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Basu J, Finocchiaro G, Miles C, Parry-Williams G, MacLachlan H, Tome Esteban MT, Sharma S, Papadakis M. The effect of ethnicity on left ventricular adaptation to exercise. Eur J Prev Cardiol 2023; 30:e69-e71. [PMID: 37086472 DOI: 10.1093/eurjpc/zwad126] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 04/19/2023] [Accepted: 04/20/2023] [Indexed: 04/24/2023]
Affiliation(s)
- Joyee Basu
- Cardiovascular Clinical Academic Group, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Gherardo Finocchiaro
- Cardiovascular Clinical Academic Group, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Christopher Miles
- Cardiovascular Clinical Academic Group, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Gemma Parry-Williams
- Cardiovascular Clinical Academic Group, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Hamish MacLachlan
- Cardiovascular Clinical Academic Group, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Maria Teresa Tome Esteban
- Cardiovascular Clinical Academic Group, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Sanjay Sharma
- Cardiovascular Clinical Academic Group, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Michael Papadakis
- Cardiovascular Clinical Academic Group, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
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Lampert R, Ackerman MJ, Marino BS, Burg M, Ainsworth B, Salberg L, Tome Esteban MT, Ho CY, Abraham R, Balaji S, Barth C, Berul CI, Bos M, Cannom D, Choudhury L, Concannon M, Cooper R, Czosek RJ, Dubin AM, Dziura J, Eidem B, Emery MS, Estes NAM, Etheridge SP, Geske JB, Gray B, Hall K, Harmon KG, James CA, Lal AK, Law IH, Li F, Link MS, McKenna WJ, Molossi S, Olshansky B, Ommen SR, Saarel EV, Saberi S, Simone L, Tomaselli G, Ware JS, Zipes DP, Day SM. Vigorous Exercise in Patients With Hypertrophic Cardiomyopathy. JAMA Cardiol 2023; 8:595-605. [PMID: 37195701 PMCID: PMC10193262 DOI: 10.1001/jamacardio.2023.1042] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [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: 02/10/2023] [Accepted: 03/24/2023] [Indexed: 05/18/2023]
Abstract
Importance Whether vigorous intensity exercise is associated with an increase in risk of ventricular arrhythmias in individuals with hypertrophic cardiomyopathy (HCM) is unknown. Objective To determine whether engagement in vigorous exercise is associated with increased risk for ventricular arrhythmias and/or mortality in individuals with HCM. The a priori hypothesis was that participants engaging in vigorous activity were not more likely to have an arrhythmic event or die than those who reported nonvigorous activity. Design, Setting, and Participants This was an investigator-initiated, prospective cohort study. Participants were enrolled from May 18, 2015, to April 25, 2019, with completion in February 28, 2022. Participants were categorized according to self-reported levels of physical activity: sedentary, moderate, or vigorous-intensity exercise. This was a multicenter, observational registry with recruitment at 42 high-volume HCM centers in the US and internationally; patients could also self-enroll through the central site. Individuals aged 8 to 60 years diagnosed with HCM or genotype positive without left ventricular hypertrophy (phenotype negative) without conditions precluding exercise were enrolled. Exposures Amount and intensity of physical activity. Main Outcomes and Measures The primary prespecified composite end point included death, resuscitated sudden cardiac arrest, arrhythmic syncope, and appropriate shock from an implantable cardioverter defibrillator. All outcome events were adjudicated by an events committee blinded to the patient's exercise category. Results Among the 1660 total participants (mean [SD] age, 39 [15] years; 996 male [60%]), 252 (15%) were classified as sedentary, and 709 (43%) participated in moderate exercise. Among the 699 individuals (42%) who participated in vigorous-intensity exercise, 259 (37%) participated competitively. A total of 77 individuals (4.6%) reached the composite end point. These individuals included 44 (4.6%) of those classified as nonvigorous and 33 (4.7%) of those classified as vigorous, with corresponding rates of 15.3 and 15.9 per 1000 person-years, respectively. In multivariate Cox regression analysis of the primary composite end point, individuals engaging in vigorous exercise did not experience a higher rate of events compared with the nonvigorous group with an adjusted hazard ratio of 1.01. The upper 95% 1-sided confidence level was 1.48, which was below the prespecified boundary of 1.5 for noninferiority. Conclusions and Relevance Results of this cohort study suggest that among individuals with HCM or those who are genotype positive/phenotype negative and are treated in experienced centers, those exercising vigorously did not experience a higher rate of death or life-threatening arrhythmias than those exercising moderately or those who were sedentary. These data may inform discussion between the patient and their expert clinician around exercise participation.
