51
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Drezner JA, Malhotra A, Prutkin JM, Papadakis M, Harmon KG, Asif IM, Owens DS, Marek JC, Sharma S. Return to play with hypertrophic cardiomyopathy: are we moving too fast? A critical review. Br J Sports Med 2021; 55:1041-1047. [PMID: 33472848 PMCID: PMC8408577 DOI: 10.1136/bjsports-2020-102921] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2020] [Indexed: 12/31/2022]
Abstract
The diagnosis of a potentially lethal cardiovascular disease in a young athlete presents a complex dilemma regarding athlete safety, patient autonomy, team or institutional risk tolerance and medical decision-making. Consensus cardiology recommendations previously supported the ‘blanket’ disqualification of athletes with hypertrophic cardiomyopathy (HCM) from competitive sport. More recently, epidemiological studies examining the relative contribution of HCM as a cause of sudden cardiac death (SCD) in young athletes and reports from small cohorts of older athletes with HCM that continue to exercise have fueled debate whether it is safe to play with HCM. Shared decision-making is endorsed within the sports cardiology community in which athletes can make an informed decision about treatment options and potentially elect to continue competitive sports participation. This review critically examines the available evidence relevant to sports eligibility decisions in young athletes diagnosed with HCM. Histopathologically, HCM presents an unstable myocardial substrate that is vulnerable to ventricular tachyarrhythmias during exercise. Studies support that young age and intense competitive sports are risk factors for SCD in patients with HCM. We provide an estimate of annual mortality based on our understanding of disease prevalence and the incidence of HCM-related SCD in different athlete populations. Adolescent and young adult male athletes and athletes participating in a higher risk sport such as basketball, soccer and American football exhibit a greater risk. This review explores the potential harms and benefits of sports disqualification in athletes with HCM and details the challenges and limitations of shared decision-making when all parties may not agree.
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Affiliation(s)
- Jonathan A Drezner
- Center for Sports Cardiology, University of Washington, Seattle, Washington, USA
| | - Aneil Malhotra
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | - Jordan M Prutkin
- Department of Internal Medicine, Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - Michael Papadakis
- Cardiology, Clinical Academic Group, St George's, University of London, London, UK
| | - Kimberly G Harmon
- Center for Sports Cardiology, University of Washington, Seattle, Washington, USA
| | - Irfan M Asif
- Center for Health Promotion, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - David S Owens
- Department of Internal Medicine, Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - Joseph C Marek
- Cardiology, Advocate Heart Institute, Downers Grove, Illinois, USA
| | - Sanjay Sharma
- Cardiology, Clinical Academic Group, St George's, University of London, London, UK
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52
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Stafford F, Thomson K, Butters A, Ingles J. Hypertrophic Cardiomyopathy: Genetic Testing and Risk Stratification. Curr Cardiol Rep 2021; 23:9. [PMID: 33433738 DOI: 10.1007/s11886-020-01437-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/18/2020] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Our knowledge of the genetic basis and molecular pathogenesis of hypertrophic cardiomyopathy (HCM) continues to evolve. We describe the genetic basis of HCM, recent advances in genetic testing and the role of genetics in guiding risk stratification and management, both now and in the future. RECENT FINDINGS While initially thought to be an exclusively Mendelian disease, we now know there are important HCM sub-groups. A proportion will have sarcomere variants as the cause of their disease, while others will have genetic variants in genes that can give rise to conditions that can mimic HCM. The role of genetics is primarily for cascade genetic testing, though there is emerging evidence of a role for prognosis and patient management. Genetic testing is a useful addition to management. Genotype may play a greater role in risk stratification, management, treatment and prognosis in future, offering improved outcomes for patients and their families with HCM.
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Affiliation(s)
- Fergus Stafford
- Cardio Genomics Program at Centenary Institute, The University of Sydney, Locked Bag 6, Newtown, NSW, 2042, Australia
| | - Kate Thomson
- Oxford Medical Genetics Laboratories, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Radcliffe Department of Medicine, Division of Cardiovascular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Alexandra Butters
- Cardio Genomics Program at Centenary Institute, The University of Sydney, Locked Bag 6, Newtown, NSW, 2042, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Jodie Ingles
- Cardio Genomics Program at Centenary Institute, The University of Sydney, Locked Bag 6, Newtown, NSW, 2042, Australia.
