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Guler A, Turkmen I, Atmaca S, Karakurt H, Kahraman S, Aydin S, Sevinc S, Tukenmez Karakurt S, Turkvatan Cansever A, Erturk M, Babur Guler G. Influence of cardiac biomarkers on predicting significant coronary artery disease in hypertrophic cardiomyopathy patients. Heart Vessels 2023; 38:1329-1336. [PMID: 37414867 DOI: 10.1007/s00380-023-02287-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 06/29/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND In this study, our aim was to investigate the role of cardiac biomarkers in predicting the presence of significant coronary artery disease in hypertrophic cardiomyopathy (HCM) patients. METHODS The study population was composed of hypertrophic cardiomyopathy patients who underwent coronary angiography at a single center between June 2021 and March 2023, and whose cardiac biomarkers were evaluated before the procedure. HCM patients were screened retrospectively. Significant CAD was defined as > 50% stenosis of the left main coronary artery or > 70% stenosis in a major coronary vessel. Demographic, echocardiographic and cardiac biomarker values were compared between the two groups. RESULTS A total of 123 patients were evaluated. Significant CAD was detected in 39 (31.7%) patients. Patients with significant CAD had higher CK-MB values than those without CAD [2.8 (2.1-4.0) vs. 3.4 (2.8-4.6), p = 0.036], and a higher level of high-sensitivity troponin T (hs-TnT) than those without CAD (24 vs. 17.8, p = 0.022). the NT-proBNP/hs-TnT ratio was found to be significantly lower in patients with CAD than in those with CAD (31.4 vs. 21.4, p = 0.019). In multivariate anaylsis, NT-proBNP/hs-TnT was determined as an independent predictor for significant CAD. In ROC analysis, NT-proBNP/hs-TnT ratio lower than the cut-off value of 30.7 could detect the presence of significant CAD with 76.9% sensitivity and 53.6% specificity (AUC: 0.632, 95% CI: 0.528-0.736, p = 0.019). CONCLUSION To sum up, we suggest that cardiac biomarkers were valuable and simple parameters in terms of significant CAD in HCM patients.
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Affiliation(s)
- Arda Guler
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, University of Health Sciences, Istasyon Mahallesi, Turgut Ozal Bulvarı, No: 11, Küçükçekmece/Istanbul, Turkey.
| | - Irem Turkmen
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, University of Health Sciences, Istasyon Mahallesi, Turgut Ozal Bulvarı, No: 11, Küçükçekmece/Istanbul, Turkey
| | - Sezgin Atmaca
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, University of Health Sciences, Istasyon Mahallesi, Turgut Ozal Bulvarı, No: 11, Küçükçekmece/Istanbul, Turkey
| | - Huseyin Karakurt
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, University of Health Sciences, Istasyon Mahallesi, Turgut Ozal Bulvarı, No: 11, Küçükçekmece/Istanbul, Turkey
| | - Serkan Kahraman
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, University of Health Sciences, Istasyon Mahallesi, Turgut Ozal Bulvarı, No: 11, Küçükçekmece/Istanbul, Turkey
| | - Sinem Aydin
- Department of Radiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Samet Sevinc
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, University of Health Sciences, Istasyon Mahallesi, Turgut Ozal Bulvarı, No: 11, Küçükçekmece/Istanbul, Turkey
| | - Seda Tukenmez Karakurt
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, University of Health Sciences, Istasyon Mahallesi, Turgut Ozal Bulvarı, No: 11, Küçükçekmece/Istanbul, Turkey
| | - Aysel Turkvatan Cansever
- Department of Radiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Mehmet Erturk
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, University of Health Sciences, Istasyon Mahallesi, Turgut Ozal Bulvarı, No: 11, Küçükçekmece/Istanbul, Turkey
| | - Gamze Babur Guler
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, University of Health Sciences, Istasyon Mahallesi, Turgut Ozal Bulvarı, No: 11, Küçükçekmece/Istanbul, Turkey
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2
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Crean AM, Small GR, Saleem Z, Maharajh G, Ruel M, Chow BJW. Application of Cardiovascular Computed Tomography to the Assessment of Patients With Hypertrophic Cardiomyopathy. Am J Cardiol 2023; 205:481-492. [PMID: 37683571 DOI: 10.1016/j.amjcard.2023.06.096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 06/24/2023] [Accepted: 06/29/2023] [Indexed: 09/10/2023]
Abstract
Hypertrophic cardiomyopathy is a common inherited cardiac condition in which regional myocardial thickening and scarring can lead to a range of symptoms including breathlessness, dizziness, chest pain, and collapse with loss of consciousness. It is vital to be able to understand the mechanisms behind these epiphenomena and to be able to distinguish, for example, between syncope because of arrhythmia versus syncope because of mechanical outflow tract obstruction. Therefore, we require a technique that can characterize anatomy, physiology, and myocardial substrate. Traditionally, this role has been the preserve of cardiac magnetic resonance (CMR) imaging. This review makes the case for cardiac computed tomography (CT) as an alternative imaging method. We review the use of functional CT to identify the components of outflow tract obstruction (and obstruction at other levels, which may be simultaneous), and as an aid to interventional and surgical planning. We demonstrate the added value of multiplanar isotropic reformats in this condition, particularly in cases where the diagnosis may be more challenging or where complications (such as early apical aneurysm) may be difficult to recognize with 2-dimensional techniques. In conclusion, our aim is to convince readers that cardiac CT is a highly valuable and versatile tool, which deserves wider usage and greater recognition in those caring for patients with hypertrophic cardiomyopathy.
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Affiliation(s)
- Andrew M Crean
- Division of Cardiology, Ottawa Heart Institute, Ottawa, Ontario, Canada.
| | - Gary R Small
- Division of Cardiology, Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Zain Saleem
- Division of Cardiology, University of Ottawa, Ottawa, Ontario, Canada
| | - Gyaandeo Maharajh
- Division of Cardiovascular Surgery, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Marc Ruel
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Benjamin J W Chow
- Division of Cardiology, Ottawa Heart Institute, Ottawa, Ontario, Canada
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3
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Coleman JA, Ashkir Z, Raman B, Bueno-Orovio A. Mechanisms and prognostic impact of myocardial ischaemia in hypertrophic cardiomyopathy. Int J Cardiovasc Imaging 2023; 39:1979-1996. [PMID: 37358707 PMCID: PMC10589194 DOI: 10.1007/s10554-023-02894-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 06/03/2023] [Indexed: 06/27/2023]
Abstract
Despite the progress made in risk stratification, sudden cardiac death and heart failure remain dreaded complications for hypertrophic cardiomyopathy (HCM) patients. Myocardial ischaemia is widely acknowledged as a contributor to cardiovascular events, but the assessment of ischaemia is not yet included in HCM clinical guidelines. This review aims to evaluate the HCM-specific pro-ischaemic mechanisms and the potential prognostic value of imaging for myocardial ischaemia in HCM. A literature review was performed using PubMed to identify studies with non-invasive imaging of ischaemia (cardiovascular magnetic resonance, echocardiography, and nuclear imaging) in HCM, prioritising studies published after the last major review in 2009. Other studies, including invasive ischaemia assessment and post-mortem histology, were also considered for mechanistic or prognostic relevance. Pro-ischaemic mechanisms in HCM reviewed included the effects of sarcomeric mutations, microvascular remodelling, hypertrophy, extravascular compressive forces and left ventricular outflow tract obstruction. The relationship between ischaemia and fibrosis was re-appraised by considering segment-wise analyses in multimodal imaging studies. The prognostic significance of myocardial ischaemia in HCM was evaluated using longitudinal studies with composite endpoints, and reports of ischaemia-arrhythmia associations were further considered. The high prevalence of ischaemia in HCM is explained by several micro- and macrostructural pathological features, alongside mutation-associated energetic impairment. Ischaemia on imaging identifies a subgroup of HCM patients at higher risk of adverse cardiovascular outcomes. Ischaemic HCM phenotypes are a high-risk subgroup associated with more advanced left ventricular remodelling, but further studies are required to evaluate the independent prognostic value of non-invasive imaging for ischaemia.
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Affiliation(s)
- James A Coleman
- Department of Computer Science, University of Oxford, Oxford, UK
| | - Zakariye Ashkir
- Oxford Centre for Clinical Magnetic Resonance Research, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Betty Raman
- Oxford Centre for Clinical Magnetic Resonance Research, John Radcliffe Hospital, University of Oxford, Oxford, UK
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4
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Lee C, Dow S, Shah K, Henkin S, Taub C. Complications of exercise and pharmacologic stress echocardiography. Front Cardiovasc Med 2023; 10:1228613. [PMID: 37600036 PMCID: PMC10435903 DOI: 10.3389/fcvm.2023.1228613] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 07/24/2023] [Indexed: 08/22/2023] Open
Abstract
Stress echocardiography is a diagnostic cardiovascular exam that is commonly utilized for multiple indications, including but not limited to the assessment of obstructive coronary artery disease, valvular disease, obstructive hypertrophic cardiomyopathy, and diastolic function. Stress echocardiography can be performed via both exercise and pharmacologic modalities. Exercise stress is performed with either treadmill or bicycle-based exercise. Pharmacologic stress is performed via either dobutamine or vasodilator-mediated (i.e., dipyridamole, adenosine) stress testing. Each of these modalities is associated with a low overall prevalence of major, life-threatening adverse outcomes, though adverse events are most common with dobutamine stress echocardiography. In light of the recent COVID-19 pandemic, the risk of infectious complications to both the patient and stress personnel cannot be negated; however, when certain precautions are taken, the risk of infectious complications appears minimal. In this article, we review each of the stress echocardiographic modalities, examine major potential adverse outcomes and contraindications, assess the risks of stress testing in the setting of a global pandemic, and examine the utilization and safety of stress testing in special patient populations (i.e., language barriers, pediatric patients, pregnancy).
