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Ostrominski JW, Guo R, Elliott PM, Ho CY. Cardiac Myosin Inhibitors for Managing Obstructive Hypertrophic Cardiomyopathy: JACC: Heart Failure State-of-the-Art Review. JACC. HEART FAILURE 2023; 11:735-748. [PMID: 37407153 DOI: 10.1016/j.jchf.2023.04.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 04/17/2023] [Accepted: 04/26/2023] [Indexed: 07/07/2023]
Abstract
Hypertrophic cardiomyopathy (HCM) is frequently caused by pathogenic variants in genes encoding sarcomere proteins and is characterized by left ventricular (LV) hypertrophy, hypercontractility, and-in many cases-left ventricular outflow tract (LVOT) obstruction. Despite standard management, obstructive HCM (oHCM) can still cause substantial morbidity, highlighting the critical need for more effective disease-specific therapeutic approaches. Over the past decade, improved understanding of the molecular pathobiology of HCM has culminated in development of cardiac myosin inhibitors (CMIs), a novel drug class that in recent randomized clinical trials has been shown to decrease LVOT obstruction, improve exercise capacity, and ameliorate symptom burden in patients with oHCM. Although promising, areas of uncertainty remain, including the long-term safety and efficacy of CMIs and whether they have the potential to modify progression of disease. Herein, we review key milestones in the clinical development of CMIs, contextualize CMIs with established oHCM therapies, and discuss future challenges and opportunities for the use of CMIs across the HCM spectrum.
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Affiliation(s)
- John W Ostrominski
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Ruby Guo
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Perry M Elliott
- Centre for Heart Muscle Disease, Institute of Cardiological Sciences, University College London and St Bartholomew's Hospital, London, United Kingdom
| | - Carolyn Y Ho
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.
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Maurizi N, Chiriatti C, Fumagalli C, Targetti M, Passantino S, Antiochos P, Skalidis I, Chiti C, Biagioni G, Tomberli A, Giovani S, Coppini R, Cecchi F, Olivotto I. Real-World Use and Predictors of Response to Disopyramide in Patients with Obstructive Hypertrophic Cardiomyopathy. J Clin Med 2023; 12:jcm12072725. [PMID: 37048808 PMCID: PMC10095445 DOI: 10.3390/jcm12072725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 03/26/2023] [Accepted: 04/03/2023] [Indexed: 04/09/2023] Open
Abstract
Background: Although disopyramide has been widely used to reduce left ventricular outflow obstruction (LVOTO) and to improve symptoms in patients with obstructive hypertrophic cardiomyopathy (oHCM), its use in real world as well as patient characteristics associated with a positive treatment response are still unclear. Methods: From 1980 to 2021, 1527 patients with HCM were evaluated and 372 (23%) had a LVOTO with active follow-up. The efficacy and safety of disopyramide were assessed systematically during 12 months (2-, 6-, and 12-month visits). Responders were patients with a final NYHA = I and a LVOTO < 30 mmHg; incomplete responders were those patients with NYHA > I and a LVOTO < 30 mmHg; and non-responders were symptomatic patients with no change in functional class NYHA and a LVOT gradient > 30 mmHg. Results: Two-hundred-fifty-four (66%) patients were in functional class NYHA I/II and 118 (34%) in NYHA III/IV. A total of 118/372 (32%, 55 ± 16 years) underwent disopyramide therapy. Twenty-eight (24%) patients responded to therapy, 39 (33%) were incomplete responders, and 51 (43%) did not respond. Responder were mainly patients in functional NYHA class I/II (24/28, 86%), whereas incomplete responders and non-responders were more often in functional NYHA class III/IV (50/54 (93%)). An independent predictor of response to disopyramide treatment was the presence of NYHA I/II at the initiation of therapy (HR 1.5 (95% CI 1.1–4.5), p = 0.03). No major life-threatening arrhythmic events or syncope occurred, despite 19 (16%) patients showing reduced QTc from baseline, 19 (16%) having no difference, while 80 (69%) patients had prolonged QTc interval. Thirty-one (26%) patients experienced side effects, in particular, 29 of the anticholinergic type. Conclusions: Disopyramide was underused in oHCM but effective in reducing LVOTO gradients and symptoms in slightly symptomatic patients with less severe disease phenotype with a safe pro-arrhythmic profile.
