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Conway KM, Thomas S, Ciafaloni E, Khan RS, Mann JR, Romitti PA, Mathews KD. Prophylactic use of cardiac medications for delay of left ventricular dysfunction in Duchenne muscular dystrophy. Birth Defects Res 2024; 116:e2260. [PMID: 37850663 DOI: 10.1002/bdr2.2260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 09/21/2023] [Accepted: 09/25/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND Epidemiological support for prophylactic treatment of left ventricular dysfunction (LVD) in Duchenne muscular dystrophy is limited. We used retrospective, population-based surveillance data from the Muscular Dystrophy Surveillance, Tracking and Research Network to evaluate whether prophylaxis delays LVD onset. METHODS We analyzed 455 males born during 1982-2009. Age at first abnormal echocardiogram (ejection fraction <55% or shortening fraction <28%) determined LVD onset. Prophylaxis was defined as cardiac medication use at least 1 year prior to LVD. Corticosteroid use was also coded. Kaplan-Meier curve estimation and Cox Proportional Hazard modeling with time-varying covariates describe associations. RESULTS LVD was identified among 40.7%; average onset age was 14.2 years. Prophylaxis was identified for 20.2% and corticosteroids for 57.4%. Prophylaxis showed delayed LVD onset (p < .001) and lower hazard of dysfunction (adjusted hazard ratio [aHR] = 0.39, 95%CL = 0.22, 0.65) compared to untreated. Compared to no treatment, continuous corticosteroids only (aHR = 1.01, 95%CL = 0.66, 1.53) and prophylaxis only (aHR = 0.67, 95%CL = 0.25, 1.50) were not cardioprotective, but prophylaxis plus continuous corticosteroids were associated with lower hazard of dysfunction (aHR = 0.37, 95%CL = 0.15, 0.80). CONCLUSIONS Proactive cardiac treatment and monitoring are critical aspects of managing Duchenne muscular dystrophy. Consistent with clinical care guidelines, this study supports clinical benefit from cardiac medications initiated prior to documented LVD and suggests further benefit when combined with corticosteroids.
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Affiliation(s)
- Kristin M Conway
- Department of Epidemiology, College of Public Health, The University of Iowa, Iowa City, Iowa, USA
| | - Shiny Thomas
- New York State Department of Health, Albany, New York, USA
| | - Emma Ciafaloni
- Department of Neurology, School of Medicine and Dentistry, University of Rochester Medical Center, Rochester, New York, USA
| | - Rabia S Khan
- Department of Pediatrics, UCLA Health Sciences, Los Angeles, California, USA
- Department of Pediatrics, Roy J and Lucille A Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Joshua R Mann
- Department of Preventive Medicine, School of Medicine and John D. Bower School of Population Health, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Paul A Romitti
- Department of Epidemiology, College of Public Health, The University of Iowa, Iowa City, Iowa, USA
| | - Katherine D Mathews
- Department of Pediatrics, Roy J and Lucille A Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
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D'Ambrosio ES, Mendell JR. Evolving Therapeutic Options for the Treatment of Duchenne Muscular Dystrophy. Neurotherapeutics 2023; 20:1669-1681. [PMID: 37673849 PMCID: PMC10684843 DOI: 10.1007/s13311-023-01423-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2023] [Indexed: 09/08/2023] Open
Abstract
Duchenne muscular dystrophy (DMD) is the most common childhood form of muscular dystrophy. It is caused by mutations in the DMD gene, leading to reduced or absent expression of the dystrophin protein. Clinically, this results in loss of ambulation, cardiomyopathy, respiratory failure, and eventually death. In the past decades, the use of corticosteroids has slowed down the disease progression. More recently, the development of genetically mediated therapies has emerged as the most promising treatment for DMD. These strategies include exon skipping with antisense oligonucleotides, gene replacement therapy with adeno-associated virus, and gene editing with CRISPR (clustered regularly interspaced short palindromic repeats) technology. In this review, we highlight the most up-to-date therapeutic progresses in the field, with emphasis on past and recent experiences, as well as the latest clinical results of DMD micro-dystrophin gene therapy. Additionally, we discuss the lessons learned along the way and the challenges encountered, all of which have helped advance the field, with the potential to finally alleviate such a devastating disease.
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Affiliation(s)
- Eleonora S D'Ambrosio
- Center for Gene Therapy, Department of Pediatrics, Abigail Wexner Research Institute, Nationwide Children's Hospital, Ohio State University, Columbus, OH, 43205, USA. eleonora.d'
| | - Jerry R Mendell
- Center for Gene Therapy, Department of Pediatrics, Abigail Wexner Research Institute, Nationwide Children's Hospital, Ohio State University, Columbus, OH, 43205, USA
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3
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Schultz TI, Raucci FJ, Salloum FN. Cardiovascular Disease in Duchenne Muscular Dystrophy. JACC Basic Transl Sci 2022; 7:608-625. [PMID: 35818510 PMCID: PMC9270569 DOI: 10.1016/j.jacbts.2021.11.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 11/06/2021] [Indexed: 12/11/2022]
Abstract
Cardiomyopathy is the leading cause of death in patients with DMD. DMD has no cure, and there is no current consensus for treatment of DMD cardiomyopathy. This review discusses therapeutic strategies to potentially reduce or prevent cardiac dysfunction in DMD patients. Additional studies are needed to firmly establish optimal treatment modalities for DMD cardiomyopathy.
Duchenne muscular dystrophy (DMD) is a devastating disease affecting approximately 1 in every 3,500 male births worldwide. Multiple mutations in the dystrophin gene have been implicated as underlying causes of DMD. However, there remains no cure for patients with DMD, and cardiomyopathy has become the most common cause of death in the affected population. Extensive research is under way investigating molecular mechanisms that highlight potential therapeutic targets for the development of pharmacotherapy for DMD cardiomyopathy. In this paper, the authors perform a literature review reporting on recent ongoing efforts to identify novel therapeutic strategies to reduce, prevent, or reverse progression of cardiac dysfunction in DMD.
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4
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Ferizovic N, Summers J, de Zárate IBO, Werner C, Jiang J, Landfeldt E, Buesch K. Prognostic indicators of disease progression in Duchenne muscular dystrophy: A literature review and evidence synthesis. PLoS One 2022; 17:e0265879. [PMID: 35333888 PMCID: PMC8956179 DOI: 10.1371/journal.pone.0265879] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 03/09/2022] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Duchenne muscular dystrophy (DMD) is a rare, severely debilitating, and fatal neuromuscular disease characterized by progressive muscle degeneration. Like in many orphan diseases, randomized controlled trials are uncommon in DMD, resulting in the need to indirectly compare treatment effects, for example by pooling individual patient-level data from multiple sources. However, to derive reliable estimates, it is necessary to ensure that the samples considered are comparable with respect to factors significantly affecting the clinical progression of the disease. To help inform such analyses, the objective of this study was to review and synthesise published evidence of prognostic indicators of disease progression in DMD. We searched MEDLINE (via Ovid), Embase (via Ovid) and the Cochrane Library (via Wiley) for records published from inception up until April 23 2021, reporting evidence of prognostic indicators of disease progression in DMD. Risk of bias was established with the grading system of the Centre for Evidence-Based Medicine (CEBM). RESULTS Our search included 135 studies involving 25,610 patients from 18 countries across six continents (Africa, Asia, Australia, Europe, North America and South America). We identified a total of 23 prognostic indicators of disease progression in DMD, namely age at diagnosis, age at onset of symptoms, ataluren treatment, ATL1102, BMI, cardiac medication, DMD genetic modifiers, DMD mutation type, drisapersen, edasalonexent, eteplirsen, glucocorticoid exposure, height, idebenone, lower limb surgery, orthoses, oxandrolone, spinal surgery, TAS-205, vamorolone, vitlolarsen, ventilation support, and weight. Of these, cardiac medication, DMD genetic modifiers, DMD mutation type, and glucocorticoid exposure were designated core prognostic indicators, each supported by a high level of evidence and significantly affecting a wide range of clinical outcomes. CONCLUSION This study provides a current summary of prognostic indicators of disease progression in DMD, which will help inform the design of comparative analyses and future data collection initiatives in this patient population.
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Affiliation(s)
- Nermina Ferizovic
- MAP BioPharma Ltd, Cambridge, England, United Kingdom
- BresMed Health Solutions, Sheffield, England, United Kingdom
| | | | | | | | - Joel Jiang
- PTC Therapeutics, South Plainfield, New Jersey, United States of America
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5
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Raccah BH, Biton B, Amir O, Gotsman I, Nahman D, Matok I. Anti-Remodeling Cardiac Therapy in Patients With Duchenne Muscular Dystrophy, Meta-Analysis Study. Front Pharmacol 2022; 12:769896. [PMID: 35126112 PMCID: PMC8811374 DOI: 10.3389/fphar.2021.769896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 12/21/2021] [Indexed: 12/04/2022] Open
Abstract
Background: Almost all Duchenne muscular dystrophy (DMD) patients that reach their 30s present cardiomyopathy. As a result, this population remains under-treated. There is no sufficient proof of the efficacy of anti-remodeling cardiac therapy for DMD cardiomyopathy (DMDCM). We aim to assess the efficacy of anti-remodeling cardiac therapy for DMDCM by using meta-analysis. Methods: PubMed (MEDLINE), Embase, and Cochrane library were searched through January 2021. Randomized control trials, case-control studies, and observational studies that reported assessments of cardiovascular outcomes and death of participants using angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, mineralocorticoid-receptor antagonists and Ivabradine, were included. The primary outcome was total mortality. Secondary outcomes included changes in left ventricular ejection fraction (LVEF), serum natriuretic peptide levels (BNP), and heart rate (HR). Data were extracted for eligibility by two independent reviewers. Random-effects meta-analysis was used to pool results. Results: Twelve studies with 439 patients were included in our meta-analysis. Treated patients have lower HR, mean difference of −17 beats per minute (CI [−25]–[−9], p < 0.01). The LVEF was improved in treated patients, with a mean difference of LVEF of 3.77% (CI 0.44–7.12, p < 0.03). Although mortality rates did not reach statistical significance there was a trend for total mortality reduction (hazard ratio 0.36, CI (0.1–1.25), p = 0.107) and for BNP reduction (SSMD: 0.141, CI ([−0.19]–[0.47]), p = 0.3). Conclusion: Pharmacologic treatment for DMDCM patients is associated with decreased HR and improved LVEF. Therefore, DMDCM patients may benefit from implementing guideline therapy for HF.
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Affiliation(s)
- Bruria Hirsh Raccah
- Division of Clinical Pharmacy, Faculty of Medicine, School of Pharmacy, Institute for Drug Research, the Hebrew University of Jerusalem, Jerusalem, Israel
- Heart Institute, Hadassah Medical Center, Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Bar Biton
- Division of Clinical Pharmacy, Faculty of Medicine, School of Pharmacy, Institute for Drug Research, the Hebrew University of Jerusalem, Jerusalem, Israel
| | - Offer Amir
- Heart Institute, Hadassah Medical Center, Faculty of Medicine, Hebrew University, Jerusalem, Israel
- The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Israel Gotsman
- Heart Institute, Hadassah Medical Center, Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Dean Nahman
- Heart Institute, Hadassah Medical Center, Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Ilan Matok
- Division of Clinical Pharmacy, Faculty of Medicine, School of Pharmacy, Institute for Drug Research, the Hebrew University of Jerusalem, Jerusalem, Israel
- *Correspondence: Ilan Matok,
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6
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Cardiac Complications of Neuromuscular Disorders. Neuromuscul Disord 2022. [DOI: 10.1016/b978-0-323-71317-7.00003-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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7
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Henson SE, Lang SM, Khoury PR, Tian C, Rutter MM, Urbina EM, Ryan TD, Taylor MD, Alsaied T. The Effect of Adiposity on Cardiovascular Function and Myocardial Fibrosis in Patients With Duchenne Muscular Dystrophy. J Am Heart Assoc 2021; 10:e021037. [PMID: 34569261 PMCID: PMC8649129 DOI: 10.1161/jaha.121.021037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Patients with Duchenne muscular dystrophy (DMD) develop cardiomyopathy because of a dystrophin deficiency causing fibrofatty replacement of the myocardium. Corticosteroid use and mobility limitations place these patients at risk for increased adiposity. We sought to determine the association of adiposity with cardiovascular dysfunction in patients with DMD. Methods and Results This was a retrospective review of patients with DMD who underwent both cardiac magnetic resonance imaging and dual‐energy x‐ray absorptiometry within 1 year. The cardiac magnetic resonance imaging parameters included left ventricular ejection fraction and the presence of late gadolinium enhancement (LGE positive [LGE+]). The adiposity indices, measured by dual‐energy x‐ray absorptiometry, included percentage of body fat, whole body fat mass indexed to height, and body mass index. A total of 324 patients were identified. Fifty‐two percent had LGE+, and 36% had cardiac dysfunction (left ventricular ejection fraction <55%). Patients with cardiac dysfunction had higher whole body fat mass indexed to height and body mass index on univariate analysis (mean difference between patients with and without cardiac dysfunction: +2.9 kg/m, P=0.001; and +1.5 kg/m2, P=0.03, respectively). whole body fat mass indexed to height remained independently associated with cardiac dysfunction on multivariable analysis after adjusting for age, LGE+, and corticosteroid duration. High whole body fat mass indexed to height and percentage of body fat were associated with LGE+ on univariate analysis (mean difference between patients with and without LGE+: +2.0 kg/m, P=0.02; and +2.4%, P=0.02, respectively). Using multivariable analysis, including age and cardiac dysfunction, high percentage of body fat remained independently associated with LGE+. Conclusions This study demonstrates an independent association of adiposity with cardiac dysfunction and LGE+ in patients with DMD. Preventing adiposity may mitigate the later development of ventricular dysfunction in DMD.
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Affiliation(s)
- Sarah E Henson
- Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Sean M Lang
- Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH.,Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH
| | - Philip R Khoury
- Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH.,Heart Institute Research Core Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Cuixia Tian
- Neurology, Cincinnati Children's Hospital Medical Center Cincinnati OH.,Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH
| | - Meilan M Rutter
- Endocrinology, Cincinnati Children's Hospital Medical Center Cincinnati OH.,Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH
| | - Elaine M Urbina
- Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH.,Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH
| | - Thomas D Ryan
- Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH.,Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH
| | - Michael D Taylor
- Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH.,Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH
| | - Tarek Alsaied
- Pediatric Cardiology and Heart Institute, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh Pittsburgh PA
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8
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Florczyk-Soluch U, Polak K, Dulak J. The multifaceted view of heart problem in Duchenne muscular dystrophy. Cell Mol Life Sci 2021; 78:5447-5468. [PMID: 34091693 PMCID: PMC8257522 DOI: 10.1007/s00018-021-03862-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 04/29/2021] [Accepted: 05/20/2021] [Indexed: 12/14/2022]
Abstract
Dystrophin is a large protein serving as local scaffolding repetitively bridging cytoskeleton and the outside of striated muscle cell. As such dystrophin is a critical brick primarily in dystrophin-associated protein complex (DAGC) and in a larger submembranous unit, costamere. Accordingly, the lack of functional dystrophin laying at the root of Duchenne muscular dystrophy (DMD) drives sarcolemma instability. From this point on, the cascade inevitably leading to the death of myocyte begins. In cardiomyocytes, intracellular calcium overload and related mitochondrial-mediated cell death mainly contribute to myocardial dysfunction and dilation while other protein dysregulation and/or mislocalization may affect electrical conduction system and favor arrhythmogenesis. Although clinically DMD manifests as progressive muscle weakness and skeletal muscle symptoms define characteristic of DMD, it is the heart problem the biggest challenge that most often develop in the form of dilated cardiomyopathy (DCM). Current standards of treatment and recent progress in respiratory care, introduced in most settings in the 1990s, have improved quality of life and median life expectancy to 4th decade of patient's age. At the same time, cardiac causes of death related to DMD increases. Despite preventive and palliative cardiac treatments available, the prognoses remain poor. Direct therapeutic targeting of dystrophin deficiency is critical, however, hindered by the large size of the dystrophin cDNA and/or stochastic, often extensive genetic changes in DMD gene. The correlation between cardiac involvement and mutations affecting specific dystrophin isoforms, may provide a mutation-specific cardiac management and novel therapeutic approaches for patients with CM. Nonetheless, the successful cardiac treatment poses a big challenge and may require combined therapy to combat dystrophin deficiency and its after-effects (critical in DMD pathogenesis). This review locates the multifaceted heart problem in the course of DMD, balancing the insights into basic science, translational efforts and clinical manifestation of dystrophic heart disease.
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Affiliation(s)
- Urszula Florczyk-Soluch
- Department of Medical Biotechnology, Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University, Kraków, Poland.
| | - Katarzyna Polak
- Department of Medical Biotechnology, Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University, Kraków, Poland
| | - Józef Dulak
- Department of Medical Biotechnology, Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University, Kraków, Poland
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9
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Power LC, Gusso S, Hornung TS, Jefferies C, Derraik JGB, Hofman PL, O'Grady GL. Exercise Cardiac Magnetic Resonance Imaging in Boys With Duchenne Muscular Dystrophy Without Cardiac Disease. Pediatr Neurol 2021; 117:35-43. [PMID: 33662889 DOI: 10.1016/j.pediatrneurol.2020.12.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 12/23/2020] [Accepted: 12/24/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Duchenne muscular dystrophy is caused by mutations in the DMD gene, resulting in cardiomyopathy in all affected children by 18 years. Although cardiomyopathy is now the leading cause of mortality in these children, there is ongoing debate regarding timely diagnosis, secondary prevention, and treatment of this condition. The purpose of this study was to use exercise cardiac magnetic resonance imaging in asymptomatic young boys with Duchenne muscular dystrophy to describe their heart function and compare this with healthy controls. METHODS We studied 11 boys with Duchenne muscular dystrophy aged 8.6 to 13.9 years and 11 healthy age- and sex-matched controls. RESULTS Compared with the controls, boys with Duchenne muscular dystrophy had lower ejection fraction at rest (57% versus 63%; P = 0.004). During submaximal exercise, they reached similar peak tachycardia but increased their heart rate and cardiac output only half as much as controls (P = 0.003 and P = 0.014, respectively). End-systolic volume remained higher in boys with Duchenne muscular dystrophy both at rest and during exercise. When transthoracic echocardiography was compared with cardiac magnetic resonance imaging, 45% of the echocardiograms had suboptimal or poor views in the Duchenne muscular dystrophy group. CONCLUSIONS Boys with Duchenne muscular dystrophy had abnormalities in left ventricular systolic function that were exaggerated by exercise stress. Exercise cardiac magnetic resonance imaging is feasible in a select population of children with Duchenne muscular dystrophy, and it has the potential to unmask early signs of cardiomyopathy.
