1
|
Amar D, Gay NR, Jean-Beltran PM, Bae D, Dasari S, Dennis C, Evans CR, Gaul DA, Ilkayeva O, Ivanova AA, Kachman MT, Keshishian H, Lanza IR, Lira AC, Muehlbauer MJ, Nair VD, Piehowski PD, Rooney JL, Smith KS, Stowe CL, Zhao B, Clark NM, Jimenez-Morales D, Lindholm ME, Many GM, Sanford JA, Smith GR, Vetr NG, Zhang T, Almagro Armenteros JJ, Avila-Pacheco J, Bararpour N, Ge Y, Hou Z, Marwaha S, Presby DM, Natarajan Raja A, Savage EM, Steep A, Sun Y, Wu S, Zhen J, Bodine SC, Esser KA, Goodyear LJ, Schenk S, Montgomery SB, Fernández FM, Sealfon SC, Snyder MP, Adkins JN, Ashley E, Burant CF, Carr SA, Clish CB, Cutter G, Gerszten RE, Kraus WE, Li JZ, Miller ME, Nair KS, Newgard C, Ortlund EA, Qian WJ, Tracy R, Walsh MJ, Wheeler MT, Dalton KP, Hastie T, Hershman SG, Samdarshi M, Teng C, Tibshirani R, Cornell E, Gagne N, May S, Bouverat B, Leeuwenburgh C, Lu CJ, Pahor M, Hsu FC, Rushing S, Walkup MP, Nicklas B, Rejeski WJ, Williams JP, Xia A, Albertson BG, Barton ER, Booth FW, Caputo T, Cicha M, De Sousa LGO, Farrar R, Hevener AL, Hirshman MF, Jackson BE, Ke BG, Kramer KS, Lessard SJ, Makarewicz NS, Marshall AG, Nigro P, Powers S, Ramachandran K, Rector RS, Richards CZT, Thyfault J, Yan Z, Zang C, Amper MAS, Balci AT, Chavez C, Chikina M, Chiu R, Gritsenko MA, Guevara K, Hansen JR, Hennig KM, Hung CJ, Hutchinson-Bunch C, Jin CA, Liu X, Maner-Smith KM, Mani DR, Marjanovic N, Monroe ME, Moore RJ, Moore SG, Mundorff CC, Nachun D, Nestor MD, Nudelman G, Pearce C, Petyuk VA, Pincas H, Ramos I, Raskind A, Rirak S, Robbins JM, Rubenstein AB, Ruf-Zamojski F, Sagendorf TJ, Seenarine N, Soni T, Uppal K, Vangeti S, Vasoya M, Vornholt A, Yu X, Zaslavsky E, Zebarjadi N, Bamman M, Bergman BC, Bessesen DH, Buford TW, Chambers TL, Coen PM, Cooper D, Haddad F, Gadde K, Goodpaster BH, Harris M, Huffman KM, Jankowski CM, Johannsen NM, Kohrt WM, Lester B, Melanson EL, Moreau KL, Musi N, Newton RL, Radom-Aizik S, Ramaker ME, Rankinen T, Rasmussen BB, Ravussin E, Schauer IE, Schwartz RS, Sparks LM, Thalacker-Mercer A, Trappe S, Trappe TA, Volpi E. Temporal dynamics of the multi-omic response to endurance exercise training. Nature 2024; 629:174-183. [PMID: 38693412 PMCID: PMC11062907 DOI: 10.1038/s41586-023-06877-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 11/16/2023] [Indexed: 05/03/2024]
Abstract
Regular exercise promotes whole-body health and prevents disease, but the underlying molecular mechanisms are incompletely understood1-3. Here, the Molecular Transducers of Physical Activity Consortium4 profiled the temporal transcriptome, proteome, metabolome, lipidome, phosphoproteome, acetylproteome, ubiquitylproteome, epigenome and immunome in whole blood, plasma and 18 solid tissues in male and female Rattus norvegicus over eight weeks of endurance exercise training. The resulting data compendium encompasses 9,466 assays across 19 tissues, 25 molecular platforms and 4 training time points. Thousands of shared and tissue-specific molecular alterations were identified, with sex differences found in multiple tissues. Temporal multi-omic and multi-tissue analyses revealed expansive biological insights into the adaptive responses to endurance training, including widespread regulation of immune, metabolic, stress response and mitochondrial pathways. Many changes were relevant to human health, including non-alcoholic fatty liver disease, inflammatory bowel disease, cardiovascular health and tissue injury and recovery. The data and analyses presented in this study will serve as valuable resources for understanding and exploring the multi-tissue molecular effects of endurance training and are provided in a public repository ( https://motrpac-data.org/ ).
Collapse
|
2
|
Behr M, Kumbier K, Cordova-Palomera A, Aguirre M, Ronen O, Ye C, Ashley E, Butte AJ, Arnaout R, Brown B, Priest J, Yu B. Learning epistatic polygenic phenotypes with Boolean interactions. PLoS One 2024; 19:e0298906. [PMID: 38625909 PMCID: PMC11020961 DOI: 10.1371/journal.pone.0298906] [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] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 01/31/2024] [Indexed: 04/18/2024] Open
Abstract
Detecting epistatic drivers of human phenotypes is a considerable challenge. Traditional approaches use regression to sequentially test multiplicative interaction terms involving pairs of genetic variants. For higher-order interactions and genome-wide large-scale data, this strategy is computationally intractable. Moreover, multiplicative terms used in regression modeling may not capture the form of biological interactions. Building on the Predictability, Computability, Stability (PCS) framework, we introduce the epiTree pipeline to extract higher-order interactions from genomic data using tree-based models. The epiTree pipeline first selects a set of variants derived from tissue-specific estimates of gene expression. Next, it uses iterative random forests (iRF) to search training data for candidate Boolean interactions (pairwise and higher-order). We derive significance tests for interactions, based on a stabilized likelihood ratio test, by simulating Boolean tree-structured null (no epistasis) and alternative (epistasis) distributions on hold-out test data. Finally, our pipeline computes PCS epistasis p-values that probabilisticly quantify improvement in prediction accuracy via bootstrap sampling on the test set. We validate the epiTree pipeline in two case studies using data from the UK Biobank: predicting red hair and multiple sclerosis (MS). In the case of predicting red hair, epiTree recovers known epistatic interactions surrounding MC1R and novel interactions, representing non-linearities not captured by logistic regression models. In the case of predicting MS, a more complex phenotype than red hair, epiTree rankings prioritize novel interactions surrounding HLA-DRB1, a variant previously associated with MS in several populations. Taken together, these results highlight the potential for epiTree rankings to help reduce the design space for follow up experiments.
Collapse
Affiliation(s)
- Merle Behr
- Faculty of Informatics and Data Science, University of Regensburg, Regensburg, Germany
| | - Karl Kumbier
- Department of Pharmaceutical Chemistry, University of California, San Francisco, San Francisco, CA, United States of America
| | | | - Matthew Aguirre
- Department of Pediatrics, Stanford Medicine, Stanford, CA, United States of America
- Department of Biomedical Data Science, Stanford Medicine, Stanford, CA, United States of America
| | - Omer Ronen
- Department of Statistics, University of California at Berkeley, Berkeley, CA, United States of America
| | - Chengzhong Ye
- Department of Statistics, University of California at Berkeley, Berkeley, CA, United States of America
| | - Euan Ashley
- Division of Cardiovascular Medicine, Stanford Medicine, Stanford, CA, United States of America
| | - Atul J. Butte
- Bakar Computational Health Sciences Institute, University of California, San Francisco, San Francisco, CA, United States of America
| | - Rima Arnaout
- Bakar Computational Health Sciences Institute, University of California, San Francisco, San Francisco, CA, United States of America
- Division of Cardiology, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States of America
| | - Ben Brown
- Department of Statistics, University of California at Berkeley, Berkeley, CA, United States of America
- Biosciences Area, Lawrence Berkeley National Laboratory, Berkeley, CA, United States of America
| | - James Priest
- Department of Pediatrics, Stanford Medicine, Stanford, CA, United States of America
| | - Bin Yu
- Department of Statistics, University of California at Berkeley, Berkeley, CA, United States of America
- Department of Electrical Engineering and Computer Sciences and Center for Computational Biology, University of California at Berkeley, Berkeley, CA, United States of America
| |
Collapse
|
3
|
Bhave S, Rodriguez V, Poterucha T, Mutasa S, Aberle D, Capaccione KM, Chen Y, Dsouza B, Dumeer S, Goldstein J, Hodes A, Leb J, Lungren M, Miller M, Monoky D, Navot B, Wattamwar K, Wattamwar A, Clerkin K, Ouyang D, Ashley E, Topkara VK, Maurer M, Einstein AJ, Uriel N, Homma S, Schwartz A, Jaramillo D, Perotte AJ, Elias P. Deep learning to detect left ventricular structural abnormalities in chest X-rays. Eur Heart J 2024:ehad782. [PMID: 38503537 DOI: 10.1093/eurheartj/ehad782] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 09/24/2023] [Accepted: 11/14/2023] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND AND AIMS Early identification of cardiac structural abnormalities indicative of heart failure is crucial to improving patient outcomes. Chest X-rays (CXRs) are routinely conducted on a broad population of patients, presenting an opportunity to build scalable screening tools for structural abnormalities indicative of Stage B or worse heart failure with deep learning methods. In this study, a model was developed to identify severe left ventricular hypertrophy (SLVH) and dilated left ventricle (DLV) using CXRs. METHODS A total of 71 589 unique CXRs from 24 689 different patients completed within 1 year of echocardiograms were identified. Labels for SLVH, DLV, and a composite label indicating the presence of either were extracted from echocardiograms. A deep learning model was developed and evaluated using area under the receiver operating characteristic curve (AUROC). Performance was additionally validated on 8003 CXRs from an external site and compared against visual assessment by 15 board-certified radiologists. RESULTS The model yielded an AUROC of 0.79 (0.76-0.81) for SLVH, 0.80 (0.77-0.84) for DLV, and 0.80 (0.78-0.83) for the composite label, with similar performance on an external data set. The model outperformed all 15 individual radiologists for predicting the composite label and achieved a sensitivity of 71% vs. 66% against the consensus vote across all radiologists at a fixed specificity of 73%. CONCLUSIONS Deep learning analysis of CXRs can accurately detect the presence of certain structural abnormalities and may be useful in early identification of patients with LV hypertrophy and dilation. As a resource to promote further innovation, 71 589 CXRs with adjoining echocardiographic labels have been made publicly available.
Collapse
Affiliation(s)
- Shreyas Bhave
- Division of Cardiology and Department of Biomedical Informatics, Columbia University Irving Medical Center, 622 West 168th Street, PH20, NewYork, NY 10032, USA
| | - Victor Rodriguez
- Division of Cardiology and Department of Biomedical Informatics, Columbia University Irving Medical Center, 622 West 168th Street, PH20, NewYork, NY 10032, USA
| | - Timothy Poterucha
- Seymour, Paul, and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, 630 West 168th Street, NewYork, NY 10032, USA
| | - Simukayi Mutasa
- Department of Radiology, Columbia University Irving Medical Center, NewYork, NY, USA
| | - Dwight Aberle
- Department of Radiology, Columbia University Irving Medical Center, NewYork, NY, USA
| | - Kathleen M Capaccione
- Department of Radiology, Columbia University Irving Medical Center, NewYork, NY, USA
| | - Yibo Chen
- Inova Fairfax Hospital Imaging Center, Inova Fairfax Medical Campus, Falls Church, VA, USA
| | - Belinda Dsouza
- Department of Radiology, Columbia University Irving Medical Center, NewYork, NY, USA
| | - Shifali Dumeer
- Department of Radiology, Columbia University Irving Medical Center, NewYork, NY, USA
| | - Jonathan Goldstein
- Department of Radiology, Columbia University Irving Medical Center, NewYork, NY, USA
| | - Aaron Hodes
- Hackensack Radiology Group, Hackensack Meridian School of Medicine, Nutley, NJ, USA
| | - Jay Leb
- Department of Radiology, Columbia University Irving Medical Center, NewYork, NY, USA
| | - Matthew Lungren
- Department of Radiology, University of California, SanFrancisco, CA, USA
| | - Mitchell Miller
- Hackensack Radiology Group, Hackensack Meridian School of Medicine, Nutley, NJ, USA
| | - David Monoky
- Hackensack Radiology Group, Hackensack Meridian School of Medicine, Nutley, NJ, USA
| | - Benjamin Navot
- Department of Radiology, Columbia University Irving Medical Center, NewYork, NY, USA
| | - Kapil Wattamwar
- Division of Vascular and Interventional Radiology, Department of Radiology, Montefiore Medical Center, Bronx, NY, USA
| | - Anoop Wattamwar
- Hackensack Radiology Group, Hackensack Meridian School of Medicine, Nutley, NJ, USA
| | - Kevin Clerkin
- Seymour, Paul, and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, 630 West 168th Street, NewYork, NY 10032, USA
| | - David Ouyang
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Euan Ashley
- Stanford Center for Inherited Cardiovascular Disease, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Veli K Topkara
- Seymour, Paul, and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, 630 West 168th Street, NewYork, NY 10032, USA
| | - Mathew Maurer
- Seymour, Paul, and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, 630 West 168th Street, NewYork, NY 10032, USA
| | - Andrew J Einstein
- Seymour, Paul, and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, 630 West 168th Street, NewYork, NY 10032, USA
- Department of Radiology, Columbia University Irving Medical Center, NewYork, NY, USA
| | - Nir Uriel
- Seymour, Paul, and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, 630 West 168th Street, NewYork, NY 10032, USA
| | - Shunichi Homma
- Seymour, Paul, and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, 630 West 168th Street, NewYork, NY 10032, USA
| | - Allan Schwartz
- Seymour, Paul, and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, 630 West 168th Street, NewYork, NY 10032, USA
| | - Diego Jaramillo
- Department of Radiology, Columbia University Irving Medical Center, NewYork, NY, USA
| | - Adler J Perotte
- Division of Cardiology and Department of Biomedical Informatics, Columbia University Irving Medical Center, 622 West 168th Street, PH20, NewYork, NY 10032, USA
| | - Pierre Elias
- Division of Cardiology and Department of Biomedical Informatics, Columbia University Irving Medical Center, 622 West 168th Street, PH20, NewYork, NY 10032, USA
- Seymour, Paul, and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, 630 West 168th Street, NewYork, NY 10032, USA
| |
Collapse
|
4
|
Santana EJ, Christle JW, Cauwenberghs N, Peterman JE, Busque V, Gomes B, Bagherzadeh SP, Moneghetti K, Kuznetsova T, Wheeler M, Ashley E, Harber MP, Arena R, Kaminsky LA, Myers J, Haddad F. Improving Reporting of Exercise Capacity Across Age Ranges Using Novel Workload Reference Equations. Am J Cardiol 2024; 215:32-41. [PMID: 38301753 DOI: 10.1016/j.amjcard.2024.01.022] [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: 10/19/2023] [Revised: 01/09/2024] [Accepted: 01/19/2024] [Indexed: 02/03/2024]
Abstract
Exercise capacity (EC) is an important predictor of survival in the general population and in subjects with cardiopulmonary disease. Despite its relevance, considering the percent-predicted workload (%pWL) given by current equations may overestimate EC in older adults. Therefore, to improve the reporting of EC in clinical practice, our main objective was to develop workload reference equations (pWL) that better reflect the relation between workload and age. Using the Fitness Registry and the Importance of Exercise National Database (FRIEND), we analyzed a reference group of 6,966 apparently healthy participants and 1,060 participants with heart failure who underwent graded treadmill cardiopulmonary exercise testing. For the first group, the mean age was 44 years (18 to 79); 56.5% of participants were males and 15.4% had obesity. Peak oxygen consumption was 11.6 ± 3.0 METs in males and 8.5 ± 2.4 METs in females. After partition analysis, we first developed sex-specific pWL equations to allow comparisons to a healthy weight reference. For males, pWL (METs) = 14.1-0.9×10-3×age2 and 11.5-0.87×10-3×age2 for females. We used those equations as denominators of %pWL, and based on their distribution, we determined thresholds for EC classification, with average EC defined by the range corresponding to 85% to 115%pWL. Compared with %pWL using current equations, the new equations yielded better-calibrated %pWL across different age ranges. We also derived body mass index-adjusted pWL equations that better assessed EC in subjects with heart failure. In conclusion, the novel pWL equations have the potential to impact the report of EC in practice.
Collapse
Affiliation(s)
- Everton J Santana
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California; Stanford Cardiovascular Institute, Stanford University, Stanford, California; Research Unit Hypertension and Cardiovascular Epidemiology, Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium.
| | - Jeffrey W Christle
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California; Stanford Cardiovascular Institute, Stanford University, Stanford, California; Stanford Sports Cardiology, Department of Medicine, Stanford University, Stanford, California
| | - Nicholas Cauwenberghs
- Research Unit Hypertension and Cardiovascular Epidemiology, Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - James E Peterman
- Fisher Institute of Health and Well-Being, Ball State University, Muncie, Indiana
| | - Vincent Busque
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Bruna Gomes
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California; Stanford Cardiovascular Institute, Stanford University, Stanford, California; Department of Cardiology, Pneumology and Angiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Shadi P Bagherzadeh
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Kegan Moneghetti
- Baker Department of Cardiometabolic Health, University of Melbourne, Melbourne, Australia
| | - Tatiana Kuznetsova
- Research Unit Hypertension and Cardiovascular Epidemiology, Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Matthew Wheeler
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Euan Ashley
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California; Department of Genetics, Stanford University School of Medicine, Stanford, California; Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, California
| | - Matthew P Harber
- Clinical Exercise Physiology Laboratory, College of Health, Ball State University, Muncie, Indiana
| | - Ross Arena
- Department of Physical Therapy, College of Applied Sciences, University of Illinois at Chicago, Chicago, Illinois; Healthy Living for Pandemic Event Protection (HL - PIVOT) Network, Chicago, Illinios
| | - Leonard A Kaminsky
- Fisher Institute of Health and Well-Being, Ball State University, Muncie, Indiana; Clinical Exercise Physiology Laboratory, College of Health, Ball State University, Muncie, Indiana; Healthy Living for Pandemic Event Protection (HL - PIVOT) Network, Chicago, Illinios
| | - Jonathan Myers
- Healthy Living for Pandemic Event Protection (HL - PIVOT) Network, Chicago, Illinios; Division of Cardiology, Veterans Affairs Palo Alto Healthcare System and Stanford University, Palo Alto, California.
| | - Francois Haddad
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California; Stanford Cardiovascular Institute, Stanford University, Stanford, California; Stanford Diabetes Research Center, Stanford University, Stanford, California; Wu Tsai Performance Alliance, Stanford University, Stanford, California.
| |
Collapse
|
5
|
Busque V, Christle JW, Moneghetti KJ, Cauwenberghs N, Kouznetsova T, Blumberg Y, Wheeler MT, Ashley E, Haddad F, Myers J. Quantifying assumptions underlying peak oxygen consumption equations across the body mass spectrum. Clin Obes 2024:e12653. [PMID: 38475989 DOI: 10.1111/cob.12653] [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: 06/02/2023] [Revised: 02/08/2024] [Accepted: 02/16/2024] [Indexed: 03/14/2024]
Abstract
The goal of this study is to quantify the assumptions associated with the Wasserman-Hansen (WH) and Fitness Registry and the Importance of Exercise: A National Database (FRIEND) predictive peak oxygen consumption (pVO2 ) equations across body mass index (BMI). Assumptions in pVO2 for both equations were first determined using a simulation and then evaluated using exercise data from the Stanford Exercise Testing registry. We calculated percent-predicted VO2 (ppVO2 ) values for both equations and compared them using the Bland-Altman method. Assumptions associated with pVO2 across BMI categories were quantified by comparing the slopes of age-adjusted VO2 ratios (pVO2 /pre-exercise VO2 ) and ppVO2 values for different BMI categories. The simulation revealed lower predicted fitness among adults with obesity using the FRIEND equation compared to the WH equations. In the clinical cohort, we evaluated 2471 patients (56.9% male, 22% with BMI >30 kg/m2 , pVO2 26.8 mlO2 /kg/min). The Bland-Altman plot revealed an average relative difference of -1.7% (95% CI: -2.1 to -1.2%) between WH and FRIEND ppVO2 values with greater differences among those with obesity. Analysis of the VO2 ratio to ppVO2 slopes across the BMI spectrum confirmed the assumption of lower fitness in those with obesity, and this trend was more pronounced using the FRIEND equation. Peak VO2 estimations between the WH and FRIEND equations differed significantly among individuals with obesity. The FRIEND equation resulted in a greater attributable reduction in pVO2 associated with obesity relative to the WH equations. The outlined relationships between BMI and predicted VO2 may better inform the clinical interpretation of ppVO2 values during cardiopulmonary exercise test evaluations.
