Hypertrophic cardiomyopathy and sudden cardiac death

Mavacamten, a precision medicine for hypertrophic cardiomyopathy: From a motor protein to patients

Hypertrophic cardiomyopathy (HCM) is a primary myocardial disorder characterized by left ventricular hypertrophy, hyperdynamic contraction, and impaired relaxation of the heart. These functional derangements arise directly from altered sarcomeric function due to either mutations in genes encoding sarcomere proteins, or other defects such as abnormal energetics. Current treatment options do not directly address this causal biology but focus on surgical and extra-sarcomeric (sarcolemmal) pharmacological symptomatic relief. Mavacamten (formerly known as MYK-461), is a small molecule designed to regulate cardiac function at the sarcomere level by selectively but reversibly inhibiting the enzymatic activity of myosin, the fundamental motor of the sarcomere. This review summarizes the mechanism and translational progress of mavacamten from proteins to patients, describing how the mechanism of action and pharmacological characteristics, involving both systolic and diastolic effects, can directly target pathophysiological derangements within the cardiac sarcomere to improve cardiac structure and function in HCM. Mavacamten was approved by the Food and Drug Administration in April 2022 for the treatment of obstructive HCM and now goes by the commercial name of Camzyos. Full information about the risks, limitations, and side effects can be found at www.accessdata.fda.gov/drugsatfda_docs/label/2022/214998s000lbl.pdf.

A Cadaveric Evaluation of Hypertrophic Obstructive Cardiomyopathy

Hypertrophic obstructive cardiomyopathy (HOCM) describes a pathologic state in which the subaortic region of the interventricular septum undergoes significant hypertrophy and fibrosis, resulting in septal bowing into the left ventricle. The reduced left ventricular chamber size and altered cardiac function impair diastolic filling, stroke volume, and cardiac output. This case report evaluates the cardiac tissue of a 36-year-old, formalin-embalmed cadaver affected by HOCM, with the goal of providing a comprehensive overview of the gross and pathologic findings associated with the condition. This donor's heart was found to be larger than average, weighing 510.1 g, which is 52% heavier than the predicted value of 335.6 g for a male of similar stature. The thickness of the interventricular septum, right ventricular free wall, and left ventricular free wall was comparable to other reports of HOCM. However, asymmetrical thickening of the left ventricular walls, which is characteristic of HOCM, was less prominent than expected. Histologic staining of the cadaveric tissue, with hematoxylin and eosin, trichrome, and desmin, further bolstered the diagnosis. Importantly, this also showed that histologic examination of embalmed tissue is effective and diagnostic, even 11 months after embalming. The report herein demonstrates that morphologic and histologic analysis of cadaveric cardiac tissue is sufficient to support a diagnosis of HOCM. To the researchers' knowledge, this is the first case report evaluating HOCM in a cadaver donated for medical education.

Regulation of endothelial nitric oxide synthase in cardiac remodeling

OBJECTIVES

Our previous study demonstrated that endothelial nitric oxide synthase (eNOS) gene serves as a candidate for modifiers of hypertrophic cardiomyopathy (HCM), which alters severity of HCM phenotypes. Herein, we sought to further elucidate the role of eNOS on cardiac myocyte hypertrophy and fibrosis, the major phenotypes of HCM.

METHODS

Male eNOS-deficient mice (eNOS-/-) and wild type control mice (eNOS+/+, C57B1/6 J) were used in this study. Myocyte size was analyzed in hematoxylin/eosin stained sections using an image analyzing system. Cardiac β-myosin heavy chain (β-MHC) and α-skeletal actin (α-SKA) levels, markers of myocyte hypertrophy were evaluated by Western blot. Cardiac collagen volume fraction (CVF) was examined in picrosirius red stained section using an image analyzing system. Cardiac expression of tissue inhibitor of metalloproteinase 1 (TIMP-1) and transforming growth factor beta 1 (TGF-β1), markers of fibrosis, were determined by Western blot.