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Affiliation(s)
- Lisa C Power
- Paediatric Neurology Department, Starship Children's Hospital, Auckland, New Zealand; Paediatric Endocrinology Department, Starship Children's Hospital, Auckland, New Zealand; Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Silmara Gusso
- Department of Exercise Sciences, University of Auckland, Auckland, New Zealand
| | - Tim S Hornung
- Paediatric Cardiology Department, Starship Children's Hospital, Auckland, New Zealand
| | - Craig Jefferies
- Paediatric Endocrinology Department, Starship Children's Hospital, Auckland, New Zealand
| | - José G B Derraik
- Liggins Institute, University of Auckland, Auckland, New Zealand; Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Paul L Hofman
- Paediatric Endocrinology Department, Starship Children's Hospital, Auckland, New Zealand; Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Gina L O'Grady
- Paediatric Neurology Department, Starship Children's Hospital, Auckland, New Zealand.
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10
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Lee S, Lee M, Hor KN. The role of imaging in characterizing the cardiac natural history of Duchenne muscular dystrophy. Pediatr Pulmonol 2021; 56:766-781. [PMID: 33651923 DOI: 10.1002/ppul.25227] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 10/19/2020] [Accepted: 11/12/2020] [Indexed: 01/11/2023]
Abstract
Duchene muscular dystrophy (DMD) is a rare but devastating disease resulting in progressive loss of ambulation, respiratory failure, DMD-associated cardiomyopathy (DMD-CM), and premature death. The use of corticosteroids and supportive respiratory care has improved outcomes, such that DMD-CM is now the leading cause of death. Historically, most programs have focused on skeletal myopathy with less attention to the cardiac phenotype. This omission is rather astonishing since patients with DMD possess an absolute genetic risk of developing cardiomyopathy. Unfortunately, heart failure signs and symptoms are vague due to skeletal muscle myopathy leading to limited ambulation. Traditional assessment of cardiac symptoms by the New York Heart Association American College of Cardiology/American Heart Association Staging (ACC/AHA) classification is of limited utility, even in advanced stages. Echocardiographic assessment can detect cardiac dysfunction late in the disease course, but this has proven to be a poor surrogate marker of early cardiovascular disease and an inadequate predictor of DMD-CM. Indeed, one explanation for the paucity of cardiac therapeutic trials for DMD-CM has been the lack of a suitable end-point. Improved outcomes require a better proactive treatment strategy; however, the barrier to treatment is the lack of a sensitive and specific tool to assess the efficacy of treatment. The use of cardiac imaging has evolved from echocardiography to cardiac magnetic resonance imaging to assess cardiac performance. The purpose of this article is to review the role of cardiac imaging in characterizing the cardiac natural history of DMD-CM, highlighting the prognostic implications and an outlook on how this field might evolve in the future.
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Affiliation(s)
- Simon Lee
- Department of Pediatrics, The Heart Center, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio, USA
| | - Marc Lee
- Department of Pediatrics, The Heart Center, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio, USA
| | - Kan N Hor
- Department of Pediatrics, The Heart Center, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio, USA
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11
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Kipke J, Birnkrant DJ, Jin JB, Aneja A, Bahler RC. A systematic review of pharmacologic therapies for the cardiomyopathy of Duchenne muscular dystrophy. Pediatr Pulmonol 2021; 56:782-795. [PMID: 33621446 DOI: 10.1002/ppul.25261] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 12/09/2020] [Accepted: 12/29/2020] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To perform a systematic review of studies evaluating pharmacologic therapies for the cardiomyopathy of Duchenne muscular dystrophy (DMD). METHODS PubMed, Google Scholar, and Embase were searched through October 8, 2020. Articles were selected using pre-determined criteria; 26 underwent detailed review by two co-authors. Study quality was assessed with the Newcastle-Ottawa scoring system (NOS); GRADE assessment evaluated their overall clinical importance. RESULTS There were few randomized controlled trials. Two of four trials of angiotensin converting enzyme inhibitors (ACEI) or ACEI plus beta-blockers (BB) found improved LV function. Two of two randomized trials of aldosterone antagonists (AA), when added to ACEI and BB therapy, demonstrated less decline of LV circumferential strain over 1 year of treatment. Observational studies of ACEI and BB had differing patient ages, symptomatology, cohort size, study duration and baseline heart function. LV function, assessed via unblinded imaging, was the most frequent outcome measure. LV dysfunction improved in some trials but was unconfirmed in others. Class IV heart failure patients had transient improvement of symptoms and LVEF. Most NOS scores reflected a low level of study quality. The Grade certainty rating, used for the summation of studies, was between "low" and "moderate." CONCLUSION Randomized trial evidence was inconsistent that either ACEI or BB or their combination improve LV function and/or alter progressive LV dysfunction. When ACEI and BB therapy are initiated for symptomatic Class IV heart failure, symptoms and LVEF improve transiently. AAs retard the rate of decline of LV function when initiated in younger DMD patients.
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Affiliation(s)
- Jasmine Kipke
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - David J Birnkrant
- Department of Pediatrics, Case Western Reserve University School of Medicine at MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Justin B Jin
- Case Western Reserve University School of Medicine at MetroHealth Medical Center, Cleveland, Ohio, USA.,Department of Pediatric Cardiology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Ashish Aneja
- Case Western Reserve University School of Medicine at MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Robert C Bahler
- Case Western Reserve University School of Medicine at MetroHealth Medical Center, Cleveland, Ohio, USA
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12
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Cardiac Phenotype-Genotype Associations in DMD/BMD: A Meta-Analysis and Systematic Review. Pediatr Cardiol 2021; 42:189-198. [PMID: 33037470 DOI: 10.1007/s00246-020-02470-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 09/18/2020] [Indexed: 01/16/2023]
Abstract
Cardiac involvement of Duchenne and Becker muscular dystrophies (DMD/BMD) is the most common cause of fatal outcomes. It is still unclear whether some DMD/BMD gene mutations might be predictive of cardiac involvement. In this study, we provide a comprehensive overview on genotypes of cardiac disease in DMD/BMD. We systematically searched the PubMed/Medline, EMBASE and Cochrane electronic databases. Search results were filtered to include only human studies, English language and all dates up to August 2019. We summarized and extensively reviewed all studies that passed the selection criteria and performed a meta-analysis on key genotype parameters of cardiac disease in DMD/BMD. Of 3450 articles scanned, we included 18 studies from 9 regions in the meta-analysis. The pooled studies included 2661 DMD/BMD patients and 1324 DMD/BMD patients with cardiac disease. The most common mutation type was exon deletion, with a pooled frequency of 90% (P < 0.01). In DMD/BMD patients with cardiac dysfunction, a higher frequency of involvement of exons 45 and 46 was found in DMD/BMD patients with cardiac dysfunction. This might be predictive of cardiac involvement in patients with DMD/BMD.
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13
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Siddiqui S, Alsaied T, Henson SE, Gandhi J, Patel P, Khoury P, Villa C, Ryan TD, Wittekind SG, Lang SM, Taylor MD. Left Ventricular Magnetic Resonance Imaging Strain Predicts the Onset of Duchenne Muscular Dystrophy-Associated Cardiomyopathy. Circ Cardiovasc Imaging 2020; 13:e011526. [PMID: 33190531 DOI: 10.1161/circimaging.120.011526] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Early detection of left ventricular (LV) dysfunction before the onset of overt Duchenne muscular dystrophy-associated cardiomyopathy (DMDAC) may direct clinical management to slow onset of dysfunction. We aimed to assess whether LV strain will predict those who develop DMDAC. METHODS We performed a single center retrospective case control study of patients with Duchenne muscular dystrophy who underwent serial cardiac magnetic resonance between 2006 and 2019. Patients with Duchenne muscular dystrophy with an LV ejection fraction ≥55% on ≥1 cardiac magnetic resonance were identified and grouped into age-matched +DMDAC and -DMDAC. Within 3 years, +DMDAC had a subsequent cardiac magnetic resonance with a decline in LV ejection fraction ≥10% and absolute LV ejection fraction ≤50%. -DMDAC maintained an LV ejection fraction ≥55% on serial cardiac magnetic resonances. Two-dimensional and 3-dimensional global radial strain, global circumferential strain (GCS), and global longitudinal strain were measured using tissue tracking software and their ability to predict DMDAC onset was assessed. Multivariable analysis adjusted for late gadolinium enhancement. RESULTS Thirty +DMDAC and 30 age-matched -DMDAC patients were included with a total of 164 studies analyzed. Before DMDAC onset, 2-dimensional global radial strain and GCS were significantly worse in +DMDAC compared with -DMDAC (25.1±6.0 versus 29.0±6.3, P=0.011; -15.4%±2.4 versus -17.3%±2.6, P=0.003). Three-dimensional GCS and global radial strain had similar findings. Among strain measures, 3-dimensional GCS had the highest area under the curve to predict DMDAC in our cohort. These findings persisted after adjusting for the presence of late gadolinium enhancement. CONCLUSIONS Reduced global radial strain and GCS may predict those at risk for developing DMDAC before onset of LV dysfunction and its clinical utility warrants further exploration.
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Affiliation(s)
- Saira Siddiqui
- The Heart Institute (S.S., T.A., S.E.H., C.V., T.D.R., S.W., S.M.L., M.D.T.), Cincinnati Children's Hospital Medical Center, OH
| | - Tarek Alsaied
- The Heart Institute (S.S., T.A., S.E.H., C.V., T.D.R., S.W., S.M.L., M.D.T.), Cincinnati Children's Hospital Medical Center, OH.,Department of Pediatrics, University of Cincinnati College of Medicine, OH (T.A., C.V., T.D.R., S.G.W., S.M.L., M.D.T.)
| | - Sarah E Henson
- The Heart Institute (S.S., T.A., S.E.H., C.V., T.D.R., S.W., S.M.L., M.D.T.), Cincinnati Children's Hospital Medical Center, OH
| | | | | | - Philip Khoury
- Heart Institute Research Core (P.K.), Cincinnati Children's Hospital Medical Center, OH
| | - Chet Villa
- The Heart Institute (S.S., T.A., S.E.H., C.V., T.D.R., S.W., S.M.L., M.D.T.), Cincinnati Children's Hospital Medical Center, OH.,Department of Pediatrics, University of Cincinnati College of Medicine, OH (T.A., C.V., T.D.R., S.G.W., S.M.L., M.D.T.)
| | - Thomas D Ryan
- The Heart Institute (S.S., T.A., S.E.H., C.V., T.D.R., S.W., S.M.L., M.D.T.), Cincinnati Children's Hospital Medical Center, OH.,Department of Pediatrics, University of Cincinnati College of Medicine, OH (T.A., C.V., T.D.R., S.G.W., S.M.L., M.D.T.)
| | - Samuel G Wittekind
- Department of Pediatrics, University of Cincinnati College of Medicine, OH (T.A., C.V., T.D.R., S.G.W., S.M.L., M.D.T.)
| | - Sean M Lang
- The Heart Institute (S.S., T.A., S.E.H., C.V., T.D.R., S.W., S.M.L., M.D.T.), Cincinnati Children's Hospital Medical Center, OH.,Department of Pediatrics, University of Cincinnati College of Medicine, OH (T.A., C.V., T.D.R., S.G.W., S.M.L., M.D.T.)
| | - Michael D Taylor
- The Heart Institute (S.S., T.A., S.E.H., C.V., T.D.R., S.W., S.M.L., M.D.T.), Cincinnati Children's Hospital Medical Center, OH.,Department of Pediatrics, University of Cincinnati College of Medicine, OH (T.A., C.V., T.D.R., S.G.W., S.M.L., M.D.T.)
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14
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Trucco F, Domingos JP, Tay CG, Ridout D, Maresh K, Munot P, Sarkozy A, Robb S, Quinlivan R, Riley M, Burch M, Fenton M, Wallis C, Chan E, Abel F, Manzur AY, Muntoni F. Cardiorespiratory Progression Over 5 Years and Role of Corticosteroids in Duchenne Muscular Dystrophy. Chest 2020; 158:1606-1616. [DOI: 10.1016/j.chest.2020.04.043] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 03/29/2020] [Accepted: 04/01/2020] [Indexed: 12/20/2022] Open
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15
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Tomazoni SS, Casalechi HL, Ferreira CDSB, Serra AJ, Dellê H, Brito RBDO, de Melo BL, Vanin AA, Ribeiro NF, Pereira AL, Monteiro KKDS, Marcos RL, de Carvalho PDTC, Frigo L, Leal-Junior ECP. Can photobiomodulation therapy be an alternative to pharmacological therapies in decreasing the progression of skeletal muscle impairments of mdx mice? PLoS One 2020; 15:e0236689. [PMID: 32785240 PMCID: PMC7423120 DOI: 10.1371/journal.pone.0236689] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 06/29/2020] [Indexed: 01/16/2023] Open
Abstract
Objective To compare the effects of photobiomodulation therapy (PBMT) and pharmacological therapy (glucocorticoids and non-steroidal anti-inflammatory drugs) applied alone and in different combinations in mdx mice. Methods The animals were randomized and divided into seven experimental groups treated with placebo, PBMT, prednisone, non-steroidal anti-inflammatory drug (NSAIDs), PBMT plus prednisone and PBMT plus NSAID. Wild type animals were used as control. All treatments were performed during 14 consecutive weeks. Muscular morphology, protein expression of dystrophin and functional performance were assessed at the end of the last treatment. Results Both treatments with prednisone and PBMT applied alone or combined, were effective in preserving muscular morphology. In addition, the treatments with PBMT (p = 0.0005), PBMT plus prednisone (p = 0.0048) and PBMT plus NSAID (p = 0.0021) increased dystrophin gene expression compared to placebo-control group. However, in the functional performance the PBMT presented better results compared to glucocorticoids (p<0.0001). In contrast, the use of NSAIDs did not appear to add benefits to skeletal muscle tissue in mdx mice. Conclusion We believe that the promising and optimistic results about the PBMT in skeletal muscle of mdx mice may in the future contribute to this therapy to be considered a safe alternative for patients with Duchenne Muscular Dystrophy (DMD) in a washout period (between treatment periods with glucocorticoids), allowing them to remain receiving effective and safe treatment in this period, avoiding at this way periods without administration of any treatment.
