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Masri A, Lester SJ, Stendahl JC, Hegde SM, Sehnert AJ, Balaratnam G, Shah A, Fox S, Wang A. Long-Term Safety and Efficacy of Mavacamten in Symptomatic Obstructive Hypertrophic Cardiomyopathy: Interim Results of the PIONEER-OLE Study. J Am Heart Assoc 2024; 13:e030607. [PMID: 38591260 DOI: 10.1161/jaha.123.030607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 01/16/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND The phase 2 PIONEER-HCM (Phase 2 Open-label Pilot Study Evaluating Mavacamten in Subjects With Symptomatic Hypertrophic Cardiomyopathy and Left Ventricular Outflow Tract Obstruction) study showed that mavacamten improved left ventricular outflow tract gradients, exercise capacity, and symptoms in patients with obstructive hypertrophic cardiomyopathy (HCM), but the results of longer-term treatment are less well described. We report interim results from the PIONEER-OLE (PIONEER Open-Label Extension) study, the longest-term study of mavacamten in patients with symptomatic obstructive HCM. METHODS AND RESULTS Patients who previously completed PIONEER-HCM (n=20) were eligible to enroll in PIONEER-OLE. Patients received oral mavacamten, 5 mg once daily (starting dose), with individualized dose titration at week 6. Evaluations included serial monitoring of safety, echocardiography, Kansas City Cardiomyopathy Questionnaire-Overall Summary Score, and serum NT-proBNP (N-terminal pro-B-type natriuretic peptide) levels. Thirteen patients enrolled and received mavacamten (median study duration at data cutoff, 201 weeks). Most patients (92.3%) received β-blockers concomitantly. Treatment-emergent adverse events were predominantly mild/moderate. One patient had an isolated reduction in left ventricular ejection fraction to 47%, which recovered and remained normal with continued treatment at a reduced dose. At week 180, mavacamten was associated with New York Heart Association class improvements from baseline (class II to I, n=9; class III to II, n=1; and unchanged, n=2), sustained reductions in left ventricular outflow tract gradients (mean [SD] change from baseline: resting, -50 [55] mm Hg; Valsalva, -70 [41] mm Hg), and serum NT-proBNP levels (median [interquartile range] change from baseline: -498 [-2184 to -76] ng/L), and improved Kansas City Cardiomyopathy Questionnaire-Overall Summary Score (mean [SD] change from baseline: +17 [16]). CONCLUSIONS This long-term analysis supports the continued safety and effectiveness of mavacamten for >3 years in obstructive HCM. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03496168.
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Affiliation(s)
- Ahmad Masri
- Division of Cardiology, Hypertrophic Cardiomyopathy Center, School of Medicine Oregon Health & Science University Portland OR
| | - Steven J Lester
- Department of Cardiovascular Diseases Mayo Clinic Arizona Phoenix AZ
| | - John C Stendahl
- Section of Cardiovascular Medicine, Department of Internal Medicine Yale School of Medicine New Haven CT
| | - Sheila M Hegde
- Division of Cardiovascular Medicine Brigham and Women's Hospital Boston MA
| | | | | | | | | | - Andrew Wang
- Duke Cardiology Duke University Hospital Durham NC
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Cremer PC, Geske JB, Owens A, Jaber WA, Harb SC, Saberi S, Wang A, Sherrid M, Naidu SS, Schaff HV, Smedira NG, Wang Q, Wolski K, Lampl KL, Sehnert AJ, Nissen SE, Desai MY. Mitral Regurgitation in Obstructive Hypertrophic Cardiomyopathy: Insight from the VALOR-HCM Study. JACC Cardiovasc Imaging 2024:S1936-878X(24)00109-8. [PMID: 38639695 DOI: 10.1016/j.jcmg.2024.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 02/01/2024] [Accepted: 02/28/2024] [Indexed: 04/20/2024]
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Rader F, Oręziak A, Choudhury L, Saberi S, Fermin D, Wheeler MT, Abraham TP, Garcia-Pavia P, Zwas DR, Masri A, Owens A, Hegde SM, Seidler T, Fox S, Balaratnam G, Sehnert AJ, Olivotto I. Mavacamten Treatment for Symptomatic Obstructive Hypertrophic Cardiomyopathy: Interim Results From the MAVA-LTE Study, EXPLORER-LTE Cohort. JACC Heart Fail 2024; 12:164-177. [PMID: 38176782 DOI: 10.1016/j.jchf.2023.09.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 09/26/2023] [Accepted: 09/28/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Data assessing the long-term safety and efficacy of mavacamten treatment for symptomatic obstructive hypertrophic cardiomyopathy are needed. OBJECTIVES The authors sought to evaluate interim results from the EXPLORER-Long Term Extension (LTE) cohort of MAVA-LTE (A Long-Term Safety Extension Study of Mavacamten in Adults Who Have Completed EXPLORER-HCM; NCT03723655). METHODS After mavacamten or placebo withdrawal at the end of the parent EXPLORER-HCM (Clinical Study to Evaluate Mavacamten [MYK-461] in Adults With Symptomatic Obstructive Hypertrophic Cardiomyopathy; NCT03470545), patients could enroll in MAVA-LTE. Patients received mavacamten 5 mg once daily; adjustments were made based on site-read echocardiograms. RESULTS Between April 9, 2019, and March 5, 2021, 231 of 244 eligible patients (94.7%) enrolled in MAVA-LTE (mean age: 60 years; 39% female). At data cutoff (August 31, 2021) 217 (93.9%) remained on treatment (median time in study: 62.3 weeks; range: 0.3-123.9 weeks). At 48 weeks, patients showed improvements in left ventricular outflow tract (LVOT) gradients (mean change ± SD from baseline: resting: -35.6 ± 32.6 mm Hg; Valsalva: -45.3 ± 35.9 mm Hg), N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels (median: -480 ng/L; Q1-Q3: -1,104 to -179 ng/L), and NYHA functional class (67.5% improved by ≥1 class). LVOT gradients and NT-proBNP reductions were sustained through 84 weeks in patients who reached this timepoint. Over 315 patient-years of exposure, 8 patients experienced an adverse event of cardiac failure, and 21 patients had an adverse event of atrial fibrillation, including 11 with no prior history of atrial fibrillation. Twelve patients (5.2%) developed transient reductions in site-read echocardiogram left ventricular ejection fraction of <50%, resulting in temporary treatment interruption; all recovered. Ten patients discontinued treatment due to treatment-emergent adverse events. CONCLUSIONS Mavacamten treatment showed clinically important and durable improvements in LVOT gradients, NT-proBNP levels, and NYHA functional class, consistent with EXPLORER-HCM. Mavacamten treatment was well tolerated over a median 62-week follow-up.
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Affiliation(s)
- Florian Rader
- Cedars-Sinai Medical Center, Los Angeles, California, USA
| | | | - Lubna Choudhury
- Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Sara Saberi
- University of Michigan, Ann Arbor, Michigan, USA
| | | | | | | | - Pablo Garcia-Pavia
- Hospital Universitario Puerta de Hierro Majadahonda, Centro de Investigación Biomédica En Red Enfermedades Cardiovasculares, Madrid, Spain; Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Donna R Zwas
- Hadassah University Medical Center, Jerusalem, Israel
| | - Ahmad Masri
- Oregon Health & Science University, Portland, Oregon, USA
| | - Anjali Owens
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Sheila M Hegde
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Tim Seidler
- University of Göttingen, Göttingen, Germany; Kerckhoff-Klinik, Department of Cardiology, Bad Nauheim, Germany
| | | | | | | | - Iacopo Olivotto
- Meyer University Children Hospital, University of Florence, Italy.
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Desai MY, Owens A, Wolski K, Geske JB, Saberi S, Wang A, Sherrid M, Cremer PC, Lakdawala NK, Tower-Rader A, Fermin D, Naidu SS, Smedira NG, Schaff H, McErlean E, Sewell C, Mudarris L, Gong Z, Lampl K, Sehnert AJ, Nissen SE. Mavacamten in Patients With Hypertrophic Cardiomyopathy Referred for Septal Reduction: Week 56 Results From the VALOR-HCM Randomized Clinical Trial. JAMA Cardiol 2023; 8:968-977. [PMID: 37639243 PMCID: PMC10463171 DOI: 10.1001/jamacardio.2023.3342] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 08/07/2023] [Indexed: 08/29/2023]
Abstract
Importance There is an unmet need for novel medical therapies before recommending invasive therapies for patients with severely symptomatic obstructive hypertrophic cardiomyopathy (HCM). Mavacamten has been shown to improve left ventricular outflow tract (LVOT) gradient and symptoms and may thus reduce the short-term need for septal reduction therapy (SRT). Objective To examine the cumulative longer-term effect of mavacamten on the need for SRT through week 56. Design, Setting, and Participants This was a double-blind, placebo-controlled, multicenter, randomized clinical trial with placebo crossover at 16 weeks, conducted from July 2020 to November 2022. Participants were recruited from 19 US HCM centers. Included in the trial were patients with obstructive HCM (New York Heart Association class III/IV) referred for SRT. Study data were analyzed April to August 2023. Interventions Patients initially assigned to mavacamten at baseline continued the drug for 56 weeks, and patients taking placebo crossed over to mavacamten from week 16 to week 56 (40-week exposure). Dose titrations were performed using echocardiographic LVOT gradient and LV ejection fraction (LVEF) measurements. Main Outcome and Measure Proportion of patients undergoing SRT, remaining guideline eligible or unevaluable SRT status at week 56. Results Of 112 patients with highly symptomatic obstructive HCM, 108 (mean [SD] age, 60.3 [12.5] years; 54 male [50.0%]) qualified for the week 56 evaluation. At week 56, 5 of 56 patients (8.9%) in the original mavacamten group (3 underwent SRT, 1 was SRT eligible, and 1 was not SRT evaluable) and 10 of 52 patients (19.2%) in the placebo crossover group (3 underwent SRT, 4 were SRT eligible, and 3 were not SRT evaluable) met the composite end point. A total of 96 of 108 patients (89%) continued mavacamten long term. Between the mavacamten and placebo-to-mavacamten groups, respectively, after 56 weeks, there was a sustained reduction in resting (mean difference, -34.0 mm Hg; 95% CI, -43.5 to -24.5 mm Hg and -33.2 mm Hg; 95% CI, -41.9 to -24.5 mm Hg) and Valsalva (mean difference, -45.6 mm Hg; 95% CI, -56.5 to -34.6 mm Hg and -54.6 mm Hg; 95% CI, -66.0 to -43.3 mm Hg) LVOT gradients. Similarly, there was an improvement in NYHA class of 1 or higher in 51 of 55 patients (93%) in the original mavacamten group and in 37 of 51 patients (73%) in the placebo crossover group. Overall, 12 of 108 patients (11.1%; 95% CI, 5.87%-18.60%), which represents 7 of 56 patients (12.5%) in the original mavacamten group and 5 of 52 patients (9.6%) in the placebo crossover group, had an LVEF less than 50% (2 with LVEF ≤30%, one of whom died), and 9 of 12 patients (75%) continued treatment. Conclusions and Relevance Results of this randomized clinical trial showed that in patients with symptomatic obstructive HCM, mavacamten reduced the need for SRT at week 56, with sustained improvements in LVOT gradients and symptoms. Although this represents a useful therapeutic option, given the potential risk of LV systolic dysfunction, there is a continued need for close monitoring. Trial Registration ClinicalTrials.gov Identifier: NCT04349072.
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Affiliation(s)
- Milind Y. Desai
- The Hypertrophic Cardiomyopathy Center, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- Coordinating Center for Clinical Research Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Anjali Owens
- Division of Cardiology, University of Pennsylvania, Philadelphia
| | - Kathy Wolski
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- Coordinating Center for Clinical Research Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jeffrey B. Geske
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Sara Saberi
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Andrew Wang
- Department of Cardiology, Duke University, Durham, North Carolina
| | - Mark Sherrid
- Department of Cardiology, New York University, New York
| | - Paul C. Cremer
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- Coordinating Center for Clinical Research Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Neal K. Lakdawala
- Division of Cardiology, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - David Fermin
- Department of Cardiology, Corewell Health, Grand Rapids, Michigan
| | - Srihari S. Naidu
- Department of Cardiology, Westchester Medical Center, Valhalla, New York
| | - Nicholas G. Smedira
- The Hypertrophic Cardiomyopathy Center, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- Department of Cardiothoracic Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Hartzell Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Ellen McErlean
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- Coordinating Center for Clinical Research Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Christina Sewell
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- Coordinating Center for Clinical Research Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | | | | | | | | | - Steven E. Nissen
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- Coordinating Center for Clinical Research Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
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Siontis KC, Abreau S, Attia ZI, Barrios JP, Dewland TA, Agarwal P, Balasubramanyam A, Li Y, Lester SJ, Masri A, Wang A, Sehnert AJ, Edelberg JM, Abraham TP, Friedman PA, Olgin JE, Noseworthy PA, Tison GH. Patient-Level Artificial Intelligence-Enhanced Electrocardiography in Hypertrophic Cardiomyopathy: Longitudinal Treatment and Clinical Biomarker Correlations. JACC Adv 2023; 2:100582. [PMID: 38076758 PMCID: PMC10702858 DOI: 10.1016/j.jacadv.2023.100582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/31/2024]
Abstract
BACKGROUND Artificial intelligence (AI) applied to 12-lead electrocardiographs (ECGs) can detect hypertrophic cardiomyopathy (HCM). OBJECTIVES The purpose of this study was to determine if AI-enhanced ECG (AI-ECG) can track longitudinal therapeutic response and changes in cardiac structure, function, or hemodynamics in obstructive HCM during mavacamten treatment. METHODS We applied 2 independently developed AI-ECG algorithms (University of California-San Francisco and Mayo Clinic) to serial ECGs (n = 216) from the phase 2 PIONEER-OLE trial of mavacamten for symptomatic obstructive HCM (n = 13 patients, mean age 57.8 years, 69.2% male). Control ECGs from 2,600 age- and sex-matched individuals without HCM were obtained. AI-ECG output was correlated longitudinally to echocardiographic and laboratory metrics of mavacamten treatment response. RESULTS In the validation cohorts, both algorithms exhibited similar performance for HCM diagnosis, and exhibited mean HCM score decreases during mavacamten treatment: patient-level score reduction ranged from approximately 0.80 to 0.45 for Mayo and 0.70 to 0.35 for USCF algorithms; 11 of 13 patients demonstrated absolute score reduction from start to end of follow-up for both algorithms. HCM scores were significantly associated with other HCM-relevant parameters, including left ventricular outflow tract gradient at rest, postexercise, and with Valsalva, and NT-proBNP level, independent of age and sex (all P < 0.01). For both algorithms, the strongest longitudinal correlation was between AI-ECG HCM score and left ventricular outflow tract gradient postexercise (slope estimate: University of California-San Francisco 0.70 [95% CI: 0.45-0.96], P < 0.0001; Mayo 0.40 [95% CI: 0.11-0.68], P = 0.007). CONCLUSIONS AI-ECG analysis longitudinally correlated with changes in echocardiographic and laboratory markers during mavacamten treatment in obstructive HCM. These results provide early evidence for a potential paradigm for monitoring HCM therapeutic response.