RESULTS

Compared to eNOS+/+ mice, we found that; 1) myocyte size was significantly increased in eNOS-/- mice; 2) cardiac expression of β-MHC was markedly elevated, while α-SKA levels remained unchanged in eNOS-/- mice; 3) cardiac total and interstitial CVF levels were significantly higher in eNOS-/- mice; and 4) cardiac TIMP-1 levels were significantly greater in eNOS-/- mice, however, cardiac TGF-β1 was not differently expressed between the two groups.

CONCLUSION

The current study revealed that eNOS plays a beneficial role in cardiac remodeling, preventing the heart from development of myocyte hypertrophy and cardiac fibrosis. These findings support our previous report that eNOS may modify the severity of HCM phenotypes.

The prevalence of Fabry disease among 1009 unrelated patients with hypertrophic cardiomyopathy: a Russian nationwide screening program using NGS technology

Background

There is a vast number of screening studies described in the literature from the beginning of the twenty-first century to the present day. Many of these studies are related to the estimation of Fabry disease (FD) morbidity among patients from high-risk groups, including adult patients with hypertrophic cardiomyopathy (HCM) and left ventricular hypertrophy (LVH). These studies show diverse detection frequencies (0–12%) depending on the methodology. Our study is the only example of large-scale selective FD screening based on the implementation of next-generation sequencing technology (NGS) as a first-level test to estimate FD morbidity in the Russian population over 18 years of age burdened with HCM.

Methods

The study included 1009 patients (578 males and 431 females), with a median age of 50 years, who were diagnosed with HCM according to current clinical guidelines. In the first stage of screening, all patients underwent molecular genetic testing (NGS method) of target regions. These regions included the coding sequences of 17 genes and mutations that can lead to the development of HCM. Lysosomal globotriaosylsphingosine (lyso-Gb3) concentrations and α-galactosidase A (α-gal A) enzyme activity were measured in the second stage of screening to reveal pathogenic or likely pathogenic variants in the GLA gene.

Results

We revealed 8 (0.8%) patients (3 (37.5%) males and 5 (62.5%) females) with an average age of 59 ± 13.3 years who had pathogenic, likely pathogenic variants and variants of uncertain significance (VUS) in the GLA gene (NM_000169.2) as a result of selective screening of 1009 Russian patients with HCM. FD was confirmed via biochemical tests in a male with the pathogenic variant c.902G > A, p.R301Q as well as in two females with likely pathogenic variants c.897C > A, p.D299E and c.1287_1288dup, p.*430Fext*?. These tests showed reduced enzymatic activity and increased substrate concentration. However, a female with the pathogenic variant c.416A > G, p.N139S and with normal enzymatic activity only had increased substrate concentrations. The revealed nucleotide variants and high values of biochemical indicators (lyso-Gb3) in these 4 patients allowed us to estimate the FD diagnosis among 1009 Russian patients with HCM. Mild extracardiac manifestations were observed in these four patients; however, both biochemical values within the reference range in females with the c.971T > G, p.L324W (VUS) variant. α-gal A activity and lyso-Gb3 concentrations were also within the normal range in two males with hemizygous variants, c.546T > C, p.D182D and c.640-794_640-791del (we regarded them as VUS), and in one female with the c.427G > A, p.A143T variant (with conflicting interpretations of pathogenicity).

Conclusion

The prevalence rate of FD among 1,009 adult Russian patients with HCM was 0.4%. We recommend FD screening among adult patients of both sexes with HCM and an undefined genetic cause via NGS method with subsequent analysis of α-gal A activity and lyso-Gb3 concentration in patients with pathogenic, likely pathogenic variants, and VUS. This strategy identifies patients with an atypical form of FD that is characterized by high residual activity of α-gal A, low concentrations of lyso-Gb3, and minor extracardiac manifestations.