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MESH Headings
- Animals
- Anti-Inflammatory Agents, Non-Steroidal/pharmacology
- Combined Modality Therapy
- Disease Models, Animal
- Disease Progression
- Dystrophin/genetics
- Gene Expression Regulation/drug effects
- Gene Expression Regulation/radiation effects
- Glucocorticoids/pharmacology
- Humans
- Low-Level Light Therapy
- Mice
- Mice, Inbred mdx
- Muscle, Skeletal/drug effects
- Muscle, Skeletal/metabolism
- Muscle, Skeletal/radiation effects
- Muscular Dystrophy, Duchenne/genetics
- Muscular Dystrophy, Duchenne/metabolism
- Muscular Dystrophy, Duchenne/physiopathology
- Muscular Dystrophy, Duchenne/therapy
- Prednisone/pharmacology
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Affiliation(s)
- Shaiane Silva Tomazoni
- Department of Global Public Health and Primary Care, Physiotherapy Research Group, University of Bergen, Bergen, Norway
| | - Heliodora Leão Casalechi
- Laboratory of Phototherapy and Innovative Technologies in Health (LaPIT), Universidade Nove de Julho (UNINOVE), São Paulo, São Paulo, Brazil
| | - Cheila de Sousa Bacelar Ferreira
- Laboratory of Phototherapy and Innovative Technologies in Health (LaPIT), Universidade Nove de Julho (UNINOVE), São Paulo, São Paulo, Brazil
| | - Andrey Jorge Serra
- Postgraduate Program in Medicine, Universidade Federal de São Paulo (UNIFESP), São Paulo, São Paulo, Brazil
| | - Humberto Dellê
- Postgraduate Program in Medicine, Universidade Nove de Julho (UNINOVE), São Paulo, São Paulo, Brazil
| | | | - Brunno Lemes de Melo
- Postgraduate Program in Medicine, Universidade Federal de São Paulo (UNIFESP), São Paulo, São Paulo, Brazil
| | - Adriane Aver Vanin
- Laboratory of Phototherapy and Innovative Technologies in Health (LaPIT), Universidade Nove de Julho (UNINOVE), São Paulo, São Paulo, Brazil
- Postgraduate Program in Rehabilitation Sciences, Universidade Nove de Julho (UNINOVE), São Paulo, São Paulo, Brazil
| | - Neide Firmo Ribeiro
- Laboratory of Phototherapy and Innovative Technologies in Health (LaPIT), Universidade Nove de Julho (UNINOVE), São Paulo, São Paulo, Brazil
- Postgraduate Program in Rehabilitation Sciences, Universidade Nove de Julho (UNINOVE), São Paulo, São Paulo, Brazil
| | - Amanda Lima Pereira
- Laboratory of Phototherapy and Innovative Technologies in Health (LaPIT), Universidade Nove de Julho (UNINOVE), São Paulo, São Paulo, Brazil
| | - Kadma Karênina Damasceno Soares Monteiro
- Laboratory of Phototherapy and Innovative Technologies in Health (LaPIT), Universidade Nove de Julho (UNINOVE), São Paulo, São Paulo, Brazil
- Postgraduate Program in Rehabilitation Sciences, Universidade Nove de Julho (UNINOVE), São Paulo, São Paulo, Brazil
| | - Rodrigo Labat Marcos
- Postgraduate Program in Biophotonics Applied to Health Sciences, Universidade Nove de Julho (UNINOVE), São Paulo, Brazil
| | | | - Lucio Frigo
- Laboratory of Phototherapy and Innovative Technologies in Health (LaPIT), Universidade Nove de Julho (UNINOVE), São Paulo, São Paulo, Brazil
- Department of Periodontology, Dental Research Division, Universidade de Guarulhos (UnG), Guarulhos, São Paulo, Brazil
| | - Ernesto Cesar Pinto Leal-Junior
- Department of Global Public Health and Primary Care, Physiotherapy Research Group, University of Bergen, Bergen, Norway
- Laboratory of Phototherapy and Innovative Technologies in Health (LaPIT), Universidade Nove de Julho (UNINOVE), São Paulo, São Paulo, Brazil
- Postgraduate Program in Rehabilitation Sciences, Universidade Nove de Julho (UNINOVE), São Paulo, São Paulo, Brazil
- * E-mail:
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16
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Tian C, Wong BL, Hornung L, Khoury JC, Rybalsky I, Shellenbarger KC, Rutter MM. Oral bisphosphonate treatment in patients with Duchenne muscular dystrophy on long term glucocorticoid therapy. Neuromuscul Disord 2020; 30:599-610. [DOI: 10.1016/j.nmd.2020.06.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 04/24/2020] [Accepted: 06/10/2020] [Indexed: 12/24/2022]
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17
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McCulloch MA, Lal AK, Knecht K, Butts RJ, Villa CR, Johnson JN, Conway J, Bock MJ, Schumacher KR, Law SP, Friedland-Little JM, Deshpande SR, West SC, Lytrivi ID, Gambetta KE, Wittlieb-Weber CA. Implantable Cardioverter Defibrillator Use in Males with Duchenne Muscular Dystrophy and Severe Left Ventricular Dysfunction. Pediatr Cardiol 2020; 41:925-931. [PMID: 32157397 DOI: 10.1007/s00246-020-02336-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 02/28/2020] [Indexed: 01/16/2023]
Abstract
Duchenne muscular dystrophy (DMD) is characterized by myocardial fibrosis and left ventricular (LV) dysfunction. Implantable cardioverter defibrillator (ICD) use has not been characterized in this population but is considered for symptomatic patients with severe LV dysfunction (SLVD) receiving guideline-directed medical therapy (GDMT). We evaluated ICD utilization and efficacy in patients with DMD. Retrospective cohort study of DMD patients from 17 centers across North America between January 2, 2005 and December 31, 2015. ICD use and its effect on survival were evaluated in patients with SLVD defined as ejection fraction (EF) < 35% and/ or shortening fraction (SF) < 16% on final echocardiogram. SLVD was present in 57/436 (13.1%) patients, of which 12 (21.1%) died during the study period. Of these 12, (mean EF 20.9 ± 6.2% and SF 13.7 ± 7.2%), 8 received GDMT, 5 received steroids, and none received an ICD. ICDs were placed in 9/57 (15.8%) patients with SLVD (mean EF 31.2 ± 8.5% and SF 10.3 ± 4.9%) at a mean age of 20.4 ± 6.3 years; 8/9 received GDMT, 7 received steroids, and all were alive at study end; mean ICD duration was 36.1 ± 26.2 months. Nine ICDs were implanted at six different institutions, associated with two appropriate shocks for ventricular tachycardia in two patients, no inappropriate shocks, and one lead fracture. ICD use may be associated with improved survival and minimal complications in DMD cardiomyopathy with SLVD. However, inconsistent GDMT utilization may be a significant confounder. Future studies should define optimal indications for ICD implantation in patients with DMD cardiomyopathy.
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Affiliation(s)
- Michael A McCulloch
- Division of Pediatric Cardiology, University of Virginia Children's Hospital, PO Box 800386, Charlottesville, VA, 22903, USA.
| | - Ashwin K Lal
- Primary Children's Hospital, University of Utah, Salt Lake City, UT, USA
| | - Kenneth Knecht
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Ryan J Butts
- Children's Medical Center of Dallas, UT Southwestern Medical Center, Dallas, TX, USA
| | - Chet R Villa
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Jennifer Conway
- Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada
| | - Matthew J Bock
- Loma Linda University Children's Hospital, Loma Linda, CA, USA
| | - Kurt R Schumacher
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Sabrina P Law
- Morgan Stanley Children's Hospital of New York Presbyterian, New York, NY, USA
| | | | | | - Shawn C West
- Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | | | - Katheryn E Gambetta
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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18
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Gogou M, Pavlou E, Haidopoulou K. Therapies that are available and under development for Duchenne muscular dystrophy: What about lung function? Pediatr Pulmonol 2020; 55:300-315. [PMID: 31834673 DOI: 10.1002/ppul.24605] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 12/03/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Respiratory failure is the principal source of morbidity and mortality among patients with Duchenne muscular dystrophy exerting a negative influence on their total quality of life. The aim of this review is to provide systematically current literature evidence about the effects of different treatment options (available or under development) for Duchenne muscular dystrophy on the pulmonary function of these patients. METHODS A comprehensive search was undertaken using multiple health-related databases, while two independent reviewers assessed the eligibility of studies. A third person addressed any disagreements between reviewers. The quality of the methodology of the included studies was also assessed. RESULTS A total of 19 original research papers (nine evaluating the role of steroids, six idebenone, three eteplirsen, one stem-cell therapy, and one ataluren) were found to fulfill our selection criteria with the majority of them (14 of 19) being prospective studies, not always including a control group. Endpoints mainly used in these studies were values of pulmonary function tests. Current and under development treatments proved to be safe and no significant adverse events were reported. A beneficial impact on pulmonary function was described by authors in the majority of these studies. The principal effect was slowing of lung disease progress, as expressed by spirometric values. However, the risk of bias was introduced in many of the above studies, while high heterogeneity in terms of treatment protocols and outcome measures limits the comparability of the results. CONCLUSION Glucocorticoids remain the best-studied pharmacologic therapy for Duchenne muscular dystrophy and very likely delay the expected decline in lung function. With regard to new therapeutic agents, initial study results are encouraging. However, larger clinical trials are needed that minimize the risk of study bias, optimize the comparability of treatment groups, examine clinically meaningful pulmonary outcome measures, and include long-term follow up.
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Affiliation(s)
- Maria Gogou
- Second Department of Pediatrics, University General Hospital AHEPA, Thessaloniki, Greece
| | - Evangelos Pavlou
- Second Department of Pediatrics, University General Hospital AHEPA, Thessaloniki, Greece
| | - Katerina Haidopoulou
- Second Department of Pediatrics, University General Hospital AHEPA, Thessaloniki, Greece
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19
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Meyers TA, Townsend D. Cardiac Pathophysiology and the Future of Cardiac Therapies in Duchenne Muscular Dystrophy. Int J Mol Sci 2019; 20:E4098. [PMID: 31443395 PMCID: PMC6747383 DOI: 10.3390/ijms20174098] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 08/12/2019] [Accepted: 08/19/2019] [Indexed: 12/25/2022] Open
Abstract
Duchenne muscular dystrophy (DMD) is a devastating disease featuring skeletal muscle wasting, respiratory insufficiency, and cardiomyopathy. Historically, respiratory failure has been the leading cause of mortality in DMD, but recent improvements in symptomatic respiratory management have extended the life expectancy of DMD patients. With increased longevity, the clinical relevance of heart disease in DMD is growing, as virtually all DMD patients over 18 year of age display signs of cardiomyopathy. This review will focus on the pathophysiological basis of DMD in the heart and discuss the therapeutic approaches currently in use and those in development to treat dystrophic cardiomyopathy. The first section will describe the aspects of the DMD that result in the loss of cardiac tissue and accumulation of fibrosis. The second section will discuss cardiac small molecule therapies currently used to treat heart disease in DMD, with a focus on the evidence supporting the use of each drug in dystrophic patients. The final section will outline the strengths and limitations of approaches directed at correcting the genetic defect through dystrophin gene replacement, modification, or repair. There are several new and promising therapeutic approaches that may protect the dystrophic heart, but their limitations suggest that future management of dystrophic cardiomyopathy may benefit from combining gene-targeted therapies with small molecule therapies. Understanding the mechanistic basis of dystrophic heart disease and the effects of current and emerging therapies will be critical for their success in the treatment of patients with DMD.
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Affiliation(s)
- Tatyana A Meyers
- Department of Integrative Biology and Physiology, Medical School, University of Minnesota, Minneapolis, MN 55455, USA
| | - DeWayne Townsend
- Department of Integrative Biology and Physiology, Medical School, University of Minnesota, Minneapolis, MN 55455, USA.
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20
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Yamamoto T, Awano H, Zhang Z, Sakuma M, Kitaaki S, Matsumoto M, Nagai M, Sato I, Imanishi T, Hayashi N, Matsuo M, Iijima K, Saegusa J. Cardiac Dysfunction in Duchenne Muscular Dystrophy Is Less Frequent in Patients With Mutations in the Dystrophin Dp116 Coding Region Than in Other Regions. CIRCULATION-GENOMIC AND PRECISION MEDICINE 2019; 11:e001782. [PMID: 29874176 PMCID: PMC6319568 DOI: 10.1161/circgen.117.001782] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 11/07/2017] [Indexed: 01/16/2023]
Abstract
Supplemental Digital Content is available in the text. Background: Duchenne muscular dystrophy (DMD), the most common inherited muscular disease in childhood, is caused by dystrophin deficiency because of mutations in the DMD gene. Although DMD is characterized by fatal progressive muscle wasting, cardiomyopathy is the most important nonmuscle symptom threatening the life of patients with DMD. The relationship between cardiac involvement and dystrophin isoforms has not been analyzed. Methods and Results: The results of 1109 echocardiograms obtained from 181 Japanese DMD patients with confirmed mutations in the DMD gene were retrospectively analyzed. Patients showed an age-related decline in left ventricular ejection fraction. Patients were divided by patterns of dystrophin isoform deficiency into 5 groups. The cardiac dysfunction-free survival was significantly higher in the group with mutations in the Dp116 coding region than the others, whereas no significant differences in the other 3 groups. At age 25 years, the cardiac dysfunction-free rate was 0.6 in the Dp116 group, but only 0.1 in others. PCR amplification of Dp116 transcript in human cardiac muscle indicated promoter activation. Conclusions: Left ventricular ejection fraction in DMD declined stepwise with age. Cardiac dysfunction was less frequent in Dp116-deficient than other patients with DMD. Dp116 transcript was identified in human cardiac muscle for the first time. These results indicate that Dp116 is associated with cardiac involvement in DMD.
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Affiliation(s)
- Tetsushi Yamamoto
- From the Department of Clinical Laboratory, Kobe University Hospital, Kobe, Japan (T.Y., S.K., I.S., T.I., N.H., J.S.); Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan (H.A., M. Matsumoto, M.N., K.I.); Department of Pathology, Medical School of Nankai University, Tianjin, China (Z.Z.); Department of Physical Therapy, Faculty of Rehabilitation, Kobe Gakuin University, Kobe, Japan (Z.Z., M. Matsuo); and Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan (M.E.-S.)
| | - Hiroyuki Awano
- From the Department of Clinical Laboratory, Kobe University Hospital, Kobe, Japan (T.Y., S.K., I.S., T.I., N.H., J.S.); Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan (H.A., M. Matsumoto, M.N., K.I.); Department of Pathology, Medical School of Nankai University, Tianjin, China (Z.Z.); Department of Physical Therapy, Faculty of Rehabilitation, Kobe Gakuin University, Kobe, Japan (Z.Z., M. Matsuo); and Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan (M.E.-S.)
| | - Zhujun Zhang
- From the Department of Clinical Laboratory, Kobe University Hospital, Kobe, Japan (T.Y., S.K., I.S., T.I., N.H., J.S.); Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan (H.A., M. Matsumoto, M.N., K.I.); Department of Pathology, Medical School of Nankai University, Tianjin, China (Z.Z.); Department of Physical Therapy, Faculty of Rehabilitation, Kobe Gakuin University, Kobe, Japan (Z.Z., M. Matsuo); and Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan (M.E.-S.)
| | - Mio Sakuma
- From the Department of Clinical Laboratory, Kobe University Hospital, Kobe, Japan (T.Y., S.K., I.S., T.I., N.H., J.S.); Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan (H.A., M. Matsumoto, M.N., K.I.); Department of Pathology, Medical School of Nankai University, Tianjin, China (Z.Z.); Department of Physical Therapy, Faculty of Rehabilitation, Kobe Gakuin University, Kobe, Japan (Z.Z., M. Matsuo); and Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan (M.E.-S.)
| | - Shoko Kitaaki
- From the Department of Clinical Laboratory, Kobe University Hospital, Kobe, Japan (T.Y., S.K., I.S., T.I., N.H., J.S.); Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan (H.A., M. Matsumoto, M.N., K.I.); Department of Pathology, Medical School of Nankai University, Tianjin, China (Z.Z.); Department of Physical Therapy, Faculty of Rehabilitation, Kobe Gakuin University, Kobe, Japan (Z.Z., M. Matsuo); and Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan (M.E.-S.)
| | - Masaaki Matsumoto
- From the Department of Clinical Laboratory, Kobe University Hospital, Kobe, Japan (T.Y., S.K., I.S., T.I., N.H., J.S.); Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan (H.A., M. Matsumoto, M.N., K.I.); Department of Pathology, Medical School of Nankai University, Tianjin, China (Z.Z.); Department of Physical Therapy, Faculty of Rehabilitation, Kobe Gakuin University, Kobe, Japan (Z.Z., M. Matsuo); and Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan (M.E.-S.)
| | - Masashi Nagai
- From the Department of Clinical Laboratory, Kobe University Hospital, Kobe, Japan (T.Y., S.K., I.S., T.I., N.H., J.S.); Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan (H.A., M. Matsumoto, M.N., K.I.); Department of Pathology, Medical School of Nankai University, Tianjin, China (Z.Z.); Department of Physical Therapy, Faculty of Rehabilitation, Kobe Gakuin University, Kobe, Japan (Z.Z., M. Matsuo); and Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan (M.E.-S.)
| | - Itsuko Sato
- From the Department of Clinical Laboratory, Kobe University Hospital, Kobe, Japan (T.Y., S.K., I.S., T.I., N.H., J.S.); Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan (H.A., M. Matsumoto, M.N., K.I.); Department of Pathology, Medical School of Nankai University, Tianjin, China (Z.Z.); Department of Physical Therapy, Faculty of Rehabilitation, Kobe Gakuin University, Kobe, Japan (Z.Z., M. Matsuo); and Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan (M.E.-S.)
| | - Takamitsu Imanishi
- From the Department of Clinical Laboratory, Kobe University Hospital, Kobe, Japan (T.Y., S.K., I.S., T.I., N.H., J.S.); Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan (H.A., M. Matsumoto, M.N., K.I.); Department of Pathology, Medical School of Nankai University, Tianjin, China (Z.Z.); Department of Physical Therapy, Faculty of Rehabilitation, Kobe Gakuin University, Kobe, Japan (Z.Z., M. Matsuo); and Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan (M.E.-S.)
| | - Nobuhide Hayashi
- From the Department of Clinical Laboratory, Kobe University Hospital, Kobe, Japan (T.Y., S.K., I.S., T.I., N.H., J.S.); Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan (H.A., M. Matsumoto, M.N., K.I.); Department of Pathology, Medical School of Nankai University, Tianjin, China (Z.Z.); Department of Physical Therapy, Faculty of Rehabilitation, Kobe Gakuin University, Kobe, Japan (Z.Z., M. Matsuo); and Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan (M.E.-S.)
| | - Masafumi Matsuo
- From the Department of Clinical Laboratory, Kobe University Hospital, Kobe, Japan (T.Y., S.K., I.S., T.I., N.H., J.S.); Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan (H.A., M. Matsumoto, M.N., K.I.); Department of Pathology, Medical School of Nankai University, Tianjin, China (Z.Z.); Department of Physical Therapy, Faculty of Rehabilitation, Kobe Gakuin University, Kobe, Japan (Z.Z., M. Matsuo); and Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan (M.E.-S.).
| | - Kazumoto Iijima
- From the Department of Clinical Laboratory, Kobe University Hospital, Kobe, Japan (T.Y., S.K., I.S., T.I., N.H., J.S.); Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan (H.A., M. Matsumoto, M.N., K.I.); Department of Pathology, Medical School of Nankai University, Tianjin, China (Z.Z.); Department of Physical Therapy, Faculty of Rehabilitation, Kobe Gakuin University, Kobe, Japan (Z.Z., M. Matsuo); and Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan (M.E.-S.)
| | - Jun Saegusa
- From the Department of Clinical Laboratory, Kobe University Hospital, Kobe, Japan (T.Y., S.K., I.S., T.I., N.H., J.S.); Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan (H.A., M. Matsumoto, M.N., K.I.); Department of Pathology, Medical School of Nankai University, Tianjin, China (Z.Z.); Department of Physical Therapy, Faculty of Rehabilitation, Kobe Gakuin University, Kobe, Japan (Z.Z., M. Matsuo); and Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan (M.E.-S.)