Collapse
Affiliation(s)
- Vincent Busque
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California, USA
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Jeffrey W Christle
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California, USA
| | - Kegan J Moneghetti
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California, USA
- Baker Department of Cardiometabolic Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Nicholas Cauwenberghs
- Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Tatiana Kouznetsova
- Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Yair Blumberg
- Azrieli Faculty of Medicine, Bar-Ilan University, Ramat Gan, Israel
| | - Matthew T Wheeler
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California, USA
| | - Euan Ashley
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California, USA
| | - Francois Haddad
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California, USA
| | - Jonathan Myers
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California, USA
- Department of Cardiovascular Medicine, Palo Alto Veterans Administration, Palo Alto, California, USA
| |
Collapse
|
6
|
Russell C, Campion M, Grove ME, Matsuda K, Klein TE, Ashley E, Naik H, Wheeler MT, Scott SA. Knowledge and attitudes on implementing cardiovascular pharmacogenomic testing. Clin Transl Sci 2024; 17:e13737. [PMID: 38421234 PMCID: PMC10903329 DOI: 10.1111/cts.13737] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 12/22/2023] [Accepted: 01/23/2024] [Indexed: 03/02/2024] Open
Abstract
Pharmacogenomics has the potential to inform drug dosing and selection, reduce adverse events, and improve medication efficacy; however, provider knowledge of pharmacogenomic testing varies across provider types and specialties. Given that many actionable pharmacogenomic genes are implicated in cardiovascular medication response variability, this study aimed to evaluate cardiology providers' knowledge and attitudes on implementing clinical pharmacogenomic testing. Sixty-one providers responded to an online survey, including pharmacists (46%), physicians (31%), genetic counselors (15%), and nurses (8%). Most respondents (94%) reported previous genetics education; however, only 52% felt their genetics education prepared them to order a clinical pharmacogenomic test. In addition, most respondents (66%) were familiar with pharmacogenomics, with genetic counselors being most likely to be familiar (p < 0.001). Only 15% of respondents had previously ordered a clinical pharmacogenomic test and a total of 36% indicated they are likely to order a pharmacogenomic test in the future; however, the vast majority of respondents (89%) were interested in pharmacogenomic testing being incorporated into diagnostic cardiovascular genetic tests. Moreover, 84% of providers preferred pharmacogenomic panel testing compared to 16% who preferred single gene testing. Half of the providers reported being comfortable discussing pharmacogenomic results with their patients, but the majority (60%) expressed discomfort with the logistics of test ordering. Reported barriers to implementation included uncertainty about the clinical utility and difficulty choosing an appropriate test. Taken together, cardiology providers have moderate familiarity with pharmacogenomics and limited experience with test ordering; however, they are interested in incorporating pharmacogenomics into diagnostic genetic tests and ordering pharmacogenomic panels.
Collapse
Affiliation(s)
- Callan Russell
- Department of GeneticsStanford UniversityStanfordCaliforniaUSA
- Present address:
Northside HospitalAtlantaGeorgiaUSA
| | - MaryAnn Campion
- Department of GeneticsStanford UniversityStanfordCaliforniaUSA
| | - Megan E. Grove
- Clinical Genomics LaboratoryStanford MedicinePalo AltoCaliforniaUSA
- Present address:
Color HealthBurlingameCaliforniaUSA
| | - Kelly Matsuda
- Division of Pharmacy and CardiologyStanford Health CarePalo AltoCaliforniaUSA
| | - Teri E. Klein
- Department of Biomedical Data ScienceStanford UniversityStanfordCaliforniaUSA
| | - Euan Ashley
- Stanford Center for Inherited Cardiovascular DiseaseStanfordCaliforniaUSA
- Department of Medicine, Division of Cardiovascular MedicineStanford UniversityStanfordCaliforniaUSA
| | - Hetanshi Naik
- Department of GeneticsStanford UniversityStanfordCaliforniaUSA
| | - Matthew T. Wheeler
- Stanford Center for Inherited Cardiovascular DiseaseStanfordCaliforniaUSA
- Department of Medicine, Division of Cardiovascular MedicineStanford UniversityStanfordCaliforniaUSA
| | - Stuart A. Scott
- Clinical Genomics LaboratoryStanford MedicinePalo AltoCaliforniaUSA
- Department of PathologyStanford UniversityStanfordCaliforniaUSA
| |
Collapse
|
7
|
Zakka C, Shad R, Chaurasia A, Dalal AR, Kim JL, Moor M, Fong R, Phillips C, Alexander K, Ashley E, Boyd J, Boyd K, Hirsch K, Langlotz C, Lee R, Melia J, Nelson J, Sallam K, Tullis S, Vogelsong MA, Cunningham JP, Hiesinger W. Almanac - Retrieval-Augmented Language Models for Clinical Medicine. NEJM AI 2024; 1:10.1056/aioa2300068. [PMID: 38343631 PMCID: PMC10857783 DOI: 10.1056/aioa2300068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
BACKGROUND Large language models (LLMs) have recently shown impressive zero-shot capabilities, whereby they can use auxiliary data, without the availability of task-specific training examples, to complete a variety of natural language tasks, such as summarization, dialogue generation, and question answering. However, despite many promising applications of LLMs in clinical medicine, adoption of these models has been limited by their tendency to generate incorrect and sometimes even harmful statements. METHODS We tasked a panel of eight board-certified clinicians and two health care practitioners with evaluating Almanac, an LLM framework augmented with retrieval capabilities from curated medical resources for medical guideline and treatment recommendations. The panel compared responses from Almanac and standard LLMs (ChatGPT-4, Bing, and Bard) versus a novel data set of 314 clinical questions spanning nine medical specialties. RESULTS Almanac showed a significant improvement in performance compared with the standard LLMs across axes of factuality, completeness, user preference, and adversarial safety. CONCLUSIONS Our results show the potential for LLMs with access to domain-specific corpora to be effective in clinical decision-making. The findings also underscore the importance of carefully testing LLMs before deployment to mitigate their shortcomings. (Funded by the National Institutes of Health, National Heart, Lung, and Blood Institute.).
Collapse
Affiliation(s)
- Cyril Zakka
- Department of Cardiothoracic Surgery, Stanford Medicine, Stanford, CA
| | - Rohan Shad
- Division of Cardiovascular Surgery, Penn Medicine, Philadelphia
| | - Akash Chaurasia
- Department of Computer Science, Stanford University, Stanford, CA
| | - Alex R Dalal
- Department of Cardiothoracic Surgery, Stanford Medicine, Stanford, CA
| | - Jennifer L Kim
- Department of Cardiothoracic Surgery, Stanford Medicine, Stanford, CA
| | - Michael Moor
- Department of Computer Science, Stanford University, Stanford, CA
| | - Robyn Fong
- Department of Computer Science, Stanford University, Stanford, CA
| | - Curran Phillips
- Department of Cardiothoracic Surgery, Stanford Medicine, Stanford, CA
| | - Kevin Alexander
- Division of Cardiovascular Medicine, Stanford Medicine, Stanford, CA
| | - Euan Ashley
- Division of Cardiovascular Medicine, Stanford Medicine, Stanford, CA
| | - Jack Boyd
- Department of Cardiothoracic Surgery, Stanford Medicine, Stanford, CA
| | - Kathleen Boyd
- Department of Pediatrics, Stanford Medicine, Stanford, CA
| | - Karen Hirsch
- Department of Neurology, Stanford Medicine, Stanford, CA
| | - Curt Langlotz
- Department of Radiology and Biomedical Informatics, Stanford Medicine, Stanford, CA
| | - Rita Lee
- Department of Cardiothoracic Surgery, Stanford Medicine, Stanford, CA
| | - Joanna Melia
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore
| | - Joanna Nelson
- Division of Infectious Diseases, Stanford Medicine, Stanford, CA
| | - Karim Sallam
- Division of Cardiovascular Medicine, Stanford Medicine, Stanford, CA
| | - Stacey Tullis
- Department of Cardiothoracic Surgery, Stanford Medicine, Stanford, CA
| | | | | | - William Hiesinger
- Department of Cardiothoracic Surgery, Stanford Medicine, Stanford, CA
| |
Collapse
|
8
|
Chemparathy A, Guen YL, Zeng Y, Gorzynski J, Jensen T, Yang C, Kasireddy N, Talozzi L, Belloy ME, Stewart I, Gitler AD, Wagner AD, Mormino E, Henderson VW, Wyss-Coray T, Ashley E, Cruchaga C, Greicius MD. A 3'UTR Insertion Is a Candidate Causal Variant at the TMEM106B Locus Associated with Increased Risk for FTLD-TDP. medRxiv 2023:2023.07.06.23292312. [PMID: 37461476 PMCID: PMC10350161 DOI: 10.1101/2023.07.06.23292312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
Background and Objectives Single nucleotide variants near TMEM106B associate with risk of frontotemporal lobar dementia with TDP-43 inclusions (FTLD-TDP) and Alzheimer's disease (AD) in genome-wide association studies (GWAS), but the causal variant at this locus remains unclear. Here we asked whether a novel structural variant on TMEM106B is the causal variant. Methods An exploratory analysis identified structural variants on neurodegeneration-related genes. Subsequent analyses focused on an Alu element insertion on the 3'UTR of TMEM106B. This study included data from longitudinal aging and neurogenerative disease cohorts at Stanford University, case-control cohorts in the Alzheimer's Disease Sequencing Project (ADSP), and expression and proteomics data from Washington University in St. Louis (WUSTL). 432 individuals from two Stanford aging cohorts were whole-genome long-read and short-read sequenced. 16,906 samples from ADSP were short-read sequenced. Genotypes, transcriptomics, and proteomics data were available in 1,979 participants from an aging and dementia cohort at WUSTL. Selection criteria were specific to each cohort. In primary analyses, the linkage disequilibrium between the TMEM106B locus variants in the FTLD-TDP GWAS and the 3'UTR insertion was estimated. We then estimated linkage by ancestry in the ADSP and evaluated the effect of the TMEM106B lead variant on mRNA and protein levels. Results The primary analysis included 432 participants (52.5% females, age range 45-92 years old). We identified a 316 bp Alu insertion overlapping the TMEM106B 3'UTR tightly linked with top GWAS variants rs3173615(C) and rs1990622(A). In ADSP European-ancestry participants, this insertion is in equivalent linkage with rs1990622(A) (R2=0.962, D'=0.998) and rs3173615(C) (R2=0.960, D'=0.996). In African-ancestry participants, the insertion is in stronger linkage with rs1990622(A) (R2=0.992, D'=0.998) than with rs3173615(C) (R2=0.811, D'=0.994). In public datasets, rs1990622 was consistently associated with TMEM106B protein levels but not with mRNA expression. In the WUSTL dataset, rs1990622 is associated with TMEM106B protein levels in plasma and cerebrospinal fluid, but not with TMEM106B mRNA expression. Discussion We identified a novel Alu element insertion in the 3'UTR of TMEM106B in tight linkage with the lead FTLD-TDP risk variant. The lead variant is associated with TMEM106B protein levels, but not expression. The 3'UTR insertion is a lead candidate for the causal variant at this complex locus, pending confirmation with functional studies.
Collapse
Affiliation(s)
- Augustine Chemparathy
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA
| | - Yann Le Guen
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Yi Zeng
- Department of Genetics, Stanford University School of Medicine, Stanford, CA
| | - John Gorzynski
- Department of Genetics, Stanford University School of Medicine, Stanford, CA
- Division of Cardiology, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Tanner Jensen
- Department of Genetics, Stanford University School of Medicine, Stanford, CA
| | - Chengran Yang
- Neurogenomics and Informatics Center, Washington University School of Medicine, St. Louis, MO
| | - Nandita Kasireddy
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA
| | - Lia Talozzi
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA
| | - Michael E. Belloy
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA
| | - Ilaria Stewart
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA
| | - Aaron D. Gitler
- Department of Genetics, Stanford University School of Medicine, Stanford, CA
| | - Anthony D. Wagner
- Wu Tsai Neurosciences Institute, Stanford University, Stanford, CA, USA
- Department of Psychology, Stanford University, Stanford, CA, USA
| | - Elizabeth Mormino
- Wu Tsai Neurosciences Institute, Stanford University, Stanford, CA, USA
- Department of Psychology, Stanford University, Stanford, CA, USA
| | - Victor W. Henderson
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA, USA
| | - Tony Wyss-Coray
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA
| | - Euan Ashley
- Department of Genetics, Stanford University School of Medicine, Stanford, CA
- Division of Cardiology, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Carlos Cruchaga
- Neurogenomics and Informatics Center, Washington University School of Medicine, St. Louis, MO
| | - Michael D. Greicius
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA
| |
Collapse
|
9
|
Callahan A, Ashley E, Datta S, Desai P, Ferris TA, Fries JA, Halaas M, Langlotz CP, Mackey S, Posada JD, Pfeffer MA, Shah NH. The Stanford Medicine data science ecosystem for clinical and translational research. JAMIA Open 2023; 6:ooad054. [PMID: 37545984 PMCID: PMC10397535 DOI: 10.1093/jamiaopen/ooad054] [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] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 03/14/2023] [Accepted: 07/19/2023] [Indexed: 08/08/2023] Open
Abstract
Objective To describe the infrastructure, tools, and services developed at Stanford Medicine to maintain its data science ecosystem and research patient data repository for clinical and translational research. Materials and Methods The data science ecosystem, dubbed the Stanford Data Science Resources (SDSR), includes infrastructure and tools to create, search, retrieve, and analyze patient data, as well as services for data deidentification, linkage, and processing to extract high-value information from healthcare IT systems. Data are made available via self-service and concierge access, on HIPAA compliant secure computing infrastructure supported by in-depth user training. Results The Stanford Medicine Research Data Repository (STARR) functions as the SDSR data integration point, and includes electronic medical records, clinical images, text, bedside monitoring data and HL7 messages. SDSR tools include tools for electronic phenotyping, cohort building, and a search engine for patient timelines. The SDSR supports patient data collection, reproducible research, and teaching using healthcare data, and facilitates industry collaborations and large-scale observational studies. Discussion Research patient data repositories and their underlying data science infrastructure are essential to realizing a learning health system and advancing the mission of academic medical centers. Challenges to maintaining the SDSR include ensuring sufficient financial support while providing researchers and clinicians with maximal access to data and digital infrastructure, balancing tool development with user training, and supporting the diverse needs of users. Conclusion Our experience maintaining the SDSR offers a case study for academic medical centers developing data science and research informatics infrastructure.
Collapse
Affiliation(s)
- Alison Callahan
- Stanford Center for Biomedical Informatics Research, Stanford University, Stanford, California, USA
| | - Euan Ashley
- Department of Medicine, School of Medicine, Stanford University, Stanford, California, USA
- Department of Genetics, School of Medicine, Stanford University, Stanford, California, USA
- Department of Biomedical Data Science, School of Medicine, Stanford University, Stanford, California, USA
| | - Somalee Datta
- Technology and Digital Solutions, Stanford Medicine, Stanford University, Stanford, California, USA
| | - Priyamvada Desai
- Technology and Digital Solutions, Stanford Medicine, Stanford University, Stanford, California, USA
| | - Todd A Ferris
- Technology and Digital Solutions, Stanford Medicine, Stanford University, Stanford, California, USA
| | - Jason A Fries
- Stanford Center for Biomedical Informatics Research, Stanford University, Stanford, California, USA
| | - Michael Halaas
- Technology and Digital Solutions, Stanford Medicine, Stanford University, Stanford, California, USA
| | - Curtis P Langlotz
- Department of Radiology, School of Medicine, Stanford University, Stanford, California, USA
| | - Sean Mackey
- Department of Anesthesia, School of Medicine, Stanford University, Stanford, California, USA
| | - José D Posada
- Technology and Digital Solutions, Stanford Medicine, Stanford University, Stanford, California, USA
| | - Michael A Pfeffer
- Technology and Digital Solutions, Stanford Medicine, Stanford University, Stanford, California, USA
| | - Nigam H Shah
- Stanford Center for Biomedical Informatics Research, Stanford University, Stanford, California, USA
- Technology and Digital Solutions, Stanford Medicine, Stanford University, Stanford, California, USA
- Clinical Excellence Research Center, School of Medicine, Stanford University, Stanford, California, USA
| |
Collapse
|
10
|
Hughes JW, Tooley J, Torres Soto J, Ostropolets A, Poterucha T, Christensen MK, Yuan N, Ehlert B, Kaur D, Kang G, Rogers A, Narayan S, Elias P, Ouyang D, Ashley E, Zou J, Perez MV. A deep learning-based electrocardiogram risk score for long term cardiovascular death and disease. NPJ Digit Med 2023; 6:169. [PMID: 37700032 PMCID: PMC10497604 DOI: 10.1038/s41746-023-00916-6] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 08/30/2023] [Indexed: 09/14/2023] Open
Abstract
The electrocardiogram (ECG) is the most frequently performed cardiovascular diagnostic test, but it is unclear how much information resting ECGs contain about long term cardiovascular risk. Here we report that a deep convolutional neural network can accurately predict the long-term risk of cardiovascular mortality and disease based on a resting ECG alone. Using a large dataset of resting 12-lead ECGs collected at Stanford University Medical Center, we developed SEER, the Stanford Estimator of Electrocardiogram Risk. SEER predicts 5-year cardiovascular mortality with an area under the receiver operator characteristic curve (AUC) of 0.83 in a held-out test set at Stanford, and with AUCs of 0.78 and 0.83 respectively when independently evaluated at Cedars-Sinai Medical Center and Columbia University Irving Medical Center. SEER predicts 5-year atherosclerotic disease (ASCVD) with an AUC of 0.67, similar to the Pooled Cohort Equations for ASCVD Risk, while being only modestly correlated. When used in conjunction with the Pooled Cohort Equations, SEER accurately reclassified 16% of patients from low to moderate risk, uncovering a group with an actual average 9.9% 10-year ASCVD risk who would not have otherwise been indicated for statin therapy. SEER can also predict several other cardiovascular conditions such as heart failure and atrial fibrillation. Using only lead I of the ECG it predicts 5-year cardiovascular mortality with an AUC of 0.80. SEER, used alongside the Pooled Cohort Equations and other risk tools, can substantially improve cardiovascular risk stratification and aid in medical decision making.
Collapse
Affiliation(s)
- J Weston Hughes
- Department of Computer Science, Stanford University, Palo Alto, CA, USA.
| | - James Tooley
- Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Jessica Torres Soto
- Department of Biomedical Informatics, Stanford University, Palo Alto, CA, USA
| | - Anna Ostropolets
- Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, NY, USA
| | - Tim Poterucha
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Matthew Kai Christensen
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Neal Yuan
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ben Ehlert
- Department of Biomedical Informatics, Stanford University, Palo Alto, CA, USA
| | | | - Guson Kang
- Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Albert Rogers
- Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Sanjiv Narayan
- Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Pierre Elias
- Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, NY, USA
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - David Ouyang
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Euan Ashley
- Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - James Zou
- Department of Computer Science, Stanford University, Palo Alto, CA, USA
- Department of Biomedical Data Science, Stanford University, Palo Alto, CA, USA
| | - Marco V Perez
- Department of Medicine, Stanford University, Palo Alto, CA, USA
| |
Collapse
|
11
|
Chemparathy A, Guen YL, Chen S, Lee EG, Leong L, Gorzynski J, Xu G, Belloy M, Kasireddy N, Tauber AP, Williams K, Stewart I, Wingo T, Lah J, Jayadev S, Hales C, Peskind E, Child DD, Keene CD, Cong L, Ashley E, Yu CE, Greicius MD. APOE loss-of-function variants: Compatible with longevity and associated with resistance to Alzheimer's Disease pathology. medRxiv 2023:2023.07.20.23292771. [PMID: 37547016 PMCID: PMC10402217 DOI: 10.1101/2023.07.20.23292771] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
The ε4 allele of apolipoprotein E (APOE) is the strongest genetic risk factor for sporadic Alzheimer's Disease (AD). Knockdown of this allele may provide a therapeutic strategy for AD, but the effect of APOE loss-of-function (LoF) on AD pathogenesis is unknown. We searched for APOE LoF variants in a large cohort of older controls and patients with AD and identified six heterozygote carriers of APOE LoF variants. Five carriers were controls (ages 71-90) and one was an AD case with an unremarkable age-at-onset between 75-79. Two APOE ε3/ε4 controls (Subjects 1 and 2) carried a stop-gain affecting the ε4 allele. Subject 1 was cognitively normal at 90+ and had no neuritic plaques at autopsy. Subject 2 was cognitively healthy within the age range 75-79 and underwent lumbar puncture at between ages 75-79 with normal levels of amyloid. The results provide the strongest human genetics evidence yet available suggesting that ε4 drives AD risk through a gain of abnormal function and support knockdown of APOE ε4 or its protein product as a viable therapeutic option.
