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Oliveira Antunes M, Fernandes F, Arteaga-Fernandez E, Alvarez Ramires FJ, Machado Correia V, Novaes Cardoso J, Romero CE, Sousa HM, Soliani MT, Dal Piaz MRR, Rodrigues Gandarella AD, Rocha Teixeira RG, Mady C, Assis Moura Tavares C, Guimarães PO, Madrini Junior V. Validation of ACC/AHA and ESC Sudden Cardiac Death Risk Guidelines in Diverse Hypertrophic Cardiomyopathy Cohort: Stratification HCM Study. Glob Heart 2024; 19:94. [PMID: 39713197 PMCID: PMC11661054 DOI: 10.5334/gh.1380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2024] [Accepted: 11/28/2024] [Indexed: 12/24/2024] Open
Abstract
Background Sudden cardiac death (SCD) is a major concern in patients with hypertrophic cardiomyopathy (HCM). The American College of Cardiology/American Heart Association (ACC/AHA) and the European Society of Cardiology (ESC) have different guidelines for SCD risk stratification. Their comparative performance in diverse populations remains uncertain. Objective Evaluate the performance of the 2020 ACC/AHA and 2014 ESC guidelines for SCD stratification in a Brazilian cohort with HCM. Methods This retrospective cohort study included patients diagnosed with HCM who were followed in a dedicated clinic at a tertiary hospital in Brazil. The primary outcome was SCD, aborted cardiac arrest due to ventricular fibrillation (VF), sustained ventricular tachycardia (SVT), an episode of VF or SVT, or appropriate ICD therapy. Risk prediction models were assessed using the C-index. Results A total of 187 patients were included, with a mean follow-up of 8.3 years. The 2020 ACC/AHA guidelines classified 106 (56%) patients as high-risk for SCD, while the 2014 ESC guidelines identified 54 (29%). The primary outcome occurred in 12% of the high-risk group identified by the ACC/AHA guidelines and 13% of the high-risk group identified by the ESC guidelines. Both guidelines showed low discriminatory power for SCD risk in this Brazilian cohort, with AUC values of 0.634 and 0.581 for the ACC/AHA and ESC guidelines, respectively. Conclusions The 2020 ACC/AHA and 2014 ESC guidelines have limitations in predicting SCD events and defining ICD indications in Brazilian HCM patients. Further studies are needed to refine risk stratification and optimize SCD prevention in this population.
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Affiliation(s)
- Murillo Oliveira Antunes
- Instituto do Coração, Faculdade de Medicina Universidade de São Paulo, São Paulo, Brazil
- Universidade de São Francisco, São Paulo, Brazil
| | - Fabio Fernandes
- Instituto do Coração, Faculdade de Medicina Universidade de São Paulo, São Paulo, Brazil
| | | | | | | | - Juliano Novaes Cardoso
- Instituto do Coração, Faculdade de Medicina Universidade de São Paulo, São Paulo, Brazil
| | | | - Henrique Martins Sousa
- Instituto do Coração, Faculdade de Medicina Universidade de São Paulo, São Paulo, Brazil
| | - Marília Taily Soliani
- Instituto do Coração, Faculdade de Medicina Universidade de São Paulo, São Paulo, Brazil
| | | | | | | | - Charles Mady
- Instituto do Coração, Faculdade de Medicina Universidade de São Paulo, São Paulo, Brazil
| | - Caio Assis Moura Tavares
- Instituto do Coração, Faculdade de Medicina Universidade de São Paulo, São Paulo, Brazil
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Patricia O. Guimarães
- Instituto do Coração, Faculdade de Medicina Universidade de São Paulo, São Paulo, Brazil
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Vagner Madrini Junior
- Instituto do Coração, Faculdade de Medicina Universidade de São Paulo, São Paulo, Brazil
- Hospital Israelita Albert Einstein, São Paulo, Brazil