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21
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Conway KM, Eichinger K, Trout C, Romitti PA, Mathews KD, Pandya SK. Needs management in families affected by childhood-onset dystrophinopathies. SAGE Open Med 2019; 7:2050312119834470. [PMID: 30854202 PMCID: PMC6399767 DOI: 10.1177/2050312119834470] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 02/05/2019] [Indexed: 12/19/2022] Open
Abstract
Purpose To collect information about the needs of families affected by childhood-onset dystrophinopathies residing in the United States. Methods Individuals with an eligible dystrophinopathy were identified by the Muscular Dystrophy Surveillance, Tracking, and Research network. Between September 2008 and December 2012, 272 caregivers completed a 48-item survey about needs related to information, healthcare services, psychosocial issues, finances, caregiver demographics, and the individual's functioning. Results Overall, at least 80% of the survey items were identified as needs for more than one-half of caregivers. Among the needs identified, physical health and access to information were currently managed for most caregivers. Items identified as needed but managed less consistently were funding for needs not covered by insurance and psychosocial support. Conclusions Healthcare providers, public health practitioners, and policymakers should be aware of the many needs reported by caregivers, and focus on addressing gaps in provision of needed financial and psychosocial services.
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Affiliation(s)
- Kristin M Conway
- Department of Epidemiology, The University of Iowa, Iowa City, IA, USA
| | - Katy Eichinger
- Department of Neurology, University of Rochester, Rochester, NY, USA
| | - Christina Trout
- Department of Pediatrics, The University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
| | - Paul A Romitti
- Department of Epidemiology, The University of Iowa, Iowa City, IA, USA
| | - Katherine D Mathews
- Department of Neurology, School of Medicine, The University of Iowa, Iowa City, IA, USA
| | - Shree K Pandya
- Department of Neurology, University of Rochester, Rochester, NY, USA
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22
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Dystrophin Cardiomyopathies: Clinical Management, Molecular Pathogenesis and Evolution towards Precision Medicine. J Clin Med 2018; 7:jcm7090291. [PMID: 30235804 PMCID: PMC6162458 DOI: 10.3390/jcm7090291] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 09/02/2018] [Accepted: 09/14/2018] [Indexed: 12/16/2022] Open
Abstract
Duchenne’s muscular dystrophy is an X-linked neuromuscular disease that manifests as muscle atrophy and cardiomyopathy in young boys. However, a considerable percentage of carrier females are often diagnosed with cardiomyopathy at an advanced stage. Existing therapy is not disease-specific and has limited effect, thus many patients and symptomatic carrier females prematurely die due to heart failure. Early detection is one of the major challenges that muscular dystrophy patients, carrier females, family members and, research and medical teams face in the complex course of dystrophic cardiomyopathy management. Despite the widespread adoption of advanced imaging modalities such as cardiac magnetic resonance, there is much scope for refining the diagnosis and treatment of dystrophic cardiomyopathy. This comprehensive review will focus on the pertinent clinical aspects of cardiac disease in muscular dystrophy while also providing a detailed consideration of the known and developing concepts in the pathophysiology of muscular dystrophy and forthcoming therapeutic options.
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23
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Power LC, O'Grady GL, Hornung TS, Jefferies C, Gusso S, Hofman PL. Imaging the heart to detect cardiomyopathy in Duchenne muscular dystrophy: A review. Neuromuscul Disord 2018; 28:717-730. [PMID: 30119965 DOI: 10.1016/j.nmd.2018.05.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 05/24/2018] [Accepted: 05/29/2018] [Indexed: 01/16/2023]
Abstract
Duchenne Muscular Dystrophy is the most common paediatric neuromuscular disorder. Mutations in the DMD gene on the X-chromosome result in progressive skeletal muscle weakness as the main clinical manifestation. However, cardiac muscle is also affected, with cardiomyopathy becoming an increasingly recognised cause of morbidity, and now the leading cause of mortality in this group. The diagnosis of cardiomyopathy has often been made late due to technical limitations in transthoracic echocardiograms and delayed symptomatology in less mobile patients. Increasingly, evidence supports earlier pharmacological intervention in cardiomyopathy to improve outcomes. However, the optimal timing of initiation remains uncertain, and the benefits of prophylactic therapy are unproven. Current treatment guidelines suggest initiation of therapy once cardiac dysfunction is detected. This review focuses on new and evolving techniques for earlier detection of Duchenne muscular dystrophy-associated cardiomyopathy. Transthoracic echocardiography or cardiac magnetic resonance imaging performed under physiological stress (dobutamine or exercise), can unmask early cardiac dysfunction. Cardiac magnetic resonance imaging can define cardiac function with greater accuracy and reliability than an echocardiogram, and is not limited by body habitus. Improved imaging techniques, used in a timely fashion, offer the potential for early detection of cardiomyopathy and improved long-term outcomes.
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Affiliation(s)
- Lisa C Power
- Paediatric Neurology Department, Starship Children's Hospital, Auckland, New Zealand; Paediatric Endocrinology Department, Starship Children's Hospital, Auckland, New Zealand; Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Gina L O'Grady
- Paediatric Neurology Department, Starship Children's Hospital, Auckland, New Zealand.
| | - Tim S Hornung
- Paediatric Cardiology Department, Starship Children's Hospital, Auckland, New Zealand
| | - Craig Jefferies
- Paediatric Endocrinology Department, Starship Children's Hospital, Auckland, New Zealand
| | - Silmara Gusso
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Paul L Hofman
- Paediatric Endocrinology Department, Starship Children's Hospital, Auckland, New Zealand; Liggins Institute, University of Auckland, Auckland, New Zealand
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24
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Feingold B, Mahle WT, Auerbach S, Clemens P, Domenighetti AA, Jefferies JL, Judge DP, Lal AK, Markham LW, Parks WJ, Tsuda T, Wang PJ, Yoo SJ. Management of Cardiac Involvement Associated With Neuromuscular Diseases: A Scientific Statement From the American Heart Association. Circulation 2017; 136:e200-e231. [DOI: 10.1161/cir.0000000000000526] [Citation(s) in RCA: 145] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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25
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Kamdar F, Garry DJ. Dystrophin-Deficient Cardiomyopathy. J Am Coll Cardiol 2017; 67:2533-46. [PMID: 27230049 DOI: 10.1016/j.jacc.2016.02.081] [Citation(s) in RCA: 231] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 02/16/2016] [Accepted: 02/23/2016] [Indexed: 12/25/2022]
Abstract
Dystrophinopathies are a group of distinct neuromuscular diseases that result from mutations in the structural cytoskeletal Dystrophin gene. Dystrophinopathies include Duchenne muscular dystrophy (DMD) and Becker muscular dystrophy (BMD), X-linked dilated cardiomyopathy, as well as DMD and BMD female carriers. The primary presenting symptom in most dystrophinopathies is skeletal muscle weakness. However, cardiac muscle is also a subtype of striated muscle and is similarly affected in many of the muscular dystrophies. Cardiomyopathies associated with dystrophinopathies are an increasingly recognized manifestation of these neuromuscular disorders and contribute significantly to their morbidity and mortality. Recent studies suggest that these patient populations would benefit from cardiovascular therapies, annual cardiovascular imaging studies, and close follow-up with cardiovascular specialists. Moreover, patients with DMD and BMD who develop end-stage heart failure may benefit from the use of advanced therapies. This review focuses on the pathophysiology, cardiac involvement, and treatment of cardiomyopathy in the dystrophic patient.
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Affiliation(s)
- Forum Kamdar
- Cardiovascular Division, Lillehei Heart Institute, University of Minnesota, Minneapolis, Minnesota
| | - Daniel J Garry
- Cardiovascular Division, Lillehei Heart Institute, University of Minnesota, Minneapolis, Minnesota.
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26
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Kim S, Zhu Y, Romitti PA, Fox DJ, Sheehan DW, Valdez R, Matthews D, Barber BJ. Associations between timing of corticosteroid treatment initiation and clinical outcomes in Duchenne muscular dystrophy. Neuromuscul Disord 2017. [PMID: 28645460 DOI: 10.1016/j.nmd.2017.05.019] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The long-term efficacy of corticosteroid treatment and timing of treatment initiation among Duchenne muscular dystrophy (DMD) patients is not well-understood. We used data from a longitudinal, population-based DMD surveillance program to examine associations between timing of treatment initiation (early childhood [before or at age 5 years], late childhood [after age 5 years], and naïve [not treated]) and five clinical outcomes (age at loss of ambulation; ages at onset of cardiomyopathy, scoliosis, and first fracture; and pulmonary function). Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using survival analysis. DMD patients who initiated corticosteroid treatment in early childhood had a higher risk of earlier onset cardiomyopathy compared to cases who initiated treatment in late childhood (HR = 2.0, 95% CI = [1.2, 3.4]) or treatment naïve patients (HR = 1.9, 95% CI = [1.1, 3.2]), and higher risk of suffering a fracture (HR = 2.3, 95% CI = [1.4, 3.7] and HR = 2.6, 95% CI = [1.6, 4.2], respectively). Patients with early childhood treatment had slightly decreased respiratory function compared with those with late childhood treatment. Ages at loss of ambulation or scoliosis diagnosis did not differ statistically among treatment groups. We caution that the results from our study are subject to several limitations, as they were based on data abstracted from medical records. Further investigations using improved reporting of disease onset and outcomes are warranted to obtain a more definitive assessment of the association between the timing of corticosteroid treatment and disease severity.
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Affiliation(s)
- Sunkyung Kim
- Division of Human Development and Disability, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 1600 Clifton Rd, Atlanta, GA 30333, USA.
| | - Yong Zhu
- Department of Epidemiology, College of Public Health, The University of Iowa, 145 N Riverside Dr, S416 CPHB, Iowa City, IA 52242, USA
| | - Paul A Romitti
- Department of Epidemiology, College of Public Health, The University of Iowa, 145 N Riverside Dr, S416 CPHB, Iowa City, IA 52242, USA
| | - Deborah J Fox
- New York State Department of Health, Empire State Plaza, Corning Tower, Albany, NY 12237, USA
| | - Daniel W Sheehan
- University at Buffalo, The State University of New York, 219 Bryant Street, Buffalo, NY 14222, USA
| | - Rodolfo Valdez
- Division of Human Development and Disability, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 1600 Clifton Rd, Atlanta, GA 30333, USA
| | - Dennis Matthews
- Children's Hospital Colorado, 13123 East 16th Avenue, Aurora, CO 80045, USA
| | - Brent J Barber
- College of Medicine, University of Arizona, Tucson, AZ 85724, USA
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27
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Ward LM, Kinnett K, Bonewald L. Proceedings of a Parent Project Muscular Dystrophy Bone Health Workshop: Morbidity due to osteoporosis in DMD: The Path Forward May 12-13, 2016, Bethesda, Maryland, USA. Neuromuscul Disord 2017; 28:64-76. [PMID: 28756052 DOI: 10.1016/j.nmd.2017.05.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 05/04/2017] [Accepted: 05/11/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Leanne M Ward
- Division of Endocrinology and Metabolism, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada.
| | - Kathi Kinnett
- Parent Project Muscular Dystrophy, Middletown, OH, USA
| | - Lynda Bonewald
- Indiana Center for Musculoskeletal Health, Departments of Anatomy and Cell Biology and Orthopaedic Surgery, Indiana University, Indianapolis, IN, USA
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28
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Quattrocelli M, Barefield DY, Warner JL, Vo AH, Hadhazy M, Earley JU, Demonbreun AR, McNally EM. Intermittent glucocorticoid steroid dosing enhances muscle repair without eliciting muscle atrophy. J Clin Invest 2017; 127:2418-2432. [PMID: 28481224 DOI: 10.1172/jci91445] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 03/09/2017] [Indexed: 12/20/2022] Open
Abstract
Glucocorticoid steroids such as prednisone are prescribed for chronic muscle conditions such as Duchenne muscular dystrophy, where their use is associated with prolonged ambulation. The positive effects of chronic steroid treatment in muscular dystrophy are paradoxical because these steroids are also known to trigger muscle atrophy. Chronic steroid use usually involves once-daily dosing, although weekly dosing in children has been suggested for its reduced side effects on behavior. In this work, we tested steroid dosing in mice and found that a single pulse of glucocorticoid steroids improved sarcolemmal repair through increased expression of annexins A1 and A6, which mediate myofiber repair. This increased expression was dependent on glucocorticoid response elements upstream of annexins and was reinforced by the expression of forkhead box O1 (FOXO1). We compared weekly versus daily steroid treatment in mouse models of acute muscle injury and in muscular dystrophy and determined that both regimens provided comparable benefits in terms of annexin gene expression and muscle repair. However, daily dosing activated atrophic pathways, including F-box protein 32 (Fbxo32), which encodes atrogin-1. Conversely, weekly steroid treatment in mdx mice improved muscle function and histopathology and concomitantly induced the ergogenic transcription factor Krüppel-like factor 15 (Klf15) while decreasing Fbxo32. These findings suggest that intermittent, rather than daily, glucocorticoid steroid regimen promotes sarcolemmal repair and muscle recovery from injury while limiting atrophic remodeling.
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29
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McKane M, Soslow JH, Xu M, Saville BR, Slaughter JC, Burnette WB, Markham LW. Does Body Mass Index Predict Premature Cardiomyopathy Onset for Duchenne Muscular Dystrophy? J Child Neurol 2017; 32:499-504. [PMID: 28084148 PMCID: PMC5352486 DOI: 10.1177/0883073816687422] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Duchenne muscular dystrophy leads to cardiomyopathy. The objective of this study was to estimate the association of body mass index with cardiomyopathy onset. Cardiomyopathy was defined as left ventricular ejection fraction <55% or left ventricular fractional shortening <28%. Overall, 48% met the criteria for cardiomyopathy. We were unable to demonstrate an association between body mass index Z score and age of cardiomyopathy onset (hazard ratio 0.79, 95% confidence interval 0.57-1.11, P = .17) after adjusting for covariates. Duration of corticosteroid use ( P = .01), but not loss of ambulatory ability ( P = .47), was associated with age of cardiomyopathy onset. We were unable to detect a significant difference in median body mass index Z scores in corticosteroid-treated boys compared with corticosteroid-naïve boys (1.11, 95% confidence interval 0.25-1.95, vs 1.05, 95% confidence interval 0.01-1.86, P = .69). No association was detected between the body mass index Z scores of Duchenne muscular dystrophy subjects and age of cardiomyopathy onset.
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Affiliation(s)
- Meghann McKane
- 1 Thomas P. Graham Division of Pediatric Cardiology Monroe Carell Jr Children's Hospital at Vanderbilt University, Nashville, TN, USA
| | - Jonathan H Soslow
- 1 Thomas P. Graham Division of Pediatric Cardiology Monroe Carell Jr Children's Hospital at Vanderbilt University, Nashville, TN, USA
| | - Meng Xu
- 2 Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Benjamin R Saville
- 2 Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - James C Slaughter
- 2 Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - W Bryan Burnette
- 3 Division of Neurology, Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Larry W Markham
- 1 Thomas P. Graham Division of Pediatric Cardiology Monroe Carell Jr Children's Hospital at Vanderbilt University, Nashville, TN, USA
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30
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El-Aloul B, Altamirano-Diaz L, Zapata-Aldana E, Rodrigues R, Malvankar-Mehta MS, Nguyen CT, Campbell C. Pharmacological therapy for the prevention and management of cardiomyopathy in Duchenne muscular dystrophy: A systematic review. Neuromuscul Disord 2016; 27:4-14. [PMID: 27815032 DOI: 10.1016/j.nmd.2016.09.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 09/16/2016] [Accepted: 09/26/2016] [Indexed: 01/03/2023]
Abstract
Cardiomyopathy is a major source of morbidity and mortality in Duchenne muscular dystrophy (DMD) patients now that respiratory care has improved. There is currently no definitive evidence guiding the management of DMD-associated cardiomyopathy (DMD-CM). The objective of this systematic review was to evaluate the effectiveness of pharmacotherapies for the prevention and/or management of DMD-CM and to determine the optimal timing to commence these interventions. A systematic search was conducted in January 2016 using MEDLINE, EMBASE and CINAHL databases and grey literature sources for studies evaluating the use of angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers, beta-blockers or aldosterone antagonists. Study quality assessment was conducted using the Downs and Black quality assessment checklist. PRISMA reporting guidelines were used. Of the 15 studies included in this review, most were of low methodological quality. Meta-analysis was not possible due to heterogeneity of studies. ACE inhibitors, angiotensin receptor blockers, beta-blockers and/or aldosterone antagonists tended to improve or preserve left ventricular systolic function and delay the progression of DMD-CM. While there is evidence supporting the use of heart failure medication in patients with DMD, data regarding these interventions for delaying the onset of DMD-CM and when to initiate therapy are lacking. PROSPERO registration: CRD42015029555.
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Affiliation(s)
- Basmah El-Aloul
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Luis Altamirano-Diaz
- Department of Paediatrics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Eugenio Zapata-Aldana
- Department of Paediatrics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada; Clinical Neurological Sciences, Children's Hospital, London Health Sciences Center, London, ON, Canada
| | - Rebecca Rodrigues
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Monali S Malvankar-Mehta
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada; Department of Ophthalmology, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Cam-Tu Nguyen
- Department of Paediatrics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada; Clinical Neurological Sciences, Children's Hospital, London Health Sciences Center, London, ON, Canada
| | - Craig Campbell
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada; Department of Paediatrics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada; Clinical Neurological Sciences, Children's Hospital, London Health Sciences Center, London, ON, Canada.
