1
|
Mazur M, Braksator W, Popjes E. Hypertrophic Cardiomyopathy: From Medical Treatment to Advanced Heart Failure Therapies. Curr Cardiol Rep 2024; 26:985-994. [PMID: 38990491 DOI: 10.1007/s11886-024-02095-6] [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] [Accepted: 07/02/2024] [Indexed: 07/12/2024]
Abstract
PURPOSE OF REVIEW There has been much debate surrounding novel medical therapies and heart transplantation listing challenges in patients with hypertrophic cardiomyopathy (HCM). RECENT FINDINGS Recent clinical trials led to FDA approval of mavacamten (a cardiac myosin inhibitor), offering symptom relief and potentially delaying/avoiding invasive septal reduction therapies for some patients with HCM and left ventricular outflow obstruction (LVOTO). For those with refractory symptoms and end-stage heart failure, heart transplantation remains the gold standard. However, the concern for the organ allocation system failing to prioritize those individuals persists. HCM is a heterogeneous genetic condition with variable penetration and clinical presentation. Even though a large portion of patients remain asymptomatic, an important minority develops debilitating symptoms refractory to medical therapy. Post-HT short- and long-term outcomes are favorable. However, HT waitlist mortality remains high. For highly selected patients with HCM, a left ventricular assist device is a viable option.
Collapse
Affiliation(s)
- Matylda Mazur
- Heart and Vascular Institute, Kaufman Center for Heart Failure, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| | - Wojciech Braksator
- Department of Cardiology and Noninvasive Cardiovascular Imaging, Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Eric Popjes
- Heart and Vascular Institute, Pennsylvania State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| |
Collapse
|
2
|
Ommen SR, Ho CY, Asif IM, Balaji S, Burke MA, Day SM, Dearani JA, Epps KC, Evanovich L, Ferrari VA, Joglar JA, Khan SS, Kim JJ, Kittleson MM, Krittanawong C, Martinez MW, Mital S, Naidu SS, Saberi S, Semsarian C, Times S, Waldman CB. 2024 AHA/ACC/AMSSM/HRS/PACES/SCMR Guideline for the Management of Hypertrophic Cardiomyopathy: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:2324-2405. [PMID: 38727647 DOI: 10.1016/j.jacc.2024.02.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/20/2024]
Abstract
AIM The "2024 AHA/ACC/AMSSM/HRS/PACES/SCMR Guideline for the Management of Hypertrophic Cardiomyopathy" provides recommendations to guide clinicians in the management of patients with hypertrophic cardiomyopathy. METHODS A comprehensive literature search was conducted from September 14, 2022, to November 22, 2022, encompassing studies, reviews, and other evidence on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through May 23, 2023, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Hypertrophic cardiomyopathy remains a common genetic heart disease reported in populations globally. Recommendations from the "2020 AHA/ACC Guideline for the Diagnosis and Treatment of Patients With Hypertrophic Cardiomyopathy" have been updated with new evidence to guide clinicians.
Collapse
|
3
|
Ommen SR, Ho CY, Asif IM, Balaji S, Burke MA, Day SM, Dearani JA, Epps KC, Evanovich L, Ferrari VA, Joglar JA, Khan SS, Kim JJ, Kittleson MM, Krittanawong C, Martinez MW, Mital S, Naidu SS, Saberi S, Semsarian C, Times S, Waldman CB. 2024 AHA/ACC/AMSSM/HRS/PACES/SCMR Guideline for the Management of Hypertrophic Cardiomyopathy: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1239-e1311. [PMID: 38718139 DOI: 10.1161/cir.0000000000001250] [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] [Indexed: 06/05/2024]
Abstract
AIM The "2024 AHA/ACC/AMSSM/HRS/PACES/SCMR Guideline for the Management of Hypertrophic Cardiomyopathy" provides recommendations to guide clinicians in the management of patients with hypertrophic cardiomyopathy. METHODS A comprehensive literature search was conducted from September 14, 2022, to November 22, 2022, encompassing studies, reviews, and other evidence on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through May 23, 2023, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Hypertrophic cardiomyopathy remains a common genetic heart disease reported in populations globally. Recommendations from the "2020 AHA/ACC Guideline for the Diagnosis and Treatment of Patients With Hypertrophic Cardiomyopathy" have been updated with new evidence to guide clinicians.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | - Victor A Ferrari
- AHA/ACC Joint Committee on Clinical Practice Guidelines liaison
- SCMR representative
| | | | - Sadiya S Khan
- ACC/AHA Joint Committee on Performance Measures representative
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
4
|
Zhang Y, Adamo M, Zou C, Porcari A, Tomasoni D, Rossi M, Merlo M, Liu H, Wang J, Zhou P, Metra M, Sinagra G, Zhang J. Management of hypertrophic cardiomyopathy. J Cardiovasc Med (Hagerstown) 2024; 25:399-419. [PMID: 38625835 PMCID: PMC11142653 DOI: 10.2459/jcm.0000000000001616] [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: 02/20/2024] [Revised: 03/06/2024] [Accepted: 03/09/2024] [Indexed: 04/18/2024]
Abstract
Hypertrophic cardiomyopathy is an important cause of heart failure and arrhythmias, including sudden death, with a major impact on the healthcare system. Genetic causes and different phenotypes are now increasingly being identified for this condition. In addition, specific medications, such as myosin inhibitors, have been recently shown as potentially able to modify its symptoms, hemodynamic abnormalities and clinical course. Our article aims to provide a comprehensive outline of the epidemiology, diagnosis and treatment of hypertrophic cardiomyopathy in the current era.