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Fernandes F, Simões MV, Correia EDB, Marcondes-Braga FG, Coelho-Filho OR, Mesquita CT, Mathias Junior W, Antunes MDO, Arteaga-Fernández E, Rochitte CE, Ramires FJA, Alves SMM, Montera MW, Lopes RD, Oliveira Junior MTD, Scolari FL, Avila WS, Canesin MF, Bocchi EA, Bacal F, Moura LZ, Saad EB, Scanavacca MI, Valdigem BP, Cano MN, Abizaid AAC, Ribeiro HB, Lemos Neto PA, Ribeiro GCDA, Jatene FB, Dias RR, Beck-da-Silva L, Rohde LEP, Bittencourt MI, Pereira ADC, Krieger JE, Villacorta Junior H, Martins WDA, Figueiredo Neto JAD, Cardoso JN, Pastore CA, Jatene IB, Tanaka ACS, Hotta VT, Romano MMD, Albuquerque DCD, Mourilhe-Rocha R, Hajjar LA, Brito Junior FSD, Caramelli B, Calderaro D, Farsky PS, Colafranceschi AS, Pinto IMF, Vieira MLC, Danzmann LC, Barberato SH, Mady C, Martinelli Filho M, Torbey AFM, Schwartzmann PV, Macedo AVS, Ferreira SMA, Schmidt A, Melo MDTD, Lima Filho MO, Sposito AC, Brito FDS, Biolo A, Madrini Junior V, Rizk SI, Mesquita ET. Guidelines on the Diagnosis and Treatment of Hypertrophic Cardiomyopathy - 2024. Arq Bras Cardiol 2024; 121:e202400415. [PMID: 39082572 DOI: 10.36660/abc.20240415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2024] Open
Affiliation(s)
- Fabio Fernandes
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Marcus V Simões
- Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Ribeirão Preto, SP - Brasil
| | | | - Fabiana Goulart Marcondes-Braga
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | - Wilson Mathias Junior
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Murillo de Oliveira Antunes
- Universidade São Francisco (USF), São Paulo, SP - Brasil; Pronto Socorro Cardiológico de Pernambuco (PROCAPE), Recife, PE - Brasil
| | - Edmundo Arteaga-Fernández
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Carlos Eduardo Rochitte
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Felix José Alvarez Ramires
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Silvia Marinho Martins Alves
- Universidade São Francisco (USF), São Paulo, SP - Brasil; Pronto Socorro Cardiológico de Pernambuco (PROCAPE), Recife, PE - Brasil
- Universidade de Pernambuco (UPE), Recife, PE - Brasil
| | | | | | - Mucio Tavares de Oliveira Junior
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - Walkiria Samuel Avila
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | - Fernando Bacal
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - Eduardo Benchimol Saad
- Hospital Samaritano, Rio de Janeiro, RJ - Brasil
- Beth Israel Deaconess Medical Center / Harvard Medical School, Boston - USA
| | - Mauricio Ibrahim Scanavacca
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | - Alexandre Antonio Cunha Abizaid
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Henrique Barbosa Ribeiro
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | - Fabio Biscegli Jatene
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - Luis Beck-da-Silva
- Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS - Brasil
| | | | | | - Alexandre da Costa Pereira
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
- Fundação Zerbini, São Paulo, SP - Brasil
| | - José Eduardo Krieger
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | | | - Juliano Novaes Cardoso
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
- Faculdade Santa Marcelina, São Paulo, SP - Brasil
| | - Carlos Alberto Pastore
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - Ana Cristina Sayuri Tanaka
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Viviane Tiemi Hotta
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
- Fleury Medicina e Saúde, São Paulo, SP - Brasil
| | | | - Denilson Campos de Albuquerque
- Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ - Brasil
- Instituto D'Or de Pesquisa e Ensino (IDOR), Rio de Janeiro, RJ - Brasil
| | | | - Ludhmila Abrahão Hajjar
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - Bruno Caramelli
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Daniela Calderaro
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | | | - Marcelo Luiz Campos Vieira
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
- Hospital Israelita Albert Einstein, São Paulo, SP - Brasil
| | | | - Silvio Henrique Barberato
- CardioEco Centro de Diagnóstico Cardiovascular e Ecocardiografia, Curitiba, PR - Brasil
- Quanta Diagnósticos, Curitiba, PR - Brasil
| | - Charles Mady
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Martino Martinelli Filho
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - Pedro Vellosa Schwartzmann
- Hospital Unimed Ribeirão Preto, Ribeirão Preto, SP - Brasil
- Centro Avançado de Pesquisa, Ensino e Diagnóstico (CAPED), Ribeirão Preto, SP - Brasil