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31
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Nakamura M, Sunagawa O, Hokama R, Tsuchiya H, Miyara T, Taba Y, Touma T. A Case of Refractory Heart Failure in Becker Muscular Dystrophy Improved With Corticosteroid Therapy. Int Heart J 2016; 57:640-4. [PMID: 27535714 DOI: 10.1536/ihj.16-044] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The patient was a 26 year-old man who was referred to our hospital in June 2011 because of severe heart failure. At age 24 years, he was found to have Becker muscular dystrophy. He received enalapril for cardiac dysfunction; however, he had worsening heart failure and was thus referred to our hospital. Echocardiography showed enlargement of the left ventricle, with a diastolic dimension of 77 mm and ejection fraction of 19%. His condition improved temporarily after an infusion of dobutamine and milrinone. He was then administered amiodarone for ventricular tachycardia; however, he subsequently developed hemoptysis. Amiodarone was discontinued and corticosteroid pulse therapy was administered followed by oral prednisolone (PSL). His creatinine phosphokinase (CPK) level and cardiomegaly improved after the corticosteroid therapy. The PSL dose was reduced gradually, bisoprolol was introduced, and the catecholamine infusion was tapered. A cardiac resynchronization device was implanted; however, the patient's condition gradually worsened, which necessitated dobutamine infusion for heart failure. We readministered 30 mg PSL, which decreased the CPK level and improved the cardiomegaly. The dobutamine infusion was discontinued, and the patient was discharged. He was given 7.5 mg PSL as an outpatient, and he returned to normal life without exacerbation of the heart failure. There are similar reports showing that corticosteroids are effective for skeletal muscle improvement in Duchenne muscular dystrophy; however, their effectiveness for heart failure has been rarely reported. We experienced a case of Becker muscular dystrophy in which corticosteroid therapy was effective for refractory heart failure.
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Affiliation(s)
- Makiko Nakamura
- Department of Cardiology, Okinawa Prefectural Nanbu Medical Center and Children's Medical Center
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32
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33
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Tian C, Wong BL, Hornung L, Khoury JC, Miller L, Bange J, Rybalsky I, Rutter MM. Bone health measures in glucocorticoid-treated ambulatory boys with Duchenne muscular dystrophy. Neuromuscul Disord 2016; 26:760-767. [PMID: 27614576 DOI: 10.1016/j.nmd.2016.08.011] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 08/14/2016] [Accepted: 08/18/2016] [Indexed: 11/17/2022]
Abstract
Osteoporosis is a major problem in boys with Duchenne Muscular Dystrophy (DMD), attributable to muscle weakness and glucocorticoid therapy. Consensus regarding bone health assessment and management is lacking. Lumbar spine areal bone mineral density (defined as bone mass per area of bone) by dual-energy X-ray absorptiometry (DXA) is frequently the primary measure used, but has limitations for boys with DMD. We retrospectively studied 292 ambulant glucocorticoid-treated boys with DMD categorized by functional mobility score, FMS 1, 2 or 3. We assessed DXA whole body and lumbar spine areal bone mineral density and content Z-scores adjusted for age and height, lateral distal femur areal bone mineral density Z-scores, frequency of fractures, and osteoporosis by International Society for Clinical Densitometry 2013 criteria. Whole body and femoral DXA indices decreased, while spine fractures increased, with declining motor function. Lumbar spine areal bone mineral density Z-scores appeared to improve with declining motor function. Bone mineral content Z-scores were consistently lower than corresponding bone mineral density Z-scores. Our findings highlight the complexity of assessing bone health in boys with DMD. Bone health indices worsened with declining motor function in ambulant boys, but interpretation was affected by measure and skeletal site examined. Whole body bone mineral content may be a valuable measure in boys with DMD. Lumbar spine areal bone mineral density Z-score as an isolated measure could be misleading. Comprehensive management of osteoporosis in boys with DMD should include vertebral fracture assessment.
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Affiliation(s)
- Cuixia Tian
- Division of Neurology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA; University of Cincinnati College of Medicine, 2600 Clifton Avenue, Cincinnati, OH 45220, USA
| | - Brenda L Wong
- Division of Neurology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA; University of Cincinnati College of Medicine, 2600 Clifton Avenue, Cincinnati, OH 45220, USA
| | - Lindsey Hornung
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Jane C Khoury
- University of Cincinnati College of Medicine, 2600 Clifton Avenue, Cincinnati, OH 45220, USA; Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA; Division of Endocrinology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Lauren Miller
- Department of Psychological Sciences, University of Connecticut, 406 Babbidge Road, Storrs, CT 06269, USA
| | - Jean Bange
- Division of Neurology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Irina Rybalsky
- Division of Neurology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Meilan M Rutter
- University of Cincinnati College of Medicine, 2600 Clifton Avenue, Cincinnati, OH 45220, USA; Division of Endocrinology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA.
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34
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Fiacco E, Castagnetti F, Bianconi V, Madaro L, De Bardi M, Nazio F, D'Amico A, Bertini E, Cecconi F, Puri PL, Latella L. Autophagy regulates satellite cell ability to regenerate normal and dystrophic muscles. Cell Death Differ 2016; 23:1839-1849. [PMID: 27447110 DOI: 10.1038/cdd.2016.70] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 05/16/2016] [Accepted: 06/13/2016] [Indexed: 12/21/2022] Open
Abstract
Autophagy is emerging as a key regulatory process during skeletal muscle development, regeneration and homeostasis, and deregulated autophagy has been implicated in muscular disorders and age-related muscle decline. We have monitored autophagy in muscles of mdx mice and human Duchenne muscular dystrophy (DMD) patients at different stages of disease. Our data show that autophagy is activated during the early, compensatory regenerative stages of DMD. A progressive reduction was observed during mdx disease progression, in coincidence with the functional exhaustion of satellite cell-mediated regeneration and accumulation of fibrosis. Moreover, pharmacological manipulation of autophagy can influence disease progression in mdx mice. Of note, studies performed in regenerating muscles of wild-type mice revealed an essential role of autophagy in the activation of satellite cells upon muscle injury. These results support the notion that regeneration-associated autophagy contributes to the early compensatory stage of DMD progression, and interventions that extend activation of autophagy might be beneficial in the treatment of DMD. Thus, autophagy could be a 'disease modifier' targeted by interventions aimed to promote regeneration and delay disease progression in DMD.
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Affiliation(s)
- E Fiacco
- Laboratory of Epigenetic and Regenerative Pharmacology, IRCCS Fondazione Santa Lucia, Rome, Italy.,Department of Medicine, Institute of Translational Pharmacology, National Research Council of Italy, Rome, Italy
| | - F Castagnetti
- Laboratory of Epigenetic and Regenerative Pharmacology, IRCCS Fondazione Santa Lucia, Rome, Italy.,Department of Medicine, Institute of Translational Pharmacology, National Research Council of Italy, Rome, Italy
| | - V Bianconi
- Laboratory of Epigenetic and Regenerative Pharmacology, IRCCS Fondazione Santa Lucia, Rome, Italy
| | - L Madaro
- Laboratory of Epigenetic and Regenerative Pharmacology, IRCCS Fondazione Santa Lucia, Rome, Italy.,Department of Life Sciences, Cell Biology and Neurobiology Institute, National Research Council of Italy, Roma, Italy
| | - M De Bardi
- Laboratory of Epigenetic and Regenerative Pharmacology, IRCCS Fondazione Santa Lucia, Rome, Italy
| | - F Nazio
- Department of Biology, University of Rome Tor Vergata, Rome, Italy.,Department of Pediatric Hematology and Oncology, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - A D'Amico
- Unit of Neuromuscular and Neurodegenerative Disorders, Bambino Gesù Children's Hospital, Rome, Italy
| | - E Bertini
- Unit of Neuromuscular and Neurodegenerative Disorders, Bambino Gesù Children's Hospital, Rome, Italy
| | - F Cecconi
- Department of Biology, University of Rome Tor Vergata, Rome, Italy.,Unit of Cell Stress and Survival, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - P L Puri
- Laboratory of Epigenetic and Regenerative Pharmacology, IRCCS Fondazione Santa Lucia, Rome, Italy.,Muscle Development and Regeneration Program, Sanford Children's Health Research Center, Sanford Prebys Burnham Medical Discovery Institute, La Jolla, CA 92037, USA
| | - L Latella
- Laboratory of Epigenetic and Regenerative Pharmacology, IRCCS Fondazione Santa Lucia, Rome, Italy.,Department of Medicine, Institute of Translational Pharmacology, National Research Council of Italy, Rome, Italy
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Gloss D, Moxley RT, Ashwal S, Oskoui M. Practice guideline update summary: Corticosteroid treatment of Duchenne muscular dystrophy: Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology 2016; 86:465-72. [PMID: 26833937 DOI: 10.1212/wnl.0000000000002337] [Citation(s) in RCA: 161] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To update the 2005 American Academy of Neurology (AAN) guideline on corticosteroid treatment of Duchenne muscular dystrophy (DMD). METHODS We systematically reviewed the literature from January 2004 to July 2014 using the AAN classification scheme for therapeutic articles and predicated recommendations on the strength of the evidence. RESULTS Thirty-four studies met inclusion criteria. RECOMMENDATIONS In children with DMD, prednisone should be offered for improving strength (Level B) and pulmonary function (Level B). Prednisone may be offered for improving timed motor function (Level C), reducing the need for scoliosis surgery (Level C), and delaying cardiomyopathy onset by 18 years of age (Level C). Deflazacort may be offered for improving strength and timed motor function and delaying age at loss of ambulation by 1.4-2.5 years (Level C). Deflazacort may be offered for improving pulmonary function, reducing the need for scoliosis surgery, delaying cardiomyopathy onset, and increasing survival at 5-15 years of follow-up (Level C for each). Deflazacort and prednisone may be equivalent in improving motor function (Level C). Prednisone may be associated with greater weight gain in the first years of treatment than deflazacort (Level C). Deflazacort may be associated with a greater risk of cataracts than prednisone (Level C). The preferred dosing regimen of prednisone is 0.75 mg/kg/d (Level B). Over 12 months, prednisone 10 mg/kg/weekend is equally effective (Level B), with no long-term data available. Prednisone 0.75 mg/kg/d is associated with significant risk of weight gain, hirsutism, and cushingoid appearance (Level B).
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Affiliation(s)
- David Gloss
- From the Department of Neurology (D.G.), Geisinger Health System, Danville, PA; Department of Neurology (R.T.M.), University of Rochester School of Medicine and Dentistry, NY; Department of Neurology (S.A.), Loma Linda University Medical Center, CA; and Departments of Pediatric and Neurology/Neurosurgery (M.O.), McGill University, Montréal, Canada
| | - Richard T Moxley
- From the Department of Neurology (D.G.), Geisinger Health System, Danville, PA; Department of Neurology (R.T.M.), University of Rochester School of Medicine and Dentistry, NY; Department of Neurology (S.A.), Loma Linda University Medical Center, CA; and Departments of Pediatric and Neurology/Neurosurgery (M.O.), McGill University, Montréal, Canada
| | - Stephen Ashwal
- From the Department of Neurology (D.G.), Geisinger Health System, Danville, PA; Department of Neurology (R.T.M.), University of Rochester School of Medicine and Dentistry, NY; Department of Neurology (S.A.), Loma Linda University Medical Center, CA; and Departments of Pediatric and Neurology/Neurosurgery (M.O.), McGill University, Montréal, Canada
| | - Maryam Oskoui
- From the Department of Neurology (D.G.), Geisinger Health System, Danville, PA; Department of Neurology (R.T.M.), University of Rochester School of Medicine and Dentistry, NY; Department of Neurology (S.A.), Loma Linda University Medical Center, CA; and Departments of Pediatric and Neurology/Neurosurgery (M.O.), McGill University, Montréal, Canada
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Matthews E, Brassington R, Kuntzer T, Jichi F, Manzur AY. Corticosteroids for the treatment of Duchenne muscular dystrophy. Cochrane Database Syst Rev 2016; 2016:CD003725. [PMID: 27149418 PMCID: PMC8580515 DOI: 10.1002/14651858.cd003725.pub4] [Citation(s) in RCA: 176] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Duchenne muscular dystrophy (DMD) is the most common muscular dystrophy of childhood. Untreated, this incurable disease, which has an X-linked recessive inheritance, is characterised by muscle wasting and loss of walking ability, leading to complete wheelchair dependence by 13 years of age. Prolongation of walking is a major aim of treatment. Evidence from randomised controlled trials (RCTs) indicates that corticosteroids significantly improve muscle strength and function in boys with DMD in the short term (six months), and strength at two years (two-year data on function are very limited). Corticosteroids, now part of care recommendations for DMD, are largely in routine use, although questions remain over their ability to prolong walking, when to start treatment, longer-term balance of benefits versus harms, and choice of corticosteroid or regimen.We have extended the scope of this updated review to include comparisons of different corticosteroids and dosing regimens. OBJECTIVES To assess the effects of corticosteroids on prolongation of walking ability, muscle strength, functional ability, and quality of life in DMD; to address the question of whether benefit is maintained over the longer term (more than two years); to assess adverse events; and to compare efficacy and adverse effects of different corticosteroid preparations and regimens. SEARCH METHODS On 16 February 2016 we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, EMBASE, CINAHL Plus, and LILACS. We wrote to authors of published studies and other experts. We checked references in identified trials, handsearched journal abstracts, and searched trials registries. SELECTION CRITERIA We considered RCTs or quasi-RCTs of corticosteroids (e.g. prednisone, prednisolone, and deflazacort) given for a minimum of three months to patients with a definite DMD diagnosis. We considered comparisons of different corticosteroids, regimens, and corticosteroids versus placebo. DATA COLLECTION AND ANALYSIS The review authors followed standard Cochrane methodology. MAIN RESULTS We identified 12 studies (667 participants) and two new ongoing studies for inclusion. Six RCTs were newly included at this update and important non-randomised cohort studies have also been published. Some important studies remain unpublished and not all published studies provide complete outcome data. PRIMARY OUTCOME MEASURE one two-year deflazacort RCT (n = 28) used prolongation of ambulation as an outcome measure but data were not adequate for drawing conclusions. SECONDARY OUTCOME MEASURES meta-analyses showed that corticosteroids (0.75 mg/kg/day prednisone or prednisolone) improved muscle strength and function versus placebo over six months (moderate quality evidence from up to four RCTs). Evidence from single trials showed 0.75 mg/kg/day superior to 0.3 mg/kg/day on most strength and function measures, with little evidence of further benefit at 1.5 mg/kg/day. Improvements were seen in time taken to rise from the floor (Gowers' time), timed walk, four-stair climbing time, ability to lift weights, leg function grade, and forced vital capacity. One new RCT (n = 66), reported better strength, function and quality of life with daily 0.75 mg/kg/day prednisone at 12 months. One RCT (n = 28) showed that deflazacort stabilised muscle strength versus placebo at two years, but timed function test results were too imprecise for conclusions to be drawn.One double-blind RCT (n = 64), largely at low risk of bias, compared daily prednisone (0.75 mg/kg/day) with weekend-only prednisone (5 mg/kg/weekend day), finding no overall difference in muscle strength and function over 12 months (moderate to low quality evidence). Two small RCTs (n = 52) compared daily prednisone 0.75 mg/kg/day with daily deflazacort 0.9 mg/kg/day, but study methods limited our ability to compare muscle strength or function. ADVERSE EFFECTS excessive weight gain, behavioural abnormalities, cushingoid appearance, and excessive hair growth were all previously shown to be more common with corticosteroids than placebo; we assessed the quality of evidence (for behavioural changes and weight gain) as moderate. Hair growth and cushingoid features were more frequent at 0.75 mg/kg/day than 0.3 mg/kg/day prednisone. Comparing daily versus weekend-only prednisone, both groups gained weight with no clear difference in body mass index (BMI) or in behavioural changes (low quality evidence for both outcomes, one study); the weekend-only group had a greater linear increase in height. Very low quality evidence suggested less weight gain with deflazacort than with prednisone at 12 months, and no difference in behavioural abnormalities. Data are insufficient to assess the risk of fractures or cataracts for any comparison.Non-randomised studies support RCT evidence in showing improved functional benefit from corticosteroids. These studies suggest sustained benefit for up to 66 months. Adverse effects were common, although generally manageable. According to a large comparative longitudinal study of daily or intermittent (10 days on, 10 days off) corticosteroid for a mean period of four years, a daily regimen prolongs ambulation and improves functional scores over the age of seven, but with a greater frequency of side effects than an intermittent regimen. AUTHORS' CONCLUSIONS Moderate quality evidence from RCTs indicates that corticosteroid therapy in DMD improves muscle strength and function in the short term (twelve months), and strength up to two years. On the basis of the evidence available for strength and function outcomes, our confidence in the effect estimate for the efficacy of a 0.75 mg/kg/day dose of prednisone or above is fairly secure. There is no evidence other than from non-randomised trials to establish the effect of corticosteroids on prolongation of walking. In the short term, adverse effects were significantly more common with corticosteroids than placebo, but not clinically severe. A weekend-only prednisone regimen is as effective as daily prednisone in the short term (12 months), according to low to moderate quality evidence from a single trial, with no clear difference in BMI (low quality evidence). Very low quality evidence indicates that deflazacort causes less weight gain than prednisone after a year's treatment. We cannot evaluate long-term benefits and hazards of corticosteroid treatment or intermittent regimens from published RCTs. Non-randomised studies support the conclusions of functional benefits, but also identify clinically significant adverse effects of long-term treatment, and a possible divergence of efficacy in daily and weekend-only regimens in the longer term. These benefits and adverse effects have implications for future research and clinical practice.