Collapse
Affiliation(s)
- Yuhui Zhang
- Heart Failure Care Unit, Heart Failure Center, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union of Medical College, National Center for Cardiovascular Diseases, Beijing, China
| | - Marianna Adamo
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia
| | - Changhong Zou
- Heart Failure Care Unit, Heart Failure Center, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union of Medical College, National Center for Cardiovascular Diseases, Beijing, China
| | - Aldostefano Porcari
- Division of Cardiology, Cardiovascular Department, Azienda Sanitaria Universitaria Integrata di Trieste, Trieste, Italy
| | - Daniela Tomasoni
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia
| | - Maddalena Rossi
- Division of Cardiology, Cardiovascular Department, Azienda Sanitaria Universitaria Integrata di Trieste, Trieste, Italy
| | - Marco Merlo
- Division of Cardiology, Cardiovascular Department, Azienda Sanitaria Universitaria Integrata di Trieste, Trieste, Italy
| | - Huihui Liu
- Heart Failure Care Unit, Heart Failure Center, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union of Medical College, National Center for Cardiovascular Diseases, Beijing, China
| | - Jinxi Wang
- Heart Failure Care Unit, Heart Failure Center, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union of Medical College, National Center for Cardiovascular Diseases, Beijing, China
| | - Ping Zhou
- Heart Failure Care Unit, Heart Failure Center, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union of Medical College, National Center for Cardiovascular Diseases, Beijing, China
| | - Marco Metra
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia
| | - Gianfranco Sinagra
- Division of Cardiology, Cardiovascular Department, Azienda Sanitaria Universitaria Integrata di Trieste, Trieste, Italy
| | - Jian Zhang
- Heart Failure Care Unit, Heart Failure Center, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union of Medical College, National Center for Cardiovascular Diseases, Beijing, China
| |
Collapse
|
5
|
Townsend M, Jeewa A, Khoury M, Cunningham C, George K, Conway J. Unique Aspects of Hypertrophic Cardiomyopathy in Children. Can J Cardiol 2024; 40:907-920. [PMID: 38244986 DOI: 10.1016/j.cjca.2024.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 01/03/2024] [Accepted: 01/14/2024] [Indexed: 01/22/2024] Open
Abstract
Hypertrophic cardiomyopathy (HCM) is a primary heart muscle disease characterized by left ventricular hypertrophy that can be asymptomatic or with presentations that vary from left ventricular outflow tract obstruction, heart failure from diastolic dysfunction, arrhythmias, and/or sudden cardiac death. Children younger than 1 year of age tend to have worse outcomes and often have HCM secondary to inborn errors of metabolism or syndromes such as RASopathies. For children who survive or are diagnosed after 1 year of age, HCM outcomes are often favourable and similar to those seen in adults. This is because of sudden cardiac death risk stratification and medical and surgical innovations. Genetic testing and timely cardiac screening are paving the way for disease-modifying treatment as gene-specific therapies are being developed.
Collapse
Affiliation(s)
- Madeleine Townsend
- Department of Cardiology, Cleveland Clinic Children's Hospital, Cleveland, Ohio, USA
| | - Aamir Jeewa
- Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Michael Khoury
- Division of Pediatric Cardiology, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | | | - Kristen George
- Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jennifer Conway
- Division of Pediatric Cardiology, Stollery Children's Hospital, Edmonton, Alberta, Canada.
| |
Collapse
|
6
|
Hill B, Grubic N, Liblik K, Johri AM. Patient Involvement in Care, Psychosocial Outcomes, and Quality of Life in Hypertrophic Cardiomyopathy: A Pilot Study. CJC Open 2024; 6:539-543. [PMID: 38559336 PMCID: PMC10980899 DOI: 10.1016/j.cjco.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 11/01/2023] [Indexed: 04/04/2024] Open
Abstract
This cross-sectional study evaluated the impact of patient involvement in care (PIC) on psychosocial outcomes and health-related quality of life (HRQoL) in patients with hypertrophic cardiomyopathy (HCM) (n = 34). Patients with low-to-moderate PIC were older than those with high PIC (66.8 years vs 57.3 years; P = 0.04). PIC was negatively correlated with depressive symptoms (r = -0.39; P = 0.02) and positively correlated with heart-focused attention (r = 0.39; P = 0.02). No significant correlations were observed between PIC and HRQoL. Greater PIC was associated with reduced depressive symptoms but increased cardiac anxiety. Future studies should investigate the relationship between PIC and HRQoL in a larger cohort.
Collapse
Affiliation(s)
- Braeden Hill
- Department of Medicine, Division of Cardiology, Cardiovascular Imaging Network at Queen’s University, Kingston, Ontario, Canada
| | - Nicholas Grubic
- Department of Medicine, Division of Cardiology, Cardiovascular Imaging Network at Queen’s University, Kingston, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Kiera Liblik
- Department of Medicine, Division of Cardiology, Cardiovascular Imaging Network at Queen’s University, Kingston, Ontario, Canada
| | - Amer M. Johri
- Department of Medicine, Division of Cardiology, Cardiovascular Imaging Network at Queen’s University, Kingston, Ontario, Canada
| |
Collapse
|
7
|
Paratz ED, Stub D, Sutherland N, Gutman S, La Gerche A, Mariani J, Taylor A, Ellims A. The challenge of risk stratification in hypertrophic cardiomyopathy: Clinical, genetic and imaging insights from a quaternary referral centre. Int J Cardiol 2024; 395:131416. [PMID: 37802298 DOI: 10.1016/j.ijcard.2023.131416] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 09/27/2023] [Accepted: 10/02/2023] [Indexed: 10/08/2023]
Abstract
BACKGROUND Hypertrophic cardiomyopathy (HCM) is the commonest genetic cardiomyopathy and may result in sudden cardiac death (SCD). Clinical risk stratification scores are utilised to estimate SCD risk and determine potential utility of a primary prevention implantable cardioverter defibrillator (ICD). METHODS Patients with a confirmed diagnosis of HCM from a quaternary HCM service were defined according to clinical characteristics, genetic profiles and cardiac imaging results. European Risk-SCD score and American Heart Association / American College of Cardiology (AHA/ACC) Score were calculated. The primary outcome was cardiac arrest. RESULTS 380 patients with HCM were followed up for a median of 6.4 years. 18 patients (4.7%) experienced cardiac arrest, with predictive factors being younger age (37.2 vs 54.4 years, p = 0.0041), unexplained syncope (33.3% vs 9.4%, p = 0.007), non-sustained ventricular tachycardia (50.0% vs 12.7%, p < 0.0001), increased septal thickness (21.5 vs 17.5 mm, p = 0.0003), and presence of a sarcomeric gene mutation (100.0% vs 65.8%, p = 0.038). The Risk-SCD and AHA/ACC scores had poor agreement (kappa coefficient 0.38). Risk-SCD score had poor sensitivity (44.4%), classifying 55.6% of patients with cardiac arrest as low-risk but was highly specific (93.7%). AHA/ACC risk score did not discriminate between groups significantly. 20 patients (5.3%) died, with most >60-year-olds having a non-cardiac cause of death (p = 0.0223). CONCLUSION This study highlights limited (38%) agreement between the Risk-SCD and AHA/ACC scores. Most cardiac arrests occurred in ostensibly low or medium-risk patients under both scores. Appropriate ICD selection remains challenging. Incorporating newer risk markers such as HCM genotyping and myocardial fibrosis quantification by cardiac MRI may assist future risk refinement.
