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Duchenne muscular dystrophy patients: troponin leak in asymptomatic and implications for drug toxicity studies. Pediatr Res 2022; 92:1613-1620. [PMID: 34429516 PMCID: PMC8866537 DOI: 10.1038/s41390-021-01682-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 07/20/2021] [Accepted: 07/27/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Cardiomyopathy is the leading cause of death in Duchenne muscular dystrophy (DMD), but studies suggest heart failure biomarkers correlate poorly with cardiomyopathy severity. DMD clinical trials have used troponin I (cTnI) as a biomarker of toxicity, but it is unclear if asymptomatic DMD patients have elevated cTnI. We longitudinally evaluated cTnI, brain natriuretic peptide (BNP), and N-terminal pro-BNP (NT-proBNP) in a DMD cohort. METHODS DMD patients were prospectively enrolled and followed for 3 years. Serum was drawn at the time of cardiac magnetic resonance (CMR). Normal biomarker values were derived from healthy subjects. Biomarkers were correlated with CMR markers. RESULTS All subjects were asymptomatic at the time of enrollment. Several DMD subjects had transiently elevated cTnI. Those with elevated cTnI were more likely to have late gadolinium enhancement on baseline CMR. NT-proBNP correlated with indexed left ventricular end diastolic and maximum left atrial volumes. Otherwise, standard cardiac biomarkers did not correlate with CMR markers of cardiomyopathy. CONCLUSIONS CTnI, BNP, and NT-proBNP do not correlate with CMR assessment of cardiomyopathy progression. A subset of DMD patients have asymptomatic cTnI leak of uncertain clinical significance, though of critical importance if cTnI is used to assess for cardiac toxicity in future drug trials. IMPACT Asymptomatic patients with Duchenne muscular dystrophy (DMD) exhibit transient troponin I leak. NT-proBNP correlated with indexed left ventricular end diastolic volume and indexed maximum left atrial volume. Other cardiac biomarkers did not correlate with cardiac magnetic resonance (CMR) markers of cardiomyopathy.
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2
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Power LC, Gusso S, Hornung TS, Jefferies C, Derraik JGB, Hofman PL, O'Grady GL. Exercise Cardiac Magnetic Resonance Imaging in Boys With Duchenne Muscular Dystrophy Without Cardiac Disease. Pediatr Neurol 2021; 117:35-43. [PMID: 33662889 DOI: 10.1016/j.pediatrneurol.2020.12.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 12/23/2020] [Accepted: 12/24/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Duchenne muscular dystrophy is caused by mutations in the DMD gene, resulting in cardiomyopathy in all affected children by 18 years. Although cardiomyopathy is now the leading cause of mortality in these children, there is ongoing debate regarding timely diagnosis, secondary prevention, and treatment of this condition. The purpose of this study was to use exercise cardiac magnetic resonance imaging in asymptomatic young boys with Duchenne muscular dystrophy to describe their heart function and compare this with healthy controls. METHODS We studied 11 boys with Duchenne muscular dystrophy aged 8.6 to 13.9 years and 11 healthy age- and sex-matched controls. RESULTS Compared with the controls, boys with Duchenne muscular dystrophy had lower ejection fraction at rest (57% versus 63%; P = 0.004). During submaximal exercise, they reached similar peak tachycardia but increased their heart rate and cardiac output only half as much as controls (P = 0.003 and P = 0.014, respectively). End-systolic volume remained higher in boys with Duchenne muscular dystrophy both at rest and during exercise. When transthoracic echocardiography was compared with cardiac magnetic resonance imaging, 45% of the echocardiograms had suboptimal or poor views in the Duchenne muscular dystrophy group. CONCLUSIONS Boys with Duchenne muscular dystrophy had abnormalities in left ventricular systolic function that were exaggerated by exercise stress. Exercise cardiac magnetic resonance imaging is feasible in a select population of children with Duchenne muscular dystrophy, and it has the potential to unmask early signs of cardiomyopathy.