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia.
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53
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Ommen SR, Mital S, Burke MA, Day SM, Deswal A, Elliott P, Evanovich LL, Hung J, Joglar JA, Kantor P, Kimmelstiel C, Kittleson M, Link MS, Maron MS, Martinez MW, Miyake CY, Schaff HV, Semsarian C, Sorajja P. 2020 AHA/ACC Guideline for the Diagnosis and Treatment of Patients With Hypertrophic Cardiomyopathy: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2020; 76:e159-e240. [PMID: 33229116 DOI: 10.1016/j.jacc.2020.08.045] [Citation(s) in RCA: 323] [Impact Index Per Article: 80.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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54
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Ommen SR, Mital S, Burke MA, Day SM, Deswal A, Elliott P, Evanovich LL, Hung J, Joglar JA, Kantor P, Kimmelstiel C, Kittleson M, Link MS, Maron MS, Martinez MW, Miyake CY, Schaff HV, Semsarian C, Sorajja P. 2020 AHA/ACC Guideline for the Diagnosis and Treatment of Patients With Hypertrophic Cardiomyopathy. Circulation 2020; 142:e558-e631. [DOI: 10.1161/cir.0000000000000937] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
| | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines Liaison
- HFSA Representative
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55
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Aguiar Rosa S, Rocha Lopes L, Fiarresga A, Ferreira RC, Mota Carmo M. Coronary microvascular dysfunction in hypertrophic cardiomyopathy: Pathophysiology, assessment, and clinical impact. Microcirculation 2020; 28:e12656. [PMID: 32896949 DOI: 10.1111/micc.12656] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 06/21/2020] [Accepted: 07/13/2020] [Indexed: 12/14/2022]
Abstract
Myocardial ischemia constitutes one of the most important pathophysiological features in hypertrophic cardiomyopathy. Chronic and recurrent myocardial ischemia leads to fibrosis, which may culminate in myocardial dysfunction. Since the direct visualization of coronary microcirculation in vivo is not possible, its function must be studied indirectly. Invasive and noninvasive techniques allow microcirculatory dysfunction to be evaluated, including echocardiography, magnetic resonance, positron emission tomography, and cardiac catheterization. Blunted myocardial blood flow and coronary flow reserve have been suggested to associate with unfavorable prognosis. Microcirculatory dysfunction may be one additional important parameter to take into account for risk stratification beyond the conventional risk factors.
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Affiliation(s)
- Sílvia Aguiar Rosa
- Department of Cardiology, Santa Marta Hospital, Lisbon, Portugal.,Nova Medical School, Lisbon, Portugal
| | - Luís Rocha Lopes
- Inherited Cardiac Disease Unit, Bart's Heart Centre, St Bartholomew's Hospital, London, UK.,Centre for Heart Muscle Disease, Institute of Cardiovascular Science, University College London, UK.,Centro Cardiovascular, Universidade de Lisboa, Lisbon, Portugal
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56
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Anghel L, Stătescu C, Șerban IL, Mărănducă MA, Butcovan D, Clement A, Bostan M, Sascău R. The Advantages of New Multimodality Imaging in Choosing the Optimal Management Strategy for Patients with Hypertrophic Cardiomyopathy. Diagnostics (Basel) 2020; 10:diagnostics10090719. [PMID: 32961665 PMCID: PMC7554758 DOI: 10.3390/diagnostics10090719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 09/15/2020] [Accepted: 09/18/2020] [Indexed: 11/16/2022] Open
Abstract
In recent years, significant advances have been made in the diagnosis and therapeutic management of hypertrophic cardiomyopathy (HCM) patients, which has led to an important improvement in their longevity and quality of life. The use of multimodality imaging has an essential role in the diagnosis, assessing the regional distribution and severity of the disease, with important prognostic implications. At the same time, imaging contributes to the identification of optimal treatment for patients with hypertrophic cardiomyopathy, whether it is pharmaceutical, interventional or surgical treatment. Novel pharmacotherapies (like myosin inhibitors), minimally invasive procedures (such as transcatheter mitral valve repair, high-intensity focused ultrasound or radiofrequency ablation) and gene-directed approaches, may soon become alternatives for HCM patients. However, there are only few data on the early diagnosis of patients with HCM, in order to initiate treatment as soon as possible, to reduce the risk of sudden cardiac death (SCD). The aim of our review is to highlight the advantages of contemporary imaging in choosing the optimal management strategies for HCM patients, considering the novel therapies which are currently applied or studied for these patients.