Collapse
Affiliation(s)
- Elizabeth D Paratz
- Baker Heart and Diabetes Institute, 75 Commercial Rd, Prahran, VIC 3181, Australia; Alfred Hospital, 55 Commercial Rd, Prahran, VIC 3181, Australia; St Vincent's Hospital Melbourne, 41 Victoria Pde, Fitzroy, VIC 3065, Australia; Ambulance Victoria, 375 Manningham Rd, Doncaster, VIC 3108, Australia.
| | - Dion Stub
- Baker Heart and Diabetes Institute, 75 Commercial Rd, Prahran, VIC 3181, Australia; Alfred Hospital, 55 Commercial Rd, Prahran, VIC 3181, Australia; Ambulance Victoria, 375 Manningham Rd, Doncaster, VIC 3108, Australia; Department of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne 3004, Australia
| | | | - Sarah Gutman
- Alfred Hospital, 55 Commercial Rd, Prahran, VIC 3181, Australia
| | - Andre La Gerche
- Baker Heart and Diabetes Institute, 75 Commercial Rd, Prahran, VIC 3181, Australia; Alfred Hospital, 55 Commercial Rd, Prahran, VIC 3181, Australia; St Vincent's Hospital Melbourne, 41 Victoria Pde, Fitzroy, VIC 3065, Australia
| | - Justin Mariani
- Alfred Hospital, 55 Commercial Rd, Prahran, VIC 3181, Australia
| | - Andrew Taylor
- Alfred Hospital, 55 Commercial Rd, Prahran, VIC 3181, Australia
| | - Andris Ellims
- Alfred Hospital, 55 Commercial Rd, Prahran, VIC 3181, Australia
| |
Collapse
|
8
|
Sweeney J, Tichnell C, Christian S, Pendelton C, Murray B, Roter DL, Jamal L, Calkins H, James CA. Characterizing Decision-Making Surrounding Exercise in ARVC: Analysis of Decisional Conflict, Decisional Regret, and Shared Decision-Making. CIRCULATION. GENOMIC AND PRECISION MEDICINE 2023; 16:e004133. [PMID: 38014565 PMCID: PMC10729899 DOI: 10.1161/circgen.123.004133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 10/25/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Limiting high-intensity exercise is recommended for patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) due to its association with penetrance, arrhythmias, and structural progression. Guidelines recommend shared decision-making (SDM) for exercise level, but there is little evidence regarding its impact. Therefore, we sought to evaluate the extent and implications of SDM for exercise, decisional conflict, and decisional regret in patients with ARVC and at-risk relatives. METHODS Adults diagnosed with ARVC or with positive genetic testing enrolled in the Johns Hopkins ARVC Registry were invited to complete a questionnaire that included exercise history and current exercise, SDM (SDM-Q-9), decisional conflict, and decisional regret. RESULTS The response rate was 64.8%. Two-thirds of participants (68.0%, n=121) reported clinically significant decisional conflict regarding exercise at diagnosis/genetic testing (DCS [decisional conflict scale]≥25), and half (55.1%, n=98) in the past year. Prevalence of decisional regret was also high with 55.3% (n=99) reporting moderate to severe decisional regret (DRS [decisional regret scale]≥25). The extent of SDM was highly variable ranging from no (0) to perfect (100) SDM (mean, 59.6±25.0). Those diagnosed in adolescence (≤age 21) reported significantly more SDM (P=0.013). Importantly, SDM was associated with less decisional conflict (ß=-0.66, R2=0.567, P<0.01) and decisional regret (ß=-0.37, R2=0.180, P<0.001) and no difference in vigorous intensity aerobic exercise in the 6 months after diagnosis/genetic testing or the past year (P=0.56; P=0.34, respectively). CONCLUSIONS SDM is associated with lower decisional conflict and decisional regret; and no difference in postdiagnosis exercise. Our data thus support SDM as the preferred model for exercise discussions for ARVC.
Collapse
Affiliation(s)
- Jessica Sweeney
- Johns Hopkins Bloomberg School of Public Health (J.S., D.L.R.), Johns Hopkins University, Baltimore
- National Human Genome Research Institute (J.S.), National Institutes of Health, Bethesda, MD
| | - Crystal Tichnell
- Division of Cardiology, Department of Medicine (C.T., C.P., B.M., H.C., C.A.J.), Johns Hopkins University, Baltimore
| | - Susan Christian
- Department of Medical Genetics, University of Alberta, Edmonton, Canada (S.C.)
| | - Catherine Pendelton
- Division of Cardiology, Department of Medicine (C.T., C.P., B.M., H.C., C.A.J.), Johns Hopkins University, Baltimore
| | - Brittney Murray
- Division of Cardiology, Department of Medicine (C.T., C.P., B.M., H.C., C.A.J.), Johns Hopkins University, Baltimore
| | - Debra L. Roter
- Johns Hopkins Bloomberg School of Public Health (J.S., D.L.R.), Johns Hopkins University, Baltimore
| | - Leila Jamal
- Center for Cancer Research, National Cancer Institute (L.J.), National Institutes of Health, Bethesda, MD
- Department of Bioethics, Clinical Center (L.J.), National Institutes of Health, Bethesda, MD
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine (C.T., C.P., B.M., H.C., C.A.J.), Johns Hopkins University, Baltimore
| | - Cynthia A. James
- Division of Cardiology, Department of Medicine (C.T., C.P., B.M., H.C., C.A.J.), Johns Hopkins University, Baltimore
| |
Collapse
|
9
|
Corneil H, Liblik K, Varghese SS, Masotti B, Moulson N, McKinney J, Allan KS, Phelan D, Thakrar A, Johri AM, Grubic N. Shared Decision-Making in Athletes Diagnosed With a Cardiovascular Condition: A Scoping Review. Curr Probl Cardiol 2023; 48:101815. [PMID: 37211302 DOI: 10.1016/j.cpcardiol.2023.101815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 05/13/2023] [Indexed: 05/23/2023]
Abstract
This scoping review summarizes existing approaches, benefits, and barriers to shared decision-making (SDM) in the context of sports cardiology. Among 6,058 records screened, 37 articles were included in this review. Most included articles defined SDM as an open dialogue between the athlete, healthcare team, and other stakeholders. The benefits and risks of management strategies, treatment options, and return-to-play were the focus of this dialogue. Key components of SDM were described through various themes, such as emphasizing patient values, considering nonphysical factors, and informed consent. Benefits of SDM included enhancing patient understanding, implementing a personalized management plan, and considering a holistic approach to care. Barriers to SDM included pressure from institutions, consideration of multiple perspectives in decision-making, and the potential liability of healthcare providers. The use of SDM when discussing management, treatment, and lifestyle modification for athletes diagnosed with a cardiovascular condition is necessary to ensure patient autonomy and engagement.