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Affiliation(s)
| | - Sean Abreau
- Division of Cardiology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
- Cardiovascular Research Institute, San Francisco, California, USA
| | - Zachi I. Attia
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Joshua P. Barrios
- Division of Cardiology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
- Cardiovascular Research Institute, San Francisco, California, USA
| | - Thomas A. Dewland
- Division of Cardiology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Priyanka Agarwal
- MyoKardia Inc, a Wholly Owned Subsidiary of Bristol Myers Squibb, Brisbane, California, USA
| | - Aarthi Balasubramanyam
- MyoKardia Inc, a Wholly Owned Subsidiary of Bristol Myers Squibb, Brisbane, California, USA
| | - Yunfan Li
- MyoKardia Inc, a Wholly Owned Subsidiary of Bristol Myers Squibb, Brisbane, California, USA
| | - Steven J. Lester
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, Arizona, USA
| | - Ahmad Masri
- Division of Cardiovascular Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Andrew Wang
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Amy J. Sehnert
- MyoKardia Inc, a Wholly Owned Subsidiary of Bristol Myers Squibb, Brisbane, California, USA
| | - Jay M. Edelberg
- MyoKardia Inc, a Wholly Owned Subsidiary of Bristol Myers Squibb, Brisbane, California, USA
| | - Theodore P. Abraham
- Division of Cardiology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Paul A. Friedman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jeffrey E. Olgin
- Division of Cardiology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
- Cardiovascular Research Institute, San Francisco, California, USA
| | - Peter A. Noseworthy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Geoffrey H. Tison
- Division of Cardiology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
- Cardiovascular Research Institute, San Francisco, California, USA
- Bakar Computational Health Sciences Institute, University of California-San Francisco, San Francisco, California, USA
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7
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Desai MY, Owens A, Geske JB, Wolski K, Saberi S, Wang A, Sherrid M, Cremer PC, Naidu SS, Smedira NG, Schaff H, McErlean E, Sewell C, Balasubramanyam A, Lampl K, Sehnert AJ, Nissen SE. Dose-Blinded Myosin Inhibition in Patients With Obstructive Hypertrophic Cardiomyopathy Referred for Septal Reduction Therapy: Outcomes Through 32 Weeks. Circulation 2023; 147:850-863. [PMID: 36335531 DOI: 10.1161/circulationaha.122.062534] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Septal reduction therapy (SRT) in patients with intractable symptoms from obstructive hypertrophic cardiomyopathy (oHCM) is associated with variable morbidity and mortality. The VALOR-HCM trial (A Study to Evaluate Mavacamten in Adults with Symptomatic Obstructive Hypertrophic Cardiomyopathy Who Are Eligible for Septal Reduction Therapy) examined the effect of mavacamten on the need for SRT through week 32 in oHCM. METHODS A double-blind randomized placebo-controlled multicenter trial at 19 US sites included patients with oHCM on maximal tolerated medical therapy referred for SRT with left ventricular outflow tract gradient ≥50 mm Hg at rest or provocation (enrollment, July 2020-October 2021). The group initially randomized to mavacamten continued the drug for 32 weeks, and the placebo group crossed over to dose-blinded mavacamten from week 16 to week 32. Dose titrations were based on investigator-blinded echocardiographic assessment of left ventricular outflow tract gradient and left ventricular ejection fraction. The principal end point was the proportion of patients proceeding with SRT or remaining guideline eligible at 32 weeks in both treatment groups. RESULTS From the 112 randomized patients with oHCM, 108 (mean age, 60.3 years; 50% men; 94% in New York Heart Association class III/IV) qualified for week 32 evaluation (56 in the original mavacamten group and 52 in the placebo cross-over group). After 32 weeks, 6 of 56 patients (10.7%) in the original mavacamten group and 7 of 52 patients (13.5%) in the placebo cross-over group met SRT guideline criteria or elected to undergo SRT. After 32 weeks, a sustained reduction in resting left ventricular outflow tract gradient (-33.0 mm Hg [95% CI, -41.1 to -24.9]) and Valsalva left ventricular outflow tract gradient (-43.0 mm Hg [95% CI, -52.1 to -33.9]) was observed in the original mavacamten group. A similar reduction in resting (-33.7 mm Hg [95% CI, -42.2 to -25.2]) and Valsalva (-52.9 mm Hg [95% CI, -63.2 to -42.6]) gradients was quantified in the cross-over group after 16 weeks of mavacamten. After 32 weeks, improvement by ≥1 New York Heart Association class was observed in 48 of 53 patients (90.6%) in the original mavacamten group and 35 of 50 patients (70%) after 16 weeks in the cross-over group. CONCLUSIONS In severely symptomatic patients with oHCM, 32 weeks of mavacamten treatment showed sustained reduction in the proportion proceeding to SRT or remaining guideline eligible, with similar effects observed in patients who crossed over from placebo after 16 weeks. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT04349072.
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Affiliation(s)
- Milind Y Desai
- From the Hypertrophic Cardiomyopathy Center (M.Y.D., N.G.S.), Heart Vascular and Thoracic Institute, Cleveland Clinic, OH.,Department of Cardiovascular Medicine (M.Y.D., K.W., P.C.C., E.M., C.S., S.E.N.), Heart Vascular and Thoracic Institute, Cleveland Clinic, OH.,Cleveland Clinic Coordinating Center for Clinical Research (M.Y.D., K.W., P.C.C., E.M., C.S., S.E.N.), Heart Vascular and Thoracic Institute, Cleveland Clinic, OH
| | - Anjali Owens
- Division of Cardiology, University of Pennsylvania, Philadelphia (A.O.)
| | - Jeffrey B Geske
- Departments of Cardiovascular Diseases (J.B.G.), Mayo Clinic, Rochester, MN
| | - Kathy Wolski
- Department of Cardiovascular Medicine (M.Y.D., K.W., P.C.C., E.M., C.S., S.E.N.), Heart Vascular and Thoracic Institute, Cleveland Clinic, OH.,Cleveland Clinic Coordinating Center for Clinical Research (M.Y.D., K.W., P.C.C., E.M., C.S., S.E.N.), Heart Vascular and Thoracic Institute, Cleveland Clinic, OH
| | - Sara Saberi
- Department of Internal Medicine, University of Michigan, Ann Arbor (S.S.)
| | - Andrew Wang
- Department of Cardiology, Duke University, Durham, NC (A.W.)
| | - Mark Sherrid
- Department of Cardiology, New York University, NY (M.S.)
| | - Paul C Cremer
- Department of Cardiovascular Medicine (M.Y.D., K.W., P.C.C., E.M., C.S., S.E.N.), Heart Vascular and Thoracic Institute, Cleveland Clinic, OH.,Cleveland Clinic Coordinating Center for Clinical Research (M.Y.D., K.W., P.C.C., E.M., C.S., S.E.N.), Heart Vascular and Thoracic Institute, Cleveland Clinic, OH
| | - Srihari S Naidu
- Department of Cardiology, Westchester Medical Center, Valhalla, NY (S.S.N.)
| | - Nicholas G Smedira
- From the Hypertrophic Cardiomyopathy Center (M.Y.D., N.G.S.), Heart Vascular and Thoracic Institute, Cleveland Clinic, OH.,Department of Cardiothoracic Surgery (N.G.S.), Heart Vascular and Thoracic Institute, Cleveland Clinic, OH
| | | | - Ellen McErlean
- Department of Cardiovascular Medicine (M.Y.D., K.W., P.C.C., E.M., C.S., S.E.N.), Heart Vascular and Thoracic Institute, Cleveland Clinic, OH.,Cleveland Clinic Coordinating Center for Clinical Research (M.Y.D., K.W., P.C.C., E.M., C.S., S.E.N.), Heart Vascular and Thoracic Institute, Cleveland Clinic, OH
| | - Christina Sewell
- Department of Cardiovascular Medicine (M.Y.D., K.W., P.C.C., E.M., C.S., S.E.N.), Heart Vascular and Thoracic Institute, Cleveland Clinic, OH.,Cleveland Clinic Coordinating Center for Clinical Research (M.Y.D., K.W., P.C.C., E.M., C.S., S.E.N.), Heart Vascular and Thoracic Institute, Cleveland Clinic, OH
| | - Aarthi Balasubramanyam
- MyoKardia, Inc, a wholly owned subsidiary of Bristol Myers Squibb, Brisbane, CA (A.B., K.L., A.J.S.)
| | - Kathy Lampl
- MyoKardia, Inc, a wholly owned subsidiary of Bristol Myers Squibb, Brisbane, CA (A.B., K.L., A.J.S.)
| | - Amy J Sehnert
- MyoKardia, Inc, a wholly owned subsidiary of Bristol Myers Squibb, Brisbane, CA (A.B., K.L., A.J.S.)
| | - Steven E Nissen
- Department of Cardiovascular Medicine (M.Y.D., K.W., P.C.C., E.M., C.S., S.E.N.), Heart Vascular and Thoracic Institute, Cleveland Clinic, OH.,Cleveland Clinic Coordinating Center for Clinical Research (M.Y.D., K.W., P.C.C., E.M., C.S., S.E.N.), Heart Vascular and Thoracic Institute, Cleveland Clinic, OH
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8
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Cresci S, Bach RG, Saberi S, Owens AT, Lakdawala NK, Nilles EK, Wojdyla DM, Sehnert AJ, Wang A. WOMEN IN EXPLORER-HCM HAD MORE SEVERE HEART FAILURE AT BASELINE BUT SIMILAR, OR GREATER, RESPONSE TO MAVACAMTEN. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)00788-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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9
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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: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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10
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Wheeler MT, Jacoby D, Elliott PM, Saberi S, Hegde SM, Lakdawala NK, Myers J, Sehnert AJ, Edelberg JM, Li W, Olivotto I. Effect of beta-blocker therapy on the response to mavacamten in patients with symptomatic obstructive hypertrophic cardiomyopathy. Eur J Heart Fail 2023; 25:260-270. [PMID: 36404399 DOI: 10.1002/ejhf.2737] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 09/28/2022] [Accepted: 11/16/2022] [Indexed: 11/22/2022] Open
Abstract
AIMS In the EXPLORER-HCM trial, mavacamten improved exercise capacity and symptoms in patients with obstructive hypertrophic cardiomyopathy (oHCM). Mavacamten effects on the primary endpoint, a composite of peak oxygen consumption (VO2 ) and New York Heart Association (NYHA) class, were greater in patients not receiving background beta-blockers than in those receiving beta-blockers. We sought to determine if the effect of background treatment was consistent across other clinically meaningful parameters. METHODS AND RESULTS Subgroup analyses by beta-blocker use were performed in patients with oHCM from the EXPLORER-HCM and mavacamten long-term extension (MAVA-LTE) studies. In EXPLORER-HCM, 189 patients (75.3%) were receiving beta-blockers, and 62 (24.7%) were receiving non-dihydropyridine calcium channel blockers or no background HCM medication; 170 patients (90.4%) receiving beta-blockers had chronotropic incompetence. Improvements in peak VO2 at week 30 with mavacamten versus placebo were lower with beta-blockers (mean difference [95% confidence interval (CI)]: 1.04 [0.12, 1.95] ml/kg/min) than without beta-blockers (mean difference [95% CI]: 2.69 [1.29, 4.09] ml/kg/min); improvements in non-heart rate-dependent parameters (VE /VCO2 slope) appeared unaffected by beta-blockers. Improvements in functional capacity parameters at week 30 with mavacamten versus placebo were independent of beta-blockade for post-exercise left ventricular outflow tract gradient (mean difference [95% CI]: -37.9 [-48.0, -27.9] mmHg with beta-blockers; -33.5 [-53.6, -13.3] mmHg without beta-blockers), proportion of patients with reduction of ≥1 NYHA class, Kansas City Cardiomyopathy Questionnaire clinical summary scores and N-terminal pro-B-type natriuretic peptide. Mavacamten benefits were reproduced and maintained in MAVA-LTE regardless of beta-blockade. CONCLUSION Mavacamten improved measures of functional capacity, left ventricular outflow tract obstruction, symptom burden and biomarkers in patients with HCM regardless of beta-blocker use. Beta-blocker use was often associated with chronotropic incompetence, affecting peak VO2 and other heart rate-dependent measures, but had minimal impact on heart rate-independent measures.
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Affiliation(s)
- Matthew T Wheeler
- Division of Cardiovascular Medicine, Center for Inherited Cardiovascular Disease, Stanford University, Stanford, CA, USA
| | - Daniel Jacoby
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, CT, USA
| | - Perry M Elliott
- University College London & St. Bartholomew's Hospital, London, UK
| | - Sara Saberi
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Sheila M Hegde
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Neal K Lakdawala
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jonathan Myers
- Division of Cardiology, Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA, USA
- Stanford University, Palo Alto, CA, USA
| | - Amy J Sehnert
- MyoKardia, Inc., a wholly owned subsidiary of Bristol Myers Squibb, Brisbane, CA, USA
| | - Jay M Edelberg
- MyoKardia, Inc., a wholly owned subsidiary of Bristol Myers Squibb, Brisbane, CA, USA
| | - Wanying Li
- MyoKardia, Inc., a wholly owned subsidiary of Bristol Myers Squibb, Brisbane, CA, USA
| | - Iacopo Olivotto
- Cardiomyopathy Unity, Azienda Ospedaliera Universitaria Careggi and University of Florence, Florence, Italy
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11
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Cremer PC, Geske JB, Owens A, Jaber WA, Harb SC, Saberi S, Wang A, Sherrid M, Naidu SS, Schaff H, Smedira NG, Wang Q, Wolski K, Lampl KL, Sehnert AJ, Nissen SE, Desai MY. Myosin Inhibition and Left Ventricular Diastolic Function in Patients With Obstructive Hypertrophic Cardiomyopathy Referred for Septal Reduction Therapy: Insights From the VALOR-HCM Study. Circ Cardiovasc Imaging 2022; 15:e014986. [PMID: 36335645 DOI: 10.1161/circimaging.122.014986] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND In the randomized phase 3 VALOR-HCM study (A Study to Evaluate Mavacamten in Adults With Symptomatic Obstructive Hypertrophic Cardiomyopathy Who Are Eligible for Septal Reduction Therapy) of patients with obstructive hypertrophic cardiomyopathy, mavacamten reduced the need for septal reduction therapy. Because mavacamten improves ventricular compliance, this sub-study examined the effects of treatment with this cardiac myosin inhibitor on diastolic function. METHODS Symptomatic obstructive hypertrophic cardiomyopathy patients on maximally tolerated medical therapy referred for septal reduction therapy were randomized 1:1 to mavacamten or placebo. At baseline and week 16, a resting and stress echocardiogram was performed with interpretation by a core laboratory. In this exploratory substudy, the principal end point was the change in parameters used to define the grade of diastolic function in patients treated with mavacamten and placebo. A related objective was to assess the proportion of patients with an improvement in diastolic function grade. A secondary aim was to assess for correlation between diastolic function parameters and the secondary end points from VALOR-HCM: New York Heart Association class, quality of life, and cardiac biomarkers. RESULTS Diastolic dysfunction grade was evaluable in 98 patients at baseline and week 16. Among patients treated with mavacamten, 29.4% (15 of 51) demonstrated improvement in diastolic function grade compared with 12.8% (6 of 47) patients with placebo (P=0.05). Average E/e' ratio decreased significantly in patients treated with mavacamten (-3.4±5.3) compared with placebo (0.57±3.5; P<0.001). Indexed left atrial volumes (mL/m2) also decreased significantly in patients who received mavacamten (-5.2±7.8) compared with placebo (-0.51±8.1; P=0.005). After adjustment for change in left ventricular outflow tract gradient and mitral regurgitation, mavacamten was significantly associated with a decrease in average E/e' ratio and indexed left atrial volumes. Change in average E/e' ratio was significantly correlated with the secondary end points from VALOR-HCM. CONCLUSIONS In this exploratory substudy, after 16 weeks of therapy, mavacamten improved diastolic function, and this change correlated with improvement in clinical and biomarker end points. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT04349072.