| | | | - Silvia Moreira Ayub Ferreira
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
- Fundação Zerbini, São Paulo, SP - Brasil
| | - Andre Schmidt
- Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Ribeirão Preto, SP - Brasil
| | | | | | - Andrei C Sposito
- Universidade Estadual de Campinas (UNICAMP), Campinas, SP - Brasil
| | - Flávio de Souza Brito
- Hospital Vera Cruz, Campinas, SP - Brasil
- Hospital das Clínicas da Faculdade de Medicina de Botucatu, Universidade Estadual Paulista "Júlio de Mesquita Filho" (UNESP), São Paulo, SP - Brasil
- Centro de Pesquisa Clínica - Indacor, São Paulo, SP - Brasil
| | - Andreia Biolo
- Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS - Brasil
- Hospital Moinhos de Vento, Porto Alegre, RS - Brasil
- Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS - Brasil
| | - Vagner Madrini Junior
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
- Hospital Israelita Albert Einstein, São Paulo, SP - Brasil
| | - Stephanie Itala Rizk
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
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Elias J. T-Wave Microalternans in Hypertrophic Cardiomyopathy: The Complexity of an Inherited Cardiac Condition with Multiple Phenotypic Expressions. Arq Bras Cardiol 2023; 120:e20230615. [PMID: 37909504 PMCID: PMC10586819 DOI: 10.36660/abc.20230615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 09/06/2023] [Accepted: 09/06/2023] [Indexed: 11/03/2023] Open
Affiliation(s)
- Jorge Elias
- Vitória Apart HospitalSerraESBrasilVitória Apart Hospital – Serviço de Eletrofisiologia, Serra, ES – Brasil
- Hospital Universitário Cassiano Antonio MoraesUfesVitóriaESBrasilHospital Universitário Cassiano Antonio Moraes (Hucam) – Ufes, Vitória, ES – Brasil
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Antunes MO, Arteaga-Fernandez E, Samesima N, Pereira HG, Matsumoto AY, Verrier RL, Pastore CA, Mady C. Prognostic Evaluation of Microvolt T-Wave Alternans in Hypertrophic Cardiomyopathy: 9-year Clinical Follow-up. Arq Bras Cardiol 2023; 120:e20220833. [PMID: 37672406 PMCID: PMC10519242 DOI: 10.36660/abc.20220833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 05/25/2023] [Accepted: 06/14/2023] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND Sudden cardiac death (SCD) resulting from ventricular arrhythmia is the main complication of hypertrophic cardiomyopathy (HCM). Microvolt T-wave alternans (MTWA) is associated with the occurrence of ventricular arrhythmias in several heart diseases, but its role in HCM remains uncertain. OBJECTIVE To evaluate the association of MTWA with the occurrence of SCD or potentially fatal ventricular arrhythmias in HCM patients in a long-term follow-up. METHODS Patients diagnosed with HCM and NYHA functional class I-II were consecutively selected. At the beginning of the follow-up, the participants performed the MTWA evaluation using the modified moving average during the stress test. The results were classified as altered or normal. The composite endpoint of SCD, ventricular fibrillation, sustained ventricular tachycardia (SVT) or appropriate implantable cardiac defibrillation (ICD) therapy was assessed. The level of significance was set at 5%. RESULTS A total of 132 patients (mean age of 39.5 ± 12.6 years) were recruited and followed for a mean of 9.5 years. The MTWA test was altered in 74 (56%) participants and normal in 58 (44%). Nine events (6.8%) occurred during the follow-up, with a prevalence of 1.0%/year - six SCDs, two appropriate ICD shocks and one episode of (SVT). Altered MTWA was associated with non-sustained ventricular tachycardia on Holter (p = 0.016), septal thickness ≥30 mm (p < 0.001) and inadequate blood pressure response to effort (p = 0.046). Five patients with altered MTWA (7%) and four patients with normal MTWA (7%) had the primary outcome [OR = 0.85 (95% CI: 0.21 - 3.35, p=0.83)]. Kaplan-Meir event curves showed no differences between normal and altered MTWA. CONCLUSION Altered MTWA was not associated with the occurrence of SCD or potentially fatal ventricular arrhythmias in HCM patients, and the low rate of these events during long-term follow-up suggests the good prognosis of this heart disease.