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Affiliation(s)
| | | | | | | | - Cynthia Taub
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Dartmouth College, Lebanon, NH, United States
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5
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Crean AM, Small GS, Chow BJW, Ruddy TD, Beanlands RSB, deKemp RA. High-resolution PET demonstrates extensive ischemia/fibrosis mismatch in a patient with hypertrophic cardiomyopathy: the power of multimodality image fusion. J Nucl Cardiol 2023; 30:1709-1712. [PMID: 35672566 DOI: 10.1007/s12350-022-02993-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 04/12/2022] [Indexed: 11/28/2022]
Affiliation(s)
- A M Crean
- Department of Medicine (Cardiology), University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - G S Small
- Department of Medicine (Cardiology), University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - B J W Chow
- Department of Medicine (Cardiology), University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - T D Ruddy
- Department of Medicine (Cardiology), University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - R S B Beanlands
- Department of Medicine (Cardiology), University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - R A deKemp
- Department of Medicine (Cardiology), University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada.
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6
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Giannopoulos AA, Buechel RR, Kaufmann PA. Coronary microvascular disease in hypertrophic and infiltrative cardiomyopathies. J Nucl Cardiol 2023; 30:800-810. [PMID: 35915323 PMCID: PMC10125945 DOI: 10.1007/s12350-022-03040-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 05/20/2022] [Indexed: 11/30/2022]
Abstract
Pathologic hypertrophy of the cardiac muscle is a commonly encountered phenotype in clinical practice, associated with a variety of structural and non-structural diseases. Coronary microvascular disease is considered to play an important role in the natural history of this pathological phenotype. Non-invasive imaging modalities, most prominently positron emission tomography and cardiac magnetic resonance, have provided insights into the pathophysiological mechanisms of the interplay between hypertrophy and the coronary microvasculature. This article summarizes the current knowledge on coronary microvascular dysfunction in the most frequently encountered forms of pathologic hypertrophy.
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Affiliation(s)
- Andreas A Giannopoulos
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital and University Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Ronny R Buechel
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital and University Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital and University Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
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7
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Nagueh SF, Phelan D, Abraham T, Armour A, Desai MY, Dragulescu A, Gilliland Y, Lester SJ, Maldonado Y, Mohiddin S, Nieman K, Sperry BW, Woo A. Recommendations for Multimodality Cardiovascular Imaging of Patients with Hypertrophic Cardiomyopathy: An Update from the American Society of Echocardiography, in Collaboration with the American Society of Nuclear Cardiology, the Society for Cardiovascular Magnetic Resonance, and the Society of Cardiovascular Computed Tomography. J Am Soc Echocardiogr 2022; 35:533-569. [PMID: 35659037 DOI: 10.1016/j.echo.2022.03.012] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Hypertrophic cardiomyopathy (HCM) is defined by the presence of left ventricular hypertrophy in the absence of other potentially causative cardiac, systemic, syndromic, or metabolic diseases. Symptoms can be related to a range of pathophysiologic mechanisms including left ventricular outflow tract obstruction with or without significant mitral regurgitation, diastolic dysfunction with heart failure with preserved and heart failure with reduced ejection fraction, autonomic dysfunction, ischemia, and arrhythmias. Appropriate understanding and utilization of multimodality imaging is fundamental to accurate diagnosis as well as longitudinal care of patients with HCM. Resting and stress imaging provide comprehensive and complementary information to help clarify mechanism(s) responsible for symptoms such that appropriate and timely treatment strategies may be implemented. Advanced imaging is relied upon to guide certain treatment options including septal reduction therapy and mitral valve repair. Using both clinical and imaging parameters, enhanced algorithms for sudden cardiac death risk stratification facilitate selection of HCM patients most likely to benefit from implantable cardioverter-defibrillators.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Saidi Mohiddin
- Inherited/Acquired Myocardial Diseases, Barts Health NHS Trust, St Bartholomew's Hospital, London, UK
| | - Koen Nieman
- Cardiovascular Medicine and Radiology (CV Imaging), Stanford University Medical Center, CA
| | - Brett W Sperry
- Saint Luke's Mid America Heart Institute, Kansas City, MO
| | - Anna Woo
- Toronto General Hospital, Toronto, Canada
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8
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Gossios T, Savvatis K, Zegkos T, Ntelios D, Rouskas P, Parcharidou D, Karvounis H, Efthimiadis GK. Deciphering hypertrophic cardiomyopathy with electrocardiography. Heart Fail Rev 2021; 27:1313-1323. [PMID: 34286451 DOI: 10.1007/s10741-021-10147-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/10/2021] [Indexed: 11/30/2022]
Abstract
The comprehensive assessment of patients with hypertrophic cardiomyopathy is a complex process, with each step concurrently focusing on confirmation of the diagnosis, differentiation between sarcomeric and non-sarcomeric disease (phenocopy), and prognostication. Novel modalities such as genetic testing and advanced imaging have allowed for substantial advancements in the understanding of this condition and facilitate patient management. However, their availability is at present not universal, and interpretation requires a high level of expertise. In this setting, electrocardiography, a fast and widely available method, still retains a significant role in everyday clinical assessment of this population. In our review, we follow a stepwise approach for the interpretation of each electrocardiographic segment, discussing clinical implications of electrocardiographic patterns in sarcomeric disease, their value in the differential diagnosis from phenocopies, and impact on patient management. Outlining the substantial amount of information to be obtained from a simple tracing, we exhibit how electrocardiography is likely to remain an integral diagnostic tool in the future as well.
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Affiliation(s)
- Thomas Gossios
- Cardiology Department, NHS Foundation Trust, Guy's and St Thomas Westminster Bridge Road, London, SE1 7EH, UK. .,Inherited Cardiac Conditions Unit, Barts Heart Centre, St Bartholomew's Hospital, London, UK. .,Cardiomyopathies Laboratory, 1st Aristotle University of Thessaloniki Cardiology Department, AHEPA University Hospital, Thessaloniki, Greece.
| | - Konstantinos Savvatis
- Inherited Cardiac Conditions Unit, Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - Thomas Zegkos
- Cardiomyopathies Laboratory, 1st Aristotle University of Thessaloniki Cardiology Department, AHEPA University Hospital, Thessaloniki, Greece
| | - Dimitrios Ntelios
- Cardiomyopathies Laboratory, 1st Aristotle University of Thessaloniki Cardiology Department, AHEPA University Hospital, Thessaloniki, Greece
| | - Pavlos Rouskas
- Cardiomyopathies Laboratory, 1st Aristotle University of Thessaloniki Cardiology Department, AHEPA University Hospital, Thessaloniki, Greece
| | - Despoina Parcharidou
- Cardiomyopathies Laboratory, 1st Aristotle University of Thessaloniki Cardiology Department, AHEPA University Hospital, Thessaloniki, Greece
| | - Haralambos Karvounis
- Cardiomyopathies Laboratory, 1st Aristotle University of Thessaloniki Cardiology Department, AHEPA University Hospital, Thessaloniki, Greece
| | - Georgios K Efthimiadis
- Cardiomyopathies Laboratory, 1st Aristotle University of Thessaloniki Cardiology Department, AHEPA University Hospital, Thessaloniki, Greece
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9
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Cardiomyopathies: An Overview. Int J Mol Sci 2021; 22:ijms22147722. [PMID: 34299342 PMCID: PMC8303989 DOI: 10.3390/ijms22147722] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 07/04/2021] [Accepted: 07/14/2021] [Indexed: 12/15/2022] Open
Abstract
Background: Cardiomyopathies are a heterogeneous group of pathologies characterized by structural and functional alterations of the heart. Aims: The purpose of this narrative review is to focus on the most important cardiomyopathies and their epidemiology, diagnosis, and management. Methods: Clinical trials were identified by Pubmed until 30 March 2021. The search keywords were “cardiomyopathies, sudden cardiac arrest, dilated cardiomyopathy (DCM), hypertrophic cardiomyopathy (HCM), restrictive cardiomyopathy, arrhythmogenic cardiomyopathy (ARCV), takotsubo syndrome”. Results: Hypertrophic cardiomyopathy (HCM) is the most common primary cardiomyopathy, with a prevalence of 1:500 persons. Dilated cardiomyopathy (DCM) has a prevalence of 1:2500 and is the leading indication for heart transplantation. Restrictive cardiomyopathy (RCM) is the least common of the major cardiomyopathies, representing 2% to 5% of cases. Arrhythmogenic cardiomyopathy (ARCV) is a pathology characterized by the substitution of the myocardium by fibrofatty tissue. Takotsubo cardiomyopathy is defined as an abrupt onset of left ventricular dysfunction in response to severe emotional or physiologic stress. Conclusion: In particular, it has been reported that HCM is the most important cause of sudden death on the athletic field in the United States. It is needless to say how important it is to know which changes in the heart due to physical activity are normal, and when they are pathological.