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Affiliation(s)
- Larisa Anghel
- Internal Medicine Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700503 Iași, Romania; (L.A.); (M.B.); (R.S.)
- Cardiology Department, Cardiovascular Diseases Institute “Prof. Dr. George I.M.Georgescu”, 700503 Iași, Romania; (D.B.); (A.C.)
| | - Cristian Stătescu
- Internal Medicine Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700503 Iași, Romania; (L.A.); (M.B.); (R.S.)
- Cardiology Department, Cardiovascular Diseases Institute “Prof. Dr. George I.M.Georgescu”, 700503 Iași, Romania; (D.B.); (A.C.)
- Correspondence: ; Tel.: +40-0232-211834
| | - Ionela-Lăcrămioara Șerban
- Physiology Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700503 Iași, Romania; (I.-L.Ș.); (M.A.M.)
| | - Minela Aida Mărănducă
- Physiology Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700503 Iași, Romania; (I.-L.Ș.); (M.A.M.)
| | - Doina Butcovan
- Cardiology Department, Cardiovascular Diseases Institute “Prof. Dr. George I.M.Georgescu”, 700503 Iași, Romania; (D.B.); (A.C.)
| | - Alexandra Clement
- Cardiology Department, Cardiovascular Diseases Institute “Prof. Dr. George I.M.Georgescu”, 700503 Iași, Romania; (D.B.); (A.C.)
| | - Mădălina Bostan
- Internal Medicine Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700503 Iași, Romania; (L.A.); (M.B.); (R.S.)
- Cardiology Department, Cardiovascular Diseases Institute “Prof. Dr. George I.M.Georgescu”, 700503 Iași, Romania; (D.B.); (A.C.)
| | - Radu Sascău
- Internal Medicine Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700503 Iași, Romania; (L.A.); (M.B.); (R.S.)
- Cardiology Department, Cardiovascular Diseases Institute “Prof. Dr. George I.M.Georgescu”, 700503 Iași, Romania; (D.B.); (A.C.)
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57
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Fahed AC, Nemer G, Bitar FF, Arnaout S, Abchee AB, Batrawi M, Khalil A, Abou Hassan OK, DePalma SR, McDonough B, Arabi MT, Ware JS, Seidman JG, Seidman CE. Founder Mutation in N Terminus of Cardiac Troponin I Causes Malignant Hypertrophic Cardiomyopathy. CIRCULATION-GENOMIC AND PRECISION MEDICINE 2020; 13:444-452. [PMID: 32885985 PMCID: PMC7676616 DOI: 10.1161/circgen.120.002991] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cardiac troponin I (TNNI3) gene mutations account for 3% of hypertrophic cardiomyopathy and carriers have a heterogeneous phenotype, with increased risk of sudden cardiac death (SCD). Only one mutation (p.Arg21Cys) has been reported in the N terminus of the protein. In model organisms, it impairs PKA (protein kinase A) phosphorylation, increases calcium sensitivity, and causes diastolic dysfunction. The phenotype of this unique mutation in patients with hypertrophic cardiomyopathy remains unknown. METHODS We sequenced 29 families with hypertrophic cardiomyopathy enriched for pediatric-onset disease and identified 5 families with the TNNI3 p.Arg21Cys mutation. Using cascade screening, we studied the clinical phenotype of 57 individuals from the 5 families with TNNI3 p.Arg21Cys-related cardiomyopathy. We performed survival analysis investigating the age at first SCD in carriers of the mutation. RESULTS All 5 families with TNNI3 p.Arg21Cys were from South Lebanon. TNNI3 p.Arg21Cys-related cardiomyopathy manifested a malignant phenotype-SCD occurred in 30 (53%) of 57 affected individuals at a median age of 22.5 years. In select carriers without left ventricular hypertrophy on echocardiogram, SCD occurred, myocyte disarray was found on autopsy heart, and tissue Doppler and cardiac magnetic resonance imaging identified subclinical disease features such as diastolic dysfunction and late gadolinium enhancement. CONCLUSIONS The TNNI3 p.Arg21Cys mutation has a founder effect in South Lebanon and causes malignant hypertrophic cardiomyopathy with early SCD even in the absence of hypertrophy. Genetic diagnosis with this mutation may be sufficient for risk stratification for SCD.