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Affiliation(s)
- Rachel Lampert
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Michael J. Ackerman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
- Department of Molecular Pharmacology & Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota
| | - Bradley S. Marino
- Department of Pediatric Cardiology, Cleveland Clinic Heart, Vascular and Thoracic Institute, Cleveland, Ohio
- Lurie Children’s Hospital, Chicago, Illinois
| | - Matthew Burg
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | - Lisa Salberg
- Hypertrophic Cardiomyopathy Association, Denville, New Jersey
| | | | - Carolyn Y. Ho
- Cardiovascular Division, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Roselle Abraham
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Seshadri Balaji
- Department of Pediatrics, Oregon Health and Science University, Portland
| | - Cheryl Barth
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Charles I. Berul
- Division of Cardiology, Children’s National Hospital, Washington, DC
- Department of Pediatrics, George Washington University School of Medicine, Washington, DC
| | - Martijn Bos
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
- Department of Molecular Pharmacology & Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota
| | - David Cannom
- Division of Cardiology, PIH Health Good Samaritan Hospital, Los Angeles, California
| | - Lubna Choudhury
- Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Robert Cooper
- Department of Cardiology, Liverpool Heart and Chest Hospital/Liverpool John Moores University, Liverpool, United Kingdom
| | - Richard J. Czosek
- Department of Pediatrics, Heart Institute, Cincinnati Children’s Hospital, Cincinnati, Ohio
| | - Anne M. Dubin
- Department of Pediatrics, Stanford School of Medicine, Stanford, California
| | - James Dziura
- Yale Center for Analytic Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Benjamin Eidem
- Department of Cardiology, Mayo Clinic, Rochester, Minnesota
- Department of Pediatrics, Mayo Clinic, Rochester, Minnesota
| | - Michael S. Emery
- Department of Cardiovascular Medicine, Cleveland Clinic Heart, Vascular and Thoracic Institute, Cleveland, Ohio
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - N. A. Mark Estes
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Susan P. Etheridge
- Department of Pediatrics, Primary Children’s Hospital, Salt Lake City, Utah
| | - Jeffrey B. Geske
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Belinda Gray
- Faculty of Medicine and Health, Royal Prince Alfred Hospital/Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Kevin Hall
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
| | | | - Cynthia A. James
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Ashwin K. Lal
- Department of Pediatrics, Primary Children’s Hospital, Salt Lake City, Utah
| | - Ian H. Law
- Department of Pediatrics, University of Iowa, Iowa City
| | - Fangyong Li
- Yale Center for Analytic Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Mark S. Link
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts
- Department of Internal Medicine, University of Texas, Southwestern, Dallas
| | - William J. McKenna
- Institute of Cardiovascular Medicine, University College London, London, United Kingdom
| | - Silvana Molossi
- Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston
| | - Brian Olshansky
- Department of Internal Medicine, University of Iowa, Iowa City
| | - Steven R. Ommen
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Elizabeth V. Saarel
- Department of Pediatric Cardiology, Cleveland Clinic Heart, Vascular and Thoracic Institute, Cleveland, Ohio
- Department of Pediatric Cardiology, St Luke’s Health System, Boise, Idaho
| | - Sara Saberi
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Laura Simone
- Yale Center for Analytic Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Gordon Tomaselli
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - James S. Ware
- National Heart and Lung Institute & MRC London Institute of Medical Sciences, Imperial College London/ Royal Brompton & Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust
| | - Douglas P. Zipes
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Sharlene M. Day
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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Bhatia RT, Malhotra A, MacLachlan H, Gati S, Marwaha S, Chatrath N, Fyyaz S, Aleixo H, Al-Turaihi S, Babu A, Basu J, Catterson P, Cooper R, Daems JJN, Dhutia H, Ferrari F, van Hattum JC, Iqbal Z, Kasiakogias A, Kenny A, Khanbhai T, Khoury S, Miles C, Oxborough D, Quazi K, Rakhit D, Sharma A, Varnava A, Tome Esteban MT, Finocchiaro G, Stein R, Jorstad HT, Papadakis M, Sharma S. Prevalence and diagnostic significance of de-novo 12-lead ECG changes after COVID-19 infection in elite soccer players. Heart 2023; 109:936-943. [PMID: 37039240 DOI: 10.1136/heartjnl-2022-322211] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 02/21/2023] [Indexed: 04/12/2023] Open
Abstract