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10
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Camaioni C, Knott KD, Augusto JB, Seraphim A, Rosmini S, Ricci F, Boubertakh R, Xue H, Hughes R, Captur G, Lopes LR, Brown LAE, Manisty C, Petersen SE, Plein S, Kellman P, Mohiddin SA, Moon JC. Inline perfusion mapping provides insights into the disease mechanism in hypertrophic cardiomyopathy. Heart 2019; 106:824-829. [PMID: 31822572 PMCID: PMC7282549 DOI: 10.1136/heartjnl-2019-315848] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 10/29/2019] [Accepted: 11/05/2019] [Indexed: 12/24/2022] Open
Abstract
Objective In patients with hypertrophic cardiomyopathy (HCM), the role of small vessel disease and myocardial perfusion remains incompletely understood and data on absolute myocardial blood flow (MBF, mL/g/min) are scarce. We measured MBF using cardiovascular magnetic resonance fully quantitative perfusion mapping to determine the relationship between perfusion, hypertrophy and late gadolinium enhancement (LGE) in HCM. Methods 101 patients with HCM with unobstructed epicardial coronary arteries and 30 controls (with matched cardiovascular risk factors) underwent pixel-wise perfusion mapping during adenosine stress and rest. Stress, rest MBF and the myocardial perfusion reserve (MPR, ratio of stress to rest) were calculated globally and segmentally and then associated with segmental wall thickness and LGE. Results In HCM, 79% had a perfusion defect on clinical read. Stress MBF and MPR were reduced compared with controls (mean±SD 1.63±0.60 vs 2.30±0.64 mL/g/min, p<0.0001 and 2.21±0.87 vs 2.90±0.90, p=0.0003, respectively). Globally, stress MBF fell with increasing indexed left ventricle mass (R2 for the model 0.186, p=0.036) and segmentally with increasing wall thickness and LGE (both p<0.0001). In 21% of patients with HCM, MBF was lower during stress than rest (MPR <1) in at least one myocardial segment, a phenomenon which was predominantly subendocardial. Apparently normal HCM segments (normal wall thickness, no LGE) had reduced stress MBF and MPR compared with controls (mean±SD 1.88±0.81 mL/g/min vs 2.32±0.78 mL/g/min, p<0.0001). Conclusions Microvascular dysfunction is common in HCM and associated with hypertrophy and LGE. Perfusion can fall during vasodilator stress and is abnormal even in apparently normal myocardium suggesting it may be an early disease marker.
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Affiliation(s)
| | - Kristopher D Knott
- Advanced Cardiac Imaging, Barts Health NHS Trust, London, UK.,Institute of Cardiovascular Science, University College London, London, UK
| | - Joao B Augusto
- Advanced Cardiac Imaging, Barts Health NHS Trust, London, UK.,Institute of Cardiovascular Science, University College London, London, UK
| | - Andreas Seraphim
- Advanced Cardiac Imaging, Barts Health NHS Trust, London, UK.,Institute of Cardiovascular Science, University College London, London, UK
| | | | | | - Redha Boubertakh
- Advanced Cardiac Imaging, Barts Health NHS Trust, London, UK.,The William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Hui Xue
- National Institutes of Health, Bethesda, Maryland, USA
| | - Rebecca Hughes
- Advanced Cardiac Imaging, Barts Health NHS Trust, London, UK.,Institute of Cardiovascular Science, University College London, London, UK
| | - Gaby Captur
- Advanced Cardiac Imaging, Barts Health NHS Trust, London, UK.,Institute of Cardiovascular Science, University College London, London, UK
| | - Luis Rocha Lopes
- Advanced Cardiac Imaging, Barts Health NHS Trust, London, UK.,Institute of Cardiovascular Science, University College London, London, UK
| | | | - Charlotte Manisty
- Advanced Cardiac Imaging, Barts Health NHS Trust, London, UK.,Institute of Cardiovascular Science, University College London, London, UK
| | - Steffen Erhard Petersen
- Advanced Cardiac Imaging, Barts Health NHS Trust, London, UK.,The William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Sven Plein
- Department of Biomedical Imaging Science, University of Leeds, Leeds, UK
| | - Peter Kellman
- National Institutes of Health, Bethesda, Maryland, USA
| | | | - James C Moon
- Advanced Cardiac Imaging, Barts Health NHS Trust, London, UK .,Institute of Cardiovascular Science, University College London, London, UK
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11
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Finocchiaro G, Sheikh N, Biagini E, Papadakis M, Maurizi N, Sinagra G, Pelliccia A, Rapezzi C, Sharma S, Olivotto I. The electrocardiogram in the diagnosis and management of patients with hypertrophic cardiomyopathy. Heart Rhythm 2019; 17:142-151. [PMID: 31349064 DOI: 10.1016/j.hrthm.2019.07.019] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Indexed: 12/20/2022]
Abstract
In an era of rapid technological development and evolving diagnostic possibilities, the electrocardiogram (ECG) is living an authentic "renaissance" in myocardial diseases. To date, the ECG remains an irreplaceable first step when evaluating patients with hypertrophic cardiomyopathy (HCM) and an abnormal ECG may be the only manifestation of disease at an early stage. In some instances, specific electrical anomalies may differentiate HCM from phenocopies such as cardiac amyloidosis and glycogen storage diseases. The exponential growth in knowledge of the complexity of HCM has led to new challenges in terms of early identification of the disease, differential diagnosis, risk stratification, and development of targeted therapies. In this scenario, the apparently "old fashioned" ECG and the array of ECG-based techniques, ranging from Holter monitoring and loop recorders to exercise testing, are as contemporary as ever. In the present review, we discuss the current role of the ECG in the diagnosis and management of HCM, focusing on various clinical settings where its appropriate use and interpretation can make a difference.
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Affiliation(s)
| | - Nabeel Sheikh
- Cardiothoracic Centre, Guy's and St Thomas' Hospital, London, United Kingdom
| | - Elena Biagini
- Cardiology, Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Michael Papadakis
- Cardiology Clinical and Academic Group, St George's, University of London, and St George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Nicolo' Maurizi
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | | | | | - Claudio Rapezzi
- Cardiology, Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Sanjay Sharma
- Cardiology Clinical and Academic Group, St George's, University of London, and St George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Iacopo Olivotto
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
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12
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Bravo PE. Is there a role for cardiac positron emission tomography in hypertrophic cardiomyopathy? J Nucl Cardiol 2019; 26:1125-1134. [PMID: 29761309 DOI: 10.1007/s12350-018-1298-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Accepted: 04/30/2018] [Indexed: 12/16/2022]
Abstract
Coronary microvascular dysfunction and, its functional consequence, myocardial ischemia are common pathologic features in patients with hypertrophic cardiomyopathy (HCM). Both have been commonly invoked as potential triggers of and/or contributors to the underlying pathophysiological processes leading to heart failure, and malignant ventricular arrhythmias. Positron emission tomography (PET) with myocardial blood flow quantification provides a unique opportunity to evaluate the integrity and function of the coronary microcirculation in HCM. The purpose of the present review is to summarize all the pertinent literature and future perspectives of the role of PET in the evaluation and risk stratification of patients with HCM.
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Affiliation(s)
- Paco E Bravo
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
- Division of Cardiology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
- , 3400 Civic Center Boulevard, 11-154 South Pavilion, Philadelphia, PA, 19104, USA.
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Song C, Wang S, Guo Y, Zheng X, Lu J, Fang X, Wang S, Huang X. Preoperative NT-proBNP Predicts Midterm Outcome After Septal Myectomy. J Am Heart Assoc 2019; 8:e011075. [PMID: 30760079 PMCID: PMC6405667 DOI: 10.1161/jaha.118.011075] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The prognostic value of N‐terminal pro–brain natriuretic peptide (NT‐proBNP) in patients with hypertrophic cardiomyopathy who underwent septal myectomy has not been well studied. Methods and Results We retrospectively evaluated NT‐proBNP levels in 758 patients (46.1±13.8 years; median follow‐up, 936 days) who underwent septal myectomy in our center between March 2011 and April 2018. The median NT‐proBNP level was 1450.5 (interquartile range 682.6‐2649.5) pg/mL. Overall, 22 (2.9%) patients died during follow‐up; of these, 86.4% were cardiovascular deaths. The 3‐year survival free from all‐cause mortality by tertile was 95.2% (95% CI 91.1% to 97.4%; NT‐proBNP >2080 pg/mL), 98.3% (95% CI 94.6% to 99.5%; NT‐proBNP, 947‐2080 pg/mL), and 99.2% (95% CI, 94.4% to 99.9%; NT‐proBNP <947 pg/mL). The 3‐year survival rate free from cardiovascular mortality by tertiles was 95.2% in the highest tertile, 98.8% in the middle tertile, and 99.2% in the lowest tertile. Cox regression analysis indicated that Ln(NT‐proBNP) was a significantly independent predictor of all‐cause mortality (hazard ratio 2.380, 95% CI 1.356‐4.178, P=0.003) and cardiovascular mortality (hazard ratio 2.788, 95% CI 1.450‐5.362, P=0.002). In addition, concomitant coronary artery bypass grafting for coronary artery disease was also an independent predictor of cardiovascular mortality (hazard ratio 5.178, 95% CI 1.597‐16.789, P=0.006). Conclusions Increased preoperative NT‐proBNP level is a strong predictor of midterm mortality in patients undergoing septal myectomy.
