1
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Arata A, Ricci F, Khanji MY, Mantini C, Angeli F, Aquilani R, Di Baldassarre A, Renda G, Mattioli AV, Nodari S, Gallina S. Sex Differences in Heart Failure: What Do We Know? J Cardiovasc Dev Dis 2023; 10:277. [PMID: 37504533 PMCID: PMC10380698 DOI: 10.3390/jcdd10070277] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 06/19/2023] [Accepted: 06/27/2023] [Indexed: 07/29/2023] Open
Abstract
Heart failure (HF) remains an important global health issue, substantially contributing to morbidity and mortality. According to epidemiological studies, men and women face nearly equivalent lifetime risks for HF. However, their experiences diverge significantly when it comes to HF subtypes: men tend to develop HF with reduced ejection fraction more frequently, whereas women are predominantly affected by HF with preserved ejection fraction. This divergence underlines the presence of numerous sex-based disparities across various facets of HF, encompassing aspects such as risk factors, clinical presentation, underlying pathophysiology, and response to therapy. Despite these apparent discrepancies, our understanding of them is far from complete, with key knowledge gaps still existing. Current guidelines from various professional societies acknowledge the existence of sex-based differences in HF management, yet they are lacking in providing explicit, actionable recommendations tailored to these differences. In this comprehensive review, we delve deeper into these sex-specific differences within the context of HF, critically examining associated definitions, risk factors, and therapeutic strategies. We provide a specific emphasis on aspects exclusive to women, such as the impact of pregnancy-induced hypertension and premature menopause, as these unique factors warrant greater attention in the broader HF discussion. Additionally, we aim to clarify ongoing controversies and knowledge gaps pertaining to the pharmacological treatment of HF and the sex-specific indications for cardiac implantable electronic devices. By shining a light on these issues, we hope to stimulate a more nuanced understanding and promote the development of more sex-responsive approaches in HF management.
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Affiliation(s)
- Allegra Arata
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University of Chieti-Pescara, 66100 Chieti, Italy
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University of Chieti-Pescara, 66100 Chieti, Italy
- William Harvey Research Institute, NIHR Barts Biomedical Research Centre, Queen Mary University London, Charterhouse Square, London EC1M 6BQ, UK
- Department of Clinical Sciences, Lund University, 214 28 Malmö, Sweden
| | - Mohammed Y Khanji
- William Harvey Research Institute, NIHR Barts Biomedical Research Centre, Queen Mary University London, Charterhouse Square, London EC1M 6BQ, UK
| | - Cesare Mantini
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University of Chieti-Pescara, 66100 Chieti, Italy
| | - Francesco Angeli
- Department of Medical and Surgical Sciences, University of Bologna, Via Zamboni, 33-40126 Bologna, Italy
| | - Roberta Aquilani
- Cardiac Surgery Intensive Care Unit, Heart Department, SS Annunziata University Hospital, Via dei Vestini 5, 66100 Chieti, Italy
| | - Angela Di Baldassarre
- Department of Medicine and Aging Sciences, and Reprogramming and Cell Differentiation Lab, Center for Advanced Studies and Technology (CAST), "G. d'Annunzio" University of Chieti-Pescara, 66100 Chieti, Italy
| | - Giulia Renda
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University of Chieti-Pescara, 66100 Chieti, Italy
| | - Anna Vittoria Mattioli
- Surgical, Medical and Dental Department of Morphological Sciences Related to Transplant, Oncology and Regenerative Medicine, University of Modena and Reggio Emilia, 41100 Modena, Italy
| | - Savina Nodari
- Department of Cardiology, University of Brescia and ASST "Spedali Civili" Hospital, 25123 Brescia, Italy
| | - Sabina Gallina
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University of Chieti-Pescara, 66100 Chieti, Italy
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2
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Salgado M, Díaz-Molina B, Cuesta-Llavona E, Aparicio A, Fernández M, Alonso V, Avanzas P, Pascual I, Neuhalfen D, Coto E, Gómez J, Lorca R. Opportunistic Genetic Screening for Familial Hypercholesterolemia in Heart Transplant Patients. J Clin Med 2023; 12:jcm12031233. [PMID: 36769882 PMCID: PMC9917546 DOI: 10.3390/jcm12031233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 01/21/2023] [Accepted: 01/31/2023] [Indexed: 02/08/2023] Open
Abstract
Heart transplantation remains the gold standard for the treatment of advanced heart failure (HF). Identification of the etiology of HF is mandatory, as the specific pathology can determine subsequent treatment. Early identification of familial hypercholesterolemia (FH), the most common genetic disorder associated with premature cardiovascular disease, has a potential important impact on clinical management and public health. We evaluated the genetic information in the genes associated with FH in a cohort of 140 heart-transplanted patients. All patients underwent NGS genetic testing including LDLR, APOB, and PCSK9. We identified four carriers of rare pathogenic variants in LDLR and APOB. Although all four identified carriers had dyslipidemia, only the one carrying the pathogenic variant LDLR c.676T>C was transplanted due to CAD. Another patient with heart valvular disease was carrier of the controversial LDLR c.2096C>T. Two additional patients with non-ischemic dilated cardiomyopathy were carriers of variants in APOB (c.4672A>G and c.5600G>A). In our cohort, we identified the genetic cause of FH in patients that otherwise would not have been diagnosed. Opportunistic genetic testing for FH provides important information to perform personalized medicine and risk stratification not only for patients but also for relatives at concealed high cardiovascular risk. Including the LDLR gene in standard NGS cardiovascular diagnostics panels should be considered.