Collapse
Affiliation(s)
- Heidi Corneil
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Kiera Liblik
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Sonu S Varghese
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Bruce Masotti
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Nathaniel Moulson
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - James McKinney
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Katherine S Allan
- Division of Cardiology, Unity Health Toronto - St Michael's Hospital, Toronto, Ontario, Canada
| | - Dermot Phelan
- The Gragg Center for Cardiovascular Performance, Sanger Heart & Vascular Institute, Atrium Health, Charlotte, North Carolina, United States
| | - Amar Thakrar
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Amer M Johri
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Nicholas Grubic
- Department of Medicine, Queen's University, Kingston, Ontario, Canada.
| |
Collapse
|
10
|
Martinez KA, Bos JM, Baggish AL, Phelan DM, Tobert KE, Newman DB, Scherer E, Petek BJ, Ackerman MJ, Martinez MW. Return-to-Play for Elite Athletes With Genetic Heart Diseases Predisposing to Sudden Cardiac Death. J Am Coll Cardiol 2023; 82:661-670. [PMID: 37587576 DOI: 10.1016/j.jacc.2023.05.059] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 05/22/2023] [Accepted: 05/24/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND People diagnosed with genetic heart diseases (GHDs) associated with sudden cardiac death (SCD) have historically been restricted from competitive sports. Recent data documenting return-to-play (RTP) experiences following shared decision making (SDM) suggest that cardiac event rates for athletes with a GHD are lower than previously described, thereby suggesting an opportunity to reconsider this paradigm. OBJECTIVES The purpose of this study was to evaluate clinical outcomes among National Collegiate Athletic Association Division I university and professional athletes diagnosed with a GHD. METHODS A multicenter retrospective analysis was performed to examine demographics, clinical characteristics, RTP outcomes, and cardiac events among elite athletes with a GHD. RESULTS A total of 76 elite (66%, Division I, 34% professional) athletes (age 19.9 ± 5 years, 28% women) diagnosed with a GHD (hypertrophic cardiomyopathy [53%], long QT syndrome, long QT syndrome [26%]) comprise this cohort. Most athletes were asymptomatic (48 of 76, 63%) before diagnosis and had their GHD detected during routine preparticipation cardiovascular screening. Most athletes (55 of 76, 72%) were initially disqualified from their sport but subsequently opted for unrestricted RTP after comprehensive clinical evaluation and SDM. To date, (mean follow-up 7 ± 6 years), only 1 exercise-related (1.3%) and 2 nonexercise-related GHD-associated adverse cardiac events occurred. There have been no fatalities during follow-up. CONCLUSIONS This is the first study describing the experience of athletes with a known SCD-predisposing GHD who are competing at the elite level. After careful evaluation, risk stratification, and tailoring of their GHD therapy, RTP following SDM appears associated with low, nonfatal events rates at elite levels of sport.
Collapse
Affiliation(s)
- Katherine A Martinez
- Department of Molecular Pharmacology and Experimental Therapeutics (Windland Smith Rice Sudden Death Genomics Laboratory), Mayo Clinic, Rochester, Minnesota, USA
| | - J Martijn Bos
- Department of Molecular Pharmacology and Experimental Therapeutics (Windland Smith Rice Sudden Death Genomics Laboratory), Mayo Clinic, Rochester, Minnesota, USA; Department of Cardiovascular Medicine (Division of Heart Rhythm Services, Windland Smith Rice Genetic Heart Rhythm Clinic), Mayo Clinic, Rochester, Minnesota, USA; Department of Pediatric and Adolescent Medicine (Division of Pediatric Cardiology), Mayo Clinic, Rochester, Minnesota, USA
| | - Aaron L Baggish
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts, USA; Department of Cardiology and Institute for Sport Science, University of Lausanne, Lausanne, Switzerland
| | - Dermot M Phelan
- Sanger Heart and Vascular Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Kathryn E Tobert
- Department of Molecular Pharmacology and Experimental Therapeutics (Windland Smith Rice Sudden Death Genomics Laboratory), Mayo Clinic, Rochester, Minnesota, USA
| | - Darrel B Newman
- Department of Cardiovascular Medicine (Division of Heart Rhythm Services, Windland Smith Rice Genetic Heart Rhythm Clinic), Mayo Clinic, Rochester, Minnesota, USA
| | - Erica Scherer
- Sanger Heart and Vascular Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Bradley J Petek
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts, USA; Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Michael J Ackerman
- Department of Molecular Pharmacology and Experimental Therapeutics (Windland Smith Rice Sudden Death Genomics Laboratory), Mayo Clinic, Rochester, Minnesota, USA; Department of Cardiovascular Medicine (Division of Heart Rhythm Services, Windland Smith Rice Genetic Heart Rhythm Clinic), Mayo Clinic, Rochester, Minnesota, USA; Department of Pediatric and Adolescent Medicine (Division of Pediatric Cardiology), Mayo Clinic, Rochester, Minnesota, USA.
| | | |
Collapse
|
11
|
Pelliccia A, Day S, Olivotto I. Leisure-time and competitive sport participation: a changing paradigm for HCM patients. Eur J Prev Cardiol 2023; 30:zwad011. [PMID: 36638119 DOI: 10.1093/eurjpc/zwad011] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 12/12/2022] [Accepted: 01/10/2023] [Indexed: 01/14/2023]
Abstract
HCM has long been considered the most frequent cause of death in athletes, and reason for disqualification from sport. However, our perception of the impact of sports on HCM is largely based on anecdotal evidence. In this review, we provide a reappraisal of current knowledge relative to 1) the impact of sport on LV remodeling, and 2) on the clinical outcome of HCM in athletes. 1) The limited available evidence argues against the hypothesis that intensive exercise conditioning may trigger and/or worsen the development of LV hypertrophy or cause changes in LV function in adult HCM athletes. 2) Recent observations challenge the concept of a detrimental effect of sport on HCM clinical course. The Reset-HCM study showed that 16-week moderate-intensity exercise resulted in a small, significant increase in exercise capacity and no adverse events. In a cohort of 88 low-risk HCM athletes followed for a 7-year period, survival analyses showed no difference in mortality between HCM who discontinued or pursued vigorous exercise programmes. Further reassurance was provided by the ICD Sports Safety Registry. Clinical implications: At present, patients' attitude to sport participation is highly variable, based on social and legal backgrounds surrounding medical practice in different countries. The shared-decision-making as suggested by current US and European guidelines allows the physician to deliver a tailored and more liberal advice. Physicians should be aware of the changing paradigm relative to exercise and sport prescription for HCM and promote active lifestyle as an integral component of modern management of HCM patients.