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Affiliation(s)
- Akl C Fahed
- Division of Cardiology, Department of Medicine, Center of Genomic Medicine, Massachusetts General Hospital (A.C.F.), Harvard Medical School, Boston.,Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA (A.C.F.)
| | - Georges Nemer
- Department of Biochemistry and Molecular Genetics, American University of Beirut, Lebanon (G.N., F.F.B., M.B., A.K., O.A.-H.).,College of Health and Life Sciences, Hamad Bin Khalifa University, Education City, Doha, Qatar (G.N.)
| | - Fadi F Bitar
- Department of Biochemistry and Molecular Genetics, American University of Beirut, Lebanon (G.N., F.F.B., M.B., A.K., O.A.-H.).,Department of Pediatrics (F.F.B., M.T.A.), American University of Beirut Medical Center, Lebanon
| | - Samir Arnaout
- Cardiology Division (S.A., A.B.A., O.A.-H.), American University of Beirut Medical Center, Lebanon
| | - Antoine B Abchee
- Cardiology Division (S.A., A.B.A., O.A.-H.), American University of Beirut Medical Center, Lebanon
| | - Manal Batrawi
- Department of Biochemistry and Molecular Genetics, American University of Beirut, Lebanon (G.N., F.F.B., M.B., A.K., O.A.-H.)
| | - Athar Khalil
- Department of Biochemistry and Molecular Genetics, American University of Beirut, Lebanon (G.N., F.F.B., M.B., A.K., O.A.-H.)
| | - Ossama K Abou Hassan
- Department of Biochemistry and Molecular Genetics, American University of Beirut, Lebanon (G.N., F.F.B., M.B., A.K., O.A.-H.).,Cardiology Division (S.A., A.B.A., O.A.-H.), American University of Beirut Medical Center, Lebanon
| | - Steven R DePalma
- Department of Genetics (S.R.D., B.M., J.G.S., C.E.S.), Harvard Medical School, Boston
| | - Barbara McDonough
- Department of Genetics (S.R.D., B.M., J.G.S., C.E.S.), Harvard Medical School, Boston
| | - Mariam T Arabi
- Department of Pediatrics (F.F.B., M.T.A.), American University of Beirut Medical Center, Lebanon
| | - James S Ware
- National Heart and Lung Institute, Imperial College London, Royal Brompton Hospital (J.S.W.).,Medical Research College London Institute of Medical Sciences, United Kingdom (J.S.W.)
| | - Jonathan G Seidman
- Department of Genetics (S.R.D., B.M., J.G.S., C.E.S.), Harvard Medical School, Boston
| | - Christine E Seidman
- Department of Genetics (S.R.D., B.M., J.G.S., C.E.S.), Harvard Medical School, Boston.,Division of Cardiology and Howard Hughes Medical Institute, Brigham and Women's Hospital, Boston, MA (C.E.S.)