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Affiliation(s)
- María Salgado
- Área del Corazón, Hospital Universitario Central Asturias, 33011 Oviedo, Spain
| | - Beatriz Díaz-Molina
- Área del Corazón, Hospital Universitario Central Asturias, 33011 Oviedo, Spain
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante, Área del Corazón, Hospital Universitario Central Asturias, 33011 Oviedo, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias, ISPA, 33011 Oviedo, Spain
| | - Elías Cuesta-Llavona
- Instituto de Investigación Sanitaria del Principado de Asturias, ISPA, 33011 Oviedo, Spain
| | - Andrea Aparicio
- Área del Corazón, Hospital Universitario Central Asturias, 33011 Oviedo, Spain
| | - María Fernández
- Área del Corazón, Hospital Universitario Central Asturias, 33011 Oviedo, Spain
| | - Vanesa Alonso
- Área del Corazón, Hospital Universitario Central Asturias, 33011 Oviedo, Spain
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante, Área del Corazón, Hospital Universitario Central Asturias, 33011 Oviedo, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias, ISPA, 33011 Oviedo, Spain
| | - Pablo Avanzas
- Área del Corazón, Hospital Universitario Central Asturias, 33011 Oviedo, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias, ISPA, 33011 Oviedo, Spain
- Departamento de Medicina, Universidad de Oviedo, 33003 Oviedo, Spain
| | - Isaac Pascual
- Área del Corazón, Hospital Universitario Central Asturias, 33011 Oviedo, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias, ISPA, 33011 Oviedo, Spain
- Departamento de Medicina, Universidad de Oviedo, 33003 Oviedo, Spain
| | - David Neuhalfen
- Departamento de Medicina, Universidad de Oviedo, 33003 Oviedo, Spain
| | - Eliecer Coto
- Instituto de Investigación Sanitaria del Principado de Asturias, ISPA, 33011 Oviedo, Spain
- Departamento de Medicina, Universidad de Oviedo, 33003 Oviedo, Spain
- Unidad de Cardiopatías Familiares, Área del Corazón y Departamento de Genética Molecular, Hospital Universitario Central Asturias, 33011 Oviedo, Spain
- Redes de Investigación Cooperativa Orientadas a Resultados en Salud (RICORs), 28029 Madrid, Spain
| | - Juan Gómez
- Instituto de Investigación Sanitaria del Principado de Asturias, ISPA, 33011 Oviedo, Spain
- Unidad de Cardiopatías Familiares, Área del Corazón y Departamento de Genética Molecular, Hospital Universitario Central Asturias, 33011 Oviedo, Spain
- Redes de Investigación Cooperativa Orientadas a Resultados en Salud (RICORs), 28029 Madrid, Spain
- CIBER-Enfermedades Respiratorias, 28029 Madrid, Spain
- Correspondence: (J.G.); (R.L.)
| | - Rebeca Lorca
- Área del Corazón, Hospital Universitario Central Asturias, 33011 Oviedo, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias, ISPA, 33011 Oviedo, Spain
- Unidad de Cardiopatías Familiares, Área del Corazón y Departamento de Genética Molecular, Hospital Universitario Central Asturias, 33011 Oviedo, Spain
- Redes de Investigación Cooperativa Orientadas a Resultados en Salud (RICORs), 28029 Madrid, Spain
- Departamento de Morfología y Biología Celular, Universidad de Oviedo, 33003 Oviedo, Spain
- Correspondence: (J.G.); (R.L.)
