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Butzner M, Kinyik-Merena C, Aguiar M, Davison N, Shreay S, Masri A. The prognostic value of peak oxygen uptake in obstructive hypertrophic cardiomyopathy: A literature review to inform economic model development. J Med Econ 2024:1-14. [PMID: 38868944 DOI: 10.1080/13696998.2024.2367920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 06/11/2024] [Indexed: 06/14/2024]
Abstract
Aims: Patients with obstructive hypertrophic cardiomyopathy (oHCM) experience significant clinical burden which is associated with a high economic burden. Peak oxygen uptake (pVO2), measured by cardiopulmonary exercise testing, is used to quantify functional capacity, and has been studied as a primary endpoint in recent clinical trials. This study aimed to gather evidence to consolidate the prognostic value of pVO2 in oHCM and to assess whether it is feasible to predict health outcomes in an economic model based on changes in pVO2.Methods: A targeted literature review was conducted in MEDLINE (via PubMed) and Embase databases to identify evidence on the prognostic value of pVO2 as a surrogate health outcome to support future oHCM economic model development. Following screening, study characteristics, population characteristics and pVO2 prognostic association data were extracted.Results: A total of 4,687 studies were identified. 3,531 and 538 studies underwent title/abstract and full-text screening, respectively, of which 151 were included and 9 of these were in hypertrophic cardiomyopathy (HCM); only 3 studies focused on oHCM. The 9 HCM studies consisted of 1 systematic literature review and 8 primary studies reporting on 27 potentially predictive relationships from a pVO2-based metric with clinical outcomes including all-cause mortality, cardiovascular mortality, sudden cardiac death, transplant, paroxysmal and permanent atrial fibrillation. pVO2 was described as a predictor of single and composite endpoints, in 3 and 6 studies respectively, with 1 study reporting on both.Limitations: This study primarily uses systemic literature review methods but does not qualify as one due to not entailing parallel reviewers during title-abstract and full-text stages of review.Conclusion: The findings of this study suggest pVO2 is predictive of multiple health outcomes, providing rationale to use pVO2 in the development of an economic model.
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Affiliation(s)
- Michael Butzner
- Cytokinetics, Inc., 350 Oyster Point Blvd., South San Francisco, CA
| | | | | | | | - Sanatan Shreay
- Cytokinetics, Inc., 350 Oyster Point Blvd., South San Francisco, CA
| | - Ahmad Masri
- Division of Cardiology, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd
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2
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Petmezas G, Papageorgiou VE, Vassilikos V, Pagourelias E, Tsaklidis G, Katsaggelos AK, Maglaveras N. Recent advancements and applications of deep learning in heart failure: Α systematic review. Comput Biol Med 2024; 176:108557. [PMID: 38728995 DOI: 10.1016/j.compbiomed.2024.108557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 04/12/2024] [Accepted: 05/05/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND Heart failure (HF), a global health challenge, requires innovative diagnostic and management approaches. The rapid evolution of deep learning (DL) in healthcare necessitates a comprehensive review to evaluate these developments and their potential to enhance HF evaluation, aligning clinical practices with technological advancements. OBJECTIVE This review aims to systematically explore the contributions of DL technologies in the assessment of HF, focusing on their potential to improve diagnostic accuracy, personalize treatment strategies, and address the impact of comorbidities. METHODS A thorough literature search was conducted across four major electronic databases: PubMed, Scopus, Web of Science and IEEE Xplore, yielding 137 articles that were subsequently categorized into five primary application areas: cardiovascular disease (CVD) classification, HF detection, image analysis, risk assessment, and other clinical analyses. The selection criteria focused on studies utilizing DL algorithms for HF assessment, not limited to HF detection but extending to any attempt in analyzing and interpreting HF-related data. RESULTS The analysis revealed a notable emphasis on CVD classification and HF detection, with DL algorithms showing significant promise in distinguishing between affected individuals and healthy subjects. Furthermore, the review highlights DL's capacity to identify underlying cardiomyopathies and other comorbidities, underscoring its utility in refining diagnostic processes and tailoring treatment plans to individual patient needs. CONCLUSIONS This review establishes DL as a key innovation in HF management, highlighting its role in advancing diagnostic accuracy and personalized care. The insights provided advocate for the integration of DL in clinical settings and suggest directions for future research to enhance patient outcomes in HF care.
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Affiliation(s)
- Georgios Petmezas
- 2nd Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece; Centre for Research and Technology Hellas, Thessaloniki, Greece.
| | | | - Vasileios Vassilikos
- 3rd Department of Cardiology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Efstathios Pagourelias
- 3rd Department of Cardiology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George Tsaklidis
- Department of Mathematics, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Aggelos K Katsaggelos
- Department of Electrical and Computer Engineering, Northwestern University, Evanston, IL, USA
| | - Nicos Maglaveras
- 2nd Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
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3
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Movahed MR, Irannejad K, Bates S. The Majority of Participants With Suspected Hypertrophic Cardiomyopathy Documented During Screening Echocardiography Have a Normal Electrocardiogram. Crit Pathw Cardiol 2024; 23:20-25. [PMID: 38381652 DOI: 10.1097/hpc.0000000000000346] [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: 02/23/2024]
Abstract
BACKGROUND Patients with hypertrophic cardiomyopathy (HCM) usually have abnormal electrocardiograms consistent with left ventricular hypertrophy (LVH). The goal of this study was to evaluate the prevalence of abnormal ECG findings (LVH, T wave inversion, left bundle branch block, and left atrial enlargement) in participants with suspected HCM detected during screening echocardiography. METHOD The Anthony Bates Foundation has been performing screening echocardiography across the United States for the prevention of sudden death since 2001. A total of 682 subjects between the ages of 8 and 71 underwent echocardiographic screening together with ECG documentation. We evaluated the prevalence of abnormal ECG in participants with suspected HCM defined as any left ventricular wall thickness ≥15 mm. RESULTS The prevalence of LVH and T wave inversion were higher in HCM subjects as expected [HCM occurred in 23.5% (4/17) vs. 5.6% (37/665), P = 0.002, T wave inversion occurred in 17.6% (3/17) vs. 4.1% (27/664), P = 0.007]. However, despite adding these 2 common ECG abnormalities in this population, the presence of detected abnormal ECG remained less than 25% (23.5% of HCM subjects had LVH or T wave inversion on ECG vs. 8.7% of control, P = 0.036). Left bundle branch block or abnormal left atrium on ECG were not found in any participants with suspected HCM. CONCLUSIONS The prevalence of abnormal ECG in the participants with suspected HCM detected during screening echocardiography is less than 25%. This suggests that ECG alone is not a sensitive marker for the detection of HCM.
