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Lorca R, Salgado M, Álvarez-Velasco R, Reguro JR, Alonso V, Gómez J, Coto E, Cuesta-Llavona E, Lopez-Negrete E, Pascual I, Avanzas P, Tome M. Survival analysis and gender differences in hypertrophic cardiomyopathy proband patients referred for genetic testing. Int J Cardiol 2024; 408:132117. [PMID: 38710232 DOI: 10.1016/j.ijcard.2024.132117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 04/02/2024] [Accepted: 04/29/2024] [Indexed: 05/08/2024]
Abstract
BACKGROUND Hypertrophic cardiomyopathy (HCM) is believed to have low overall mortality rate, that could be influenced by gender, particularly among probands. We aimed to evaluate the survival rates and possible gender differences in a homogeneous cohort of HCM proband patients, referred for genetic testing, from the same geographical area, without differences in medical care access nor clinical referral pathways. METHODS we compared the mortality rates of a cohort of consecutive HCM probands referred for genetic testing (2000-2022), from a Spanish region (xxx1) with a centralized genetic testing pathway, with its control reference population by Ederer II method. Gender differences were analyzed. RESULTS Among the 649 HCM probands included in this study, there were significantly more men than women (61.3% vs 38.7, p < 0.05), with an earlier diagnosis (53.5 vs 61.1 years old, p < 0.05). Clinical evolution or arrhythmogenic HCM profile did no show no significant gender differences. Mean follow up was 9,8 years ±6,6 SD (9,9 ± 7 vs 9,6 ± 6,1, p = 0.59). No statistically significant differences in observed mortality, expected survival and excess mortality were found in the general HCM proband cohort. However, we found a significant excess mortality in female probands with HCM. No additional differences in analysis by genetic status were identified. CONCLUSION Expected survival in our HCM probands did not differ from its reference population. However, despite no gender differences in phenotype severity were identified, proband HCM women did present a diagnosis delay and worse mortality outcomes.
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Affiliation(s)
- Rebeca Lorca
- Área del Corazón, Hospital Universitario Central Asturias, Oviedo 33011, Spain; Instituto de Investigación Sanitaria del Principado de Asturias, ISPA, Oviedo 33011, Spain; Departamento de Fisiología, Universidad de Oviedo, Oviedo 33003, Spain; Unidad de Cardiopatías Familiares, Área del Corazón y Departamento de Genética Molecular, Hospital Universitario Central Asturias, Oviedo 33011, Spain; Redes de Investigación Cooperativa Orientadas a Resultados en Salud (RICORs), Madrid 28029, Spain.
| | - María Salgado
- Área del Corazón, Hospital Universitario Central Asturias, Oviedo 33011, Spain; Instituto de Investigación Sanitaria del Principado de Asturias, ISPA, Oviedo 33011, Spain
| | - Rut Álvarez-Velasco
- Área del Corazón, Hospital Universitario Central Asturias, Oviedo 33011, Spain; Instituto de Investigación Sanitaria del Principado de Asturias, ISPA, Oviedo 33011, Spain
| | - Julián R Reguro
- Área del Corazón, Hospital Universitario Central Asturias, Oviedo 33011, Spain; Instituto de Investigación Sanitaria del Principado de Asturias, ISPA, Oviedo 33011, Spain; Unidad de Cardiopatías Familiares, Área del Corazón y Departamento de Genética Molecular, Hospital Universitario Central Asturias, Oviedo 33011, Spain
| | - Vanesa Alonso
- Área del Corazón, Hospital Universitario Central Asturias, Oviedo 33011, Spain; Instituto de Investigación Sanitaria del Principado de Asturias, ISPA, Oviedo 33011, Spain
| | - Juan Gómez
- Instituto de Investigación Sanitaria del Principado de Asturias, ISPA, Oviedo 33011, Spain; Unidad de Cardiopatías Familiares, Área del Corazón y Departamento de Genética Molecular, Hospital Universitario Central Asturias, Oviedo 33011, Spain; Redes de Investigación Cooperativa Orientadas a Resultados en Salud (RICORs), Madrid 28029, Spain
| | - Eliecer Coto
- Instituto de Investigación Sanitaria del Principado de Asturias, ISPA, Oviedo 33011, Spain; Unidad de Cardiopatías Familiares, Área del Corazón y Departamento de Genética Molecular, Hospital Universitario Central Asturias, Oviedo 33011, Spain; Redes de Investigación Cooperativa Orientadas a Resultados en Salud (RICORs), Madrid 28029, Spain; Departamento de Medicina, Universidad de Oviedo, Oviedo 33003, Spain