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3
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García-Hernandez S, Iglesias LM. Genetic Testing as a Guide for Treatment in Dilated Cardiomyopathies. Curr Cardiol Rep 2022; 24:1537-1546. [PMID: 35994197 DOI: 10.1007/s11886-022-01772-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/10/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE OF REVIEW Dilated cardiomyopathy (DCM) is one of the most prevalent primary cardiomyopathies and may be caused by genetic and non-genetic etiologies. DCM may also be the final common pathway of other cardiomyopathies such as hypertrophic, arrhythmogenic, or non-compaction cardiomyopathy. We review the main DCM genetic substrates, specific genotype-phenotype aspects, the role of genetic testing in risk stratification, and advances regarding genotype-based precision medicine. RECENT FINDINGS Performing a comprehensive genetic study could have a diagnostic yield up to 40% in DCM, and it is considered a cost-effective approach nowadays. The detection of a specific underlying genetic substrate explaining the disease can have important consequences for clinical management, especially for familial cascade screening, optimizing medical treatment, and improving the arrhythmic risk stratification. The identification of the genetic substrate underlying dilated cardiomyopathy makes possible the genotype-phenotype correlation analysis and a better understanding of the natural history of this disease. Nowadays, there are many promising targeting-gene therapies in different developing phases.
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Affiliation(s)
- Soledad García-Hernandez
- Scientific Department, Health in Code S.L., A Coruña, Spain.,Inherited Cardiac Diseases Unit, Hospital Universitario San Cecilio, Granada, Spain
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4
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Argirò A, Ho C, Day SM, van der Velden J, Cerbai E, Saberi S, Tardiff JC, Lakdawala NK, Olivotto I. Sex-Related Differences in Genetic Cardiomyopathies. J Am Heart Assoc 2022; 11:e024947. [PMID: 35470690 PMCID: PMC9238595 DOI: 10.1161/jaha.121.024947] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Cardiomyopathies are a heterogeneous collection of diseases that have in common primary functional and structural abnormalities of the heart muscle, often genetically determined. The most effective categorization of cardiomyopathies is based on the presenting phenotype, with hypertrophic, dilated, arrhythmogenic, and restrictive cardiomyopathy as the prototypes. Sex modulates the prevalence, morpho-functional manifestations and clinical course of cardiomyopathies. Aspects as diverse as ion channel expression and left ventricular remodeling differ in male and female patients with myocardial disease, although the reasons for this are poorly understood. Moreover, clinical differences may also result from complex societal/environmental discrepancies between sexes that may disadvantage women. This review provides a state-of-the-art appraisal of the influence of sex on cardiomyopathies, highlighting the many gaps in knowledge and open research questions.
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Affiliation(s)
- Alessia Argirò
- Cardiomyopathy UnitCareggi University HospitalFlorenceItaly
- Department of Experimental and Clinical MedicineUniversity of FlorenceItaly
- Division of General CardiologyCareggi University HospitalFlorenceItaly
| | - Carolyn Ho
- Cardiovascular DivisionBrigham and Women's HospitalHarvard Medical SchoolBostonMA
| | - Sharlene M. Day
- Division of Cardiovascular MedicinePerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Jolanda van der Velden
- Department of PhysiologyAmsterdam Cardiovascular SciencesAmsterdam University Medical CenterVrije UniversiteitAmsterdamNetherlands
| | - Elisabetta Cerbai
- Department of Neurosciences, Psychology, Drug Research and Child HealthUniversity of FlorenceItaly
| | - Sara Saberi
- Division of Cardiovascular MedicineDepartment of Internal MedicineUniversity of MichiganMichigan MedicineAnn ArborMI
| | - Jil C. Tardiff
- Department of Biomedical EngineeringThe University of ArizonaTucsonAZ
| | - Neal K. Lakdawala
- Cardiovascular DivisionBrigham and Women's HospitalHarvard Medical SchoolBostonMA
| | - Iacopo Olivotto
- Cardiomyopathy UnitCareggi University HospitalFlorenceItaly
- Department of Experimental and Clinical MedicineUniversity of FlorenceItaly
- Division of General CardiologyCareggi University HospitalFlorenceItaly
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5
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Diagnostic yield of genetic testing in heart transplant recipients with prior cardiomyopathy. J Heart Lung Transplant 2022; 41:1218-1227. [PMID: 35581137 PMCID: PMC9512016 DOI: 10.1016/j.healun.2022.03.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 03/24/2022] [Accepted: 03/29/2022] [Indexed: 01/15/2023] Open
Abstract