Collapse
Affiliation(s)
- Augustine Chemparathy
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA
| | - Yann Le Guen
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Sunny Chen
- Geriatric Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA
| | - Eun-Gyung Lee
- Geriatric Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA
| | - Lesley Leong
- Geriatric Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA
| | - John Gorzynski
- Department of Genetics, Stanford University School of Medicine, Stanford, CA
| | - Guangxue Xu
- Department of Pathology, Stanford University School of Medicine, Stanford, CA
| | - Michael Belloy
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA
| | - Nandita Kasireddy
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA
| | - Andrés Peña Tauber
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA
| | - Kennedy Williams
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA
| | - Ilaria Stewart
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA
| | - Thomas Wingo
- Emory University School of Medicine, Atlanta, GA
- Goizueta Alzheimer’s Disease Center, Emory University School of Medicine, Atlanta, GA
| | - James Lah
- Department of Neurology, Emory University School of Medicine, Atlanta, GA
| | - Suman Jayadev
- Department of Neurology, University of Washington, Seattle, WA
| | - Chad Hales
- Emory University School of Medicine, Atlanta, GA
- Goizueta Alzheimer’s Disease Center, Emory University School of Medicine, Atlanta, GA
| | - Elaine Peskind
- Veterans Affairs Northwest Network Mental Illness Research, Education, and Clinical Center, Veteran Affairs Puget Sound Health Care System, Seattle, WA
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA
| | - Daniel D Child
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, Seattle, WA
| | - C Dirk Keene
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, Seattle, WA
| | - Le Cong
- Department of Pathology, Stanford University School of Medicine, Stanford, CA
| | - Euan Ashley
- Department of Genetics, Stanford University School of Medicine, Stanford, CA
- Center for Inherited Cardiovascular Disease, Stanford University, Stanford, CA
- Division of Cardiology, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Chang-En Yu
- Geriatric Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA
- Department of Medicine, University of Washington, Seattle, WA
| | - Michael D. Greicius
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA
| |
Collapse
|
12
|
Patti A, Blumberg Y, Hedman K, Neunhäuserer D, Haddad F, Wheeler M, Ashley E, Moneghetti KJ, Myers J, Christle JW. Respiratory gas kinetics in patients with congestive heart failure during recovery from peak exercise. Clinics (Sao Paulo) 2023; 78:100225. [PMID: 37356413 DOI: 10.1016/j.clinsp.2023.100225] [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: 07/15/2022] [Revised: 03/20/2023] [Accepted: 04/12/2023] [Indexed: 06/27/2023] Open
Abstract
BACKGROUND Cardiopulmonary Exercise Testing (CPX) is essential for the assessment of exercise capacity for patients with Chronic Heart Failure (CHF). Respiratory gas and hemodynamic parameters such as Ventilatory Efficiency (VE/VCO2 slope), peak oxygen uptake (peak VO2), and heart rate recovery are established diagnostic and prognostic markers for clinical populations. Previous studies have suggested the clinical value of metrics related to respiratory gas collected during recovery from peak exercise, particularly recovery time to 50% (T1/2) of peak VO2. The current study explores these metrics in detail during recovery from peak exercise in CHF. METHODS Patients with CHF who were referred for CPX and healthy individuals without formal diagnoses were assessed for inclusion. All subjects performed CPX on cycle ergometers to volitional exhaustion and were monitored for at least five minutes of recovery. CPX data were analyzed for overshoot of respiratory exchange ratio (RER=VCO2/VO2), ventilatory equivalent for oxygen (VE/VO2), end-tidal partial pressure of oxygen (PETO2), and T1/2 of peak VO2 and VCO2. RESULTS Thirty-two patients with CHF and 30 controls were included. Peak VO2 differed significantly between patients and controls (13.5 ± 3.8 vs. 32.5 ± 9.8 mL/Kg*min-1, p < 0.001). Mean Left Ventricular Ejection Fraction (LVEF) was 35.9 ± 9.8% for patients with CHF compared to 61.1 ± 8.2% in the control group. The T1/2 of VO2, VCO2 and VE was significantly higher in patients (111.3 ± 51.0, 132.0 ± 38.8 and 155.6 ± 45.5s) than in controls (58.08 ± 13.2, 74.3 ± 21.1, 96.7 ± 36.8s; p < 0.001) while the overshoot of PETO2, VE/VO2 and RER was significantly lower in patients (7.2 ± 3.3, 41.9 ± 29.1 and 25.0 ± 13.6%) than in controls (10.1 ± 4.6, 62.1 ± 17.7 and 38.7 ± 15.1%; all p < 0.01). Most of the recovery metrics were significantly correlated with peak VO2 in CHF patients, but not with LVEF. CONCLUSIONS Patients with CHF have a significantly blunted recovery from peak exercise. This is reflected in delays of VO2, VCO2, VE, PETO2, RER and VE/VO2, reflecting a greater energy required to return to baseline. Abnormal respiratory gas kinetics in CHF was negatively correlated with peak VO2 but not baseline LVEF.
Collapse
Affiliation(s)
- Alessandro Patti
- Division of Cardiovascular Medicine, Department of Medicine, Stanford, California, USA; Division of Sports and Exercise Medicine, Department of Medicine, University of Padova, Padova, Italy
| | - Yair Blumberg
- Division of Cardiovascular Medicine, Department of Medicine, Stanford, California, USA; Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Kristofer Hedman
- Department of Clinical Physiology, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Daniel Neunhäuserer
- Division of Sports and Exercise Medicine, Department of Medicine, University of Padova, Padova, Italy
| | - Francois Haddad
- Division of Cardiovascular Medicine, Department of Medicine, Stanford, California, USA; Stanford Sports Cardiology, Stanford University, Stanford, California, USA
| | - Matthew Wheeler
- Division of Cardiovascular Medicine, Department of Medicine, Stanford, California, USA; Stanford Sports Cardiology, Stanford University, Stanford, California, USA
| | - Euan Ashley
- Division of Cardiovascular Medicine, Department of Medicine, Stanford, California, USA; Stanford Sports Cardiology, Stanford University, Stanford, California, USA
| | - Kegan J Moneghetti
- Division of Cardiovascular Medicine, Department of Medicine, Stanford, California, USA; Stanford Sports Cardiology, Stanford University, Stanford, California, USA; Baker Department of Cardiometabolic Health, University of Melbourne, Australia; National Centre for Sports Cardiology, St Vincent's Hospital, Melbourne, Australia
| | - Jonathan Myers
- Division of Cardiovascular Medicine, Department of Medicine, Stanford, California, USA; Stanford Sports Cardiology, Stanford University, Stanford, California, USA; Division of Cardiology, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Jeffrey W Christle
- Division of Cardiovascular Medicine, Department of Medicine, Stanford, California, USA; Stanford Sports Cardiology, Stanford University, Stanford, California, USA.
| |
Collapse
|
13
|
Zakka C, Chaurasia A, Shad R, Dalal AR, Kim JL, Moor M, Alexander K, Ashley E, Boyd J, Boyd K, Hirsch K, Langlotz C, Nelson J, Hiesinger W. Almanac: Retrieval-Augmented Language Models for Clinical Medicine. Res Sq 2023:rs.3.rs-2883198. [PMID: 37205549 PMCID: PMC10187428 DOI: 10.21203/rs.3.rs-2883198/v1] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Large-language models have recently demonstrated impressive zero-shot capabilities in a variety of natural language tasks such as summarization, dialogue generation, and question-answering. Despite many promising applications in clinical medicine, adoption of these models in real-world settings has been largely limited by their tendency to generate incorrect and sometimes even toxic statements. In this study, we develop Almanac, a large language model framework augmented with retrieval capabilities for medical guideline and treatment recommendations. Performance on a novel dataset of clinical scenarios (n= 130) evaluated by a panel of 5 board-certified and resident physicians demonstrates significant increases in factuality (mean of 18% at p-value < 0.05) across all specialties, with improvements in completeness and safety. Our results demonstrate the potential for large language models to be effective tools in the clinical decision-making process, while also emphasizing the importance of careful testing and deployment to mitigate their shortcomings.
Collapse
Affiliation(s)
- Cyril Zakka
- Department of Cardiothoracic Surgery, Stanford Medicine
| | - Akash Chaurasia
- Department of Cardiothoracic Surgery, Stanford Medicine
- Department of Computer Science, Stanford University
| | - Rohan Shad
- Division of Cardiovascular Surgery, Penn Medicine
| | - Alex R. Dalal
- Department of Cardiothoracic Surgery, Stanford Medicine
| | | | - Michael Moor
- Department of Computer Science, Stanford University
| | | | - Euan Ashley
- Division of Cardiovascular Medicine, Stanford Medicine
| | - Jack Boyd
- Department of Cardiothoracic Surgery, Stanford Medicine
| | | | | | - Curt Langlotz
- Department of Radiology and Biomedical Informatics, Stanford Medicine
| | | | | |
Collapse
|
14
|
Gotthardt M, Badillo-Lisakowski V, Parikh VN, Ashley E, Furtado M, Carmo-Fonseca M, Schudy S, Meder B, Grosch M, Steinmetz L, Crocini C, Leinwand L. Cardiac splicing as a diagnostic and therapeutic target. Nat Rev Cardiol 2023:10.1038/s41569-022-00828-0. [PMID: 36653465 DOI: 10.1038/s41569-022-00828-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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] [Accepted: 12/09/2022] [Indexed: 01/19/2023]
Abstract
Despite advances in therapeutics for heart failure and arrhythmias, a substantial proportion of patients with cardiomyopathy do not respond to interventions, indicating a need to identify novel modifiable myocardial pathobiology. Human genetic variation associated with severe forms of cardiomyopathy and arrhythmias has highlighted the crucial role of alternative splicing in myocardial health and disease, given that it determines which mature RNA transcripts drive the mechanical, structural, signalling and metabolic properties of the heart. In this Review, we discuss how the analysis of cardiac isoform expression has been facilitated by technical advances in multiomics and long-read and single-cell sequencing technologies. The resulting insights into the regulation of alternative splicing - including the identification of cardiac splice regulators as therapeutic targets and the development of a translational pipeline to evaluate splice modulators in human engineered heart tissue, animal models and clinical trials - provide a basis for improved diagnosis and therapy. Finally, we consider how the medical and scientific communities can benefit from facilitated acquisition and interpretation of splicing data towards improved clinical decision-making and patient care.
Collapse
Affiliation(s)
- Michael Gotthardt
- Neuromuscular and Cardiovascular Cell Biology, Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany. .,DZHK (German Center for Cardiovascular Research Partner Site Berlin), Berlin, Germany. .,Department of Cardiology, Charité - Universitätsmedizin Berlin, Berlin, Germany.
| | - Victor Badillo-Lisakowski
- Neuromuscular and Cardiovascular Cell Biology, Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany.,DZHK (German Center for Cardiovascular Research Partner Site Berlin), Berlin, Germany
| | - Victoria Nicole Parikh
- Stanford Center for Inherited Cardiovascular Disease, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Euan Ashley
- Stanford Center for Inherited Cardiovascular Disease, Stanford University School of Medicine, Palo Alto, CA, USA.,Stanford Genome Technology Center, Stanford University, Palo Alto, CA, USA.,Department of Genetics, School of Medicine, Stanford University, Stanford, CA, USA
| | - Marta Furtado
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Maria Carmo-Fonseca
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Sarah Schudy
- Institute for Cardiomyopathies, Department of Medicine III, University of Heidelberg, Heidelberg, Germany
| | - Benjamin Meder
- Institute for Cardiomyopathies, Department of Medicine III, University of Heidelberg, Heidelberg, Germany.,DZHK (German Center for Cardiovascular Research Partner Site Heidelberg-Mannheim), Heidelberg, Germany
| | - Markus Grosch
- European Molecular Biology Laboratory (EMBL), Genome Biology Unit, Heidelberg, Germany
| | - Lars Steinmetz
- Stanford Genome Technology Center, Stanford University, Palo Alto, CA, USA.,Department of Genetics, School of Medicine, Stanford University, Stanford, CA, USA.,European Molecular Biology Laboratory (EMBL), Genome Biology Unit, Heidelberg, Germany
| | - Claudia Crocini
- Department of Molecular, Cellular, and Developmental Biology and BioFrontiers Institute, University of Colorado, Boulder, CO, USA
| | - Leslie Leinwand
- Department of Molecular, Cellular, and Developmental Biology and BioFrontiers Institute, University of Colorado, Boulder, CO, USA
| |
Collapse
|
15
|
Gomes B, Hedman K, Kuznetsova T, Cauwenberghs N, Hsu D, Kobayashi Y, Ingelsson E, Oxborough D, George K, Salerno M, Ashley E, Haddad F. Defining left ventricular remodeling using lean body mass allometry: a UK Biobank study. Eur J Appl Physiol 2023; 123:989-1001. [PMID: 36617359 DOI: 10.1007/s00421-022-05125-9] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 12/20/2022] [Indexed: 01/09/2023]
Abstract
PURPOSE The geometric patterns of ventricular remodeling are determined using indexed left ventricular mass (LVM), end-diastolic volume (LVEDV) and concentricity, most often measured using the mass-to-volume ratio (MVR). The aims of this study were to validate lean body mass (LBM)-based allometric coefficients for scaling and to determine an index of concentricity that is independent of both volume and LBM. METHODS Participants from the UK Biobank who underwent both CMR and dual-energy X-ray absorptiometry (DXA) during 2014-2015 were considered (n = 5064). We excluded participants aged ≥ 70 years or those with cardiometabolic risk factors. We determined allometric coefficients for scaling using linear regression of the logarithmically transformed ventricular remodeling parameters. We further defined a multiplicative allometric relationship for LV concentricity (LVC) adjusting for both LVEDV and LBM. RESULTS A total of 1638 individuals (1057 female) were included. In subjects with lower body fat percentage (< 25% in males, < 35% in females, n = 644), the LBM allometric coefficients for scaling LVM and LVEDV were 0.85 ± 0.06 and 0.85 ± 0.03 respectively (R2 = 0.61 and 0.57, P < 0.001), with no evidence of sex-allometry interaction. While the MVR was independent of LBM, it demonstrated a negative association with LVEDV in (females: r = - 0.44, P < 0.001; males: - 0.38, P < 0.001). In contrast, LVC was independent of both LVEDV and LBM [LVC = LVM/(LVEDV0.40 × LBM0.50)] leading to increased overlap between LV hypertrophy and higher concentricity. CONCLUSIONS We validated allometric coefficients for LBM-based scaling for CMR indexed parameters relevant for classifying geometric patterns of ventricular remodeling.
Collapse
Affiliation(s)
- Bruna Gomes
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, 94304, USA.
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA.
- Department of Cardiology, Pneumology and Angiology, Heidelberg University Hospital, Heidelberg, Germany.
- Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94304, USA.
| | - Kristofer Hedman
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, 94304, USA
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA
- Department of Clinical Physiology in Linköping, Linköping University, Linköping, Sweden
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Tatiana Kuznetsova
- Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Nicholas Cauwenberghs
- Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - David Hsu
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, 94304, USA
| | - Yukari Kobayashi
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, 94304, USA
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA
| | - Erik Ingelsson
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, 94304, USA
| | - David Oxborough
- Research Institute for Sports and Exercise Sciences, Liverpool John Moores University, Liverpool, L3 9UT, UK
| | - Keith George
- Research Institute for Sports and Exercise Sciences, Liverpool John Moores University, Liverpool, L3 9UT, UK
| | - Michael Salerno
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, 94304, USA
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA
| | - Euan Ashley
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, 94304, USA
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA
| | - Francois Haddad
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, 94304, USA.
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA.
- Stanford University School of Medicine, Falk Building 870 Quarry Rd, Stanford, CA, 94304, USA.
| |
Collapse
|
16
|
Cannatà A, Merlo M, Dal Ferro M, Barbati G, Manca P, Paldino A, Graw S, Gigli M, Stolfo D, Johnson R, Roy D, Tharratt K, Bromage DI, Jirikowic J, Abbate A, Goodwin A, Rao K, Marawan A, Carr-White G, Robert L, Parikh V, Ashley E, McDonagh T, Lakdawala NK, Fatkin D, Taylor MRG, Mestroni L, Sinagra G. Association of Titin Variations With Late-Onset Dilated Cardiomyopathy. JAMA Cardiol 2022; 7:371-377. [PMID: 35138330 PMCID: PMC8829739 DOI: 10.1001/jamacardio.2021.5890] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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: 08/31/2021] [Accepted: 12/09/2021] [Indexed: 12/21/2022]
Abstract
IMPORTANCE Dilated cardiomyopathy (DCM) is frequently caused by genetic factors. Studies identifying deleterious rare variants have predominantly focused on early-onset cases, and little is known about the genetic underpinnings of the growing numbers of patients with DCM who are diagnosed when they are older than 60 years (ie, late-onset DCM). OBJECTIVE To investigate the prevalence, type, and prognostic impact of disease-associated rare variants in patients with late-onset DCM. DESIGN, SETTING, AND PARTICIPANTS A population of patients with late-onset DCM who had undergone genetic testing in 7 international tertiary referral centers worldwide were enrolled from March 1990 to August 2020. A positive genotype was defined as the presence of pathogenic or likely pathogenic (P/LP) variants. MAIN OUTCOMES AND MEASURES The study outcome was all-cause mortality. RESULTS A total of 184 patients older than 60 years (103 female [56%]; mean [SD] age, 67 [6] years; mean [SD] left ventricular ejection fraction, 32% [10%]) were studied. Sixty-six patients (36%) were carriers of a P/LP variant. Titin-truncating variants were the most prevalent (present in 46 [25%] of the total population and accounting for 46 [69%] of all genotype-positive patients). During a median (interquartile range) follow-up of 42 (10-115) months, 23 patients (13%) died; 17 (25%) of these were carriers of P/LP variants, while 6 patients (5.1%) were genotype-negative. CONCLUSIONS AND RELEVANCE Late-onset DCM might represent a distinct subgroup characterized by and a high genetic variation burden, largely due to titin-truncating variants. Patients with a positive genetic test had higher mortality than genotype-negative patients. These findings support the extended use of genetic testing also in older patients.
