiomyopathy (NHCM) could include perturbations of ventricular relaxation, diastolic compliance, or compensatory atrial systolic function. We hypothesized that a loss of atrial contractility in NHCM patients leads to reduced functional capacity. To test this hypothesis, we compared resting noninvasive left atrial ejection phase indices in 49 consecutive patients with NHCM (ages 36+/-10 years; 41% female) and normal left ventricular ejection fraction (mean, 68%+/-8%) with objective metabolic exercise parameters. Left atrial active emptying fraction, ejection force, and kinetic energy failed to predict exercise capacity. Only left atrial total and active emptying volumes correlated weakly with minute volume/CO2 production slope (r=0.31 and r=0.33; p<0.05 for both). Furthermore, when subjects were stratified by New York Heart Association symptomatology, exercise parameters--but not atrial contractility--differed between groups. These data, obtained at rest, fail to suggest that NHCM-related heart failure symptoms are due to an atrial myopathy.
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Affiliation(s)
- Yukitaka Shizukuda
- Cardiovascular Branch, National, Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA
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Matsumoto AY, Arteaga E, Ianni BM, Braga AMFW, Buck PC, Mady C. Relationships among exercise capacity, hypertrophy, and left ventricular diastolic function in nonobstructive hypertrophic cardiomyopathy. Am Heart J 2005; 150:144-9. [PMID: 16084161 DOI: 10.1016/j.ahj.2004.08.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2004] [Accepted: 08/22/2004] [Indexed: 10/25/2022]
Abstract
AIM The aim of this study was to analyze the relationships among exercise capacity (EC), hypertrophy, and diastolic function in nonobstructive hypertrophic cardiomyopathy (NOHCM). METHODS AND RESULTS Twenty-seven patients with NOHCM were studied. Left ventricular hypertrophy (LVH) was determined by appropriate echocardiographic indexes. For diastolic function evaluation, the following were measured: the early (E) and late (A) waves, E/A, and deceleration time of E of the mitral flow; the systolic (S), diastolic (D), and atrial reversal (AR) waves, S/D, and the atrial systolic filling fraction of the pulmonary vein flow; and the early (Ea), late (Aa) waves, Ea/Aa, and E/Ea by tissue Doppler imaging. The difference between the duration of AR and A waves (DurAR - DurA), the peak VO2, and anaerobic threshold (AT) were also determined. In these patients, the E/Ea ratio was 8.9 +/- 3.2 and DurAR - DurA was 22.6 +/- 32.6 milliseconds. The peak VO2 and AT correlated with D (r = 0.55, P = .003 and .51, P = .007, respectively) and Ea/Aa (r = 0.56, P = .007 and .45, P = .03, respectively). There was no correlation between EC and LVH. CONCLUSIONS Patients with NOHCM demonstrated evidences of elevated left ventricular (LV) end-diastolic pressure with normal filling pressure. EC compromise may be attributed to relaxation changes with inadequate filling of the left ventricle.
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Affiliation(s)
- Afonso Y Matsumoto
- Departmnet of Cardiomyopathy, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil.
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Maron MS, Zenovich AG, Casey SA, Link MS, Udelson JE, Aeppli DM, Maron BJ. Significance and relation between magnitude of left ventricular hypertrophy and heart failure symptoms in hypertrophic cardiomyopathy. Am J Cardiol 2005; 95:1329-33. [PMID: 15904638 DOI: 10.1016/j.amjcard.2005.01.077] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2004] [Revised: 01/20/2005] [Accepted: 01/18/2005] [Indexed: 11/27/2022]
Abstract
In hypertrophic cardiomyopathy (HC), an important subgroup of patients develop progressive and disabling symptoms that are related to heart failure and death. Although a direct relation has been demonstrated between left ventricular (LV) wall thickness and likelihood of sudden and unexpected death (usually in patients who are asymptomatic or mildly symptomatic), it is unresolved whether magnitude of hypertrophy is similarly associated with severity of heart failure. To determine the relation of LV wall thickness to heart failure symptoms in HC, 700 consecutive patients who had HC were assessed by 2-dimensional echocardiography. The relation between maximum level of heart failure symptoms by New York Heart Association functional class and maximum LV wall thickness was not linear but rather parabolic. Therefore, marked symptoms were most commonly associated with moderate degrees of LV hypertrophy (wall thickness 16 to 24 mm; 27%) but less frequently with extreme hypertrophy (>/=30 mm 13%) or mild hypertrophy (</=15 mm; 19%, p = 0.0001). Mean New York Heart Association functional class showed a similar pattern with respect to moderate hypertrophy (1.9 +/- 0.8), mild hypertrophy (1.6 +/- 0.9), and extreme hypertrophy (1.6 +/- 0.7, p = 0.005). Multivariable regression analysis showed the parabolic relation between heart failure symptoms and magnitude of LV hypertrophy to be independent of other hypertrophic cardiomyopathy related clinical variables. In conclusion, no direct relation was evident between symptoms of heart failure and magnitude of LV wall thickness, with implications for the natural history of HC.