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Affiliation(s)
- Paul C Cremer
- Department of Cardiovascular Medicine (P.C.C., W.A.J., S.C.H., Q.W., K.W., S.E.N., M.Y.D.), Cleveland Clinic, OH.,Cleveland Clinic Coordinating Center for Clinical Research Heart Vascular and Thoracic Institute (P.C.C., W.A.J., S.C.H., Q.W., K.W., S.E.N., M.Y.D.), Cleveland Clinic, OH
| | - Jeffrey B Geske
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (J.B.G.)
| | - Anjali Owens
- Division of Cardiology, University of Pennsylvania (A.O.)
| | - Wael A Jaber
- Department of Cardiovascular Medicine (P.C.C., W.A.J., S.C.H., Q.W., K.W., S.E.N., M.Y.D.), Cleveland Clinic, OH.,Cleveland Clinic Coordinating Center for Clinical Research Heart Vascular and Thoracic Institute (P.C.C., W.A.J., S.C.H., Q.W., K.W., S.E.N., M.Y.D.), Cleveland Clinic, OH
| | - Serge C Harb
- Department of Cardiovascular Medicine (P.C.C., W.A.J., S.C.H., Q.W., K.W., S.E.N., M.Y.D.), Cleveland Clinic, OH.,Cleveland Clinic Coordinating Center for Clinical Research Heart Vascular and Thoracic Institute (P.C.C., W.A.J., S.C.H., Q.W., K.W., S.E.N., M.Y.D.), Cleveland Clinic, OH
| | - Sara Saberi
- Department of Internal Medicine, University of Michigan, Ann Arbor (S.S.)
| | - Andrew Wang
- Department of Cardiology, Duke University, Durham, NC (A.W.)
| | - Mark Sherrid
- Department of Cardiology, New York University (M.S.)
| | - Srihari S Naidu
- Department of Cardiology, Westchester Medical Center, NY (S.S.N.)
| | - Hartzell Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN (H.S.)
| | - Nicholas G Smedira
- Department of Cardiothoracic Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, OH (N.G.S.).,Hypertrophic Cardiomyopathy Center, Cleveland Clinic, OH (N.G.S., M.Y.D.)
| | - Qiuqing Wang
- Department of Cardiovascular Medicine (P.C.C., W.A.J., S.C.H., Q.W., K.W., S.E.N., M.Y.D.), Cleveland Clinic, OH.,Cleveland Clinic Coordinating Center for Clinical Research Heart Vascular and Thoracic Institute (P.C.C., W.A.J., S.C.H., Q.W., K.W., S.E.N., M.Y.D.), Cleveland Clinic, OH
| | - Kathy Wolski
- Department of Cardiovascular Medicine (P.C.C., W.A.J., S.C.H., Q.W., K.W., S.E.N., M.Y.D.), Cleveland Clinic, OH.,Cleveland Clinic Coordinating Center for Clinical Research Heart Vascular and Thoracic Institute (P.C.C., W.A.J., S.C.H., Q.W., K.W., S.E.N., M.Y.D.), Cleveland Clinic, OH
| | - Kathy L Lampl
- MyoKardia, Inc, a wholly-owned subsidiary of Bristol Myers Squibb, Brisbane, CA (K.L.L., A.J.S.)
| | - Amy J Sehnert
- MyoKardia, Inc, a wholly-owned subsidiary of Bristol Myers Squibb, Brisbane, CA (K.L.L., A.J.S.)
| | - Steven E Nissen
- Department of Cardiovascular Medicine (P.C.C., W.A.J., S.C.H., Q.W., K.W., S.E.N., M.Y.D.), Cleveland Clinic, OH.,Cleveland Clinic Coordinating Center for Clinical Research Heart Vascular and Thoracic Institute (P.C.C., W.A.J., S.C.H., Q.W., K.W., S.E.N., M.Y.D.), Cleveland Clinic, OH
| | - Milind Y Desai
- Department of Cardiovascular Medicine (P.C.C., W.A.J., S.C.H., Q.W., K.W., S.E.N., M.Y.D.), Cleveland Clinic, OH.,Cleveland Clinic Coordinating Center for Clinical Research Heart Vascular and Thoracic Institute (P.C.C., W.A.J., S.C.H., Q.W., K.W., S.E.N., M.Y.D.), Cleveland Clinic, OH.,Hypertrophic Cardiomyopathy Center, Cleveland Clinic, OH (N.G.S., M.Y.D.)
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12
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Abraham T, Sehnert AJ, Anderson W, Landis J, Li W, Kurio G, Olivotto I. Mavacamten induces a clinical, hemodynamic, and biomarker response beyond the primary endpoint in EXPLORER-HCM: results from a post hoc machine learning analysis. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Introduction
Mavacamten, a first-in-class selective inhibitor of cardiac myosin, was demonstrated in EXPLORER-HCM (NCT03470545) to be superior to placebo in achieving a primary endpoint of either (1) a ≥1.5 mL/kg/min increase in peak oxygen consumption (pVO2) and at least one New York Heart Association (NYHA) class reduction, or (2) a ≥3.0 mL/kg/min pVO2 increase without NYHA class worsening, in adults with obstructive hypertrophic cardiomyopathy (oHCM). However, the observed benefits of mavacamten were broader than the primary endpoint, suggesting a complex effect of the drug beyond improvements in these two parameters.
Purpose
A post hoc investigation of mavacamten clinical effects beyond the primary endpoint of EXPLORER-HCM.
Methods
EXPLORER data at week 30 were analyzed to evaluate improvements from baseline in primary (specified above), secondary (e.g. postexercise left ventricular outflow tract gradient and Kansas City Cardiomyopathy Questionnaire-Clinical Summary Score) and exploratory endpoints (e.g. circulating NT-ProBNP and cardiac Troponin I). Responses were classified as improved or not improved based on published thresholds, clinical standards and analyses of the EXPLORER data. Patients were grouped according to their improvement status using unsupervised hierarchical clustering.
Results
The cluster analysis resulted in four main groups with the following trends (Table); Group 1 = patients who met the primary endpoint and showed improvement in secondary/exploratory endpoints; Group 2 = patients with improvement in secondary/exploratory endpoints who did not meet the primary endpoint; Group 3 = patients who met the primary endpoint without substantial secondary/exploratory endpoint responses; Group 4 = patients without appreciable improvement in any endpoint. A substantially larger proportion of patients in Group 1 received mavacamten compared with placebo (88% vs. 12%, respectively). A similar trend was observed in Group 2 patients who exhibited improvements in secondary/exploratory endpoints (85% mavacamten vs. 15% placebo). Group 3 consisted predominantly of placebo-treated patients who met the primary endpoint but had negligible responses to secondary/exploratory endpoints (5% mavacamten vs. 95% placebo). Group 4 consisted predominantly of placebo-treated patients without appreciable clinically relevant responses from this analysis (10% mavacamten vs. 90% placebo).
Conclusions
Mavacamten was associated with clinical improvements beyond the primary endpoint of EXPLORER-HCM and was predominantly accompanied by amelioration of other measures associated with oHCM pathophysiology. In contrast, most placebo-treated patients who met the primary endpoint did not exhibit improvement in the underlying pathophysiology. These findings suggest a potential underestimation of mavacamten clinical impact based on the primary endpoint and prompt a deeper examination of mavacamten efficacy in patients with oHCM based on other clinically relevant endpoints.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): MyoKardia, Inc., a wholly owned subsidiary of Bristol Myers Squibb
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Affiliation(s)
- T Abraham
- University of California San Francisco , San Francisco , United States of America
| | - A J Sehnert
- MyoKardia, Inc., a wholly owned subsidiary of Bristol Myers Squibb , Brisbane , United States of America
| | - W Anderson
- Bristol Myers Squibb , Brisbane , United States of America
| | - J Landis
- Bristol Myers Squibb , Princeton , United States of America
| | - W Li
- MyoKardia, Inc., a wholly owned subsidiary of Bristol Myers Squibb , Brisbane , United States of America
| | - G Kurio
- MyoKardia, Inc., a wholly owned subsidiary of Bristol Myers Squibb , Brisbane , United States of America
| | - I Olivotto
- Azienda Ospedaliera Universitaria Careggi and University of Florence , Florence , Italy
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13
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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] [What about the content of this article? (0)] [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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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. Pharmacoecon 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] [What about the content of this article? (0)] [Affiliation(s)] [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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15
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Desai MY, Owens A, Geske JB, Wolski K, Naidu SS, Smedira NG, Cremer PC, Schaff H, McErlean E, Sewell C, Li W, Sterling L, Lampl K, Edelberg JM, Sehnert AJ, Nissen SE. Myosin Inhibition in Patients With Obstructive Hypertrophic Cardiomyopathy Referred for Septal Reduction Therapy. J Am Coll Cardiol 2022; 80:95-108. [PMID: 35798455 DOI: 10.1016/j.jacc.2022.04.048] [Citation(s) in RCA: 109] [Impact Index Per Article: 54.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 04/08/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Septal reduction therapy (SRT), surgical myectomy or alcohol ablation, is recommended for obstructive hypertrophic cardiomyopathy (oHCM) patients with intractable symptoms despite maximal medical therapy, but is associated with morbidity and mortality. OBJECTIVES This study sought to determine whether the oral myosin inhibitor mavacamten enables patients to improve sufficiently to no longer meet guideline criteria or choose to not undergo SRT. METHODS Patients with left ventricular (LV) outflow tract (LVOT) gradient ≥50 mm Hg at rest/provocation who met guideline criteria for SRT were randomized, double blind, to mavacamten, 5 mg daily, or placebo, titrated up to 15 mg based on LVOT gradient and LV ejection fraction. The primary endpoint was the composite of the proportion of patients proceeding with SRT or who remained guideline-eligible after 16 weeks' treatment. RESULTS One hundred and twelve oHCM patients were enrolled, mean age 60 ± 12 years, 51% men, 93% New York Heart Association (NYHA) functional class III/IV, with a mean post-exercise LVOT gradient of 84 ± 35.8 mm Hg. After 16 weeks, 43 of 56 placebo patients (76.8%) and 10 of 56 mavacamten patients (17.9%) met guideline criteria or underwent SRT, difference (58.9%; 95% CI: 44.0%-73.9%; P < 0.001). Hierarchical testing of secondary outcomes showed significant differences (P < 0.001) favoring mavacamten, mean differences in post-exercise peak LVOT gradient -37.2 mm Hg; ≥1 NYHA functional class improvement 41.1%; improvement in patient-reported outcome 9.4 points; and NT-proBNP and cardiac troponin I between-groups geometric mean ratio 0.33 and 0.53. CONCLUSIONS In oHCM patients with intractable symptoms, mavacamten significantly reduced the fraction of patients meeting guideline criteria for SRT after 16 weeks. Long-term freedom from SRT remains to be determined. (A Study to Evaluate Mavacamten in Adults With Symptomatic Obstructive HCM Who Are Eligible for Septal Reduction Therapy [VALOR-HCM]; NCT04349072).
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Affiliation(s)
- Milind Y Desai
- Hypertrophic Cardiomyopathy Center, Cleveland Clinic, Cleveland, Ohio, USA; Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA; Cleveland Clinic Coordinating Center for Clinical Research, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Anjali Owens
- Division of Cardiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jeffrey B Geske
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Kathy Wolski
- Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA; Cleveland Clinic Coordinating Center for Clinical Research, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Srihari S Naidu
- Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | - Nicholas G Smedira
- Hypertrophic Cardiomyopathy Center, Cleveland Clinic, Cleveland, Ohio, USA; Department of Cardiothoracic Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Paul C Cremer
- Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA; Cleveland Clinic Coordinating Center for Clinical Research, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Hartzell Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Ellen McErlean
- Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA; Cleveland Clinic Coordinating Center for Clinical Research, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Christina Sewell
- Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA; Cleveland Clinic Coordinating Center for Clinical Research, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Wanying Li
- MyoKardia, Inc, a wholly owned subsidiary of Bristol Myers Squibb, Brisbane, California, USA
| | - Lulu Sterling
- MyoKardia, Inc, a wholly owned subsidiary of Bristol Myers Squibb, Brisbane, California, USA
| | - Kathy Lampl
- MyoKardia, Inc, a wholly owned subsidiary of Bristol Myers Squibb, Brisbane, California, USA
| | - Jay M Edelberg
- MyoKardia, Inc, a wholly owned subsidiary of Bristol Myers Squibb, Brisbane, California, USA
| | - Amy J Sehnert
- MyoKardia, Inc, a wholly owned subsidiary of Bristol Myers Squibb, Brisbane, California, USA
| | - Steven E Nissen
- Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA; Cleveland Clinic Coordinating Center for Clinical Research, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA.
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16
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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. Pharmacoecon 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] [What about the content of this article? (0)] [Affiliation(s)] [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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Edelberg JM, Sehnert AJ, Mealiffe ME, Del Rio CL, McDowell R. The Impact of Mavacamten on the Pathophysiology of Hypertrophic Cardiomyopathy: A Narrative Review. Am J Cardiovasc Drugs 2022; 22:497-510. [PMID: 35435607 PMCID: PMC9467968 DOI: 10.1007/s40256-022-00532-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/24/2022] [Indexed: 11/25/2022]
Abstract
Hypertrophic cardiomyopathy (HCM) is a chronic, progressive disease of the cardiomyocyte with a diverse and heterogeneous clinical presentation and course. This diversity and heterogeneity have added to the complexity of modeling the pathophysiological pathways that contribute to the disease burden. The development of novel therapeutic approaches targeting precise mechanisms within the underlying biology of HCM provides a tool to model and test these pathways. Here, we integrate the results of clinical observations with mavacamten, an allosteric, selective, and reversible inhibitor of cardiac myosin, the motor unit of the sarcomere, to develop an integrated pathophysiological pathway model of HCM, confirming the key role of excess sarcomeric activity. This model may serve as a foundation to understand the role of HCM pathophysiological pathways in the clinical presentation of the disease, and how a targeted therapeutic intervention capable of normalizing sarcomeric activity and repopulating low-energy utilization states may reduce the impact of these pathways in HCM and potentially related disease states.