Collapse
Affiliation(s)
- Antonio Cannatà
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
- Department of Cardiovascular Sciences, Faculty of Life Sciences & Medicine, King’s College London, London, United Kingdom
- Department of Cardiology, King’s College Hospital, London, United Kingdom
| | - Marco Merlo
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Matteo Dal Ferro
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Giulia Barbati
- Biostatistics Unit, University of Trieste, Trieste, Italy
| | - Paolo Manca
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Alessia Paldino
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Sharon Graw
- Cardiovascular Institute and Adult Medical Genetics Program, University of Colorado Anschutz Medical Campus, Aurora
| | - Marta Gigli
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Davide Stolfo
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Renee Johnson
- Molecular Cardiology Division, Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia
- Faculty of Medicine, UNSW Sydney, Kensington, New South Wales, Australia
- Cardiology Department, St Vincent’s Hospital, Darlinghurst, New South Wales, Australia
| | - Darius Roy
- Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kevin Tharratt
- Center for Inherited Heart Disease, Stanford University, Stanford, California
| | - Daniel I. Bromage
- Department of Cardiovascular Sciences, Faculty of Life Sciences & Medicine, King’s College London, London, United Kingdom
- Department of Cardiology, King’s College Hospital, London, United Kingdom
| | - Jean Jirikowic
- Cardiovascular Institute and Adult Medical Genetics Program, University of Colorado Anschutz Medical Campus, Aurora
| | - Antonio Abbate
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond
| | - Allison Goodwin
- VCU Medical Center, Clinical Genetics Services, Richmond, Virginia
| | - Krishnasree Rao
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond
| | - Amr Marawan
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond
| | - Gerry Carr-White
- Department of Cardiology, Guys and St Thomas’ NHS Trust, London, United Kingdom
| | - Leema Robert
- Department of Clinical Genetics, Guys and St Thomas' NHS Trust, London, United Kingdom
| | - Victoria Parikh
- Center for Inherited Heart Disease, Stanford University, Stanford, California
| | - Euan Ashley
- Center for Inherited Heart Disease, Stanford University, Stanford, California
| | - Theresa McDonagh
- Department of Cardiovascular Sciences, Faculty of Life Sciences & Medicine, King’s College London, London, United Kingdom
- Department of Cardiology, King’s College Hospital, London, United Kingdom
| | - Neal K. Lakdawala
- Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Diane Fatkin
- Molecular Cardiology Division, Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia
- Faculty of Medicine, UNSW Sydney, Kensington, New South Wales, Australia
- Cardiology Department, St Vincent’s Hospital, Darlinghurst, New South Wales, Australia
| | - Matthew R. G. Taylor
- Cardiovascular Institute and Adult Medical Genetics Program, University of Colorado Anschutz Medical Campus, Aurora
| | - Luisa Mestroni
- Cardiovascular Institute and Adult Medical Genetics Program, University of Colorado Anschutz Medical Campus, Aurora
| | - Gianfranco Sinagra
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| |
Collapse
|
17
|
Ram-Mohan N, Kim D, Zudock EJ, Hashemi MM, Tjandra KC, Rogers AJ, Blish CA, Nadeau KC, Newberry JA, Quinn JV, O'Hara R, Ashley E, Nguyen H, Jiang L, Hung P, Blomkalns AL, Yang S. SARS-CoV-2 RNAemia Predicts Clinical Deterioration and Extrapulmonary Complications from COVID-19. Clin Infect Dis 2022; 74:218-226. [PMID: 33949665 PMCID: PMC8135992 DOI: 10.1093/cid/ciab394] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The determinants of coronavirus disease 2019 (COVID-19) disease severity and extrapulmonary complications (EPCs) are poorly understood. We characterized relationships between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNAemia and disease severity, clinical deterioration, and specific EPCs. METHODS We used quantitative and digital polymerase chain reaction (qPCR and dPCR) to quantify SARS-CoV-2 RNA from plasma in 191 patients presenting to the emergency department with COVID-19. We recorded patient symptoms, laboratory markers, and clinical outcomes, with a focus on oxygen requirements over time. We collected longitudinal plasma samples from a subset of patients. We characterized the role of RNAemia in predicting clinical severity and EPCs using elastic net regression. RESULTS Of SARS-CoV-2-positive patients, 23.0% (44 of 191) had viral RNA detected in plasma by dPCR, compared with 1.4% (2 of 147) by qPCR. Most patients with serial measurements had undetectable RNAemia within 10 days of symptom onset, reached maximum clinical severity within 16 days, and symptom resolution within 33 days. Initially RNAemic patients were more likely to manifest severe disease (odds ratio, 6.72 [95% confidence interval, 2.45-19.79]), worsening of disease severity (2.43 [1.07-5.38]), and EPCs (2.81 [1.26-6.36]). RNA loads were correlated with maximum severity (r = 0.47 [95% confidence interval, .20-.67]). CONCLUSIONS dPCR is more sensitive than qPCR for the detection of SARS-CoV-2 RNAemia, which is a robust predictor of eventual COVID-19 severity and oxygen requirements, as well as EPCs. Because many COVID-19 therapies are initiated on the basis of oxygen requirements, RNAemia on presentation might serve to direct early initiation of appropriate therapies for the patients most likely to deteriorate.
Collapse
Affiliation(s)
- Nikhil Ram-Mohan
- Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - David Kim
- Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Elizabeth J Zudock
- Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Marjan M Hashemi
- Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Kristel C Tjandra
- Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Angela J Rogers
- Department of Medicine-Pulmonary, Allergy & Critical Care Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Catherine A Blish
- Department of Medicine/Infectious Diseases, Stanford University School of Medicine, Palo Alto, California, USA
| | - Kari C Nadeau
- Department of Medicine-Pulmonary, Allergy & Critical Care Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Jennifer A Newberry
- Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - James V Quinn
- Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Ruth O'Hara
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California, USA
| | - Euan Ashley
- Department of Medicine-Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | | | | | - Paul Hung
- Combinati Inc, Palo Alto, California, USA
| | - Andra L Blomkalns
- Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Samuel Yang
- Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| |
Collapse
|
18
|
Butters A, Arnott C, Sweeting J, Claggett B, Ashley E, Parikh V, Colan S, Day S, Owens A, Helms A, Saberi S, Jacoby D, Michels M, Olivotto I, Pereira A, Rosanno J, Wittekind S, Ware J, Atherton J, Semsarian C, Lakdawala N, Ho C, Ingles J. Sex Disaggregated Analysis of Risk Factors for Adverse Outcomes in Hypertrophic Cardiomyopathy. Heart Lung Circ 2022. [DOI: 10.1016/j.hlc.2022.04.011] [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] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
19
|
Cannata A, Merlo M, Dal Ferro M, Manca P, Paldino A, Barbati G, Graw S, Bromage D, Johnson R, Roy D, Gigli M, Stolfo D, Abbate A, Parkih V, Ashley E, Lakdawala N, Carr-White G, Fatkin D, Mcdonagh T, Taylor M, Mestroni L, Sinagra G. 418 Titin mutations and female sex characterize dilated cardiomyopathy in the elderly. Eur Heart J Suppl 2021. [DOI: 10.1093/eurheartj/suab142.006] [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] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
Aims
Dilated cardiomyopathy (DCM) is frequently caused by genetic factors. Studies identifying deleterious rare variants have predominantly focused on early-onset cases, and little is known about the genetic underpinnings of the growing numbers of patients with DCM who are diagnosed after 60 years of age (i.e. late-onset DCM). The aim is to investigate the prevalence, type, and prognostic impact of disease-associated rare variants in late-onset DCM patients.
Methods and results
We analysed a population of late-onset DCM patients who had undergone genetic testing in seven international tertiary referral centres worldwide. A positive genotype was defined as the presence of ‘pathogenic’ or ‘likely pathogenic’ (P/LP) variants. The study outcome was all-cause mortality. 184 patients over age 60 years (56% females, mean age 67 ± 6 years, mean left ventricular ejection fraction 32 ± 10%) were studied. Sixty-six patients (36%) were carriers of a P/LP variant. Titin truncating variants (TTNtv) were the most prevalent (present in 25% of the total population and accounting for 69% of all genotype-positive patients). During a median follow-up of 42 months (interquartile range: 10–115), 23 patients (13%) died; 17 of these (25%) were carriers of P/LP variants while six patients (5.1%) were genotype-negative (P < 0.001).
Conclusions
In the largest series worldwide, to date, of patients with late-onset DCM, we found a high prevalence of female sex and a high genetic mutation burden, largely due to TTNtv. Patients with a positive genetic test had higher mortality than genotype-negative patients. These findings support the extended use of genetic testing also in the elderly.
Collapse
Affiliation(s)
- Antonio Cannata
- Azienda Sanitaria Universitaria Giuliano Isontina, Italy
- King’s College London, UK
| | - Marco Merlo
- Azienda Sanitaria Universitaria Giuliano Isontina, Italy
| | | | - Paolo Manca
- Azienda Sanitaria Universitaria Giuliano Isontina, Italy
| | | | - Giulia Barbati
- Azienda Sanitaria Universitaria Giuliano Isontina, Italy
| | | | | | | | | | - Marta Gigli
- Azienda Sanitaria Universitaria Giuliano Isontina, Italy
| | - Davide Stolfo
- Azienda Sanitaria Universitaria Giuliano Isontina, Italy
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Myers J, de Souza E Silva CG, Arena R, Kaminsky L, Christle JW, Busque V, Ashley E, Moneghetti K. Comparison of the FRIEND and Wasserman-Hansen Equations in Predicting Outcomes in Heart Failure. J Am Heart Assoc 2021; 10:e021246. [PMID: 34689609 PMCID: PMC8751827 DOI: 10.1161/jaha.121.021246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background Percentage of age‐predicted peak oxygen uptake (VO2) achieved (ppVO2) has been widely used to stratify risk in patients with heart failure. However, there are limitations to traditional normal standards. We compared the recently derived FRIEND (Fitness Registry and the Importance of Exercise: A National Data Base) equation to the widely used Wasserman‐Hansen (WH) ppVO2 equation to predict outcomes in patients with heart failure. Methods and Results A subgroup of 4055 heart failure patients from the FRIEND registry (mean age 53±15 years) was followed for a mean of 28±16 months. The FRIEND and WH equations along with measured peak VO2 expressed in mL/kg−1 per min−1 were compared for mortality and composite cardiovascular events. ppVO2 was higher for the FRIEND versus the WH equation (66±30% versus 58±25%; P<0.001). The areas under the receiver operating characteristic curves were slightly but significantly higher for the FRIEND equation for mortality (0.74 versus 0.72; P=0.03) and cardiac events (0.70 versus 0.68; P=0.008). Area under the receiver operating characteristic curve for measured peak VO2 was 0.70 (P<0.001) for mortality and 0.73 (P<0.001) for cardiovascular events. For each 1‐SD higher ppVO2 for the FRIEND equation, mortality was reduced by 18% (hazard ratio, 0.82; 95% CI, 0.69–0.97; P<0.02); for each 1‐SD higher ppVO2 for the WH equation, the mortality was reduced by 17% (hazard ratio, 0.83; 95% CI, 0.71–0.97; P=0.02). The corresponding reductions in risk per 1 SD for cardiovascular events for the FRIEND and WH equations were 23 and 21%, respectively (both P<0.001). Conclusions Peak VO2 expressed as percentage of an age‐predicted standard strongly predicts mortality and major cardiovascular events in patients with heart failure. The FRIEND registry equation exhibited test characteristics slightly superior to the commonly used WH equation.
Collapse
Affiliation(s)
- Jonathan Myers
- Cardiology Division Veterans Affairs Palo Alto Health Care System Palo Alto CA.,Division of Cardiovascular Medicine Stanford University School of Medicine Stanford CA.,Healthy Living for Pandemic Event Protection (HL-PIVOT) Network Chicago IL
| | - Christina G de Souza E Silva
- Exercise Medicine Clinic - CLINIMEX Rio de Janeiro Brazil.,Heart Institute Edson Saad Federal University of Rio de Janeiro Brazil
| | - Ross Arena
- Healthy Living for Pandemic Event Protection (HL-PIVOT) Network Chicago IL.,Department of Physical Therapy College of Applied Health Sciences University of Illinois at Chicago IL
| | - Leonard Kaminsky
- Healthy Living for Pandemic Event Protection (HL-PIVOT) Network Chicago IL.,Fisher Institute of Health and Well-Being and Clinical Exercise Physiology Laboratory Ball State University Muncie IN
| | - Jeffrey W Christle
- Division of Cardiovascular Medicine Stanford University School of Medicine Stanford CA.,Healthy Living for Pandemic Event Protection (HL-PIVOT) Network Chicago IL
| | - Vincent Busque
- Division of Cardiovascular Medicine Stanford University School of Medicine Stanford CA
| | - Euan Ashley
- Division of Cardiovascular Medicine Stanford University School of Medicine Stanford CA
| | - Kegan Moneghetti
- Division of Cardiovascular Medicine Stanford University School of Medicine Stanford CA
| |
Collapse
|
21
|
Rogers AJ, Bhatia NK, Tooley J, Thakkar V, Torres J, Torres J, Xu J, Singh Tung J, Alhusseini MI, Clifford G, Merchant FM, Bailis P, Clopton P, Ashley E, Perez M, Zaharia M, Narayan SM. B-PO01-081 MACHINE LEARNING OF THE ELECTROCARDIOGRAM IDENTIFIES CARDIAC WALL MOTION ABNORMALITIES BEYOND THE Q WAVE. Heart Rhythm 2021. [DOI: 10.1016/j.hrthm.2021.06.226] [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: 11/16/2022]
|
22
|
Webster DE, Tummalacherla M, Higgins M, Wing D, Ashley E, Kelly VE, McConnell MV, Muse ED, Olgin JE, Mangravite LM, Godino J, Kellen MR, Omberg L. Smartphone-Based VO2max Measurement With Heart Snapshot in Clinical and Real-world Settings With a Diverse Population: Validation Study. JMIR Mhealth Uhealth 2021; 9:e26006. [PMID: 34085945 PMCID: PMC8214186 DOI: 10.2196/26006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 02/04/2021] [Accepted: 04/12/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Maximal oxygen consumption (VO2max) is one of the most predictive biometrics for cardiovascular health and overall mortality. However, VO2max is rarely measured in large-scale research studies or routine clinical care because of the high cost, participant burden, and requirement for specialized equipment and staff. OBJECTIVE To overcome the limitations of clinical VO2max measurement, we aim to develop a digital VO2max estimation protocol that can be self-administered remotely using only the sensors within a smartphone. We also aim to validate this measure within a broadly representative population across a spectrum of smartphone devices. METHODS Two smartphone-based VO2max estimation protocols were developed: a 12-minute run test (12-MRT) based on distance measured by GPS and a 3-minute step test (3-MST) based on heart rate recovery measured by a camera. In a 101-person cohort, balanced across age deciles and sex, participants completed a gold standard treadmill-based VO2max measurement, two silver standard clinical protocols, and the smartphone-based 12-MRT and 3-MST protocols in the clinic and at home. In a separate 120-participant cohort, the video-based heart rate measurement underlying the 3-MST was measured for accuracy in individuals across the spectrum skin tones while using 8 different smartphones ranging in cost from US $99 to US $999. RESULTS When compared with gold standard VO2max testing, Lin concordance was pc=0.66 for 12-MRT and pc=0.61 for 3-MST. However, in remote settings, the 12-MRT was significantly less concordant with the gold standard (pc=0.25) compared with the 3-MST (pc=0.61), although both had high test-retest reliability (12-MRT intraclass correlation coefficient=0.88; 3-MST intraclass correlation coefficient=0.86). On the basis of the finding that 3-MST concordance was generalizable to remote settings whereas 12-MRT was not, the video-based heart rate measure within the 3-MST was selected for further investigation. Heart rate measurements in any of the combinations of the six Fitzpatrick skin tones and 8 smartphones resulted in a concordance of pc≥0.81. Performance did not correlate with device cost, with all phones selling under US $200 performing better than pc>0.92. CONCLUSIONS These findings demonstrate the importance of validating mobile health measures in the real world across a diverse cohort and spectrum of hardware. The 3-MST protocol, termed as heart snapshot, measured VO2max with similar accuracy to supervised in-clinic tests such as the Tecumseh (pc=0.94) protocol, while also generalizing to remote and unsupervised measurements. Heart snapshot measurements demonstrated fidelity across demographic variation in age and sex, across diverse skin pigmentation, and between various iOS and Android phone configurations. This software is freely available for all validation data and analysis code.
Collapse
Affiliation(s)
| | | | - Michael Higgins
- Exercise and Physical Activity Resource Center, University of California at San Diego, San Diego, CA, United States
| | - David Wing
- Exercise and Physical Activity Resource Center, University of California at San Diego, San Diego, CA, United States
| | - Euan Ashley
- Department of Genetics, Stanford University School of Medicine, Stanford, CA, United States
| | - Valerie E Kelly
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, United States
| | - Michael V McConnell
- Stanford University School of Medicine, Stanford, CA, United States.,Google Health, Palo Alto, CA, United States
| | - Evan D Muse
- Scripps Research Translational Institute and Scripps Clinic, La Jolla, CA, United States
| | - Jeffrey E Olgin
- Division of Cardiology and the Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, United States
| | | | - Job Godino
- Exercise and Physical Activity Resource Center, University of California at San Diego, San Diego, CA, United States.,Scripps Research Translational Institute and Scripps Clinic, La Jolla, CA, United States
| | | | | |
Collapse
|
23
|
Patti A, Blumberg Y, Moneghetti KJ, Neunhaeuserer D, Haddad F, Myers J, Ashley E, Christle JW. Assessing post-exercise respiratory gas kinetics in clinical sample - a pilot study. Eur J Prev Cardiol 2021. [DOI: 10.1093/eurjpc/zwab061.013] [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]
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background
Cardiopulmonary exercise testing (CPX) is established in the evaluation of patients with cardiac and pulmonary diseases, and its clinical utility seems to be expanding. Currently the most important diagnostic and prognostic ventilatory metrics of CPX rely on the exercise phase. Nevertheless, a consistent body of evidence suggests that important information can be derived from the recovery phase, especially in the first few minutes after exercise. In this context, patients with heart failure (HF) demonstrate a slower recovery of the oxygen consumption (VO2) compared with healthy individuals. Purpose: To comprehensively investigate the behavior of respiratory gases during recovery from CPX in a diverse cohort of HF patients. Methods: All individuals who performed CPX at the department of cardiology of Stanford University Hospital were eligible for the study. Patients were included in the experimental group if they (i) were recorded for five minutes after the exercise phase of CPX and (ii) had documented heart failure. They were excluded if they had other clinical diagnoses which may be responsible for exercise intolerance or symptoms or were unable to give informed consent. Healthy controls were recruited from the local community and were included if they did not have documented or suspected disease. Respiratory gases were collected on a breath-by-breath basis and analysed after applying a 30 second rolling average filter. Metrics were analyzed as absolute values, percentage change from peak and the half-time of recovery (T ½; i.e. the duration until a metric had returned to ½ of its value at peak). Data was analyzed over time within patients and averages between groups using parametric statistical methods. In accordance with previous studies, the amount of change in a metric after exercise is presented as the "magnitude" of overshoot. Results: 32 patients with HF (11 Female, 47 ± 13 yrs) and 30 healthy subjects (14 Female, 43 ± 12 yrs) were included. A comparison of ventilatory metrics during recovery between HF and controls is depicted in Figure 1. Peak VO2 was 1135 ± 419 mL/min (13.5 ± 3.8 mL/Kg/min) vs 2408 ± 787 mL/min (32.5 ± 9.0 mL/Kg/min); P <0.01. A significant difference between patients with HF and healthy subjects was found in T ½ of VO2 (111.3 ± 51.0s vs 58.0 ± 13.2s, p < 0.01) and VCO2 (132.0 ± 38.8s vs 74.3 ± 21.1s, p < 0.01). The magnitude of the overshoot was also found to be significantly reduced in patients with HF for VE/VO2 (41.9 ± 29.1% vs 62.1 ± 17.7%, P < 0.01), RQ (25.0 ± 13.6% vs 38.7 ± 15.1%, p < 0.01) and PETO2 (7.2 ± 3.3% vs 10.1 ± 4.6%, p < 0.01). Finally, the magnitude of the RQ overshoot showed a moderate correlation with peak VO2 (ϱ=0.58, p < 0.01). Conclusions: We observed that ventilatory kinetics measured in early recovery after CPX differ significantly between healthy subjects and patients with HF. The assessment of post exercise respiratory gases in a clinical setting may add to the prognostic and diagnostic value of CPX in heart failure.
Abstract Figure.
Collapse
Affiliation(s)
- A Patti
- Stanford University, Palo Alto, United States of America
| | - Y Blumberg
- Bar Ilan University, The Azrieli faculty of Medicine, Ramat Gan, Israel
| | - KJ Moneghetti
- Stanford University, Palo Alto, United States of America
| | | | - F Haddad
- Stanford University, Palo Alto, United States of America
| | - J Myers
- Stanford University, Palo Alto, United States of America
| | - E Ashley
- Stanford University, Palo Alto, United States of America
| | - JW Christle
- Stanford University, Palo Alto, United States of America
| |
Collapse
|
24
|
Zhang X, Walsh R, Whiffin N, Buchan R, Midwinter W, Wilk A, Govind R, Li N, Ahmad M, Mazzarotto F, Roberts A, Theotokis PI, Mazaika E, Allouba M, de Marvao A, Pua CJ, Day SM, Ashley E, Colan SD, Michels M, Pereira AC, Jacoby D, Ho CY, Olivotto I, Gunnarsson GT, Jefferies JL, Semsarian C, Ingles J, O'Regan DP, Aguib Y, Yacoub MH, Cook SA, Barton PJR, Bottolo L, Ware JS. Disease-specific variant pathogenicity prediction significantly improves variant interpretation in inherited cardiac conditions. Genet Med 2021; 23:69-79. [PMID: 33046849 PMCID: PMC7790749 DOI: 10.1038/s41436-020-00972-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 09/08/2020] [Accepted: 09/09/2020] [Indexed: 11/18/2022] Open
Abstract
PURPOSE Accurate discrimination of benign and pathogenic rare variation remains a priority for clinical genome interpretation. State-of-the-art machine learning variant prioritization tools are imprecise and ignore important parameters defining gene-disease relationships, e.g., distinct consequences of gain-of-function versus loss-of-function variants. We hypothesized that incorporating disease-specific information would improve tool performance. METHODS We developed a disease-specific variant classifier, CardioBoost, that estimates the probability of pathogenicity for rare missense variants in inherited cardiomyopathies and arrhythmias. We assessed CardioBoost's ability to discriminate known pathogenic from benign variants, prioritize disease-associated variants, and stratify patient outcomes. RESULTS CardioBoost has high global discrimination accuracy (precision recall area under the curve [AUC] 0.91 for cardiomyopathies; 0.96 for arrhythmias), outperforming existing tools (4-24% improvement). CardioBoost obtains excellent accuracy (cardiomyopathies 90.2%; arrhythmias 91.9%) for variants classified with >90% confidence, and increases the proportion of variants classified with high confidence more than twofold compared with existing tools. Variants classified as disease-causing are associated with both disease status and clinical severity, including a 21% increased risk (95% confidence interval [CI] 11-29%) of severe adverse outcomes by age 60 in patients with hypertrophic cardiomyopathy. CONCLUSIONS A disease-specific variant classifier outperforms state-of-the-art genome-wide tools for rare missense variants in inherited cardiac conditions ( https://www.cardiodb.org/cardioboost/ ), highlighting broad opportunities for improved pathogenicity prediction through disease specificity.