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58
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Weissler-Snir A, Dorian P, Rakowski H, Care M, Spears D. Primary prevention implantable cardioverter-defibrillators in hypertrophic cardiomyopathy-Are there predictors of appropriate therapy? Heart Rhythm 2020; 18:63-70. [PMID: 32800967 DOI: 10.1016/j.hrthm.2020.08.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 08/06/2020] [Accepted: 08/09/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Identifying patients with hypertrophic cardiomyopathy (HCM) who warrant a primary prevention implantable cardioverter-defibrillator (ICD) is crucial. ICDs are effective in terminating life-threatening arrhythmias; however, ICDs carry risks of complications. OBJECTIVE The purpose of this study was to assess the incidence and predictors of appropriate ICD therapies, inappropriate shocks, and device-related complications in patients with HCM and primary prevention ICDs. METHODS All patients with HCM who underwent primary prevention ICD implantation at Toronto General Hospital between September 2000 and December 2017 were identified. Therapies (shocks or antitachycardia pacing) for ventricular tachycardia >180 beats/min or ventricular fibrillation were considered appropriate. RESULTS Three hundred two patients were followed for a mean 6.1 ± 4.3 years (1801 patient-years of follow-up). Thirty-eight patients (12.6%) received at least 1 appropriate ICD therapy (2.3%/y); the 5-year cumulative probability of receiving appropriate ICD therapy was 9.6%. None of the conventional risk factors nor the European Society of Cardiology risk score was associated with appropriate ICD therapy. In multivariable analysis, age < 40 years at implantation and atrial fibrillation were independent predictors of appropriate ICD therapy. In a subgroup of patients who had undergone cardiac magnetic resonance imaging before ICD implantation, severe late gadolinium enhancement was the strongest predictor of appropriate ICD therapies. ICD-related complications or inappropriate shocks occurred in 87 patients (28.8%), with an inappropriate shock rate of 2.1%/y; the 5-year cumulative probability was 10.7%. CONCLUSION The incidence of appropriate ICD therapies in patients with HCM and primary prevention ICDs is lower than previously reported; a high proportion of patients suffer from an ICD-related complication. Traditional risk factors have low predictive utility. Severe late gadolinium enhancement, atrial fibrillation, and young age are important predictors of ventricular tachyarrhythmias in HCM.
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Affiliation(s)
- Adaya Weissler-Snir
- Division of Cardiology, Hartford Hospital, University of Connecticut, Hartford, Connecticut.
| | - Paul Dorian
- Division of Cardiology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Harry Rakowski
- Division of Cardiology, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
| | - Melanie Care
- Division of Cardiology, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
| | - Danna Spears
- Division of Cardiology, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
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59
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Maron BJ, Mackey-Bojack S, Facile E, Duncanson E, Rowin EJ, Maron MS. Hypertrophic Cardiomyopathy and Sudden Death Initially Identified at Autopsy. Am J Cardiol 2020; 127:139-141. [PMID: 32375998 DOI: 10.1016/j.amjcard.2020.04.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 04/04/2020] [Accepted: 04/10/2020] [Indexed: 11/16/2022]
Abstract
Hypertrophic cardiomyopathy (HC) is associated with a well-recognized risk for unexpected sudden death (SD). Most such reported patients have been referred to dedicated centers and/or expert cardiologists for risk stratification, with the number of SDs decreasing sharply due to penetration of the implantable cardioverter-defibrillator (ICDs) into HC practice. However, the clinical circumstances, and morphologic features of HC patients who incur SD without the opportunity to be considered for preventive intervention with ICDs are largely undefined. Using the long-standing unique Jesse Edwards Registry (St. Paul, Minnesota), we studied 86 selected heart specimens from young HC patients who died suddenly and unexpectedly without prior clinical evaluation, ages 31 ± 16 years. The patients were predominantly male (87%) with only modest phenotypic expression and maximum LV wall thickening of only 18 ± 4 mm. SD events occurred predominantly with sedentary/mild activities (66%) often in bed or asleep (32%), but also during physical activity (22%) including with organized competitive sports. This largely unappreciated sub-population of patients with HC (and SD) is characterized by mild-to-moderate degree of LV hypertrophy, representing a clinical challenge which is particularly relevant in the current ICD era for HC, with the potential for SD prevention.
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Affiliation(s)
- Barry J Maron
- HCM Institute, Tufts Medical Center, Boston, Massachusetts
| | | | | | | | - Ethan J Rowin
- HCM Institute, Tufts Medical Center, Boston, Massachusetts
| | - Martin S Maron
- HCM Institute, Tufts Medical Center, Boston, Massachusetts.