| | - Elías Cuesta-Llavona
- Instituto de Investigación Sanitaria del Principado de Asturias, ISPA, Oviedo 33011, Spain; Unidad de Cardiopatías Familiares, Área del Corazón y Departamento de Genética Molecular, Hospital Universitario Central Asturias, Oviedo 33011, Spain; Redes de Investigación Cooperativa Orientadas a Resultados en Salud (RICORs), Madrid 28029, Spain
| | - Eva Lopez-Negrete
- Departamento de Medicina, Universidad de Oviedo, Oviedo 33003, Spain
| | - Isaac Pascual
- Área del Corazón, Hospital Universitario Central Asturias, Oviedo 33011, Spain; Instituto de Investigación Sanitaria del Principado de Asturias, ISPA, Oviedo 33011, Spain; Departamento de Medicina, Universidad de Oviedo, Oviedo 33003, Spain
| | - Pablo Avanzas
- Área del Corazón, Hospital Universitario Central Asturias, Oviedo 33011, Spain; Instituto de Investigación Sanitaria del Principado de Asturias, ISPA, Oviedo 33011, Spain; Departamento de Medicina, Universidad de Oviedo, Oviedo 33003, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Maite Tome
- St George's University Hospitals NHS Foundation Trust, London, UK
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Topriceanu CC, Pereira AC, Moon JC, Captur G, Ho CY. Meta-Analysis of Penetrance and Systematic Review on Transition to Disease in Genetic Hypertrophic Cardiomyopathy. Circulation 2024; 149:107-123. [PMID: 37929589 PMCID: PMC10775968 DOI: 10.1161/circulationaha.123.065987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 10/27/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Hypertrophic cardiomyopathy (HCM) is characterized by unexplained left ventricular hypertrophy and is classically caused by pathogenic or likely pathogenic variants (P/LP) in genes encoding sarcomere proteins. Not all subclinical variant carriers will manifest clinically overt disease because penetrance (proportion of sarcomere or sarcomere-related P/LP variant carriers who develop disease) is variable, age dependent, and not reliably predicted. METHODS A systematic search of the literature was performed. We used random-effects generalized linear mixed model meta-analyses to contrast the cross-sectional prevalence and penetrance of sarcomere or sarcomere-related genes in 2 different contexts: clinically-based studies on patients and families with HCM versus population or community-based studies. Longitudinal family/clinical studies were additionally analyzed to investigate the rate of phenotypic conversion from subclinical to overt HCM during follow-up. RESULTS In total, 455 full-text manuscripts and articles were assessed. In family/clinical studies, the prevalence of sarcomere variants in patients diagnosed with HCM was 34%. The penetrance across all genes in nonproband relatives carrying P/LP variants identified during cascade screening was 57% (95% CI, 52%-63%), and the mean age at HCM diagnosis was 38 years (95% CI, 36%-40%). Penetrance varied from ≈32% for MYL3 (myosin light chain 3) to ≈55% for MYBPC3 (myosin-binding protein C3), ≈60% for TNNT2 (troponin T2) and TNNI3 (troponin I3), and ≈65% for MYH7 (myosin heavy chain 7). Population-based genetic studies demonstrate that P/LP sarcomere variants are present in the background population but at a low prevalence of <1%. The penetrance of HCM in incidentally identified P/LP variant carriers was also substantially lower at ≈11%, ranging from 0% in Atherosclerosis Risk in Communities to 18% in UK Biobank. In longitudinal family studies, the pooled phenotypic conversion across all genes was 15% over an average of ≈8 years of follow-up, starting from a mean of ≈16 years of age. However, short-term gene-specific phenotypic conversion varied between ≈12% for MYBPC3 and ≈23% for MYH7. CONCLUSIONS The penetrance of P/LP variants is highly variable and influenced by currently undefined and context-dependent genetic and environmental factors. Additional longitudinal studies are needed to improve our understanding of true lifetime penetrance in families and in the community and to identify drivers of the transition from subclinical to overt HCM.