Collapse
Affiliation(s)
- Xiaolei Zhang
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Cardiovascular Research Centre, Royal Brompton and Harefield NHS, Foundation Trust London, London, United Kingdom
| | - Roddy Walsh
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Cardiovascular Research Centre, Royal Brompton and Harefield NHS, Foundation Trust London, London, United Kingdom
| | - Nicola Whiffin
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Cardiovascular Research Centre, Royal Brompton and Harefield NHS, Foundation Trust London, London, United Kingdom
| | - Rachel Buchan
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Cardiovascular Research Centre, Royal Brompton and Harefield NHS, Foundation Trust London, London, United Kingdom
| | - William Midwinter
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Cardiovascular Research Centre, Royal Brompton and Harefield NHS, Foundation Trust London, London, United Kingdom
| | - Alicja Wilk
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Cardiovascular Research Centre, Royal Brompton and Harefield NHS, Foundation Trust London, London, United Kingdom
| | - Risha Govind
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Cardiovascular Research Centre, Royal Brompton and Harefield NHS, Foundation Trust London, London, United Kingdom
| | - Nicholas Li
- Cardiovascular Research Centre, Royal Brompton and Harefield NHS, Foundation Trust London, London, United Kingdom
- MRC London Institute of Medical Sciences, Imperial College London, London, United Kingdom
| | - Mian Ahmad
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Cardiovascular Research Centre, Royal Brompton and Harefield NHS, Foundation Trust London, London, United Kingdom
| | - Francesco Mazzarotto
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
- Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Angharad Roberts
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Cardiovascular Research Centre, Royal Brompton and Harefield NHS, Foundation Trust London, London, United Kingdom
| | - Pantazis I Theotokis
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Cardiovascular Research Centre, Royal Brompton and Harefield NHS, Foundation Trust London, London, United Kingdom
| | - Erica Mazaika
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Cardiovascular Research Centre, Royal Brompton and Harefield NHS, Foundation Trust London, London, United Kingdom
| | - Mona Allouba
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Aswan Heart Centre, Magdi Yacoub Heart Foundation, Aswan, Egypt
| | - Antonio de Marvao
- MRC London Institute of Medical Sciences, Imperial College London, London, United Kingdom
| | | | - Sharlene M Day
- Division of Cardiovascular Medicine and Penn Cardiovascular Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Euan Ashley
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, CA, USA
| | - Steven D Colan
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Michelle Michels
- Department of Cardiology, Thoraxcenter, Erasmus MC Rotterdam, Rotterdam, Netherlands
| | - Alexandre C Pereira
- Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Daniel Jacoby
- Department of Internal Medicine, Yale University, New Haven, CT, USA
| | - Carolyn Y Ho
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Iacopo Olivotto
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | | | - John L Jefferies
- The Cardiovascular Institute, University of Tennessee, Memphis, TN, USA
| | - Chris Semsarian
- Centenary Institute, The University of Sydney, Sydney, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Jodie Ingles
- Centenary Institute, The University of Sydney, Sydney, Australia
| | - Declan P O'Regan
- MRC London Institute of Medical Sciences, Imperial College London, London, United Kingdom
| | - Yasmine Aguib
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Aswan Heart Centre, Magdi Yacoub Heart Foundation, Aswan, Egypt
| | - Magdi H Yacoub
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Aswan Heart Centre, Magdi Yacoub Heart Foundation, Aswan, Egypt
| | - Stuart A Cook
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Cardiovascular Research Centre, Royal Brompton and Harefield NHS, Foundation Trust London, London, United Kingdom
- National Heart Centre, Singapore, Singapore
- Duke-National University of Singapore, Singapore, Singapore
| | - Paul J R Barton
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Cardiovascular Research Centre, Royal Brompton and Harefield NHS, Foundation Trust London, London, United Kingdom
| | - Leonardo Bottolo
- Department of Medical Genetics, University of Cambridge, Cambridge, United Kingdom.
- Alan Turing Institute, London, United Kingdom.
- MRC Biostatistics Unit, University of Cambridge, Cambridge, United Kingdom.
| | - James S Ware
- National Heart and Lung Institute, Imperial College London, London, United Kingdom.
- Cardiovascular Research Centre, Royal Brompton and Harefield NHS, Foundation Trust London, London, United Kingdom.
- MRC London Institute of Medical Sciences, Imperial College London, London, United Kingdom.
| |
Collapse
|
25
|
Ram-Mohan N, Kim D, Zudock EJ, Hashemi MM, Tjandra KC, Rogers AJ, Blish CA, Nadeau KC, Newberry JA, Quinn JV, O’Hara R, Ashley E, Nguyen H, Jiang L, Hung P, Blomkalns AL, Yang S. SARS-CoV-2 RNAaemia predicts clinical deterioration and extrapulmonary complications from COVID-19. medRxiv 2020:2020.12.19.20248561. [PMID: 33398290 PMCID: PMC7781329 DOI: 10.1101/2020.12.19.20248561] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background The determinants of COVID-19 disease severity and extrapulmonary complications (EPCs) are poorly understood. We characterise the relationships between SARS-CoV-2 RNAaemia and disease severity, clinical deterioration, and specific EPCs. Methods We used quantitative (qPCR) and digital (dPCR) PCR to quantify SARS-CoV-2 RNA from nasopharyngeal swabs and plasma in 191 patients presenting to the Emergency Department (ED) with COVID-19. We recorded patient symptoms, laboratory markers, and clinical outcomes, with a focus on oxygen requirements over time. We collected longitudinal plasma samples from a subset of patients. We characterised the role of RNAaemia in predicting clinical severity and EPCs using elastic net regression. Findings 23·0% (44/191) of SARS-CoV-2 positive patients had viral RNA detected in plasma by dPCR, compared to 1·4% (2/147) by qPCR. Most patients with serial measurements had undetectable RNAaemia 10 days after onset of symptoms, but took 16 days to reach maximum severity, and 33 days for symptoms to resolve. Initially RNAaemic patients were more likely to manifest severe disease (OR 6·72 [95% CI, 2·45 - 19·79]), worsening of disease severity (OR 2·43 [95% CI, 1·07 - 5·38]), and EPCs (OR 2·81 [95% CI, 1·26 - 6·36]). RNA load correlated with maximum severity (r = 0·47 [95% CI, 0·20 - 0·67]). Interpretation dPCR is more sensitive than qPCR for the detection of SARS-CoV-2 RNAaemia, which is a robust predictor of eventual COVID-19 severity and oxygen requirements, as well as EPCs. Since many COVID-19 therapies are initiated on the basis of oxygen requirements, RNAaemia on presentation might serve to direct early initiation of appropriate therapies for the patients most likely to deteriorate.
Collapse
Affiliation(s)
- Nikhil Ram-Mohan
- Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto CA 94305
| | - David Kim
- Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto CA 94305
| | - Elizabeth J Zudock
- Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto CA 94305
| | - Marjan M Hashemi
- Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto CA 94305
| | - Kristel C Tjandra
- Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto CA 94305
| | - Angela J Rogers
- Department of Medicine - Pulmonary, Allergy & Critical Care Medicine, Stanford University School of Medicine, Palo Alto CA 94305
| | - Catherine A Blish
- Department of Medicine/Infectious Diseases, Stanford University School of Medicine, Palo Alto CA 94305
| | - Kari C. Nadeau
- Department of Medicine - Pulmonary, Allergy & Critical Care Medicine, Stanford University School of Medicine, Palo Alto CA 94305
| | - Jennifer A Newberry
- Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto CA 94305
| | - James V Quinn
- Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto CA 94305
| | - Ruth O’Hara
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto CA 94305
| | - Euan Ashley
- Department of Medicine – Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto CA 94305
| | - Hien Nguyen
- COMBiNATi Inc., 2450 Embarcadero Way, Palo Alto CA 94303
| | - Lingxia Jiang
- COMBiNATi Inc., 2450 Embarcadero Way, Palo Alto CA 94303
| | - Paul Hung
- COMBiNATi Inc., 2450 Embarcadero Way, Palo Alto CA 94303
| | | | - Andra L Blomkalns
- Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto CA 94305
| | - Samuel Yang
- Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto CA 94305
| |
Collapse
|
26
|
Hayeems RZ, Dimmock D, Bick D, Belmont JW, Green RC, Lanpher B, Jobanputra V, Mendoza R, Kulkarni S, Grove ME, Taylor SL, Ashley E. Clinical utility of genomic sequencing: a measurement toolkit. NPJ Genom Med 2020; 5:56. [PMID: 33319814 PMCID: PMC7738524 DOI: 10.1038/s41525-020-00164-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [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: 04/15/2020] [Accepted: 11/12/2020] [Indexed: 12/21/2022] Open
Abstract
Whole-genome sequencing (WGS) is positioned to become one of the most robust strategies for achieving timely diagnosis of rare genomic diseases. Despite its favorable diagnostic performance compared to conventional testing strategies, routine use and reimbursement of WGS are hampered by inconsistencies in the definition and measurement of clinical utility. For example, what constitutes clinical utility for WGS varies by stakeholder's perspective (physicians, patients, families, insurance companies, health-care organizations, and society), clinical context (prenatal, pediatric, critical care, adult medicine), and test purpose (diagnosis, screening, treatment selection). A rapidly evolving technology landscape and challenges associated with robust comparative study design in the context of rare disease further impede progress in this area of empiric research. To address this challenge, an expert working group of the Medical Genome Initiative was formed. Following a consensus-based process, we align with a broad definition of clinical utility and propose a conceptually-grounded and empirically-guided measurement toolkit focused on four domains of utility: diagnostic thinking efficacy, therapeutic efficacy, patient outcome efficacy, and societal efficacy. For each domain of utility, we offer specific indicators and measurement strategies. While we focus on diagnostic applications of WGS for rare germline diseases, this toolkit offers a flexible framework for best practices around measuring clinical utility for a range of WGS applications. While we expect this toolkit to evolve over time, it provides a resource for laboratories, clinicians, and researchers looking to characterize the value of WGS beyond the laboratory.
Collapse
Affiliation(s)
- Robin Z Hayeems
- Program in Child Health Evaluative Sciences, The Hospital for Sick Children and the Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada.
| | - David Dimmock
- Rady Children's Hospital Institute for Genomic Medicine, San Diego, CA, USA
| | - David Bick
- HudsonAlpha Institute for Biotechnology, Huntsville, AL, USA
| | | | - Robert C Green
- Brigham and Women's Hospital Broad Institute and Harvard Medical School, Boston, MA, USA
| | | | - Vaidehi Jobanputra
- New York Genome Center, New York, NY, USA
- Department of Pathology and Cell Biology Columbia University Medical Center, New York, NY, USA
| | - Roberto Mendoza
- The Division of Clinical and Metabolic Genetics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Shashi Kulkarni
- Baylor Genetics and Baylor College of Medicine, Houston, TX, USA
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | | | | | | |
Collapse
|
27
|
Córdova-Palomera A, Tcheandjieu C, Fries JA, Varma P, Chen VS, Fiterau M, Xiao K, Tejeda H, Keavney BD, Cordell HJ, Tanigawa Y, Venkataraman G, Rivas MA, Ré C, Ashley E, Priest JR. Cardiac Imaging of Aortic Valve Area From 34 287 UK Biobank Participants Reveals Novel Genetic Associations and Shared Genetic Comorbidity With Multiple Disease Phenotypes. Circ: Genomic and Precision Medicine 2020; 13:e003014. [DOI: 10.1161/circgen.120.003014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
The aortic valve is an important determinant of cardiovascular physiology and anatomic location of common human diseases.
Methods:
From a sample of 34 287 white British ancestry participants, we estimated functional aortic valve area by planimetry from prospectively obtained cardiac magnetic resonance imaging sequences of the aortic valve. Aortic valve area measurements were submitted to genome-wide association testing, followed by polygenic risk scoring and phenome-wide screening, to identify genetic comorbidities.
Results:
A genome-wide association study of aortic valve area in these UK Biobank participants showed 3 significant associations, indexed by rs71190365 (chr13:50764607,
DLEU1
,
P
=1.8×10
−9
), rs35991305 (chr12:94191968,
CRADD
,
P
=3.4×10
−8
), and chr17:45013271:C:T (
GOSR2
,
P
=5.6×10
−8
). Replication on an independent set of 8145 unrelated European ancestry participants showed consistent effect sizes in all 3 loci, although rs35991305 did not meet nominal significance. We constructed a polygenic risk score for aortic valve area, which in a separate cohort of 311 728 individuals without imaging demonstrated that smaller aortic valve area is predictive of increased risk for aortic valve disease (odds ratio, 1.14;
P
=2.3×10
−6
). After excluding subjects with a medical diagnosis of aortic valve stenosis (remaining n=308 683 individuals), phenome-wide association of >10 000 traits showed multiple links between the polygenic score for aortic valve disease and key health-related comorbidities involving the cardiovascular system and autoimmune disease. Genetic correlation analysis supports a shared genetic etiology with between aortic valve area and birth weight along with other cardiovascular conditions.
Conclusions:
These results illustrate the use of automated phenotyping of cardiac imaging data from the general population to investigate the genetic etiology of aortic valve disease, perform clinical prediction, and uncover new clinical and genetic correlates of cardiac anatomy.
Collapse
Affiliation(s)
- Aldo Córdova-Palomera
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Stanford, CA (A.C.-P., C.T., K.X., H.T., J.R.P.)
| | - Catherine Tcheandjieu
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Stanford, CA (A.C.-P., C.T., K.X., H.T., J.R.P.)
| | - Jason A. Fries
- Department of Computer Science (J.F., V.S.C., M.F., C.R.), Stanford University, CA
- Center for Biomedical Informatics Research (J.F.), Stanford University, CA
| | - Paroma Varma
- Department of Electrical Engineering (P.V.), Stanford University, CA
| | - Vincent S. Chen
- Department of Computer Science (J.F., V.S.C., M.F., C.R.), Stanford University, CA
| | - Madalina Fiterau
- Department of Computer Science (J.F., V.S.C., M.F., C.R.), Stanford University, CA
| | - Ke Xiao
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Stanford, CA (A.C.-P., C.T., K.X., H.T., J.R.P.)
| | - Heliodoro Tejeda
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Stanford, CA (A.C.-P., C.T., K.X., H.T., J.R.P.)
| | - Bernard D. Keavney
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom (B.K.)
- Division of Medicine, Manchester University National Health Service Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom (B.K.)
| | - Heather J. Cordell
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, United Kingdom (H.J.C.)
| | - Yosuke Tanigawa
- Department of Biomedical Data Science (Y.T., G.V., M.R.), Stanford University, CA
| | - Guhan Venkataraman
- Department of Biomedical Data Science (Y.T., G.V., M.R.), Stanford University, CA
| | - Manuel A. Rivas
- Department of Biomedical Data Science (Y.T., G.V., M.R.), Stanford University, CA
| | - Christopher Ré
- Department of Computer Science (J.F., V.S.C., M.F., C.R.), Stanford University, CA
| | - Euan Ashley
- Department of Medicine (E.A.), Stanford University, CA
- Chan Zuckerberg Biohub, San Francisco, CA (E.A., J.R.P.)
| | - James R. Priest
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Stanford, CA (A.C.-P., C.T., K.X., H.T., J.R.P.)
- Chan Zuckerberg Biohub, San Francisco, CA (E.A., J.R.P.)
| |
Collapse
|
28
|
Soeng S, Ling C, Cusack TP, Dance D, Hinfonthong P, Lee S, Newton P, Nosten F, Reed T, Roberts T, Sengduangphachanh A, Sihalath S, Wangrangsimakul T, Turner P, Ashley E. Impact of delays to incubation and storage temperature on blood culture results in tropical countries: A multi-centre study. Int J Infect Dis 2020. [DOI: 10.1016/j.ijid.2020.09.521] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
|
29
|
Tun N, Mclean A, Deed X, Hlaing M, Aung Y, Wilkins E, Ashley E, Smithuis F. Is stopping secondary prophylaxis safe in HIV-positive talaromycosis patients? Experience from Myanmar. HIV Med 2020; 21:671-673. [PMID: 32741092 PMCID: PMC7590157 DOI: 10.1111/hiv.12921] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2020] [Indexed: 11/30/2022]
Abstract
Objectives The aim of the study was to determine whether it is safe to stop secondary prophylaxis in patients with talaromycosis after immune reconstitution with a sustained increase in CD4 count to ≥ 100 cells/µL after antiretroviral therapy (ART). Methods A retrospective cohort analysis was performed in HIV‐infected patients treated for talaromycosis between June 2009 and June 2017 in Medical Action Myanmar (MAM) clinics. Results Among a cohort of 5466 HIV‐infected patients, 41 patients were diagnosed with and treated for clinical talaromycosis. All the patients were on ART and had a CD4 count < 100 cells/µL. Of these 41 patients, 24 patients (71%) were skin smear positive for talaromycosis, while results were negative in 17 patients. Median CD4 count and haemoglobin concentration were 24 cells/µL and 7.7 g/dL, respectively. Seventy‐three per cent (30) were male. Among the 41 patients, 11 (27%) died and six (15%) were transferred to other centres. Twenty‐four patients (58% of the total diagnosed) stopped itraconazole secondary prophylaxis after starting active ART with CD4 counts > 100 cells/µL for at least 1 year. Throughout the duration of follow‐up post itraconazole cessation, the observed incidence of relapse was zero with a total follow‐up of 93.8 person‐years (95% confidence interval 0–4 per 100 person‐years). The median (25th, 75th percentile) duration of follow‐up post‐prophylaxis discontinuation was 2.8 (2.1, 6.3) years. Conclusions Secondary prophylaxis can be safely stopped in patients with talaromycosis after immune reconstitution with a sustained increase in CD4 count to ≥ 100 cells/µL after highly active antiretroviral therapy.
Collapse
Affiliation(s)
- N Tun
- Medical Action Myanmar, Yangon, Myanmar.,Myanmar Oxford Clinical Research Unit, Yangon, Myanmar
| | - A Mclean
- Medical Action Myanmar, Yangon, Myanmar.,Myanmar Oxford Clinical Research Unit, Yangon, Myanmar
| | - X Deed
- Medical Action Myanmar, Yangon, Myanmar
| | - M Hlaing
- Medical Action Myanmar, Yangon, Myanmar
| | - Y Aung
- Medical Action Myanmar, Yangon, Myanmar
| | - E Wilkins
- North Manchester, Infectious Diseases Crumpsall Manchester, Manchester, UK
| | - E Ashley
- Myanmar Oxford Clinical Research Unit, Yangon, Myanmar.,Centre for Tropical Medicine and Global Health Oxford, Oxford University, Oxfordshire, UK
| | - F Smithuis
- Medical Action Myanmar, Yangon, Myanmar.,Myanmar Oxford Clinical Research Unit, Yangon, Myanmar.,Centre for Tropical Medicine and Global Health Oxford, Oxford University, Oxfordshire, UK
| |
Collapse
|
30
|
Dainis A, Zaleta-Rivera K, Ribeiro A, Chang ACH, Shang C, Lan F, Burridge PW, Liu WR, Wu JC, Chang ACY, Pruitt BL, Wheeler M, Ashley E. Silencing of MYH7 ameliorates disease phenotypes in human iPSC-cardiomyocytes. Physiol Genomics 2020; 52:293-303. [PMID: 32567507 DOI: 10.1152/physiolgenomics.00021.2020] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Allele-specific RNA silencing has been shown to be an effective therapeutic treatment in a number of diseases, including neurodegenerative disorders. Studies of allele-specific silencing in hypertrophic cardiomyopathy (HCM) to date have focused on mouse models of disease. We here examine allele-specific silencing in a human-cell model of HCM. We investigate two methods of silencing, short hairpin RNA (shRNA) and antisense oligonucleotide (ASO) silencing, using a human induced pluripotent stem cell-derived cardiomyocyte (hiPSC-CM) model. We used cellular micropatterning devices with traction force microscopy and automated video analysis to examine each strategy's effects on contractile defects underlying disease. We find that shRNA silencing ameliorates contractile phenotypes of disease, reducing disease-associated increases in cardiomyocyte velocity, force, and power. We find that ASO silencing, while better able to target and knockdown a specific disease-associated allele, showed more modest improvements in contractile phenotypes. These findings are the first exploration of allele-specific silencing in a human HCM model and provide a foundation for further exploration of silencing as a therapeutic treatment for MYH7-mutation-associated cardiomyopathy.