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60
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Liao YW, Redfern J, Somauroo JD, Cooper RM. Hypertrophic cardiomyopathy and exercise restrictions: time to let the shackles off? THE BRITISH JOURNAL OF CARDIOLOGY 2020; 27:11. [PMID: 35747091 PMCID: PMC8793933 DOI: 10.5837/bjc.2020.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The health benefits of physical activity are well documented. Patients with hypertrophic cardiomyopathy (HCM) are often discouraged from participating in physical activity due to a perceived increase in the risk of sudden cardiac death (SCD). As a result, only 45% of patients with HCM meet the minimum guidelines for physical activity, and many report an intentional reduction in exercise following diagnosis. Despite most SCD being unrelated to HCM, guidelines traditionally focused on the avoidance of potential risk through restriction of exercise, without clear recommendations on how to negate the negative health impact of inactivity. Retrospective reviews have demonstrated that the majority of cardiac arrests in patients with HCM occurred at rest or on mild exertion and that the overall incidence of HCM-related SCD is significantly lower than previously reported. We will discuss current international guidelines and recommendations and consider the outcomes of various studies that have investigated the effects of exercise of different intensities on patients with HCM. In light of the growing evidence suggesting that carefully guided exercise can be both beneficial and safe in patients with HCM, we ask whether it is time to let the shackles off exercise restriction in HCM.
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Affiliation(s)
- Yuen W Liao
- Foundation Year 2 Doctor Institute of Cardiovascular Medicine and Science, Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool, L14 3PE
| | - James Redfern
- Cardiology Specialty Registrar Institute of Cardiovascular Medicine and Science, Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool, L14 3PE
| | - John D Somauroo
- Consultant Cardiologist Institute of Cardiovascular Medicine and Science, Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool, L14 3PE
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61
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Dorian P, Goodman JM, Connelly KA. Policies to Prevent Sudden Cardiac Death in Young Athletes: Challenging, But More Testing Is Not the Answer. J Am Heart Assoc 2020; 9:e016332. [PMID: 32306795 PMCID: PMC7428526 DOI: 10.1161/jaha.120.016332] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Paul Dorian
- Division of Cardiology Department of Medicine St. Michael's Hospital University of Toronto Ontario Canada
| | - Jack M Goodman
- Faculty of Kinesiology and Physical Education University of Toronto Canada
| | - Kim A Connelly
- Division of Cardiology Department of Medicine St. Michael's Hospital University of Toronto Ontario Canada
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62
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Weissler-Snir A, Dorian P. Response by Weissler-Snir and Dorian to Letter Regarding Article, "Hypertrophic Cardiomyopathy-Related Sudden Cardiac Death in Young People in Ontario". Circulation 2020; 141:e703-e704. [PMID: 32223681 DOI: 10.1161/circulationaha.120.045962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Adaya Weissler-Snir
- Division of Cardiology, St. Michael's Hospital, and Department of Medicine, University of Toronto, Canada (A.W.-S., P.D.).,Hartford HealthCare Heart and Vascular Institute, University of Connecticut (A.W.-S.)
| | - Paul Dorian
- Division of Cardiology, St. Michael's Hospital, and Department of Medicine, University of Toronto, Canada (A.W.-S., P.D.).,Keenan Research Centre of the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada (P.D.)
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63
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Madias JE. Letter by Madias Regarding Article, "Hypertrophic Cardiomyopathy-Related Sudden Cardiac Death in Young People in Ontario". Circulation 2020; 141:e701-e702. [PMID: 32223672 DOI: 10.1161/circulationaha.119.045161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- John E Madias
- Icahn School of Medicine at Mount Sinai, New York, NY. Division of Cardiology, Elmhurst Hospital Center, New York, NY
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64
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Brough J, Jain M, Jerves T, Kruszka P, McGuffey E. Genetic screening for hypertrophic cardiomyopathy in large, asymptomatic military cohorts. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2020; 184:124-128. [PMID: 32030882 DOI: 10.1002/ajmg.c.31772] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 01/27/2020] [Accepted: 01/28/2020] [Indexed: 11/10/2022]
Abstract
Sudden cardiac death (SCD) is one of the leading causes of mortality in the U.S. military and competitive athletes. In this study, we simulate how genetic screening may be implemented in the military to prevent an SCD endpoint resulting from hypertrophic cardiomyopathy (HCM). We created a logistic regression model to predict variant pathogenicity in the most common HCM associated genes MYH7 and MYBPC3. Model predictions were used in conjunction with the gnomAD database to identify frequencies of pathogenic variants. Extrapolating these variants to a military population, lives saved and cost benefit analyses were conducted for screening for HCM related to pathogenic variants in MYH7 and MYBPC3. Genetic screening for HCM followed by echocardiography in individuals with pathogenic variants is predicted to save an average of 2.9 lives per accession cohort, based on historical cohort sizes, and result in a break-even cost of ~$7 per test. The false positives, defined as disqualified individuals for military service who do not have HCM, are predicted to be 0 individuals per accession cohort. This study suggests that the main barriers for the implementation of genetic screening for the U.S. military are the low detection rate and variant interpretation.