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Affiliation(s)
- Jay M Edelberg
- Clinical Development, Cardiovascular Global Drug Development, MyoKardia, Inc., A Wholly Owned Subsidiary of Bristol Myers Squibb, Brisbane, CA, USA
| | - Amy J Sehnert
- Clinical Development, Cardiovascular Global Drug Development, MyoKardia, Inc., A Wholly Owned Subsidiary of Bristol Myers Squibb, Brisbane, CA, USA
| | - Matthew E Mealiffe
- Early Clinical Development, MyoKardia, Inc., A Wholly Owned Subsidiary of Bristol Myers Squibb, Brisbane, CA, USA
| | - Carlos L Del Rio
- Clinical Development, Cardiovascular Global Drug Development, MyoKardia, Inc., A Wholly Owned Subsidiary of Bristol Myers Squibb, Brisbane, CA, USA
| | - Robert McDowell
- Research & Early Development, MyoKardia, Inc., A Wholly Owned Subsidiary of Bristol Myers Squibb, 1000 Sierra Point Parkway, Brisbane, CA, 94005, USA.
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18
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Tison GH, Siontis KC, Abreau S, Attia Z, Agarwal P, Balasubramanyam A, Li Y, Sehnert AJ, Edelberg JM, Friedman PA, Olgin JE, Noseworthy PA. Assessment of Disease Status and Treatment Response With Artificial Intelligence-Enhanced Electrocardiography in Obstructive Hypertrophic Cardiomyopathy. J Am Coll Cardiol 2022; 79:1032-1034. [PMID: 35272798 PMCID: PMC10101773 DOI: 10.1016/j.jacc.2022.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 12/08/2021] [Accepted: 01/10/2022] [Indexed: 01/27/2023]
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19
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Hegde SM, Lester SJ, Solomon SD, Michels M, Elliott PM, Nagueh SF, Choudhury L, Zemanek D, Zwas DR, Jacoby D, Wang A, Ho CY, Li W, Sehnert AJ, Olivotto I, Abraham TP. Effect of Mavacamten on Echocardiographic Features in Symptomatic Patients With Obstructive Hypertrophic Cardiomyopathy. J Am Coll Cardiol 2021; 78:2518-2532. [PMID: 34915982 DOI: 10.1016/j.jacc.2021.09.1381] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 08/27/2021] [Accepted: 09/28/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND EXPLORER-HCM (Clinical Study to Evaluate Mavacamten [MYK-461] in Adults With Symptomatic Obstructive Hypertrophic Cardiomyopathy) demonstrated that mavacamten, a cardiac myosin inhibitor, improves symptoms, exercise capacity, and left ventricular outflow tract (LVOT) obstruction in patients with obstructive hypertrophic cardiomyopathy (oHCM). OBJECTIVES The purpose of this study was to evaluate mavacamten's effect on measures of cardiac structure and function and its association with changes in other clinical measures. METHODS Key echocardiographic parameters from serial echocardiograms over 30 weeks from 251 symptomatic oHCM patients (mavacamten [n = 123], placebo [n = 128]) were assessed in a core laboratory. RESULTS More patients on mavacamten (80.9%; n = 76 of 94) vs placebo (34.0%; n = 33 of 97) showed complete resolution of mitral valve systolic anterior motion after 30 weeks (difference, 46.8%; P < 0.0001). Mavacamten also improved measures of diastolic function vs placebo, including left atrial volume index (LAVI) (mean ± SD baseline: 40 ± 12 mL/m2 vs 41 ± 14 mL/m2; mean change from baseline of -7.5 mL/m2 [95% CI: -9.0 to -6.1 mL/m2] vs -0.09 mL/m2 [95% CI: -1.6 to 1.5 mL/m2]; P < 0.0001) and lateral E/e' (baseline, 15 ± 6 vs 15 ± 8; change of -3.8 [95% CI: -4.7 to -2.8] vs 0.04 [95% CI: -0.9 to 1.0]; P < 0.0001). Among mavacamten-treated patients, improvement in resting, Valsalva, and post-exercise LVOT gradients, LAVI, and lateral E/e' was associated with reduction in N-terminal pro-B-type natriuretic peptide (P ≤ 0.03 for all). Reduction in LAVI was associated with improved peak exercise oxygen consumption (P = 0.04). CONCLUSIONS Mavacamten significantly improved measures of left ventricular diastolic function and systolic anterior motion. Improvement in LVOT obstruction, LAVI, and E/e' was associated with reduction in a biomarker of myocardial wall stress (N-terminal pro-B-type natriuretic peptide). These findings demonstrate improvement in important markers of the pathophysiology of oHCM with mavacamten. (Clinical Study to Evaluate Mavacamten [MYK-461] in Adults With Symptomatic Obstructive Hypertrophic Cardiomyopathy; NCT03470545).
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Affiliation(s)
- Sheila M Hegde
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.
| | - Steven J Lester
- Department of Cardiovascular Diseases, Mayo Clinic, Phoenix, Arizona, USA
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michelle Michels
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Perry M Elliott
- Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Sherif F Nagueh
- Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Lubna Choudhury
- Bluhm Cardiovascular Institute, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - David Zemanek
- 2nd Department of Internal Medicine-Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Donna R Zwas
- Heart Institute, Hadassah University Medical Center, Jerusalem, Israel
| | - Daniel Jacoby
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University, New Haven, Connecticut, USA
| | - Andrew Wang
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Carolyn Y Ho
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Wanying Li
- MyoKardia, Inc, a wholly owned subsidiary of Bristol Myers Squibb, Brisbane, California, USA
| | - Amy J Sehnert
- MyoKardia, Inc, a wholly owned subsidiary of Bristol Myers Squibb, Brisbane, California, USA
| | - Iacopo Olivotto
- Cardiomyopathy Unit, Azienda Ospedaliera Universitaria Careggi and the University of Florence, Florence, Italy
| | - Theodore P Abraham
- UCSF HCM Center of Excellence, University of California San Francisco, San Francisco, California, 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: 81] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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21
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Rader F, Choudhury L, Saberi S, Fermin D, Wheeler MT, Abraham TP, Oreziak A, Garcia-Pavia P, Zwas D, Sehnert AJ, Balaratnam G, Ma G, Olivotto I. LONG-TERM SAFETY OF MAVACAMTEN IN PATIENTS WITH OBSTRUCTIVE HYPERTROPHIC CARDIOMYOPATHY: INTERIM RESULTS OF THE MAVA-LONG TERM EXTENSION (LTE) STUDY. J Am Coll Cardiol 2021. [DOI: 10.1016/s0735-1097(21)01891-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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22
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Ho CY, Mealiffe ME, Bach RG, Bhattacharya M, Choudhury L, Edelberg JM, Hegde SM, Jacoby D, Lakdawala NK, Lester SJ, Ma Y, Marian AJ, Nagueh SF, Owens A, Rader F, Saberi S, Sehnert AJ, Sherrid MV, Solomon SD, Wang A, Wever-Pinzon O, Wong TC, Heitner SB. Evaluation of Mavacamten in Symptomatic Patients With Nonobstructive Hypertrophic Cardiomyopathy. J Am Coll Cardiol 2021; 75:2649-2660. [PMID: 32466879 DOI: 10.1016/j.jacc.2020.03.064] [Citation(s) in RCA: 158] [Impact Index Per Article: 52.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 03/26/2020] [Accepted: 03/29/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Patients with nonobstructive hypertrophic cardiomyopathy (nHCM) often experience a high burden of symptoms; however, there are no proven pharmacological therapies. By altering the contractile mechanics of the cardiomyocyte, myosin inhibitors have the potential to modify pathophysiology and improve symptoms associated with HCM. OBJECTIVES MAVERICK-HCM (Mavacamten in Adults With Symptomatic Non-Obstructive Hypertrophic Cardiomyopathy) explored the safety and efficacy of mavacamten, a first-in-class reversible inhibitor of cardiac-specific myosin, in nHCM. METHODS The MAVERICK-HCM trial was a multicenter, double-blind, placebo-controlled, dose-ranging phase II study in adults with symptomatic nHCM (New York Heart Association functional class II/III), left ventricular ejection fraction (LVEF) ≥55%, and N-terminal pro-B-type natriuretic peptide (NT-proBNP) ≥300 pg/ml. Participants were randomized 1:1:1 to mavacamten at a pharmacokinetic-adjusted dose (targeting plasma levels of 200 or 500 ng/ml), or placebo for 16 weeks, followed by an 8-week washout. Initial dose was 5 mg daily with 1 dose titration at week 6. RESULTS Fifty-nine participants were randomized (19, 21, 19 patients to 200 ng/ml, 500 ng/ml, placebo, respectively). Their mean age was 54 years, and 58% were women. Serious adverse events occurred in 10% of participants on mavacamten and in 21% participants on placebo. Five participants on mavacamten had reversible reduction in LVEF ≤45%. NT-proBNP geometric mean decreased by 53% in the pooled mavacamten group versus 1% in the placebo group, with geometric mean differences of -435 and -6 pg/ml, respectively (p = 0.0005). Cardiac troponin I (cTnI) geometric mean decreased by 34% in the pooled mavacamten group versus a 4% increase in the placebo group, with geometric mean differences of -0.008 and 0.001 ng/ml, respectively (p = 0.009). CONCLUSIONS Mavacamten, a novel myosin inhibitor, was well tolerated in most subjects with symptomatic nHCM. Furthermore, treatment was associated with a significant reduction in NT-proBNP and cTnI, suggesting improvement in myocardial wall stress. These results set the stage for future studies of mavacamten in this patient population using clinical parameters, including LVEF, to guide dosing. (A Phase 2 Study of Mavacamten in Adults With Symptomatic Non-Obstructive Hypertrophic Cardiomyopathy [MAVERICK-HCM]; NCT03442764).
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Affiliation(s)
- Carolyn Y Ho
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
| | | | - Richard G Bach
- Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri
| | | | - Lubna Choudhury
- Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Chicago, Illinois
| | | | - Sheila M Hegde
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Daniel Jacoby
- Department of Internal Medicine, Section of Cardiovascular Diseases, Yale University School of Medicine, New Haven, Connecticut
| | - Neal K Lakdawala
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Steven J Lester
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, Phoenix, Arizona
| | - Yanfei Ma
- MyoKardia, Inc., Brisbane, California
| | - Ali J Marian
- Center for Cardiovascular Genetics, Institute of Molecular Medicine, University of Texas Health Sciences Center at Houston, Houston, Texas
| | - Sherif F Nagueh
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Anjali Owens
- Heart and Vascular Center, Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Florian Rader
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Sara Saberi
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan
| | | | - Mark V Sherrid
- Hypertrophic Cardiomyopathy Program, New York University School of Medicine, New York, New York
| | - Scott D Solomon
- Department of Internal Medicine, Section of Cardiovascular Diseases, Yale University School of Medicine, New Haven, Connecticut
| | - Andrew Wang
- Duke Cardiology, Duke Health Center at Southpoint, Durham, North Carolina
| | - Omar Wever-Pinzon
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah
| | - Timothy C Wong
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Stephen B Heitner
- Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
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Zaiser E, Sehnert AJ, Duenas A, Saberi S, Brookes E, Reaney M. Patient experiences with hypertrophic cardiomyopathy: a conceptual model of symptoms and impacts on quality of life. J Patient Rep Outcomes 2020; 4:102. [PMID: 33259041 PMCID: PMC7708573 DOI: 10.1186/s41687-020-00269-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 11/18/2020] [Indexed: 01/06/2023] Open
Abstract
Background Hypertrophic cardiomyopathy (HCM) is a primary myocardial disorder defined by left ventricular hypertrophy that cannot be explained by another cardiac or systemic disease. There is a general lack of knowledge about patients’ perspectives on the symptoms and day-to-day limitations they experience as a result of HCM. We therefore sought an in-depth understanding of patients’ experiences of obstructive (oHCM) and nonobstructive (nHCM) forms of the disease, including symptoms and their quality of life impacts, and to develop a conceptual model to capture them. Methods Development of the HCM conceptual model involved a web-based survey to capture patients’ insights, a targeted literature review (which included relevant guidelines and patient advocacy websites), one-to-one interviews with clinical experts, and one-to-one qualitative concept elicitation interviews with patients. Key symptoms and their impacts most important to patients’ experiences were identified and used to develop a conceptual model of the patient experience with HCM. Results The HCM symptoms reported by patient interviewees (n = 27) were largely consistent with findings from the patient web survey (n = 444), literature review, and interviews with three expert clinicians. The symptoms most commonly reported in patient interviews included tiredness (89%), shortness of breath (89%), shortness of breath with physical activity (89%), and dizziness/light-headedness (89%). Other symptoms commonly reported included chest pain (angina) (70%), chest pain (angina) with physical exertion (70%), and palpitations (fluttering or rapid heartbeat) (81%). The most commonly reported impacts of HCM symptoms on patients’ lives included limitations to physical activities (78%), emotional impacts, including feeling anxious or depressed (78%), and impacts on work (63%). Symptoms and impacts were similar for both oHCM and nHCM. Conclusions A conceptual model was developed, which identifies the core symptoms that patients with oHCM and nHCM reported as most frequent and most important: shortness of breath, palpitations, fatigue/tiredness, dizziness/light-headedness, and chest pain, as well as the impacts those symptoms have on patients’ lives. This HCM conceptual model reflecting patients’ experiences and perspectives was used in the development of a patient-reported outcomes instrument for use in clinical trials and it may also help inform the clinical management of HCM.
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Affiliation(s)
| | | | | | - Sara Saberi
- Frankel Cardiovascular Center, University of Michigan Hospital, Michigan Medicine, Ann Arbor, Michigan, USA
| | | | - Matthew Reaney
- IQVIA, 3 Forbury Place, 23 Forbury Road, Reading, RG1 3JH, UK.