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Affiliation(s)
- Martin S Maron
- Hypertrophic Cardiomyopathy Center, Division of Cardiology, Tufts-New England Medical Center, Boston, Massachusetts 02111, USA.
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Fassbach M, Schwartzkopff B. Elevated serum markers for collagen synthesis in patients with hypertrophic cardiomyopathy and diastolic dysfunction. ACTA ACUST UNITED AC 2005; 94:328-35. [PMID: 15868361 DOI: 10.1007/s00392-005-0214-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2004] [Accepted: 12/06/2004] [Indexed: 12/15/2022]
Abstract
OBJECTIVES The hypothesis of impaired collagenolysis in patients with hypertrophic cardiomyopathy (HCM) was tested by measuring serum markers of type-I collagen metabolism. These markers were correlated with echocardiographic parameters of diastolic function. BACKGROUND HCM is a common disease in the adult population with a wide range of clinical manifestations. Left ventricular hypertrophy and increased intramyocardial collagen content are known to cause diastolic dysfunction in patients with HCM. METHODS In 26 patients with HCM and 38 control subjects (aged: 57+/-3 and 54+/-2 years, p=n.s.) serum levels of collagenolytic matrixmetalloproteinase-1 (MMP-1) and its inhibitor TIMP-1, the markers for collagen type-I synthesis (PICP) and degradation (ICTP) were determined by ELISA and RIA. Diastolic function were determined by Doppler echocardiography. RESULTS Free TIMP-1 was elevated in HCM compared to controls (216,78+/-9,89 vs 183.77+/-7.57 ng/ml ; p=0.006) as well as PICP (165.92+/-10.26 vs 114.57+/-6.38 mug/l; p<0.001). Free MMP-1 was significantly lower in HCM (1.13+/-0.20 vs 2.33+/-0.34; p=0.01). ICTP did not differ. The MMP-1/TIMP-1 ratio was significantly lower in HCM (0.006+/-0.001 vs 0.012+/-0.001, p=0.003). PICP correlated positively with diastolic E/A ratio (r=0.389; p=0.05) and septal thickness (r=0.484; p=0.01). CONCLUSIONS Serum marker of collagen synthesis (PICP) is increased in patients with HCM. Increased marker for inhibition of collagenolysis (TIMP-1) and a disturbed balance of collagen synthesis and degradation (ratio) with a predominance of inhibition of collagenolysis indicates collagen accumulation (fibrosis), which explains passive diastolic dysfunction in patients with HCM.