Serotonin receptor subtype-2B signaling is associated with interleukin-18-induced cardiomyoblast hypertrophy in vitro

Background

In patients with heart failure, interleukin-18 (IL-18) levels increase in the circulatory system and injured myocardial tissue. Serotonin (5-hydroxytryptamine) receptors subtype 2B (HTR2B) play an essential role in cardiac function and development, and their overexpression in rats leads to myocardial hypertrophy. Epigallocatechin gallate (EGCG) is cardioprotective in myocardial ischemia-reperfusion injury in rats and can prevent pressure overload-mediated cardiac hypertrophy in vivo. Mice deficient in peroxisome proliferator-activated receptor delta (PPARδ) can have cardiac dysfunction, myocardial hypertrophy, and heart failure. Matrix metalloproteinases (MMPs) are possibly involved in cardiac remodeling. However, the relationship between IL-18 signaling, cardiac hypertrophy, and the molecular mechanisms involved remain to be fully elucidated.

Objectives

To elucidate the relationship between HTR2B and IL-18-induced myocardial hypertrophy and examine the antihypertrophic effects of EGCG and PPARδ.

Methods

We induced H9c2 cardiomyoblast hypertrophy with IL-18 in vitro and investigated the downstream signaling by real-time polymerase chain reaction (PCR) and western blotting. Hypertrophy was assessed by flow cytometry. We determined the effects of EGCG and PPARδ on IL-18-induced hypertrophic signaling via HTR2B-dependent mechanisms.

Results

IL-18-induced H9c2 hypertrophy upregulated brain natriuretic peptide (BNP) protein and mRNA expression by inducing the expression of nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB), and the hypertrophy was attenuated by pretreatment with EGCG (20 μM) and L-165,041 (2 μM), a PPARδ agonist. IL-18 upregulated the expression of HTR2B, which was inhibited by pretreatment with EGCG and L-165,041. SB215505 (0.1 μM), a HTR2B antagonist and siRNA for HTR2B, attenuated H9c2 hypertrophy significantly. Inhibition of HTR2B also downregulated the expression of MMP-3 and MMP-9.

Conclusions

IL-18 and HTR2B play critical roles in cardiomyoblast hypertrophy. EGCG and L-165,041 inhibit the expression of HTR2B and augment remodeling of H9c2 cardiomyoblasts, possibly mediated by MMP-3 and MMP-9.

Unique Medical Considerations for the Athlete Undergoing Anesthesia

Athletes are among a unique group such that they may possess a serious underlying pathologic condition that may often go unnoticed given their high caliber of physical fitness. However, several considerations should be investigated, especially in the perioperative period, in order to minimize morbidity and mortality. Namely, cardiac pathologic condition can result in sudden death, and pulmonary pathologic condition may affect airway and respiratory management. Moreover, patients undergoing orthopedic surgery are at the highest risk for venous thromboembolism. Regardless of the condition, it is crucial to be vigilant and explore the unique medical considerations for the athlete undergoing anesthesia.

Post-operative management of hypertrophic obstructive cardiomyopathy

Hypertrophic obstructive cardiomyopathy patients are at increased risk of sudden cardiac arrest due to dynamic left ventricular outflow tract obstruction, myocardial ischaemia and arrhythmias. Septal myectomy remains the gold standard therapy for patients with hypertrophic obstructive cardiomyopathy (HOCM) refractory to other therapy. This review comprehensively focuses on the post-operative management and complications of HOCM patients undergoing surgical correction. Although these patients are at risk of various perioperative complications from anaesthesia and surgery due to the underlying complexity of their disease, surgical myectomy is associated with excellent long-term outcomes if carried out in experienced centers.

Left ventricular hypertrophy and sudden cardiac death

Sudden cardiac death (SCD) is among the leading causes of death worldwide, and it remains a public health problem, as it involves young subjects. Current guideline-directed risk stratification for primary prevention is largely based on left ventricular (LV) ejection fraction (LVEF), and preventive strategies such as implantation of a cardiac defibrillator (ICD) are justified only for documented low LVEF (i.e., ≤ 35%). Unfortunately, only a small percentage of primary prevention ICDs, implanted on the basis of a low LVEF, will deliver life-saving therapies on an annual basis. On the other hand, the vast majority of patients that experience SCD have LVEF > 35%, which is clamoring for better understanding of the underlying mechanisms. It is mandatory that additional variables be considered, both independently and in combination with the EF, to improve SCD risk prediction. LV hypertrophy (LVH) is a strong independent risk factor for SCD regardless of the etiology and the severity of symptoms. Concentric and eccentric LV hypertrophy, and even earlier concentric remodeling without hypertrophy, are all associated with increased risk of SCD. In this paper, we summarize the physiology and physiopathology of LVH, review the epidemiological evidence supporting the association between LVH and SCD, briefly discuss the mechanisms linking LVH with SCD, and emphasize the need to evaluate LV geometry as a potential risk stratification tool regardless of the LVEF.