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Saberi S, Cardim N, Yamani M, Schulz-Menger J, Li W, Florea V, Sehnert AJ, Kwong RY, Jerosch-Herold M, Masri A, Owens A, Lakdawala NK, Kramer CM, Sherrid M, Seidler T, Wang A, Sedaghat-Hamedani F, Meder B, Havakuk O, Jacoby D. Mavacamten Favorably Impacts Cardiac Structure in Obstructive Hypertrophic Cardiomyopathy: EXPLORER-HCM Cardiac Magnetic Resonance Substudy Analysis. Circulation 2020; 143:606-608. [PMID: 33190524 DOI: 10.1161/circulationaha.120.052359] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Sara Saberi
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Medical School, Ann Arbor (S.S.)
| | - Nuno Cardim
- Department of Cardiology, Cardiovascular MR and CT unit (UNICA), Hospital da Luz, Lisbon, Portugal (N.C.)
| | | | - Jeanette Schulz-Menger
- Charité Medical University Berlin, ECRC and Department of Cardiology, HELIOS Klinik Berlin-Buch, Clinic for Cardiology and Nephrology, DZHK partnersite Berlin, Germany (J.S-M.)
| | - Wanying Li
- MyoKardia, Brisbane, CA (W.L., V.F., A.J.S.)
| | | | | | - Raymond Y Kwong
- Cardiovascular Division, Department of Medicine (R.Y.K., M.J-H.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Michael Jerosch-Herold
- Cardiovascular Division, Department of Medicine (R.Y.K., M.J-H.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ahmad Masri
- Center for Hypertrophic Cardiomyopathy, Knight Cardiovascular Institute, Oregon Health & Science University, Portland (A.M.)
| | - Anjali Owens
- Center for Inherited Cardiac Disease, Division of Cardiovascular Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia (A.O.)
| | - Neal K Lakdawala
- Department of Cardiovascular Medicine (N.K.L.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Christopher M Kramer
- Cardiovascular Division, Department of Medicine, University of Virginia Health System, Charlottesville (C.M.K.)
| | - Mark Sherrid
- Hypertrophic Cardiomyopathy Program, NYU Langone Health, New York (M.S.)
| | - Tim Seidler
- Department of Cardiology and Pulmonology, University Medical Center Göttingen, Germany (T.S.)
| | - Andrew Wang
- Duke Cardiology, Duke Health Center at Southpoint, Durham, NC (A.W.)
| | - Farbod Sedaghat-Hamedani
- Department of Internal Medicine III, Institute for Cardiomyopathies, University of Heidelberg, Germany (F.S.-H., B.M.)
| | - Benjamin Meder
- Department of Internal Medicine III, Institute for Cardiomyopathies, University of Heidelberg, Germany (F.S.-H., B.M.)
| | - Ofer Havakuk
- Department of Cardiology, Tel Aviv Medical Center, affiliated to Sackler School of Medicine, Tel Aviv University, Israel (O.H.)
| | - Daniel Jacoby
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (D.J.)
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Olivotto I, Oreziak A, Barriales-Villa R, Abraham TP, Masri A, Garcia-Pavia P, Saberi S, Lakdawala NK, Wheeler MT, Owens A, Kubanek M, Wojakowski W, Jensen MK, Gimeno-Blanes J, Afshar K, Myers J, Hegde SM, Solomon SD, Sehnert AJ, Zhang D, Li W, Bhattacharya M, Edelberg JM, Waldman CB, Lester SJ, Wang A, Ho CY, Jacoby D. Mavacamten for treatment of symptomatic obstructive hypertrophic cardiomyopathy (EXPLORER-HCM): a randomised, double-blind, placebo-controlled, phase 3 trial. Lancet 2020; 396:759-769. [PMID: 32871100 DOI: 10.1016/s0140-6736(20)31792-x] [Citation(s) in RCA: 420] [Impact Index Per Article: 105.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 08/02/2020] [Accepted: 08/04/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND Cardiac muscle hypercontractility is a key pathophysiological abnormality in hypertrophic cardiomyopathy, and a major determinant of dynamic left ventricular outflow tract (LVOT) obstruction. Available pharmacological options for hypertrophic cardiomyopathy are inadequate or poorly tolerated and are not disease-specific. We aimed to assess the efficacy and safety of mavacamten, a first-in-class cardiac myosin inhibitor, in symptomatic obstructive hypertrophic cardiomyopathy. METHODS In this phase 3, randomised, double-blind, placebo-controlled trial (EXPLORER-HCM) in 68 clinical cardiovascular centres in 13 countries, patients with hypertrophic cardiomyopathy with an LVOT gradient of 50 mm Hg or greater and New York Heart Association (NYHA) class II-III symptoms were assigned (1:1) to receive mavacamten (starting at 5 mg) or placebo for 30 weeks. Visits for assessment of patient status occurred every 2-4 weeks. Serial evaluations included echocardiogram, electrocardiogram, and blood collection for laboratory tests and mavacamten plasma concentration. The primary endpoint was a 1·5 mL/kg per min or greater increase in peak oxygen consumption (pVO2) and at least one NYHA class reduction or a 3·0 mL/kg per min or greater pVO2 increase without NYHA class worsening. Secondary endpoints assessed changes in post-exercise LVOT gradient, pVO2, NYHA class, Kansas City Cardiomyopathy Questionnaire-Clinical Summary Score (KCCQ-CSS), and Hypertrophic Cardiomyopathy Symptom Questionnaire Shortness-of-Breath subscore (HCMSQ-SoB). 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 to mavacamten (n=123 [49%]) or placebo (n=128 [51%]). 45 (37%) of 123 patients on mavacamten versus 22 (17%) of 128 on placebo met the primary endpoint (difference +19·4%, 95% CI 8·7 to 30·1; p=0·0005). Patients on mavacamten had greater reductions than those on placebo in post-exercise LVOT gradient (-36 mm Hg, 95% CI -43·2 to -28·1; p<0·0001), greater increase in pVO2 (+1·4 mL/kg per min, 0·6 to 2·1; p=0·0006), and improved symptom scores (KCCQ-CSS +9·1, 5·5 to 12·7; HCMSQ-SoB -1·8, -2·4 to -1·2; p<0·0001). 34% more patients in the mavacamten group improved by at least one NYHA class (80 of 123 patients in the mavacamten group vs 40 of 128 patients in the placebo group; 95% CI 22·2 to 45·4; p<0·0001). Safety and tolerability were similar to placebo. Treatment-emergent adverse events were generally mild. One patient died by sudden death in the placebo group. INTERPRETATION Treatment with mavacamten improved exercise capacity, LVOT obstruction, NYHA functional class, and health status in patients with obstructive hypertrophic cardiomyopathy. The results of this pivotal trial highlight the benefits of disease-specific treatment for this condition. FUNDING MyoKardia.
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Affiliation(s)
- Iacopo Olivotto
- Cardiomyopathy Unit, Azienda Ospedaliera Universitaria Careggi, Florence, Italy; University of Florence, Florence, Italy.
| | - Artur Oreziak
- 1st Department of Arrhythmia, National Institute of Cardiology, Warsaw, Poland
| | - Roberto Barriales-Villa
- Unidad de Cardiopatías Familiares, Instituto de Investigación Biomédica de A Coruña, A Coruña, Spain; Complexo Hospitalario Universitario de A Coruña, A Coruña, Spain; Servizo Galego de Saúde, A Coruña, Spain; Universidade da Coruña, A Coruña, Spain; Centro de Investigación Biomédica en Red, Madrid, Spain
| | - Theodore P Abraham
- Division of Cardiology, University of California San Francisco, San Francisco, CA, USA
| | - Ahmad Masri
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Pablo Garcia-Pavia
- Centro de Investigación Biomédica en Red, Madrid, Spain; Department of Cardiology, Hospital Universitario Puerta de Hierro, Madrid, Spain; Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain
| | - Sara Saberi
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Neal K Lakdawala
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Matthew T Wheeler
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Anjali Owens
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Milos Kubanek
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Wojciech Wojakowski
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Morten K Jensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Juan Gimeno-Blanes
- Inherited Cardiac Disease Unit, University Hospital Virgen de la Arrixaca, Murcia, Spain
| | - Kia Afshar
- Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, UT, USA
| | - Jonathan Myers
- Division of Cardiology, Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA, USA; Stanford University, Palo Alto, CA, USA
| | - Sheila M Hegde
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | | | | | | | | | | | | | - Steven J Lester
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Andrew Wang
- Duke University School of Medicine, Durham, NC, USA
| | - Carolyn Y Ho
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Daniel Jacoby
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University, New Haven, CT, USA
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26
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Ho CY, Olivotto I, Jacoby D, Lester SJ, Roe M, Wang A, Waldman CB, Zhang D, Sehnert AJ, Heitner SB. Study Design and Rationale of EXPLORER-HCM: Evaluation of Mavacamten in Adults With Symptomatic Obstructive Hypertrophic Cardiomyopathy. Circ Heart Fail 2020; 13:e006853. [PMID: 32498620 DOI: 10.1161/circheartfailure.120.006853] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Obstructive hypertrophic cardiomyopathy (oHCM) is characterized by unexplained left ventricular (LV) hypertrophy associated with dynamic LV outflow tract obstruction. Current medical therapies are nonspecific and have limited efficacy in relieving symptoms. Mavacamten is a first-in-class targeted inhibitor of cardiac myosin, which has been shown to reduce LV outflow tract obstruction, improve exercise capacity, and relieve symptoms of oHCM in the PIONEER-HCM phase 2 study. METHODS EXPLORER-HCM is a multicenter, phase 3, randomized, double-blind, placebo-controlled trial to investigate the efficacy and safety of mavacamten in treating symptomatic oHCM. Eligible adults with oHCM and New York Heart Association Functional Class II or III are randomized 1:1 to receive once-daily, oral mavacamten, or matching placebo for 30 weeks. The primary composite functional end point is clinical response at week 30 compared to baseline defined as either (1) an increase in peak oxygen consumption ≥1.5 mL/kg/min and reduction of at least one New York Heart Association class; or (2) an improvement of ≥3.0 mL/kg/min in peak oxygen consumption with no worsening of New York Heart Association class. Secondary end points include change in postexercise LV outflow tract gradient, New York Heart Association class, peak oxygen consumption, and patient-reported outcomes assessed by the Kansas City Cardiomyopathy Questionnaire and a novel HCM-specific instrument. Exploratory end points aim to characterize the effect of mavacamten on multiple aspects of oHCM pathophysiology. CONCLUSIONS EXPLORER-HCM is a phase 3 trial in oHCM testing a first-in-class, targeted strategy of myosin inhibition to improve symptom burden and exercise capacity through reducing LV outflow tract obstruction. Results of this trial will provide evidence to support the first disease-specific treatment for HCM. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03470545.
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Affiliation(s)
- Carolyn Y Ho
- Brigham and Women's Hospital, Boston, MA (C.Y.H.)
| | | | | | | | - Matthew Roe
- Duke Clinical Research Institute, Durham, NC (M.R.)
| | - Andrew Wang
- Duke University School of Medicine, Durham, NC (A.W.)
| | | | | | | | - Stephen B Heitner
- Knight Cardiovascular Institute, Oregon Health and Sciences University, Portland (S.B.H.)
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27
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Wang A, Heitner SB, Jacoby D, Lester S, Fang L, Balaratnam G, Sehnert AJ. 228Long-term safety and effectiveness of mavacamten in symptomatic obstructive hypertrophic cardiomyopathy (oHCM) patients (pts): update from PIONEER open-label extension (PIONEER-OLE) study. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz747.0063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
In a phase 2 PIONEER-HCM study, pts with symptomatic, obstructive hypertrophic cardiomyopathy (oHCM) showed improvement in left ventricular outflow tract (LVOT) obstruction, exercise capacity, and symptoms after 12 wk of treatment with the novel myosin modulator, mavacamten (Mava).
Purpose
To examine the long-term safety and effectiveness of Mava in PIONEER-OLE study
Methods
PIONEER-OLE (NCT03496168) is an ongoing 2-y multicenter study for adults with symptomatic oHCM who completed PIONEER-HCM (NCT02842242). The starting dose of Mava is 5 mg/d with titration at wk 6 to an individualized therapeutic dose (5, 10, or 15 mg). Evaluations are at wk 4, 6, 8, 12 and every 12 wk thereafter to monitor LV ejection fraction (LVEF), LVOT gradient, New York Heart Association (NYHA) class, NT-proBNP, drug concentration, and safety.
Results
13 pts (mean age, 57.8 y; 9 male; 12 on beta-blockers) were enrolled. Mean baseline LVOT obstruction and LVEF, and wk 12 changes from baseline, were similar to those in PIONEER-HCM (Table). Mava significantly reduced resting and provoked LVOT gradients and NT-proBNP at wk 12 and 24 compared with baseline (P<0.004). Of 10 pts who reached wk 24, 8 reported improvement in NYHA class (1 improved Class III to II; 7 improved Class II to I), and 2 pts remained Class II. Mava has been well tolerated up to 40 wk; 31 adverse events (AEs; 22 mild, 5 moderate) were reported in 8 pts; 1 pt had 3 severe and 1 serious AE (cholangiocarcinoma); all AEs were unrelated to study drug.
Results from PIONEER-OLE Parameter PIONEER-HCMa PIONEER-OLE Baseline Wk 12 Baselineb Wk 12 Change at Wk 12 Wilcoxon Signed Wk 24 Change at Wk 24 Wilcoxon Signed Mean ± SD Mean ± SD Mean ± SD Mean ± SD Mean ± SD Rank Mean ± SD Mean ± SD Rank (n=13) (n=13) (n=13)c (n=12)c (n=12)c P value (n=10)c (n=10)c P value LVOT Rest gradient, mmHg 69.7±53.9 27.8±31.3 67.3±42.8 12.0±5.4 −57.9±43.2 0.0005 10.5±4.8 −66.6±42.4 0.0020 LVOT Valsalva gradient, mmHg 93.7±55.6 36.8±37.5 89.9±30.7 (n=12) 23.6±20.0 −66.4±35.3 (n=11) 0.0020 21.1±11.5 −67.3±33.5 (n=9) 0.0039 LVEF, % 73.0±5.6 64.6±10.5 72.0±4.9 67.6±7.2 −4.4±5.5 0.0269 68.2±6.5 −3.2±3.3 0.0195 NT-proBNP, pg/mL 1601.3±2782 (n=12) 684±980 1836±2886 181±211 −1759±2789 0.0005 170±225 −2128±3104 0.0039 Data extraction date January 24, 2019. aCombined results shown for pts from PIONEER-HCM originally in cohort A (n=5) and cohort B (n=8). bBaseline in PIONEER-OLE occurred 6–18 months after completion of PIONEER-HCM. cNumber of pts with data available for analysis, unless otherwise specified.
Conclusion
Despite management with current therapies, pts enrolled in PIONEER-OLE with similar levels of obstruction and hypercontractility as in PIONEER-HCM. In this longest observation period, Mava significantly reduced obstruction (LVOT gradient) in pts with oHCM beyond standard HCM therapy, while maintaining normal LVEF and improving symptoms.