Collapse
Affiliation(s)
| | - Sharlene Day
- Division of Cardiovascular Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Iacopo Olivotto
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| |
Collapse
|
12
|
Huang AL, MacNamara J, Link MS, Martinez M, Dearani JA, Cannon BC, Levine BD, Ackerman MJ. Asymptomatic Apical Hypertrophic Cardiomyopathy in an Elite Competitive Athlete. JACC Case Rep 2022; 6:101705. [PMID: 36704059 PMCID: PMC9871207 DOI: 10.1016/j.jaccas.2022.101705] [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: 07/20/2022] [Revised: 11/01/2022] [Accepted: 11/15/2022] [Indexed: 12/15/2022]
Abstract
A 17-year-old male elite athlete presented for evaluation after an abnormal pre-competitive college screening electrocardiogram. Subsequent evaluation revealed the presence of hypertrophic cardiomyopathy. He remained asymptomatic throughout four years of follow-up. Through shared decision making, he continued to play competitively and is now a professional athlete. (Level of Difficulty: Advanced.).
Collapse
Affiliation(s)
- Athena L. Huang
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - James MacNamara
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Mark S. Link
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | | | | | | | | - Michael J. Ackerman
- Mayo Clinic, Rochester, Minnesota, USA,Address for correspondence: Dr Michael J. Ackerman, Mayo Clinic, Guggenheim Building, Room 501, 200 First Street SW, Rochester, Minnesota 55905, USA.
| |
Collapse
|
13
|
Athletic Activity for Patients With Hypertrophic Cardiomyopathy and Other Inherited Cardiovascular Diseases: JACC Focus Seminar 3/4. J Am Coll Cardiol 2022; 80:1268-1283. [PMID: 36075839 DOI: 10.1016/j.jacc.2022.07.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 07/25/2022] [Indexed: 02/08/2023]
Abstract
As explored throughout this JACC Focus Seminar series, participation in regular exercise offers significant positive benefits for cardiovascular health. However, patients with underlying inherited cardiovascular diseases, such as hypertrophic cardiomyopathy, have historically been restricted from sports participation because of the risk of sudden cardiac death. Over the last decade, new data has challenged this restrictive approach. Today, the notion of individualized, patient-centered shared decision-making is being progressively adopted to guide patients with an inherited cardiovascular disease to decide if they can undertake regular exercise, or even if they can participate in competitive sports. Here in this part 3 of a 4-part seminar series, we focus on these concepts and recent data with respect to exercise and the heart in patients with hypertrophic cardiomyopathy and other inherited cardiovascular diseases, with particular emphasis on participation in recreational and competitive sports for these individuals.
Collapse
|
14
|
Maron BJ, Desai MY, Nishimura RA, Spirito P, Rakowski H, Towbin JA, Rowin EJ, Maron MS, Sherrid MV. Diagnosis and Evaluation of Hypertrophic Cardiomyopathy. J Am Coll Cardiol 2022; 79:372-389. [DOI: 10.1016/j.jacc.2021.12.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 10/27/2021] [Accepted: 11/02/2021] [Indexed: 12/20/2022]
|
15
|
Dong Y, Yang W, Chen C, Ji J, Zheng W, Zhang F, Yang B, Li X, Zhou X. Validation of the 2020 AHA/ACC Risk Stratification for Sudden Cardiac Death in Chinese Patients With Hypertrophic Cardiomyopathy. Front Cardiovasc Med 2021; 8:691653. [PMID: 34485400 PMCID: PMC8415905 DOI: 10.3389/fcvm.2021.691653] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 07/19/2021] [Indexed: 11/30/2022] Open
Abstract
Background: Sudden cardiac death (SCD) is a common cause of death in hypertrophic cardiomyopathy (HCM), but identification of patients at a high risk of SCD is challenging. The study aimed to validate the three SCD risk stratifications recommended by the 2011 ACCF/AHA guideline, the 2014 ESC guideline, and the 2020 AHA/ACC guideline in Chinese HCM patients. Methods: The study population consisted of a consecutive cohort of 511 patients with HCM without a history of SCD event. The endpoint was a composite of SCD or an equivalent event (appropriate implantable cardioverter defibrillator therapy or successful resuscitation after cardiac arrest). Results: During a follow-up of 4.7 ± 1.7 years, 15 patients (2.9%) reached the SCD endpoint and 12 (2.3%) were protected by implantable cardioverter defibrillator for primary prevention. A total of 13 (2.8%) patients experiencing SCD events were misclassified as low-risk patients by the 2011 ACCF/AHA guideline, 12 (2.3%) by the 2014 ESC model, and 7 (1.6%) by the 2020 AHA/ACC guideline. The SCD risk stratification in the 2020 AHA/ACC guideline showed greater area under the curve (0.71; 95% CI 0.56–0.87, p < 0.001) than the one in the 2011 ACCF/AHA guideline (0.52; 95% CI 0.37–0.67, p = 0.76) and 2014 ESC guideline (0.68; 95% CI 0.54–0.81, p = 0.02). Conclusion: The SCD risk stratification recommended by the 2020 AHA/ACC guideline showed a better discrimination than previous stratifications in Chinese patients with HCM. A larger multicenter, independent, and prospective study with long-term follow-up would be warranted to validate our result.
Collapse
Affiliation(s)
- Yan Dong
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Wen Yang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Chongchong Chen
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jiamei Ji
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Wei Zheng
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Fengxiang Zhang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Bing Yang
- Department of Cardiology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xiaorong Li
- Department of Cardiology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xiujuan Zhou
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| |
Collapse
|
16
|
Ommen SR, Mital S, Burke MA, Day SM, Deswal A, Elliott P, Evanovich LL, Hung J, Joglar JA, Kantor P, Kimmelstiel C, Kittleson M, Link MS, Maron MS, Martinez MW, Miyake CY, Schaff HV, Semsarian C, Sorajja P, O'Gara PT, Beckman JA, Levine GN, Al-Khatib SM, Armbruster A, Birtcher KK, Ciggaroa J, Dixon DL, de Las Fuentes L, Deswal A, Fleisher LA, Gentile F, Goldberger ZD, Gorenek B, Haynes N, Hernandez AF, Hlatky MA, Joglar JA, Jones WS, Marine JE, Mark D, Palaniappan L, Piano MR, Tamis-Holland J, Wijeysundera DN, Woo YJ. 2020 AHA/ACC guideline for the diagnosis and treatment of patients with hypertrophic cardiomyopathy: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg 2021; 162:e23-e106. [PMID: 33926766 DOI: 10.1016/j.jtcvs.2021.04.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
17
|
Semsarian C, Davis L. The Wait is Over: The 2020 American Heart Association/American College of Cardiology (AHA/ACC) Hypertrophic Cardiomyopathy Guidelines Have Arrived. Heart Lung Circ 2021; 30:465-468. [PMID: 33610474 DOI: 10.1016/j.hlc.2021.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.