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Affiliation(s)
- Changpeng Song
- 1 Department of Special Medical Treatment Center Fuwai Hospital, National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Shengwei Wang
- 2 Department of Cardiovascular Surgery Fuwai Hospital National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Ying Guo
- 1 Department of Special Medical Treatment Center Fuwai Hospital, National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Xinxin Zheng
- 1 Department of Special Medical Treatment Center Fuwai Hospital, National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Jie Lu
- 1 Department of Special Medical Treatment Center Fuwai Hospital, National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Xiaonan Fang
- 1 Department of Special Medical Treatment Center Fuwai Hospital, National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Shuiyun Wang
- 2 Department of Cardiovascular Surgery Fuwai Hospital National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Xiaohong Huang
- 1 Department of Special Medical Treatment Center Fuwai Hospital, National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
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Microvascular Dysfunction in Hypertrophic Cardiomyopathy. CURRENT CARDIOVASCULAR IMAGING REPORTS 2019. [DOI: 10.1007/s12410-019-9478-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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15
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Abstract
Hypertrophic cardiomyopathy (HCM) is a heart disease characterized by hypertrophy of the left ventricular myocardium and is most often caused by mutations in sarcomere genes. The structural and functional abnormalities are not explained by flow-limiting coronary artery disease or loading conditions. The disease affects at least 0.2% of the population worldwide and is the most common cause of sudden cardiac death in young people and competitive athletes because of fatal ventricular arrhythmia. In some patients, however, HCM has a benign course. Therefore, it is of utmost importance to properly evaluate patients and single out those who would benefit from an implanted cardioverter defibrillator. In this article, we review and summarize the sudden cardiac death risk stratification algorithms, methods of preventing death due to HCM, and novel factors that may improve the existing prediction models.
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16
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Hypertrophic Cardiomyopathy-Past, Present and Future. J Clin Med 2017; 6:jcm6120118. [PMID: 29231893 PMCID: PMC5742807 DOI: 10.3390/jcm6120118] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 11/21/2017] [Accepted: 12/05/2017] [Indexed: 12/15/2022] Open
Abstract
Hypertrophic cardiomyopathy (HCM) is the most common genetic cardiomyopathy with a prevalence of 1 in 500 in the general population. Since the first pathological case series at post mortem in 1957, we have come a long way in its understanding, diagnosis and management. Here, we will describe the history of our understanding of HCM including the initial disease findings, diagnostic methods and treatment options. We will review the current guidelines for the diagnosis and management of HCM, current gaps in the evidence base and discuss the new and promising developments in this field.
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17
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Tower-Rader A, Betancor J, Lever HM, Desai MY. A Comprehensive Review of Stress Testing in Hypertrophic Cardiomyopathy: Assessment of Functional Capacity, Identification of Prognostic Indicators, and Detection of Coronary Artery Disease. J Am Soc Echocardiogr 2017; 30:829-844. [DOI: 10.1016/j.echo.2017.05.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Indexed: 01/17/2023]
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18
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Myocardial blood flow and left ventricular functional reserve in hypertrophic cardiomyopathy: a 13NH 3 gated PET study. Eur J Nucl Med Mol Imaging 2017; 44:866-875. [PMID: 28050630 DOI: 10.1007/s00259-016-3603-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 12/16/2016] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Ischemia in hypertrophic cardiomyopathy (HCM) is caused by coronary microvascular dysfunction (CMD), which is detected by measuring myocardial blood flow (MBF) with PET. Whether CMD may be associated with ischemic left ventricular (LV) dysfunction is unclear. We therefore assessed LV ejection fraction (EF) reserve in HCM patients undergoing dipyridamole (Dip) PET. METHODS Resting and stress 13NH3 dynamic as well as gated PET were performed in 34 HCM patients. Segmental MBF and transmural perfusion gradient (TPG = subendocardial / subepicardial MBF) were assessed. LVEF reserve was considered abnormal if Dip LVEF decreased more than 5 units as compared to rest. RESULTS Eighteen patients had preserved (group A) and 16 abnormal LVEF reserve (group B; range -7 to -32). Group B patients had greater wall thickness than group A, but resting volumes, LVEF, resting and Dip MBF, and myocardial flow reserve were similar. Group B had slightly higher summed stress score and summed difference score in visual analysis than group A, and a significantly higher summed stress wall motion score. In group B, resting TPG was slightly lower (1.31 ± 0.29 vs. 1.37 ± 0.34, p <0.05), and further decreased after Dip, whilst in group A it increased (B = 1.20 ± 0.39, p < 0.0001 vs. rest and vs. A = 1.40 ± 0.43). The number of segments per patient with TPG <1 was higher than in group A (p < 0.001) and was a significant predictor of impaired LVEF reserve (OR 1.86, p < 0.02), together with wall thickness (OR 1.3, p < 0.02). CONCLUSION Abnormal LVEF response is common in HCM patients following Dip, and is related to abnormal TPG, suggesting that subendocardial ischemia might occur under Dip and cause transient LV dysfunction. Although in vivo this effect may be hindered by the adrenergic drive associated with effort, these findings may have relevance in understanding exercise limitation and heart failure symptoms in HCM.
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Parato VM, Olivotto I, Maron MS, Nanda NC, Pandian NG. Left Ventricular Apex Involvement in Hypertrophic Cardiomyopathy. Echocardiography 2015; 32:1575-80. [PMID: 26174694 DOI: 10.1111/echo.12986] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Vito Maurizio Parato
- Cardiology Unit and Echocardiography, Madonna del Soccorso Hospital, San Benedetto del Tronto and Politecnica delle Marche University, Ancona, Italy
| | - Iacopo Olivotto
- Referral Center for Cardiomyopathies, Careggi University Hospital, Florence, Italy
| | | | - Navin C Nanda
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama
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20
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Delgado V, Bax JJ. Clinical topic: Nuclear imaging in hypertrophic cardiomyopathy. J Nucl Cardiol 2015; 22:408-18. [PMID: 25548121 DOI: 10.1007/s12350-014-0054-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 12/09/2014] [Indexed: 10/24/2022]
Abstract
Non-invasive cardiac imaging plays a central role in the diagnosis and management of patients with hypertrophic cardiomyopathy. Transthoracic echocardiography is the imaging technique of first choice to evaluate wall thickness, left ventricular systolic and diastolic function, presence of left ventricular outflow tract obstruction, and abnormal mitral anatomy, whereas cardiac magnetic resonance provides additional information on tissue characterization (replacement fibrosis) using late gadolinium enhancement. Nuclear imaging techniques permit also the assessment of left ventricular systolic and diastolic function in patients with hypertrophic cardiomyopathy but are more frequently used to evaluate myocardial ischemia (particularly assessment of microvascular dysfunction using positron emission tomography) and abnormal sympathetic myocardial innervation. This review article provides an overview of the use of nuclear imaging techniques to refine the phenotyping and risk stratification of patients with hypertrophic cardiomyopathy with particular focus on prediction of progression to overt heart failure, detection of myocardial ischemia, and evaluation of the arrhythmogenic substrate and risk of sudden cardiac death.
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Affiliation(s)
- Victoria Delgado
- Heart and Lung Center, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
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21
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Parekh RS, Meoni LA, Jaar BG, Sozio SM, Shafi T, Tomaselli GF, Lima JA, Tereshchenko LG, Estrella MM, Kao WHL. Rationale and design for the Predictors of Arrhythmic and Cardiovascular Risk in End Stage Renal Disease (PACE) study. BMC Nephrol 2015; 16:63. [PMID: 25903746 PMCID: PMC4434806 DOI: 10.1186/s12882-015-0050-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 04/01/2015] [Indexed: 11/24/2022] Open
Abstract
Background Sudden cardiac death occurs commonly in the end-stage renal disease population receiving dialysis, with 25% dying of sudden cardiac death over 5 years. Despite this high risk, surprisingly few prospective studies have studied clinical- and dialysis-related risk factors for sudden cardiac death and arrhythmic precursors of sudden cardiac death in end-stage renal disease. Methods/Design We present a brief summary of the risk factors for arrhythmias and sudden cardiac death in persons with end-stage renal disease as the rationale for the Predictors of Arrhythmic and Cardiovascular Risk in End Stage Renal Disease (PACE) study, a prospective cohort study of patients recently initiated on chronic hemodialysis, with the overall goal to understand arrhythmic and sudden cardiac death risk. Participants were screened for eligibility and excluded if they already had a pacemaker or an automatic implantable cardioverter defibrillator. We describe the study aims, design, and data collection of 574 incident hemodialysis participants from the Baltimore region in Maryland, U.S.A.. Participants were recruited from 27 hemodialysis units and underwent detailed clinical, dialysis and cardiovascular evaluation at baseline and follow-up. Cardiovascular phenotyping was conducted on nondialysis days with signal averaged electrocardiogram, echocardiogram, pulse wave velocity, ankle, brachial index, and cardiac computed tomography and angiography conducted at baseline. Participants were followed annually with study visits including electrocardiogram, pulse wave velocity, and ankle brachial index up to 4 years. A biorepository of serum, plasma, DNA, RNA, and nails were collected to study genetic and serologic factors associated with disease. Discussion Studies of modifiable risk factors for sudden cardiac death will help set the stage for clinical trials to test therapies to prevent sudden cardiac death in this high-risk population.