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Affiliation(s)
- M Fassbach
- Dept. of Cardiology, Angiology and Pneumology, Heinrich-Heine-University Düsseldorf, Moorenstrasse 5, 40225 Düsseldorf, Germany
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Sachdev V, Shizukuda Y, Brenneman CL, Birdsall CW, Waclawiw MA, Arai AE, Mohiddin SA, Tripodi D, Fananapazir L, Plehn JF. Left atrial volumetric remodeling is predictive of functional capacity in nonobstructive hypertrophic cardiomyopathy. Am Heart J 2005; 149:730-6. [PMID: 15990760 DOI: 10.1016/j.ahj.2004.07.017] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The left atrium is afterload sensitive, responding to immediate changes in left ventricular (LV) diastolic pressure, and left atrial volumetric remodeling has been reported in conditions associated with abnormal diastolic function. We examined the relationship between left atrial volumetric remodeling and objective measures of exercise capacity in patients with nonobstructive hypertrophic cardiomyopathy (HCM). METHODS We compared LA volume indices, other 2-dimensional and Doppler echocardiographic parameters, invasive hemodynamic measures, and magnetic resonance imaging (MRI)-derived LV mass with exercise duration, maximal oxygen uptake (MV* O2), anaerobic threshold (AT), and ventilatory efficiency (VE/V* CO2 slope) in 43 patients with nonobstructive HCM. Patients underwent cardiac catheterization within 48 hours and metabolic stress testing within 1 week of their echocardiogram and MRI examinations. RESULTS Left atrial volume at end-ventricular systole (LA max) and end-atrial emptying (LA min) correlated with MV* O2 (r = -0.39, P < .01 for both), AT (r = -0.42, r = -0.39, respectively, P < .01 for both), and VE/V* CO2 slope (r = 0.45, P = .003; r = 0.41, P = .008). Patients with an LA max > or =33 mL/m2 had significantly lower MV* O2 (P = .025) and AT levels (P = .017) and higher VE/V* CO2 slope levels (P = .004) as compared with patients with a smaller LA size. In multivariate analysis, MRI-determined LV mass, which was not a univariate correlate of exercise tolerance, provided additional effect when combined with LA volume index. CONCLUSIONS Left atrial volumetric remodeling predicts exercise capacity in nonobstructive HCM and may reflect chronic LV diastolic burden. This simple noninvasive measure of LA size may provide a long-term indication of the effects of chronically elevated filling pressures in patients with HCM and further studies testing its prognostic value are necessary.
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Affiliation(s)
- Vandana Sachdev
- Echocardiography Laboratory, Cardiovascular Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Md 20892, USA.
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Maron BJ, Tholakanahalli VN, Zenovich AG, Casey SA, Duprez D, Aeppli DM, Cohn JN. Usefulness of B-Type Natriuretic Peptide Assay in the Assessment of Symptomatic State in Hypertrophic Cardiomyopathy. Circulation 2004; 109:984-9. [PMID: 14967727 DOI: 10.1161/01.cir.0000117098.75727.d8] [Citation(s) in RCA: 98] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background—
Hypertrophic cardiomyopathy (HCM) has a diverse clinical spectrum that often includes progressive heart failure symptoms and disability. Assessment of symptom severity may be highly subjective, encumbered by the heterogeneous clinical presentation. Plasma B-type natriuretic peptide (BNP) has been used widely as an objective marker for heart failure severity and outcome, predominantly in coronary heart disease with ventricular dilatation and systolic dysfunction.
Methods and Results—
We prospectively assessed plasma BNP as a quantitative clinical marker of heart failure severity in 107 consecutive HCM patients. BNP showed a statistically significant relationship to magnitude of functional limitation, assessed by New York Heart Association (NYHA) functional class: I, 136±159 pg/mL; II, 338±439 pg/mL; and III/IV, 481±334 pg/mL (
P
<0.001). Multivariable analysis showed that BNP was independently related to NYHA class as well as age and left ventricular wall thickness (each with a value of
P
=0.0001). BNP ≥200 pg/mL was the most reliable predictor of heart failure symptoms, with positive and negative predictive values of 63% and 79%, respectively. BNP power in distinguishing patients with or without heart failure symptoms was less than that for differentiating between no (or only mild) and severe symptoms (area under receiver operating characteristic curve=0.75 and 0.83, respectively).
Conclusions—
Plasma BNP is independently related to the presence and magnitude of heart failure symptoms in patients with HCM. As a clinical marker for heart failure, BNP is limited by considerable overlap in values between categories of heart failure severity as well as confounding variables of left ventricular wall thickness and age.
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Affiliation(s)
- Barry J Maron
- Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, and University of Minnesota, Minneapolis, MN 55407, USA.