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Affiliation(s)
- Lisa C Power
- Paediatric Neurology Department, Starship Children's Hospital, Auckland, New Zealand; Paediatric Endocrinology Department, Starship Children's Hospital, Auckland, New Zealand; Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Silmara Gusso
- Department of Exercise Sciences, University of Auckland, Auckland, New Zealand
| | - Tim S Hornung
- Paediatric Cardiology Department, Starship Children's Hospital, Auckland, New Zealand
| | - Craig Jefferies
- Paediatric Endocrinology Department, Starship Children's Hospital, Auckland, New Zealand
| | - José G B Derraik
- Liggins Institute, University of Auckland, Auckland, New Zealand; Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Paul L Hofman
- Paediatric Endocrinology Department, Starship Children's Hospital, Auckland, New Zealand; Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Gina L O'Grady
- Paediatric Neurology Department, Starship Children's Hospital, Auckland, New Zealand.
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Kipke J, Birnkrant DJ, Jin JB, Aneja A, Bahler RC. A systematic review of pharmacologic therapies for the cardiomyopathy of Duchenne muscular dystrophy. Pediatr Pulmonol 2021; 56:782-795. [PMID: 33621446 DOI: 10.1002/ppul.25261] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 12/09/2020] [Accepted: 12/29/2020] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To perform a systematic review of studies evaluating pharmacologic therapies for the cardiomyopathy of Duchenne muscular dystrophy (DMD). METHODS PubMed, Google Scholar, and Embase were searched through October 8, 2020. Articles were selected using pre-determined criteria; 26 underwent detailed review by two co-authors. Study quality was assessed with the Newcastle-Ottawa scoring system (NOS); GRADE assessment evaluated their overall clinical importance. RESULTS There were few randomized controlled trials. Two of four trials of angiotensin converting enzyme inhibitors (ACEI) or ACEI plus beta-blockers (BB) found improved LV function. Two of two randomized trials of aldosterone antagonists (AA), when added to ACEI and BB therapy, demonstrated less decline of LV circumferential strain over 1 year of treatment. Observational studies of ACEI and BB had differing patient ages, symptomatology, cohort size, study duration and baseline heart function. LV function, assessed via unblinded imaging, was the most frequent outcome measure. LV dysfunction improved in some trials but was unconfirmed in others. Class IV heart failure patients had transient improvement of symptoms and LVEF. Most NOS scores reflected a low level of study quality. The Grade certainty rating, used for the summation of studies, was between "low" and "moderate." CONCLUSION Randomized trial evidence was inconsistent that either ACEI or BB or their combination improve LV function and/or alter progressive LV dysfunction. When ACEI and BB therapy are initiated for symptomatic Class IV heart failure, symptoms and LVEF improve transiently. AAs retard the rate of decline of LV function when initiated in younger DMD patients.
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Affiliation(s)
- Jasmine Kipke
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - David J Birnkrant
- Department of Pediatrics, Case Western Reserve University School of Medicine at MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Justin B Jin
- Case Western Reserve University School of Medicine at MetroHealth Medical Center, Cleveland, Ohio, USA.,Department of Pediatric Cardiology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Ashish Aneja
- Case Western Reserve University School of Medicine at MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Robert C Bahler
- Case Western Reserve University School of Medicine at MetroHealth Medical Center, Cleveland, Ohio, USA
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4
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Kim HG, Eun LY, Park HK. Is It Possible for Children in Duchenne Muscular Dystrophy to Preserve Cardiac Function with Medical Assistance? CHILDREN-BASEL 2020; 7:children7110249. [PMID: 33266491 PMCID: PMC7700218 DOI: 10.3390/children7110249] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 11/17/2020] [Accepted: 11/19/2020] [Indexed: 01/16/2023]
Abstract
In patients with Duchenne muscular dystrophy (DMD), death secondary to cardiac or respiratory failure typically occurs in the second or third decade without treatment. Although cardiac dysfunction is treated with standard heart-failure strategies, it remains insufficient in DMD children. The purpose of this study was to evaluate the efficiency of cardiac medication and noninvasive ventilator support in DMD cardiomyopathy children with analyzing echocardiographic data. Forty-eight DMD children patients were included and divided into 2 groups by left ventricular (LV) ejection fraction (EF) at the time of initial treatment. Group 1: LV EF ≥ 45% and Group 2: LV EF < 45%. p-values were calculated using a Linear mixed model to estimate the association between cardiac medications and echocardiographic measurements. Before and after cardiac medications, the change values were significantly different in interventricular septal thickness at end diastole (IVSd), interventricular septal thickness at end systole (IVSs), left ventricular internal diameter end systole (LVIDs), left ventricular posterior wall thickness end diastole (LVPWd), ejection fraction (EF), fractional shortening (FS), deceleration time (DT), DT slope, Lat A’ and Lat E/E’ (p < 0.05). Group 2 patients revealed to take more kinds of cardiac medications than Group 1 (p < 0.05) including ACEIs, beta-blocker, and inotropics, then LV EF was better preserved in Group 2 than Group 1. It is certainly helpful to take individualized medical combination therapy including inotropic agents for cardiomyopathy in DMD children patients with EF < 45%.
