Identification of the first homozygous intragenic deletion in the YY1AP1 gene in a consanguineous family: New insights into the phenotypic variability associated with Grange syndrome

Grange syndrome (GRNG-MIM#135580) is a rare recessive disorder associating variable features including diffuse vascular stenosis, brachysyndactyly, osteopenia with increased bone fragility, cardiac malformations, and variable developmental delay. Since its first description in 1998, only 15 individuals from 10 families have been reported, carrying homozygous or compound heterozygous frameshift or nonsense variants in YY1AP1. In a patient with cutaneous and bone syndactyly and a hemorrhagic stroke at the age of 16 months, consistent with a clinical diagnosis of GRNG, we performed exome sequencing after negative array-CGH and congenital limb malformation panel results. Copy number variant analysis from exome data identified a homozygous intragenic out-of-frame deletion of 1.84 kb encompassing exons seven and eight of YY1AP1, confirming a molecular diagnosis of GRNG. Genetic counseling led to the identification of additional family members compatible with GRNG. Here, we provide new insights into the phenotypic variability associated with GRNG and highlight the utility of the detection of small copy number variants to identify the molecular causes of heterogeneous malformative genetic disorders.

Ultra-fast remote up-titration of heart failure treatment: a safe, efficient and feasible protocol

Introduction

Heart failure (HF) is a common disease with a significant economic burden, mainly caused by HF hospitalisations and significant morbi-mortality. Nevertheless, HF patients are still undertreated due to a clinical inertia that needs to be reversed as soon as possible using new, safe and available methods. Remote up-titrating HF medication might be the solution to rapidly optimize HF treatment to maximal tolerated doses.

Purpose

Our objective was to describe the safety, efficacy and feasibility of an ultra-fast remote up-titration protocol of HF treatment.

Methods

Patients with a recent hospitalization due to a HF decompensation and left ventricular ejection fraction <50% were retrospectively included in our database. We collected clinical, biological and treatment data at enrollment and at the end of HF medication optimization. Our protocol consisted in remote consultation (via telephone or video-consultation) every 15 days with a 72h prior blood test. Blood pressure (BP), heart rate (HR) and weight were recorded either by tele-monitoring or self-measurement.

Results

We evaluated 96 patients, 25% female with a mean LVEF at 29%, main etiology of HF was ischemic (48%) and mean NTproBNP was 2384 pg/mL. Mean BP was 112/70 mmHg, HR was 73 bpm, glomerular filtration rate (GFR) 71 ml/min and potassium concentration was 4,4 mEq/L. Ninety four patients were initially treated with a beta blocker (BB), 29% of our cohort was treated either with an angiotensin-converting enzyme inhibitor (ACEI) or an angiotensin receptor blocker (ARB) and 59% was treated with angiotensin receptor neprilysin inhibitor (ARNI). A total of 72 patients were treated with a mineralocorticoid receptor antagonist (MRA) and 58 patients were also treated with an inhibitor of sodium-glucose transport protein 2 (SLGT2i), Figure 1. Median duration of tele-titration consultation was 42 days. We up-titrated BB in 50% of our patients, of which 10% were at maximum dose, making a total of 98% of our cohort under BB treatment. Sixty percent of patients under ACEI or ARB were switched to ARNI. Of the 82% of patients under ARNI, up to 50% achieved the maximal dose.

We introduced or up-titrated ARM in 41 patients, reaching the target dose in 37%. Dose variations and mean initial and final doses are shown in Figure 2.1 and 2.2

Minor adverse events that motivated a down-titration or a cessation of treatment were, hyperkalemia 5%, acute renal failure (ARF) 6%, hypotension 3% and bradycardia 2%. Non urgent hospitalization due to ARF with hyperkalemia or HF only occurred in 2 cases.

The limiting factors for not reaching the optimal targeted dose were low HR in 20%, hypotension in 11%, high concentration of potassium 10% and chronic renal failure in 9%.

Conclusion

Remote up-titration of HF medication is a promising tool in the fight against clinical inertia and a fast, feasible, safe (only 2% of major events) and efficient solution to our undertreated patients.

Funding Acknowledgement

Type of funding sources: None.

Benefits of interventional telemonitoring in patients with chronic heart failure

Background

The aim of this study was to assess the effect of interventional specialized Telemonitoring (ITM) compared to standard telemonitoring (STM) and standard of care (SC) on preventing all causes of death, cardiovascular mortality and unplanned hospitalization in heart failure (HF) patients.

Methods and results

414 HF-patients derived from two French cohorts (OSICAT and ETAPES) were included in this study, and subsequently randomized into three groups ITM-group (n=220), STM-group (n=99) and SC-group (n=95). The telemonitoring was performed by the specialized HF-cardiology staff at a university hospital. During the mean follow-up period of 344 days, there were significantly fewer primary endpoints like unplanned hospitalization (13.6% vs 34.3% vs 36.8%, p<0.05), all-cause of death (4.5% vs 20.2% vs 16.8%, p<0.05) and cardiovascular mortality (3.2% vs 15.2% vs 8.4%, p<0.05) in the ITM-group. The multivariate logistic regression revealed a significant negative association between the ITM and unplanned hospitalization (OR=0.293 95% CI [0.160–0.535], p<0.05) and all-cause of death (OR=0.243 95% CI [0.099–0.596], p=0.002), respectively. Kaplan Meier and log rank test showed significant difference in median event-free survival in favor of ITM-group.

Conclusions

Using ITM to follow-up HF-patients results in reducing the rate of unplanned hospitalization and all cause of death.

Funding Acknowledgement

Type of funding sources: None.