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Affiliation(s)
- Mohammad Reza Movahed
- From the Department of Medicine, University of Arizona Sarver Heart Center, Tucson
- Department of Medicine, University of Arizona, College of Medicine, Phoenix
| | - Kyvan Irannejad
- Department of Medicine, Jamaica Hospital Medical Center, Queens, NY
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Cresci S, Bach RG, Saberi S, Owens AT, Spertus JA, Hegde SM, Lakdawala NK, Nilles EK, Wojdyla DM, Sehnert AJ, Wang A. Effect of Mavacamten in Women Compared With Men With Obstructive Hypertrophic Cardiomyopathy: Insights From EXPLORER-HCM. Circulation 2024; 149:498-509. [PMID: 37961906 PMCID: PMC11006596 DOI: 10.1161/circulationaha.123.065600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 10/24/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Compared with men, women with hypertrophic cardiomyopathy (HCM) have a higher incidence of heart failure and worse outcomes. We investigated baseline clinical and echocardiographic characteristics and response to mavacamten among women compared with men in the EXPLORER-HCM study (Clinical Study to Evaluate Mavacamten [MYK-461] in Adults With Symptomatic Obstructive Hypertrophic Cardiomyopathy). METHODS A prespecified post hoc analysis of sex from the blinded, randomized EXPLORER-HCM trial of mavacamten versus placebo in symptomatic patients with obstructive HCM was performed. Baseline characteristics were compared with t tests for continuous variables (expressed as mean values) and χ2 tests for categorical variables. Prespecified primary, secondary, and exploratory end points and echocardiographic measurements from baseline to end of treatment (week 30) were analyzed with ANCOVA for continuous end points and a generalized linear model with binomial distribution for binary end points, with adjustment for each outcome's baseline value, New York Heart Association class, β-blocker use, and ergometer type. RESULTS At baseline, women (n=102) were older (62 years versus 56 years; P<0.0001), had lower peak oxygen consumption (16.7 mL·kg-1·min-1 versus 21.3 mL·kg-1·min-1; P<0.0001), were more likely to be assigned New York Heart Association class III (42% versus 17%; P<0.0001), had worse health status (Kansas City Cardiomyopathy Questionnaire-Clinical Summary Score 64 versus 75; P<0.0001), and had higher baseline plasma NT-proBNP (N-terminal pro-B-type natriuretic peptide) levels (1704 ng/L versus 990 ng/L; P=0.004) than men (n=149). After 30 weeks of mavacamten treatment, similar improvements were observed in women and men in the primary composite end point (percentage difference on mavacamten versus placebo, 22% versus 19%, respectively; P=0.759) and in the secondary end points of change in postexercise left ventricular outflow tract gradient (-42.4 mm Hg versus -33.6 mm Hg; P=0.348), change in peak oxygen consumption (1.2 mL·kg-1·min-1 versus 1.6 mL·kg-1·min-1; P=0.633), and percentage achieving ≥1 New York Heart Association class improvement (41% versus 28%; P=0.254). However, women had greater improvement in health status (Kansas City Cardiomyopathy Questionnaire-Clinical Summary Score 14.8 versus 6.1; P=0.026) and in the exploratory end point of NT-proBNP levels (-1322 ng/L versus -649 ng/L; P=0.0008). CONCLUSIONS Although at baseline women with symptomatic obstructive HCM enrolled in EXPLORER-HCM were older and had worse heart failure and health status than men, treatment with mavacamten resulted in similar improvements in the primary and most secondary EXPLORER-HCM end points and greater improvements in health status and NT-proBNP. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03470545.
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Affiliation(s)
- Sharon Cresci
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO
- Department of Genetics, Washington University School of Medicine, St. Louis, MO
| | - Richard G. Bach
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | | | - Anjali T. Owens
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John A. Spertus
- University of Missouri-Kansas City’s Healthcare Institute for Innovations in Quality and Saint Luke’s Mid America Heart Institute, Kansas City, Missouri, USA
| | - Sheila M. Hegde
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Neal K. Lakdawala
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
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5
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Davies B, Forman J, McIlroy C, Joe H, Safabakhsh S, Liew J, Parker J, Du D, Andrade JG, Bennett MT, Hawkins NM, Chakrabarti S, Yeung J, Deyell MW, Krahn AD, Moss R, Ong K, Laksman Z. Patient experiences of implantable cardiac monitoring in hypertrophic cardiomyopathy: an exploratory study. Eur J Cardiovasc Nurs 2023; 22:780-785. [PMID: 36705579 DOI: 10.1093/eurjcn/zvad017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 01/23/2023] [Accepted: 01/24/2023] [Indexed: 01/28/2023]
Abstract
AIMS Hypertrophic cardiomyopathy (HCM) is the most common inherited heart disease. Insertable cardiac monitors (ICMs) are increasingly used in this population to provide closer monitoring, with the potential for notification systems. However, little is known regarding the psychological impact this information may have on patients. The Abbott Confirm Rx™ ICM has the capability of connecting to the patient's smartphone to enable active participation in their care, as well as two-way communication between the patient and their care providers. This study aimed to explore individuals' experiences of having a smartphone-enabled ICM to monitor for arrhythmias in HCM. METHODS AND RESULTS Semi-structured interviews were conducted with 10 participants. Utilizing a grounded theory approach, the interview guide was modified based on emerging themes throughout the study. Reflexive thematic analysis was applied to categorize interview data into codes and overacting themes, with each interview independently coded by two study members. Analysis revealed three key themes: (i) psychological impact, (ii) educational needs, and (iii) technology expectations. Participants reported that receiving feedback from ICM transmissions resulted in improved symptom clarity, providing reassurance, and aiding implantable cardioverter defibrillator decision-making. Some participants reported uncertainty regarding when to send manual transmissions. Lastly, participants reported the app interface did not meet expectations with regard to the amount of data available for patients. CONCLUSION Overall, utilizing a smartphone app to facilitate two-way communication of ICM transmissions was well accepted. Future directions include addressing gaps in educational needs and improvements in the patient interface with increased access to data.