Background The importance of genetic testing for cardiomyopathies has increased in the last decade. However, in heart transplant patients with former cardiomyopathy, genetic testing in retrospect is not routinely performed. We hypothesize that the yield of genetic testing in this population is considerable, and will have a major impact for both patients and relatives. Methods Patients that underwent heart transplantation (HTx) between 1995 and 2020 and were still in follow-up, were offered genetic testing if the primary etiology was non-ischemic cardiomyopathy. Next generation sequencing (NGS) of known cardiomyopathy genes was performed and variants were classified as variant of unknown significance (class 3), likely pathogenic (class 4) or pathogenic (class 5) variant. Results Of the 99 HTx patients in active follow-up, only 6 patients had a genetic diagnosis at the time of HTx. In this study, 31 selected patients with prior non-ischemic cardiomyopathy underwent genetic testing post HTx. 23/31 patients (74.2%) carried a variant that was classified as class 3 or higher. In 12/31 patients a class 4/5 variant (38.7%) was identified, and in 11/31 patients (35.5%) a class 3 variant. Class 5 Variants in TTN were the most prevalent (7/31), followed by class 5 variants in MYBPC3 (2/31). A positive family history was present in 21/31 (67.7%) and a second precipitating factor (e.g., alcohol abuse, pregnancy) was present in 17/31 patients (54.8%). Diagnostic yield of genetic testing was similar between patients with or without familial history and/or second hit. Through cascade screening 48 family members were screened for presence of a class 4/5 variant, of whom 19 (39.6%) were genotype positive, of whom 10 (52.6%) showed a cardiac phenotype. Appropriate follow-up was offered. Conclusions Genetic testing for cardiomyopathy genes established a molecular diagnosis in 38.7% of patients post HTx. These results highlight the importance of genetic testing in this population as it is still often overlooked in patients that already underwent HTx in the past. Genetic testing is highly recommended, independent of family history or second precipitating factors, as it might identify relatives at risk.
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6
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Myocardial inflammation and sudden death in the inherited cardiomyopathies. Can J Cardiol 2022; 38:427-438. [DOI: 10.1016/j.cjca.2022.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 01/08/2022] [Accepted: 01/08/2022] [Indexed: 12/20/2022] Open
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7
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Sex Differences, Genetic and Environmental Influences on Dilated Cardiomyopathy. J Clin Med 2021; 10:jcm10112289. [PMID: 34070351 PMCID: PMC8197492 DOI: 10.3390/jcm10112289] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/11/2021] [Accepted: 05/18/2021] [Indexed: 12/15/2022] Open
Abstract
Dilated cardiomyopathy (DCM) is characterized by dilatation of the left ventricle and impaired systolic function and is the second most common cause of heart failure after coronary heart disease. The etiology of DCM is diverse including genetic pathogenic variants, infection, inflammation, autoimmune diseases, exposure to chemicals/toxins as well as endocrine and neuromuscular causes. DCM is inherited in 20–50% of cases where more than 30 genes have been implicated in the development of DCM with pathogenic variants in TTN (Titin) most frequently associated with disease. Even though male sex is a risk factor for heart failure, few studies have examined sex differences in the pathogenesis of DCM. We searched the literature for studies examining idiopathic or familial/genetic DCM that reported data by sex in order to determine the sex ratio of disease. We found 31 studies that reported data by sex for non-genetic DCM with an average overall sex ratio of 2.5:1 male to female and 7 studies for familial/genetic DCM with an overall average sex ratio of 1.7:1 male to female. No manuscripts that we found had more females than males in their studies. We describe basic and clinical research findings that may explain the increase in DCM in males over females based on sex differences in basic physiology and the immune and fibrotic response to damage caused by mutations, infections, chemotherapy agents and autoimmune responses.
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8
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Abstract
In the absence of contemporary, population-based epidemiological studies, estimates of the incidence and prevalence of the inherited cardiomyopathies have been derived from screening studies, most often of young adult populations, to assess cardiovascular risk or to detect the presence of disease in athletes or military recruits. The global estimates for hypertrophic cardiomyopathy (1/500 individuals), dilated cardiomyopathy (1/250) and arrhythmogenic right ventricular cardiomyopathy (1/5,000) are probably conservative given that only individuals who fulfil diagnostic criteria would have been included. This caveat is highly relevant because a substantial minority or even a majority of individuals who carry disease-causing genetic variants and are at risk of disease complications have incomplete and/or late-onset disease expression. The genetic literature on cardiomyopathy, which is often focused on the identification of genetic variants, has been biased in favour of pedigrees with higher penetrance. In clinical practice, an abnormal electrocardiogram with normal or non-diagnostic imaging results is a common finding for the sarcomere variants that cause hypertrophic cardiomyopathy, the titin and sarcomere variants that cause dilated cardiomyopathy and the desmosomal variants that cause either arrhythmogenic right ventricular cardiomyopathy or dilated cardiomyopathy. Therefore, defining the genetic epidemiology is also challenging given the overlapping phenotypes, incomplete and age-related expression, and highly variable penetrance even within individual families carrying the same genetic variant.