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de la Morena Valenzuela G, Florenciano Sánchez R, García Almagro FJ, González Caballero E, Pascual Figal D, Soria Arcos F, Villegas García M, Ruipérez Abizanda JA, Valdés Chávarri M. [Functional assessment of patients with hypertrophic cardiomyopathy by maximal oxygen consumption]. Rev Esp Cardiol 2004; 56:865-72. [PMID: 14519273 DOI: 10.1016/s0300-8932(03)76974-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION AND OBJECTIVES Differences between anatomical severity and clinical manifestations are frequent in patients with hypertrophic cardiomyopathy. Our objective was to assess functional capacity in a consecutive group of patients with hypertrophic cardiomyopathy measuring exercise aerobic parameters, as well as clinical and echocardiographic variables. PATIENTS AND METHOD We studied 98 consecutive patients with hypertrophic cardiomyopathy. All patients underwent both echocardiographic and cardiopulmonary exercise testing. The control group consisted of 22 untrained persons. We studied exercise capacity by analyzing maximal oxygen consumption and aerobic functional capacity, among other variables. RESULTS Patients with hypertrophic cardiomyopathy attained significantly lower maximal oxygen consumption values than controls (24.1 5.9 vs 36.4 5.9 ml/kg/min; p = 0.0001). Maximal aerobic capacity was significantly different among patients with NYHA functional capacity class I, II or III (78.9 13.5%; 71.9 14.7%; 63.9 15.7%; p = 0.009). However, considerable overlap was found between groups in maximal aerobic capacity. Functional impairment was greater in patients with left ventricular thickness > 20 mm, ejection fraction < 50%, left atrial dimension > 45 mm and pseudonormal or restrictive transmitral flow pattern. CONCLUSIONS Patients with hypertrophic cardiomyopathy show significant functional impairment, which is difficult to detect from their clinical manifestations. Optimal assessment requires cardiopulmonary exercise testing.
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Maron BJ, McKenna WJ, Danielson GK, Kappenberger LJ, Kuhn HJ, Seidman CE, Shah PM, Spencer WH, Spirito P, Ten Cate FJ, Wigle ED. American College of Cardiology/European Society of Cardiology clinical expert consensus document on hypertrophic cardiomyopathy. A report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents and the European Society of Cardiology Committee for Practice Guidelines. J Am Coll Cardiol 2003; 42:1687-713. [PMID: 14607462 DOI: 10.1016/s0735-1097(03)00941-0] [Citation(s) in RCA: 995] [Impact Index Per Article: 47.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Lombardi R, Betocchi S, Losi MA, Tocchetti CG, Aversa M, Miranda M, D'Alessandro G, Cacace A, Ciampi Q, Chiariello M. Myocardial collagen turnover in hypertrophic cardiomyopathy. Circulation 2003; 108:1455-60. [PMID: 12952838 DOI: 10.1161/01.cir.0000090687.97972.10] [Citation(s) in RCA: 154] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Myocardial interstitial fibrosis is a characteristic of hypertrophic cardiomyopathy (HCM). This study evaluates the collagen turnover in HCM and its impact on left ventricular (LV) diastolic function. METHODS AND RESULTS Thirty-six HCM patients and 14 sex- and age-matched controls were studied. Collagen turnover was assessed as follows. By radioimmunoassay, a byproduct of collagen III synthesis (PIIINP) and 3 peptides resulting from collagen I synthesis (PICP and PINP) and degradation (ICTP) were measured. By ELISA, matrix metalloproteinases (MMPs) were determined, as follows: active MMP-2; active MMP-9; and MMP-1 as active, free (as active MMP-1 plus its precursor), and total (as free MMP-1 plus MMP-1/tissue inhibitor complexes). Tissue inhibitor of metalloproteinases-1 (TIMP-1) was also assayed. All patients underwent echocardiography. The difference in duration between transmitral forward (A) and pulmonary venous retrograde (AR) waves (A-Ar) was considered an estimate of passive diastolic function. Furthermore, restrictive or pseudonormal LV filling patterns were considered to identify patients with passive diastolic dysfunction. Patients had higher levels of PIIINP, ICTP, MMP-2, MMP-9, and total TIMP-1 than did controls. PIIINP was inversely related to LV end-diastolic diameter. A-Ar was inversely related to PICP, PINP, and their differences with ICTP (estimates of collagen I buildup). Furthermore, A-Ar was directly related to MMP-1 and MMP-2. CONCLUSIONS As compared with controls, collagen turnover is enhanced in HCM patients. As collagen I synthesis prevails over degradation and MMP-1 and MMP-2 are inhibited, passive diastolic dysfunction occurs in patients with HCM.
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Affiliation(s)
- Raffaella Lombardi
- Department of Clinical Medicine, Cardiovascular and Immunological Sciences, Federico II University School of Medicine, Naples, Italy
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