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Affiliation(s)
- Brianna Davies
- Center for Cardiovascular Innovation, Division of Cardiology, Department of Medicine, University of British Columbia, Room 220, 1033 Davie St. Vancouver BC, V6E 1M7, Canada
| | - Jacqueline Forman
- Center for Cardiovascular Innovation, Division of Cardiology, Department of Medicine, University of British Columbia, Room 220, 1033 Davie St. Vancouver BC, V6E 1M7, Canada
| | - Cheryl McIlroy
- Center for Cardiovascular Innovation, Division of Cardiology, Department of Medicine, University of British Columbia, Room 220, 1033 Davie St. Vancouver BC, V6E 1M7, Canada
| | - Heather Joe
- Center for Cardiovascular Innovation, Division of Cardiology, Department of Medicine, University of British Columbia, Room 220, 1033 Davie St. Vancouver BC, V6E 1M7, Canada
| | - Sina Safabakhsh
- Center for Cardiovascular Innovation, Division of Cardiology, Department of Medicine, University of British Columbia, Room 220, 1033 Davie St. Vancouver BC, V6E 1M7, Canada
| | - Janet Liew
- Center for Cardiovascular Innovation, Division of Cardiology, Department of Medicine, University of British Columbia, Room 220, 1033 Davie St. Vancouver BC, V6E 1M7, Canada
| | - Jeremy Parker
- Center for Cardiovascular Innovation, Division of Cardiology, Department of Medicine, University of British Columbia, Room 220, 1033 Davie St. Vancouver BC, V6E 1M7, Canada
| | - Darson Du
- Center for Cardiovascular Innovation, Division of Cardiology, Department of Medicine, University of British Columbia, Room 220, 1033 Davie St. Vancouver BC, V6E 1M7, Canada
| | - Jason G Andrade
- Center for Cardiovascular Innovation, Division of Cardiology, Department of Medicine, University of British Columbia, Room 220, 1033 Davie St. Vancouver BC, V6E 1M7, Canada
| | - Matthew T Bennett
- Center for Cardiovascular Innovation, Division of Cardiology, Department of Medicine, University of British Columbia, Room 220, 1033 Davie St. Vancouver BC, V6E 1M7, Canada
| | - Nathaniel M Hawkins
- Center for Cardiovascular Innovation, Division of Cardiology, Department of Medicine, University of British Columbia, Room 220, 1033 Davie St. Vancouver BC, V6E 1M7, Canada
| | - Santabhanu Chakrabarti
- Center for Cardiovascular Innovation, Division of Cardiology, Department of Medicine, University of British Columbia, Room 220, 1033 Davie St. Vancouver BC, V6E 1M7, Canada
| | - John Yeung
- Center for Cardiovascular Innovation, Division of Cardiology, Department of Medicine, University of British Columbia, Room 220, 1033 Davie St. Vancouver BC, V6E 1M7, Canada
| | - Marc W Deyell
- Center for Cardiovascular Innovation, Division of Cardiology, Department of Medicine, University of British Columbia, Room 220, 1033 Davie St. Vancouver BC, V6E 1M7, Canada
| | - Andrew D Krahn
- Center for Cardiovascular Innovation, Division of Cardiology, Department of Medicine, University of British Columbia, Room 220, 1033 Davie St. Vancouver BC, V6E 1M7, Canada
| | - Robert Moss
- Center for Cardiovascular Innovation, Division of Cardiology, Department of Medicine, University of British Columbia, Room 220, 1033 Davie St. Vancouver BC, V6E 1M7, Canada
| | - Kevin Ong
- Center for Cardiovascular Innovation, Division of Cardiology, Department of Medicine, University of British Columbia, Room 220, 1033 Davie St. Vancouver BC, V6E 1M7, Canada
| | - Zachary Laksman
- Center for Cardiovascular Innovation, Division of Cardiology, Department of Medicine, University of British Columbia, Room 220, 1033 Davie St. Vancouver BC, V6E 1M7, Canada
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Braunwald E, Saberi S, Abraham TP, Elliott PM, Olivotto I. Mavacamten: a first-in-class myosin inhibitor for obstructive hypertrophic cardiomyopathy. Eur Heart J 2023; 44:4622-4633. [PMID: 37804245 PMCID: PMC10659958 DOI: 10.1093/eurheartj/ehad637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 08/09/2023] [Accepted: 09/11/2023] [Indexed: 10/09/2023] Open
Abstract
Mavacamten is a first-in-class, targeted, cardiac-specific myosin inhibitor approved by the US Food and Drug Administration for the treatment of adults with symptomatic New York Heart Association Classes II and III obstructive hypertrophic cardiomyopathy (oHCM). Mavacamten was developed to target the hyper-contractile phenotype, which plays a critical role in the pathophysiology of the disease. In Phase 2 and 3 clinical trials, mavacamten was well tolerated, reduced left ventricular outflow tract gradients, improved exercise capacity and symptoms, and was associated with improvements in other clinically relevant parameters, such as patient-reported outcomes and circulating biomarkers. In addition, treatment with mavacamten was associated with evidence of favourable cardiac remodelling in multi-modality imaging studies. Mavacamten substantially reduced guideline eligibility for septal reduction therapy candidates with oHCM and drug-refractory symptoms. In this article, the available efficacy and safety data from completed and ongoing clinical studies of mavacamten in patients with symptomatic oHCM are reviewed. Longer term extension studies may help address questions related to the positioning of mavacamten in current oHCM management algorithms, interactions with background therapy, as well as the potential for disease modification beyond symptomatic relief of left ventricular outflow tract obstruction.
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Affiliation(s)
- Eugene Braunwald
- Division of Cardiovascular Medicine, TIMI Study Group, Brigham and Women’s Hospital, 60 Fenwood Road, Boston, MA 02115, USA
- Department Medicine, Harvard Medical School, Boston, MA, USA
| | - Sara Saberi
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Theodore P Abraham
- UCSF HCM Center of Excellence, University of California San Francisco, San Francisco, CA, USA
| | - Perry M Elliott
- Institute of Cardiovascular Science, University College London, London, UK
| | - Iacopo Olivotto
- Meyer Children’s Hospital, University of Florence, Florence, Italy
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Wolfgang M, Beskow L, Hooker G, Roberson M, Anderson K. Stigma manifestations in cardiomyopathy care impact outcomes for black patients: a qualitative study. BMC Cardiovasc Disord 2023; 23:553. [PMID: 37950168 PMCID: PMC10638684 DOI: 10.1186/s12872-023-03556-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 10/11/2023] [Indexed: 11/12/2023] Open
Abstract
INTRODUCTION Inequities in clinical care may contribute to racial disparities observed in studies of heart disease morbidity and cardiogenetic testing outcomes. There is a lack of research aimed at understanding the complexity of those inequities, but stigma likely contributes. This qualitative exploratory study helps close that gap in the literature by describing intersectional stigma manifestations perceived by the Black cardiomyopathy patient population at one academic medical center. METHODS Qualitative interviews were conducted with 14 Black cardiomyopathy patients. Interviews aimed to elicit patients' experiences with discrimination related to diagnosis, symptoms, genetic testing, knowledge of genetic results, genetic counseling, providers' actions, and providers' communication. The interview guide was informed by The Health Stigma and Discrimination Framework. Data were also collected about participant demographics, type of cardiomyopathy, age of diagnosis, documentation of relevant family history, and completion of genetic counseling and/or genetic testing. RESULTS More than half of participants reported intersectional stigma manifestations related to their race, age, and/or weight while receiving care from cardiologists, nurse practitioners, genetic counselors, or clinical support staff. Stigma manifestations included physical roughness during patient care, withholding diagnostically-relevant information from the patient, impersonal care, coercion, and use of offensive stereotyped language by providers. These stigma manifestations impacted access to care, uptake of genetic testing, timeline to diagnosis, patient emotion, patient-provider trust, and adherence to medical recommendations. CONCLUSIONS This study provides nuanced qualitative descriptions of stigma manifestations that affect patient and clinical outcomes in cardiology care and genetic services in one medical center in the Southeastern United States. The results of this study suggest that provider bias and stigma manifestations have an adverse effect on cardiogenetic and clinical outcomes among Black cardiomyopathy patients. Clinical interventions are suggested to assist health professionals in providing culturally-competent and respectful care. These results help inform patient-provider communication, clinical policies, and evidence-based practice in cardiology care and genetics. Continued study of this topic across more institutions and with a larger sample size is needed to confirm the generalizability of the conclusions.