Risk stratification in hypertrophic cardiomyopathy

Sudden cardiac death (SCD) is the most devastating complication of hypertrophic cardiomyopathy (HCM). The greatest challenge in the management of HCM is identifying those at increased risk, since an implantable cardioverter-defibrillator (ICD) is a potentially life-saving therapy. We sought to summarize the available data on SCD in HCM and provide a clinical perspective on the current differing and somewhat conflicting data on risk stratification, with balanced guidance regarding rational clinical decision-making. Additionally, we sought to determine the status of the current implementation of guidelines compiled by HCM experts worldwide. The HCM Risk-SCD model helps improve the risk stratification of HCM patients for primary prevention of SCD by calculating an individual risk estimate that contributes to the clinical decision-making process. Improved risk stratification is important for decision-making before ICD implantation for the primary prevention of SCD.

Holter monitoring demonstrates that ventricular arrhythmias are common in cats with decompensated and compensated hypertrophic cardiomyopathy

Arrhythmias can complicate cardiac disease in cats and are a potential cause of sudden death. The aim of this study was to evaluate the presence and nature of cardiac arrhythmias, and the potential correlation between plasma serum troponin I (cTnI) concentrations and the presence or severity of arrhythmias in cats with decompensated (dHCM) and compensated hypertrophic cardiomyopathy (cHCM). Forty one client-owned cats were studied: 16 with cHCM, 15 with dHCM and 10 healthy control cats. Physical examination, echocardiography, cTnI and 24-h Holter recordings were obtained in all cats and thoracic radiographs in cats with dHCM. Cats in both HCM groups were followed for 1 year after their initial Holter examination. The median (range) number of ventricular premature complexes (VPCs) over 24h was 867 (1-35,160) in cats with dHCM, 431 (0-18,919) in cats with cHCM and 2 (0-13) in healthy control cats. The median number of episodes of ventricular tachycardia (VTach) was 0 (0-1497) in dHCM and 0.5 (0-91) in cats with cHCM. The number of VPCs, VTach episodes and heart rate was not different between the HCM groups. Plasma serum troponin I was highest in the cats with dHCM, but there was no correlation between cTnI concentration and the number of arrhythmias. Thirteen of 31 cats with HCM died, but an association with the presence and complexity of ventricular arrhythmias was not observed. Compared to healthy cats, ventricular arrhythmias were common in cats with cHCM and dHCM, but neither presence nor complexity of arrhythmias could be linked to prognosis.

The Preoperative Patient With a Systolic Murmur

Context:

Patients with undifferentiated systolic murmurs present commonly during the perioperative period. Traditional bedside assessment and auscultation has not changed significantly in almost 200 years and relies on interpreting indirect acoustic events as a means of evaluating underlying cardiac pathology. This is notoriously inaccurate, even in expert cardiology hands, since many different valvular and cardiac diseases present with a similar auditory signal.

Evidence Acquisition:

The data on systolic murmurs, physical examination, perioperative valvular disease in the setting of non-cardiac surgery is reviewed.

Results:

Significant valvular heart disease increases perioperative risk in major non-cardiac surgery and increases long term patient morbidity and mortality. We propose a more modern approach to physical examination that incorporates the use of focused echocardiography to allow direct visualization of cardiac structure and function. This improves the diagnostic accuracy of clinical assessment, allows rational planning of surgery and anaesthesia technique, risk stratification, postoperative monitoring and appropriate referral to physicians and cardiologists.