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Affiliation(s)
- Emma Matthews
- National Hospital for Neurology and NeurosurgeryMRC Centre for Neuromuscular DiseasesQueen SquareLondonUK
| | - Ruth Brassington
- National Hospital for Neurology and NeurosurgeryMRC Centre for Neuromuscular DiseasesQueen SquareLondonUK
| | - Thierry Kuntzer
- CHU Vaudois and University of LausanneNerve‐Muscle Unit, Service of NeurologyLausanneSwitzerland1011
| | - Fatima Jichi
- Joint Research Office, University College LondonUCL School of Life & Medical SciencesGower StreetLondonUKWC1E 6BT
| | - Adnan Y Manzur
- Great Ormond Street Hospital for Children NHS TrustDubowitz Neuromuscular CentreGreat Ormond StreetLondonUKWC1N 3JH
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Translating golden retriever muscular dystrophy microarray findings to novel biomarkers for cardiac/skeletal muscle function in Duchenne muscular dystrophy. Pediatr Res 2016; 79:629-36. [PMID: 26672735 PMCID: PMC4837049 DOI: 10.1038/pr.2015.257] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 09/28/2015] [Indexed: 12/31/2022]
Abstract
BACKGROUND In Duchenne muscular dystrophy (DMD), abnormal cardiac function is typically preceded by a decade of skeletal muscle disease. Molecular reasons for differences in onset and progression of these muscle groups are unknown. Human biomarkers are lacking. METHODS We analyzed cardiac and skeletal muscle microarrays from normal and golden retriever muscular dystrophy (GRMD) dogs (ages 6, 12, or 47+ mo) to gain insight into muscle dysfunction and to identify putative DMD biomarkers. These biomarkers were then measured using human DMD blood samples. RESULTS We identified GRMD candidate genes that might contribute to the disparity between cardiac and skeletal muscle disease, focusing on brain-derived neurotropic factor (BDNF) and osteopontin (OPN/SPP1, hereafter indicated as SPP1). BDNF was elevated in cardiac muscle of younger GRMD but was unaltered in skeletal muscle, while SPP1 was increased only in GRMD skeletal muscle. In human DMD, circulating levels of BDNF were inversely correlated with ventricular function and fibrosis, while SPP1 levels correlated with skeletal muscle function. CONCLUSION These results highlight gene expression patterns that could account for differences in cardiac and skeletal disease in GRMD. Most notably, animal model-derived data were translated to DMD and support use of BDNF and SPP1 as biomarkers for cardiac and skeletal muscle involvement, respectively.
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Houang EM, Haman KJ, Filareto A, Perlingeiro RC, Bates FS, Lowe DA, Metzger JM. Membrane-stabilizing copolymers confer marked protection to dystrophic skeletal muscle in vivo. Mol Ther Methods Clin Dev 2015; 2:15042. [PMID: 26623440 PMCID: PMC4641511 DOI: 10.1038/mtm.2015.42] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 10/01/2015] [Accepted: 10/01/2015] [Indexed: 01/16/2023]
Abstract
Duchenne muscular dystrophy (DMD) is a fatal disease of striated muscle deterioration. A unique therapeutic approach for DMD is the use of synthetic membrane stabilizers to protect the fragile dystrophic sarcolemma against contraction-induced mechanical stress. Block copolymer-based membrane stabilizer poloxamer 188 (P188) has been shown to protect the dystrophic myocardium. In comparison, the ability of synthetic membrane stabilizers to protect fragile DMD skeletal muscles has been less clear. Because cardiac and skeletal muscles have distinct structural and functional features, including differences in the mechanism of activation, variance in sarcolemma phospholipid composition, and differences in the magnitude and types of forces generated, we speculated that optimized membrane stabilization could be inherently different. Our objective here is to use principles of pharmacodynamics to evaluate membrane stabilization therapy for DMD skeletal muscles. Results show a dramatic differential effect of membrane stabilization by optimization of pharmacodynamic-guided route of poloxamer delivery. Data show that subcutaneous P188 delivery, but not intravascular or intraperitoneal routes, conferred significant protection to dystrophic limb skeletal muscles undergoing mechanical stress in vivo. In addition, structure-function examination of synthetic membrane stabilizers further underscores the importance of copolymer composition, molecular weight, and dosage in optimization of poloxamer pharmacodynamics in vivo.
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Affiliation(s)
- Evelyne M Houang
- Department of Integrative Biology and Physiology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Karen J Haman
- Department of Chemical Engineering and Material Science, University of Minnesota, Minneapolis, Minnesota, USA
| | - Antonio Filareto
- Department of Medicine, Lillehei Heart Institute, University of Minnesota, Minneapolis, Minnesota, USA
| | - Rita C Perlingeiro
- Department of Medicine, Lillehei Heart Institute, University of Minnesota, Minneapolis, Minnesota, USA
| | - Frank S Bates
- Department of Chemical Engineering and Material Science, University of Minnesota, Minneapolis, Minnesota, USA
| | - Dawn A Lowe
- Rehabilitation Science and Program in Physical Therapy, University of Minnesota, Minneapolis, Minnesota, USA
| | - Joseph M Metzger
- Department of Integrative Biology and Physiology, University of Minnesota, Minneapolis, Minnesota, USA
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Liu DZ, Stamova B, Hu S, Ander BP, Jickling GC, Zhan X, Sharp FR, Wong B. MicroRNA and mRNA Expression Changes in Steroid Naïve and Steroid Treated DMD Patients. J Neuromuscul Dis 2015; 2:387-396. [PMID: 27858746 PMCID: PMC5240570 DOI: 10.3233/jnd-150076] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background: Duchenne Muscular Dystrophy (DMD) is a recessive X-linked form of muscular dystrophy. Steroid therapy has clinical benefits for DMD patients, but the mechanism remains unclear. Objective: This study was designed to identify mRNAs and microRNAs regulated in Duchenne Muscular Dystrophy patients prior to and after steroid therapy. Methods: Genome wide transcriptome profiling of whole blood was performed to identify mRNAs and microRNAs regulated in DMD patients. Results: The data show many regulated mRNAs and some microRNAs, including some muscle-specific microRNAs (e.g., miR-206), that were significantly altered in blood of young (age 3–10) DMD patients compared to young controls. A total of 95 microRNAs, but no mRNAs, were differentially expressed in older DMD patients compared to matched controls (age 11–20). Steroid treatment reversed expression patterns of several microRNAs (miR-206, miR-181a, miR-4538, miR-4539, miR-606, and miR-454) that were altered in the young DMD patients. As an example, the over-expression of miR-206 in young DMD patients is predicted to down-regulate a set of target genes (e.g., RHGAP31, KHSRP, CORO1B, PTBP1, C7orf58, DLG4, and KLF4) that would worsen motor function. Since steroids decreased miR-206 expression to control levels, this could provide one mechanism by which steroids improve motor function. Conclusions: These identified microRNA-mRNA alterations will help better understand the pathophysiology of DMD and the response to steroid treatment.
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Affiliation(s)
- Da Zhi Liu
- Department of Neurology and the M.I.N.D. Institute, University of California at Davis, Sacramento, California, USA
| | - Boryana Stamova
- Department of Neurology and the M.I.N.D. Institute, University of California at Davis, Sacramento, California, USA
| | - Shengyong Hu
- Division of Pediatric Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Bradley P Ander
- Department of Neurology and the M.I.N.D. Institute, University of California at Davis, Sacramento, California, USA
| | - Glen C Jickling
- Department of Neurology and the M.I.N.D. Institute, University of California at Davis, Sacramento, California, USA
| | - Xinhua Zhan
- Department of Neurology and the M.I.N.D. Institute, University of California at Davis, Sacramento, California, USA
| | - Frank R Sharp
- Department of Neurology and the M.I.N.D. Institute, University of California at Davis, Sacramento, California, USA
| | - Brenda Wong
- Division of Pediatric Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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40
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McNally EM, Kaltman JR, Benson DW, Canter CE, Cripe LH, Duan D, Finder JD, Groh WJ, Hoffman EP, Judge DP, Kertesz N, Kinnett K, Kirsch R, Metzger JM, Pearson GD, Rafael-Fortney JA, Raman SV, Spurney CF, Targum SL, Wagner KR, Markham LW. Contemporary cardiac issues in Duchenne muscular dystrophy. Working Group of the National Heart, Lung, and Blood Institute in collaboration with Parent Project Muscular Dystrophy. Circulation 2015; 131:1590-8. [PMID: 25940966 DOI: 10.1161/circulationaha.114.015151] [Citation(s) in RCA: 216] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Elizabeth M McNally
- From Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (E.M.M.); Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (J.R.K., G.D.P.); Division of Cardiology, Children's Hospital of Wisconsin, Milwaukee (D.W.B.); Department of Pediatrics, Washington University, St. Louis, MO (C.E.C.); The Heart Center, Nationwide Children's Hospital, Columbus, OH (L.H.C., N.K.); Department of Molecular Microbiology and Immunology, School of Medicine, University of Missouri, Columbia (D.D.); Division of Pulmonary Medicine, Children's Hospital of Pittsburgh, PA (J.D.F.); Center for Genetic Medicine Research (E.P.H.) and Division of Cardiology, Children's National Heart Institute, Center for Genetic Medicine Research (C.F.S.), Children's National Health System, Washington, DC; Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, MD (D.P.J.); Parent Project Muscular Dystrophy, Middletown, OH (K.K.); Division of Cardiac Critical Care, Children's Hospital of Philadelphia, PA (R.K.); Department of Integrative Biology and Physiology, University of Minnesota Medical School, Minneapolis (J.M.M.); Department of Molecular and Cellular Biochemistry (J.A.R.-F.) and Division of Cardiovascular Medicine (S.V.R.), Ohio State University, Columbus; Division of Cardiovascular and Renal Products, US Food and Drug Administration, Silver Spring, MD (S.L.T.); Hugo W. Moser Research Institute, Kennedy Krieger Institute, Baltimore, MD (K.R.W.); and Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University, Nashville, TN (L.W.M.).
| | - Jonathan R Kaltman
- From Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (E.M.M.); Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (J.R.K., G.D.P.); Division of Cardiology, Children's Hospital of Wisconsin, Milwaukee (D.W.B.); Department of Pediatrics, Washington University, St. Louis, MO (C.E.C.); The Heart Center, Nationwide Children's Hospital, Columbus, OH (L.H.C., N.K.); Department of Molecular Microbiology and Immunology, School of Medicine, University of Missouri, Columbia (D.D.); Division of Pulmonary Medicine, Children's Hospital of Pittsburgh, PA (J.D.F.); Center for Genetic Medicine Research (E.P.H.) and Division of Cardiology, Children's National Heart Institute, Center for Genetic Medicine Research (C.F.S.), Children's National Health System, Washington, DC; Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, MD (D.P.J.); Parent Project Muscular Dystrophy, Middletown, OH (K.K.); Division of Cardiac Critical Care, Children's Hospital of Philadelphia, PA (R.K.); Department of Integrative Biology and Physiology, University of Minnesota Medical School, Minneapolis (J.M.M.); Department of Molecular and Cellular Biochemistry (J.A.R.-F.) and Division of Cardiovascular Medicine (S.V.R.), Ohio State University, Columbus; Division of Cardiovascular and Renal Products, US Food and Drug Administration, Silver Spring, MD (S.L.T.); Hugo W. Moser Research Institute, Kennedy Krieger Institute, Baltimore, MD (K.R.W.); and Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University, Nashville, TN (L.W.M.).
| | - D Woodrow Benson
- From Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (E.M.M.); Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (J.R.K., G.D.P.); Division of Cardiology, Children's Hospital of Wisconsin, Milwaukee (D.W.B.); Department of Pediatrics, Washington University, St. Louis, MO (C.E.C.); The Heart Center, Nationwide Children's Hospital, Columbus, OH (L.H.C., N.K.); Department of Molecular Microbiology and Immunology, School of Medicine, University of Missouri, Columbia (D.D.); Division of Pulmonary Medicine, Children's Hospital of Pittsburgh, PA (J.D.F.); Center for Genetic Medicine Research (E.P.H.) and Division of Cardiology, Children's National Heart Institute, Center for Genetic Medicine Research (C.F.S.), Children's National Health System, Washington, DC; Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, MD (D.P.J.); Parent Project Muscular Dystrophy, Middletown, OH (K.K.); Division of Cardiac Critical Care, Children's Hospital of Philadelphia, PA (R.K.); Department of Integrative Biology and Physiology, University of Minnesota Medical School, Minneapolis (J.M.M.); Department of Molecular and Cellular Biochemistry (J.A.R.-F.) and Division of Cardiovascular Medicine (S.V.R.), Ohio State University, Columbus; Division of Cardiovascular and Renal Products, US Food and Drug Administration, Silver Spring, MD (S.L.T.); Hugo W. Moser Research Institute, Kennedy Krieger Institute, Baltimore, MD (K.R.W.); and Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University, Nashville, TN (L.W.M.)
| | - Charles E Canter
- From Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (E.M.M.); Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (J.R.K., G.D.P.); Division of Cardiology, Children's Hospital of Wisconsin, Milwaukee (D.W.B.); Department of Pediatrics, Washington University, St. Louis, MO (C.E.C.); The Heart Center, Nationwide Children's Hospital, Columbus, OH (L.H.C., N.K.); Department of Molecular Microbiology and Immunology, School of Medicine, University of Missouri, Columbia (D.D.); Division of Pulmonary Medicine, Children's Hospital of Pittsburgh, PA (J.D.F.); Center for Genetic Medicine Research (E.P.H.) and Division of Cardiology, Children's National Heart Institute, Center for Genetic Medicine Research (C.F.S.), Children's National Health System, Washington, DC; Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, MD (D.P.J.); Parent Project Muscular Dystrophy, Middletown, OH (K.K.); Division of Cardiac Critical Care, Children's Hospital of Philadelphia, PA (R.K.); Department of Integrative Biology and Physiology, University of Minnesota Medical School, Minneapolis (J.M.M.); Department of Molecular and Cellular Biochemistry (J.A.R.-F.) and Division of Cardiovascular Medicine (S.V.R.), Ohio State University, Columbus; Division of Cardiovascular and Renal Products, US Food and Drug Administration, Silver Spring, MD (S.L.T.); Hugo W. Moser Research Institute, Kennedy Krieger Institute, Baltimore, MD (K.R.W.); and Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University, Nashville, TN (L.W.M.)
| | - Linda H Cripe
- From Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (E.M.M.); Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (J.R.K., G.D.P.); Division of Cardiology, Children's Hospital of Wisconsin, Milwaukee (D.W.B.); Department of Pediatrics, Washington University, St. Louis, MO (C.E.C.); The Heart Center, Nationwide Children's Hospital, Columbus, OH (L.H.C., N.K.); Department of Molecular Microbiology and Immunology, School of Medicine, University of Missouri, Columbia (D.D.); Division of Pulmonary Medicine, Children's Hospital of Pittsburgh, PA (J.D.F.); Center for Genetic Medicine Research (E.P.H.) and Division of Cardiology, Children's National Heart Institute, Center for Genetic Medicine Research (C.F.S.), Children's National Health System, Washington, DC; Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, MD (D.P.J.); Parent Project Muscular Dystrophy, Middletown, OH (K.K.); Division of Cardiac Critical Care, Children's Hospital of Philadelphia, PA (R.K.); Department of Integrative Biology and Physiology, University of Minnesota Medical School, Minneapolis (J.M.M.); Department of Molecular and Cellular Biochemistry (J.A.R.-F.) and Division of Cardiovascular Medicine (S.V.R.), Ohio State University, Columbus; Division of Cardiovascular and Renal Products, US Food and Drug Administration, Silver Spring, MD (S.L.T.); Hugo W. Moser Research Institute, Kennedy Krieger Institute, Baltimore, MD (K.R.W.); and Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University, Nashville, TN (L.W.M.)
| | - Dongsheng Duan
- From Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (E.M.M.); Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (J.R.K., G.D.P.); Division of Cardiology, Children's Hospital of Wisconsin, Milwaukee (D.W.B.); Department of Pediatrics, Washington University, St. Louis, MO (C.E.C.); The Heart Center, Nationwide Children's Hospital, Columbus, OH (L.H.C., N.K.); Department of Molecular Microbiology and Immunology, School of Medicine, University of Missouri, Columbia (D.D.); Division of Pulmonary Medicine, Children's Hospital of Pittsburgh, PA (J.D.F.); Center for Genetic Medicine Research (E.P.H.) and Division of Cardiology, Children's National Heart Institute, Center for Genetic Medicine Research (C.F.S.), Children's National Health System, Washington, DC; Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, MD (D.P.J.); Parent Project Muscular Dystrophy, Middletown, OH (K.K.); Division of Cardiac Critical Care, Children's Hospital of Philadelphia, PA (R.K.); Department of Integrative Biology and Physiology, University of Minnesota Medical School, Minneapolis (J.M.M.); Department of Molecular and Cellular Biochemistry (J.A.R.-F.) and Division of Cardiovascular Medicine (S.V.R.), Ohio State University, Columbus; Division of Cardiovascular and Renal Products, US Food and Drug Administration, Silver Spring, MD (S.L.T.); Hugo W. Moser Research Institute, Kennedy Krieger Institute, Baltimore, MD (K.R.W.); and Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University, Nashville, TN (L.W.M.)