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Affiliation(s)
- Han Geul Kim
- Division of Pediatric Cardiology, Department of Pediatrics, Yonsei University College of Medicine, Seoul 03722, Korea;
| | - Lucy Youngmin Eun
- Division of Pediatric Cardiology, Department of Pediatrics, Yonsei University College of Medicine, Seoul 03722, Korea;
- Correspondence: (L.Y.E.); (H.K.P.)
| | - Han Ki Park
- Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul 03722, Korea
- Correspondence: (L.Y.E.); (H.K.P.)
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Segawa K, Sugawara N, Maruo K, Kimura K, Komaki H, Takahashi Y, Sasaki M. Left Ventricular End-Diastolic Diameter and Cardiac Mortality in Duchenne Muscular Dystrophy. Neuropsychiatr Dis Treat 2020; 16:171-178. [PMID: 32021209 PMCID: PMC6972578 DOI: 10.2147/ndt.s235166] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 12/07/2019] [Indexed: 01/16/2023] Open
Abstract
PURPOSE This study aimed to examine weather left ventricular end-diastolic diameter (LVDd) could predict mortality from heart failure in patients with Duchenne muscular dystrophy (DMD) receiving standard cardio-protective therapies. PATIENTS AND METHODS One hundred thirty-three patients with DMD aged ≥10 years who underwent echocardiography from 2011 to 2015 were included in this study and retrospectively followed until August 2018. Patients were divided into two groups according to LVDd at initial echocardiography: ≤ 54 mm (Group 1: n=119) and ≥ 55 mm (Group 2: n=14). To identify factors other than LVDd that may affect heart failure-related mortality, Group 2 patients who developed no left atrial (LA) enlargement, moderate mitral regurgitation (MR), or pulmonary hypertension (PH) during the observation period (Group 2A: n=5) were compared with those who newly developed one or more of those complications (Group 2B: n=7). Clinical outcomes were all-cause mortality and mortality from heart failure. RESULTS Mean observation period was 5.5±1.5 years in Group 1 and 4.4±1.9 years in Group 2. A total of 14 patients (10.5%) died, including 6 of 119 (5.0%) patients in Group 1 and 8 of 14 (57.1%) patients in Group 2 (p<0.001). Among these, 1 (0.8%) patient in Group 1 and 8 (57.1%) patients in Group 2 died from heart failure (p<0.001). Group 2B patients had shorter survival compared to Group 2A patients (p=0.006). CONCLUSION LVDd ≥ 55 mm is a predictive factor for mortality from heart failure in patients with DMD. Complications including LA enlargement, moderate MR, and PH were found to be predictive factors for mortality from heart failure in a short period.