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Affiliation(s)
- Rulan S Parekh
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, USA. .,Department of Epidemiology, Bloomberg School of Public Health
- , Johns Hopkins University, Baltimore, USA. .,Departments of Paediatrics and Medicine, Hospital for Sick Children, University Health Network and University of Toronto, Toronto, ON, Canada.
| | - Lucy A Meoni
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, USA. .,Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA. .,Welch Center for Prevention, Epidemiology, and Clinical Research, Baltimore, USA.
| | - Bernard G Jaar
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, USA. .,Department of Epidemiology, Bloomberg School of Public Health
- , Johns Hopkins University, Baltimore, USA. .,Welch Center for Prevention, Epidemiology, and Clinical Research, Baltimore, USA. .,Nephrology Center of Maryland, Baltimore, USA.
| | - Stephen M Sozio
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, USA. .,Department of Epidemiology, Bloomberg School of Public Health
- , Johns Hopkins University, Baltimore, USA.
| | - Tariq Shafi
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, USA.
| | - Gordon F Tomaselli
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, USA.
| | - Joao A Lima
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, USA.
| | - Larisa G Tereshchenko
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, USA. .,Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA.
| | - Michelle M Estrella
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, USA.
| | - W H Linda Kao
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, USA. .,Department of Epidemiology, Bloomberg School of Public Health
- , Johns Hopkins University, Baltimore, USA. .,Welch Center for Prevention, Epidemiology, and Clinical Research, Baltimore, USA.
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Shariat M, Thavendiranathan P, Nguyen E, Wintersperger B, Paul N, Rakowski H, Crean AM. Utility of coronary CT angiography in outpatients with hypertrophic cardiomyopathy presenting with angina symptoms. J Cardiovasc Comput Tomogr 2014; 8:429-37. [DOI: 10.1016/j.jcct.2014.09.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 08/15/2014] [Accepted: 09/16/2014] [Indexed: 12/25/2022]
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23
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Elliott PM, Anastasakis A, Borger MA, Borggrefe M, Cecchi F, Charron P, Hagege AA, Lafont A, Limongelli G, Mahrholdt H, McKenna WJ, Mogensen J, Nihoyannopoulos P, Nistri S, Pieper PG, Pieske B, Rapezzi C, Rutten FH, Tillmanns C, Watkins H. 2014 ESC Guidelines on diagnosis and management of hypertrophic cardiomyopathy: the Task Force for the Diagnosis and Management of Hypertrophic Cardiomyopathy of the European Society of Cardiology (ESC). Eur Heart J 2014; 35:2733-79. [PMID: 25173338 DOI: 10.1093/eurheartj/ehu284] [Citation(s) in RCA: 2818] [Impact Index Per Article: 281.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
MESH Headings
- Ablation Techniques/methods
- Adult
- Angina Pectoris/etiology
- Arrhythmias, Cardiac/etiology
- Cardiac Imaging Techniques/methods
- Cardiac Pacing, Artificial/methods
- Cardiomyopathy, Hypertrophic/diagnosis
- Cardiomyopathy, Hypertrophic/etiology
- Cardiomyopathy, Hypertrophic/therapy
- Child
- Clinical Laboratory Techniques/methods
- Death, Sudden, Cardiac/prevention & control
- Delivery of Health Care
- Diagnosis, Differential
- Electrocardiography/methods
- Female
- Genetic Counseling/methods
- Genetic Testing/methods
- Heart Failure/etiology
- Heart Valve Diseases/diagnosis
- Heart Valve Diseases/therapy
- Humans
- Medical History Taking/methods
- Pedigree
- Physical Examination/methods
- Preconception Care/methods
- Pregnancy
- Pregnancy Complications, Cardiovascular/diagnosis
- Pregnancy Complications, Cardiovascular/therapy
- Prenatal Care/methods
- Risk Factors
- Sports Medicine
- Syncope/etiology
- Thoracic Surgical Procedures/methods
- Ventricular Outflow Obstruction/etiology
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24
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Selbst SM, Palermo R, Durani Y, Giordano K. Adolescent Chest Pain—Is It the Heart? CLINICAL PEDIATRIC EMERGENCY MEDICINE 2011. [DOI: 10.1016/j.cpem.2011.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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25
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Affiliation(s)
- J. Keith Pinckard
- Southwestern Institute of Forensic Sciences and University of Texas Southwestern Medial Center at Dallas
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26
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Recent progress in the genetics of cardiomyopathy and its role in the clinical evaluation of patients with cardiomyopathy. Curr Opin Cardiol 2011; 26:155-64. [DOI: 10.1097/hco.0b013e3283439797] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Tarumi T, Takebayashi S, Fujita M, Nakano T, Ito M, Yamakado T. Pacing tachycardia exaggerates left ventricular diastolic dysfunction but not systolic function and regional asynergy or asynchrony in patients with hypertrophic cardiomyopathy. Europace 2010; 12:1308-15. [PMID: 20647230 DOI: 10.1093/europace/euq254] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS Myocardial ischaemia and angina have been demonstrated in patients with hypertrophic cardiomyopathy (HCM). We hypothesized that left ventricular (LV) systolic or diastolic dysfunction would be provocated by pacing tachycardia in patients with HCM. METHODS AND RESULTS We investigated LV global and regional systolic and diastolic function in 17 patients with HCM without LV outflow obstruction and 7 normal subjects by analysing LV angiograms and simultaneously obtained high-fidelity LV pressures before and after rapid cardiac pacing (150 b.p.m.). Biplane LV silhouettes were digitized frame by frame (50 frames/s). To quantify regional dynamics, the ventricular area of the right anterior oblique projection was divided into six sections originating from the midpoint of the long axis at end-diastole. There were no significant changes in LV function after pacing in normal subjects. In HCM, the ejection fractions remained unchanged. However, LV end-diastolic pressures rose (+12 mmHg, P < 0.01), and the time constants of isovolumic pressure decay were significantly increased (T(1/2): +5.2 ms, P < 0.01; T(1/)(e): +6.8 ms, P < 0.01). The LV global diastolic pressure-volume relationships and regional diastolic pressure-area relationships of regional myocardium shifted upward (indicating decreased diastolic distensibility) in all patients. These diastolic abnormalities were not accompanied by regional asynchrony or asynergy. CONCLUSION Most patients with HCM have a reduced reactive capacity to chronotropic stress, which is haemodynamically characterized by evenly distributed diastolic dysfunction. In contrast with coronary artery disease, these diastolic abnormalities were not accompanied by systolic dysfunction, regional asynchrony, asynergy, or inhomogenous diastolic distensibility.
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Affiliation(s)
- Toshiaki Tarumi
- Department of Cardiology, Mie University of Medicine, Tsu, Mie, Japan
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Microvascular dysfunction, myocardial ischemia, and progression to heart failure in patients with hypertrophic cardiomyopathy. J Cardiovasc Transl Res 2009; 2:452-61. [PMID: 20560003 DOI: 10.1007/s12265-009-9142-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2009] [Accepted: 10/05/2009] [Indexed: 01/19/2023]
Abstract
Microvascular dysfunction can be demonstrated in most patients with hypertrophic cardiomyopathy (HCM), both in the hypertrophied and nonhypertrophied myocardial walls, mostly due to intimal and medial hyperplasia of the intramural coronary arteries and subsequent lumen reduction. As a consequence, regional myocardial ischemia may be triggered by exercise, increased heart rate, or arrhythmias, in areas which are unable to increase myocardial blood flow. In patients with HCM, microvascular dysfunction leading to severe myocardial hypoperfusion during maximal hyperemia represents a strong predictor of unfavorable outcome, left ventricular remodeling with progressive wall thinning, left ventricular dysfunction, and heart failure. Accurate quantitative assessment of microvascular dysfunction and myocardial ischemia is not easily feasible in clinical practice. Although signs of inducible myocardial ischemia may be detected by electrocardiogram, echocardiography, or myocardial scintigraphy, the vasodilator response to dipyridamole by positron emission tomography is considered the method of choice for the assessment of maximal regional and global flow. Cardiac magnetic resonance provides further information, by late gadolinium enhancement (LGE), which may show areas where replacement fibrosis has occurred following microvascular ischemia and focal necrosis. LGE areas colocalize with severe regional microvascular dysfunction, are associated with increased prevalence of ventricular arrhythmias, and show more extensive distribution in the late stages of the disease, when heart failure is the dominant feature. The present review aims to provide a concise overview of the available evidence of microvascular dysfunction and ischemia eventually leading to disease progression and heart failure in HCM patients.