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Affiliation(s)
- Murillo Oliveira Antunes
- Universidade de São PauloFaculdade de MedicinaHospital das ClínicasSão PauloSPBrasilInstituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP – Brasil
- Universidade São FranciscoBragança PaulistaSPBrasilUniversidade São Francisco, Bragança Paulista, SP – Brasil
| | - Edmundo Arteaga-Fernandez
- Universidade de São PauloFaculdade de MedicinaHospital das ClínicasSão PauloSPBrasilInstituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP – Brasil
| | - Nelson Samesima
- Universidade de São PauloFaculdade de MedicinaHospital das ClínicasSão PauloSPBrasilInstituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP – Brasil
| | - Horácio Gomes Pereira
- Universidade de São PauloFaculdade de MedicinaHospital das ClínicasSão PauloSPBrasilInstituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP – Brasil
| | | | - Richard L. Verrier
- Beth Israel Deaconess Medical CenterBostonEUABeth Israel Deaconess Medical Center, Boston – EUA
| | - Carlos Alberto Pastore
- Universidade de São PauloFaculdade de MedicinaHospital das ClínicasSão PauloSPBrasilInstituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP – Brasil
| | - Charles Mady
- Universidade de São PauloFaculdade de MedicinaHospital das ClínicasSão PauloSPBrasilInstituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP – Brasil
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Pereira Filho HG, Samesima N, Madaloso BA, de Oliveira Tobias NMM, Facin M, Pastore CA. Modified moving average methodology applied to the treadmill stress testing analysis of microvolt T-wave alternans. Sci Rep 2022; 12:22454. [PMID: 36575194 PMCID: PMC9794681 DOI: 10.1038/s41598-022-26535-x] [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: 06/21/2022] [Accepted: 12/15/2022] [Indexed: 12/28/2022] Open
Abstract
Sudden cardiac death is impactful. There has been an increase in the search for tools capable of identifying individuals who are most susceptible, such as the microvolt T-wave alternans. This study aims to analyze the applicability of the modified moving average methodology to obtain the microvolt T-wave alternans using treadmill specific protocols. Medical records of patients during the period August 2006-December 2014 were retrospectively analyzed. Five hundred and thirty nine exams were then included, divided into groups according to the protocol and updating factor used: Ellestad factor 8 or 32, Naughton factor 8 or 32. The topics for analysis were the alternans behavior, noise and confirmation according to the groups of leads analyzed (frontal, transversal and orthogonal planes). The greater microvolt T-wave alternans was found during the stress phase in most of the tests. Group Naughton 8 presented lower noise in this phase for the transverse and orthogonal planes (p = 0.0082 and p < 0.0001), with greater confirmation of frontal and orthogonal planes in comparison with group Ellestad 8 (p = 0.0002 and 0.0008). The results indicate the viability of simultaneous performance of the stress test and measurement of the T wave alternans with Naughton protocol with 1/8 updating factor.