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Affiliation(s)
- Constantin-Cristian Topriceanu
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (C.-C.T., A.C.P., C.Y.H.). UCL Institute of Cardiovascular Science (C.-C.T., J.C.M., G.C.) and UCL MRC Unit for Lifelong Health and Ageing (G.C.), University College London, UK. Cardiac MRI Unit, Barts Heart Centre, West Smithfield, London, UK (C.-C.T., J.C.M.). The Royal Free Hospital, Centre for Inherited Heart Muscle Conditions, Cardiology Department, Hampstead, London, UK (G.C.)
| | - Alexandre C. Pereira
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (C.-C.T., A.C.P., C.Y.H.). UCL Institute of Cardiovascular Science (C.-C.T., J.C.M., G.C.) and UCL MRC Unit for Lifelong Health and Ageing (G.C.), University College London, UK. Cardiac MRI Unit, Barts Heart Centre, West Smithfield, London, UK (C.-C.T., J.C.M.). The Royal Free Hospital, Centre for Inherited Heart Muscle Conditions, Cardiology Department, Hampstead, London, UK (G.C.)
| | - James C. Moon
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (C.-C.T., A.C.P., C.Y.H.). UCL Institute of Cardiovascular Science (C.-C.T., J.C.M., G.C.) and UCL MRC Unit for Lifelong Health and Ageing (G.C.), University College London, UK. Cardiac MRI Unit, Barts Heart Centre, West Smithfield, London, UK (C.-C.T., J.C.M.). The Royal Free Hospital, Centre for Inherited Heart Muscle Conditions, Cardiology Department, Hampstead, London, UK (G.C.)
| | - Gabriella Captur
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (C.-C.T., A.C.P., C.Y.H.). UCL Institute of Cardiovascular Science (C.-C.T., J.C.M., G.C.) and UCL MRC Unit for Lifelong Health and Ageing (G.C.), University College London, UK. Cardiac MRI Unit, Barts Heart Centre, West Smithfield, London, UK (C.-C.T., J.C.M.). The Royal Free Hospital, Centre for Inherited Heart Muscle Conditions, Cardiology Department, Hampstead, London, UK (G.C.)
| | - Carolyn Y. Ho
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (C.-C.T., A.C.P., C.Y.H.). UCL Institute of Cardiovascular Science (C.-C.T., J.C.M., G.C.) and UCL MRC Unit for Lifelong Health and Ageing (G.C.), University College London, UK. Cardiac MRI Unit, Barts Heart Centre, West Smithfield, London, UK (C.-C.T., J.C.M.). The Royal Free Hospital, Centre for Inherited Heart Muscle Conditions, Cardiology Department, Hampstead, London, UK (G.C.)
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Fernández Suárez N, Viadero Ubierna MT, Garde Basas J, Onecha de la Fuente ME, Amigo Lanza MT, Martin Gorria G, Rivas Pérez A, Ruiz Guerrero L, González-Lamuño D. Description of a Cohort with a New Truncating MYBPC3 Variant for Hypertrophic Cardiomyopathy in Northern Spain. Genes (Basel) 2023; 14:genes14040840. [PMID: 37107598 PMCID: PMC10137663 DOI: 10.3390/genes14040840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/21/2023] [Accepted: 03/24/2023] [Indexed: 04/03/2023] Open
Abstract
Background: The pathogenicity of the different genetic variants causing hypertrophic cardiomyopathy (HCM) and the genotype/phenotype correlations are difficult to assess in clinical practice, as most mutations are unique or identified in non-informative families. Pathogenic variants in the sarcomeric gene MYBPC3 inherited with an autosomal dominant pattern, whereas incomplete and age-dependent penetrance are the most common causes of HCM. Methods: We describe the clinical characteristics of a new truncating MYBPC3 variant, p.Val931Glyfs*120, in 75 subjects from 18 different families from northern Spain with the p.Val931Glyfs*120 variant. Results: Our cohort allows us to estimate the penetrance and prognosis of this variant. The penetrance of the disease increases with age, whereas 50% of males in our sample developed HCM by the age of 36 years old, and 50% of women developed the disease by the time they reached 48 years of age (p = 0.104). Men have more documented arrhythmias with potential risk of sudden death (p = 0.018), requiring implantation of cardioverter defibrillators (p = 0.024). Semi-professional/competitive sport among males is related to earlier onset of HCM (p = 0.004). Conclusions: The p.Val931Glyfs*120 truncating variant in MYBPC3 is associated with a moderate phenotype of HCM, with a high penetrance, onset in middle age, and a worse outcome in males due to higher risk of sudden death due to arrhythmias.