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Affiliation(s)
| | - Laura Beskow
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gillian Hooker
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Mya Roberson
- Vanderbilt University Medical Center, Nashville, TN, USA
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8
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Nielsen SK, Hansen FG, Rasmussen TB, Fischer T, Lassen JF, Madsen T, Møller DS, Klausen IC, Brodersen JB, Jensen MSK, Mogensen J. Patients With Hypertrophic Cardiomyopathy and Normal Genetic Investigations Have Few Affected Relatives. J Am Coll Cardiol 2023; 82:1751-1761. [PMID: 37879779 DOI: 10.1016/j.jacc.2023.08.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/17/2023] [Accepted: 08/22/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND Current guidelines recommend that relatives of index patients with hypertrophic cardiomyopathy (HCM) are offered clinical investigations to identify individuals at risk of adverse disease complications and sudden cardiac death. However, the value of family screening in relatives of index patients with a normal genetic investigation of recognized HCM genes is largely unknown. OBJECTIVES The purpose of this study was to perform family screening among relatives of HCM index patients with a normal genetic investigation to establish the frequency of familial disease and the clinical characteristics of affected individuals. METHODS Clinical and genetic investigations were performed in consecutive and unrelated HCM index patients. Relatives of index patients who did not carry pathogenic/likely pathogenic variants in recognized HCM genes were invited for clinical investigations. RESULTS In total, 60% (270 of 453) of HCM index patients had a normal genetic investigation. A total of 80% of their relatives (751 of 938, median age 44 years) participated in the study. Of these, 5% (34 of 751) were diagnosed with HCM at baseline, whereas 0.3% (2 of 717 [751-34]) developed the condition during 5 years of follow-up. Their median age at diagnosis was 57 years (IQR: 51-70 years). Two-thirds (22 of 36) were diagnosed following family screening, whereas one-third (14 of 36) had been diagnosed previously because of cardiac symptoms, a murmur, or an abnormal electrocardiogram. None of the affected relatives experienced adverse disease complications. The risk of SCD was low. CONCLUSIONS Systematic family screening of index patients with HCM and normal genetic investigations was associated with a low frequency of affected relatives who appeared to have a favorable prognosis.
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Affiliation(s)
- Søren K Nielsen
- Department of Cardiology, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark; Department of Cardiology, Lillebaelt Hospital, Vejle, Denmark
| | - Frederikke G Hansen
- Department of Cardiology, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | - Thomas Fischer
- Department of Cardiology, Lillebaelt Hospital, Vejle, Denmark
| | - Jens F Lassen
- Department of Cardiology, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Trine Madsen
- Department of Cardiology Aalborg University Hospital, Aalborg, Denmark
| | - Dorthe S Møller
- Department of Cardiology, Viborg Regional Hospital, Viborg, Denmark
| | - Ib C Klausen
- Department of Cardiology, Viborg Regional Hospital, Viborg, Denmark
| | - John B Brodersen
- Centre of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark; Research Unit for General Practice, Region Zealand, Copenhagen, Denmark; Research Unit for General Practice, UiT The Arctic University of Norway, Oslo, Norway
| | - Morten S K Jensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jens Mogensen
- Department of Cardiology Aalborg University Hospital, Aalborg, Denmark.
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9
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Reza N, Day SM, Owens AT. Patient-reported outcomes in clinical studies of patients with hypertrophic cardiomyopathy. Prog Cardiovasc Dis 2023; 80:60-65. [PMID: 37625609 PMCID: PMC10543561 DOI: 10.1016/j.pcad.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 08/19/2023] [Indexed: 08/27/2023]
Abstract
OBJECTIVES This study aimed to characterize patient-reported outcomes (PROs) in registered clinical studies of participants with hypertrophic cardiomyopathy (HCM). BACKGROUND Therapy for HCM is primarily targeted toward alleviation of symptoms and improvement in function and quality of life. Yet, the contemporary landscape of PROs in HCM clinical research has not been investigated. METHODS ClinicalTrials.gov was queried to identify clinical studies of HCM that reported PROs as outcome measures. All studies of HCM as the disease condition were included, and PROs were identified using specific search terms in the Outcome Measures field. Study characteristics were collected and compared between those that did versus did not report PROs. RESULTS From November 1987 to February 2022, 181 studies including participants with HCM were registered on ClinicalTrials.gov. Of these, 35 (19%) included PROs as outcome measures. Studies reporting PROs were more likely to be designated as interventional (85.7% vs. 46.6%; p < 0.001) and to involve randomization (65.7% vs. 24.7%; p = 0.003) compared with those that did not report PROs. Prior to 2007, no clinical studies that reported PROs were registered in ClinicalTrials.gov; however, PRO reporting has increased over the last 15 years. Of the 66 PRO tools or domains included as outcome measures, the Kansas City Cardiomyopathy Questionnaire was the most often used. CONCLUSIONS Only approximately one in five registered clinical studies of participants with HCM report PROs. As medical, percutaneous, and surgical therapies for HCM continue to advance, HCM-specific PRO tools that assess the impacts of these new treatments on meaningful patient-related endpoints are urgently needed.
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Affiliation(s)
- Nosheen Reza
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Sharlene M Day
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Anjali Tiku Owens
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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10
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Desai NR, Sutton MB, Xie J, Fine JT, Gao W, Owens AT, Naidu SS. Clinical Outcomes, Resource Utilization, and Treatment Over the Disease Course of Symptomatic Obstructive Hypertrophic Cardiomyopathy in the United States. Am J Cardiol 2023; 192:16-23. [PMID: 36709525 DOI: 10.1016/j.amjcard.2022.12.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 11/21/2022] [Accepted: 12/26/2022] [Indexed: 01/28/2023]
Abstract
We sought to describe the clinical outcomes, resource utilization, and treatment options for patients with symptomatic obstructive hypertrophic cardiomyopathy (HCM) over the course of their disease. Adults with obstructive HCM who were symptomatic were identified from the IBM MarketScan Commercial and Medicare supplemental database (January 2009 to March 2019). The index date was the initial obstructive HCM diagnosis date. Patients were required to have ≥12-month continuous eligibility before and after the index date. Incidence rates (IRs) and cumulative risk of cardiovascular events, healthcare resource utilization, and pharmacotherapy were assessed after index and compared with matched controls. Among 4,617 eligible patients with obstructive HCM, 2,917 (63.2%, mean age 60, 47.2% women) were symptomatic at index date. The most common cardiovascular events were atrial fibrillation/flutter (IR:1.421 per person-year [PPY], heart failure (IR: 0.895 PPY), and dyspnea (IR:0.797 PPY). Patients incurred higher resource use with frequent tests and monitoring, hospitalizations (0.454 PPY), and emergency room visits (0.611 PPY). The use of pharmacotherapy increased from 61.2% in the 6-month preindex period to 83.9% in the 6-month postindex period and remained stable after diagnosis. These events ranged from 3 to over 60-fold higher compared with controls, with the largest difference observed in arrhythmic events. The majority of patients were symptomatic at the time of obstructive HCM diagnosis, resulting in significantly increased cardiovascular complications and frequent disease monitoring after diagnosis versus controls. In conclusion, healthcare resource utilization was substantial, and these findings suggest a higher clinical and economic burden over the disease course among patients with symptomatic obstructive HCM, despite current treatment.
