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Syncope in hypertrophic cardiomyopathy (part I): An updated systematic review and meta-analysis. Int J Cardiol 2022; 357:88-94. [PMID: 35304190 DOI: 10.1016/j.ijcard.2022.03.028] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 03/02/2022] [Accepted: 03/11/2022] [Indexed: 12/30/2022]
Abstract
AIMS To describe the proportion of patients with syncope among those affected by hypertrophic cardiomyopathy (HCM) and the relevance of syncope as risk factor for sudden cardiac death and life-threatening arrhythmic events. METHOD AND RESULTS Systematic review of original articles that assessed syncope in HCM patients. Literature search of PubMed including all English publications from 1973 to 2021.We found 57 articles for a total of 21.791 patients; of these, 14 studies reported on arrhythmic events in the follow-up. Syncope was reported in 15.8% (3.452 of 21.791) patients. It was considered unexplained in 91% of cases. Life-threatening arrhythmic events occurred in 3.6% of non-syncopal patients and in 7.7% of syncopal patients during a mean follow-up of 5.6 years. A relative risk of 1.99 (95%CI 1.39 to 2.86) was estimated for syncope patients by the random effect model using Haldane continuity correction for 0 events. CONCLUSIONS In the current practice, the cause of syncope remained unexplained in most patients affected by HCM. The management of patients seems mainly driven by risk stratification rather than identification of the aetiology of syncope. There is a need of precise instructions how to apply the recommendations of current guidelines to this disease, which tests are indicated and how to interpret their findings. The protocol was registered in Prospero (ID: 275963).
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Arnold AD, Howard JP, Chiew K, Kerrigan WJ, de Vere F, Johns HT, Churlilov L, Ahmad Y, Keene D, Shun-Shin MJ, Cole GD, Kanagaratnam P, Sohaib SMA, Varnava A, Francis DP, Whinnett ZI. Right ventricular pacing for hypertrophic obstructive cardiomyopathy: meta-analysis and meta-regression of clinical trials. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2020; 5:321-333. [PMID: 30715300 PMCID: PMC6775860 DOI: 10.1093/ehjqcco/qcz006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 01/25/2019] [Accepted: 01/31/2019] [Indexed: 01/25/2023]
Abstract
Aims Right ventricular pacing for left ventricular outflow tract gradient reduction in hypertrophic obstructive cardiomyopathy remains controversial. We undertook a meta-analysis for echocardiographic and functional outcomes. Methods and results Thirty-four studies comprising 1135 patients met eligibility criteria. In the four blinded randomized controlled trials (RCTs), pacing reduced gradient by 35% [95% confidence interval (CI) 23.2–46.9, P < 0.0001], but there was only a trend towards improved New York Heart Association (NYHA) class [odds ratio (OR) 1.82, CI 0.96–3.44; P = 0.066]. The unblinded observational studies reported a 54.3% (CI 44.1–64.6, P < 0.0001) reduction in gradient, which was a 18.6% greater reduction than the RCTs (P = 0.0351 for difference between study designs). Observational studies reported an effect on unblinded NYHA class at an OR of 8.39 (CI 4.39–16.04, P < 0.0001), 450% larger than the OR in RCTs (P = 0.0042 for difference between study designs). Across all studies, the gradient progressively decreased at longer follow durations, by 5.2% per month (CI 2.5–7.9, P = 0.0001). Conclusion Right ventricular pacing reduces gradient in blinded RCTs. There is a non-significant trend to reduction in NYHA class. The bias in assessment of NYHA class in observational studies appears to be more than twice as large as any genuine treatment effect.
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Affiliation(s)
- Ahran D Arnold
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, Du Cane Road, London, UK
| | - James P Howard
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, Du Cane Road, London, UK
| | - Kayla Chiew
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, Du Cane Road, London, UK
| | - William J Kerrigan
- Cardiology Department, Imperial College Healthcare NHS Trust, Du Cane Road, London, UK
| | - Felicity de Vere
- Cardiology Department, Imperial College Healthcare NHS Trust, Du Cane Road, London, UK
| | - Hannah T Johns
- University of Melbourne, Burgundy Street, Heidelberg, Victoria, Australia
| | - Leonid Churlilov
- University of Melbourne, Burgundy Street, Heidelberg, Victoria, Australia
| | - Yousif Ahmad
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, Du Cane Road, London, UK
| | - Daniel Keene
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, Du Cane Road, London, UK
| | - Matthew J Shun-Shin
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, Du Cane Road, London, UK
| | - Graham D Cole
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, Du Cane Road, London, UK
| | - Prapa Kanagaratnam
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, Du Cane Road, London, UK
| | - S M Afzal Sohaib
- Cardiology Department, St Bartholomew's Hospital, W Smithfield, London, UK
| | - Amanda Varnava
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, Du Cane Road, London, UK
| | - Darrel P Francis
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, Du Cane Road, London, UK
| | - Zachary I Whinnett
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, Du Cane Road, London, UK
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Daubert C, Gadler F, Mabo P, Linde C. Pacing for hypertrophic obstructive cardiomyopathy: an update and future directions. Europace 2017; 20:908-920. [DOI: 10.1093/europace/eux131] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 04/18/2017] [Indexed: 11/15/2022] Open
Affiliation(s)
- Claude Daubert
- Faculté de Médecine, Université de Rennes 1, France
- LTSI INSERM U1099, Rennes, France
| | - Fredrik Gadler