| | - Jonathan D Finder
- From Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (E.M.M.); Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (J.R.K., G.D.P.); Division of Cardiology, Children's Hospital of Wisconsin, Milwaukee (D.W.B.); Department of Pediatrics, Washington University, St. Louis, MO (C.E.C.); The Heart Center, Nationwide Children's Hospital, Columbus, OH (L.H.C., N.K.); Department of Molecular Microbiology and Immunology, School of Medicine, University of Missouri, Columbia (D.D.); Division of Pulmonary Medicine, Children's Hospital of Pittsburgh, PA (J.D.F.); Center for Genetic Medicine Research (E.P.H.) and Division of Cardiology, Children's National Heart Institute, Center for Genetic Medicine Research (C.F.S.), Children's National Health System, Washington, DC; Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, MD (D.P.J.); Parent Project Muscular Dystrophy, Middletown, OH (K.K.); Division of Cardiac Critical Care, Children's Hospital of Philadelphia, PA (R.K.); Department of Integrative Biology and Physiology, University of Minnesota Medical School, Minneapolis (J.M.M.); Department of Molecular and Cellular Biochemistry (J.A.R.-F.) and Division of Cardiovascular Medicine (S.V.R.), Ohio State University, Columbus; Division of Cardiovascular and Renal Products, US Food and Drug Administration, Silver Spring, MD (S.L.T.); Hugo W. Moser Research Institute, Kennedy Krieger Institute, Baltimore, MD (K.R.W.); and Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University, Nashville, TN (L.W.M.)
| | | | - Eric P Hoffman
- From Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (E.M.M.); Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (J.R.K., G.D.P.); Division of Cardiology, Children's Hospital of Wisconsin, Milwaukee (D.W.B.); Department of Pediatrics, Washington University, St. Louis, MO (C.E.C.); The Heart Center, Nationwide Children's Hospital, Columbus, OH (L.H.C., N.K.); Department of Molecular Microbiology and Immunology, School of Medicine, University of Missouri, Columbia (D.D.); Division of Pulmonary Medicine, Children's Hospital of Pittsburgh, PA (J.D.F.); Center for Genetic Medicine Research (E.P.H.) and Division of Cardiology, Children's National Heart Institute, Center for Genetic Medicine Research (C.F.S.), Children's National Health System, Washington, DC; Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, MD (D.P.J.); Parent Project Muscular Dystrophy, Middletown, OH (K.K.); Division of Cardiac Critical Care, Children's Hospital of Philadelphia, PA (R.K.); Department of Integrative Biology and Physiology, University of Minnesota Medical School, Minneapolis (J.M.M.); Department of Molecular and Cellular Biochemistry (J.A.R.-F.) and Division of Cardiovascular Medicine (S.V.R.), Ohio State University, Columbus; Division of Cardiovascular and Renal Products, US Food and Drug Administration, Silver Spring, MD (S.L.T.); Hugo W. Moser Research Institute, Kennedy Krieger Institute, Baltimore, MD (K.R.W.); and Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University, Nashville, TN (L.W.M.)
| | - Daniel P Judge
- From Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (E.M.M.); Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (J.R.K., G.D.P.); Division of Cardiology, Children's Hospital of Wisconsin, Milwaukee (D.W.B.); Department of Pediatrics, Washington University, St. Louis, MO (C.E.C.); The Heart Center, Nationwide Children's Hospital, Columbus, OH (L.H.C., N.K.); Department of Molecular Microbiology and Immunology, School of Medicine, University of Missouri, Columbia (D.D.); Division of Pulmonary Medicine, Children's Hospital of Pittsburgh, PA (J.D.F.); Center for Genetic Medicine Research (E.P.H.) and Division of Cardiology, Children's National Heart Institute, Center for Genetic Medicine Research (C.F.S.), Children's National Health System, Washington, DC; Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, MD (D.P.J.); Parent Project Muscular Dystrophy, Middletown, OH (K.K.); Division of Cardiac Critical Care, Children's Hospital of Philadelphia, PA (R.K.); Department of Integrative Biology and Physiology, University of Minnesota Medical School, Minneapolis (J.M.M.); Department of Molecular and Cellular Biochemistry (J.A.R.-F.) and Division of Cardiovascular Medicine (S.V.R.), Ohio State University, Columbus; Division of Cardiovascular and Renal Products, US Food and Drug Administration, Silver Spring, MD (S.L.T.); Hugo W. Moser Research Institute, Kennedy Krieger Institute, Baltimore, MD (K.R.W.); and Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University, Nashville, TN (L.W.M.)
| | - Naomi Kertesz
- From Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (E.M.M.); Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (J.R.K., G.D.P.); Division of Cardiology, Children's Hospital of Wisconsin, Milwaukee (D.W.B.); Department of Pediatrics, Washington University, St. Louis, MO (C.E.C.); The Heart Center, Nationwide Children's Hospital, Columbus, OH (L.H.C., N.K.); Department of Molecular Microbiology and Immunology, School of Medicine, University of Missouri, Columbia (D.D.); Division of Pulmonary Medicine, Children's Hospital of Pittsburgh, PA (J.D.F.); Center for Genetic Medicine Research (E.P.H.) and Division of Cardiology, Children's National Heart Institute, Center for Genetic Medicine Research (C.F.S.), Children's National Health System, Washington, DC; Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, MD (D.P.J.); Parent Project Muscular Dystrophy, Middletown, OH (K.K.); Division of Cardiac Critical Care, Children's Hospital of Philadelphia, PA (R.K.); Department of Integrative Biology and Physiology, University of Minnesota Medical School, Minneapolis (J.M.M.); Department of Molecular and Cellular Biochemistry (J.A.R.-F.) and Division of Cardiovascular Medicine (S.V.R.), Ohio State University, Columbus; Division of Cardiovascular and Renal Products, US Food and Drug Administration, Silver Spring, MD (S.L.T.); Hugo W. Moser Research Institute, Kennedy Krieger Institute, Baltimore, MD (K.R.W.); and Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University, Nashville, TN (L.W.M.)
| | - Kathi Kinnett
- From Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (E.M.M.); Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (J.R.K., G.D.P.); Division of Cardiology, Children's Hospital of Wisconsin, Milwaukee (D.W.B.); Department of Pediatrics, Washington University, St. Louis, MO (C.E.C.); The Heart Center, Nationwide Children's Hospital, Columbus, OH (L.H.C., N.K.); Department of Molecular Microbiology and Immunology, School of Medicine, University of Missouri, Columbia (D.D.); Division of Pulmonary Medicine, Children's Hospital of Pittsburgh, PA (J.D.F.); Center for Genetic Medicine Research (E.P.H.) and Division of Cardiology, Children's National Heart Institute, Center for Genetic Medicine Research (C.F.S.), Children's National Health System, Washington, DC; Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, MD (D.P.J.); Parent Project Muscular Dystrophy, Middletown, OH (K.K.); Division of Cardiac Critical Care, Children's Hospital of Philadelphia, PA (R.K.); Department of Integrative Biology and Physiology, University of Minnesota Medical School, Minneapolis (J.M.M.); Department of Molecular and Cellular Biochemistry (J.A.R.-F.) and Division of Cardiovascular Medicine (S.V.R.), Ohio State University, Columbus; Division of Cardiovascular and Renal Products, US Food and Drug Administration, Silver Spring, MD (S.L.T.); Hugo W. Moser Research Institute, Kennedy Krieger Institute, Baltimore, MD (K.R.W.); and Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University, Nashville, TN (L.W.M.)
| | - Roxanne Kirsch
- From Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (E.M.M.); Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (J.R.K., G.D.P.); Division of Cardiology, Children's Hospital of Wisconsin, Milwaukee (D.W.B.); Department of Pediatrics, Washington University, St. Louis, MO (C.E.C.); The Heart Center, Nationwide Children's Hospital, Columbus, OH (L.H.C., N.K.); Department of Molecular Microbiology and Immunology, School of Medicine, University of Missouri, Columbia (D.D.); Division of Pulmonary Medicine, Children's Hospital of Pittsburgh, PA (J.D.F.); Center for Genetic Medicine Research (E.P.H.) and Division of Cardiology, Children's National Heart Institute, Center for Genetic Medicine Research (C.F.S.), Children's National Health System, Washington, DC; Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, MD (D.P.J.); Parent Project Muscular Dystrophy, Middletown, OH (K.K.); Division of Cardiac Critical Care, Children's Hospital of Philadelphia, PA (R.K.); Department of Integrative Biology and Physiology, University of Minnesota Medical School, Minneapolis (J.M.M.); Department of Molecular and Cellular Biochemistry (J.A.R.-F.) and Division of Cardiovascular Medicine (S.V.R.), Ohio State University, Columbus; Division of Cardiovascular and Renal Products, US Food and Drug Administration, Silver Spring, MD (S.L.T.); Hugo W. Moser Research Institute, Kennedy Krieger Institute, Baltimore, MD (K.R.W.); and Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University, Nashville, TN (L.W.M.)
| | - Joseph M Metzger
- From Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (E.M.M.); Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (J.R.K., G.D.P.); Division of Cardiology, Children's Hospital of Wisconsin, Milwaukee (D.W.B.); Department of Pediatrics, Washington University, St. Louis, MO (C.E.C.); The Heart Center, Nationwide Children's Hospital, Columbus, OH (L.H.C., N.K.); Department of Molecular Microbiology and Immunology, School of Medicine, University of Missouri, Columbia (D.D.); Division of Pulmonary Medicine, Children's Hospital of Pittsburgh, PA (J.D.F.); Center for Genetic Medicine Research (E.P.H.) and Division of Cardiology, Children's National Heart Institute, Center for Genetic Medicine Research (C.F.S.), Children's National Health System, Washington, DC; Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, MD (D.P.J.); Parent Project Muscular Dystrophy, Middletown, OH (K.K.); Division of Cardiac Critical Care, Children's Hospital of Philadelphia, PA (R.K.); Department of Integrative Biology and Physiology, University of Minnesota Medical School, Minneapolis (J.M.M.); Department of Molecular and Cellular Biochemistry (J.A.R.-F.) and Division of Cardiovascular Medicine (S.V.R.), Ohio State University, Columbus; Division of Cardiovascular and Renal Products, US Food and Drug Administration, Silver Spring, MD (S.L.T.); Hugo W. Moser Research Institute, Kennedy Krieger Institute, Baltimore, MD (K.R.W.); and Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University, Nashville, TN (L.W.M.)
| | - Gail D Pearson
- From Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (E.M.M.); Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (J.R.K., G.D.P.); Division of Cardiology, Children's Hospital of Wisconsin, Milwaukee (D.W.B.); Department of Pediatrics, Washington University, St. Louis, MO (C.E.C.); The Heart Center, Nationwide Children's Hospital, Columbus, OH (L.H.C., N.K.); Department of Molecular Microbiology and Immunology, School of Medicine, University of Missouri, Columbia (D.D.); Division of Pulmonary Medicine, Children's Hospital of Pittsburgh, PA (J.D.F.); Center for Genetic Medicine Research (E.P.H.) and Division of Cardiology, Children's National Heart Institute, Center for Genetic Medicine Research (C.F.S.), Children's National Health System, Washington, DC; Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, MD (D.P.J.); Parent Project Muscular Dystrophy, Middletown, OH (K.K.); Division of Cardiac Critical Care, Children's Hospital of Philadelphia, PA (R.K.); Department of Integrative Biology and Physiology, University of Minnesota Medical School, Minneapolis (J.M.M.); Department of Molecular and Cellular Biochemistry (J.A.R.-F.) and Division of Cardiovascular Medicine (S.V.R.), Ohio State University, Columbus; Division of Cardiovascular and Renal Products, US Food and Drug Administration, Silver Spring, MD (S.L.T.); Hugo W. Moser Research Institute, Kennedy Krieger Institute, Baltimore, MD (K.R.W.); and Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University, Nashville, TN (L.W.M.)
| | - Jill A Rafael-Fortney
- From Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (E.M.M.); Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (J.R.K., G.D.P.); Division of Cardiology, Children's Hospital of Wisconsin, Milwaukee (D.W.B.); Department of Pediatrics, Washington University, St. Louis, MO (C.E.C.); The Heart Center, Nationwide Children's Hospital, Columbus, OH (L.H.C., N.K.); Department of Molecular Microbiology and Immunology, School of Medicine, University of Missouri, Columbia (D.D.); Division of Pulmonary Medicine, Children's Hospital of Pittsburgh, PA (J.D.F.); Center for Genetic Medicine Research (E.P.H.) and Division of Cardiology, Children's National Heart Institute, Center for Genetic Medicine Research (C.F.S.), Children's National Health System, Washington, DC; Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, MD (D.P.J.); Parent Project Muscular Dystrophy, Middletown, OH (K.K.); Division of Cardiac Critical Care, Children's Hospital of Philadelphia, PA (R.K.); Department of Integrative Biology and Physiology, University of Minnesota Medical School, Minneapolis (J.M.M.); Department of Molecular and Cellular Biochemistry (J.A.R.-F.) and Division of Cardiovascular Medicine (S.V.R.), Ohio State University, Columbus; Division of Cardiovascular and Renal Products, US Food and Drug Administration, Silver Spring, MD (S.L.T.); Hugo W. Moser Research Institute, Kennedy Krieger Institute, Baltimore, MD (K.R.W.); and Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University, Nashville, TN (L.W.M.)
| | - Subha V Raman
- From Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (E.M.M.); Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (J.R.K., G.D.P.); Division of Cardiology, Children's Hospital of Wisconsin, Milwaukee (D.W.B.); Department of Pediatrics, Washington University, St. Louis, MO (C.E.C.); The Heart Center, Nationwide Children's Hospital, Columbus, OH (L.H.C., N.K.); Department of Molecular Microbiology and Immunology, School of Medicine, University of Missouri, Columbia (D.D.); Division of Pulmonary Medicine, Children's Hospital of Pittsburgh, PA (J.D.F.); Center for Genetic Medicine Research (E.P.H.) and Division of Cardiology, Children's National Heart Institute, Center for Genetic Medicine Research (C.F.S.), Children's National Health System, Washington, DC; Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, MD (D.P.J.); Parent Project Muscular Dystrophy, Middletown, OH (K.K.); Division of Cardiac Critical Care, Children's Hospital of Philadelphia, PA (R.K.); Department of Integrative Biology and Physiology, University of Minnesota Medical School, Minneapolis (J.M.M.); Department of Molecular and Cellular Biochemistry (J.A.R.-F.) and Division of Cardiovascular Medicine (S.V.R.), Ohio State University, Columbus; Division of Cardiovascular and Renal Products, US Food and Drug Administration, Silver Spring, MD (S.L.T.); Hugo W. Moser Research Institute, Kennedy Krieger Institute, Baltimore, MD (K.R.W.); and Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University, Nashville, TN (L.W.M.)
| | - Christopher F Spurney
- From Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (E.M.M.); Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (J.R.K., G.D.P.); Division of Cardiology, Children's Hospital of Wisconsin, Milwaukee (D.W.B.); Department of Pediatrics, Washington University, St. Louis, MO (C.E.C.); The Heart Center, Nationwide Children's Hospital, Columbus, OH (L.H.C., N.K.); Department of Molecular Microbiology and Immunology, School of Medicine, University of Missouri, Columbia (D.D.); Division of Pulmonary Medicine, Children's Hospital of Pittsburgh, PA (J.D.F.); Center for Genetic Medicine Research (E.P.H.) and Division of Cardiology, Children's National Heart Institute, Center for Genetic Medicine Research (C.F.S.), Children's National Health System, Washington, DC; Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, MD (D.P.J.); Parent Project Muscular Dystrophy, Middletown, OH (K.K.); Division of Cardiac Critical Care, Children's Hospital of Philadelphia, PA (R.K.); Department of Integrative Biology and Physiology, University of Minnesota Medical School, Minneapolis (J.M.M.); Department of Molecular and Cellular Biochemistry (J.A.R.-F.) and Division of Cardiovascular Medicine (S.V.R.), Ohio State University, Columbus; Division of Cardiovascular and Renal Products, US Food and Drug Administration, Silver Spring, MD (S.L.T.); Hugo W. Moser Research Institute, Kennedy Krieger Institute, Baltimore, MD (K.R.W.); and Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University, Nashville, TN (L.W.M.)
| | - Shari L Targum
- From Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (E.M.M.); Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (J.R.K., G.D.P.); Division of Cardiology, Children's Hospital of Wisconsin, Milwaukee (D.W.B.); Department of Pediatrics, Washington University, St. Louis, MO (C.E.C.); The Heart Center, Nationwide Children's Hospital, Columbus, OH (L.H.C., N.K.); Department of Molecular Microbiology and Immunology, School of Medicine, University of Missouri, Columbia (D.D.); Division of Pulmonary Medicine, Children's Hospital of Pittsburgh, PA (J.D.F.); Center for Genetic Medicine Research (E.P.H.) and Division of Cardiology, Children's National Heart Institute, Center for Genetic Medicine Research (C.F.S.), Children's National Health System, Washington, DC; Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, MD (D.P.J.); Parent Project Muscular Dystrophy, Middletown, OH (K.K.); Division of Cardiac Critical Care, Children's Hospital of Philadelphia, PA (R.K.); Department of Integrative Biology and Physiology, University of Minnesota Medical School, Minneapolis (J.M.M.); Department of Molecular and Cellular Biochemistry (J.A.R.-F.) and Division of Cardiovascular Medicine (S.V.R.), Ohio State University, Columbus; Division of Cardiovascular and Renal Products, US Food and Drug Administration, Silver Spring, MD (S.L.T.); Hugo W. Moser Research Institute, Kennedy Krieger Institute, Baltimore, MD (K.R.W.); and Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University, Nashville, TN (L.W.M.)
| | - Kathryn R Wagner
- From Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (E.M.M.); Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (J.R.K., G.D.P.); Division of Cardiology, Children's Hospital of Wisconsin, Milwaukee (D.W.B.); Department of Pediatrics, Washington University, St. Louis, MO (C.E.C.); The Heart Center, Nationwide Children's Hospital, Columbus, OH (L.H.C., N.K.); Department of Molecular Microbiology and Immunology, School of Medicine, University of Missouri, Columbia (D.D.); Division of Pulmonary Medicine, Children's Hospital of Pittsburgh, PA (J.D.F.); Center for Genetic Medicine Research (E.P.H.) and Division of Cardiology, Children's National Heart Institute, Center for Genetic Medicine Research (C.F.S.), Children's National Health System, Washington, DC; Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, MD (D.P.J.); Parent Project Muscular Dystrophy, Middletown, OH (K.K.); Division of Cardiac Critical Care, Children's Hospital of Philadelphia, PA (R.K.); Department of Integrative Biology and Physiology, University of Minnesota Medical School, Minneapolis (J.M.M.); Department of Molecular and Cellular Biochemistry (J.A.R.-F.) and Division of Cardiovascular Medicine (S.V.R.), Ohio State University, Columbus; Division of Cardiovascular and Renal Products, US Food and Drug Administration, Silver Spring, MD (S.L.T.); Hugo W. Moser Research Institute, Kennedy Krieger Institute, Baltimore, MD (K.R.W.); and Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University, Nashville, TN (L.W.M.)
| | - Larry W Markham
- From Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (E.M.M.); Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (J.R.K., G.D.P.); Division of Cardiology, Children's Hospital of Wisconsin, Milwaukee (D.W.B.); Department of Pediatrics, Washington University, St. Louis, MO (C.E.C.); The Heart Center, Nationwide Children's Hospital, Columbus, OH (L.H.C., N.K.); Department of Molecular Microbiology and Immunology, School of Medicine, University of Missouri, Columbia (D.D.); Division of Pulmonary Medicine, Children's Hospital of Pittsburgh, PA (J.D.F.); Center for Genetic Medicine Research (E.P.H.) and Division of Cardiology, Children's National Heart Institute, Center for Genetic Medicine Research (C.F.S.), Children's National Health System, Washington, DC; Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, MD (D.P.J.); Parent Project Muscular Dystrophy, Middletown, OH (K.K.); Division of Cardiac Critical Care, Children's Hospital of Philadelphia, PA (R.K.); Department of Integrative Biology and Physiology, University of Minnesota Medical School, Minneapolis (J.M.M.); Department of Molecular and Cellular Biochemistry (J.A.R.-F.) and Division of Cardiovascular Medicine (S.V.R.), Ohio State University, Columbus; Division of Cardiovascular and Renal Products, US Food and Drug Administration, Silver Spring, MD (S.L.T.); Hugo W. Moser Research Institute, Kennedy Krieger Institute, Baltimore, MD (K.R.W.); and Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University, Nashville, TN (L.W.M.).