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Affiliation(s)
- Nihar R Desai
- Yale University School of Medicine, New Haven, Connecticut.
| | - Megan B Sutton
- MyoKardia, Inc., a wholly owned subsidiary of Bristol-Myers Squibb, Brisbane, Brisbane, California
| | - Jipan Xie
- Analysis Group, Inc., Los Angeles, California
| | - Jennifer T Fine
- MyoKardia, Inc., a wholly owned subsidiary of Bristol-Myers Squibb, Brisbane, Brisbane, California
| | - Wei Gao
- Analysis Group, Inc., Boston, Massachusetts
| | - Anjali T Owens
- Heart and Vascular Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Srihari S Naidu
- Westchester Medical Center, Westchester Medical Center Health Network, Valhalla, New York; New York Medical College, Valhalla, New York
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11
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Wheeler MT, Olivotto I, Elliott PM, Saberi S, Owens AT, Maurer MS, Masri A, Sehnert AJ, Edelberg JM, Chen YM, Florea V, Malhotra R, Wang A, Oręziak A, Myers J. Effects of Mavacamten on Measures of Cardiopulmonary Exercise Testing Beyond Peak Oxygen Consumption: A Secondary Analysis of the EXPLORER-HCM Randomized Trial. JAMA Cardiol 2023; 8:240-247. [PMID: 36652223 PMCID: PMC9857843 DOI: 10.1001/jamacardio.2022.5099] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 11/17/2022] [Indexed: 01/19/2023]
Abstract
Importance Mavacamten, a cardiac myosin inhibitor, improved peak oxygen uptake (pVO2) in patients with symptomatic obstructive hypertrophic cardiomyopathy (HCM) in the EXPLORER-HCM study. However, the full extent of mavacamten's effects on exercise performance remains unclear. Objective To investigate the effect of mavacamten on exercise physiology using cardiopulmonary exercise testing (CPET). Design, Setting, and Participants Exploratory analyses of the data from the EXPLORER-HCM study, a randomized, double-blind, placebo-controlled, phase 3 trial that was conducted in 68 cardiovascular centers in 13 countries. In total, 251 patients with symptomatic obstructive HCM were enrolled. Interventions Patients were randomly assigned in a 1:1 ratio to mavacamten or placebo. Main Outcomes and Measures The following prespecified exploratory cardiovascular and performance parameters were assessed with a standardized treadmill or bicycle ergometer test protocol at baseline and week 30: carbon dioxide output (VCO2), minute ventilation (VE), peak VE/VCO2 ratio, ventilatory efficiency (VE/VCO2 slope), peak respiratory exchange ratio (RER), peak circulatory power, ventilatory power, ventilatory threshold, peak metabolic equivalents (METs), peak exercise time, partial pressure of end-tidal carbon dioxide (PETCO2), and VO2/workload slope. Results Two hundred fifty-one patients were enrolled. The mean (SD) age was 58.5 (11.9) years and 59% of patients were male. There were significant improvements with mavacamten vs placebo in the following peak-exercise CPET parameters: peak VE/VCO2 ratio (least squares [LS] mean difference, -2.2; 95% CI, -3.05 to -1.26; P < .001), peak METs (LS mean difference, 0.4; 95% CI, 0.17-0.60; P < .001), peak circulatory power (LS mean difference, 372.9 mL/kg/min × mm Hg; 95% CI, 153.12-592.61; P = .001), and peak PETCO2 (LS mean difference, 2.0 mm Hg; 95% CI, 1.12-2.79; P < .001). Mavacamten also improved peak exercise time compared with placebo (LS mean difference, 0.7 minutes; 95% CI, 0.13-1.24; P = .02). There was a significant improvement in nonpeak-exercise CPET parameters, such as VE/VCO2 slope (LS mean difference, -2.6; 95% CI, -3.58 to -1.52; P < .001) and ventilatory power (LS mean difference, 0.6 mm Hg; 95% CI, 0.29-0.90; P < .001) favoring mavacamten vs placebo. Conclusions and Relevance Mavacamten improved a range of CPET parameters beyond pVO2, indicating consistent and broad benefits on maximal exercise capacity. Although improvements in peak-exercise CPET parameters are clinically meaningful, the favorable effects of mavacamten on submaximal exertional tolerance provide further insights into the beneficial impact of mavacamten in patients with obstructive HCM. Trial Registration ClinicalTrials.gov Identifier: NCT03470545.
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Affiliation(s)
- Matthew T. Wheeler
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Iacopo Olivotto
- Azienda Ospedaliera Universitaria Careggi, Florence, Italy
- University of Florence, Florence, Italy
| | - Perry M. Elliott
- Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Sara Saberi
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Medical School, Ann Arbor
| | - Anjali T. Owens
- Center for Inherited Cardiovascular Disease, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | | | - Ahmad Masri
- Center for Hypertrophic Cardiomyopathy, Knight Cardiovascular Institute, Oregon Health & Science University, Portland
| | - Amy J. Sehnert
- MyoKardia, Inc, a wholly owned subsidiary of Bristol Myers Squibb, Brisbane, California
| | - Jay M. Edelberg
- MyoKardia, Inc, a wholly owned subsidiary of Bristol Myers Squibb, Brisbane, California
| | - Yu-Mao Chen
- Bristol Myers Squibb, Princeton Pike, New Jersey
| | - Victoria Florea
- MyoKardia, Inc, a wholly owned subsidiary of Bristol Myers Squibb, Brisbane, California
| | - Rajeev Malhotra
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Andrew Wang
- Duke University Hospital, Durham, North Carolina
| | - Artur Oręziak
- 1st Department of Arrhythmia, National Institute of Cardiology, Warsaw, Poland
| | - Jonathan Myers
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California
- Stanford University, Stanford, California
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12
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Park JB, Yun JY, Kim B, Rhee TM, Lee HJ, Lee H, Hwang IC, Yoon YE, Park HE, Lee SP, Choi SY, Kim YJ, Cho GY, Han K, Kim HK. Risk of incident mental disorders in hypertrophic cardiomyopathy: a nationwide propensity-matched study. Eur J Prev Cardiol 2023; 30:85-94. [PMID: 36348515 DOI: 10.1093/eurjpc/zwac260] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 10/16/2022] [Accepted: 11/03/2022] [Indexed: 11/10/2022]
Abstract
AIMS We sought to determine the risk of mental disorders in patients with hypertrophic cardiomyopathy (HCM) compared with those without HCM. METHODS AND RESULTS This is a retrospective propensity score-matched cohort study using nationwide population-based data from the Korean National Health Insurance Service. Overall, 4046 patients with HCM and 12138 matched individuals were followed up until the first diagnosis of mental disorders or the end of the follow up. The primary outcome was a composite of incident mood, anxiety, stress-related, or somatoform disorders. Secondary outcomes included two components of the primary outcome (i.e. mood disorders and anxiety/stress-related/somatoform disorders). During a median follow-up period of 4.1 years, the incidence rate of the primary outcome was 54.4 and 31.5/1000 person-years among the HCM and control groups, respectively, resulting in a hazard ratio (HR) of 1.719 (95% confidence interval: 1.589-1.860). Within the first month after HCM diagnosis, the HR for the primary outcome was 3.074 (2.096-4.508). Beyond 1 month, the HRs decreased, ranging from 2.281 (1.952-2.665) during 1-12 months, to 2.087 (1.831-2.380) during 12-36 months and 1.258 (1.090-1.452) after 36 months of follow up. Similar results were observed for the secondary outcomes. In sensitivity analysis, the risk of the specific categories of mental disorders, including single or recurrent depressive episodes and anxiety disorders, was also higher in patients with HCM than matched controls. CONCLUSION HCM was significantly associated with the risk of incident mental disorders, particularly within 1 year after HCM diagnosis, underscoring the importance of screening mental health problems, including mood and anxiety disorders, in patients with HCM.