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Affiliation(s)
- Horacio Gomes Pereira Filho
- grid.11899.380000 0004 1937 0722Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Unidade de Eletrocardiografia, Sao Paulo, SP 05403-900 Brazil
| | - Nelson Samesima
- grid.11899.380000 0004 1937 0722Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Unidade de Eletrocardiografia, Sao Paulo, SP 05403-900 Brazil
| | - Bruna Affonso Madaloso
- grid.11899.380000 0004 1937 0722Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Unidade de Eletrocardiografia, Sao Paulo, SP 05403-900 Brazil
| | - Nancy Maria Martins de Oliveira Tobias
- grid.11899.380000 0004 1937 0722Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Unidade de Eletrocardiografia, Sao Paulo, SP 05403-900 Brazil
| | - Mirella Facin
- grid.11899.380000 0004 1937 0722Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Unidade de Eletrocardiografia, Sao Paulo, SP 05403-900 Brazil
| | - Carlos Alberto Pastore
- grid.11899.380000 0004 1937 0722Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Unidade de Eletrocardiografia, Sao Paulo, SP 05403-900 Brazil
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Chakraborty P, Suszko AM, Viswanathan K, Sheikholeslami K, Spears D, Adler A, Woo A, Rakowski H, Chauhan VS. Microvolt QRS Alternans in Hypertrophic Cardiomyopathy: A Novel Risk Marker of Late Ventricular Arrhythmias. J Am Heart Assoc 2021; 10:e022036. [PMID: 34854315 PMCID: PMC9075383 DOI: 10.1161/jaha.121.022036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background Unlike T‐wave alternans (TWA), the relation between QRS alternans (QRSA) and ventricular arrhythmia (VA) risk has not been evaluated in hypertrophic cardiomyopathy (HCM). We assessed microvolt QRSA/TWA in relation to HCM risk factors and late VA outcomes in HCM. Methods and Results Prospectively enrolled patients with HCM (n=130) with prophylactic implantable cardioverter‐defibrillators underwent digital 12‐lead ECG recordings during ventricular pacing (100–120 beats/min). QRSA/TWA was quantified using the spectral method. Patients were categorized as QRSA+ and/or TWA+ if sustained alternans was present in ≥2 precordial leads. The VA end point was appropriate implantable cardioverter‐defibrillator therapy over 5 years of follow‐up. QRSA+ and TWA+ occurred together in 28% of patients and alone in 7% and 7% of patients, respectively. QRSA magnitude increased with pacing rate (1.9±0.6 versus 6.2±2.0 µV; P=0.006). Left ventricular thickness was greater in QRSA+ than in QRSA− patients (22±7 versus 20±6 mm; P=0.035). Over 5 years follow‐up, 17% of patients had VA. The annual VA rate was greater in QRSA+ versus QRSA− patients (5.8% versus 2.0%; P=0.006), with the QRSA+/TWA− subgroup having the greatest rate (13.3% versus 2.6%; P<0.001). In those with <2 risk factors, QRSA− patients had a low annual VA rate compared QRSA+ patients (0.58% versus 7.1%; P=0.001). Separate Cox models revealed QRSA+ (hazard ratio [HR], 2.9 [95% CI, 1.2–7.0]; P=0.019) and QRSA+/TWA− (HR, 7.9 [95% CI, 2.9–21.7]; P<0.001) as the most significant VA predictors. TWA and HCM risk factors did not predict VA. Conclusions In HCM, microvolt QRSA is a novel, rate‐dependent phenomenon that can exist without TWA and is associated with greater left ventricular thickness. QRSA increases VA risk 3‐fold in all patients, whereas the absence of QRSA confers low VA risk in patients with <2 risk factors. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02560844.
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Affiliation(s)
- Praloy Chakraborty
- Division of Cardiology Peter Munk Cardiac Center University Health Network Toronto Ontario Canada
| | - Adrian M Suszko
- Division of Cardiology Peter Munk Cardiac Center University Health Network Toronto Ontario Canada
| | - Karthik Viswanathan
- Division of Cardiology Peter Munk Cardiac Center University Health Network Toronto Ontario Canada
| | - Kimia Sheikholeslami
- Division of Cardiology Peter Munk Cardiac Center University Health Network Toronto Ontario Canada
| | - Danna Spears
- Division of Cardiology Peter Munk Cardiac Center University Health Network Toronto Ontario Canada
| | - Arnon Adler
- Division of Cardiology Peter Munk Cardiac Center University Health Network Toronto Ontario Canada
| | - Anna Woo
- Division of Cardiology Peter Munk Cardiac Center University Health Network Toronto Ontario Canada
| | - Harry Rakowski
- Division of Cardiology Peter Munk Cardiac Center University Health Network Toronto Ontario Canada
| | - Vijay S Chauhan
- Division of Cardiology Peter Munk Cardiac Center University Health Network Toronto Ontario Canada