BACKGROUND AND AIM The efficacy of pre-COVID-19 and post-COVID-19 infection 12-lead ECGs for identifying athletes with myopericarditis has never been reported. We aimed to assess the prevalence and significance of de-novo ECG changes following COVID-19 infection. METHODS In this multicentre observational study, between March 2020 and May 2022, we evaluated consecutive athletes with COVID-19 infection. Athletes exhibiting de-novo ECG changes underwent cardiovascular magnetic resonance (CMR) scans. One club mandated CMR scans for all players (n=30) following COVID-19 infection, despite the absence of cardiac symptoms or de-novo ECG changes. RESULTS 511 soccer players (median age 21 years, IQR 18-26 years) were included. 17 (3%) athletes demonstrated de-novo ECG changes, which included reduction in T-wave amplitude in the inferior and lateral leads (n=5), inferior leads (n=4) and lateral leads (n=4); inferior T-wave inversion (n=7); and ST-segment depression (n=2). 15 (88%) athletes with de-novo ECG changes revealed evidence of inflammatory cardiac sequelae. All 30 athletes who underwent a mandatory CMR scan had normal findings. Athletes revealing de-novo ECG changes had a higher prevalence of cardiac symptoms (71% vs 12%, p<0.0001) and longer median symptom duration (5 days, IQR 3-10) compared with athletes without de-novo ECG changes (2 days, IQR 1-3, p<0.001). Among athletes without cardiac symptoms, the additional yield of de-novo ECG changes to detect cardiac inflammation was 20%. CONCLUSIONS 3% of athletes demonstrated de-novo ECG changes post COVID-19 infection, of which 88% were diagnosed with cardiac inflammation. Most affected athletes exhibited cardiac symptoms; however, de-novo ECG changes contributed to a diagnosis of cardiac inflammation in 20% of athletes without cardiac symptoms.
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Affiliation(s)
- Raghav T Bhatia
- Cardiovascular Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Aneil Malhotra
- Cardiovascular Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
- Manchester Academic Health Science Centre, Manchester University National Health Service Foundation Trust, Manchester, UK
| | - Hamish MacLachlan
- Cardiovascular Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Sabiha Gati
- Cardiovascular Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
- Department of Cardiology, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Sarandeep Marwaha
- Cardiovascular Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Nikhil Chatrath
- Cardiovascular Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Saad Fyyaz
- Cardiovascular Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
| | | | - Samar Al-Turaihi
- Cardiovascular Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Aswin Babu
- Cardiovascular Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Joyee Basu
- Cardiovascular Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Paul Catterson
- Department of Medicine, Newcastle United Football Club, Newcastle, UK
| | | | - Joelle J N Daems
- Department of Cardiology, Amsterdam UMC location, University of Amsterdam, Amsterdam, The Netherlands
| | - Harshil Dhutia
- Cardiovascular Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Filipe Ferrari
- Graduate Program in Cardiology and Cardiovascular Sciences, Universidade Federal do Rio Grande do Sul, Hospital de Clinicas de Porto Alegre, Rio, Brazil
| | - Juliette C van Hattum
- Department of Cardiology, Amsterdam UMC location, University of Amsterdam, Amsterdam, The Netherlands
| | - Zafar Iqbal
- Department of Sports Medicine, Crystal Palace Football Club, London, UK
| | - Alexandros Kasiakogias
- Cardiovascular Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
| | | | | | - Shafik Khoury
- Cardiovascular Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Chris Miles
- Cardiovascular Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - David Oxborough
- Research Institute for Sport and Exercise Science, Liverpool John Moores University, Liverpool, UK
| | - Kashif Quazi
- Cardiovascular Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Dhrubo Rakhit
- Department of Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Anushka Sharma
- Cardiovascular Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Amanda Varnava
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK
| | - Maria Teresa Tome Esteban
- Cardiovascular Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Gherardo Finocchiaro
- Cardiovascular Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Ricardo Stein
- Graduate Program in Cardiology and Cardiovascular Sciences, Universidade Federal do Rio Grande do Sul, Hospital de Clinicas de Porto Alegre, Rio, Brazil
| | - Harald T Jorstad
- Department of Cardiology, Amsterdam UMC location, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Michael Papadakis
- Cardiovascular Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Sanjay Sharma
- Cardiovascular Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
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Millar LM, Fanton Z, Finocchiaro G, Sanchez-Fernandez G, Dhutia H, Malhotra A, Merghani A, Papadakis M, Behr ER, Bunce N, Oxborough D, Reed M, O'Driscoll J, Tome Esteban MT, D'Silva A, Carr-White G, Webb J, Sharma R, Sharma S. Response to eLetter: Fascinating helpful article, but how typical were the patients with DCM and what does this tell us? Heart 2020; 106:1532-1533. [PMID: 32759294 DOI: 10.1136/heartjnl-2020-317724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 11/04/2022] Open
Affiliation(s)
- Lynne Martina Millar
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust and Institute of Molecular and Clinical Sciences St. George's University of London, London, UK