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Affiliation(s)
- Jun-Bean Park
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, 03080 Seoul, Republic of Korea.,Cardiovascular Center, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, 03080 Seoul, Republic of Korea
| | - Je-Yeon Yun
- Department of Neuropsychiatry, Seoul National University Hospital, Seoul, Republic of Korea.,Yeongeon Student Support Center, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Bongsung Kim
- Department of Medical Statistics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Tae-Min Rhee
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, 03080 Seoul, Republic of Korea.,Cardiovascular Center, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, 03080 Seoul, Republic of Korea
| | - Hyun-Jung Lee
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, 03080 Seoul, Republic of Korea.,Cardiovascular Center, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, 03080 Seoul, Republic of Korea
| | - Heesun Lee
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, 03080 Seoul, Republic of Korea.,Department of Internal Medicine, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - In-Chang Hwang
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, 03080 Seoul, Republic of Korea.,Department of Cardiology, Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, South Korea
| | - Yeonyee E Yoon
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, 03080 Seoul, Republic of Korea.,Department of Cardiology, Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, South Korea
| | - Hyo Eun Park
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, 03080 Seoul, Republic of Korea.,Department of Internal Medicine, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Seung-Pyo Lee
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, 03080 Seoul, Republic of Korea.,Cardiovascular Center, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, 03080 Seoul, Republic of Korea
| | - Su-Yeon Choi
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, 03080 Seoul, Republic of Korea.,Department of Internal Medicine, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Yong-Jin Kim
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, 03080 Seoul, Republic of Korea.,Cardiovascular Center, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, 03080 Seoul, Republic of Korea
| | - Goo-Yeong Cho
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, 03080 Seoul, Republic of Korea.,Department of Cardiology, Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, South Korea
| | - Kyungdo Han
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, Republic of Korea
| | - Hyung-Kwan Kim
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, 03080 Seoul, Republic of Korea.,Cardiovascular Center, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, 03080 Seoul, Republic of Korea
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13
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Jin K. Using electronic health record data to improve understanding of the risk of mental disorders in patients diagnosed with hypertrophic cardiomyopathy. Eur J Prev Cardiol 2023; 30:82-84. [PMID: 36529915 DOI: 10.1093/eurjpc/zwac303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 12/13/2022] [Accepted: 12/15/2022] [Indexed: 12/23/2022]
Affiliation(s)
- Kai Jin
- Department of Non-Communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, UK
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14
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Woodland M, Al-Horani RA. New Era: Mavacamten for Obstructive Hypertrophic Cardiomyopathy. Cardiovasc Hematol Agents Med Chem 2023; 21:78-83. [PMID: 36278454 PMCID: PMC10249146 DOI: 10.2174/1871525721666221019095218] [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: 05/26/2022] [Revised: 08/23/2022] [Accepted: 09/16/2022] [Indexed: 11/22/2022]
Abstract
Obstructive hypertrophic cardiomyopathy results from asymmetric septal hypertrophy, which eventually obstructs the outflow of the left ventricle. Obstructive hypertrophic cardiomyopathy is linked to mutations in genes that encode for sarcomere proteins, including actin, β-myosin heavy chain, titin, and troponin. The mutations lead to structural abnormalities in myocytes and myofibrils, causing conduction irregularities and abnormal force generation. Obstructive hypertrophic cardiomyopathy is a chronic disease that worsens over time, and patients become at higher risk of developing atrial fibrillation, heart failure, and stroke. Up until recently, there were no disease- specific medications for obstructive hypertrophic cardiomyopathy. Nevertheless, the US Food and Drug Administration approved mavacamten on April 28, 2022, for the treatment of symptomatic obstructive hypertrophic cardiomyopathy (New York Heart Association class II to III) in adults to improve functional capacity and symptoms. Its approval was based on data from EXPLORER- HCM and EXPLORER-LTE (NCT03723655). Mavacamten is a novel, first-in-class, orally active, allosteric inhibitor of cardiac myosin ATPase, which decreases the formation of actin- myosin cross-bridges, and thus, it reduces myocardial contractility, and it improves myocardial energetics. It represents a paradigm-shifting pharmacological treatment of obstructive hypertrophic cardiomyopathy. In this review, we describe its chemical and mechanistic aspects as well as its pharmacokinetics, adverse effects and warnings, potential drug-drug interactions, and contraindications.
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Affiliation(s)
- Ma’Lik Woodland
- Division of Basic Pharmaceutical Sciences, College of Pharmacy, Xavier University of Louisiana, New Orleans LA 70125, USA
| | - Rami A. Al-Horani
- Division of Basic Pharmaceutical Sciences, College of Pharmacy, Xavier University of Louisiana, New Orleans LA 70125, USA
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15
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Langley PC. Concerns with Patient Reported Outcome Measurement and Value Claims for Therapy Response: The Case of Mavacamten and Symptomatic Hypertrophic Cardiomyopathy (SHCM). Innov Pharm 2022; 13:10.24926/iip.v13i2.4861. [PMID: 36654699 PMCID: PMC9836750 DOI: 10.24926/iip.v13i2.4861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Fundamental measurement is the basis for a rational assessment of patient reported outcome (PRO) value claims; both as response to therapy and the submission of credible and evaluable value claims to formulary committees and other health system decision makers. It is important to emphasize the importance of creating interval and ratio scales as opposed to nominal and ordinal scales to support value claims; a recognition that follows from acceptance of conjoint simultaneous measurement and the contribution of Rasch or modern measurement theory (RMT). Failure to appreciate the role of RMT has led thousands of researchers simply to apply numerals to events, inappropriately applying the techniques of classical statistical analysis, with the result that all that is produced are ordinal PRO scores. Instead, we should be aiming for interval and ratio scores based on a comprehensible latent trait and the application of the Rasch model. The purpose of this brief commentary is to review the measurement properties of PRO value claims for mavacamten (Camzyos; Bristol Myers Squibb) in symptomatic hypertrophic cardiomyopathy (SHCM) and to judge whether they have any validity when judged against the requirements of modern measurement theory. The assessment includes both the recent evidence report by the Institute for Clinical and Economic Review (ICER) for mavacamten as well as pivotal randomized trial (RCT) value claims that combine clinical endpoints with PROs that fail the standards of fundamental evidence. These include the Kansas City Cardiomyopathy Questionnaire (KCCQ), the New York Heart Association (NYHA) functional classification and the EuroQuol EQ-5D-5L multiattribute health related quality of life (HRQoL) preference instrument. The review concludes that apart from purely clinical claims based on the various pivotal trials, there are no PRO claims for mavacamten in SHCM that meet the required measurement standards.