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Affiliation(s)
- William J McKenna
- Institute of Cardiovascular Science, University College London, London, UK. .,Heart Hospital, Hamad Medical Corporation, Doha, Qatar.
| | - Daniel P Judge
- Section of Advanced HF & Transplant Cardiology, Medical University of South Carolina, Charleston, SC, USA
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9
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Marume K, Noguchi T, Tateishi E, Morita Y, Miura H, Nishimura K, Ohta-Ogo K, Yamada N, Tsujita K, Izumi C, Kusano K, Ogawa H, Yasuda S. Prognosis and Clinical Characteristics of Dilated Cardiomyopathy With Family History via Pedigree Analysis. Circ J 2020; 84:1284-1293. [PMID: 32624524 DOI: 10.1253/circj.cj-19-1176] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The clinical characteristics and prognostic outcomes of dilated cardiomyopathy (DCM) with a familial history (FHx) via pedigree analysis are unclear.Methods and Results:We conducted a prospective observational study of 514 consecutive Japanese patients with DCM. FHx was defined as the presence of DCM in ≥1 family member within 2-degrees relative based on pedigree analysis. The primary endpoint was a composite of major cardiac events (sudden cardiac death and pump failure death). The prevalence of FHx was 7.4% (n=38). During a median follow-up of 3.6 years, 77 (15%) patients experienced a major cardiac event. Multivariable Cox regression analysis identified FHx as independently associated with major cardiac events (hazard ratio [HR] 4.32; 95% confidence interval [CI], 2.04-9.19; P<0.001) compared with conventional risk factors such as age, QRS duration, and left ventricular volume. In the propensity score-matched cohort (n=38 each), the FHx group had a significantly higher incidence of major cardiac events (HR, 4.48; 95% CI, 1.25-16.13; P=0.022). In addition, the FHx group had a higher prevalence of a diffuse late gadolinium enhancement (LGE) pattern than the no-FHx group (32% vs. 17%, P=0.022). CONCLUSIONS DCM patients with FHx had a worse prognosis, which was associated with a higher prevalence of a diffuse LGE pattern, than patients without FHx.
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Affiliation(s)
- Kyohei Marume
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center.,Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Emi Tateishi
- Department of Radiology, National Cerebral and Cardiovascular Center
| | - Yoshiaki Morita
- Department of Radiology, National Cerebral and Cardiovascular Center.,Department of Radiology, Tohoku University Hospital
| | - Hiroyuki Miura
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Kunihiro Nishimura
- Department of Statistics and Data Analysis, National Cerebral and Cardiovascular Center
| | - Keiko Ohta-Ogo
- Department of Pathology, National Cerebral and Cardiovascular Center
| | - Naoaki Yamada
- Department of Radiology, Osaka Neurological Institute
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Hisao Ogawa
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
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10
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Lamounier Júnior A, Ferrari F, Max R, Ritt LEF, Stein R. Importance of Genetic Testing in Dilated Cardiomyopathy: Applications and Challenges in Clinical Practice. Arq Bras Cardiol 2019; 113:274-281. [PMID: 31483024 PMCID: PMC6777894 DOI: 10.5935/abc.20190144] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 03/13/2019] [Accepted: 04/10/2019] [Indexed: 12/29/2022] Open
Abstract
Dilated cardiomyopathy (DCM) is a clinical syndrome characterized by left ventricular dilatation and contractile dysfunction. It is the most common cause of heart failure in young adults. The advent of next-generation sequencing has contributed to the discovery of a large amount of genomic data related to DCM. Mutations involving genes that encode cytoskeletal proteins, the sarcomere, and ion channels account for approximately 40% of cases previously classified as idiopathic DCM. In this scenario, geneticists and cardiovascular genetics specialists have begun to work together, building knowledge and establishing more accurate diagnoses. However, proper interpretation of genetic results is essential and multidisciplinary teams dedicated to the management and analysis of the obtained information should be considered. In this review, we approach genetic factors associated with DCM and their prognostic relevance and discuss how the use of genetic testing, when well recommended, can help cardiologists in the decision-making process.