| | - Zephryn Fanton
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust and Institute of Molecular and Clinical Sciences St. George's University of London, London, UK
| | - Gherardo Finocchiaro
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust and Institute of Molecular and Clinical Sciences St. George's University of London, London, UK
| | - Gabriel Sanchez-Fernandez
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust and Institute of Molecular and Clinical Sciences St. George's University of London, London, UK
| | - Harshil Dhutia
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust and Institute of Molecular and Clinical Sciences St. George's University of London, London, UK
| | - Aneil Malhotra
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust and Institute of Molecular and Clinical Sciences St. George's University of London, London, UK.,Division of Cardiovascular Sciences, University of Manchester, Division of Cardiovascular Sciences, Manchester, UK
| | - Ahmed Merghani
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust and Institute of Molecular and Clinical Sciences St. George's University of London, London, UK
| | - Michael Papadakis
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust and Institute of Molecular and Clinical Sciences St. George's University of London, London, UK
| | - Elijah R Behr
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust and Institute of Molecular and Clinical Sciences St. George's University of London, London, UK
| | - Nick Bunce
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust and Institute of Molecular and Clinical Sciences St. George's University of London, London, UK
| | - David Oxborough
- Research Institute of Sports and Exercise Science, Liverpool John Moores University, Liverpool, UK
| | - Matthew Reed
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust and Institute of Molecular and Clinical Sciences St. George's University of London, London, UK
| | | | - Maria Teresa Tome Esteban
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust and Institute of Molecular and Clinical Sciences St. George's University of London, London, UK
| | - Andrew D'Silva
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust and Institute of Molecular and Clinical Sciences St. George's University of London, London, UK
| | - Gerry Carr-White
- Department of Cardiology, Guy's and St. Thomas' Foundation Trust, London, UK
| | - Jessica Webb
- Department of Cardiology, Guy's and St. Thomas' Foundation Trust, London, UK.,King's College London School of Medical Education, London, UK
| | - Rajan Sharma
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust and Institute of Molecular and Clinical Sciences St. George's University of London, London, UK
| | - Sanjay Sharma
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust and Institute of Molecular and Clinical Sciences St. George's University of London, London, UK
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Millar LM, Fanton Z, Finocchiaro G, Sanchez-Fernandez G, Dhutia H, Malhotra A, Merghani A, Papadakis M, Behr ER, Bunce N, Oxborough D, Reed M, O'Driscoll J, Tome Esteban MT, D'Silva A, Carr-White G, Webb J, Sharma R, Sharma S. Differentiation between athlete’s heart and dilated cardiomyopathy in athletic individuals. Heart 2020; 106:1059-1065. [DOI: 10.1136/heartjnl-2019-316147] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 03/22/2020] [Accepted: 03/25/2020] [Indexed: 12/30/2022] Open
Abstract
ObjectiveDistinguishing early dilated cardiomyopathy (DCM) from physiological left ventricular (LV) dilatation with LV ejection fraction <55% in athletes (grey zone) is challenging. We evaluated the role of a cascade of investigations to differentiate these two entities.MethodsThirty-five asymptomatic active males with DCM, 25 male athletes in the ‘grey zone’ and 24 male athletes with normal LV ejection fraction underwent N-terminal pro-brain natriuretic peptide (NT-proBNP) measurement, ECG and exercise echocardiography. Grey-zone athletes and patients with DCM underwent cardiovascular magnetic resonance (CMR) and Holter monitoring.ResultsLarger LV cavity dimensions and lower LV ejection fraction were the only differences between grey-zone and control athletes. None of the grey-zone athletes had abnormal NT-proBNP, increased ectopic burden/complex arrhythmias or pathological late gadolinium enhancement on CMR. These features were also absent in 71%, 71% and 50% of patients with DCM, respectively. 95% of grey-zone athletes and 60% of patients with DCM had normal ECG. During exercise echocardiography, 96% grey-zone athletes increased LV ejection fraction by >11% from baseline to peak exercise compared with 23% of patients with DCM (p<0.0001). Peak LV ejection fraction was >63% in 92% grey-zone athletes compared with 17% patients with DCM (p<0.0001). Failure to increase LV ejection fraction >11% from baseline to peak exercise or achieve a peak LV ejection fraction >63% had sensitivity of 77% and 83%, respectively, and specificity of 96% and 92%, respectively, for predicting DCM.ConclusionComprehensive assessment using a cascade of routine investigations revealed that exercise stress echocardiography has the greatest discriminatory value in differentiating between grey-zone athletes and asymptomatic patients with DCM. Our findings require validation in larger studies.