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Affiliation(s)
- Paul C Langley
- Adjunct Professor, College of Pharmacy, University of Minnesota, Minneapolis MN,Corresponding author: Paul C. Langley, PhD Adjunct Professor, College of Pharmacy University of Minnesota, Minneapolis, MN Director, Maimon Research LLC; Tucson, AZ Website: www.maimonresearch.com
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16
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Coscarella IL, Landim-Vieira M, Pinto JR, Chelko SP. Arrhythmogenic Cardiomyopathy: Exercise Pitfalls, Role of Connexin-43, and Moving beyond Antiarrhythmics. Int J Mol Sci 2022; 23:ijms23158753. [PMID: 35955883 PMCID: PMC9369094 DOI: 10.3390/ijms23158753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/28/2022] [Accepted: 08/03/2022] [Indexed: 12/11/2022] Open
Abstract
Arrhythmogenic Cardiomyopathy (ACM), a Mendelian disorder that can affect both left and right ventricles, is most often associated with pathogenic desmosomal variants that can lead to fibrofatty replacement of the myocardium, a pathological hallmark of this disease. Current therapies are aimed to prevent the worsening of disease phenotypes and sudden cardiac death (SCD). Despite the use of implantable cardioverter defibrillators (ICDs) there is no present therapy that would mitigate the loss in electrical signal and propagation by these fibrofatty barriers. Recent studies have shown the influence of forced vs. voluntary exercise in a variety of healthy and diseased mice; more specifically, that exercised mice show increased Connexin-43 (Cx43) expression levels. Fascinatingly, increased Cx43 expression ameliorated the abnormal electrical signal conduction in the myocardium of diseased mice. These findings point to a major translational pitfall in current therapeutics for ACM patients, who are advised to completely cease exercising and already demonstrate reduced Cx43 levels at the myocyte intercalated disc. Considering cardiac dysfunction in ACM arises from the loss of cardiomyocytes and electrical signal conduction abnormalities, an increase in Cx43 expression-promoted by low to moderate intensity exercise and/or gene therapy-could very well improve cardiac function in ACM patients.
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Affiliation(s)
- Isabella Leite Coscarella
- Department of Biomedical Sciences, Florida State University College of Medicine, Tallahassee, FL 32303, USA
| | - Maicon Landim-Vieira
- Department of Biomedical Sciences, Florida State University College of Medicine, Tallahassee, FL 32303, USA
| | - José Renato Pinto
- Department of Biomedical Sciences, Florida State University College of Medicine, Tallahassee, FL 32303, USA
| | - Stephen P. Chelko
- Department of Biomedical Sciences, Florida State University College of Medicine, Tallahassee, FL 32303, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21215, USA
- Correspondence: ; Tel.: +1-850-644-2215
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17
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Nassif M, Fine JT, Dolan C, Reaney M, Addepalli P, Allen VD, Sehnert AJ, Gosch K, Spertus JA. Validation of the Kansas City Cardiomyopathy Questionnaire in Symptomatic Obstructive Hypertrophic Cardiomyopathy. JACC: HEART FAILURE 2022; 10:531-539. [DOI: 10.1016/j.jchf.2022.03.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 03/09/2022] [Accepted: 03/09/2022] [Indexed: 04/08/2023]
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18
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Reaney M, Allen V, Sehnert AJ, Fang L, Hagège AA, Naidu SS, Olivotto I. Development of the Hypertrophic Cardiomyopathy Symptom Questionnaire (HCMSQ): A New Patient-Reported Outcome (PRO) Instrument. PHARMACOECONOMICS - OPEN 2022; 6:563-574. [PMID: 35653062 PMCID: PMC9283619 DOI: 10.1007/s41669-022-00335-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/10/2022] [Indexed: 05/22/2023]
Abstract
BACKGROUND Currently, there is no patient-reported outcome (PRO) instrument specifically designed to evaluate hypertrophic cardiomyopathy (HCM). OBJECTIVE We present the development and psychometric validation of a novel PRO measure, the HCM Symptom Questionnaire version 1.0 (HCMSQv1.0). METHODS Cognitive debriefing interviews and a card-sorting task were conducted in 33 patients with HCM to support development of the HCMSQv1.0, showing the scale to be interpretable and relevant to patients' experiences. Baseline blinded data from two trials (EXPLORER-HCM and MAVERICK-HCM) were pooled (N = 299) to develop the scoring algorithm of HCMSQv1.0. Measurement properties were examined, followed by a meaningful-change analysis to interpret scores. Rasch modeling, mixed-model repeated measures, exploratory factor analysis, confirmatory factor analysis, and missing-data simulation analysis informed the number of domains and the items in each domain. RESULTS The scoring algorithm for HCMSQv1.0 consists of four domains: shortness of breath, tiredness, cardiovascular symptoms, and syncope; plus a total score, with higher scores indicating more severe symptoms. Item characteristics, internal consistency, test-retest reliability, construct validity, and responsiveness were acceptable. A clinically meaningful responder definition of 1-2 points on the HCMSQv1.0 score for shortness of breath and total score, and approximately 1 point on the tiredness and cardiovascular symptom scores, was calculated based on distribution- and anchor-based methods. CONCLUSION Our findings support the HCMSQv1.0 as a fit-for-purpose PRO instrument for assessing treatment benefit in patients with HCM. Studies in larger patient populations are ongoing to confirm responder definition and scoring approaches encompassing key HCM symptoms.