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Affiliation(s)
- Kazuhiko Segawa
- Department of Cardiology, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Norio Sugawara
- Department of Psychiatry, Dokkyo Medical University School of Medicine, Tochigi, Japan
| | - Kazushi Maruo
- Department of Biostatistics, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Koichi Kimura
- Department of General Medicine, The Institute of Medical Science, the University of Tokyo, Tokyo, Japan
| | - Hirofumi Komaki
- Translational Medical Center, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Yuji Takahashi
- Department of Neurology, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Masayuki Sasaki
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
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Dittrich S, Graf E, Trollmann R, Neudorf U, Schara U, Heilmann A, von der Hagen M, Stiller B, Kirschner J, Pozza RD, Müller-Felber W, Weiss K, von Au K, Khalil M, Motz R, Korenke C, Lange M, Wilichowski E, Pattathu J, Ebinger F, Wiechmann N, Schröder R. Effect and safety of treatment with ACE-inhibitor Enalapril and β-blocker metoprolol on the onset of left ventricular dysfunction in Duchenne muscular dystrophy - a randomized, double-blind, placebo-controlled trial. Orphanet J Rare Dis 2019; 14:105. [PMID: 31077250 PMCID: PMC6509833 DOI: 10.1186/s13023-019-1066-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 04/17/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND X-linked Duchenne muscular dystrophy (DMD), the most frequent human hereditary skeletal muscle myopathy, inevitably leads to progressive dilated cardiomyopathy. We assessed the effect and safety of a combined treatment with the ACE-inhibitor enalapril and the β-blocker metoprolol in a German cohort of infantile and juvenile DMD patients with preserved left ventricular function. METHODS TRIAL DESIGN Sixteen weeks single-arm open run-in therapy with enalapril and metoprolol followed by a two-arm 1:1 randomized double-blind placebo-controlled treatment in a multicenter setting. INCLUSION CRITERIA DMD boys aged 10-14 years with left ventricular fractional shortening [LV-FS] ≥ 30% in echocardiography. Primary endpoint: time from randomization to first occurrence of LV-FS < 28%. Secondary: changes of a) LV-FS from baseline, b) blood pressure, c), heart rate and autonomic function in ECG and Holter-ECG, e) cardiac biomarkers and neurohumeral serum parameters, f) quality of life, and g) adverse events. RESULTS From 3/2010 to 12/2013, 38 patients from 10 sites were centrally randomized after run-in, with 21 patients continuing enalapril and metoprolol medication and 17 patients receiving placebo. Until end of study 12/2015, LV-FS < 28% was reached in 6/21 versus 7/17 patients. Cox regression adjusted for LV-FS after run-in showed a statistically non-significant benefit for medication over placebo (hazard ratio: 0.38; 95% confidence interval: 0.12 to 1.22; p = 0.10). Analysis of secondary outcome measures revealed a time-dependent deterioration of LV-FS with no statistically significant differences between the two study arms. Blood pressure, maximal heart rate and mean-NN values were significantly lower at the end of open run-in treatment compared to baseline. Outcome analysis 19 months after randomization displayed significantly lower maximum heart rate and higher noradrenalin and renin values in the intervention group. No difference between treatments was seen for quality of life. As a single, yet important adverse event, the reversible deterioration of walking abilities of one DMD patient during the run-in period was observed. CONCLUSIONS Our analysis of enalapril and metoprolol treatment in DMD patients with preserved left ventricular function is suggestive to delay the progression of the intrinsic cardiomyopathy to left ventricular failure, but did not reach statistical significance, probably due to insufficient sample size. CLINICAL TRIAL REGISTRATION DRKS-number 00000115, EudraCT-number 2009-009871-36.
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Affiliation(s)
- Sven Dittrich
- Department Pediatric Cardiology, Erlangen University Hospital, Friedrich-Alexander Universität Erlangen-Nürnberg, Loschgestraße 15, 91054, Erlangen, Germany. .,German Competence Network for Congenital Heart Defects partner site, Berlin, Germany.
| | - Erika Graf
- Institute of Medical Biometry and Statistics, Clinical Trials Unit, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Regina Trollmann