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Affiliation(s)
- Arsonval Lamounier Júnior
- Health in Code S.L., Scientific Department, A Coruña -
Spain
- Universidade da Coruña, GRINCAR (Cardiovascular Research
Group), A Coruña - Spain
| | - Filipe Ferrari
- Graduate Program in Cardiology and Cardiovascular Sciences, Hospital
de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto
Alegre, RS - Brazil
- Exercise Cardiology Research Group (CardioEx), Hospital de
Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto
Alegre, RS - Brazil
| | - Renato Max
- Hospital Universitário Onofre Lopes, Natal, RN - Brazil
| | - Luiz Eduardo Fonteles Ritt
- Escola Bahiana de Medicina e Saúde Pública, Salvador,
BA - Brazil
- Hospital Cárdio Pulmonar, Salvador, BA - Brazil
| | - Ricardo Stein
- Graduate Program in Cardiology and Cardiovascular Sciences, Hospital
de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto
Alegre, RS - Brazil
- Exercise Cardiology Research Group (CardioEx), Hospital de
Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto
Alegre, RS - Brazil
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11
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Cannie DE, Akhtar MM, Elliott P. Hidden in Heart Failure. Eur Cardiol 2019; 14:89-96. [PMID: 31360229 PMCID: PMC6659034 DOI: 10.15420/ecr.2019.19.2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 06/06/2019] [Indexed: 02/06/2023] Open
Abstract
Current diagnostic strategies fail to illuminate the presence of rare disease in the heart failure population. One-third of heart failure patients are categorised as suffering an idiopathic dilated cardiomyopathy, while others are labelled only as heart failure with preserved ejection fraction. Those affected frequently suffer from delays in diagnosis, which can have a significant impact on quality of life and prognosis. Traditional rhetoric argues that delineation of this patient population is superfluous to treatment, as elucidation of aetiology will not lead to a deviation from standard management protocols. This article emphasises the importance of identifying genetic, inflammatory and infiltrative causes of heart failure to enable patients to access tailored management strategies.
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Affiliation(s)
- Douglas Ewan Cannie
- University College London Institute for Cardiovascular Science London, UK.,Barts Heart Centre, Barts Health NHS Trust London, UK
| | - Mohammed Majid Akhtar
- University College London Institute for Cardiovascular Science London, UK.,Barts Heart Centre, Barts Health NHS Trust London, UK
| | - Perry Elliott
- University College London Institute for Cardiovascular Science London, UK.,Barts Heart Centre, Barts Health NHS Trust London, UK
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12
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Miller EJ, Jacoby D. Advanced Cardiac Imaging and the Complexity of Diagnosing Cardiac Sarcoidosis. Circ Cardiovasc Imaging 2019; 12:e009275. [DOI: 10.1161/circimaging.119.009275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Edward J. Miller
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
| | - Daniel Jacoby
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
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13
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Kadakia RS, Link MS, Dominic P, Morin DP. Sudden cardiac death in nonischemic cardiomyopathy. Prog Cardiovasc Dis 2019; 62:235-241. [PMID: 31075279 DOI: 10.1016/j.pcad.2019.05.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Accepted: 05/04/2019] [Indexed: 12/27/2022]
Abstract
Sudden cardiac death (SCD) is a major cause of mortality in patients with nonischemic cardiomyopathy (NICM). Identifying patients who are at highest risk for SCD is an ongoing challenge. At present, guidelines recommend the use of an implantable cardioverter-defibrillator (ICD) in patients with NICM with a reduced left ventricular ejection fraction (LVEF) and heart failure (HF) symptoms. Some recent data, however, suggest that ICDs may not increase longevity in this population. Conversely, community-based studies have demonstrated that many at-risk individuals who may benefit from ICD therapy remain unprotected. Current recommendations for ICD implantation are continually debated, justifying comprehensive individualized risk assessment. Various promising techniques for further risk stratification are under evaluation, including cardiac magnetic resonance imaging, electrocardiographic assessment of electrical instability, and genetic testing. However, none of these strategies has been fully adapted into guidelines. Hence, clinical risk stratification practice today depends on LVEF and HF symptoms, which have poor sensitivity and specificity for predicting SCD risk.
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Affiliation(s)
- Rikin S Kadakia
- Ochsner Medical Center, New Orleans, LA, United States of America
| | - Mark S Link
- University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Paari Dominic
- Ochsner Louisiana State University Shreveport, Shreveport, LA, United States of America
| | - Daniel P Morin
- Ochsner Medical Center, New Orleans, LA, United States of America; University of Queensland Ochsner Clinical School, New Orleans, LA, United States of America.