Collapse
Affiliation(s)
- Alexandra Dainis
- Department of Genetics, Stanford University, Stanford, California
| | | | - Alexandre Ribeiro
- Stanford Cardiovascular Institute, Stanford, California.,Mechanical Engineering, Stanford University, Stanford, California
| | | | | | - Feng Lan
- Beijing Anzhen Hospital, Capital Medical University, Beijing City, China
| | - Paul W Burridge
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - W Robert Liu
- Department of Cardiovascular Medicine, Stanford University, Stanford, California
| | - Joseph C Wu
- Stanford Cardiovascular Institute, Stanford, California
| | - Alex Chia Yu Chang
- Department of Cardiology and Shanghai Institute of Precision Medicine, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Beth L Pruitt
- Mechanical Engineering, University of California, Santa Barbara, Santa Barbara, California.,Biomolecular Science and Engineering, University of California, Santa Barbara, Santa Barbara, California
| | - Matthew Wheeler
- Department of Cardiovascular Medicine, Stanford University, Stanford, California.,Stanford Center for Inherited Cardiovascular Disease, Stanford University, Stanford, California
| | - Euan Ashley
- Department of Cardiovascular Medicine, Stanford University, Stanford, California.,Stanford Center for Inherited Cardiovascular Disease, Stanford University, Stanford, California
| |
Collapse
|
31
|
Marshall CR, Bick D, Belmont JW, Taylor SL, Ashley E, Dimmock D, Jobanputra V, Kearney HM, Kulkarni S, Rehm H. The Medical Genome Initiative: moving whole-genome sequencing for rare disease diagnosis to the clinic. Genome Med 2020; 12:48. [PMID: 32460895 PMCID: PMC7254704 DOI: 10.1186/s13073-020-00748-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [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: 03/17/2020] [Accepted: 05/11/2020] [Indexed: 02/03/2023] Open
Abstract
Clinical whole-genome sequencing (WGS) offers clear diagnostic benefits for patients with rare disease. However, there are barriers to its widespread adoption, including a lack of standards for clinical practice. The Medical Genome Initiative consortium was formed to provide practical guidance and support the development of standards for the use of clinical WGS.
Collapse
Affiliation(s)
| | - David Bick
- HudsonAlpha Institute for Biotechnology, Huntsville, AL, USA
| | | | | | - Euan Ashley
- Stanford Medicine Clinical Genomics Program, Stanford Health Care, Stanford, CA, USA
| | - David Dimmock
- Rady Children's Institute for Genomic Medicine, San Diego, CA, USA
| | | | | | | | - Heidi Rehm
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | | |
Collapse
|
32
|
Hedman K, Patti A, Moneghetti KJ, Hsu D, Christle JW, Ashley E, Hadley D, Haddad F, Froelicher V. Impact of the distance from the chest wall to the heart on surface ECG voltage in athletes. BMJ Open Sport Exerc Med 2020; 6:e000696. [PMID: 32201618 PMCID: PMC7061894 DOI: 10.1136/bmjsem-2019-000696] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2020] [Indexed: 11/12/2022] Open
Abstract
Objective Available ECG criteria for detection of left ventricular (LV) hypertrophy have been reported to have limited diagnostic capability. Our goal was to describe how the distance between the chest wall and the left ventricle determined by echocardiography affected the relationship between ECG voltage and LV mass (LVM) in athletes. Methods We retrospectively evaluated digitised ECG data from college athletes undergoing routine echocardiography as part of their preparticipation evaluation. Along with LV mass and volume, we determined the chest wall–LV distance in the parasternal short-axis and long-axis views from two-dimensional transthoracic echocardiographic images and explored the relation with ECG QRS voltages in all leads, as well as summed voltages as included in six major ECG-LVH criteria. Results 239 athletes (43 women) were included (age 19±1 years). In men, greater LV–chest wall distance was associated with higher R-wave amplitudes in leads aVL and I (R=0.20 and R=0.25, both p<0.01), while in women greater distance was associated with higher R-amplitudes in V5 and V6 (R=0.42 and R=0.34, both p<0.01). In women, the chest wall–LV distance was the only variable independently (and positively) associated with R V5 voltage, while LVM, height and weight contributed to the relationship in men. Conclusions The chest wall–LV distance was weakly associated with ECG voltage in athletes. Inconsistent associations in men and women imply different intrathoracic factors affecting impedance and conductance between sexes. This may help explain the poor relationship between QRS voltage and LVM in athletes.
Collapse
Affiliation(s)
- Kristofer Hedman
- Department of Medicine, Stanford Cardiovascular Institute, Stanford University, Stanford, California, USA.,Department of Clinical Physiology and Department of Health, Medicine and Caring Sciences, Linköpings universitet, Linköping, Sweden
| | - Alessandro Patti
- Stanford Sports Cardiology, Stanford University, Stanford, California, USA.,Sport and Exercise Medicine Division, Department of Medicine, University of Padova, Padova, Italy
| | - Kegan J Moneghetti
- Department of Medicine, Stanford Cardiovascular Institute, Stanford University, Stanford, California, USA.,Stanford Sports Cardiology, Stanford University, Stanford, California, USA
| | - David Hsu
- Department of Medicine, Stanford Cardiovascular Institute, Stanford University, Stanford, California, USA.,Stanford Sports Cardiology, Stanford University, Stanford, California, USA
| | - Jeffrey W Christle
- Department of Medicine, Stanford Cardiovascular Institute, Stanford University, Stanford, California, USA.,Stanford Sports Cardiology, Stanford University, Stanford, California, USA
| | - Euan Ashley
- Department of Medicine, Stanford Cardiovascular Institute, Stanford University, Stanford, California, USA.,Stanford Sports Cardiology, Stanford University, Stanford, California, USA
| | | | - Francois Haddad
- Department of Medicine, Stanford Cardiovascular Institute, Stanford University, Stanford, California, USA.,Stanford Sports Cardiology, Stanford University, Stanford, California, USA
| | - Victor Froelicher
- Department of Medicine, Stanford Cardiovascular Institute, Stanford University, Stanford, California, USA.,Stanford Sports Cardiology, Stanford University, Stanford, California, USA
| |
Collapse
|
33
|
Sahli-Costabal F, Seo K, Ashley E, Kuhl E. Classifying Drugs by their Arrhythmogenic Risk Using Machine Learning. Biophys J 2020; 118:1165-1176. [PMID: 32023435 DOI: 10.1101/545863] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 11/27/2019] [Accepted: 01/13/2020] [Indexed: 05/25/2023] Open
Abstract
All medications have adverse effects. Among the most serious of these are cardiac arrhythmias. Current paradigms for drug safety evaluation are costly, lengthy, conservative, and impede efficient drug development. Here, we combine multiscale experiment and simulation, high-performance computing, and machine learning to create a risk estimator to stratify new and existing drugs according to their proarrhythmic potential. We capitalize on recent developments in machine learning and integrate information across 10 orders of magnitude in space and time to provide a holistic picture of the effects of drugs, either individually or in combination with other drugs. We show, both experimentally and computationally, that drug-induced arrhythmias are dominated by the interplay between two currents with opposing effects: the rapid delayed rectifier potassium current and the L-type calcium current. Using Gaussian process classification, we create a classifier that stratifies drugs into safe and arrhythmic domains for any combinations of these two currents. We demonstrate that our classifier correctly identifies the risk categories of 22 common drugs exclusively on the basis of their concentrations at 50% current block. Our new risk assessment tool explains under which conditions blocking the L-type calcium current can delay or even entirely suppress arrhythmogenic events. Using machine learning in drug safety evaluation can provide a more accurate and comprehensive mechanistic assessment of the proarrhythmic potential of new drugs. Our study paves the way toward establishing science-based criteria to accelerate drug development, design safer drugs, and reduce heart rhythm disorders.
Collapse
Affiliation(s)
| | - Kinya Seo
- Department of Medicine, Stanford University, Stanford, California
| | - Euan Ashley
- Department of Medicine, Stanford University, Stanford, California; Department of Pathology, Stanford University, Stanford, California
| | - Ellen Kuhl
- Department of Mechanical Engineering, Stanford University, Stanford, California; Department of Bioengineering, Stanford University, Stanford, California.
| |
Collapse
|
34
|
Toepfer CN, Garfinkel AC, Venturini G, Wakimoto H, Repetti G, Alamo L, Sharma A, Agarwal R, Ewoldt JF, Cloonan P, Letendre J, Lun M, Olivotto I, Colan S, Ashley E, Jacoby D, Michels M, Redwood CS, Watkins HC, Day SM, Staples JF, Padrón R, Chopra A, Ho CY, Chen CS, Pereira AC, Seidman JG, Seidman CE. Myosin Sequestration Regulates Sarcomere Function, Cardiomyocyte Energetics, and Metabolism, Informing the Pathogenesis of Hypertrophic Cardiomyopathy. Circulation 2020; 141:828-842. [PMID: 31983222 PMCID: PMC7077965 DOI: 10.1161/circulationaha.119.042339] [Citation(s) in RCA: 154] [Impact Index Per Article: 38.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 12/20/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Hypertrophic cardiomyopathy (HCM) is caused by pathogenic variants in sarcomere protein genes that evoke hypercontractility, poor relaxation, and increased energy consumption by the heart and increased patient risks for arrhythmias and heart failure. Recent studies show that pathogenic missense variants in myosin, the molecular motor of the sarcomere, are clustered in residues that participate in dynamic conformational states of sarcomere proteins. We hypothesized that these conformations are essential to adapt contractile output for energy conservation and that pathophysiology of HCM results from destabilization of these conformations. METHODS We assayed myosin ATP binding to define the proportion of myosins in the super relaxed state (SRX) conformation or the disordered relaxed state (DRX) conformation in healthy rodent and human hearts, at baseline and in response to reduced hemodynamic demands of hibernation or pathogenic HCM variants. To determine the relationships between myosin conformations, sarcomere function, and cell biology, we assessed contractility, relaxation, and cardiomyocyte morphology and metabolism, with and without an allosteric modulator of myosin ATPase activity. We then tested whether the positions of myosin variants of unknown clinical significance that were identified in patients with HCM, predicted functional consequences and associations with heart failure and arrhythmias. RESULTS Myosins undergo physiological shifts between the SRX conformation that maximizes energy conservation and the DRX conformation that enables cross-bridge formation with greater ATP consumption. Systemic hemodynamic requirements, pharmacological modulators of myosin, and pathogenic myosin missense mutations influenced the proportions of these conformations. Hibernation increased the proportion of myosins in the SRX conformation, whereas pathogenic variants destabilized these and increased the proportion of myosins in the DRX conformation, which enhanced cardiomyocyte contractility, but impaired relaxation and evoked hypertrophic remodeling with increased energetic stress. Using structural locations to stratify variants of unknown clinical significance, we showed that the variants that destabilized myosin conformations were associated with higher rates of heart failure and arrhythmias in patients with HCM. CONCLUSIONS Myosin conformations establish work-energy equipoise that is essential for life-long cellular homeostasis and heart function. Destabilization of myosin energy-conserving states promotes contractile abnormalities, morphological and metabolic remodeling, and adverse clinical outcomes in patients with HCM. Therapeutic restabilization corrects cellular contractile and metabolic phenotypes and may limit these adverse clinical outcomes in patients with HCM.
Collapse
Affiliation(s)
- Christopher N. Toepfer
- Department of Genetics, Harvard Medical School, Boston, MA (C.N.T., A.C.G., G.V., H.W., G.R., A.S., R.A., A.C.P., J.G.S., C.E.S.)
- Cardiovascular Medicine, Radcliffe Department of Medicine (C.N.T., C.S.R., H.C.W.), University of Oxford, UK
- Wellcome Centre for Human Genetics (C.N.T., H.C.W.), University of Oxford, UK
| | - Amanda C. Garfinkel
- Department of Genetics, Harvard Medical School, Boston, MA (C.N.T., A.C.G., G.V., H.W., G.R., A.S., R.A., A.C.P., J.G.S., C.E.S.)
| | - Gabriela Venturini
- Department of Genetics, Harvard Medical School, Boston, MA (C.N.T., A.C.G., G.V., H.W., G.R., A.S., R.A., A.C.P., J.G.S., C.E.S.)
- Laboratory of Genetics and Molecular Cardiology, Heart Institute (InCor)-University of São Paulo Medical School, Brazil (G.V., A.C.P.)
| | - Hiroko Wakimoto
- Department of Genetics, Harvard Medical School, Boston, MA (C.N.T., A.C.G., G.V., H.W., G.R., A.S., R.A., A.C.P., J.G.S., C.E.S.)
| | - Giuliana Repetti
- Department of Genetics, Harvard Medical School, Boston, MA (C.N.T., A.C.G., G.V., H.W., G.R., A.S., R.A., A.C.P., J.G.S., C.E.S.)
| | - Lorenzo Alamo
- Centro de Biología Estructural, Instituto Venezolano de Investigaciones Cientifìcas (IVIC), Caracas (L.A., R.P.)
| | - Arun Sharma
- Department of Genetics, Harvard Medical School, Boston, MA (C.N.T., A.C.G., G.V., H.W., G.R., A.S., R.A., A.C.P., J.G.S., C.E.S.)
| | - Radhika Agarwal
- Department of Genetics, Harvard Medical School, Boston, MA (C.N.T., A.C.G., G.V., H.W., G.R., A.S., R.A., A.C.P., J.G.S., C.E.S.)
| | - Jourdan F. Ewoldt
- Department of Biomedical Engineering, Boston University, MA (J.F.E., P.C., J.L., A.C., C.S.C.)
| | - Paige Cloonan
- Department of Biomedical Engineering, Boston University, MA (J.F.E., P.C., J.L., A.C., C.S.C.)
| | - Justin Letendre
- Department of Biomedical Engineering, Boston University, MA (J.F.E., P.C., J.L., A.C., C.S.C.)
| | - Mingyue Lun
- Department of Medicine, Division of Genetics (M.L.), Brigham and Women’s Hospital, Boston, MA
| | - Iacopo Olivotto
- Cardiomyopathy Unit and Genetic Unit, Careggi University Hospital, Florence, Italy (I.O.)
| | - Steve Colan
- Department of Cardiology, Boston Children’s Hospital, MA (S.C.)
| | - Euan Ashley
- Center for Inherited Cardiovascular Disease, Stanford University, CA (E.A.)
| | - Daniel Jacoby
- Department of Internal Medicine, Section of Cardiovascular Diseases, Yale School of Medicine, New Haven, CT (D.J.)
| | - Michelle Michels
- Department of Cardiology, Thorax Center, Erasmus MC, Rotterdam, The Netherlands (M.M.)
| | - Charles S. Redwood
- Cardiovascular Medicine, Radcliffe Department of Medicine (C.N.T., C.S.R., H.C.W.), University of Oxford, UK
| | - Hugh C. Watkins
- Cardiovascular Medicine, Radcliffe Department of Medicine (C.N.T., C.S.R., H.C.W.), University of Oxford, UK
- Wellcome Centre for Human Genetics (C.N.T., H.C.W.), University of Oxford, UK
| | - Sharlene M. Day
- Department of Internal Medicine, University of Michigan, Ann Arbor (S.M.D.)
| | - James F. Staples
- Department of Biology, University of Western Ontario, London, Canada (J.F.S.)
| | - Raúl Padrón
- Centro de Biología Estructural, Instituto Venezolano de Investigaciones Cientifìcas (IVIC), Caracas (L.A., R.P.)
- Division of Cell Biology and Imaging, Department of Radiology, University of Massachusetts Medical School, Worcester (R.P.)
| | - Anant Chopra
- Department of Biomedical Engineering, Boston University, MA (J.F.E., P.C., J.L., A.C., C.S.C.)
| | - Carolyn Y. Ho
- Cardiovascular Division (C.Y.H., C.E.S.), Brigham and Women’s Hospital, Boston, MA
| | - Christopher S. Chen
- Department of Biomedical Engineering, Boston University, MA (J.F.E., P.C., J.L., A.C., C.S.C.)
| | - Alexandre C. Pereira
- Department of Genetics, Harvard Medical School, Boston, MA (C.N.T., A.C.G., G.V., H.W., G.R., A.S., R.A., A.C.P., J.G.S., C.E.S.)
- Laboratory of Genetics and Molecular Cardiology, Heart Institute (InCor)-University of São Paulo Medical School, Brazil (G.V., A.C.P.)
| | - Jonathan G. Seidman
- Department of Genetics, Harvard Medical School, Boston, MA (C.N.T., A.C.G., G.V., H.W., G.R., A.S., R.A., A.C.P., J.G.S., C.E.S.)
| | - Christine E. Seidman
- Department of Genetics, Harvard Medical School, Boston, MA (C.N.T., A.C.G., G.V., H.W., G.R., A.S., R.A., A.C.P., J.G.S., C.E.S.)
- Cardiovascular Division (C.Y.H., C.E.S.), Brigham and Women’s Hospital, Boston, MA
- Howard Hughes Medical Institute, Chevy Chase, MD (C.E.S.)
| |
Collapse
|
35
|
Sahli-Costabal F, Seo K, Ashley E, Kuhl E. Classifying Drugs by their Arrhythmogenic Risk Using Machine Learning. Biophys J 2020; 118:1165-1176. [PMID: 32023435 PMCID: PMC7063479 DOI: 10.1016/j.bpj.2020.01.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 11/27/2019] [Accepted: 01/13/2020] [Indexed: 12/17/2022] Open
Abstract
All medications have adverse effects. Among the most serious of these are cardiac arrhythmias. Current paradigms for drug safety evaluation are costly, lengthy, conservative, and impede efficient drug development. Here, we combine multiscale experiment and simulation, high-performance computing, and machine learning to create a risk estimator to stratify new and existing drugs according to their proarrhythmic potential. We capitalize on recent developments in machine learning and integrate information across 10 orders of magnitude in space and time to provide a holistic picture of the effects of drugs, either individually or in combination with other drugs. We show, both experimentally and computationally, that drug-induced arrhythmias are dominated by the interplay between two currents with opposing effects: the rapid delayed rectifier potassium current and the L-type calcium current. Using Gaussian process classification, we create a classifier that stratifies drugs into safe and arrhythmic domains for any combinations of these two currents. We demonstrate that our classifier correctly identifies the risk categories of 22 common drugs exclusively on the basis of their concentrations at 50% current block. Our new risk assessment tool explains under which conditions blocking the L-type calcium current can delay or even entirely suppress arrhythmogenic events. Using machine learning in drug safety evaluation can provide a more accurate and comprehensive mechanistic assessment of the proarrhythmic potential of new drugs. Our study paves the way toward establishing science-based criteria to accelerate drug development, design safer drugs, and reduce heart rhythm disorders.