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30
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The case for myocardial ischemia in hypertrophic cardiomyopathy. J Am Coll Cardiol 2009; 54:866-75. [PMID: 19695469 DOI: 10.1016/j.jacc.2009.04.072] [Citation(s) in RCA: 192] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2009] [Revised: 04/20/2009] [Accepted: 04/21/2009] [Indexed: 02/07/2023]
Abstract
Since its original description 50 years ago, myocardial ischemia has been a recognized but underappreciated aspect of the pathophysiology of hypertrophic cardiomyopathy (HCM). Nevertheless, the assessment of myocardial ischemia is still not part of routine clinical diagnostic or management strategies. Morphologic abnormalities of the intramural coronary arterioles represent the primary morphologic substrate for microvascular dysfunction and its functional consequence-that is, blunted myocardial blood flow (MBF) during stress. Recently, a number of studies using contemporary cardiovascular imaging modalities such as positron emission tomography (PET) and cardiovascular magnetic resonance (CMR) have led to an enhanced understanding of the role that myocardial ischemia and its sequelae fibrosis play on clinical outcome. In this regard, studies with PET have shown that HCM patients have impaired MBF after dipyridamole infusion and that this blunted MBF is a powerful independent predictor of cardiovascular mortality and adverse LV remodeling associated with LV systolic dysfunction. Stress CMR with late gadolinium enhancement (LGE) has also shown that MBF is reduced in relation to magnitude of wall thickness and in those LV segments occupied by LGE (i.e., fibrosis). These CMR observations show an association between ischemia, myocardial fibrosis, and LV remodeling, providing support that abnormal MBF caused by microvascular dysfunction is responsible for myocardial ischemia-mediated myocyte death, and ultimately replacement fibrosis. Efforts should now focus on detecting myocardial ischemia before adverse LV remodeling begins, so that interventional treatment strategies can be initiated earlier in the clinical course to mitigate ischemia and beneficially alter the natural history of HCM.
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Sorajja P, Chareonthaitawee P, Ommen SR, Miller TD, Hodge DO, Gibbons RJ. Prognostic utility of single-photon emission computed tomography in adult patients with hypertrophic cardiomyopathy. Am Heart J 2006; 151:426-35. [PMID: 16442910 DOI: 10.1016/j.ahj.2005.02.050] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2004] [Accepted: 02/14/2005] [Indexed: 01/01/2023]
Abstract
BACKGROUND Data derived from stress myocardial perfusion imaging (MPI) carry prognostic significance in young patients with hypertrophic cardiomyopathy (HCM), but there are limited data on the utility of stress MPI in patients with HCM who are older. This study examined the prognostic significance of stress MPI in an adult population of patients with HCM. METHODS We examined 158 patients with HCM (aged 60 +/- 16 years, 61% men) who underwent exercise or pharmacologic stress MPI. Summed stress score (SSS, normal = 56) and summed reversibility scores were calculated for each patient. Follow-up was complete in 157 (99%) patients at a median duration of 5.2 years. RESULTS Normal single-photon emission computed tomography (SPECT) images were present in 38% of the population. Summed stress score (P = .01) and summed reversibility score (P = .03) were both significantly associated with cardiovascular death. Survival at 10 years was significantly better in those with normal versus abnormal SPECT (89% vs 67%, P = .04). Ten-year survival also was better in those without versus those with ischemia (90% vs 64%, P = .02). Five-year survival could be stratified by SSS risk categories: low risk (SSS > or = 53), 97%; intermediate risk (SSS = 48-52), 94%; and high risk (SSS < or = 47), 79% (P = .04). Bivariate models of SSS and other significant covariates supported an independent relation of SSS to cardiovascular death. CONCLUSIONS In an older population of patients with HCM referred for SPECT imaging, abnormal stress MPI identifies those at increased risk of cardiovascular death.
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Affiliation(s)
- Paul Sorajja
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, MN 55905, USA
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Woo A, Williams WG, Choi R, Wigle ED, Rozenblyum E, Fedwick K, Siu S, Ralph-Edwards A, Rakowski H. Clinical and Echocardiographic Determinants of Long-Term Survival After Surgical Myectomy in Obstructive Hypertrophic Cardiomyopathy. Circulation 2005; 111:2033-41. [PMID: 15824202 DOI: 10.1161/01.cir.0000162460.36735.71] [Citation(s) in RCA: 224] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Surgical myectomy has been the standard treatment for patients with drug-refractory obstructive hypertrophic cardiomyopathy. The clinical and echocardiographic predictors of long-term survival and freedom from cardiovascular morbidity after myectomy have been unclear.
Methods and Results—
We studied a consecutive cohort of 338 adult patients (age at operation 47±14 [range 18 to 77] years, 60% male) who underwent myectomy at our institution. Preoperative resting left ventricular outflow tract (LVOT) gradient was 66±32 mm Hg (range 5 to 158 mm Hg). Early postoperative mortality was 1.5% (5 deaths): 4 deaths occurred between 1978 and 1992, and 1 death occurred between 1993 and 2002. During long-term follow-up, 83% of patients reported an improvement to functional class I or II. The majority of patients (98%) had no resting LVOT gradient. Long-term survival was excellent, with 98±1% survival at 1 year, 95±1% at 5 years, and 83±3% at 10 years after myectomy. Multivariable Cox regression analysis identified 5 predictors of overall mortality: (1) age ≥50 years at surgery (hazard ratio [HR] 2.8, 95% CI 1.5 to 5.1,
P
=0.001), (2) female gender (HR 2.5, 95% CI 1.5 to 4.3,
P
=0.0009), (3) history of preoperative atrial fibrillation (HR 2.2, 95% CI 1.2 to 4.0,
P
=0.008), (4) concomitant CABG (HR 3.7, 95% CI 1.7 to 8.2,
P
=0.001), and (5) preoperative left atrial diameter ≥46 mm (HR 2.9, 95% CI 1.6 to 5.4,
P
=0.0008). Significant predictors of late major cardiovascular events found on multivariable analysis were (1) female gender (HR 3.3, 95% CI 2.0 to 5.4,
P
<0.0001), (2) history of preoperative atrial fibrillation (HR 1.9, 95% CI 1.1 to 3.3,
P
=0.02), and (3) preoperative left atrial diameter ≥46 mm (HR 2.5, 95% CI 1.5 to 4.3,
P
=0.0008).
Conclusions—
Myectomy provides excellent relief for LVOT obstruction in patients with hypertrophic cardiomyopathy. Preoperative clinical and echocardiographic variables can predict long-term outcome after myectomy.
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Affiliation(s)
- Anna Woo
- Division of Cardiology, Toronto General Hospital, 4N-506, 200 Elizabeth St, Toronto, Ontario, Canada M5G 2C4.
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33
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Abstract
Hypertrophic cardiomyopathy is a primary disorder of the myocardium characterised by disproportionate hypertrophy of the ventricular wall. It is the most common genetic cardiac disease with an incidence of 1 in 500 and it is diagnosed most commonly using transthoracic echocardiography. This review article discusses: the diagnosis of hypertrophic cardiomyopathy; the differential diagnoses; the characteristic histological signs found at postmortem and/or myectomy and the clinical symptoms and signs. Current recommendations for myectomy of first degree relatives, based on the ACC/ESC guidelines, are discussed as well as general management and then specific management for various subgroups and symptomatic patients.
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Affiliation(s)
- Emma Ivens
- Department of Cardiology, Epworth Hospital, Richmond, Vic., Australia.
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34
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Sorajja P, Ommen SR, Nishimura RA, Gersh BJ, Berger PB, Tajik AJ. Adverse prognosis of patients with hypertrophic cardiomyopathy who have epicardial coronary artery disease. Circulation 2003; 108:2342-8. [PMID: 14581405 DOI: 10.1161/01.cir.0000097110.55312.bf] [Citation(s) in RCA: 129] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Adult patients with hypertrophic cardiomyopathy (HCM) may develop concomitant atherosclerotic coronary artery disease (CAD). There is a paucity of data on the clinical outcomes of HCM patients who have CAD. METHODS AND RESULTS We examined the outcome of 433 adult patients with HCM according to the presence and severity of CAD. All patients were aged > or =21 years, had a left ventricular ejection fraction of > or =50%, and were without a history of prior surgical revascularization (mean age, 63 years; 212 men). Compared with HCM patients with mild-to-moderate or no CAD, those with severe CAD demonstrated markedly reduced survival. Ten-year overall survival was 46.1%, 70.5%, and 77.1% for patients with severe, mild-to-moderate, and no CAD, respectively (unadjusted P=0.0001; adjusted P=0.0006). For the end point of cardiac death, this survival was 62.3%, 81.0%, and 80.9% (unadjusted P=0.009; adjusted P=0.004). For the end point of sudden cardiac death, this survival was 77.4%, 93.2%, and 90.3% (unadjusted P=0.01; adjusted P=0.01). The presence of severe CAD also was highly predictive of these events (risk ratio for respective event: 2.31, 2.15, and 2.77) in multivariate models that additionally identified age, prior stroke, hyperlipidemia, and atrial fibrillation as significant covariates. CONCLUSIONS Among adult patients with HCM who undergo coronary angiography, those who have concomitant severe CAD are at increased risk of death. This risk far exceeds historical death rates of CAD patients with normal left ventricular function.