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Critoph CH, Pantazis A, Tome Esteban MT, Salazar-Mendiguchía J, Pagourelias ED, Moon JC, Elliott PM. The influence of aortoseptal angulation on provocable left ventricular outflow tract obstruction in hypertrophic cardiomyopathy. Open Heart 2014; 1:e000176. [PMID: 25371813 PMCID: PMC4216933 DOI: 10.1136/openhrt-2014-000176] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 08/27/2014] [Accepted: 10/01/2014] [Indexed: 02/06/2023] Open
Abstract
Objectives Aortoseptal angulation (AoSA) can predict provocable left ventricular outflow tract obstruction (LVOTO) in patients with symptomatic hypertrophic cardiomyopathy (HCM). Lack of a standardised measurement technique in HCM without the need for complex three-dimensional (3D) imaging limits its usefulness in routine clinical practice. This study aimed to validate a simple measurement of AoSA using 2D echocardiography and cardiac MR (CMR) imaging as a predictor of LVOTO. Methods We retrospectively assessed 160 patients with non-obstructive HCM, referred for exercise stress echocardiography. AoSA was measured using resting 2D echocardiography in all patients, and CMR in 29. Twenty-five controls with normal echocardiograms were used for comparison. Results Patients with HCM had a reduced AoSA compared with controls (113°±12 vs 126°±6), p<0.0001. Sixty (38%) patients had provocable LVOTO, with smaller angles than non-obstructive patients (108°±12 vs 116°±12, p<0.0001). AoSA, degree of mitral valvular regurgitation and incomplete systolic anterior motion (SAM) were associated with peak left ventricular outflow tract gradient (r=0.508, p<0.0001). An angle ≤100° had 27% sensitivity, 91% specificity and 59% positive predictive value for predicting provocable LVOTO. When combined with SAM, specificity was 99% and positive predictive value 88%. Intraclass correlation coefficient of AoSA measured by two observers was 0.901 (p<0.0001). Bland-Altman analysis of echocardiographic AoSA showed good agreement with the CMR-derived angle. Conclusions Measurement of AoSA using echocardiography in HCM is easy, reproducible and comparable to CMR. Patients with provocable LVOTO have reduced angles compared with non-obstructive patients. AoSA is highly specific for provocable LVOTO and should prompt further evaluation in symptomatic patients without resting obstruction.
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Affiliation(s)
- Christopher Howell Critoph
- Department of Inherited Cardiovascular Disease , The Heart Hospital, University College London , London , UK
| | - Antonios Pantazis
- Department of Inherited Cardiovascular Disease , The Heart Hospital, University College London , London , UK
| | - Maria Teresa Tome Esteban
- Department of Inherited Cardiovascular Disease , The Heart Hospital, University College London , London , UK
| | - Joel Salazar-Mendiguchía
- Cardiomyopathies, Advanced Heart Failure and Transplant Unit , Hospital Universitari de Bellvitge , Barcelona , Spain
| | - Efstathios D Pagourelias
- Department of Inherited Cardiovascular Disease , The Heart Hospital, University College London , London , UK
| | - James C Moon
- Department of Inherited Cardiovascular Disease , The Heart Hospital, University College London , London , UK
| | - Perry Mark Elliott
- Department of Inherited Cardiovascular Disease , The Heart Hospital, University College London , London , UK
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Tome Esteban MT. Dynamic evaluation of exercise limitation and functional class in patients with hypertrophic cardiomyopathy. Rev Esp Cardiol (Engl Ed) 2013; 66:83-84. [PMID: 24775379 DOI: 10.1016/j.rec.2012.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2012] [Accepted: 09/19/2012] [Indexed: 06/03/2023]
Affiliation(s)
- Maria Teresa Tome Esteban
- Inherited Cardiovascular Disease Unit, The Heart Hospital, University College London Hospital, London, United Kingdom.