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Khayata M, Al-Kindi SG, Oliveira GH. Contemporary characteristics and outcomes of adults with familial dilated cardiomyopathy listed for heart transplantation. World J Cardiol 2019; 11:38-46. [PMID: 30705741 PMCID: PMC6354074 DOI: 10.4330/wjc.v11.i1.38] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 11/01/2018] [Accepted: 01/04/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Familial dilated cardiomyopathy (FDCM) account for 20%-30% of non-ischemic cardiomyopathies (NICM). Previous published data showed that some patients with FDCM tend to have rapidly progressive disease; however, five-year mortality was not significantly different in the familial and non-familial forms of NICM with optimal medical therapy.
AIM To better define the characteristics and clinical outcomes of FDCM patients listed for heart transplantation (HT).
METHODS We queried the United Network for Organ Sharing Registry to identify FDCM patients listed for HT between January 2008 and September 2015 and compared them to NICM and ischemic cardiomyopathy (ICM) patients. We included all patients ≥ 18 years old and we separated patients to three groups: FDCM, NICM and ICM. Chi-square test was used to compare between categorical variables, the t-test was used to compare between continues variables, and Cox-proportional hazards model was used to perform time-dependent survival analyses.
RESULTS Of the 24809 adults listed for HT, we identified 677 patients (2.7%) with the diagnosis of FDCM. Compared to patients with NICM and ICM, FDCM patients were younger (FDCM 43.9 ± 13.5 vs NICM 50.9 ± 12.3, P < 0.001, vs ICM 58.5 ± 8.1, P < 0.001), more frequently listed as status 2 (FDCM 35.2% vs NICM 26.5%, P < 0.001), with significantly lower left ventricular assist device (LVAD) utilization (FDCM 18.4% vs NICM 25.1%, P < 0.001; vs ICM 25.6%, P < 0.001), but higher use of total artificial heart (FDCM 1.3% vs NICM 0.6%, P = 0.039; vs ICM 0.4%, P = 0.002). Additionally, patients with FDCM were less frequently delisted for clinical deterioration or death and more likely to be transplanted compared to those with NICM [hazard ratio (HR): 0.617, 95% confidence interval (CI): 0.47-0.81; HR: 1.25, 95%CI: 1.14-1.37, respectively], and ICM (HR: 0.5, 95%CI: 0.38-0.66; HR: 1.18, 95%CI: 1.08-1.3, respectively). There was more frequent rejection among patients with FDCM (FDCM 11.4% vs NICM 9.8%, P = 0.28; vs ICM 8.4%, P = 0.034). One, three, and five post-transplant survival of patients with FDCM (91%, 88% and 80%) was similar to those with NICM (91%, 84%, 79%, P = 0.225), but superior to those with ICM (89%, 82%, 75%, P = 0.008), respectively.
CONCLUSION End-stage FDCM patients are more likely to be transplanted, more likely to have early rejection, and have similar or higher survival than patients with other cardiomyopathies.
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Affiliation(s)
- Mohamed Khayata
- Cardiology Section, Department of Internal Medicine, University Hospitals Cleveland Medical Center, Harrington Heart and Vascular Institute, Cleveland, OH 44106, United States
| | - Sadeer G Al-Kindi
- Cardiology Section, Department of Internal Medicine, University Hospitals Cleveland Medical Center, Harrington Heart and Vascular Institute, Cleveland, OH 44106, United States
| | - Guilherme H Oliveira
- Cardiology Section, Department of Internal Medicine, University Hospitals Cleveland Medical Center, Harrington Heart and Vascular Institute, Cleveland, OH 44106, United States
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Should Primary Prevention ICDs Still Be Placed in Patients with Non-ischemic Cardiomyopathy? A Review of the Evidence. Curr Cardiol Rep 2018; 20:31. [PMID: 29574588 DOI: 10.1007/s11886-018-0974-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
PURPOSE OF REVIEW Recent evidence has suggested that implantable defibrillator (ICD) in non-ischemic cardiomyopathy (NICM) may not offer mortality benefit in the presence of guideline-directed medical therapy (GDMT) and cardiac resynchronization therapy (CRT). RECENT FINDINGS Despite significant benefits of GDMT and CRT, current evidence is derived from ICD trials that rely predominantly on reduced left ventricular ejection fraction alone (LVEF). The majority of patients with sudden cardiac death (SCD) have LVEF > 30% indicating that LVEF by itself is an inadequate predictor of SCD. The Danish study to assess the efficacy of ICD in patients with non-ischemic systolic heart failure on mortality (DANISH) highlights the importance of better risk stratifying NICM patients for ICD implantation. Assessment of life expectancy, comorbidities, presence of advanced heart failure, etiology of NICM, and the presence of myocardial fibrosis can help risk stratify ICD beyond LVEF. Genetics and biomarkers can be of further assistance in risk stratification.