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Affiliation(s)
- Paul Sorajja
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minn 55905, USA
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35
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Cecchi F, Olivotto I, Gistri R, Lorenzoni R, Chiriatti G, Camici PG. Coronary microvascular dysfunction and prognosis in hypertrophic cardiomyopathy. N Engl J Med 2003; 349:1027-35. [PMID: 12968086 DOI: 10.1056/nejmoa025050] [Citation(s) in RCA: 509] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Microvascular dysfunction, reflected by an inadequate increase in myocardial blood flow in response to dipyridamole infusion, is a recognized feature of hypertrophic cardiomyopathy. Its long-term effect on the prognosis is unknown. We prospectively evaluated a cohort of patients with hypertrophic cardiomyopathy after they had undergone quantitative assessment of myocardial blood flow by positron-emission tomography (PET). METHODS Fifty-one patients (New York Heart Association class I or II) were followed for a mean (+/-SD) of 8.1+/-2.1 years after PET. Twelve subjects with atypical chest pain served as controls. Measurement of flow was performed at base line and after the infusion of the coronary vasodilator dipyridamole, with the use of nitrogen-13-labeled ammonia. Patients were then divided into three equal groups with increasing values of myocardial blood flow. RESULTS The response of myocardial blood flow to dipyridamole was severely blunted in the patients, as compared with the controls (1.50+/-0.69 vs. 2.71+/-0.94 ml per minute per gram of tissue, P<0.001). Sixteen patients (31 percent) had an unfavorable outcome (death from cardiovascular causes, progression to New York Heart Association class III or IV, or sustained ventricular arrhythmias requiring the implantation of a cardioverter-defibrillator) 2.2 to 9.1 years after PET. Reduced blood flow in response to dipyridamole was strongly associated with an unfavorable outcome. Multivariate analysis showed that among patients in the lowest of the three flow groups the age-adjusted relative hazard of death from cardiovascular causes was 9.6 (P=0.02) and the relative hazard of an unfavorable outcome (a combined end point) was 20.1 (P=0.003), as compared with patients in the two other flow groups. Specifically, all four patients who died from heart failure and three of five who died suddenly were in this subgroup. CONCLUSIONS In patients with hypertrophic cardiomyopathy, the degree of microvascular dysfunction is a strong, independent predictor of clinical deterioration and death. Severe microvascular dysfunction is often present in patients with mild or no symptoms and may precede clinical deterioration by years.
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Affiliation(s)
- Franco Cecchi
- Regional Referral Center for Myocardial Diseases, Azienda Ospedaliera Careggi, Florence, Italy.
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36
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Boon D, van Goudoever J, Huijskes R, Piek JJ, van Montfrans GA. Diagnostic value of simultaneous non-invasive continuous, ambulatory finger blood pressure and electrocardiogram monitoring in a patient with hypertrophic obstructive cardiomyopathy. Blood Press Monit 2002; 7:329-33. [PMID: 12488654 DOI: 10.1097/00126097-200212000-00007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The pathophysiology of hypertrophic obstructive cardiomyopathy (HOCM) is complex and heterogeneous, and it may be difficult to disentangle the various pathophysiologic properties leading to complaints. OBJECTIVES To elucidate the sequence of acute pathophysiologic changes leading to complaints in a patient with HOCM. METHODS Cardiopres measurements [the combination of non-invasive, continuous finger artery blood pressure monitoring, and three-lead electrocardiogram (ECG) recordings] were performed during physiologic, supine exercise--before and after replacement of metoprolol by verapamil. Within 24 h of the Cardiopres measurement standard Doppler echocardiography was performed. Finger artery pressure wave was analysed using Beatscope software (BMI-TNO, Amsterdam, The Netherlands), ST analysis was performed with H-Scribe (Mortara Instrument, Bilt, The Netherlands). RESULTS Exercise under metoprolol: finger BP decreased from 130/65 mmHg to 90/60 mmHg, heart rate increased from 65 bpm to 100 bpm and ST analysis revealed significant ST depression in all leads. The occurrence of ST depression preceded the hypotension. Echocardiography showed a dynamic gradient of 70 mmHg. Exercise under verapamil: the patient had less complaints, BP increased from 125/60 mmHg to 165/65 mmHg, heart rate increased from 75 bpm to 107 bpm and ST analysis showed no ST depression > 1 mm. Echocardiography showed no change. CONCLUSIONS The use of the Cardiopres during a physiological stimulus showed improvement in exercise capacity in a patient with HOCM, while the standard test, stress-echocardiography, showed no correlation with clinical status. The Cardiopres is a useful diagnostic and research tool, allowing non-invasive, ambulatory monitoring of blood pressure and ECG changes.
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Affiliation(s)
- Diederik Boon
- Department of Internal Medicine, Academic Medical Center, Amsterdam, The Netherlands. /nl
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37
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Thaman R, Firoozi S, Hamid MS, McKenna WJ. Hypertrophic cardiomyopathy: management issues in the new millennium. Curr Cardiol Rep 2002; 4:226-32. [PMID: 11960592 DOI: 10.1007/s11886-002-0055-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Hypertrophic cardiomyopathy is an inherited cardiac disorder. Sudden cardiac death frequently occurs in otherwise healthy individuals, and accounts for nearly 35% of all sudden deaths within this age group. Although symptoms occur commonly, they often go unreported. Despite this, a degree of functional limitation is often seen on objective assessment. Management of hypertrophic cardiomyopathy is aimed at relieving symptoms, identifying and treating those individuals at increased risk of sudden death, and screening family members.
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Affiliation(s)
- Rajesh Thaman
- Department of Cardiological Sciences, St. George's Hospital Medical School, Cranmer Terrace, London SW17 0RE, England
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38
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Sharma S, Firoozi S, McKenna WJ. Value of exercise testing in assessing clinical state and prognosis in hypertrophic cardiomyopathy. Cardiol Rev 2001; 9:70-6. [PMID: 11209145 DOI: 10.1097/00045415-200103000-00005] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/26/2000] [Indexed: 11/26/2022]
Abstract
Hypertrophic cardiomyopathy (HCM) is a genetic disease of the sarcomeric contractile proteins. A majority of patients with HCM are limited in terms of functional capacity, and a minority of these patients die suddenly. The main aims of management are symptom alleviation and prevention of sudden cardiac death. In patients with HCM, cardiopulmonary exercise testing provides a much more accurate index of functional capacity than New York Heart Association classification status, and it is useful in assessing symptoms after various therapeutic strategies have been implemented. Exercise testing is also valuable in identifying patients with HCM who are at high risk of sudden cardiac death and is an integral part of the algorithm in risk stratification and delivery of prophylactic therapy. Also, cardiopulmonary exercise testing plays an important role in differentiating HCM from other conditions associated with left ventricular hypertrophy, such as physiologic athlete's heart. Therefore, during the last few years, cardiopulmonary exercise testing has provided insights into the diagnosis, determinants, and mechanisms of exercise limitation in HCM. This understanding aids physicians in targeting therapy and developing new treatment modalities.
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Affiliation(s)
- S Sharma
- Department of Cardiological Sciences, St George's Hospital Medical School, Cranmer Terrace, London SW17 0RE, UK
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39
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Firoozi S, Sharma S, McKenna WJ. The role of exercise testing in the evaluation of the patient with hypertrophic cardiomyopathy. Curr Cardiol Rep 2001; 3:152-9. [PMID: 11177674 DOI: 10.1007/s11886-001-0043-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Hypertrophic cardiomyopathy (HCM) is a genetic disease of the sarcomeric contractile proteins that is characterized by left ventricular hypertrophy and myocyte disarray. The majority of patients are limited in terms of functional capacity and a minority die suddenly. The main aims of management are symptom alleviation and prevention of sudden cardiac death. In patients with HCM, cardiopulmonary exercise testing provides a more accurate index of functional capacity than New York Heart Association classification status and is useful in assessing symptoms following various therapeutic interventions. Cardiopulmonary exercise testing plays an important role in differentiating HCM from other conditions associated with left ventricular hypertrophy. Cardiopulmonary exercise testing is also valuable in identifying individuals at high risk of sudden cardiac death and is an integral part of the algorithm in risk stratification and delivery of prophylactic therapy. Over the past few years, cardiopulmonary exercise testing has provided insight into the determinants and mechanisms of exercise limitation. This understanding helps in targeting therapy and the development of new treatment modalities.
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Affiliation(s)
- S Firoozi
- Department of Cardiological Sciences, St. George's Hospital Medical School, Cranmer Terrace, London SW17 0RE, England.