| | - Lindsay Davis
- Former Miss Ohio, Heart Health Advocate, Hypertrophic Cardiomyopathy Patient, New York, USA. https://twitter.com/lindsayluvdavis
| |
Collapse
|
18
|
Evolution of risk stratification and sudden death prevention in hypertrophic cardiomyopathy: Twenty years with the implantable cardioverter-defibrillator. Heart Rhythm 2021; 18:1012-1023. [PMID: 33508516 DOI: 10.1016/j.hrthm.2021.01.019] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 01/14/2021] [Accepted: 01/20/2021] [Indexed: 11/21/2022]
Abstract
Hypertrophic cardiomyopathy (HCM) is a relatively common inherited myocardial disorder, once regarded as largely untreatable with ominous prognosis and most visibly as a common cause of sudden death (SD) in the young. Over the last several years, HCM has been transformed into a contemporary treatable disease with management options that significantly alter clinical course. With the use of implantable cardioverter-defibrillators (ICDs) in the HCM patient population, a new paradigm has emerged, with primary prevention device therapy reliably terminating potentially lethal ventricular tachyarrhythmias (3%-4% per year) and being largely responsible for a >10-fold decrease in disease-related mortality (to 0.5% per year), independent of age. An evidenced-based and guideline directed clinical risk stratification algorithm has evolved, including variables identified with cardiac magnetic resonance. One or more risk markers judged major and relevant within a patient's clinical profile can be considered sufficient to recommend a primary prevention implant (associated with a measure of physician judgment and shared decision-making). ICD decisions using the prospective individual risk marker strategy have been associated with 95% sensitivity for identifying patients who subsequently experienced appropriate ICD therapy, (albeit often delayed substantially for >5 or >10 years after implant), but without heart failure deterioration or HCM death following device intervention. A rigid mathematically derived statistical risk model proposed by the European Society of Cardiology is associated with low sensitivity (ie, 33%) for predicting SD events. Introduction of prophylactically inserted ICDs to HCM 20 years ago has significantly altered the clinical course and landscape of this disease. SD prevention has reduced HCM mortality significantly, making preservation of life and the potential for normal longevity a reality for most patients.
Collapse
|
19
|
Drezner JA, Malhotra A, Prutkin JM, Papadakis M, Harmon KG, Asif IM, Owens DS, Marek JC, Sharma S. Return to play with hypertrophic cardiomyopathy: are we moving too fast? A critical review. Br J Sports Med 2021; 55:1041-1047. [PMID: 33472848 PMCID: PMC8408577 DOI: 10.1136/bjsports-2020-102921] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2020] [Indexed: 12/31/2022]
Abstract
The diagnosis of a potentially lethal cardiovascular disease in a young athlete presents a complex dilemma regarding athlete safety, patient autonomy, team or institutional risk tolerance and medical decision-making. Consensus cardiology recommendations previously supported the ‘blanket’ disqualification of athletes with hypertrophic cardiomyopathy (HCM) from competitive sport. More recently, epidemiological studies examining the relative contribution of HCM as a cause of sudden cardiac death (SCD) in young athletes and reports from small cohorts of older athletes with HCM that continue to exercise have fueled debate whether it is safe to play with HCM. Shared decision-making is endorsed within the sports cardiology community in which athletes can make an informed decision about treatment options and potentially elect to continue competitive sports participation. This review critically examines the available evidence relevant to sports eligibility decisions in young athletes diagnosed with HCM. Histopathologically, HCM presents an unstable myocardial substrate that is vulnerable to ventricular tachyarrhythmias during exercise. Studies support that young age and intense competitive sports are risk factors for SCD in patients with HCM. We provide an estimate of annual mortality based on our understanding of disease prevalence and the incidence of HCM-related SCD in different athlete populations. Adolescent and young adult male athletes and athletes participating in a higher risk sport such as basketball, soccer and American football exhibit a greater risk. This review explores the potential harms and benefits of sports disqualification in athletes with HCM and details the challenges and limitations of shared decision-making when all parties may not agree.
Collapse
Affiliation(s)
- Jonathan A Drezner
- Center for Sports Cardiology, University of Washington, Seattle, Washington, USA
| | - Aneil Malhotra
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | - Jordan M Prutkin
- Department of Internal Medicine, Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - Michael Papadakis
- Cardiology, Clinical Academic Group, St George's, University of London, London, UK
| | - Kimberly G Harmon
- Center for Sports Cardiology, University of Washington, Seattle, Washington, USA
| | - Irfan M Asif
- Center for Health Promotion, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - David S Owens
- Department of Internal Medicine, Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - Joseph C Marek
- Cardiology, Advocate Heart Institute, Downers Grove, Illinois, USA
| | - Sanjay Sharma
- Cardiology, Clinical Academic Group, St George's, University of London, London, UK
| |
Collapse
|
20
|
Ommen SR, Mital S, Burke MA, Day SM, Deswal A, Elliott P, Evanovich LL, Hung J, Joglar JA, Kantor P, Kimmelstiel C, Kittleson M, Link MS, Maron MS, Martinez MW, Miyake CY, Schaff HV, Semsarian C, Sorajja P. 2020 AHA/ACC Guideline for the Diagnosis and Treatment of Patients With Hypertrophic Cardiomyopathy: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2020; 76:3022-3055. [PMID: 33229115 DOI: 10.1016/j.jacc.2020.08.044] [Citation(s) in RCA: 156] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
AIM This executive summary of the hypertrophic cardiomyopathy clinical practice guideline provides recommendations and algorithms for clinicians to diagnose and manage hypertrophic cardiomyopathy in adult and pediatric patients as well as supporting documentation to encourage their use. METHODS A comprehensive literature search was conducted from January 1, 2010, to April 30, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. STRUCTURE Many recommendations from the earlier hypertrophic cardiomyopathy guidelines have been updated with new evidence or a better understanding of earlier evidence. This summary operationalizes the recommendations from the full guideline and presents a combination of diagnostic work-up, genetic and family screening, risk stratification approaches, lifestyle modifications, surgical and catheter interventions, and medications that constitute components of guideline directed medical therapy. For both guideline-directed medical therapy and other recommended drug treatment regimens, the reader is advised to follow dosing, contraindications and drug-drug interactions based on product insert materials.