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Absence of Cardiac Benefit with Early Combination ACE Inhibitor and Beta Blocker Treatment in mdx Mice. J Cardiovasc Transl Res 2015; 8:198-207. [DOI: 10.1007/s12265-015-9623-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 04/06/2015] [Indexed: 02/07/2023]
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Spurney CF, McCaffrey FM, Cnaan A, Morgenroth LP, Ghelani SJ, Gordish-Dressman H, Arrieta A, Connolly AM, Lotze TE, McDonald CM, Leshner RT, Clemens PR. Feasibility and Reproducibility of Echocardiographic Measures in Children with Muscular Dystrophies. J Am Soc Echocardiogr 2015; 28:999-1008. [PMID: 25906753 DOI: 10.1016/j.echo.2015.03.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Indexed: 01/16/2023]
Abstract
BACKGROUND Cardiac disease is a major cause of death in patients with muscular dystrophies. The use of feasible and reproducible echocardiographic measures of cardiac function is critical to advance the field of therapeutics for dystrophic cardiomyopathy. METHODS Participants aged 8 to 18 years with genetically confirmed Duchenne muscular dystrophy (DMD), Becker muscular dystrophy, or limb-girdle muscular dystrophy were enrolled at five centers, and standardized echocardiographic examinations were performed. Measures of systolic and diastolic function and speckle-tracking echocardiography-derived cardiac strain were reviewed independently by two central readers. Furthermore, echocardiographic measures from participants with DMD were compared with those from retrospective age-matched control subjects from a single site to assess measures of myocardial function. RESULTS Forty-eight participants (mean age, 13.3 ± 2.7 years) were enrolled. Shortening fraction had a greater interobserver correlation (intraclass correlation coefficient [ICC] = 0.63) compared with ejection fraction (ICC = 0.49). One reader could measure ejection fraction in only 53% of participants. Myocardial performance index measured by pulse-wave Doppler and Doppler tissue imaging showed similar ICCs (0.55 and 0.54). Speckle-tracking echocardiography showed a high ICC (0.96). Focusing on participants with DMD (n = 33), significantly increased mitral A-wave velocities, lower E/A ratios, and lower Doppler tissue imaging mitral lateral E' velocities were observed compared with age-matched control subjects. Speckle-tracking echocardiography demonstrated subclinical myocardial dysfunction with decreased average circumferential and longitudinal strain in three distinct subgroups: participants with DMD with normal shortening fractions, participants with DMD aged < 13 years, and participants with DMD with myocardial performance index scores < 0.40 compared with control subjects. CONCLUSIONS In a muscular dystrophy cohort, assessment of cardiac function is feasible and reproducible using shortening fraction, diastolic measures, and myocardial performance index. Cardiac strain measures identified early myocardial disease in patients with DMD.
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Affiliation(s)
| | | | - Avital Cnaan
- Children's National Health System, Washington, District of Columbia
| | | | - Sunil J Ghelani
- Children's National Health System, Washington, District of Columbia
| | | | - Adrienne Arrieta
- Children's National Health System, Washington, District of Columbia
| | | | | | | | - Robert T Leshner
- Children's National Health System, Washington, District of Columbia; University of California, San Diego, San Diego, California
| | - Paula R Clemens
- University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Veterans Affairs Medical Center, Pittsburgh, Pennsylvania
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Short-term effects of corticosteroid therapy on cardiac and skeletal muscles in muscular dystrophies. J Investig Med 2015; 62:875-9. [PMID: 24866459 DOI: 10.1097/01.jim.0000446835.98223.ce] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Duchenne muscular dystrophy (DMD) is the most common muscular dystrophy of childhood. It leads to progressive deterioration in cardiac and skeletal muscles. Corticosteroids are considered an effective therapy. OBJECTIVE This study aimed to evaluate the role of short-term prednisone therapy in improving left ventricular (LV) systolic function, LV mass (LVM), and motor power in cases of muscular dystrophies. PATIENTS AND METHODS Twenty-five cases of muscular dystrophy including 17 cases of DMD, 3 cases of Becker muscular dystrophies, and 5 cases of female patients with DMD-like phenotype were included in the study. The diagnosis of 12 patients was confirmed by muscle biopsy with immunohistochemistry; the patients were subjected to motor assessment, measurement of creatine kinase level, and echocardiographic examination before and after prednisone therapy. Transthoracic echocardiographic assessment of the LV systolic function (fractional shortening) was done. Myocardial performance index and LVM were calculated. Intermittent dosage of prednisone was administered 5 mg/kg per day on 2 consecutive days weekly for 3 months. RESULTS Fractional shortening improved on prednisone therapy (P = 0.009) and LVM increased (P = 0.012); improvement in walking was detected in 77% of the patients, climbing stairs improved in 88.9%, Gower sign improved in 70%, and rising from chair improved in 60%. Prednisone had no effect on the patients with marked motor impairment (on wheelchair). The creatine kinase level was significantly lower after steroid therapy (P = 0.04). CONCLUSIONS Three months of intermittent prednisone therapy could improve cardiac and skeletal muscle function in congenital muscular dystrophy.
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Affiliation(s)
- Subha V. Raman
- Division of Cardiovascular Medicine, Ohio State University, Columbus, OH (S.V.R.)
| | - Linda H. Cripe
- Nationwide Children's Hospital Heart Center, Coloumbus, OH (L.H.C.)
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Fox DJ, Kumar A, West NA, DiRienzo AG, James KA, Oleszek J. Trends with corticosteroid use in males with Duchenne muscular dystrophy born 1982-2001. J Child Neurol 2015; 30:21-6. [PMID: 24682290 DOI: 10.1177/0883073813517263] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study examines trends in corticosteroid use for males with Duchenne muscular dystrophy by birth year, race/ethnicity, and knowledge of Duchenne muscular dystrophy family history. Firstborn males (n = 521) selected from a population-based surveillance system of Duchenne muscular dystrophy were analyzed using Kaplan Meier and regression methods. Comparing males born 1982 to 1986 with males born 1997 to 2001, steroid use increased from 54% to 72% and mean age at steroid initiation decreased from 8.2 to 7.1 years. Hispanics and non-Hispanic Black males used steroids less frequently and delayed initiation compared to white males. Compared to males without a Duchenne muscular dystrophy family history, males with known family history were half as likely to use steroids. Duration of steroid use increased over time and age at initiation decreased. Racial/ethnic disparities exist for steroid use and should be addressed to improve outcome and quality of life for boys with Duchenne muscular dystrophy.
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Affiliation(s)
- Deborah J Fox
- New York State Department of Health, Albany, NY, USA
| | - Anil Kumar
- New York State Department of Health, Albany, NY, USA
| | - Nancy A West
- Department of Epidemiology, University of Colorado School of Public Health, Aurora, CO, USA
| | - A Gregory DiRienzo
- Department of Epidemiology and Biostatistics, State University of New York at Albany, Rensselaer, NY, USA
| | - Katherine A James
- Colorado Department of Public Health and Environment, Denver, CO, USA
| | - Joyce Oleszek
- Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
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Goudot FX, Wahbi K, Aïssou L, Sorbets E, Siam-Tsieu V, Eymard B, Themar Noel C, Devaux JY, Dessault O, Duboc D, Meune C. Reduced inotropic reserve is predictive of further degradation in left ventricular ejection fraction in patients with Duchenne muscular dystrophy. Eur J Heart Fail 2014; 17:177-81. [DOI: 10.1002/ejhf.213] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Affiliation(s)
| | - Karim Wahbi
- Paris Descartes University; APHP, Department of Cardiology, Cochin Hospital; Paris France
- Myology Institute; APHP, Pitié-Salpêtrière Hospital; Paris France
| | - Linda Aïssou
- Paris 13 University, Avicenne Hospital; Department of Cardiology; APHP Bobigny France
| | - Emmanuel Sorbets
- Paris 13 University, Avicenne Hospital; Department of Cardiology; APHP Bobigny France
- Department of Cardiology; Bichat Hospital; APHP Paris France
| | - Valérie Siam-Tsieu
- Paris Descartes University; APHP, Department of Cardiology, Cochin Hospital; Paris France
| | - Bruno Eymard
- Myology Institute; APHP, Pitié-Salpêtrière Hospital; Paris France
| | | | - Jean-Yves Devaux
- Saint-Antoine Hospital; Department of Nuclear Medicine; Paris France
| | - Odile Dessault
- Saint-Antoine Hospital; Department of Nuclear Medicine; Paris France
| | - Denis Duboc
- Paris Descartes University; APHP, Department of Cardiology, Cochin Hospital; Paris France
| | - Christophe Meune
- Paris 13 University, Avicenne Hospital; Department of Cardiology; APHP Bobigny France
- Paris Descartes University; APHP, Department of Cardiology, Cochin Hospital; Paris France
- INSERM UMR S-942; Paris France
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Annexstad EJ, Lund-Petersen I, Rasmussen M. Duchenne muscular dystrophy. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2014; 134:1361-4. [PMID: 25096430 DOI: 10.4045/tidsskr.13.0836] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Duchenne muscular dystrophy is one of the most severe muscle diseases to affect children. In the last twenty years, treatments have been established that have significantly improved patients' quality of life and life expectancy. The purpose of this article is to outline the main features of the disease and its treatment, and to examine possible future treatment options. METHOD The article is based on a literature search in PubMed, current international guidelines and our own clinical experience. RESULTS Close monitoring by an interdisciplinary rehabilitation team forms the basis of treatment. Treatment with glucocorticoids can slow disease progression and improve motor function in the short term. The treatment may cause side effects, which must be monitored and which may require intervention. A not insignificant proportion of patients have cognitive and neuropsychiatric problems that must be addressed. Active intervention in response to signs of respiratory or cardiac failure is important. More causal treatment of Duchenne muscular dystrophy is under testing and offers cautious hope for future patients. INTERPRETATION With improved treatment and increased life expectancy come new challenges for patients with Duchenne muscular dystrophy and their families, as well as new demands on the support services. This patient group requires close and comprehensive follow-up, also in the transition from child to adult.
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Affiliation(s)
- Ellen J Annexstad
- Kompetansesenter for medfødte muskelsykdommer Oslo universitetssykehus og Barneavdelingen Sykehuset Østfold Fredrikstad
| | | | - Magnhild Rasmussen
- Barneavdeling for nevrofag og Kompetansesenter for medfødte muskelsykdommer Oslo universitetssykehus
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Spurney C, Shimizu R, Hache LP, Kolski H, Gordish-Dressman H, Clemens PR. Cooperative International Neuromuscular Research Group Duchenne Natural History Study demonstrates insufficient diagnosis and treatment of cardiomyopathy in Duchenne muscular dystrophy. Muscle Nerve 2014; 50:250-6. [PMID: 24395289 PMCID: PMC4081523 DOI: 10.1002/mus.24163] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Revised: 12/18/2013] [Accepted: 12/31/2013] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Cardiomyopathy is a common cause of morbidity and death in patients with Duchenne muscular dystrophy (DMD). METHODS This investigation was a cross-sectional cross-sectional analysis of clinical data from the multi-institutional Cooperative International Neuromuscular Research Group (CINRG) DMD Natural History Study of 340 DMD patients aged 2-28 years. Cardiomyopathy was defined as shortening fraction (SF) <28% or ejection fraction (EF) <55%. RESULTS Two hundred thirty-one participants reported a prior clinical echocardiogram study, and 174 had data for SF or EF. The prevalence of cardiomyopathy was 27% (47 of 174), and it was associated significantly with age and clinical stage. The association of cardiomyopathy with age and clinical stage was not changed by glucocorticoid use as a covariate (P > 0.68). In patients with cardiomyopathy, 57% (27 of 47) reported not taking any cardiac medications. Cardiac medications were used in 12% (15 of 127) of patients without cardiomyopathy. CONCLUSIONS We found that echocardiograms were underutilized, and cardiomyopathy was undertreated in this DMD natural history cohort.
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Affiliation(s)
| | | | | | - Hanna Kolski
- Glenrose Rehabilitation Hospital, University of Alberta, Edmonton, Canada
| | | | - Paula R. Clemens
- University of Pittsburgh, Pittsburgh, PA
- Neurology Service, Department of Veterans Affairs Medical Center, Pittsburgh, PA
| | - the CINRG Investigators
- Children’s National Medical Center, Washington, DC
- University of Pittsburgh, Pittsburgh, PA
- Glenrose Rehabilitation Hospital, University of Alberta, Edmonton, Canada
- Neurology Service, Department of Veterans Affairs Medical Center, Pittsburgh, PA
- UC Davis Medical Center, Sacramento CA
- Washington University, St. Louis, MO
- Apollo Children’s Hospital, Chennai, India
- Holland Bloorview Kids Rehabilitation Hospital, Toronto, Canada
- Alberta Children’s Hospital, Calgary, Canada
- Queen Silvia Children’s Hospital, Göteborg, Sweden
- Royal Children’s Hospital, Melbourne, Australia
- Hadassah Hebrew University Hospital, Jerusalem, Israel
- Instituto de Neurosciencias Fundacion Favaloro, Buenos Aires, Argentina
- Mayo Clinic, Rochester, MN
- Children’s Hospital of Richmond, Richmond, VA
- University of Tennessee, Memphis, TN
- Children’s Hospital at Westmead, Sydney, Australia
- University of Puerto Rico, San Juan, PR
- Centro Clinico Nemo, Milan, Italy
- Texas Children’s Hospital, Houston, TX
- University of Minnesota, Minneapolis, MN
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50
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Ashwath ML, Jacobs IB, Crowe CA, Ashwath RC, Super DM, Bahler RC. Left ventricular dysfunction in duchenne muscular dystrophy and genotype. Am J Cardiol 2014; 114:284-9. [PMID: 24878125 DOI: 10.1016/j.amjcard.2014.04.038] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Revised: 04/17/2014] [Accepted: 04/17/2014] [Indexed: 12/26/2022]
Abstract
Prognosis in patients with Duchenne muscular dystrophy (DMD) is guarded, and most deaths are due to cardiac or respiratory causes. It is unclear if some DMD gene mutations might be predictive of either mild or severe cardiac dysfunction. We studied 75 patients with DMD followed at our institution. Cardiac function, as assessed by yearly echocardiography, showed marked variability in left ventricular (LV) function. Some patients in their 3rd decade had no or minimal dysfunction, whereas others in their 2nd decade had very severe dysfunction. Therefore, 4 severity groups were defined ranging from no or mild LV dysfunction to severe LV dysfunction using patient age at first abnormal echocardiographic finding and degree of LV dysfunction. Genetic data were collected for all patients. Most patients had mutations from exon 1 to 20 to exon 41 to 55. The distribution of the 4 severity groups of LV dysfunction did not significantly differ between these 2 mutation groups. An analysis based on the number of exons involved (<5 vs ≥5 exons) also found no significant difference in cardiac severity. When patients having identical mutations were compared with their cardiac course, concordance was often not evident. Steroid therapy had no apparent protection for the development of cardiomyopathy. In conclusion, 75 patients with DMD showed marked variability in the severity of LV dysfunction. Neither the age of onset nor the severity of cardiomyopathy correlated with any of the mutation groups.
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Affiliation(s)
- Mahi L Ashwath
- MetroHealth Medical Center, Departments of Medicine and Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Irwin B Jacobs
- MetroHealth Medical Center, Departments of Medicine and Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Carol A Crowe
- MetroHealth Medical Center, Departments of Medicine and Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Ravi C Ashwath
- Rainbow Babies and Childrens Hospital, Departments of Medicine and Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Dennis M Super
- MetroHealth Medical Center, Departments of Medicine and Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Robert C Bahler
- MetroHealth Medical Center, Departments of Medicine and Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio.
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