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Szlovák J, Tomek J, Zhou X, Tóth N, Veress R, Horváth B, Szentandrássy N, Levijoki J, Papp JG, Herring N, Varró A, Eisner DA, Rodriguez B, Nagy N. Blockade of sodium‑calcium exchanger via ORM-10962 attenuates cardiac alternans. J Mol Cell Cardiol 2021; 153:111-122. [PMID: 33383036 PMCID: PMC8035081 DOI: 10.1016/j.yjmcc.2020.12.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 12/08/2020] [Accepted: 12/21/2020] [Indexed: 12/27/2022]
Abstract
Repolarization alternans, a periodic oscillation of long-short action potential duration, is an important source of arrhythmogenic substrate, although the mechanisms driving it are insufficiently understood. Despite its relevance as an arrhythmia precursor, there are no successful therapies able to target it specifically. We hypothesized that blockade of the sodium‑calcium exchanger (NCX) could inhibit alternans. The effects of the selective NCX blocker ORM-10962 were evaluated on action potentials measured with microelectrodes from canine papillary muscle preparations, and calcium transients measured using Fluo4-AM from isolated ventricular myocytes paced to evoke alternans. Computer simulations were used to obtain insight into the drug's mechanisms of action. ORM-10962 attenuated cardiac alternans, both in action potential duration and calcium transient amplitude. Three morphological types of alternans were observed, with differential response to ORM-10962 with regards to APD alternans attenuation. Analysis of APD restitution indicates that calcium oscillations underlie alternans formation. Furthermore, ORM-10962 did not markedly alter APD restitution, but increased post-repolarization refractoriness, which may be mediated by indirectly reduced L-type calcium current. Computer simulations reproduced alternans attenuation via ORM-10962, suggesting that it is acts by reducing sarcoplasmic reticulum release refractoriness. This results from the ORM-10962-induced sodium‑calcium exchanger block accompanied by an indirect reduction in L-type calcium current. Using a computer model of a heart failure cell, we furthermore demonstrate that the anti-alternans effect holds also for this disease, in which the risk of alternans is elevated. Targeting NCX may therefore be a useful anti-arrhythmic strategy to specifically prevent calcium driven alternans.
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Affiliation(s)
- Jozefina Szlovák
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, University of Szeged, Hungary
| | - Jakub Tomek
- Department of Physiology, Anatomy, and Genetics, University of Oxford, United Kingdom; Department of Computer Science, University of Oxford, United Kingdom.
| | - Xin Zhou
- Department of Computer Science, University of Oxford, United Kingdom
| | - Noémi Tóth
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, University of Szeged, Hungary
| | - Roland Veress
- Department of Physiology, Faculty of Medicine, University of Debrecen, Hungary
| | - Balázs Horváth
- Department of Physiology, Faculty of Medicine, University of Debrecen, Hungary; Faculty of Pharmacy, University of Debrecen, Hungary
| | | | | | - Julius Gy Papp
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, University of Szeged, Hungary; MTA-SZTE Research Group of Cardiovascular Pharmacology, Hungarian Academy of Sciences, Szeged, Hungary
| | - Neil Herring
- Department of Physiology, Anatomy, and Genetics, University of Oxford, United Kingdom
| | - András Varró
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, University of Szeged, Hungary; MTA-SZTE Research Group of Cardiovascular Pharmacology, Hungarian Academy of Sciences, Szeged, Hungary
| | - David A Eisner
- Unit of Cardiac Physiology, Manchester Academic Health Science Centre, University of Manchester, Core Technology Facility, Manchester, UK
| | - Blanca Rodriguez
- Department of Computer Science, University of Oxford, United Kingdom
| | - Norbert Nagy
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, University of Szeged, Hungary; MTA-SZTE Research Group of Cardiovascular Pharmacology, Hungarian Academy of Sciences, Szeged, Hungary