Collapse
Affiliation(s)
| | - Kinya Seo
- Department of Medicine, Stanford University, Stanford, California
| | - Euan Ashley
- Department of Medicine, Stanford University, Stanford, California; Department of Pathology, Stanford University, Stanford, California
| | - Ellen Kuhl
- Department of Mechanical Engineering, Stanford University, Stanford, California; Department of Bioengineering, Stanford University, Stanford, California.
| |
Collapse
|
36
|
Hedman K, Moneghetti KJ, Hsu D, Christle JW, Patti A, Ashley E, Hadley D, Haddad F, Froelicher V. Limitations of Electrocardiography for Detecting Left Ventricular Hypertrophy or Concentric Remodeling in Athletes. Am J Med 2020; 133:123-132.e8. [PMID: 31738876 DOI: 10.1016/j.amjmed.2019.06.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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: 06/11/2019] [Revised: 06/12/2019] [Accepted: 06/13/2019] [Indexed: 01/20/2023]
Abstract
BACKGROUND Electrocardiography (ECG) is used to screen for left ventricular hypertrophy (LVH), but common ECG-LVH criteria have been found less effective in athletes. The purpose of this study was to comprehensively evaluate the value of ECG for identifying athletes with LVH or a concentric cardiac phenotype. METHODS A retrospective analysis of 196 male Division I college athletes routinely screened with ECG and echocardiography within the Stanford Athletic Cardiovascular Screening Program was performed. Left-ventricular mass and volume were determined using echocardiography. LVH was defined as left ventricular mass (LVM) >102 g/m²; a concentric cardiac phenotype as LVM-to-volume (M/V) ≥1.05 g/mL. Twelve-lead electrocardiograms including high-resolution time intervals and QRS voltages were obtained. Thirty-seven previously published ECG-LVH criteria were applied, of which the majority have never been evaluated in athletes. C-statistics, including area under the receiver operating curve (AUC) and likelihood ratios were calculated. RESULTS ECG lead voltages were poorly associated with LVM (r = 0.18-0.30) and M/V (r = 0.15-0.25). The proportion of athletes with ECG-LVH was 0%-74% across criteria, with sensitivity and specificity ranging between 0% and 91% and 27% and 99.5%, respectively. The average AUC of the criteria in identifying the 11 athletes with LVH was 0.57 (95% confidence interval [CI] 0.56-0.59), and the average AUC for identifying the 8 athletes with a concentric phenotype was 0.59 (95% CI 0.56-0.62). CONCLUSION The diagnostic capacity of all ECG-LVH criteria were inadequate and, therefore, not clinically useful in screening for LVH or a concentric phenotype in athletes. This is probably due to the weak association between LVM and ECG voltage.
Collapse
Affiliation(s)
- Kristofer Hedman
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, Calif; Stanford Cardiovascular Institute, Department of Medicine, Stanford University, Stanford, Calif; Department of Clinical Physiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
| | - Kegan J Moneghetti
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, Calif; Stanford Sports Cardiology, Stanford University, Stanford, Calif
| | - David Hsu
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, Calif; Stanford Sports Cardiology, Stanford University, Stanford, Calif
| | - Jeffrey W Christle
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, Calif; Stanford Sports Cardiology, Stanford University, Stanford, Calif
| | - Alessandro Patti
- Stanford Sports Cardiology, Stanford University, Stanford, Calif; Sport and Exercise Medicine Division, Department of Medicine, University of Padova, Italy
| | - Euan Ashley
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, Calif; Stanford Sports Cardiology, Stanford University, Stanford, Calif
| | | | - Francois Haddad
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, Calif; Stanford Cardiovascular Institute, Department of Medicine, Stanford University, Stanford, Calif; Stanford Sports Cardiology, Stanford University, Stanford, Calif
| | - Victor Froelicher
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, Calif; Stanford Sports Cardiology, Stanford University, Stanford, Calif
| |
Collapse
|
37
|
Moneghetti KJ, Singh T, Hedman K, Christle JW, Kooreman Z, Kobayashi Y, Bouajila S, Amsallem M, Wheeler M, Gerche AL, Ashley E, Haddad F. Echocardiographic Assessment of Left Ventricular Remodeling in American Style Footballers. Int J Sports Med 2019; 41:27-35. [PMID: 31791086 DOI: 10.1055/a-1014-2994] [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] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Several athletic programs incorporate echocardiography during pre-participation screening of American Style Football (ASF) players with great variability in reported echocardiographic values. Pre-participation screening was performed in National Collegiate Athletic Association Division I ASF players from 2008 to 2016 at the Division of Sports Cardiology. The echocardiographic protocol focused on left ventricular (LV) mass, mass-to-volume ratio, sphericity, ejection fraction, and longitudinal Lagrangian strain. LV mass was calculated using the area-length method in end-diastole and end-systole. A total of two hundred and thirty players were included (18±1 years, 57% were Caucasian, body mass index 29±4 kg/m2) after four players (2%) were excluded for pathological findings. Although there was no difference in indexed LV mass by race (Caucasian 78±11 vs. African American 81±10 g/m2, p=0.089) or sphericity (Caucasian 1.81±0.13 vs. African American 1.78±0.14, p=0.130), the mass-to-volume ratio was higher in African Americans (0.91±0.09 vs. 0.83±0.08, p<0.001). No race-specific differences were noted in LV longitudinal Lagrangian strain. Player position appeared to have a limited role in defining LV remodeling. In conclusion, significant echocardiographic differences were observed in mass-to-volume ratio between African American and Caucasian players. These demographics should be considered as part of pre-participation screening.
Collapse
Affiliation(s)
- Kegan James Moneghetti
- School of Medicine, Cardiovascular Division, Stanford University, Stanford, United States.,Sports Cardiology, Stanford University, Stanford, United States
| | - Tamanna Singh
- School of Medicine, Cardiovascular Division, Stanford University, Stanford, United States
| | - Kristofer Hedman
- School of Medicine, Cardiovascular Division, Stanford University, Stanford, United States
| | | | - Zoe Kooreman
- School of Medicine, Cardiovascular Division, Stanford University, Stanford, United States
| | - Yukari Kobayashi
- School of Medicine, Cardiovascular Division, Stanford University, Stanford, United States
| | - Sara Bouajila
- School of Medicine, Cardiovascular Division, Stanford University, Stanford, United States
| | - Myriam Amsallem
- School of Medicine, Cardiovascular Division, Stanford University, Stanford, United States
| | - Matthew Wheeler
- School of Medicine, Cardiovascular Division, Stanford University, Stanford, United States.,Sports Cardiology, Stanford University, Stanford, United States
| | - Andre La Gerche
- Baker IDI Heart and Diabetes Institute, Sports Cardiology Laboratory, Melbourne, Australia
| | - Euan Ashley
- School of Medicine, Cardiovascular Division, Stanford University, Stanford, United States.,Sports Cardiology, Stanford University, Stanford, United States
| | - Francois Haddad
- School of Medicine, Cardiovascular Division, Stanford University, Stanford, United States
| |
Collapse
|
38
|
Myers J, Christle JW, Tun A, Yilmaz B, Moneghetti KJ, Yuen E, Soofi M, Ashley E. Cardiopulmonary Exercise Testing, Impedance Cardiography, and Reclassification of Risk in Patients Referred for Heart Failure Evaluation. J Card Fail 2019; 25:961-968. [DOI: 10.1016/j.cardfail.2019.08.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 07/28/2019] [Accepted: 08/19/2019] [Indexed: 10/26/2022]
|
39
|
Goodyer WR, Dunn K, Caleshu C, Jackson M, Wylie J, Moscarello T, Platt J, Reuter C, Smith A, Trela A, Ceresnak SR, Motonaga KS, Ashley E, Yang P, Dubin AM, Perez M. Broad Genetic Testing in a Clinical Setting Uncovers a High Prevalence of Titin Loss-of-Function Variants in Very Early Onset Atrial Fibrillation. Circ Genom Precis Med 2019; 12:e002713. [PMID: 31638414 PMCID: PMC10626994 DOI: 10.1161/circgen.119.002713] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- William R. Goodyer
- Cardiovascular Institute, Stanford University
- Division of Pediatric Cardiology, Department of Pediatrics, Lucille Packard Children’s Hospital
| | - Kyla Dunn
- Stanford Center for Inherited Cardiovascular Disease, Stanford University School of Medicine, Stanford, CA
| | - Colleen Caleshu
- Stanford Center for Inherited Cardiovascular Disease, Stanford University School of Medicine, Stanford, CA
| | - Mary Jackson
- Stanford Center for Inherited Cardiovascular Disease, Stanford University School of Medicine, Stanford, CA
| | - Jennifer Wylie
- Stanford Center for Inherited Cardiovascular Disease, Stanford University School of Medicine, Stanford, CA
| | - Tia Moscarello
- Stanford Center for Inherited Cardiovascular Disease, Stanford University School of Medicine, Stanford, CA
| | - Julia Platt
- Stanford Center for Inherited Cardiovascular Disease, Stanford University School of Medicine, Stanford, CA
| | - Chloe Reuter
- Stanford Center for Inherited Cardiovascular Disease, Stanford University School of Medicine, Stanford, CA
| | - Allysonne Smith
- Stanford Center for Inherited Cardiovascular Disease, Stanford University School of Medicine, Stanford, CA
| | - Anthony Trela
- Division of Pediatric Cardiology, Department of Pediatrics, Lucille Packard Children’s Hospital
| | - Scott R. Ceresnak
- Division of Pediatric Cardiology, Department of Pediatrics, Lucille Packard Children’s Hospital
| | - Kara S. Motonaga
- Division of Pediatric Cardiology, Department of Pediatrics, Lucille Packard Children’s Hospital
| | - Euan Ashley
- Cardiovascular Institute, Stanford University
- Stanford Center for Inherited Cardiovascular Disease, Stanford University School of Medicine, Stanford, CA
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Phillip Yang
- Cardiovascular Institute, Stanford University
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Anne M. Dubin
- Division of Pediatric Cardiology, Department of Pediatrics, Lucille Packard Children’s Hospital
| | - Marco Perez
- Cardiovascular Institute, Stanford University
- Stanford Center for Inherited Cardiovascular Disease, Stanford University School of Medicine, Stanford, CA
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| |
Collapse
|
40
|
Kerkar A, Hazard F, Caleshu C, Shah R, Reuter C, Ashley E, Parikh VN. Pathological Overlap of Arrhythmogenic Right Ventricular Cardiomyopathy and Cardiac Sarcoidosis. Circ: Genomic and Precision Medicine 2019; 12:452-454. [DOI: 10.1161/circgen.119.002638] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ashwini Kerkar
- Department of Internal Medicine (A.K), Stanford University School of Medicine, CA
| | - Florette Hazard
- Department of Clinical Pathology (F.H.), Stanford University School of Medicine, CA
| | - Colleen Caleshu
- Department of Medicine — Division of Cardiovascular Medicine (C.C., C.R., E.A., V.N.P., R.S.), Stanford University School of Medicine, CA
- Center for Inherited Cardiovascular Disease (C.C., C.R., E.A., V.N.P.), Stanford University School of Medicine, CA
| | - Rajan Shah
- Department of Medicine — Division of Cardiovascular Medicine (C.C., C.R., E.A., V.N.P., R.S.), Stanford University School of Medicine, CA
| | - Chloe Reuter
- Department of Medicine — Division of Cardiovascular Medicine (C.C., C.R., E.A., V.N.P., R.S.), Stanford University School of Medicine, CA
- Center for Inherited Cardiovascular Disease (C.C., C.R., E.A., V.N.P.), Stanford University School of Medicine, CA
| | - Euan Ashley
- Department of Medicine — Division of Cardiovascular Medicine (C.C., C.R., E.A., V.N.P., R.S.), Stanford University School of Medicine, CA
- Center for Inherited Cardiovascular Disease (C.C., C.R., E.A., V.N.P.), Stanford University School of Medicine, CA
| | - Victoria N. Parikh
- Department of Medicine — Division of Cardiovascular Medicine (C.C., C.R., E.A., V.N.P., R.S.), Stanford University School of Medicine, CA
- Center for Inherited Cardiovascular Disease (C.C., C.R., E.A., V.N.P.), Stanford University School of Medicine, CA
| |
Collapse
|
41
|
Tremblay-Gravel M, Malhamé I, Avram R, Gravel GM, Desplantie O, Pacheco C, Moayedi Y, Moscarello T, Ducharme A, Ashley E, Jolicoeur M, Wheeler M, Khandelwal A. OUTCOMES OF AFRICAN AMERICAN VS. NON-AFRICAN AMERICAN WOMEN WITH PERIPARTUM CARDIOMYOPATHY: A COMPARISON ANALYSIS BETWEEN CANADIAN AND UNITED STATES COHORTS. Can J Cardiol 2019. [DOI: 10.1016/j.cjca.2019.07.424] [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] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
|
42
|
Axelsson Raja A, Farhad H, Valente AM, Couce JP, Jefferies JL, Bundgaard H, Zahka K, Lever H, Murphy AM, Ashley E, Day SM, Sherrid MV, Shi L, Bluemke DA, Canter CE, Colan SD, Ho CY. Prevalence and Progression of Late Gadolinium Enhancement in Children and Adolescents With Hypertrophic Cardiomyopathy. Circulation 2019; 138:782-792. [PMID: 29622585 DOI: 10.1161/circulationaha.117.032966] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [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 Late gadolinium enhancement (LGE) on cardiac magnetic resonance imaging (CMR) is believed to represent dense replacement fibrosis. It is seen in ≈60% of adult patients with hypertrophic cardiomyopathy (HCM). However, the prevalence of LGE in children and adolescents with HCM is not well established. In addition, longitudinal studies describing the development and evolution of LGE in pediatric HCM are lacking. This study assesses the prevalence, progression, and clinical correlations of LGE in children and adolescents with, or genetically predisposed to, HCM. METHODS CMR scans from 195 patients ≤21 years of age were analyzed in an observational, retrospective study, including 155 patients with overt HCM and 40 sarcomere mutation carriers without left ventricular (LV) hypertrophy. The extent of LGE was quantified by measuring regions with signal intensity >6 SD above nulled remote myocardium. RESULTS Patients were 14.3±4.5 years of age at baseline and 68% were male. LGE was present in 70 (46%) patients with overt HCM (median extent, 3.3%; interquartile range, 0.8-7.1%), but absent in mutation carriers without LV hypertrophy. Thirty-one patients had >1 CMR (median interval between studies, 2.4 years; interquartile range, 1.5-3.2 years). LGE was detected in 13 patients (42%) at baseline and in 16 patients (52%) at follow-up CMR. The median extent of LGE increased by 2.4 g/y (range, 0-13.2 g/y) from 2.9% (interquartile range, 0.8-3.2%) of LV mass to 4.3% (interquartile range, 2.9-6.8%) ( P=0.02). In addition to LGE, LV mass and left atrial volume, indexed to body surface area, and z score for LV mass, as well, increased significantly from first to most recent CMR. CONCLUSIONS LGE was present in 46% of children and adolescents with overt HCM, in contrast to ≈60% typically reported in adult HCM. In the subset of patients with serial imaging, statistically significant increases in LGE, LV mass, and left atrial size were detected over 2.5 years, indicating disease progression over time. Further prospective studies are required to confirm these findings and to better understand the clinical implications of LGE in pediatric HCM.
Collapse
Affiliation(s)
- Anna Axelsson Raja
- Rigshospitalet, University of Copenhagen, Denmark (A.A., H.B.).,Brigham and Women's Hospital, Boston, MA (A.A., H.F., C.Y.H.)
| | - Hoshang Farhad
- Brigham and Women's Hospital, Boston, MA (A.A., H.F., C.Y.H.)
| | | | - John-Paul Couce
- Boston Children's Hospital, MA (A.M.V., J.-P.C., S.D.C.).,The present affiliation for J.-P. Couce is the London School of Hygiene and Tropical Medicine
| | | | | | | | | | | | - Euan Ashley
- Stanford University School of Medicine, Palo Alto, CA (E.A.)
| | | | | | - Ling Shi
- New England Research Institutes, Watertown, MA (L.S.)
| | | | - Charles E Canter
- Washington University School of Medicine, St. Louis, MO (C.E.C.)
| | - Steven D Colan
- Boston Children's Hospital, MA (A.M.V., J.-P.C., S.D.C.)
| | - Carolyn Y Ho
- Brigham and Women's Hospital, Boston, MA (A.A., H.F., C.Y.H.)
| |
Collapse
|
43
|
Abnousi F, Kang G, Giacomini J, Yeung A, Zarafshar S, Vesom N, Ashley E, Harrington R, Yong C. A novel noninvasive method for remote heart failure monitoring: the EuleriAn video Magnification apPLications In heart Failure studY (AMPLIFY). NPJ Digit Med 2019; 2:80. [PMID: 31453375 PMCID: PMC6704101 DOI: 10.1038/s41746-019-0159-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [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: 11/20/2018] [Accepted: 07/30/2019] [Indexed: 11/17/2022] Open
Abstract
Current remote monitoring devices for heart failure have been shown to reduce hospitalizations but are invasive and costly; accurate non-invasive options remain limited. The EuleriAn Video Magnification ApPLications In Heart Failure StudY (AMPLIFY) pilot aimed to evaluate the accuracy of a novel noninvasive method that uses Eulerian video magnification. Video recordings were performed on the neck veins of 50 patients who were scheduled for right heart catheterization at the Palo Alto VA Medical Center. The recorded jugular venous pulsations were then enhanced by applying Eulerian phase-based motion magnification. Assessment of jugular venous pressure was compared across three categories: (1) physicians who performed bedside exams, (2) physicians who reviewed both the amplified and unamplified videos, and (3) direct invasive measurement of right atrial pressure from right heart catheterization. Motion magnification reduced inaccuracy of the clinician assessment of central venous pressure compared to the gold standard of right heart catheterization (mean discrepancy of −0.80 cm H2O; 95% CI −2.189 to 0.612, p = 0.27) when compared to both unamplified video (−1.84 cm H2O; 95% CI −3.22 to −0.46, p = 0.0096) and the bedside exam (−2.90 cm H2O; 95% CI −4.33 to 1.40, p = 0.0002). Major categorical disagreements with right heart catheterization were significantly reduced with motion magnification (12%) when compared to unamplified video (25%) or the bedside exam (27%). This novel method of assessing jugular venous pressure improves the accuracy of the clinical exam and may enable accurate remote monitoring of heart failure patients with minimal patient risk.
Collapse
Affiliation(s)
- Freddy Abnousi
- 1Division of Cardiovascular Medicine, Department of Medicine, Stanford University Medical Center, Palo Alto, CA USA.,2Yale School of Medicine, Palo Alto, CA USA.,3Yale School of Medicine, New Haven, CT USA
| | - Guson Kang
- 1Division of Cardiovascular Medicine, Department of Medicine, Stanford University Medical Center, Palo Alto, CA USA
| | - John Giacomini
- 1Division of Cardiovascular Medicine, Department of Medicine, Stanford University Medical Center, Palo Alto, CA USA.,Veterans Affairs Palo Alto Medical Center, Palo Alto, CA USA
| | - Alan Yeung
- 1Division of Cardiovascular Medicine, Department of Medicine, Stanford University Medical Center, Palo Alto, CA USA
| | - Shirin Zarafshar
- 1Division of Cardiovascular Medicine, Department of Medicine, Stanford University Medical Center, Palo Alto, CA USA.,Veterans Affairs Palo Alto Medical Center, Palo Alto, CA USA
| | - Nicholas Vesom
- 1Division of Cardiovascular Medicine, Department of Medicine, Stanford University Medical Center, Palo Alto, CA USA
| | - Euan Ashley
- 1Division of Cardiovascular Medicine, Department of Medicine, Stanford University Medical Center, Palo Alto, CA USA
| | - Robert Harrington
- 1Division of Cardiovascular Medicine, Department of Medicine, Stanford University Medical Center, Palo Alto, CA USA
| | - Celina Yong
- 1Division of Cardiovascular Medicine, Department of Medicine, Stanford University Medical Center, Palo Alto, CA USA.,Veterans Affairs Palo Alto Medical Center, Palo Alto, CA USA
| |
Collapse
|
44
|
Johnson KW, Torres Soto J, Glicksberg BS, Shameer K, Miotto R, Ali M, Ashley E, Dudley JT. Artificial Intelligence in Cardiology. J Am Coll Cardiol 2019; 71:2668-2679. [PMID: 29880128 DOI: 10.1016/j.jacc.2018.03.521] [Citation(s) in RCA: 451] [Impact Index Per Article: 90.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 03/01/2018] [Accepted: 03/05/2018] [Indexed: 01/24/2023]
Abstract
Artificial intelligence and machine learning are poised to influence nearly every aspect of the human condition, and cardiology is not an exception to this trend. This paper provides a guide for clinicians on relevant aspects of artificial intelligence and machine learning, reviews selected applications of these methods in cardiology to date, and identifies how cardiovascular medicine could incorporate artificial intelligence in the future. In particular, the paper first reviews predictive modeling concepts relevant to cardiology such as feature selection and frequent pitfalls such as improper dichotomization. Second, it discusses common algorithms used in supervised learning and reviews selected applications in cardiology and related disciplines. Third, it describes the advent of deep learning and related methods collectively called unsupervised learning, provides contextual examples both in general medicine and in cardiovascular medicine, and then explains how these methods could be applied to enable precision cardiology and improve patient outcomes.