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Xu H, Dorn GW, Shetty A, Parihar A, Dave T, Robinson SW, Gottlieb SS, Donahue MP, Tomaselli GF, Kraus WE, Mitchell BD, Liggett SB. A Genome-Wide Association Study of Idiopathic Dilated Cardiomyopathy in African Americans. J Pers Med 2018; 8:E11. [PMID: 29495422 PMCID: PMC5872085 DOI: 10.3390/jpm8010011] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 02/17/2018] [Accepted: 02/21/2018] [Indexed: 01/03/2023] Open
Abstract
Idiopathic dilated cardiomyopathy (IDC) is the most common form of non-ischemic chronic heart failure. Despite the higher prevalence of IDC in African Americans, the genetics of IDC have been relatively understudied in this ethnic group. We performed a genome-wide association study to identify susceptibility genes for IDC in African Americans recruited from five sites in the U.S. (662 unrelated cases and 1167 controls). The heritability of IDC was calculated to be 33% (95% confidence interval: 19-47%; p = 6.4 × 10-7). We detected association of a variant in a novel intronic locus in the CACNB4 gene meeting genome-wide levels of significance (p = 4.1 × 10-8). The CACNB4 gene encodes a calcium channel subunit expressed in the heart that is important for cardiac muscle contraction. This variant has not previously been associated with IDC in any racial group. Pathway analysis, based on the 1000 genes most strongly associated with IDC, showed an enrichment for genes related to calcium signaling, growth factor signaling, neuronal/neuromuscular signaling, and various types of cellular level signaling, including gap junction and cAMP signaling. Our results suggest a novel locus for IDC in African Americans and provide additional insights into the genetic architecture and etiology.
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Affiliation(s)
- Huichun Xu
- Division of Endocrinology, Diabetes and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
| | - Gerald W Dorn
- Center for Pharmacogenomics, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA.
| | - Amol Shetty
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
| | - Ankita Parihar
- Division of Endocrinology, Diabetes and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
| | - Tushar Dave
- Division of Endocrinology, Diabetes and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
| | - Shawn W Robinson
- Division of Cardiovascular Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
| | - Stephen S Gottlieb
- Division of Cardiovascular Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
| | - Mark P Donahue
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC 27708, USA.
| | - Gordon F Tomaselli
- Department of Medicine, Division of Cardiology, Johns Hopkins University, Baltimore, MD 21218, USA.
| | - William E Kraus
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC 27708, USA.
- Duke Molecular Physiology Institute, Duke University Medical Center, Durham, NC 27701, USA.
| | - Braxton D Mitchell
- Division of Endocrinology, Diabetes and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
- Geriatrics Research and Education Clinical Center, Baltimore Veterans Administration Medical Center, Baltimore, MD 21201, USA.
| | - Stephen B Liggett
- Department of Internal Medicine and Molecular Pharmacology and Physiology, and the Center for Personalized Medicine and Genomics, University of South Florida Morsani College of Medicine, Tampa, FL 33612, USA.
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Manolis AS. Sudden death risk stratification in non-ischemic dilated cardiomyopathy using old and new tools: a clinical challenge. Expert Rev Cardiovasc Ther 2017; 15:315-325. [PMID: 28292197 DOI: 10.1080/14779072.2017.1307735] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Risk stratification for sudden cardiac death in non-ischemic dilated cardiomyopathy (NIDCM) remains a clinical challenge. Areas covered: Currently, left ventricular ejection fraction (LVEF), severity of heart failure symptoms according to NYHA classification, and morphology and duration of the QRS complex guide device management in these patients with implantation of a cardioverter defibrillator (ICD) and/or cardiac resynchronization therapy (CRT) devices. Recently, the results of a randomized trial stirred some controversy regarding the utility of ICD in NIDCM patients, however, a subsequent meta-analysis confirmed prior findings of the survival-prolonging benefit of device therapy. Newer risk markers, like late gadolinium enhancement in cardiac magnetic resonance imaging (CMR) detecting myocardial fibrosis, are encouraging in improving risk stratification in these patients. Furthermore, resurgence of an old tool, the electrophysiology study (EPS), and technical advances in genetics in identifying high-risk familial NIDCM, appear promising in this direction. Expert commentary: Based on old and new tools, a more individualized approach may be applied in NIDCM patients, whereby CMR, EPS and genetics may provide further guidance, particularly in patients with LVEF>35%. These issues are herein reviewed and a practical algorithm is proposed for risk stratification and device implantation in NIDCM patients with LVEF below and above 35%.
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Affiliation(s)
- Antonis S Manolis
- a Third Department of Cardiology , Athens University School of Medicine , Athens , Greece
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