Acknowledgement/Funding
MyoKardia
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Affiliation(s)
- A Wang
- Duke Health Center at Southpoint, Durham, United States of America
| | - S B Heitner
- Oregon Health & Science University, Knight Cardiovascular Institute, Portland, United States of America
| | - D Jacoby
- Yale University School of Medicine, New Haven, United States of America
| | - S Lester
- Mayo Clinic Arizona, Phoenix, United States of America
| | - L Fang
- MyoKardia, Inc., South San Francisco, United States of America
| | - G Balaratnam
- MyoKardia, Inc., South San Francisco, United States of America
| | - A J Sehnert
- MyoKardia, Inc., South San Francisco, United States of America
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Heitner SB, Jacoby D, Lester SJ, Owens A, Wang A, Zhang D, Lambing J, Lee J, Semigran M, Sehnert AJ. Mavacamten Treatment for Obstructive Hypertrophic Cardiomyopathy: A Clinical Trial. Ann Intern Med 2019; 170:741-748. [PMID: 31035291 DOI: 10.7326/m18-3016] [Citation(s) in RCA: 163] [Impact Index Per Article: 32.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Mavacamten, an orally administered, small-molecule modulator of cardiac myosin, targets underlying biomechanical abnormalities in obstructive hypertrophic cardiomyopathy (oHCM). OBJECTIVE To characterize the effect of mavacamten on left ventricular outflow tract (LVOT) gradient. DESIGN Open-label, nonrandomized, phase 2 trial. (ClinicalTrials.gov: NCT02842242). SETTING 5 academic centers. PARTICIPANTS 21 symptomatic patients with oHCM. INTERVENTION Patients in cohort A received mavacamten, 10 to 20 mg/d, without background medications. Those in cohort B received mavacamten, 2 to 5 mg/d, with β-blockers allowed. MEASUREMENTS The primary end point was change in postexercise LVOT gradient at 12 weeks. Secondary end points included changes in peak oxygen consumption (pVO2), resting and Valsalva LVOT gradients, left ventricular ejection fraction (LVEF), and numerical rating scale dyspnea score. RESULTS In cohort A, mavacamten reduced mean postexercise LVOT gradient from 103 mm Hg (SD, 50) at baseline to 19 mm Hg (SD, 13) at 12 weeks (mean change, -89.5 mm Hg [95% CI, -138.3 to -40.7 mm Hg]; P = 0.008). Resting LVEF was also reduced (mean change, -15% [CI, -23% to -6%]). Peak VO2 increased by a mean of 3.5 mL/kg/min (CI, 1.2 to 5.9 mL/kg/min). In cohort B, the mean postexercise LVOT gradient decreased from 86 mm Hg (SD, 43) to 64 mm Hg (SD, 26) (mean change, -25.0 mm Hg [CI, -47.1 to -3.0 mm Hg]; P = 0.020), and mean change in resting LVEF was -6% (CI, -10% to -1%). Peak VO2 increased by a mean of 1.7 mL/kg/min (SD, 2.3) (CI, 0.03 to 3.3 mL/kg/min). Dyspnea scores improved in both cohorts. Mavacamten was well tolerated, with mostly mild (80%), moderate (19%), and unrelated (79%) adverse events. The most common adverse events definitely or possibly related to mavacamten were decreased LVEF at higher plasma concentrations and atrial fibrillation. LIMITATION Small size; open-label design. CONCLUSION Mavacamten can reduce LVOT obstruction and improve exercise capacity and symptoms in patients with oHCM. PRIMARY FUNDING SOURCE MyoKardia.
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Affiliation(s)
| | - Daniel Jacoby
- Yale New Haven Hospital, New Haven, Connecticut (D.J.)
| | | | - Anjali Owens
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania (A.O.)
| | - Andrew Wang
- Duke University Medical Center, Durham, North Carolina (A.W.)
| | - David Zhang
- MyoKardia, South San Francisco, California (D.Z., J.L., J.L., M.S., A.J.S.)
| | - Joseph Lambing
- MyoKardia, South San Francisco, California (D.Z., J.L., J.L., M.S., A.J.S.)
| | - June Lee
- MyoKardia, South San Francisco, California (D.Z., J.L., J.L., M.S., A.J.S.)
| | - Marc Semigran
- MyoKardia, South San Francisco, California (D.Z., J.L., J.L., M.S., A.J.S.)
| | - Amy J Sehnert
- MyoKardia, South San Francisco, California (D.Z., J.L., J.L., M.S., A.J.S.)
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29
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Li BT, Janku F, Jung B, Hou C, Madwani K, Alden R, Razavi P, Reis-Filho JS, Shen R, Isbell JM, Blocker AW, Eattock N, Gnerre S, Satya RV, Xu H, Zhao C, Hall MP, Hu Y, Sehnert AJ, Brown D, Ladanyi M, Rudin CM, Hunkapiller N, Feeney N, Mills GB, Paweletz CP, Janne PA, Solit DB, Riely GJ, Aravanis A, Oxnard GR. Ultra-deep next-generation sequencing of plasma cell-free DNA in patients with advanced lung cancers: results from the Actionable Genome Consortium. Ann Oncol 2019; 30:597-603. [PMID: 30891595 PMCID: PMC6503621 DOI: 10.1093/annonc/mdz046] [Citation(s) in RCA: 107] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Noninvasive genotyping using plasma cell-free DNA (cfDNA) has the potential to obviate the need for some invasive biopsies in cancer patients while also elucidating disease heterogeneity. We sought to develop an ultra-deep plasma next-generation sequencing (NGS) assay for patients with non-small-cell lung cancers (NSCLC) that could detect targetable oncogenic drivers and resistance mutations in patients where tissue biopsy failed to identify an actionable alteration. PATIENTS AND METHODS Plasma was prospectively collected from patients with advanced, progressive NSCLC. We carried out ultra-deep NGS using cfDNA extracted from plasma and matched white blood cells using a hybrid capture panel covering 37 lung cancer-related genes sequenced to 50 000× raw target coverage filtering somatic mutations attributable to clonal hematopoiesis. Clinical sensitivity and specificity for plasma detection of known oncogenic drivers were calculated and compared with tissue genotyping results. Orthogonal ddPCR validation was carried out in a subset of cases. RESULTS In 127 assessable patients, plasma NGS detected driver mutations with variant allele fractions ranging from 0.14% to 52%. Plasma ddPCR for EGFR or KRAS mutations revealed findings nearly identical to those of plasma NGS in 21 of 22 patients, with high concordance of variant allele fraction (r = 0.98). Blinded to tissue genotype, plasma NGS sensitivity for de novo plasma detection of known oncogenic drivers was 75% (68/91). Specificity of plasma NGS in those who were driver-negative by tissue NGS was 100% (19/19). In 17 patients with tumor tissue deemed insufficient for genotyping, plasma NGS identified four KRAS mutations. In 23 EGFR mutant cases with acquired resistance to targeted therapy, plasma NGS detected potential resistance mechanisms, including EGFR T790M and C797S mutations and ERBB2 amplification. CONCLUSIONS Ultra-deep plasma NGS with clonal hematopoiesis filtering resulted in de novo detection of targetable oncogenic drivers and resistance mechanisms in patients with NSCLC, including when tissue biopsy was inadequate for genotyping.
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Affiliation(s)
- B T Li
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York.
| | - F Janku
- Department of Investigational Cancer Therapeutics, MD Anderson Cancer Center, Houston
| | - B Jung
- Illumina, Inc., San Francisco
| | - C Hou
- Illumina, Inc., San Francisco
| | - K Madwani
- Department of Investigational Cancer Therapeutics, MD Anderson Cancer Center, Houston
| | - R Alden
- Department of Medical Oncology, Lowe Center for Thoracic Oncology, Dana-Farber Cancer Institute, Boston
| | - P Razavi
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York
| | | | - R Shen
- Epidemiology and Biostatistics
| | - J M Isbell
- Surgery, Memorial Sloan Kettering Cancer Center, New York
| | | | | | | | | | - H Xu
- Illumina, Inc., San Francisco
| | - C Zhao
- Illumina, Inc., San Diego
| | | | - Y Hu
- Department of Medical Oncology, Lowe Center for Thoracic Oncology, Dana-Farber Cancer Institute, Boston
| | | | | | | | - C M Rudin
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York
| | | | - N Feeney
- Belfer Center for Applied Cancer Science, Dana-Farber Cancer Institute, Boston
| | - G B Mills
- Department of Investigational Cancer Therapeutics, MD Anderson Cancer Center, Houston
| | - C P Paweletz
- Belfer Center for Applied Cancer Science, Dana-Farber Cancer Institute, Boston
| | - P A Janne
- Department of Medical Oncology, Lowe Center for Thoracic Oncology, Dana-Farber Cancer Institute, Boston; Belfer Center for Applied Cancer Science, Dana-Farber Cancer Institute, Boston
| | - D B Solit
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York; Human Oncology and Pathogenesis Program, Memorial Sloan Cancer Center, New York, USA
| | - G J Riely
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York
| | | | - G R Oxnard
- Department of Medical Oncology, Lowe Center for Thoracic Oncology, Dana-Farber Cancer Institute, Boston
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Bianchi DW, Chudova D, Sehnert AJ, Bhatt S, Murray K, Prosen TL, Garber JE, Wilkins-Haug L, Vora NL, Warsof S, Goldberg J, Ziainia T, Halks-Miller M. Noninvasive Prenatal Testing and Incidental Detection of Occult Maternal Malignancies. JAMA 2015; 314:162-9. [PMID: 26168314 DOI: 10.1001/jama.2015.7120] [Citation(s) in RCA: 273] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
IMPORTANCE Understanding the relationship between aneuploidy detection on noninvasive prenatal testing (NIPT) and occult maternal malignancies may explain results that are discordant with the fetal karyotype and improve maternal clinical care. OBJECTIVE To evaluate massively parallel sequencing data for patterns of copy-number variations that might prospectively identify occult maternal malignancies. DESIGN, SETTING, AND PARTICIPANTS Case series identified from 125,426 samples submitted between February 15, 2012, and September 30, 2014, from asymptomatic pregnant women who underwent plasma cell-free DNA sequencing for clinical prenatal aneuploidy screening. Analyses were conducted in a clinical laboratory that performs DNA sequencing. Among the clinical samples, abnormal results were detected in 3757 (3%); these were reported to the ordering physician with recommendations for further evaluation. EXPOSURES NIPT for fetal aneuploidy screening (chromosomes 13, 18, 21, X, and Y). MAIN OUTCOMES AND MEASURES Detailed genome-wide bioinformatics analysis was performed on available sequencing data from 8 of 10 women with known cancers. Genome-wide copy-number changes in the original NIPT samples and in subsequent serial samples from individual patients when available are reported. Copy-number changes detected in NIPT sequencing data in the known cancer cases were compared with the types of aneuploidies detected in the overall cohort. RESULTS From a cohort of 125,426 NIPT results, 3757 (3%) were positive for 1 or more aneuploidies involving chromosomes 13, 18, 21, X, or Y. From this set of 3757 samples, 10 cases of maternal cancer were identified. Detailed clinical and sequencing data were obtained in 8. Maternal cancers most frequently occurred with the rare NIPT finding of more than 1 aneuploidy detected (7 known cancers among 39 cases of multiple aneuploidies by NIPT, 18% [95% CI, 7.5%-33.5%]). All 8 cases that underwent further bioinformatics analysis showed unique patterns of nonspecific copy-number gains and losses across multiple chromosomes. In 1 case, blood was sampled after completion of treatment for colorectal cancer and the abnormal pattern was no longer evident. CONCLUSIONS AND RELEVANCE In this preliminary study, a small number of cases of occult malignancy were subsequently diagnosed among pregnant women whose noninvasive prenatal testing results showed discordance with the fetal karyotype. The clinical importance of these findings will require further research.
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Affiliation(s)
- Diana W Bianchi
- Mother Infant Research Institute, Tufts Medical Center, Boston, Massachusetts
| | | | | | | | - Kathryn Murray
- Center for Genetics and Maternal Fetal Medicine, Springfield, Oregon
| | - Tracy L Prosen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Minnesota, Minneapolis
| | | | - Louise Wilkins-Haug
- Division of Maternal Fetal Medicine and Reproductive Genetics, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Stephen Warsof
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk
| | - James Goldberg
- San Francisco Perinatal Associates, San Francisco, California
| | - Tina Ziainia
- Sharp Rees-Stealy Medical Group, San Diego, California
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Platt LD, Janicki MB, Prosen T, Goldberg JD, Adashek J, Figueroa R, Rodis J, Liao W, Sehnert AJ, Snyder HL, Warsof SL. Impact of noninvasive prenatal testing in regionally dispersed medical centers in the United States. Am J Obstet Gynecol 2014; 211:368.e1-7. [PMID: 24705127 DOI: 10.1016/j.ajog.2014.03.065] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Revised: 01/17/2014] [Accepted: 03/31/2014] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Noninvasive prenatal testing using cell-free DNA is a new alternative to screen for common fetal aneuploidies. It is not known what impact regional location may play on noninvasive prenatal testing implementation and downstream invasive prenatal procedure use in the United States. STUDY DESIGN Six different regionally based centers collected data on noninvasive prenatal testing indication and results between February and November 2012, as well as their invasive prenatal procedure rates before and after offering noninvasive prenatal testing. Statistical analyses were performed using the 2-proportion Z-test. RESULTS Of 1477 patients who underwent noninvasive prenatal testing; 693 (47%) were from centers in the West; 522 (35.3%) from centers in the East; and 262 (17.7%) from 1 center in the Midwest. Statistically significant differences were observed between West Coast and nonWest Coast sites for gestational age (14.1 weeks; P ≤ .0001). Advanced maternal age (AMA-only) was the most frequent indication in 5 of 6 sites (range, 21.8-62.9%) A total of 98 invasive prenatal procedures performed on 94 (6.4%) patients of which 64 (65.3%) were performed at centers in the West. More invasive procedures were performed following negative noninvasive prenatal testing results (n = 61) than abnormal noninvasive prenatal testing results (n = 30). The overall rate of patients undergoing invasive procedure after an abnormal noninvasive prenatal testing result was 32.6% (30 of 92). All 6 centers reported a decrease in invasive procedure volume after noninvasive prenatal testing introduction. CONCLUSION This study demonstrates differences in clinical implementation of noninvasive prenatal testing across regionally dispersed centers in the United States, suggesting patient demographics and views toward prenatal testing influence use as well as downstream management.
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Affiliation(s)
- Lawrence D Platt
- Center for Fetal Medicine and Women's Ultrasound and the Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles
| | - Mary Beth Janicki
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Saint Francis Hospital and Medical Center, Hartford, CT
| | - Tracy Prosen
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Women's Health, University of Minnesota School of Medicine, Minneapolis, MN
| | - James D Goldberg
- Prenatal Diagnosis Center, San Francisco Perinatal Associates, San Francisco, CA
| | | | - Reinaldo Figueroa
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Saint Francis Hospital and Medical Center, Hartford, CT
| | - John Rodis
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Saint Francis Hospital and Medical Center, Hartford, CT
| | - Wayne Liao
- Department of Clinical Affairs, Illumina, Redwood City, CA
| | - Amy J Sehnert
- Department of Clinical Affairs, Illumina, Redwood City, CA
| | - Holly L Snyder
- Department of Genetic Services, Illumina, Redwood City, CA
| | - Steven L Warsof
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA
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Tiller GE, Kershberg HB, Goff J, Coffeen C, Liao W, Sehnert AJ. Women's views and the impact of noninvasive prenatal testing on procedures in a managed care setting. Prenat Diagn 2014; 35:428-33. [PMID: 25201151 DOI: 10.1002/pd.4495] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 08/28/2014] [Accepted: 09/01/2014] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To prospectively determine the impact of noninvasive prenatal testing (NIPT) on invasive procedure utilization in a managed care setting and to elucidate women's views. METHODS Pregnant women at 10- 20 weeks' gestation with high-risk indications for fetal aneuploidy in the Kaiser Permanente Southern California organization were eligible. Enrolled patients received routine prenatal counseling, completed a questionnaire and were offered the option of NIPT by a genetic counselor. Downstream data through 28 weeks' gestation were collected from the electronic medical record (EMR). The EMR was also used to identify a matched historical cohort from 1 year prior to NIPT availability. Rates of invasive prenatal procedures were compared using McNemar's test. RESULTS Two hundred women completed the questionnaire and underwent NIPT. Twenty-two subjects (11%) in the prospective cohort underwent an invasive prenatal procedure compared with 58 (29%) in the historical cohort (p<0.0001). Safety and accuracy were the most important factors in considering NIPT. At the time of survey, only 12% indicated being very comfortable with the possibility of undergoing amniocentesis. CONCLUSION This prospective study demonstrates a 62% reduction in invasive prenatal procedures after NIPT testing and finds safety, accuracy, and personal beliefs key to women's decision-making.