- Department of Pediatrics, Division of Pediatric Neurology, Erlangen University Hospital, Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Ulrich Neudorf
- Clinic for Pediatrics III, University Hospital Essen, Essen, Germany
| | - Ulrike Schara
- Department of Neuropediatrics, University Hospital Essen, Essen, Germany
| | - Antje Heilmann
- Department of Pediatrics, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Maja von der Hagen
- Department of Neurological Surgery, University Hospital Carl-Gustav-Carus, Technical University of Dresden, Dresden, Germany
| | - Brigitte Stiller
- Department of Congenital Heart Disease and Pediatric Cardiology, University Heart Center Freiburg, Bad Krozingen, Freiburg, Germany
| | - Janbernd Kirschner
- Department of Neuropediatrics and Muscle Disorders, University Medical Center, Freiburg, Germany
| | - Robert Dalla Pozza
- Department of Pediatric Cardiology, Ludwig Maximilians-University of Munich, Munich, Germany
| | - Wolfgang Müller-Felber
- Department of Pediatric Neurology and Developmental Medicine, Ludwig-Maximilians- University of Munich, Munich, Germany
| | - Katja Weiss
- Pediatric Cardiology and Congenital Heart Disease, University Hospital Charité, Berlin, Germany
| | - Katja von Au
- Department of Pediatrics, Division of Neurology, University Hospital Charité, Berlin, Germany
| | - Markus Khalil
- Division of Pediatric Heart Surgery, Pediatric Heart Center, University Hospital UKGM, Justus-Liebig University, Giessen, Germany
| | - Reinald Motz
- Department of Pediatric Cardiology, Elisabeth Children's Hospital, Oldenburg, Germany
| | | | - Martina Lange
- Department of Pediatric Cardiology and Intensive Care Medicine, Heart Center, University Medical Center Göttingen, Göttingen, Germany
| | - Ekkehard Wilichowski
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Joseph Pattathu
- Department of Pediatric Cardiology, University of Heidelberg, Heidelberg, Germany
| | | | - Nicola Wiechmann
- Clinical Trials Unit of the Medical Center, University of Freiburg, Freiburg, Germany
| | - Rolf Schröder
- Institute of Neuropathology, Erlangen University Hospital, Erlangen, Germany
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Power LC, O'Grady GL, Hornung TS, Jefferies C, Gusso S, Hofman PL. Imaging the heart to detect cardiomyopathy in Duchenne muscular dystrophy: A review. Neuromuscul Disord 2018; 28:717-730. [PMID: 30119965 DOI: 10.1016/j.nmd.2018.05.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 05/24/2018] [Accepted: 05/29/2018] [Indexed: 01/16/2023]
Abstract
Duchenne Muscular Dystrophy is the most common paediatric neuromuscular disorder. Mutations in the DMD gene on the X-chromosome result in progressive skeletal muscle weakness as the main clinical manifestation. However, cardiac muscle is also affected, with cardiomyopathy becoming an increasingly recognised cause of morbidity, and now the leading cause of mortality in this group. The diagnosis of cardiomyopathy has often been made late due to technical limitations in transthoracic echocardiograms and delayed symptomatology in less mobile patients. Increasingly, evidence supports earlier pharmacological intervention in cardiomyopathy to improve outcomes. However, the optimal timing of initiation remains uncertain, and the benefits of prophylactic therapy are unproven. Current treatment guidelines suggest initiation of therapy once cardiac dysfunction is detected. This review focuses on new and evolving techniques for earlier detection of Duchenne muscular dystrophy-associated cardiomyopathy. Transthoracic echocardiography or cardiac magnetic resonance imaging performed under physiological stress (dobutamine or exercise), can unmask early cardiac dysfunction. Cardiac magnetic resonance imaging can define cardiac function with greater accuracy and reliability than an echocardiogram, and is not limited by body habitus. Improved imaging techniques, used in a timely fashion, offer the potential for early detection of cardiomyopathy and improved long-term outcomes.
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Affiliation(s)
- Lisa C Power
- Paediatric Neurology Department, Starship Children's Hospital, Auckland, New Zealand; Paediatric Endocrinology Department, Starship Children's Hospital, Auckland, New Zealand; Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Gina L O'Grady
- Paediatric Neurology Department, Starship Children's Hospital, Auckland, New Zealand.