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Different Phenotypes in Monozygotic Twins, Carriers of the Same Pathogenic Variant for Hypertrophic Cardiomyopathy. Life (Basel) 2022; 12:life12091346. [PMID: 36143383 PMCID: PMC9506491 DOI: 10.3390/life12091346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/07/2022] [Accepted: 08/27/2022] [Indexed: 11/20/2022] Open
Abstract
Hypertrophic cardiomyopathy (HCM) is a monogenic disease with autosomal dominant inheritance. Genotype−phenotype relationships are complex, with variable penetrance even within the same family. The involvement of other modulating genetic and environmental factors is unknown. We aimed to analyze the HCM in monozygotic twins, carriers of the same founder pathogenic variant MYBPC3 p.G263*. The relationship was verified using the PowerPlex 16 HS System kit. Phenotypic differences and environmental differences (overloading conditions, coexistence and location, lifestyle, sport, and intensity) were analyzed. Three pairs of twins genetically identical for all markers and carriers of MYBPC3 G263* were identified. No environmental differences were identified. One of the 89-year-old twins had symptomatic severe obstructive HCM that required septal ablation, while her twin has remained asymptomatic with mild phenotype >80 years. A 49-year-old twin had a severe phenotype of obstructive HCM and pending myectomy, while his twin had a mild asymptomatic phenotype. In the last pair of twins, one presented a much larger left ventricular hypertrophy than his identical twin. In summary, we present three pairs of HCM twin patients sharing not only the genetic cause of the inherited disease but the entire genetic background. Despite identical genetic information and the absence of other known clinical, environmental, or lifestyle differences, the severity of the HCM phenotype is strikingly different. These unexplained differences should prompt the study of other unknown modulating factors, either epigenetic or environmental.
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Field E, Norrish G, Acquaah V, Dady K, Cicerchia MN, Ochoa JP, Syrris P, McLeod K, McGowan R, Fell H, Lopes LR, Cervi E, Kaski JPP. Cardiac myosin binding protein-C variants in paediatric-onset hypertrophic cardiomyopathy: natural history and clinical outcomes. J Med Genet 2022; 59:768-775. [PMID: 34400558 PMCID: PMC7613139 DOI: 10.1136/jmedgenet-2021-107774] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 07/14/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Variants in the cardiac myosin-binding protein C gene (MYBPC3) are a common cause of hypertrophic cardiomyopathy (HCM) in adults and have been associated with late-onset disease, but there are limited data on their role in paediatric-onset HCM. The objective of this study was to describe natural history and clinical outcomes in a large cohort of children with HCM and pathogenic/likely pathogenic (P/LP) MYBPC3 variants. METHODS AND RESULTS Longitudinal data from 62 consecutive patients diagnosed with HCM under 18 years of age and carrying at least one P/LP MYBPC3 variant were collected from a single specialist referral centre. The primary patient outcome was a major adverse cardiac event (MACE). Median age at diagnosis was 10 (IQR: 2-14) years, with 12 patients (19.4%) diagnosed in infancy. Forty-seven (75%) were boy and 31 (50%) were probands. Median length of follow-up was 3.1 (IQR: 1.6-6.9) years. Nine patients (14.5%) experienced an MACE during follow-up and five (8%) died. Twenty patients (32.3%) had evidence of ventricular arrhythmia, including 6 patients (9.7%) presenting with out-of-hospital cardiac arrest. Five-year freedom from MACE for those with a single or two MYBPC3 variants was 95.2% (95% CI: 78.6% to 98.5%) and 68.4% (95% CI: 40.6% to 88.9%), respectively (HR 4.65, 95% CI: 1.16 to 18.66, p=0.03). CONCLUSIONS MYBPC3 variants can cause childhood-onset disease, which is frequently associated with life-threatening ventricular arrhythmia. Clinical outcomes in this cohort vary substantially from aetiologically and genetically mixed paediatric HCM cohorts described previously, highlighting the importance of identifying specific genetic subtypes for clinical management of childhood HCM.