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Affiliation(s)
- Matthew Reaney
- IQVIA, 3 Forbury Place, 23 Forbury Road, Reading, RG1 3JH, UK.
| | | | - Amy J Sehnert
- MyoKardia, Inc. (a wholly owned subsidiary of Bristol Myers Squibb), Brisbane, CA, USA
| | - Liang Fang
- MyoKardia, Inc. (a wholly owned subsidiary of Bristol Myers Squibb), Brisbane, CA, USA
| | - Albert A Hagège
- Cardiology Department, Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges-Pompidou, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Srihari S Naidu
- Westchester Medical Center, WMC Health Network, New York Medical College, Valhalla, NY, USA
| | - Iacopo Olivotto
- Cardiomyopathy Unit, Careggi University Hospital, University of Florence, Florence, Italy
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19
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Reaney M, Addepalli P, Allen V, Spertus JA, Dolan C, Sehnert AJ, Fine JT. Longitudinal Psychometric Analysis of the Hypertrophic Cardiomyopathy Symptom Questionnaire (HCMSQ) Using Outcomes from the Phase III EXPLORER-HCM Trial. PHARMACOECONOMICS - OPEN 2022; 6:575-586. [PMID: 35718845 PMCID: PMC9283589 DOI: 10.1007/s41669-022-00340-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/16/2022] [Indexed: 05/05/2023]
Abstract
BACKGROUND Hypertrophic cardiomyopathy (HCM) symptoms include shortness of breath (SOB), fatigue, chest pain, palpitations, dizziness, and fainting. The HCM Symptom Questionnaire (HCMSQ), the only patient-reported outcome instrument designed to specifically measure HCM symptoms, yields four domain scores (SOB, tiredness, cardiovascular symptoms, syncope) and a total score. We evaluated the longitudinal psychometric properties of the HCMSQ using baseline to week 30 data from the phase III EXPLORER-HCM trial (NCT03470545). METHODS Test-retest reliability was assessed via intraclass correlation of patients with stable Patient Global Impression of Change (PGIC) and Patient Global Impression of Severity (PGIS) responses. Sensitivity to change was assessed via Spearman correlations with the Kansas City Cardiomyopathy Questionnaire (KCCQ-23) and the EuroQoL visual analogue scale (EQ VAS), and via one-way ANOVA comparing change groups defined on clinical (New York Heart Association [NYHA] class, left ventricular outflow tract [LVOT] gradient, peak oxygen consumption [pVO2]) and patient-reported (PGIS, PGIC) variables. Meaningful change thresholds were established via PGIC/PGIS. RESULTS All HCMSQ scores showed strong evidence of test-retest reliability (intraclass correlation coefficient > 0.70). Sensitivity to change was demonstrated with mostly strong/moderate correlations with KCCQ-23 and EQ VAS, and significant differences (p ≤ 0.05) in PGIS, PGIC, pVO2, and NYHA (except tiredness domain) change categories, but not LVOT gradient. Clinically meaningful score reductions were ≥1 point for tiredness and cardiovascular symptoms domains, ≥ 2.5 points for SOB domain, and ≥2 points for total score. CONCLUSIONS Results suggest that HCMSQ is fit for purpose in capturing HCM symptoms and may provide evidence of treatment benefit from the patients' perspectives.
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Affiliation(s)
- Matthew Reaney
- IQVIA, 3 Forbury Place, 23 Forbury Road, Reading, RG1 3JH, UK.
| | | | | | - John A Spertus
- Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City, Kansas City, MO, USA
| | | | - Amy J Sehnert
- MyoKardia, Inc., a wholly owned subsidiary of Bristol Myers Squibb, Brisbane, CA, USA
| | - Jennifer T Fine
- MyoKardia, Inc., a wholly owned subsidiary of Bristol Myers Squibb, Brisbane, CA, USA
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20
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Spertus JA, Fine JT, Elliott P, Ho CY, Olivotto I, Saberi S, Li W, Dolan C, Reaney M, Sehnert AJ, Jacoby D. Mavacamten for treatment of symptomatic obstructive hypertrophic cardiomyopathy (EXPLORER-HCM): health status analysis of a randomised, double-blind, placebo-controlled, phase 3 trial. Lancet 2021; 397:2467-2475. [PMID: 34004177 DOI: 10.1016/s0140-6736(21)00763-7] [Citation(s) in RCA: 92] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 03/24/2021] [Accepted: 03/26/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Improving symptoms is a primary treatment goal in patients with obstructive hypertrophic cardiomyopathy. Currently available pharmacological options for hypertrophic cardiomyopathy are not disease-specific and are often inadequate or poorly tolerated. We aimed to assess the effect of mavacamten, a first-in-class cardiac myosin inhibitor, on patients' health status-ie, symptoms, physical and social function, and quality of life. METHODS We did a health status analysis of EXPLORER-HCM, a phase 3, double-blind, randomised, placebo-controlled trial. The study took place at 68 clinical cardiovascular centres in 13 countries. Adult patients (≥18 years) with symptomatic obstructive hypertrophic cardiomyopathy (gradient ≥50 mm Hg and New York Heart Association class II-III) were randomly assigned (1:1) to mavacamten or placebo for 30 weeks, followed by an 8-week washout period. Both patients and staff were masked to study treatment. The primary outcome for this secondary analysis was the Kansas City Cardiomyopathy Questionnaire (KCCQ), a well validated disease-specific measure of patients' health status. It was administered at baseline and weeks 6, 12, 18, 30 (end of treatment), and 38 (end of study). Changes from baseline to week 30 in KCCQ overall summary (OS) score and all subscales were analysed using mixed model repeated measures. This study is registered with ClinicalTrials.gov, NCT03470545. FINDINGS Between May 30, 2018, and July 12, 2019, 429 adults were assessed for eligibility, of whom 251 (59%) were enrolled and randomly assigned. Of 123 patients randomly assigned to mavacamten, 92 (75%) completed the KCCQ at baseline and week 30 and of the 128 patients randomly assigned to placebo 88 (69%) completed the KCCQ at baseline and week 30. At 30 weeks, the change in KCCQ-OS score was greater with mavacamten than placebo (mean score 14·9 [SD 15·8] vs 5·4 [13·7]; difference +9·1 [95% CI 5·5-12·8]; p<0·0001), with similar benefits across all KCCQ subscales. The proportion of patients with a very large change (KCCQ-OS ≥20 points) was 36% (33 of 92) in the mavacamten group versus 15% (13 of 88) in the placebo group, with an estimated absolute difference of 21% (95% CI 8·8-33·4) and number needed to treat of five (95% CI 3-11). These gains returned to baseline after treatment was stopped. INTERPRETATION Mavacamten markedly improved the health status of patients with symptomatic obstructive hypertrophic cardiomyopathy compared with placebo, with a low number needed to treat for marked improvement. Given that the primary goals of treatment are to improve symptoms, physical and social function, and quality of life, mavacamten represents a new potential strategy for achieving these goals. FUNDING MyoKardia, a Bristol Myers Squibb company.
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Affiliation(s)
- John A Spertus
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA; University of Missouri, Kansas City, MO, USA.
| | - Jennifer T Fine
- MyoKardia, a Bristol Myers Squibb company, Brisbane, CA, USA
| | - Perry Elliott
- Centre for Heart Muscle Disease, Institute of Cardiovascular Science, University College London, London, UK
| | - Carolyn Y Ho
- Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Iacopo Olivotto
- Cardiomyopathy Unit, Azienda Ospedaliera Universitaria Careggi, Florence, Italy
| | - Sara Saberi
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Wanying Li
- MyoKardia, a Bristol Myers Squibb company, Brisbane, CA, USA
| | | | | | - Amy J Sehnert
- MyoKardia, a Bristol Myers Squibb company, Brisbane, CA, USA
| | - Daniel Jacoby
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University, New Haven, CT, USA
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