Collapse
|
21
|
Ommen SR, Mital S, Burke MA, Day SM, Deswal A, Elliott P, Evanovich LL, Hung J, Joglar JA, Kantor P, Kimmelstiel C, Kittleson M, Link MS, Maron MS, Martinez MW, Miyake CY, Schaff HV, Semsarian C, Sorajja P. 2020 AHA/ACC Guideline for the Diagnosis and Treatment of Patients With Hypertrophic Cardiomyopathy: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2020; 142:e533-e557. [PMID: 33215938 DOI: 10.1161/cir.0000000000000938] [Citation(s) in RCA: 115] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Aim This executive summary of the hypertrophic cardiomyopathy clinical practice guideline provides recommendations and algorithms for clinicians to diagnose and manage hypertrophic cardiomyopathy in adult and pediatric patients as well as supporting documentation to encourage their use. Methods A comprehensive literature search was conducted from January 1, 2010, to April 30, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Structure Many recommendations from the earlier hypertrophic cardiomyopathy guidelines have been updated with new evidence or a better understanding of earlier evidence. This summary operationalizes the recommendations from the full guideline and presents a combination of diagnostic work-up, genetic and family screening, risk stratification approaches, lifestyle modifications, surgical and catheter interventions, and medications that constitute components of guideline directed medical therapy. For both guideline-directed medical therapy and other recommended drug treatment regimens, the reader is advised to follow dosing, contraindications and drug-drug interactions based on product insert materials.
Collapse
Affiliation(s)
| | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines Liaison
- HFSA Representative
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Ommen SR, Mital S, Burke MA, Day SM, Deswal A, Elliott P, Evanovich LL, Hung J, Joglar JA, Kantor P, Kimmelstiel C, Kittleson M, Link MS, Maron MS, Martinez MW, Miyake CY, Schaff HV, Semsarian C, Sorajja P. 2020 AHA/ACC Guideline for the Diagnosis and Treatment of Patients With Hypertrophic Cardiomyopathy: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2020; 76:e159-e240. [PMID: 33229116 DOI: 10.1016/j.jacc.2020.08.045] [Citation(s) in RCA: 358] [Impact Index Per Article: 89.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
|
23
|
Ommen SR, Mital S, Burke MA, Day SM, Deswal A, Elliott P, Evanovich LL, Hung J, Joglar JA, Kantor P, Kimmelstiel C, Kittleson M, Link MS, Maron MS, Martinez MW, Miyake CY, Schaff HV, Semsarian C, Sorajja P. 2020 AHA/ACC Guideline for the Diagnosis and Treatment of Patients With Hypertrophic Cardiomyopathy. Circulation 2020; 142:e558-e631. [DOI: 10.1161/cir.0000000000000937] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
| | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines Liaison
- HFSA Representative
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Maron MS, Brush J, Rowin EJ, Maron BJ. Back to the future: Predicting sudden death in hypertrophic cardiomyopathy relying on individual risk markers and physician judgment without mathematical scoring. Heart Rhythm 2020; 18:148-150. [PMID: 32717313 DOI: 10.1016/j.hrthm.2020.07.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/17/2020] [Accepted: 07/20/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Martin S Maron
- HCM Center and Research Institute, Tufts Medical Center, Boston, Massachusetts.
| | - John Brush
- Sentara Healthcare and Eastern Virginia Medical School, Norfolk, Virginia
| | - Ethan J Rowin
- HCM Center and Research Institute, Tufts Medical Center, Boston, Massachusetts
| | - Barry J Maron
- HCM Center and Research Institute, Tufts Medical Center, Boston, Massachusetts
| |
Collapse
|
25
|
Maron MS, Rowin EJ, Wessler BS, Mooney PJ, Fatima A, Patel P, Koethe BC, Romashko M, Link MS, Maron BJ. Enhanced American College of Cardiology/American Heart Association Strategy for Prevention of Sudden Cardiac Death in High-Risk Patients With Hypertrophic Cardiomyopathy. JAMA Cardiol 2020; 4:644-657. [PMID: 31116360 DOI: 10.1001/jamacardio.2019.1391] [Citation(s) in RCA: 215] [Impact Index Per Article: 53.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Importance Strategies for reliable selection of high-risk patients with hypertrophic cardiomyopathy (HCM) for prevention of sudden cardiac death (SCD) with implantable cardioverter/defibrillators (ICDs) are incompletely resolved. Objective To assess the reliability of SCD prediction methods leading to prophylactic ICD recommendations to reduce the number of SCDs occurring in patients with HCM. Design, Setting, and Participants In this observational longitudinal study, 2094 predominantly adult patients with HCM consecutively evaluated over 17 years in a large HCM clinical center were studied. All patients underwent prospective ICD decision making relying on individual major risk markers derived from the HCM literature and an enhanced American College of Cardiology/American Heart Association (ACC/AHA) guidelines-based risk factor algorithm with complete clinical outcome follow-up. Data were collected from June 2017 to February 2018, and data were analyzed from February to July 2018. Main Outcomes and Measures Arrhythmic SCD or appropriate ICD intervention for ventricular tachycardia or ventricular fibrillation. Results Of the 2094 study patients, 1313 (62.7%) were male, and the mean (SD) age was 51 (17) years. Of 527 patients with primary prevention ICDs implanted based on 1 or more major risk markers, 82 (15.6%) experienced device therapy-terminated ventricular tachycardia or ventricular fibrillation episodes, which exceeded the 5 HCM-related SCDs occurring among 1567 patients without ICDs (0.3%), including 2 who declined device therapy, by 49-fold (95% CI, 20-119; P = .001). Cumulative 5-year probability of an appropriate ICD intervention was 10.5% (95% CI, 8.0-13.5). The enhanced ACC/AHA clinical risk factor strategy was highly sensitive for predicting SCD events (range, 87%-95%) but less specific for identifying patients without SCD events (78%). The C statistic calculated for enhanced ACC/AHA guidelines was 0.81 (95% CI, 0.77-0.85), demonstrating good discrimination between patients who did or did not experience an SCD event. Compared with enhanced ACC/AHA risk factors, the European Society of Cardiology risk score retrospectively applied to the study patients was much less sensitive than the ACC/AHA criteria (34% [95% CI, 22-44] vs 95% [95% CI, 89-99]), consistent with recognizing fewer high-risk patients. Conclusions and Relevance A systematic enhanced ACC/AHA guideline and practice-based risk factor strategy prospectively predicted SCD events in nearly all at-risk patients with HCM, resulting in prophylactically implanted ICDs that prevented many catastrophic arrhythmic events in this at-risk population.