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Tome Esteban MT. Evaluación dinámica de la capacidad funcional y la limitación con el esfuerzo de los pacientes con miocardiopatía hipertrófica. Rev Esp Cardiol 2013. [DOI: 10.1016/j.recesp.2012.09.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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9
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Pablo Kaski J, Syrris P, Shaw A, Alapi KZ, Cordeddu V, Esteban MTT, Jenkins S, Ashworth M, Hammond P, Tartaglia M, McKenna WJ, Elliott PM. Prevalence of Sequence Variants in the RAS-Mitogen Activated Protein Kinase Signaling Pathway in Pre-Adolescent Children With Hypertrophic Cardiomyopathy. ACTA ACUST UNITED AC 2012; 5:317-26. [DOI: 10.1161/circgenetics.111.960468] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background—
Most cases of apparently idiopathic hypertrophic cardiomyopathy (HCM) in children are caused by mutations in cardiac sarcomere protein genes. HCM also commonly occurs as an associated feature in some patients with disorders caused by mutations in genes encoding components of the RAS-mitogen activated protein kinase (MAPK) signaling pathway. Although diagnosis of these disorders is based on typical phenotypic features, the dysmorphic manifestations can be subtle and therefore overlooked. The aim of this study was to determine the prevalence of mutations in RAS-MAPK genes in preadolescent children with idiopathic HCM.
Methods and Results—
Seventy-eight patients diagnosed with apparently nonsyndromic HCM aged ≤13 years underwent clinical and genetic evaluation. The entire protein coding sequence of 9 genes implicated in Noonan syndrome and related conditions (
PTPN11
,
SOS1
,
HRAS
,
KRAS
,
NRAS
,
BRAF
,
RAF1
,
MAP2K1,
and
MAP2K2
), together with
CBL
(exons 8 and 9) and
SHOC2
(4A>G), were screened for mutations. Five probands (6.4%) carried novel sequence variants in
SOS1
(2 individuals),
BRAF
,
MAP2K1,
and
MAP2K2
. Structural and molecular data suggest that these variants may have functional significance. Nine cardiac sarcomere protein genes were screened also; 2 individuals also had mutations in
MYBPC.
Conclusions—
This study reports novel and potentially pathogenic sequence variants in genes of the RAS-MAPK pathway, suggesting that genetic lesions promoting signaling dysregulation through RAS contribute to disease pathogenesis or progression in children with HCM.
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Affiliation(s)
- Juan Pablo Kaski
- From the Institute of Child Health (J.P.K., P.H., W.J.M., P.M.E.), Department of Medicine (P.S., K.Z.A., W.J.M., P.M.E.), University College, London, United Kingdom; Department of Cardiology (J.P.K., M.T.T.E.), Department of Clinical Genetics (A.S.), Department of Histopathology (M.A.), Great Ormond Street Hospital, London, United Kingdom; Department of Hematology, Oncology and Molecular Medicine, Istituto Superiore di Sanità, Rome, Italy (V.C., M.T.); The Heart Hospital, University College London
| | - Petros Syrris
- From the Institute of Child Health (J.P.K., P.H., W.J.M., P.M.E.), Department of Medicine (P.S., K.Z.A., W.J.M., P.M.E.), University College, London, United Kingdom; Department of Cardiology (J.P.K., M.T.T.E.), Department of Clinical Genetics (A.S.), Department of Histopathology (M.A.), Great Ormond Street Hospital, London, United Kingdom; Department of Hematology, Oncology and Molecular Medicine, Istituto Superiore di Sanità, Rome, Italy (V.C., M.T.); The Heart Hospital, University College London
| | - Adam Shaw
- From the Institute of Child Health (J.P.K., P.H., W.J.M., P.M.E.), Department of Medicine (P.S., K.Z.A., W.J.M., P.M.E.), University College, London, United Kingdom; Department of Cardiology (J.P.K., M.T.T.E.), Department of Clinical Genetics (A.S.), Department of Histopathology (M.A.), Great Ormond Street Hospital, London, United Kingdom; Department of Hematology, Oncology and Molecular Medicine, Istituto Superiore di Sanità, Rome, Italy (V.C., M.T.); The Heart Hospital, University College London