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40
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Yi G, Poloniecki J, Dickie S, Elliott PM, Malik M, McKenna WJ. Can the assessment of dynamic QT dispersion on exercise electrocardiogram predict sudden cardiac death in hypertrophic cardiomyopathy? Pacing Clin Electrophysiol 2000; 23:1953-6. [PMID: 11139965 DOI: 10.1111/j.1540-8159.2000.tb07060.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Premature sudden cardiac death (SD) is a critical event in the natural history of hypertrophic cardiomyopathy (HCM), and occurs during or just after physical exertion in approximately 60% of instances. Abnormalities in ventricular repolarization may not be present at rest in some patients but may become apparent under certain conditions. This study was performed to examine whether dynamic QT dispersion during exercise is associated with SD in HCM. Twenty-four HCM patients with catastrophic events (group I; 18 SD, 6 ventricular fibrillation) and 24 event-free survivors (group II) were studied. The two groups were pair-matched for age, gender, and maximum left ventricular wall thickness. QT intervals were manually measured from 12-lead exercise electrocardiogram (ECG) with a digitizing board. A custom-developed program was used to calculate QT and JT dispersion. The QT/RR relationship was evaluated by the slope of linear regression analysis. Before exercise, significant differences in heart rate and JT dispersion were found between group I and II. During exercise, heart rate increased and QT decreased significantly in both groups. QT and JT dispersion decreased in both groups, though the magnitude of reduction was greater in group I than in group II. No significant differences in QTc interval and QT or JT dispersion were found between the groups at any stages. At 3 minutes of recovery, heart rate had decreased but remained higher than before exercise, and all measurements of QT components remained shorter compared with those made before exercise in both groups. There was a strong correlation between QT and RR interval during exercise in all study patients (r = 0.95). No difference in the slope of QT against RR intervals was found between the groups (0.317 vs 0.319). In conclusion, exercise reduced QT dispersion in patients with HCM. The dynamic changes in QT dispersion examined by this method on exercise ECG did not make additional contributions in their risk stratification.
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Affiliation(s)
- G Yi
- Dept. of Cardiological Sciences, St. George's Hospital Medical School, Cranmer Terrace, London SW17 0RE, United Kingdom.
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41
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Shimizu M, Ino H, Okeie K, Emoto Y, Yamaguchi M, Yasuda T, Fujino N, Fujii H, Fujita S, Mabuchi T, Taki J, Mabuchi H. Exercise-induced ST-segment depression and systolic dysfunction in patients with nonobstructive hypertrophic cardiomyopathy. Am Heart J 2000; 140:52-60. [PMID: 10874263 DOI: 10.1067/mhj.2000.106642] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND ST-segment depression is common in patients with hypertrophic cardiomyopathy (HCM). However, it is not clear whether exercise-induced ST-segment depression in patients with HCM and patent coronary arteries is associated with changes in left ventricular function. METHODS Left ventricular function was continuously evaluated in 53 patients with nonobstructive HCM during supine ergometer exercise with a radionuclide ventricular function monitor equipped with a cadmium telluride detector. On the basis of the ST-segment changes during exercise, the patients were divided into 2 groups: group N had no ST-segment depression, and group D had >/=0.1 mV ST-segment depression. RESULTS Exercise duration, blood pressure, heart rate, and rate-pressure product during exercise did not differ between the 2 groups. End-diastolic volume at rest and at peak exercise did not differ between groups D and N. In contrast, the end-systolic volume in group N decreased during exercise, whereas in group D it increased. As a result, the left ventricular ejection fraction in group D decreased from 70% +/- 7% to 59% +/- 15% (P <.0001), whereas ejection fraction in group N increased from 65% +/- 8% to 71% +/- 11% (P =.0002). There was a strong correlation between exercise-induced ST-segment depression and changes in ejection fraction from rest to peak exercise (P <.0001). CONCLUSIONS These results suggest that the exercise-induced ST-segment depression seen in patients with nonobstructive HCM is associated with systolic dysfunction during exercise.
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Affiliation(s)
- M Shimizu
- Second Department of Internal Medicine, School of Medicine, Kanazawa University, Japan.
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42
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Abstract
Chest pain in the pediatric population is a common and mostly benign occurrence. A thorough history and physical examination are usually all that are necessary in excluding the rare, life-threatening causes of chest pain. These rare, life-threatening events require immediate evaluation, treatment, and subspecialty consultation. Idiopathic chest pain is the most common diagnosis, and the symptoms are typically chronic. laboratory testing is usually nondiagnostic, costly, and burdensome to patients and therefore unnecessary. A long-term, trusting relationship with the patients and their families is needed to reassure them and allow symptoms to resolve.
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Affiliation(s)
- K C Kocis
- University of Southern California School of Medicine, Children's Hospital, Los Angeles, USA
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43
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Haider AW, Larson MG, Benjamin EJ, Levy D. Increased left ventricular mass and hypertrophy are associated with increased risk for sudden death. J Am Coll Cardiol 1998; 32:1454-9. [PMID: 9809962 DOI: 10.1016/s0735-1097(98)00407-0] [Citation(s) in RCA: 578] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES This study examined the relations of echocardiographically determined left ventricular (LV) mass and hypertrophy to the risk of sudden death. BACKGROUND Echocardiographic LV hypertrophy is associated with increased risk for all-cause mortality and cardiovascular disease morbidity and mortality. However, little is known about the association of echocardiographic LV hypertrophy with sudden death. METHODS We examined the relations of LV mass and hypertrophy to the incidence of sudden death in 3,661 subjects enrolled in the Framingham Heart Study who were > or =40 years of age. The baseline examination was performed from 1979 to 1983 and LV hypertrophy was defined as LV mass (adjusted for height) > 143 g/m in men and > 102 g/m in women. During up to 14 years of follow-up there were 60 sudden deaths. Cox models examined the relations of LV mass and LV hypertrophy to sudden death risk after adjusting for known risk factors. RESULTS The prevalence of LV hypertrophy was 21.5%. The risk factor-adjusted hazard ratio (HR) for sudden death was 1.45 (95% confidence interval [CI] 1.10 to 1.92, p=0.008) for each 50-g/m increment in LV mass. For LV hypertrophy, the risk factor-adjusted HR for sudden death was 2.16 (95% CI 1.22 to 3.81, p=0.008). After excluding the first 4 years of follow-up, both increased LV mass and LV hypertrophy conferred long-term risk of sudden death (HR 1.53, 95% CI 1.01 to 2.28, p=0.047 and HR 3.28, 95% CI 1.58 to 6.83, p=0.002, respectively). CONCLUSIONS Increased LV mass and hypertrophy are associated with increased risk for sudden death after accounting for known risk factors.
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Affiliation(s)
- A W Haider
- National Heart, Lung, and Blood Institute's Framingham Heart Study, Massachusetts 01702, USA
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44
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Lazzeroni E, Picano E, Morozzi L, Maurizio AR, Palma G, Ceriati R, Iori E, Barilli A. Dipyridamole-induced ischemia as a prognostic marker of future adverse cardiac events in adult patients with hypertrophic cardiomyopathy. Echo Persantine Italian Cooperative (EPIC) Study Group, Subproject Hypertrophic Cardiomyopathy. Circulation 1997; 96:4268-72. [PMID: 9416892 DOI: 10.1161/01.cir.96.12.4268] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Myocardial ischemia may play a role in the natural history of hypertrophic cardiomyopathy (HCM). To assess the relative prevalence and the prognostic value of dipyridamole-induced ischemia, 79 patients with HCM and without concomitant coronary artery disease (53 men; mean age, 46+/-15 years) underwent a high-dose (up to 0.84 mg/kg over 10 minutes) dipyridamole test with 12-lead ECG and two-dimensional echo monitoring and were followed up for a mean of 6 years. METHODS AND RESULTS Twenty-nine patients (37%) showed ECG (ie, ST depression > or = 2 mV) signs of myocardial ischemia during dipyridamole test (group 1), whereas 50 (63%) had a negative test (group 2). No patient had transient wall motion abnormalities during the dipyridamole test. During the follow-up, 16 events (ie, left ventricular or atrial enlargement, unstable angina, syncope, atrial fibrillation, and bundle-branch block) occurred in 29 patients in group 1 and 5 in 50 patients in group 2 (55% versus 10%, P<.001). Patients with a positive dipyridamole test showed worse 72-month event-free survival rates compared with patients with a negative test (36.2% versus 84.2%, P<.001). A forward stepwise event-free survival analysis identified dipyridamole test positivity by ECG criteria (chi2=19.7, P=.0001), rest gradient (chi2=11.3, P=.0008), and age (chi2=4.1; P=.0413) as independent and additive predictors of subsequent events. CONCLUSIONS ECG signs of myocardial ischemia elicited by dipyridamole are frequent in patients with HCM and identify patients at higher risk of cardiac events, suggesting a potentially important pathogenetic role of inducible myocardial ischemia in determining adverse cardiac events in these patients.
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Affiliation(s)
- E Lazzeroni
- Division of Cardiology, Parma Hospital, Italy.
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