Collapse
Affiliation(s)
- Martin S Maron
- Hypertrophic Cardiomyopathy Center and Research Institute, Division of Cardiology, Tufts Medical Center, Boston, Massachusetts
| | - Ethan J Rowin
- Hypertrophic Cardiomyopathy Center and Research Institute, Division of Cardiology, Tufts Medical Center, Boston, Massachusetts
| | - Benjamin S Wessler
- Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies, Division of Cardiology, Tufts Medical Center, Boston, Massachusetts
| | - Paula J Mooney
- Hypertrophic Cardiomyopathy Center and Research Institute, Division of Cardiology, Tufts Medical Center, Boston, Massachusetts
| | - Amber Fatima
- Hypertrophic Cardiomyopathy Center and Research Institute, Division of Cardiology, Tufts Medical Center, Boston, Massachusetts
| | - Parth Patel
- Hypertrophic Cardiomyopathy Center and Research Institute, Division of Cardiology, Tufts Medical Center, Boston, Massachusetts
| | - Benjamin C Koethe
- Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies, Division of Cardiology, Tufts Medical Center, Boston, Massachusetts
| | - Mikhail Romashko
- Hypertrophic Cardiomyopathy Center and Research Institute, Division of Cardiology, Tufts Medical Center, Boston, Massachusetts
| | - Mark S Link
- Division of Cardiology, Department of Internal Medicine, University of Texas, Dallas.,Southwestern Medical Center, Dallas, Texas
| | - Barry J Maron
- Hypertrophic Cardiomyopathy Center and Research Institute, Division of Cardiology, Tufts Medical Center, Boston, Massachusetts
| |
Collapse
|
26
|
Abstract
Hypertrophic cardiomyopathy (HCM) is a worldwide genetic heart disease and a common cause of sudden death in the young. Penetration of the implantable cardioverter-defibrillator (ICD) into this patient population over the past 20 years has made accurate selection of patients for primary prevention ICDs a priority. Consequently, a new paradigm has emerged in the management of this complex disease with ICD therapy responsible for a substantial decrease in overall HCM-related mortality (to 0.5%/y) and independent of patient age. Selection of candidates for ICDs has matured substantially with the formulation of an enhanced risk stratification algorithm. One or more contemporary risk markers judged major within a given patient’s clinical profile, in association with physician judgment and shared decision-making, is sufficient to consider a primary prevention ICD implant. An enhanced American College of Cardiology/American Heart Association risk factor model (including new contrast-magnetic resonance–based markers, such as left ventricular apical aneurysm) used prospectively to make ICD decisions proved to be 95% sensitive for identifying patients who would experience ≥1 appropriate device therapies terminating ventricular tachycardia/fibrillation. The number of HCM patients required to treat with ICDs to save 1 patient with abolition of lethal ventricular tachyarrhythmias was 6:1, similar to randomized defibrillator trials in other cardiomyopathies. In contrast to patients with ischemic heart disease, after ICD shock HCM patients rarely experience transformation to heart failure deterioration or sudden arrhythmic death. The mathematically derived risk score model proposed by the European Society of Cardiology was inferior for identifying high-risk patients susceptible to arrhythmic sudden death with a sensitivity of only 33%, leaving many patients exposed to the possibility of sudden death without ICDs. In conclusion, introduction of the ICD associated with a matured risk stratification algorithm has altered management strategy and clinical course of many HCM patients, making the likelihood of sudden death prevention a reality and fulfilling the aspiration of preservation of life and reduced mortality for this vulnerable patient population.
Collapse
Affiliation(s)
- Barry J. Maron
- From the HCM Institute, Division of Cardiology, Tufts Medical Center, Boston, MA
| | - Ethan J. Rowin
- From the HCM Institute, Division of Cardiology, Tufts Medical Center, Boston, MA
| | - Martin S. Maron
- From the HCM Institute, Division of Cardiology, Tufts Medical Center, Boston, MA
| |
Collapse
|
27
|
Joyner MJ. Hypertrophic cardiomyopathy and exercise: a need for more information. J Physiol 2019; 597:1225-1226. [DOI: 10.1113/jp277538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Michael J. Joyner
- Department of Anesthesiology & Perioperative MedicineMayo Clinic Rochester MN 55905 USA
| |
Collapse
|
28
|
Affiliation(s)
- Barry J Maron
- From the Hypertrophic Cardiomyopathy Center and Research Institute, Tufts Medical Center, Boston
| |
Collapse
|
29
|
Berg AE, Meyers LL, Dent KM, Rothwell EW, Everitt MD. Psychological impact of sports restriction in asymptomatic adolescents with hypertrophic cardiomyopathy, dilated cardiomyopathy, and long QT syndrome. PROGRESS IN PEDIATRIC CARDIOLOGY 2018. [DOI: 10.1016/j.ppedcard.2018.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
|
30
|
Rowin EJ, Orfanos A, Estes NM, Wang W, Link MS, Maron MS, Maron BJ. Occurrence and Natural History of Clinically Silent Episodes of Atrial Fibrillation in Hypertrophic Cardiomyopathy. Am J Cardiol 2017; 119:1862-1865. [PMID: 28395893 DOI: 10.1016/j.amjcard.2017.02.040] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 02/22/2017] [Accepted: 02/22/2017] [Indexed: 10/20/2022]
Abstract
Overt symptomatic atrial fibrillation (AF) occurs in over 20% of patients with hypertrophic cardiomyopathy (HC) leading to impaired quality of life, loss of productivity, and the risk for embolic stroke. However, the overall burden presented by AF in the HC population is unresolved due to the unknown frequency of silent asymptomatic episodes that do not necessarily achieve clinical recognition but nevertheless may have important disease-related implications. Therefore, stored electrograms were analyzed retrospectively for AF in 75 consecutive patients with HC (without AF history) implanted with dual-chamber cardioverter-defibrillators. Patients were followed for 5.0 ± 4.1 years at the Tufts Medical Center HCM Institute; ages were 50 ± 15 years, and 55% were male. Implantable cardioverter-defibrillator interrogation in the 75 patients showed AF to be absent in 54 (72%), 18 (24%) had clinically silent AF episodes, and the remaining 3 (4%) without previous asymptomatic episodes developed symptomatic and clinically overt paroxysmal AF. Of the 18 patients with clinically silent AF, 8 developed symptomatic AF, 4.1 ± 1.5 years later. Nonfatal embolic stroke occurred in 1 patient associated with asymptomatic AF and without other risk factors. In conclusion, clinically silent AF appears to be common in HC, occurring in almost 25% of patients. Such asymptomatic episodes of AF have important future implications, including potential thromboembolic risk, and development of symptomatic and clinically overt AF requiring prophylactic anticoagulation.
Collapse
|