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Affiliation(s)
- George E Tiller
- Department of Genetics, Southern California Permanente Medical Group, Los Angeles, CA, USA
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Bianchi DW, Parker RL, Wentworth J, Madankumar R, Saffer C, Das AF, Craig JA, Chudova DI, Devers PL, Jones KW, Oliver K, Rava RP, Sehnert AJ. DNA sequencing versus standard prenatal aneuploidy screening. N Engl J Med 2014; 370:799-808. [PMID: 24571752 DOI: 10.1056/nejmoa1311037] [Citation(s) in RCA: 434] [Impact Index Per Article: 43.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND In high-risk pregnant women, noninvasive prenatal testing with the use of massively parallel sequencing of maternal plasma cell-free DNA (cfDNA testing) accurately detects fetal autosomal aneuploidy. Its performance in low-risk women is unclear. METHODS At 21 centers in the United States, we collected blood samples from women with singleton pregnancies who were undergoing standard aneuploidy screening (serum biochemical assays with or without nuchal translucency measurement). We performed massively parallel sequencing in a blinded fashion to determine the chromosome dosage for each sample. The primary end point was a comparison of the false positive rates of detection of fetal trisomies 21 and 18 with the use of standard screening and cfDNA testing. Birth outcomes or karyotypes were the reference standard. RESULTS The primary series included 1914 women (mean age, 29.6 years) with an eligible sample, a singleton fetus without aneuploidy, results from cfDNA testing, and a risk classification based on standard screening. For trisomies 21 and 18, the false positive rates with cfDNA testing were significantly lower than those with standard screening (0.3% vs. 3.6% for trisomy 21, P<0.001; and 0.2% vs. 0.6% for trisomy 18, P=0.03). The use of cfDNA testing detected all cases of aneuploidy (5 for trisomy 21, 2 for trisomy 18, and 1 for trisomy 13; negative predictive value, 100% [95% confidence interval, 99.8 to 100]). The positive predictive values for cfDNA testing versus standard screening were 45.5% versus 4.2% for trisomy 21 and 40.0% versus 8.3% for trisomy 18. CONCLUSIONS In a general obstetrical population, prenatal testing with the use of cfDNA had significantly lower false positive rates and higher positive predictive values for detection of trisomies 21 and 18 than standard screening. (Funded by Illumina; ClinicalTrials.gov number, NCT01663350.).
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Affiliation(s)
- Diana W Bianchi
- From the Mother Infant Research Institute, Tufts Medical Center and Tufts University School of Medicine, Boston (D.W.B.); Lyndhurst Clinical Research, Winston-Salem, NC (R.L.P.); the Group for Women, Norfolk, VA (J.W.); Long Island Jewish Medical Center, North Shore-LIJ Health Systems, New Hyde Park, NY (R.M.); West Coast OB/GYN, San Diego (C.S.), InClin, San Mateo (A.F.D.), and Illumina, Redwood City (D.I.C., P.L.D., K.W.J., K.O., R.P.R., A.J.S.) - all in California; and Colorado Permanente Medical Group, Denver (J.A.C.)
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Futch T, Spinosa J, Bhatt S, de Feo E, Rava RP, Sehnert AJ. Initial clinical laboratory experience in noninvasive prenatal testing for fetal aneuploidy from maternal plasma DNA samples. Prenat Diagn 2014; 33:569-74. [PMID: 23592485 PMCID: PMC3709117 DOI: 10.1002/pd.4123] [Citation(s) in RCA: 146] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Objective The aim of this study is to report the experience of noninvasive prenatal DNA testing using massively parallel sequencing in an accredited clinical laboratory. Methods Laboratory information was examined for blood samples received for testing between February and November 2012 for chromosome 21 (Chr21), Chr18, and Chr13. Monosomy X (MX) testing was available from July 2012 for cystic hygroma indication. Outcomes were collected from providers on samples with positive results. Results There were 5974 samples tested, and results were issued within an average of 5.1 business days. Aneuploidy was detected in 284 (4.8%) samples (155 Chr21, 66 Chr18, 19 Chr13, 40 MX, and four double aneuploidy). Follow-ups are available for 245/284 (86%), and 77/284 (27.1%) are confirmed, including one double-aneuploidy case concordant with cytogenetics from maternal malignancy. Fourteen (0.2%) discordant (putative false-positive) results (one Chr21, six Chr18, three Chr13, three MX, and one Chr21/13) have been identified. Five (0.08%) false-negative cases are reported (two trisomy 21, two trisomy 18, and one MX). In 170 (2.8%) cases, the result for a single chromosome was indefinite. Conclusions This report suggests that clinical testing of maternal cell-free DNA for fetal aneuploidy operates within performance parameters established in validation studies. Noninvasive prenatal testing is sensitive to biological contributions from placental and maternal sources. ©2013 Verinata Health, Inc. Prenatal Diagnosis published by John Wiley & Sons, Ltd.
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Affiliation(s)
- Tracy Futch
- Genetic Services, Verinata Health, Inc., Redwood City, CA, USA
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Abstract
Abstract
BACKGROUND
Noninvasive prenatal testing based on massively parallel sequencing (MPS) of cell-free DNA in maternal plasma has become rapidly integrated into clinical practice for detecting fetal chromosomal aneuploidy. We directly determined the fetal fraction (FF) from results obtained with MPS tag counting and examined the relationships of FF to such biological parameters as fetal karyotype and maternal demographics.
METHODS
FF was determined from samples previously collected for the MELISSA (Maternal Blood Is Source to Accurately Diagnose Fetal Aneuploidy) study. Samples were resequenced, analyzed blindly, and aligned to the human genome (assembly hg19). FF was calculated in pregnancies with male or aneuploid fetuses by means of an equation that incorporated the ratio of the tags in these samples to those of a euploid training set.
RESULTS
The mean (SD) FF from euploid male pregnancies was 0.126 (0.052) (n = 160). Weak but statistically significant correlations were found between FF and the maternal body mass index (r2 = 0.18; P = 2.3 × 10−8) and between FF and gestational age (r2 = 0.02; P = 0.047). No relationship with maternal ethnicity or age was observed. Mean FF values for trisomies 21 (n = 90), 18 (n = 38), and 13 (n = 16) and for monosomy X (n = 20) were 0.135 (0.051), 0.089 (0.039), 0.090 (0.062), and 0.106 (0.045), respectively.
CONCLUSIONS
MPS tag-count data can be used to determine FF directly and accurately. Compared with male euploid fetuses, the FF is higher in maternal plasma when the fetus has trisomy 21 and is lower when the fetus has trisomy 18, 13, or monosomy X. The different biologies of these aneuploidies have practical implications for the determination of cutoff values, which in turn will affect the diagnostic sensitivity and specificity of the test.
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Affiliation(s)
| | | | - Amy J Sehnert
- Verinata Health, an Illumina Company, Redwood City, CA
| | - Diana W Bianchi
- Mother Infant Research Institute at Tufts Medical Center and Tufts University School of Medicine, Boston, MA
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Swanson A, Sehnert AJ, Bhatt S. Non-invasive Prenatal Testing: Technologies, Clinical Assays and Implementation Strategies for Women's Healthcare Practitioners. Curr Genet Med Rep 2013; 1:113-121. [PMID: 23687624 PMCID: PMC3655220 DOI: 10.1007/s40142-013-0010-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The field of prenatal genetic testing has exploded with new non-invasive technologies and test options in the past several years. It is challenging for women's healthcare providers to keep up with the multitude of publications and provide patients with the most accurate and up-to-date information possible regarding prenatal testing. In this article, we examine the sequencing technologies that provide the framework for non-invasive prenatal testing (NIPT) and review the major North American NIPT clinical validation studies published in 2011 and 2012. This paper also compares and contrasts the commercially available non-invasive prenatal tests in the United States, discusses clinical implementation recommendations from professional societies and highlights considerations for genetic counseling.
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Affiliation(s)
- Amy Swanson
- Department of Clinical Affairs, Verinata Health, an Illumina Company, 800 Saginaw Drive, Redwood City, CA 94063 USA
| | - Amy J. Sehnert
- Department of Clinical Affairs, Verinata Health, an Illumina Company, 800 Saginaw Drive, Redwood City, CA 94063 USA
| | - Sucheta Bhatt
- Department of Clinical Affairs, Verinata Health, an Illumina Company, 800 Saginaw Drive, Redwood City, CA 94063 USA
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Sehnert AJ, Rhees B, Comstock D, de Feo E, Heilek G, Burke J, Rava RP. Optimal Detection of Fetal Chromosomal Abnormalities by Massively Parallel DNA Sequencing of Cell-Free Fetal DNA from Maternal Blood. Clin Chem 2011; 57:1042-9. [PMID: 21519036 DOI: 10.1373/clinchem.2011.165910] [Citation(s) in RCA: 239] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND
Massively parallel DNA sequencing of cell-free fetal DNA from maternal blood can detect fetal chromosomal abnormalities. Although existing algorithms focus on the detection of fetal trisomy 21 (T21), these same algorithms have difficulty detecting trisomy 18 (T18).
METHODS
Blood samples were collected from 1014 patients at 13 US clinic locations before they underwent an invasive prenatal procedure. All samples were processed to plasma, and the DNA extracted from 119 samples underwent massively parallel DNA sequencing. Fifty-three sequenced samples came from women with an abnormal fetal karyotype. To minimize the intra- and interrun sequencing variation, we developed an optimized algorithm by using normalized chromosome values (NCVs) from the sequencing data on a training set of 71 samples with 26 abnormal karyotypes. The classification process was then evaluated on an independent test set of 48 samples with 27 abnormal karyotypes.
RESULTS
Mapped sites for chromosomes of interest in the sequencing data from the training set were normalized individually by calculating the ratio of the number of sites on the specified chromosome to the number of sites observed on an optimized normalizing chromosome (or chromosome set). Threshold values for trisomy or sex chromosome classification were then established for all chromosomes of interest, and a classification schema was defined. Sequencing of the independent test set led to 100% correct classification of T21 (13 of 13) and T18 (8 of 8) samples. Other chromosomal abnormalities were also identified.
CONCLUSION
Massively parallel sequencing is capable of detecting multiple fetal chromosomal abnormalities from maternal plasma when an optimized algorithm is used.
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Affiliation(s)
| | - Brian Rhees
- Verinata Health, Inc., San Carlos, CA
- current affiliation: Caris Life Sciences, Phoenix, AZ
| | | | | | - Gabrielle Heilek
- Verinata Health, Inc., San Carlos, CA
- current affiliation: Roche Molecular Systems, Pleasanton, CA
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Rosenberg S, Elashoff MR, Beineke P, Daniels SE, Wingrove JA, Tingley WG, Sager PT, Sehnert AJ, Yau M, Kraus WE, Newby LK, Schwartz RS, Voros S, Ellis SG, Tahirkheli N, Waksman R, McPherson J, Lansky A, Winn ME, Schork NJ, Topol EJ. Multicenter validation of the diagnostic accuracy of a blood-based gene expression test for assessing obstructive coronary artery disease in nondiabetic patients. Ann Intern Med 2010; 153:425-34. [PMID: 20921541 PMCID: PMC3786733 DOI: 10.7326/0003-4819-153-7-201010050-00005] [Citation(s) in RCA: 146] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Diagnosing obstructive coronary artery disease (CAD) in at-risk patients can be challenging and typically requires both noninvasive imaging methods and coronary angiography, the gold standard. Previous studies have suggested that peripheral blood gene expression can indicate the presence of CAD. OBJECTIVE To validate a previously developed 23-gene, expression-based classification test for diagnosis of obstructive CAD in nondiabetic patients. DESIGN Multicenter prospective trial with blood samples obtained before coronary angiography. (ClinicalTrials.gov registration number: NCT00500617) SETTING: 39 centers in the United States. PATIENTS An independent validation cohort of 526 nondiabetic patients with a clinical indication for coronary angiography. MEASUREMENTS Receiver-operating characteristic (ROC) analysis of classifier score measured by real-time polymerase chain reaction, additivity to clinical factors, and reclassification of patient disease likelihood versus disease status defined by quantitative coronary angiography. Obstructive CAD was defined as 50% or greater stenosis in 1 or more major coronary arteries by quantitative coronary angiography. RESULTS The area under the ROC curve (AUC) was 0.70 ± 0.02 (P < 0.001); the test added to clinical variables (Diamond-Forrester method) (AUC, 0.72 with the test vs. 0.66 without; P = 0.003) and added somewhat to an expanded clinical model (AUC, 0.745 with the test vs. 0.732 without; P = 0.089). The test improved net reclassification over both the Diamond-Forrester method and the expanded clinical model (P < 0.001). At a score threshold that corresponded to a 20% likelihood of obstructive CAD (14.75), the sensitivity and specificity were 85% and 43% (yielding a negative predictive value of 83% and a positive predictive value of 46%), with 33% of patient scores below this threshold. LIMITATION Patients with chronic inflammatory disorders, elevated levels of leukocytes or cardiac protein markers, or diabetes were excluded. CONCLUSION A noninvasive whole-blood test based on gene expression and demographic characteristics may be useful for assessing obstructive CAD in nondiabetic patients without known CAD. PRIMARY FUNDING SOURCE CardioDx.
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Lansky AJ, Elashoff MR, Sehnert AJ, Lieu HD, Wingrove JA, Daniels SE, Rosenberg S, Voros S, Schwartz RS, Kraus WE, Topol EJ. MYOCARDIAL PERFUSION IMAGING PERFORMANCE IN THE PREDICT MULTI-CENTER TRIAL; GENDER SPECIFIC ANALYSIS AND COMPARISON WITH THE CORUS CAD GENE EXPRESSION SCORE. J Am Coll Cardiol 2010. [DOI: 10.1016/s0735-1097(10)61740-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Wingrove JA, Daniels SE, Sehnert AJ, Tingley W, Elashoff MR, Rosenberg S, Buellesfeld L, Grube E, Newby LK, Ginsburg GS, Kraus WE. Correlation of Peripheral-Blood Gene Expression With the Extent of Coronary Artery Stenosis. ACTA ACUST UNITED AC 2008; 1:31-8. [DOI: 10.1161/circgenetics.108.782730] [Citation(s) in RCA: 147] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
The molecular pathophysiology of coronary artery disease (CAD) includes cytokine release and a localized inflammatory response within the vessel wall. The extent to which CAD and its severity is reflected by gene expression in circulating cells is unknown.