Conclusions:

With a thorough preoperative assessment incorporating focused echocardiography, anaesthetists are in the unique position to enhance their role as perioperative physicians and influence short and long term outcomes of their patients.

Medicinal effect and its JP2/RyR2-based mechanism of Smilax glabra flavonoids on angiotensin II-induced hypertrophy model of cardiomyocytes

ETHNOPHARMACOLOGICAL RELEVANCE

Rhizome and root of Smilax glabra Roxb (Liliaceae family) is a widely used traditional Chinese medicine (TCM) named Tu-fu-ling (TFL) for cardiac disease therapy. The TFL flavonoids (TFLF) has been extracted and proven to possess the anti-cardiac hypertrophy effect in our previous reports. Such effect could be mediated by the modulation of intracellular Ca(2+) flux in myocardial cells, in which junctophilin-2 (JP2) and ryanodine receptor 2 (RyR2) play an important role. However, its mechanism of the anti-cardiac hypertrophy effect remains unclarified.

MATERIALS AND METHODS

2μmol/L Ang II was applied to induce hypertrophy model of rat primary cardiomyocytes. After treatment of TFLF at 0.25, 0.5 and 1.0mg/ml, the cell size was microscopic measured, and the protein and mRNA expressions of JP2 and RyR2 in cardiomyocytes were estimated by immunofluorescence imaging, ELISA and real-time PCR assay.

RESULTS

Obvious hypertrophy of cardiomyocytes was induced by Ang II but reversed by TFLF from 0.5 to 1.0mg/ml. The protein and mRNA expressions of JP2 and RyR2 in cardiomyocytes were also inhibited by Ang II but restored by TFLF at its dose range. Such effect of TFLF was exerted at a dose dependent manner, which was even better than that of verapamil.

CONCLUSIONS

Our findings may evidence the correlation between JP2/RyR2 and myocardiac hypertrophy, and indicate the JP2/RyR2-mediated anti-hypertrophy mechanism of TFLF for the first time. It deserves to be developed as a promising TCM candidate of new drug for myocardial hypertrophy treatment.

Validation of the 2014 European Society of Cardiology guidelines risk prediction model for the primary prevention of sudden cardiac death in hypertrophic cardiomyopathy

BACKGROUND

The recently released 2014 European Society of Cardiology guidelines of hypertrophic cardiomyopathy (HCM) use a new clinical risk prediction model for sudden cardiac death (SCD), based on the HCM Risk-SCD study. Our study is the first external and independent validation of this new risk prediction model.

METHODS AND RESULTS

The study population consisted of a consecutive cohort of 706 patients with HCM without prior SCD event, from 2 tertiary referral centers. The primary end point was a composite of SCD and appropriate implantable cardioverter-defibrillator therapy, identical to the HCM Risk-SCD end point. The 5-year SCD risk was calculated using the HCM Risk-SCD formula. Receiver operating characteristic curves and C-statistics were calculated for the 2014 European Society of Cardiology guidelines, and risk stratification methods of the 2003 American College of Cardiology/European Society of Cardiology guidelines and 2011 American College of Cardiology Foundation/American Heart Association guidelines. During follow-up of 7.7±5.3 years, SCD occurred in 42 (5.9%) of 706 patients (ages 49±16 years; 34% women). The C-statistic of the new model was 0.69 (95% CI, 0.57-0.82; P=0.008), which performed significantly better than the conventional risk factor models based on the 2003 guidelines (C-statistic of 0.55: 95% CI, 0.47-0.63; P=0.3), and 2011 guidelines (C-statistic of 0.60: 95% CI, 0.50-0.70; P=0.07).

CONCLUSIONS

The HCM Risk-SCD model improves the risk stratification of patients with HCM for primary prevention of SCD, and calculating an individual risk estimate contributes to the clinical decision-making process. Improved risk stratification is important for the decision making before implantable cardioverter-defibrillator implantation for the primary prevention of SCD.