| | - Tim S Hornung
- Paediatric Cardiology Department, Starship Children's Hospital, Auckland, New Zealand
| | - Craig Jefferies
- Paediatric Endocrinology Department, Starship Children's Hospital, Auckland, New Zealand
| | - Silmara Gusso
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Paul L Hofman
- Paediatric Endocrinology Department, Starship Children's Hospital, Auckland, New Zealand; Liggins Institute, University of Auckland, Auckland, New Zealand
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Lee S, Lee H, Eun LY, Gang SW. Cardiac function associated with home ventilator care in Duchenne muscular dystrophy. KOREAN JOURNAL OF PEDIATRICS 2018; 61:59-63. [PMID: 29563946 PMCID: PMC5854844 DOI: 10.3345/kjp.2018.61.2.59] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 09/09/2017] [Accepted: 09/28/2017] [Indexed: 01/16/2023]
Abstract
Purpose Cardiomyopathy is becoming the leading cause of death in patients with Duchenne muscular dystrophy because mechanically assisted lung ventilation and assisted coughing have helped resolve respiratory complications. To clarify cardiopulmonary function, we compared cardiac function between the home ventilator-assisted and non-ventilator-assisted groups. Methods We retrospectively reviewed patients with Duchenne muscular dystrophy from January 2010 to March 2016 at Gangnam Severance Hospital. Demographic characteristics, pulmonary function, and echocardiography data were investigated. Results Fifty-four patients with Duchenne muscular dystrophy were divided into 2 groups: home ventilator-assisted and non-ventilator-assisted. The patients in the home ventilator group were older (16.25±1.85 years) than those in the nonventilator group (14.73±1.36 years) (P=0.001). Height, weight, and body surface area did not differ significantly between groups. The home ventilator group had a lower seated functional vital capacity (1,038±620.41 mL) than the nonventilator group (1,455±603.12 mL). Mean left ventricular ejection fraction and fractional shortening were greater in the home ventilator group, but the data did not show any statistical difference. The early ventricular filling velocity/late ventricular filling velocity ratio (1.7±0.44) was lower in the home ventilator group than in the nonventilator group (2.02±0.62). The mitral valve annular systolic velocity was higher in the home ventilator group (estimated β, 1.06; standard error, 0.48). Patients with Duchenne muscular dystrophy on a ventilator may have better systolic and diastolic cardiac functions. Conclusion Noninvasive ventilator assistance can help preserve cardiac function. Therefore, early utilization of noninvasive ventilation or oxygen may positively influence cardiac function in patients with Duchenne muscular dystrophy.
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Affiliation(s)
- Sangheun Lee
- Division of Pediatric Cardiology, Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Heeyoung Lee
- Division of Pediatric Cardiology, Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Lucy Youngmin Eun
- Division of Pediatric Cardiology, Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Woong Gang
- Department of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul, Korea
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Sadek AA, Mahmoud SM, El-Aal MA, Allam AA, El-Halim WIA. Evaluation of cardiac functions in children with Duchenne Muscular Dystrophy: A prospective case-control study. Electron Physician 2017; 9:5732-5739. [PMID: 29403612 PMCID: PMC5783121 DOI: 10.19082/5732] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Accepted: 08/26/2017] [Indexed: 12/21/2022] Open
Abstract
Background Duchenne muscular dystrophy (DMD) is the most common childhood form of muscular dystrophy. The incidence of cardiomyopathy in DMD increases with age, so its early detection is important because institution of cardioprotective medical therapies may slow adverse remodeling and attenuate heart failure symptoms in these patients. Objective To assess the cardiac functions in children clinically suspected to have DMD. Methods Over a one-year period, 28 male children aged from 3 to 18 years old, who met the criteria for diagnosis of DMD compared to 47 healthy controls children, were approached to participate in the study. The included children were subjected to full clinical examination, and blood samples were collected to determine creatinine phosphokinase (CPK), troponin I enzyme, myoglobin and lactate dehydrogenase (LDH) enzyme level. Echocardiography and 12-leads electrocardiogram (ECG) were also done for children in both groups. Data were analyzed using Independent-samples t-test, Mann-Whitney U, Chi square, and Fisher’s exact test. Results The mean age of the cases group was 7.29±3.24 years versus 8.06±2.86 years for controls. In DMD group, 25% had positive family history of DMD while 35.7% of them had positive consanguinity. All cases had elevated CPK level while CPK level in controls was normal (p<0.0001). LDH level was elevated in 19 cases (67.86%) of DMD while all controls children had normal LDH level (p<0.0001). Furthermore, the mean serum myoglobin level of DMD patients was higher relative to that of healthy controls (39.39±7.25 versus 33.68 ±12.38 ng/ml respectively) (p=0.01). Echocardiography of our patients revealed that seven cases (25%) had low ejection fraction (EF) and fraction shortening (FS). In addition, all controls children had normal EF (p<0.0001) and normal FS (p<0.0001). Interestingly, ECG showed that 28.57% of cases had sinus tachycardia vs. 6.88% for controls (p=0.0001). Prolonged QTc interval was present in 39.29% of cases (mean 431.39±43.60) while all controls had normal QTc duration for age (mean of 415.17±25.2) (p<0.0001). Conclusion ECG manifestations in children with DMD in the form of sinus tachycardia and prolonged QTc interval are an early alarm for developing cardiomyopathy before overt echocardiographic findings appear.