Collapse
Affiliation(s)
- Kipp W Johnson
- Institute for Next Generation Healthcare, Mount Sinai Health System, New York, New York; Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jessica Torres Soto
- Division of Cardiovascular Medicine, Stanford University, Palo Alto, California; Departments of Medicine, Genetics, and Biomedical Data Science, Stanford University, Palo Alto, California; Center for Inherited Cardiovascular Disease, Stanford University, Palo Alto, California
| | - Benjamin S Glicksberg
- Institute for Next Generation Healthcare, Mount Sinai Health System, New York, New York; Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York; Institute for Computational Health Sciences, University of California, San Francisco, California
| | - Khader Shameer
- Department of Information Services, Center for Research Informatics and Innovation, Northwell Health, New Hyde Park, New York
| | - Riccardo Miotto
- Institute for Next Generation Healthcare, Mount Sinai Health System, New York, New York; Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Mohsin Ali
- Institute for Next Generation Healthcare, Mount Sinai Health System, New York, New York; Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Euan Ashley
- Division of Cardiovascular Medicine, Stanford University, Palo Alto, California; Departments of Medicine, Genetics, and Biomedical Data Science, Stanford University, Palo Alto, California; Center for Inherited Cardiovascular Disease, Stanford University, Palo Alto, California
| | - Joel T Dudley
- Institute for Next Generation Healthcare, Mount Sinai Health System, New York, New York; Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York.
| |
Collapse
|
45
|
Kobayashi Y, Moneghetti KJ, Bouajila S, Stolfo D, Finocchiaro G, Kuznetsova T, Liang D, Schnittger I, Ashley E, Wheeler M, Haddad F. Time based versus strain based myocardial performance indices in hypertrophic cardiomyopathy, the merging role of left atrial strain. Eur Heart J Cardiovasc Imaging 2019; 20:334-342. [PMID: 30060097 DOI: 10.1093/ehjci/jey097] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [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: 02/05/2018] [Revised: 03/28/2018] [Accepted: 06/21/2018] [Indexed: 11/15/2022] Open
Abstract
AIMS The myocardial performance index (MPI) is a time-based index of global myocardial performance. In this study, we sought to compare the prognostic value of the MPI with other strain and remodelling indices in hypertrophic cardiomyopathy (HCM). METHODS AND RESULTS We enrolled 126 patients with HCM and 50 age- and sex-matched controls. Along with traditional echocardiographic assessment, MPI, left ventricular global longitudinal strain (LVGLS), E/e' ratio, and total left atrial (LA) global strain (LAS) were also measured. Time-based MPI was calculated from flow or tissue-based pulse wave Doppler (PWD and TDI) as the (isovolumic-relaxation and contraction time)/systolic-time. We used hierarchical clustering and network analysis to better visualize the relationship between parameters. The primary endpoint was the composite of all-cause death, heart transplantation, left ventricular assist device implantation, and clinical worsening. Left ventricular outflow tract (LVOT) obstruction was present in 56% of patients. Compared with controls, patients with HCM had worse LVGLS (-14.0 ± 3.4% vs. -19.6 ± 1.5%), higher E/e' (12.9 ± 7.2 vs. 6.1 ± 1.5), LA volume index (LAVI) (36.4 ± 13.8 ml/m2 vs. 25.6 ± 6.7 ml/m2), and MPI (0.55 ± 0.17 vs. 0.40 ± 0.11 for PWD and 0.59 ± 0.22 vs. 0.46 ± 0.09 for TDI) (all P < 0.001). During a median follow-up of 55 months, 47 endpoints occurred. PWD or TDI-based MPI was not associated with outcome, while LAVI, LAS, LVGLS, and E/e' were (all P < 0.01). On multivariable analysis, LVOT obstruction (P < 0.001), LAS (P < 0.001), and E/e' (P = 0.02) were retained as independent associates. They were in different clusters suggesting complemental relationship between them. CONCLUSION Time-based index is less predictive of outcome than strain or tissue Doppler indices. LAS may be a promising prognostic marker in HCM.
Collapse
Affiliation(s)
- Yukari Kobayashi
- Division of Cardiovascular Medicine, Stanford University School of Medicine, 300 Pasteur Drive Room H2170, Stanford, CA, USA.,Stanford Cardiovascular Institute, 300 Pasteur Drive, Stanford, CA, USA
| | - Kegan J Moneghetti
- Division of Cardiovascular Medicine, Stanford University School of Medicine, 300 Pasteur Drive Room H2170, Stanford, CA, USA.,Stanford Cardiovascular Institute, 300 Pasteur Drive, Stanford, CA, USA
| | - Sara Bouajila
- Division of Cardiovascular Medicine, Stanford University School of Medicine, 300 Pasteur Drive Room H2170, Stanford, CA, USA.,Stanford Cardiovascular Institute, 300 Pasteur Drive, Stanford, CA, USA
| | - Davide Stolfo
- Division of Cardiovascular Medicine, Stanford University School of Medicine, 300 Pasteur Drive Room H2170, Stanford, CA, USA.,Stanford Cardiovascular Institute, 300 Pasteur Drive, Stanford, CA, USA
| | - Gherardo Finocchiaro
- Division of Cardiovascular Medicine, Stanford University School of Medicine, 300 Pasteur Drive Room H2170, Stanford, CA, USA.,Stanford Cardiovascular Institute, 300 Pasteur Drive, Stanford, CA, USA
| | - Tatiana Kuznetsova
- Stanford Cardiovascular Institute, 300 Pasteur Drive, Stanford, CA, USA.,KU Leuven Department of Cardiovascular Sciences, Research Unit Hypertension and Cardiovascular Epidemiology, University of Leuven, Campus Sint Rafaël, Kapucijnenvoer 35, Block D, Leuven, Belgium
| | - David Liang
- Division of Cardiovascular Medicine, Stanford University School of Medicine, 300 Pasteur Drive Room H2170, Stanford, CA, USA.,Stanford Cardiovascular Institute, 300 Pasteur Drive, Stanford, CA, USA
| | - Ingela Schnittger
- Division of Cardiovascular Medicine, Stanford University School of Medicine, 300 Pasteur Drive Room H2170, Stanford, CA, USA.,Stanford Cardiovascular Institute, 300 Pasteur Drive, Stanford, CA, USA
| | - Euan Ashley
- Division of Cardiovascular Medicine, Stanford University School of Medicine, 300 Pasteur Drive Room H2170, Stanford, CA, USA.,Stanford Cardiovascular Institute, 300 Pasteur Drive, Stanford, CA, USA
| | - Matthew Wheeler
- Division of Cardiovascular Medicine, Stanford University School of Medicine, 300 Pasteur Drive Room H2170, Stanford, CA, USA.,Stanford Cardiovascular Institute, 300 Pasteur Drive, Stanford, CA, USA
| | - Francois Haddad
- Division of Cardiovascular Medicine, Stanford University School of Medicine, 300 Pasteur Drive Room H2170, Stanford, CA, USA.,Stanford Cardiovascular Institute, 300 Pasteur Drive, Stanford, CA, USA
| |
Collapse
|
46
|
Kobayashi Y, Tremblay-Gravel M, Boralkar KA, Li X, Nishi T, Amsallem M, Moneghetti KJ, Bouajila S, Selej M, Ozen MO, Demirci U, Ashley E, Wheeler M, Knowlton KU, Kouznetsova T, Haddad F. Approaching Higher Dimension Imaging Data Using Cluster-Based Hierarchical Modeling in Patients with Heart Failure Preserved Ejection Fraction. Sci Rep 2019; 9:10431. [PMID: 31320698 PMCID: PMC6639369 DOI: 10.1038/s41598-019-46873-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [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] [Received: 04/18/2019] [Accepted: 07/04/2019] [Indexed: 02/05/2023] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a major cause of morbidity and mortality, accounting for the majority of heart failure (HF) hospitalization. To identify the most complementary predictors of mortality among clinical, laboratory and echocardiographic data, we used cluster based hierarchical modeling. Using Stanford Translational Research Database, we identified patients hospitalized with HFpEF between 2005 and 2016 in whom echocardiogram and NT-proBNP were both available at the time of admission. Comprehensive echocardiographic assessment including left ventricular longitudinal strain (LVLS), right ventricular function and right ventricular systolic pressure (RVSP) was performed. The outcome was defined as all-cause mortality. Among patients identified, 186 patients with complete echocardiographic assessment were included in the analysis. The cohort included 58% female, with a mean age of 78.7 ± 13.5 years, LVLS of −13.3 ± 2.5%, an estimated RVSP of 38 ± 13 mmHg. Unsupervised cluster analyses identified six clusters including ventricular systolic-function cluster, diastolic-hemodynamic cluster, end-organ function cluster, vital-sign cluster, complete blood count and sodium clusters. Using a stepwise hierarchical selection from each cluster, we identified NT-proBNP (standard hazard ratio [95%CI] = 1.56 [1.17–2.08]) and RVSP (1.37 [1.09–1.78]) as independent correlates of outcome. When adding these parameters to the well validated Get with the Guideline Heart Failure risk score, the Chi-square was significantly improved (p = 0.01). In conclusion, NT-proBNP and RVSP were independently predictive in HFpEF among clinical, imaging, and biomarker parameters. Cluster-based hierarchical modeling may help identify the complementally predictive parameters in small cohorts with higher dimensional clinical data.
Collapse
Affiliation(s)
- Yukari Kobayashi
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, United States. .,Stanford Cardiovascular Institute, Stanford, CA, United States.
| | - Maxime Tremblay-Gravel
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, United States.,Stanford Cardiovascular Institute, Stanford, CA, United States
| | - Kalyani A Boralkar
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, United States.,Stanford Cardiovascular Institute, Stanford, CA, United States
| | - Xiao Li
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Tomoko Nishi
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, United States.,Stanford Cardiovascular Institute, Stanford, CA, United States
| | - Myriam Amsallem
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, United States.,Stanford Cardiovascular Institute, Stanford, CA, United States
| | - Kegan J Moneghetti
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, United States.,Stanford Cardiovascular Institute, Stanford, CA, United States
| | - Sara Bouajila
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, United States.,Stanford Cardiovascular Institute, Stanford, CA, United States
| | - Mona Selej
- Medical Director, Franchise, Medical Affairs Strategy, Actelion Pharmaceuticals US, Inc South, San Francisco, California, United States
| | - Mehmet O Ozen
- Stanford Cardiovascular Institute, Stanford, CA, United States.,Bio-Acoustic -MEMS in Medicine (BAMM) Laboratories, Canary Center at Stanford for Cancer Early Detection, Department of Radiology, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Utkan Demirci
- Stanford Cardiovascular Institute, Stanford, CA, United States.,Bio-Acoustic -MEMS in Medicine (BAMM) Laboratories, Canary Center at Stanford for Cancer Early Detection, Department of Radiology, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Euan Ashley
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, United States.,Stanford Cardiovascular Institute, Stanford, CA, United States
| | - Matthew Wheeler
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, United States.,Stanford Cardiovascular Institute, Stanford, CA, United States
| | - Kirk U Knowlton
- Intermountain Medical Center Intermountain Heart Institute, Salt Lake City, UT, United States
| | - Tatiana Kouznetsova
- Research Unit Hypertension and Cardiovascular Epidemiology, Department of Cardiovascular Sciences, Leuven, Belgium
| | - Francois Haddad
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, United States.,Stanford Cardiovascular Institute, Stanford, CA, United States
| |
Collapse
|
47
|
Fries JA, Varma P, Chen VS, Xiao K, Tejeda H, Saha P, Dunnmon J, Chubb H, Maskatia S, Fiterau M, Delp S, Ashley E, Ré C, Priest JR. Weakly supervised classification of aortic valve malformations using unlabeled cardiac MRI sequences. Nat Commun 2019; 10:3111. [PMID: 31308376 PMCID: PMC6629670 DOI: 10.1038/s41467-019-11012-3] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 06/13/2019] [Indexed: 11/23/2022] Open
Abstract
Biomedical repositories such as the UK Biobank provide increasing access to prospectively collected cardiac imaging, however these data are unlabeled, which creates barriers to their use in supervised machine learning. We develop a weakly supervised deep learning model for classification of aortic valve malformations using up to 4,000 unlabeled cardiac MRI sequences. Instead of requiring highly curated training data, weak supervision relies on noisy heuristics defined by domain experts to programmatically generate large-scale, imperfect training labels. For aortic valve classification, models trained with imperfect labels substantially outperform a supervised model trained on hand-labeled MRIs. In an orthogonal validation experiment using health outcomes data, our model identifies individuals with a 1.8-fold increase in risk of a major adverse cardiac event. This work formalizes a deep learning baseline for aortic valve classification and outlines a general strategy for using weak supervision to train machine learning models using unlabeled medical images at scale.
Collapse
Affiliation(s)
- Jason A Fries
- Department of Computer Science, Stanford University, Stanford, CA, 94305, USA.
- Center for Biomedical Informatics Research, Stanford University, Palo Alto, CA, 94305, USA.
| | - Paroma Varma
- Department of Electrical Engineering, Stanford University, Palo Alto, CA, 94305, USA
| | - Vincent S Chen
- Department of Computer Science, Stanford University, Stanford, CA, 94305, USA
| | - Ke Xiao
- Department of Pediatrics, Stanford University, Stanford, CA, 94304, USA
| | - Heliodoro Tejeda
- Department of Pediatrics, Stanford University, Stanford, CA, 94304, USA
| | - Priyanka Saha
- Department of Pediatrics, Stanford University, Stanford, CA, 94304, USA
| | - Jared Dunnmon
- Department of Computer Science, Stanford University, Stanford, CA, 94305, USA
| | - Henry Chubb
- Department of Pediatrics, Stanford University, Stanford, CA, 94304, USA
| | - Shiraz Maskatia
- Department of Pediatrics, Stanford University, Stanford, CA, 94304, USA
| | - Madalina Fiterau
- Department of Computer Science, Stanford University, Stanford, CA, 94305, USA
| | - Scott Delp
- Department of Bioengineering, Stanford University, Palo Alto, CA, 94305, USA
| | - Euan Ashley
- Department of Medicine, Stanford University, Stanford, CA, 94304, USA
- Chan Zuckerberg BioHub, San Francisco, CA, 94158, USA
| | - Christopher Ré
- Department of Computer Science, Stanford University, Stanford, CA, 94305, USA
- Chan Zuckerberg BioHub, San Francisco, CA, 94158, USA
| | - James R Priest
- Department of Pediatrics, Stanford University, Stanford, CA, 94304, USA
- Chan Zuckerberg BioHub, San Francisco, CA, 94158, USA
| |
Collapse
|
48
|
Tooley J, Ouyang D, Hadley D, Turakhia M, Wang P, Ashley E, Froelicher V, Perez M. Comparison of QT Interval Measurement Methods and Correction Formulas in Atrial Fibrillation. Am J Cardiol 2019; 123:1822-1827. [PMID: 30961909 DOI: 10.1016/j.amjcard.2019.02.057] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 02/21/2019] [Accepted: 02/22/2019] [Indexed: 11/24/2022]
Abstract
Antiarrhythmic drugs used in atrial fibrillation (AF) cause QT prolongation and are associated with torsades de pointes, a deadly ventricular arrhythmia. No consensus exists on the optimal method of QT measurement or correction in AF. Therefore, we compared common methods to measure and correct QT in AF to identify the most accurate approach. We identified patients who had electrocardiograms done at Stanford Hospital (Stanford, California) between January 2014 and October 2016 with conversion from AF to sinus rhythm (SR) within a 24-hour period. QT intervals were determined using different measurement methods and corrected using the Bazett's, Framingham, Fridericia, or Hodges formulas for heart rate (HR). Comparisons were made between QT in a patient's last instance of AF to SR. Computerized measurements were taken from 715 patients. Manual measurements were taken from a 50-patient subset. Bazett's formula produced the longest corrected QT in AF compared with other formulas (p <0.005). Measuring QT as an average over multiple beats resulted in a smaller difference between AF and SR than choosing a single beat. Determining QT from a 5-beat average resulted in a QTc that was 19.0 ms higher (interquartile range 0.30 to 43.7) in AF than SR. After correcting for residual effect of HR on QTc, there was not a significant difference between QTc in AF to SR. In conclusion, measuring QT over multiple beats produces a more accurate measurement of QT in AF. Differences between QTc in AF and SR exist because of imperfect HR correction formula and not due to an independent effect of AF.
Collapse
|
49
|
Hedman K, Moneghetti KJ, Christle JW, Bagherzadeh SP, Amsallem M, Ashley E, Froelicher V, Haddad F. Blood pressure in athletic preparticipation evaluation and the implication for cardiac remodelling. Heart 2019; 105:1223-1230. [PMID: 31142598 DOI: 10.1136/heartjnl-2019-314815] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [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: 01/25/2019] [Revised: 03/26/2019] [Accepted: 04/04/2019] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To explore blood pressure (BP) in athletes at preparticipation evaluation (PPE) in the context of recently updated US and European hypertension guidelines, and to determine the relationship between BP and left ventricular (LV) remodelling. METHODS In this retrospective study, athletes aged 13-35 years who underwent PPE facilitated by the Stanford Sports Cardiology programme were considered. Resting BP was measured in both arms; repeated once if ≥140/90 mm Hg. Athletes with abnormal ECGs or known hypertension were excluded. BP was categorised per US/European hypertension guidelines. In a separate cohort of athletes undergoing routine PPE echocardiography, we explored the relationship between BP and LV remodelling (LV mass, mass/volume ratio, sphericity index) and LV function. RESULTS In cohort 1 (n=2733, 65.5% male), 34.3% of athletes exceeded US hypertension thresholds. Male sex (B=3.17, p<0.001), body mass index (BMI) (B=0.80, p<0.001) and height (B=0.25, p<0.001) were the strongest independent correlates of systolic BP. In the second cohort (n=304, ages 17-26), systolic BP was an independent correlate of LV mass/volume ratio (B=0.002, p=0.001). LV longitudinal strain was similar across BP categories, while higher BP was associated with slower early diastolic relaxation. CONCLUSION In a large contemporary cohort of athletes, one-third presented with BP levels above the current US guidelines' thresholds for hypertension, highlighting that lowering the BP thresholds at PPE warrants careful consideration as well as efforts to standardise measurements. Higher systolic BP was associated with male sex, BMI and height and with LV remodelling and diastolic function, suggesting elevated BP in athletes during PPE may signify a clinically relevant condition.
Collapse
Affiliation(s)
- Kristofer Hedman
- Department of Medicine, Division of Cardiovascular Medicine, Stanford, California, USA.,Department of Medicine, Stanford Cardiovascular Institute, Stanford, California, USA
| | - Kegan J Moneghetti
- Department of Medicine, Division of Cardiovascular Medicine, Stanford, California, USA.,Stanford University, Stanford Sports Cardiology, Stanford, California, USA
| | - Jeffrey W Christle
- Department of Medicine, Division of Cardiovascular Medicine, Stanford, California, USA.,Stanford University, Stanford Sports Cardiology, Stanford, California, USA
| | - Shadi P Bagherzadeh
- Department of Medicine, Division of Cardiovascular Medicine, Stanford, California, USA.,Department of Medicine, Stanford Cardiovascular Institute, Stanford, California, USA
| | - Myriam Amsallem
- Department of Medicine, Division of Cardiovascular Medicine, Stanford, California, USA.,Department of Medicine, Stanford Cardiovascular Institute, Stanford, California, USA
| | - Euan Ashley
- Department of Medicine, Division of Cardiovascular Medicine, Stanford, California, USA.,Stanford University, Stanford Sports Cardiology, Stanford, California, USA
| | - Victor Froelicher
- Department of Medicine, Division of Cardiovascular Medicine, Stanford, California, USA.,Stanford University, Stanford Sports Cardiology, Stanford, California, USA
| | - Francois Haddad
- Department of Medicine, Division of Cardiovascular Medicine, Stanford, California, USA.,Department of Medicine, Stanford Cardiovascular Institute, Stanford, California, USA
| |
Collapse
|
50
|
Dainis A, Tseng E, Clark TA, Hon T, Wheeler M, Ashley E. Targeted Long-Read RNA Sequencing Demonstrates Transcriptional Diversity Driven by Splice-Site Variation in
MYBPC3. Circ: Genomic and Precision Medicine 2019; 12:e002464. [DOI: 10.1161/circgen.119.002464] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | - Tyson A. Clark
- Pacific Biosciences, Menlo Park, CA (E.T., T.A.C., T.H.)
| | - Ting Hon
- Pacific Biosciences, Menlo Park, CA (E.T., T.A.C., T.H.)
| | - Matthew Wheeler
- Department of Medicine (M.W., E.A.), Stanford University, CA
- Stanford Center for Inherited Cardiovascular Disease (M.W., E.A.), Stanford University, CA
| | - Euan Ashley
- Department of Genetics (A.D., E.A.), Stanford University, CA
- Department of Medicine (M.W., E.A.), Stanford University, CA
- Stanford Center for Inherited Cardiovascular Disease (M.W., E.A.), Stanford University, CA
| |
Collapse
|