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Affiliation(s)
- Niccolò Maurizi
- Department of Clinical and Experimental Medicine, University of Florence, 50121 Florence, Italy
- Service of Cardiology, University Hospital of Lausanne, 1009 Lausanne, Switzerland
| | - Chiara Chiriatti
- Cardiomyopathy Unit, Careggi University Hospital, 50134 Florence, Italy
| | - Carlo Fumagalli
- Cardiomyopathy Unit, Careggi University Hospital, 50134 Florence, Italy
| | - Mattia Targetti
- Cardiomyopathy Unit, Careggi University Hospital, 50134 Florence, Italy
| | - Silvia Passantino
- Cardiomyopathy Unit, Careggi University Hospital, 50134 Florence, Italy
| | - Panagiotis Antiochos
- Service of Cardiology, University Hospital of Lausanne, 1009 Lausanne, Switzerland
| | - Ioannis Skalidis
- Service of Cardiology, University Hospital of Lausanne, 1009 Lausanne, Switzerland
| | - Chiara Chiti
- Cardiomyopathy Unit, Careggi University Hospital, 50134 Florence, Italy
| | - Giulia Biagioni
- Cardiomyopathy Unit, Careggi University Hospital, 50134 Florence, Italy
| | - Alessia Tomberli
- Cardiomyopathy Unit, Careggi University Hospital, 50134 Florence, Italy
| | - Sara Giovani
- Cardiomyopathy Unit, Careggi University Hospital, 50134 Florence, Italy
| | - Raffaele Coppini
- Department NeuroFarBa, University of Florence, 50121 Florence, Italy
| | | | - Iacopo Olivotto
- Department of Clinical and Experimental Medicine, University of Florence, 50121 Florence, Italy
- Service of Cardiology, Meyer Children’s Hospital IRCCS, 50139 Florence, Italy
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Wazzan AA, Galli E, Lacout M, Paven E, L'official G, Schnell F, Oger E, Donal E. Could echocardiographic left atrial characterization have additive value for detecting risks of atrial arrhythmias and stroke in patients with hypertrophic cardiomyopathy? Eur Heart J Cardiovasc Imaging 2022; 24:616-624. [PMID: 35793319 DOI: 10.1093/ehjci/jeac131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 06/09/2022] [Indexed: 11/13/2022] Open
Abstract
AIMS Atrial arrhythmia (AA) is considered a turning point for prognosis in patients with hypertrophic cardiomyopathy (HCM). We sought to assess whether the occurrence of AA and stroke could be estimated by an echocardiographic evaluation. METHODS AND RESULTS A total of 216 patients with HCM (52 ± 16 years old) were analysed. All patients underwent transthoracic echocardiography for the evaluation of left atrial volume (LAV), peak left atrial strain (PLAS), and peak atrial contraction strain. The patients were followed for 2.9 years for the occurrence of a composite endpoint including AA and/or stroke and peripheral embolism. Among the 216 patients, 78 (36%) met the composite endpoint. These patients were older (57.1 ± 14.4 vs. 50.3 ± 16.7 years; P = 0.0035), had a higher prevalence of arterial hypertension (62.3 vs. 42.3%; P = 0.005), and had higher NT-proBNP. The LAV (47 ± 20 vs. 37.2 ± 15.7 mL/m²; P = 0.0001) was significantly higher in patients who met the composite endpoint, whereas PLAS was significantly impaired (19.3 ± 9.54 vs. 26.6 ± 9.12%; P < 0.0001). After adjustment, PLAS was independently associated with events with an odds ratio of 0.42 (95% confidence interval 0.29-0.61; P < 0.0001). Stroke occurred in 67% of the patients without any clinical AA. The PLAS with a cut-off of under 15.5% provided event prediction with 91% specificity. Using a 15% cut-off, PLAS also demonstrated a predictive value for new-onset of AA. CONCLUSION The decrease in PLAS was strongly associated with the risk of stroke, even in patients without any documented AA. Its value for guiding the management of patients with HCM requires further investigation.
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Affiliation(s)
- Adrien Al Wazzan
- University of Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, Rennes, France
| | - Elena Galli
- University of Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, Rennes, France
| | - Marion Lacout
- University of Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, Rennes, France
| | - Elise Paven
- University of Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, Rennes, France
| | | | - Frederic Schnell
- University of Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, Rennes, France
| | - Emmanuel Oger
- EA Reperes, CHU Rennes, University of Rennes, Rennes, France
| | - Erwan Donal
- University of Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, Rennes, France
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