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Confounding factors about microvolt T-wave alternans testing and lifethreatening ventricular arrhytmias. Anatol J Cardiol 2018; 21:51-52. [PMID: 30587708 PMCID: PMC6382893 DOI: 10.14744/anatoljcardiol.2018.92160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Assessment of the relationship between the ambulatory electrocardiography-based micro T-wave alternans and the predicted risk score of sudden cardiac death at 5 years in patients with hypertrophic cardiomyopathy. Anatol J Cardiol 2018; 20:165-173. [PMID: 30152798 PMCID: PMC6237941 DOI: 10.14744/anatoljcardiol.2018.15945] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE Micro T-wave alternans (MTWA) has been associated with poor arrhythmic prognosis in various cardiac disorders. The aim of this study was to assess the relationship between the presence of MTWA and the predicted 5-year risk of sudden cardiac death (HCM Risk-SCD) among patients with hypertrophic cardiomyopathy (HCM). METHODS A total of 117 consecutive HCM patients were included in this prospective observational study. Patients were divided into two groups, according to the presence [MTWA (+) group (n=44)] or absence [MTWA (-) group (n=73)] of MTWA on ambulatory (Holter) electrocardiography. RESULTS The risk of HCM Risk-SCD (%), the rate of high-risk patients (HCM Risk-ECG >6%), the requirement for cardiopulmonary resuscitation, and implanted cardioverter defibrillator therapy, the percentage of some clinical, echocardiographic, and Holter findings were all statistically higher in the MTWA (+) group than in the MTWA (-) group (all p<0.05). Both in the univariate and multivariate analyses, T-wave alternans (+) and the New York Heart Association's functional classification assigned that the HCM Risk-SCD is an independent predictor of high risk. In the receiver operating characteristic curve analysis, the HCM Risk-SCD >4.9% was identified as an effective cutoff point in the MTWA (+) for HCM. The HCM Risk-SCD value of more than 4.9 yielded a sensitivity of 93.2% and a specificity of 84.5%. CONCLUSION The presence of the MTWA on ambulatory electrocardiogram seems to be significantly associated with increasing percentages of the predicted HCM Risk-SCD score in patients with HCM. The MTWA was determined as an independent high-risk indicator for HCM Risk-SCD.
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Blanco-Velasco M, Goya-Esteban R, Cruz-Roldán F, García-Alberola A, Rojo-Álvarez JL. Benchmarking of a T-wave alternans detection method based on empirical mode decomposition. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2017; 145:147-155. [PMID: 28552120 DOI: 10.1016/j.cmpb.2017.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 03/22/2017] [Accepted: 04/11/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND AND OBJECTIVE T-wave alternans (TWA) is a fluctuation of the ST-T complex occurring on an every-other-beat basis of the surface electrocardiogram (ECG). It has been shown to be an informative risk stratifier for sudden cardiac death, though the lack of gold standard to benchmark detection methods has promoted the use of synthetic signals. This work proposes a novel signal model to study the performance of a TWA detection. Additionally, the methodological validation of a denoising technique based on empirical mode decomposition (EMD), which is used here along with the spectral method, is also tackled. METHODS The proposed test bed system is based on the following guidelines: (1) use of open source databases to enable experimental replication; (2) use of real ECG signals and physiological noise; (3) inclusion of randomized TWA episodes. Both sensitivity (Se) and specificity (Sp) are separately analyzed. Also a nonparametric hypothesis test, based on Bootstrap resampling, is used to determine whether the presence of the EMD block actually improves the performance. RESULTS The results show an outstanding specificity when the EMD block is used, even in very noisy conditions (0.96 compared to 0.72 for SNR = 8 dB), being always superior than that of the conventional SM alone. Regarding the sensitivity, using the EMD method also outperforms in noisy conditions (0.57 compared to 0.46 for SNR=8 dB), while it decreases in noiseless conditions. CONCLUSIONS The proposed test setting designed to analyze the performance guarantees that the actual physiological variability of the cardiac system is reproduced. The use of the EMD-based block in noisy environment enables the identification of most patients with fatal arrhythmias.
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Affiliation(s)
- Manuel Blanco-Velasco
- Department of Teoría de la Señal y Comunicaciones, Universidad de Alcalá, Alcalá de Henares 28805, Madrid, Spain.
| | - Rebeca Goya-Esteban
- Department of Teoría de la Señal y Comunicaciones, Universidad Rey Juan Carlos, Fuenlabrada 28943, Madrid, Spain.
| | - Fernando Cruz-Roldán
- Department of Teoría de la Señal y Comunicaciones, Universidad de Alcalá, Alcalá de Henares 28805, Madrid, Spain.
| | - Arcadi García-Alberola
- Arrhythmia Unit, Hospital Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain.
| | - José Luis Rojo-Álvarez
- Department of Teoría de la Señal y Comunicaciones, Universidad Rey Juan Carlos, Fuenlabrada 28943, Madrid, Spain.
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