| | - Krisztina Zuborne Alapi
- From the Institute of Child Health (J.P.K., P.H., W.J.M., P.M.E.), Department of Medicine (P.S., K.Z.A., W.J.M., P.M.E.), University College, London, United Kingdom; Department of Cardiology (J.P.K., M.T.T.E.), Department of Clinical Genetics (A.S.), Department of Histopathology (M.A.), Great Ormond Street Hospital, London, United Kingdom; Department of Hematology, Oncology and Molecular Medicine, Istituto Superiore di Sanità, Rome, Italy (V.C., M.T.); The Heart Hospital, University College London
| | - Viviana Cordeddu
- From the Institute of Child Health (J.P.K., P.H., W.J.M., P.M.E.), Department of Medicine (P.S., K.Z.A., W.J.M., P.M.E.), University College, London, United Kingdom; Department of Cardiology (J.P.K., M.T.T.E.), Department of Clinical Genetics (A.S.), Department of Histopathology (M.A.), Great Ormond Street Hospital, London, United Kingdom; Department of Hematology, Oncology and Molecular Medicine, Istituto Superiore di Sanità, Rome, Italy (V.C., M.T.); The Heart Hospital, University College London
| | - Maria Teresa Tome Esteban
- From the Institute of Child Health (J.P.K., P.H., W.J.M., P.M.E.), Department of Medicine (P.S., K.Z.A., W.J.M., P.M.E.), University College, London, United Kingdom; Department of Cardiology (J.P.K., M.T.T.E.), Department of Clinical Genetics (A.S.), Department of Histopathology (M.A.), Great Ormond Street Hospital, London, United Kingdom; Department of Hematology, Oncology and Molecular Medicine, Istituto Superiore di Sanità, Rome, Italy (V.C., M.T.); The Heart Hospital, University College London
| | - Sharon Jenkins
- From the Institute of Child Health (J.P.K., P.H., W.J.M., P.M.E.), Department of Medicine (P.S., K.Z.A., W.J.M., P.M.E.), University College, London, United Kingdom; Department of Cardiology (J.P.K., M.T.T.E.), Department of Clinical Genetics (A.S.), Department of Histopathology (M.A.), Great Ormond Street Hospital, London, United Kingdom; Department of Hematology, Oncology and Molecular Medicine, Istituto Superiore di Sanità, Rome, Italy (V.C., M.T.); The Heart Hospital, University College London
| | - Michael Ashworth
- From the Institute of Child Health (J.P.K., P.H., W.J.M., P.M.E.), Department of Medicine (P.S., K.Z.A., W.J.M., P.M.E.), University College, London, United Kingdom; Department of Cardiology (J.P.K., M.T.T.E.), Department of Clinical Genetics (A.S.), Department of Histopathology (M.A.), Great Ormond Street Hospital, London, United Kingdom; Department of Hematology, Oncology and Molecular Medicine, Istituto Superiore di Sanità, Rome, Italy (V.C., M.T.); The Heart Hospital, University College London
| | - Peter Hammond
- From the Institute of Child Health (J.P.K., P.H., W.J.M., P.M.E.), Department of Medicine (P.S., K.Z.A., W.J.M., P.M.E.), University College, London, United Kingdom; Department of Cardiology (J.P.K., M.T.T.E.), Department of Clinical Genetics (A.S.), Department of Histopathology (M.A.), Great Ormond Street Hospital, London, United Kingdom; Department of Hematology, Oncology and Molecular Medicine, Istituto Superiore di Sanità, Rome, Italy (V.C., M.T.); The Heart Hospital, University College London
| | - Marco Tartaglia
- From the Institute of Child Health (J.P.K., P.H., W.J.M., P.M.E.), Department of Medicine (P.S., K.Z.A., W.J.M., P.M.E.), University College, London, United Kingdom; Department of Cardiology (J.P.K., M.T.T.E.), Department of Clinical Genetics (A.S.), Department of Histopathology (M.A.), Great Ormond Street Hospital, London, United Kingdom; Department of Hematology, Oncology and Molecular Medicine, Istituto Superiore di Sanità, Rome, Italy (V.C., M.T.); The Heart Hospital, University College London
| | - William J. McKenna
- From the Institute of Child Health (J.P.K., P.H., W.J.M., P.M.E.), Department of Medicine (P.S., K.Z.A., W.J.M., P.M.E.), University College, London, United Kingdom; Department of Cardiology (J.P.K., M.T.T.E.), Department of Clinical Genetics (A.S.), Department of Histopathology (M.A.), Great Ormond Street Hospital, London, United Kingdom; Department of Hematology, Oncology and Molecular Medicine, Istituto Superiore di Sanità, Rome, Italy (V.C., M.T.); The Heart Hospital, University College London