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Affiliation(s)
- Joe Brough
- Medical Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland.,School of Medicine, Stanford University, Palo Alto, California
| | - Mahim Jain
- Bone and Osteogenesis Imperfecta Department, Kennedy Krieger Institute, Baltimore, Maryland
| | - Teodoro Jerves
- Medical Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
| | - Paul Kruszka
- Medical Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
| | - Elizabeth McGuffey
- Science and Mathematics Department, U.S. Naval Academy, Annapolis, Maryland
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Ramchand J, Fava AM, Chetrit M, Desai MY. Advanced imaging for risk stratification of sudden death in hypertrophic cardiomyopathy. Heart 2020; 106:793-801. [DOI: 10.1136/heartjnl-2019-315176] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 12/18/2019] [Accepted: 12/31/2019] [Indexed: 01/29/2023] Open
Abstract
Hypertrophic cardiomyopathy (HCM) is a common inherited cardiac condition, which typically manifests as left ventricular hypertrophy. A small subset of patients with HCM have an increased risk of sudden cardiac death (SCD) from ventricular arrhythmias. Risk of SCD can be effectively reduced following implantation of implantable cardiac defibrillators (ICD), although this treatment carries a risk of complications such as inappropriate shocks. With this in mind, we turn to advances in cardiac imaging to guide risk stratification for SCD and to select the appropriate individual who may benefit from ICD implantation. In this review, we have taken the opportunity to briefly summarise the role of imaging in the diagnosis of HCM before focusing on how specific imaging features influence risk of SCD in patients with HCM.
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Parrott A, Khoury PR, Shikany AR, Lorts A, Villa CR, Miller EM. Investigation of de novo variation in pediatric cardiomyopathy. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2020; 184:116-123. [PMID: 31912959 DOI: 10.1002/ajmg.c.31764] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 12/23/2019] [Accepted: 12/27/2019] [Indexed: 12/20/2022]
Abstract
Pediatric cardiomyopathies can be caused by variants in genes encoding the sarcomere and cytoskeleton in cardiomyocytes. Variants are typically inherited in an autosomal dominant manner with variable expressivity. De novo variants have been reported, however their overall frequency is largely unknown. We sought to determine the rate of de novo, pathogenic and likely pathogenic (P/LP) variants in children with a diagnosis of hypertrophic, dilated, or restrictive cardiomyopathy (HCM, DCM, or RCM), and to compare disease outcomes between individuals with and without a de novo variant. A retrospective record review identified 126 individuals with HCM (55%), DCM (37%), or RCM (8%) ≤18 years of age who had genetic testing. Overall, 50 (40%) had positive genetic testing and 18% of P/LP variants occurred de novo. The rate of de novo variation in those with RCM (80%) was higher than in those with HCM (9%) or DCM (20%). There was evidence of germline mosaicism in one family with RCM. Individuals with de novo variants were more likely than those without to have a history of arrhythmia (p = .049), sudden cardiac arrest (p = .024), hospitalization (p = .041), and cardiac transplantation (p = .030). The likelihood of de novo variation and impact on family risk and screening should be integrated into genetic counseling.
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Affiliation(s)
- Ashley Parrott
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Philip R Khoury
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Amy R Shikany
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Angela Lorts
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Chet R Villa
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Erin M Miller
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Affiliation(s)
- Andrew Grace
- Royal Papworth Hospital Foundation Trust, Cambridge Biomedical Campus, UK. Department of Biochemistry, University of Cambridge, UK
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