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Affiliation(s)
- Abdelrahim Abdrabou Sadek
- Assistant Professor, Head of Pediatric Neurology and Psychiatry Unit, Pediatric Department, Faculty of Medicine, Sohag University, Sohag, Egypt
| | | | - Mohammed Abd El-Aal
- Professor and Chairman of Pediatric Cardiology Unit and Pediatric Department, Faculty of Medicine, Sohag University, Sohag, Egypt
| | - Ahmed Ahmed Allam
- Lecturer, Clinical Pathology Department, Faculty of Medicine, Sohag University, Sohag, Egypt
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10
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Aimo A, Giannoni A, Castiglione V, Mancuso M, Siciliano G, Piepoli MF, Passino C, Emdin M. Neurohormonal modulation for treatment of cardiac involvement in dystrophinopathies and mitochondrial disease. Eur J Prev Cardiol 2017; 24:1718-1724. [DOI: 10.1177/2047487317725018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Alberto Aimo
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Alberto Giannoni
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | | | | | | | | | - Claudio Passino
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Michele Emdin
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
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El-Aloul B, Altamirano-Diaz L, Zapata-Aldana E, Rodrigues R, Malvankar-Mehta MS, Nguyen CT, Campbell C. Pharmacological therapy for the prevention and management of cardiomyopathy in Duchenne muscular dystrophy: A systematic review. Neuromuscul Disord 2016; 27:4-14. [PMID: 27815032 DOI: 10.1016/j.nmd.2016.09.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 09/16/2016] [Accepted: 09/26/2016] [Indexed: 01/03/2023]
Abstract
Cardiomyopathy is a major source of morbidity and mortality in Duchenne muscular dystrophy (DMD) patients now that respiratory care has improved. There is currently no definitive evidence guiding the management of DMD-associated cardiomyopathy (DMD-CM). The objective of this systematic review was to evaluate the effectiveness of pharmacotherapies for the prevention and/or management of DMD-CM and to determine the optimal timing to commence these interventions. A systematic search was conducted in January 2016 using MEDLINE, EMBASE and CINAHL databases and grey literature sources for studies evaluating the use of angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers, beta-blockers or aldosterone antagonists. Study quality assessment was conducted using the Downs and Black quality assessment checklist. PRISMA reporting guidelines were used. Of the 15 studies included in this review, most were of low methodological quality. Meta-analysis was not possible due to heterogeneity of studies. ACE inhibitors, angiotensin receptor blockers, beta-blockers and/or aldosterone antagonists tended to improve or preserve left ventricular systolic function and delay the progression of DMD-CM. While there is evidence supporting the use of heart failure medication in patients with DMD, data regarding these interventions for delaying the onset of DMD-CM and when to initiate therapy are lacking. PROSPERO registration: CRD42015029555.
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Affiliation(s)
- Basmah El-Aloul
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Luis Altamirano-Diaz
- Department of Paediatrics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Eugenio Zapata-Aldana
- Department of Paediatrics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada; Clinical Neurological Sciences, Children's Hospital, London Health Sciences Center, London, ON, Canada
| | - Rebecca Rodrigues
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Monali S Malvankar-Mehta
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada; Department of Ophthalmology, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Cam-Tu Nguyen
- Department of Paediatrics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada; Clinical Neurological Sciences, Children's Hospital, London Health Sciences Center, London, ON, Canada
| | - Craig Campbell
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada; Department of Paediatrics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada; Clinical Neurological Sciences, Children's Hospital, London Health Sciences Center, London, ON, Canada.