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Affiliation(s)
- Ella Field
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Institute of Cardiovascular Science, University College London, London, UK
| | - Gabrielle Norrish
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Institute of Cardiovascular Science, University College London, London, UK
| | - Vanessa Acquaah
- Institute of Cardiovascular Science, University College London, London, UK
| | - Kathleen Dady
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Institute of Cardiovascular Science, University College London, London, UK
| | | | | | - Petros Syrris
- Institute of Cardiovascular Science, University College London, London, UK
| | - Karen McLeod
- Department of Paediatric Cardiology, Royal Hospital for Children, Glasgow, UK
| | - Ruth McGowan
- West of Scotland Centre for Genomic Medicine, Glasgow, UK
| | - Hannah Fell
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Luis R Lopes
- Institute of Cardiovascular Science, University College London, London, UK
- Inherited Cardiovascular Disease Unit, Saint Bartholomew's Hospital Barts Heart Centre, London, UK
| | - Elena Cervi
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Institute of Cardiovascular Science, University College London, London, UK
| | - Juan Pablo Pablo Kaski
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Institute of Cardiovascular Science, University College London, London, UK
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Méndez I, Fernández AI, Espinosa MÁ, Cuenca S, Lorca R, Rodríguez JF, Tamargo M, García-Montero M, Gómez C, Vilches S, Vázquez N, Álvarez R, Medrano C, Yotti R, Fernández-Avilés F, Bermejo J. Founder mutation in myosin-binding protein C with an early onset and a high penetrance in males. Open Heart 2021; 8:openhrt-2021-001789. [PMID: 34588271 PMCID: PMC8483030 DOI: 10.1136/openhrt-2021-001789] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 08/30/2021] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE One of the challenges in hypertrophic cardiomyopathy (HCM) is to determine the pathogenicity of genetic variants and to establish genotype/phenotype correlations. This study aimed to: (1) demonstrate that MYBPC3 c.2149-1G>A is a founder pathogenic variant, (2) describe the phenotype and clinical characteristics of mutation carriers and (3) compare these patients with those with the most frequent pathogenic HCM variants: MYBPC3 p.Arg502Trp/Gln. METHODS We reviewed genetic tests performed in HCM probands at our institution. We carried out transcript analyses to demonstrate the splicing effect, and haplotype analyses to support the founder effect of MYBPC3 c.2149-1G>A. Carriers with this mutation were compared with those from MYBPC3 p.Arg502Trp/Gln in terms of presentation features, imaging and outcomes. RESULTS MYBPC3 c.2149-1G>A was identified in 8 of 570 probands and 25 relatives. Penetrance was age and sex dependent, 50.0% of the carriers over age 36 years and 75.0% of the carriers over 40 years showing HCM. Penetrance was significantly higher in males: in carriers older than 30 years old, 100.0% of males vs 50.0% of females had a HCM phenotype (p=0.01). Males were also younger at diagnosis (32±13 vs 53±10 years old, p<0.001). MYBPC3 c.2149-1G>A resulted in an abnormal transcript that led to haploinsufficiency and was segregated in two haplotypes. However, both came from one founder haplotype. Affected carriers showed a better functional class and higher left ventricular ejection fraction (LVEF) than patients with MYBPC3 p.Arg502Trp/Gln (p<0.05 for both). Nevertheless, the rate of major adverse outcomes was similar between the two groups. CONCLUSIONS MYBPC3 c.2149-1G>A splicing variant is a founder mutation. Affected males show an early onset of HCM and with higher penetrance than women. Carriers show better functional class and higher LVEF than MYBPC3 p.Arg502Trp/Gln carriers, but a similar rate of major adverse outcomes.
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Affiliation(s)
- Irene Méndez
- Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain .,CIBERCV, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Ana Isabel Fernández
- CIBERCV, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Maria Ángeles Espinosa
- Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,CIBERCV, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Sofía Cuenca
- Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,CIBERCV, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Rebeca Lorca
- Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,CIBERCV, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - José Fernando Rodríguez
- Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,CIBERCV, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Maria Tamargo
- Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,CIBERCV, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Marta García-Montero
- Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,CIBERCV, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Cristina Gómez
- Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,CIBERCV, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Silvia Vilches
- Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,CIBERCV, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Nélida Vázquez
- Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Reyes Álvarez
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Facultad de Medicina, Universidad Complutense, Madrid, Spain.,Pediatric Cardiology, Hospital Materno Infantil Gregorio Marañón, Madrid, Spain
| | - Constancio Medrano
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Facultad de Medicina, Universidad Complutense, Madrid, Spain.,Pediatric Cardiology, Hospital Materno Infantil Gregorio Marañón, Madrid, Spain
| | | | - Francisco Fernández-Avilés
- Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,CIBERCV, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Javier Bermejo
- Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,CIBERCV, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Facultad de Medicina, Universidad Complutense, Madrid, Spain
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