| | - Perry M. Elliott
- From the Institute of Child Health (J.P.K., P.H., W.J.M., P.M.E.), Department of Medicine (P.S., K.Z.A., W.J.M., P.M.E.), University College, London, United Kingdom; Department of Cardiology (J.P.K., M.T.T.E.), Department of Clinical Genetics (A.S.), Department of Histopathology (M.A.), Great Ormond Street Hospital, London, United Kingdom; Department of Hematology, Oncology and Molecular Medicine, Istituto Superiore di Sanità, Rome, Italy (V.C., M.T.); The Heart Hospital, University College London
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Kaski JP, Syrris P, Esteban MTT, Jenkins S, Pantazis A, Deanfield JE, McKenna WJ, Elliott PM. Prevalence of sarcomere protein gene mutations in preadolescent children with hypertrophic cardiomyopathy. ACTA ACUST UNITED AC 2009; 2:436-41. [PMID: 20031618 DOI: 10.1161/circgenetics.108.821314] [Citation(s) in RCA: 142] [Impact Index Per Article: 9.5] [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 Hypertrophic cardiomyopathy (HCM) in infants and children is thought to be commonly associated with metabolic disorders and malformation syndromes. Familial disease caused by mutations in cardiac sarcomere protein genes, which accounts for most cases in adolescents and adults, is believed to be a very rare cause of HCM. METHODS AND RESULTS Seventy-nine consecutive patients diagnosed with HCM aged 13 years or younger underwent detailed clinical and genetic evaluation. The protein-coding sequences of 9 sarcomere protein genes (MYH7, MYBPC3, TNNI3, TNNT2, TPM1, MYL2, MYL3, ACTC, and TNNC1), the genes encoding desmin (DES), and the gamma-2 subunit of AMP kinase (PRKAG2) were screened for mutations. A family history of HCM was present in 48 patients (60.8%). Forty-seven mutations (15 novel) were identified in 42 (53.2%) patients (5 patients had 2 mutations). The genes most commonly implicated were MYH7 (48.9%) and MYBPC3 (36.2%); mutations in TNNT2, ACTC, MYL3, and TNNI3 accounted for <5% of cases each. A total of 16.7% patients with sarcomeric mutations were diagnosed before 1 year of age. There were no differences in clinical and echocardiographic features between those children with sarcomere protein gene mutations and those without or between patients with 2 mutations and those with 1 or no mutations. CONCLUSIONS This study shows that familial disease is common among infants and children with HCM and that, in most cases, disease is caused by mutations in cardiac sarcomere protein genes. The major implication is that all first-degree relatives of any child diagnosed with HCM should be offered screening. Furthermore, the finding that one sixth of patients with sarcomeric disease were diagnosed in infancy suggests that current views on pathogenesis and natural history of familial HCM may have to be revised.
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Affiliation(s)
- Juan Pablo Kaski
- Inherited Cardiovascular Diseases Unit, Institute of Child Health, University College London, London, United Kingdom
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11
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Shah JS, Esteban MTT, Thaman R, Sharma R, Mist B, Pantazis A, Ward D, Kohli SK, Page SP, Demetrescu C, Sevdalis E, Keren A, Pellerin D, McKenna WJ, Elliott PM. Prevalence of exercise-induced left ventricular outflow tract obstruction in symptomatic patients with non-obstructive hypertrophic cardiomyopathy. Heart 2007; 94:1288-94. [DOI: 10.1136/hrt.2007.126003] [Citation(s) in RCA: 156] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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12
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Tome Esteban MT. Profile of a young cardiologist. Circulation 2006; 113:f32. [PMID: 16509007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
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