Investigation of Sudden Death in Athletes: The Fittest Bodies in the Morgue

Sporting events are generally viewed as regulated activities with fit and healthy participants; therefore, when deaths occur, they draw considerable public interest. Athletic participants can be considered a vulnerable population based on inherent risks within certain sports and the associated physiologic stresses, which may complicate underlying medical conditions. Sudden deaths in young athletes participating in high school and collegiate organized sports occur at an average of four to six deaths per year; however, sudden deaths related to exercise outside of an organized sport setting remain unaccounted for in the overall prevalence of these deaths. A typical forensic pathology practice will see not only these higher-profile deaths occurring during an organized sporting event, but also lower-profile occurrences of individuals dying during more recreational or unstructured exercise. Sport-related deaths can essentially be categorized as those that occur due to dangers inherent in the sport itself, such as forms of heat-related illnesses, blunt force trauma, and water-related deaths, and those that occur due to susceptibilities of a given predisposed participant, including sickle cell trait, hypertrophic cardiomyopathy, and other cardiovascular diseases. This article will address both types of vulnerabilities and provide guidance for appropriate and specific medicolegal death investigation and autopsy procedures in these deaths.

Focused transthoracic echocardiography by sports medicine physicians: measurements relevant to hypertrophic cardiomyopathy

OBJECTIVES

The purpose of this study was to investigate whether sports medicine physicians can use portable echocardiography to obtain measurements pertinent to hypertrophic cardiomyopathy.

METHODS

Thirty male collegiate athletes, aged 18 to 21 years, were prospectively enrolled. Focused portable echocardiography was performed by a board-certified sports medicine physician and a resident physician, followed by comprehensive echocardiography within 2 weeks by a registered diagnostic cardiac sonographer. A left parasternal long-axis view was acquired to measure 3 dimensions: (1) end-diastolic interventricular septal thickness (IVSd), (2) end-diastolic left ventricular internal diameter (LVIDd), and (3) end-diastolic left ventricular posterior wall thickness (LVPWd).

RESULTS

Intraclass correlation coefficients between the sports medicine physician and the sonographer were strong: 0.77 for IVSd, 0.73 for LVIDd, and 0.64 for LVPWd. Intraclass correlation coefficients between measurements by the resident physician and sonographer were strong to moderate: 0.61 for IVSd, 0.62 for LVIDd, and 0.63 for LVPWd. Across all 3 readers, intraclass correlation coefficient calculations were 0.77 for IVSd, 0.81 LVIDd, and 0.75 for LVPWd, which indicated strong inter-rater reliability.

CONCLUSIONS

Sports medicine physicians are able to obtain measurements relevant to the diagnosis of hypertrophic cardiomyopathy with focused portable echocardiography that are consistent with comprehensive echocardiography by a registered sonographer.

Hypertrophic cardiomyopathy: from mutation to functional analysis of defective protein

Aim

To analyze the genesis of hypertrophic cardiomyopathy on a large cohort of patients from molecular genetics point of view and perform the functional analysis of the 3D molecular model of defective myosin-7 protein in silico.

Methods

The study enrolled 153 patients with diagnosed hypertrophic cardiomyopathy from different parts of the Czech Republic. DNA samples were analyzed for mutations in exons 21 and 22 of the MYH7 gene, which have been associated with high mutation clustering. The 3D model of human myosin-7 was built using the x-ray structure of nucleotide-free scallop myosin S1 as the structural template. We performed de novo structure prediction of mutant and wild type peptides spanning the 769-788 amino acids region of the myosin-7 protein.

Results

The Arg⁸⁷⁰His and Asp⁷⁷⁸Val amino acid alterations were found in 2 unrelated patients with a severe form of hypertrophic cardiomyopathy. The Asp⁷⁷⁸Val variation was chosen for subsequent 3D molecular modeling in silico. The mutation of the Asp by Val not only changes the character of the interaction pattern with other amino acids or ions but Val, being a small hydrophobic amino acid, can also completely change the stability of the region.

Conclusion

Mutation location in the MYH7 gene and changes in amino acid composition may have a crucial negative impact on the outcome of the disease in patients with hypertrophic cardiomyopathy. In addition, a mutation that changes the charge of the amino acid is more likely to affect protein function than a conservative mutation.