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Spurney CF, McCaffrey FM, Cnaan A, Morgenroth LP, Ghelani SJ, Gordish-Dressman H, Arrieta A, Connolly AM, Lotze TE, McDonald CM, Leshner RT, Clemens PR. Feasibility and Reproducibility of Echocardiographic Measures in Children with Muscular Dystrophies. J Am Soc Echocardiogr 2015; 28:999-1008. [PMID: 25906753 DOI: 10.1016/j.echo.2015.03.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Indexed: 01/16/2023]
Abstract
BACKGROUND Cardiac disease is a major cause of death in patients with muscular dystrophies. The use of feasible and reproducible echocardiographic measures of cardiac function is critical to advance the field of therapeutics for dystrophic cardiomyopathy. METHODS Participants aged 8 to 18 years with genetically confirmed Duchenne muscular dystrophy (DMD), Becker muscular dystrophy, or limb-girdle muscular dystrophy were enrolled at five centers, and standardized echocardiographic examinations were performed. Measures of systolic and diastolic function and speckle-tracking echocardiography-derived cardiac strain were reviewed independently by two central readers. Furthermore, echocardiographic measures from participants with DMD were compared with those from retrospective age-matched control subjects from a single site to assess measures of myocardial function. RESULTS Forty-eight participants (mean age, 13.3 ± 2.7 years) were enrolled. Shortening fraction had a greater interobserver correlation (intraclass correlation coefficient [ICC] = 0.63) compared with ejection fraction (ICC = 0.49). One reader could measure ejection fraction in only 53% of participants. Myocardial performance index measured by pulse-wave Doppler and Doppler tissue imaging showed similar ICCs (0.55 and 0.54). Speckle-tracking echocardiography showed a high ICC (0.96). Focusing on participants with DMD (n = 33), significantly increased mitral A-wave velocities, lower E/A ratios, and lower Doppler tissue imaging mitral lateral E' velocities were observed compared with age-matched control subjects. Speckle-tracking echocardiography demonstrated subclinical myocardial dysfunction with decreased average circumferential and longitudinal strain in three distinct subgroups: participants with DMD with normal shortening fractions, participants with DMD aged < 13 years, and participants with DMD with myocardial performance index scores < 0.40 compared with control subjects. CONCLUSIONS In a muscular dystrophy cohort, assessment of cardiac function is feasible and reproducible using shortening fraction, diastolic measures, and myocardial performance index. Cardiac strain measures identified early myocardial disease in patients with DMD.
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Affiliation(s)
| | | | - Avital Cnaan
- Children's National Health System, Washington, District of Columbia
| | | | - Sunil J Ghelani
- Children's National Health System, Washington, District of Columbia
| | | | - Adrienne Arrieta
- Children's National Health System, Washington, District of Columbia
| | | | | | | | - Robert T Leshner
- Children's National Health System, Washington, District of Columbia; University of California, San Diego, San Diego, California
| | - Paula R Clemens
- University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Veterans Affairs Medical Center, Pittsburgh, Pennsylvania
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O'Brien L, Varadi R, Goldstein RS, Evans RA. Cardiac management of ventilator-assisted individuals with Duchenne muscular dystrophy. Chron Respir Dis 2015; 11:103-10. [PMID: 24728656 DOI: 10.1177/1479972314529673] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
As life expectancy of patients with Duchenne muscular dystrophy (DMD) has increased to the 5th decade, in part due to improved ventilatory support, cardiomyopathy is projected to increase as a cause of death. International guidelines recommend an annual assessment of cardiac function and initiation of appropriate pharmacological treatment. We conducted an audit of the cardiac management in patients with DMD requiring ventilatory support and reported a case series of the collated cardiac investigations. Patients with DMD requiring ventilatory support were included in the study. The date of the last electrocardiogram (ECG), echocardiogram (ECHO), cardiology review and pharmacological management were retrieved from the medical records. If an annual cardiac assessment had not been performed this was requested and the latest ECGs and ECHO reports were collated. A total of 30 patients with DMD (29 males, mean (SD) age of 30 (7) years) met the inclusion criteria. Although there was ECG and ECHO documentation in 24 and 21 individuals, respectively, it was only recent in 10 and 6 individuals. In all, 60% of patients had been assessed by a cardiologist, but only 10% within the last year. Over half of the patients failed to attend their new appointments. From the available results, 18 of the 19 patients had an abnormal ECG, 11 of the 16 patients had left ventricular (LV) impairment and 55% of patients had a change in prescription following cardiac investigations. There is a need for a coordinated cardiorespiratory approach towards adult patients with DMD. Over a third of patients had normal LV function suggesting that cardiomyopathy is not inevitable in this group.
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Affiliation(s)
- Lauren O'Brien
- 1Department of Respiratory Medicine, West Park Healthcare Centre, Toronto, Ontario, Canada
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Current Concepts in the Management of Duchenne Muscular Dystrophy. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2013. [DOI: 10.1007/s40141-013-0011-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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