Methods and Results—
From an initial coronary catheterization cohort we identified 41 patients, comprising 27 cases with angiographically significant CAD and 14 controls without coronary stenosis. Whole-genome microarray analysis performed on peripheral-blood mononuclear cells yielded 526 genes with >1.3-fold differential expression (
P
<0.05) between cases and controls. Real-time polymerase chain reaction on 106 genes (the 50 most significant microarray genes and 56 additional literature genes) in an independent subset of 95 patients (63 cases, 32 controls) from the same cohort yielded 14 genes (
P
<0.05) that independently discriminated CAD state in a multivariable analysis that included clinical and demographic factors. From an independent second catheterization cohort, 215 patients were selected for real-time polymerase chain reaction–based replication. A case:control subset of 107 patients (86 cases, 21 controls) replicated 11 of the 14 multivariably significant genes from the first cohort. An analysis of the 14 genes in the entire set of 215 patients demonstrated that gene expression was proportional to maximal coronary artery stenosis (
P
<0.001 by ANOVA).
Conclusions—
Gene expression in peripheral-blood cells reflects the presence and extent of CAD in patients undergoing angiography.
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Affiliation(s)
- James A. Wingrove
- From CardioDx, Palo Alto, Calif (J.A.W., S.E.D., A.J.S., W.T., M.R.E., S.R.); Helios Heart Center, Siegburg, Germany (L.B., E.G.); and Division of Cardiovascular Medicine, Duke University, Durham, NC (L.K.N., G.S.G., W.E.K.)
| | - Susan E. Daniels
- From CardioDx, Palo Alto, Calif (J.A.W., S.E.D., A.J.S., W.T., M.R.E., S.R.); Helios Heart Center, Siegburg, Germany (L.B., E.G.); and Division of Cardiovascular Medicine, Duke University, Durham, NC (L.K.N., G.S.G., W.E.K.)
| | - Amy J. Sehnert
- From CardioDx, Palo Alto, Calif (J.A.W., S.E.D., A.J.S., W.T., M.R.E., S.R.); Helios Heart Center, Siegburg, Germany (L.B., E.G.); and Division of Cardiovascular Medicine, Duke University, Durham, NC (L.K.N., G.S.G., W.E.K.)
| | - Whittemore Tingley
- From CardioDx, Palo Alto, Calif (J.A.W., S.E.D., A.J.S., W.T., M.R.E., S.R.); Helios Heart Center, Siegburg, Germany (L.B., E.G.); and Division of Cardiovascular Medicine, Duke University, Durham, NC (L.K.N., G.S.G., W.E.K.)
| | - Michael R. Elashoff
- From CardioDx, Palo Alto, Calif (J.A.W., S.E.D., A.J.S., W.T., M.R.E., S.R.); Helios Heart Center, Siegburg, Germany (L.B., E.G.); and Division of Cardiovascular Medicine, Duke University, Durham, NC (L.K.N., G.S.G., W.E.K.)
| | - Steven Rosenberg
- From CardioDx, Palo Alto, Calif (J.A.W., S.E.D., A.J.S., W.T., M.R.E., S.R.); Helios Heart Center, Siegburg, Germany (L.B., E.G.); and Division of Cardiovascular Medicine, Duke University, Durham, NC (L.K.N., G.S.G., W.E.K.)
| | - Lutz Buellesfeld
- From CardioDx, Palo Alto, Calif (J.A.W., S.E.D., A.J.S., W.T., M.R.E., S.R.); Helios Heart Center, Siegburg, Germany (L.B., E.G.); and Division of Cardiovascular Medicine, Duke University, Durham, NC (L.K.N., G.S.G., W.E.K.)
| | - Eberhard Grube
- From CardioDx, Palo Alto, Calif (J.A.W., S.E.D., A.J.S., W.T., M.R.E., S.R.); Helios Heart Center, Siegburg, Germany (L.B., E.G.); and Division of Cardiovascular Medicine, Duke University, Durham, NC (L.K.N., G.S.G., W.E.K.)
| | - L. Kristin Newby
- From CardioDx, Palo Alto, Calif (J.A.W., S.E.D., A.J.S., W.T., M.R.E., S.R.); Helios Heart Center, Siegburg, Germany (L.B., E.G.); and Division of Cardiovascular Medicine, Duke University, Durham, NC (L.K.N., G.S.G., W.E.K.)
| | - Geoffrey S. Ginsburg
- From CardioDx, Palo Alto, Calif (J.A.W., S.E.D., A.J.S., W.T., M.R.E., S.R.); Helios Heart Center, Siegburg, Germany (L.B., E.G.); and Division of Cardiovascular Medicine, Duke University, Durham, NC (L.K.N., G.S.G., W.E.K.)
| | - William E. Kraus
- From CardioDx, Palo Alto, Calif (J.A.W., S.E.D., A.J.S., W.T., M.R.E., S.R.); Helios Heart Center, Siegburg, Germany (L.B., E.G.); and Division of Cardiovascular Medicine, Duke University, Durham, NC (L.K.N., G.S.G., W.E.K.)
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Kaufman BD, Auerbach S, Reddy S, Manlhiot C, Deng L, Prakash A, Printz BF, Gruber D, Papavassiliou DP, Hsu DT, Sehnert AJ, Chung WK, Mital S. RAAS gene polymorphisms influence progression of pediatric hypertrophic cardiomyopathy. Hum Genet 2007; 122:515-23. [PMID: 17851694 DOI: 10.1007/s00439-007-0429-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2007] [Accepted: 09/04/2007] [Indexed: 12/27/2022]
Abstract
Hypertrophic Cardiomyopathy (HCM) is a disease with variable rate of progression. Young age is an independent risk factor for poor outcome in HCM. The influence of renin-angiotensin-aldosterone (RAAS) genotype on the progression of HCM in children is unknown. Children with HCM (n = 65) were enrolled prospectively across two centers (2001-2005). All subjects were genotyped for five RAAS gene polymorphisms previously associated with LV hypertrophy (pro-LVH): AGT M235T, ACE DD, CMA-1903 A/G, AGTR1 1666 A/C and CYP11B2-344 C/T. Linear regression models, based on maximum likelihood estimates, were created to assess the independent effect of RAAS genotype on LV hypertrophy (LVH). Forty-six subjects were homozygous for <2 and 19 were homozygous for > or =2 pro-LVH RAAS polymorphisms. Mean age at presentation was 9.6 +/- 6 years. Forty children had follow-up echocardiograms after a median of 1.5 years. Indexed LV mass (LVMI) and LV mass z-scores were higher at presentation and follow-up in subjects with > or =2 pro-LVH genotypes compared to those with <2 (P < 0.05). Subjects with > or =2 pro-LVH genotypes also demonstrated a greater increase in septal thickness (IVST) and in LV outflow tract (LVOT) obstruction on follow-up (P < 0.05). On multivariate analysis, a higher number of pro-LVH genotypes was associated with a larger effect size (P < 0.05). Pro-LVH RAAS gene polymorphisms are associated with progressive septal hypertrophy and LVOT obstruction in children with HCM. Identification of RAAS modifier genes may help to risk-stratify patients with HCM.
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MESH Headings
- Adolescent
- Adult
- Alleles
- Base Sequence
- Cardiomyopathy, Hypertrophic, Familial/diagnostic imaging
- Cardiomyopathy, Hypertrophic, Familial/etiology
- Cardiomyopathy, Hypertrophic, Familial/genetics
- Child
- Child, Preschool
- DNA Primers/genetics
- Echocardiography, Doppler
- Female
- Gene Frequency
- Genotype
- Humans
- Hypertrophy, Left Ventricular/diagnostic imaging
- Hypertrophy, Left Ventricular/etiology
- Hypertrophy, Left Ventricular/genetics
- Infant
- Infant, Newborn
- Male
- Phenotype
- Polymorphism, Genetic
- Prospective Studies
- Renin-Angiotensin System/genetics
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Affiliation(s)
- Beth D Kaufman
- Department of Pediatrics, Columbia University, New York, NY, 10032, USA
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Sehnert AJ. Use of Denaturing High-Performance Liquid Chromatography to Detect Mutations in Pediatric Cardiomyopathies. CONGENIT HEART DIS 2006; 126:257-70. [PMID: 16930018 DOI: 10.1385/1-59745-088-x:257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This chapter describes the use of denaturing high-performance liquid chromatography as a high-throughput method to detect genetic mutations in pediatric cardiomyopathies. An overview of the classification, incidence, and etiologies of the major cardiomyopathies is provided, with emphasis on the special circumstances of the pediatric patient. During the past 15 yr, the genetic bases of inherited dilated, hypertrophic, and restrictive cardiomyopathy have been elucidated. As the list of known and candidate cardiomyopathy genes continues to grow and our ability to screen for genetic mutations improves, the cause of cardiomyopathy will be identified in a larger percentage of cases. This outcome is highly relevant to children with cardiomyopathy as well as those at risk for developing the disease because of their family history.
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Affiliation(s)
- Amy J Sehnert
- Department of Pediatrics, University of California, Pediatrics Heart Center, San Francisco, CA, USA
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Tidyman WE, Sehnert AJ, Huq A, Agard J, Deegan F, Stainier DYR, Ordahl CP. In vivo regulation of the chicken cardiac troponin T gene promoter in zebrafish embryos. Dev Dyn 2003; 227:484-96. [PMID: 12889057 DOI: 10.1002/dvdy.10328] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
The chicken cardiac troponin T (cTnT) gene is representative of numerous cardiac and skeletal muscle-specific genes that contain muscle-CAT (MCAT) elements within their promoters. We examined the regulation of the chicken cTnT gene in vivo in zebrafish embryos, and in vitro in cardiomyocyte, myoblast, and fibroblast cultures. Defined regions of the cTnT promoter were linked to the green fluorescent protein (GFP) gene for in vivo analysis, and the luciferase gene for in vitro analysis. Injection of the cTnT promoter constructs into fertilized zebrafish eggs resulted in GFP expression in both heart and skeletal muscle cells reproducing the pattern of expression of the endogenous cTnT gene in the chicken embryo. Promoter deletion analysis revealed that the cis-regulatory regions responsible for cardiac and skeletal muscle-specific expression functioned in an equivalent manner in both in vitro and in vivo environments. In addition, we show that mutation of the poly-ADP ribose polymerase-I (PARP-I) binding site adjacent to the distal MCAT element in the chicken cTnT promoter produced a non-cell-specific promoter in vitro and in the zebrafish. Thus, the PARP-I transcriptional regulatory mechanism that governs muscle specificity of the chicken cTnT promoter is conserved across several chordate classes spanning at least 350 million years of evolution.
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Affiliation(s)
- William E Tidyman
- Department of Anatomy and Cardiovascular Research Institute, University of California San Francisco, 94143, USA
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Abstract
Heart disease is a leading cause of death in the developed world. Abnormalities of heart muscle (cardiomyopathies) and/or electrical conduction (arrhythmias) are frequent causes of heart failure and sudden death. During the past twelve years, identification of genetic mutations that cause familial cardiomyopathies and arrhythmias has fueled a massive increase in molecular investigation into these diseases. Today, studies of zebrafish mutants with defective heart function are providing insight into the genes required to generate a normal heartbeat.
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Affiliation(s)
- Amy J Sehnert
- Departmentt of Pediatrics, Pediatric Cardiology Division, University of California, San Fransisco, 513 Parnassus Avenue, San Francisco, CA 94143, USA.
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47
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Sehnert AJ, Huq A, Weinstein BM, Walker C, Fishman M, Stainier DYR. Cardiac troponin T is essential in sarcomere assembly and cardiac contractility. Nat Genet 2002; 31:106-10. [PMID: 11967535 DOI: 10.1038/ng875] [Citation(s) in RCA: 462] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Mutations of the gene (TNNT2) encoding the thin-filament contractile protein cardiac troponin T are responsible for 15% of all cases of familial hypertrophic cardiomyopathy, the leading cause of sudden death in young athletes. Mutant proteins are thought to act through a dominant-negative mode that impairs function of heart muscle. TNNT2 mutations can also lead to dilated cardiomyopathy, a leading cause of heart failure. Despite the importance of cardiac troponin T in human disease, its loss-of-function phenotype has not been described. We show that the zebrafish silent heart (sih) mutation affects the gene tnnt2. We characterize two mutated alleles of sih that severely reduce tnnt2 expression: one affects mRNA splicing, and the other affects gene transcription. Tnnt2, together with alpha-tropomyosin (Tpma) and cardiac troponins C and I (Tnni3), forms a calcium-sensitive regulatory complex within sarcomeres. Unexpectedly, in addition to loss of Tnnt2 expression in sih mutant hearts, we observed a significant reduction in Tpma and Tnni3, and consequently, severe sarcomere defects. This interdependence of thin-filament protein expression led us to postulate that some mutations in tnnt2 may trigger misregulation of thin-filament protein expression, resulting in sarcomere loss and myocyte disarray, the life-threatening hallmarks of TNNT2 mutations in mice and humans.
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Affiliation(s)
- Amy J Sehnert
- Department of Biochemistry and Biophysics, University of California at San Francisco, 513 Parnassus Avenue, Box 0448, San Francisco, California 94143-0448, USA
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Abstract
The average polymorphonuclear neutrophil (PMN) lives only a day and then dies by apoptosis. We previously found that the calcium-dependent protease calpain is required for apoptosis in several mouse models of cell death. Here we identify calpain, and its endogenous inhibitor calpastatin, as regulators of human neutrophil apoptosis. Cell death triggered by the translation inhibitor cycloheximide is calpain-dependent, as evidenced using either a calpain active site inhibitor (N-acetyl-leucyl-leucyl-norleucinal) or agents that target calpain's calcium binding sites (PD150606, PD151746). No significant effect on cycloheximide-triggered apoptosis was found by using inhibitors of the proteasome or of other papain-like cysteine proteases, providing further evidence that the active site calpain inhibitor prevents apoptosis via its action on calpain. In addition, we find that potentiation of calpain activity by depleting its endogenous inhibitor, calpastatin, is sufficient to cause apoptosis of neutrophils. Nevertheless, apoptosis signalled via the Fas antigen proceeds regardless of the presence of calpain inhibitor. These experiments support a growing body of work, indicating an upstream regulatory role for calpain in many, but not all, forms of apoptotic cell death. They also identify calpastatin as a participant in apoptotic cell death and suggest that for at least one cell type, a decrease in calpastatin is a sufficient stimulus to initiate calpain-dependent apoptosis.
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Affiliation(s)
- M K Squier
- Department of Immunology, School of Medicine, University of Colorado Health Sciences Center, Denver 80262, USA.
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Abstract
All cells of the hematopoietic system have finite life spans, shorter by far than that of the host. They end their lives by committing a form of cellular suicide or programmed cell death. The morphology of this process is considerably different from that of necrosis and is called apoptosis. Apoptotic cells undergo a stereotyped sequence of changes, including shrinkage and nuclear collapse. The cell is quickly recognized and eaten by a phagocyte, without the elicitation of an inflammatory response. Although most cells have specific triggers of apoptosis, the killer T cell seems able to induce apoptosis in any cell it recognizes. The process of apoptosis is regulated by cytokines, and may be modulated both in vitro and in vivo.
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Affiliation(s)
- M K Squier
- Department of Immunology, University of Colorado Medical School, Denver 80262
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