- Karolinska University Hospital, Heart and Vascular Theme, FoU Tema Hjärta Kärl S102, S- 17176 Stockholm, Sweden
- Karolinska Institutet, Department of Medicine, Stockholm, Sweden
| | - Philippe Mabo
- Faculté de Médecine, Université de Rennes 1, France
- LTSI INSERM U1099, Rennes, France
- Service de Cardiologie et Maladies vasculaires, Centre Hospitalier Universitaire de Rennes 35033, France
| | - Cecilia Linde
- Karolinska University Hospital, Heart and Vascular Theme, FoU Tema Hjärta Kärl S102, S- 17176 Stockholm, Sweden
- Karolinska Institutet, Department of Medicine, Stockholm, Sweden
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Qintar M, Morad A, Alhawasli H, Shorbaji K, Firwana B, Essali A, Kadro W. Pacing for drug-refractory or drug-intolerant hypertrophic cardiomyopathy. Cochrane Database Syst Rev 2012; 2012:CD008523. [PMID: 22592731 PMCID: PMC8094451 DOI: 10.1002/14651858.cd008523.pub2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Hypertrophic cardiomyopathy (HCM) is a genetic disease with an autosomal-dominant inheritance for which negative inotropes are the most widely used initial therapies. Observational studies and small randomised trials have suggested symptomatic and functional benefits using pacing and several theories have been put forward to explain why. Pacing, although not the primary treatment for HCM, could be beneficial to patients with relative or absolute contraindications to surgery or alcohol ablation. Several randomised controlled trials comparing pacing to other therapeutic modalities have been conducted but no Cochrane-style systematic review has been done. OBJECTIVES To assess the effects of pacing in drug-refractory or drug-intolerant hypertrophic cardiomyopathy patients. SEARCH METHODS We searched the following on the 14/4/2010: CENTRAL (The Cochrane Library 2010, Issue 1), MEDLINE OVID (from 1950 onwards ), EMBASE OVID (from 1980 onwards ), Web of Science with Conference Proceedings (from 1970 onwards). No language restrictions were applied. SELECTION CRITERIA Randomised controlled trials of either parallel or crossover design that assess the beneficial and harmful effects of pacing for hypertrophic cardiomyopathy were included. When crossover studies were identified, we considered data only from the first phase. DATA COLLECTION AND ANALYSIS Data from included studies were extracted onto a pre-formed data extraction paper by two authors independently. Data was then entered into Review Manager 5.1 for analysis. Risk of bias was assessed using the guidance provided in the Cochrane Handbook. For dichotomous data, relative risk was calculated; and for continuous data, the mean differences were calculated. Where appropriate data were available, meta-analysis was performed. Where meta-analysis was not possible, a narrative synthesis was written. A QUROUM flow chart was provided to show the flow of papers. MAIN RESULTS Five studies (reported in 10 papers) were identified. However, three of the five studies provided un-usable data. Thus the data from only two studies (reported in seven papers) with 105 participants were included for this review. There was insufficient data to compare results on all-cause mortality, cost effectiveness, exercise capacity, Quality of life and Peak O2 consumption.When comparing active pacing versus placebo pacing on exercise capacity, one study showed that exercise time decreased from (13.1 ± 4.4) minutes to (12.6 ± 4.3) minutes in the placebo group and increased from (12.1 ± 5.6) minutes to (12.9 ± 4.2) minutes in the treatment group (MD 0.30; 95% CI -1.54 to 2.14). Statistically significant data from the same study showed that left ventricular outflow tract obstruction decreased from (71 ± 32) mm Hg to (52 ± 34) mm Hg in the placebo group and from (70 ± 24) mm Hg to (33 ± 27) mm Hg in the active pacing group (MD -19.00; 95% CI -32.29 to -5.71). This study was also able to show that New York Heart Association (NYHA) functional class decreased from (2.5 ± 0.5) to (2.2 ± 0.6) in the inactive pacing group and decreased from (2.6 ± 0.5) to (1.7 ± 0.7) in the placebo group (MD -0.50; 95% CI -0.78 to -0.22).When comparing active pacing versus trancoronary ablation of septal hypertrophy (TASH), data from one study showed that NYHA functional class decreased from (3.2 ± 0.7) to (1.5 ± 0.5) in the TASH group and decreased from (3.0 ± 0.1) to (1.9 ± 0.6) in the pacemaker group. This study also showed that LV wall thickness remained unchanged in the active pacing group compared to reduction from (22 ± 4) mm to (17 ± 3) mm in the TASH group (MD 0.60; 95% CI -5.65 to 6.85) and that LV outflow tract obstruction decreased from (80 ± 35.5) mm Hg in the TASH group to (49.3 ± 37.7) mm Hg in the pacemaker group. AUTHORS' CONCLUSIONS Trials published to date lack information on clinically relevant end-points. Existing data is derived from small trials at high risk of bias, which concentrate on physiological measures. Their results are inconclusive. Further large and high quality trials with more appropriate outcomes are warranted.
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Affiliation(s)
- Mohammed Qintar
- Cleveland Clinic, OH, USA, Faculty of Medicine, Damascus University, Damascus, Syrian Arab Republic.
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Prinz C, Farr M, Hering D, Horstkotte D, Faber L. The diagnosis and treatment of hypertrophic cardiomyopathy. DEUTSCHES ARZTEBLATT INTERNATIONAL 2011; 108:209-15. [PMID: 21505608 DOI: 10.3238/arztebl.2011.0209] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2009] [Accepted: 03/11/2010] [Indexed: 11/27/2022]
Abstract
BACKGROUND Hypertrophic cardiomyopathy (HCM) is the most common hereditary disease of the heart. METHODS In this article, we summarize the current state of the diagnosis and treatment of HCM on the basis of a selective review of recent publications with relevance to clinical practice. RESULTS Several hundred mutations in more than 27 genes, most of which encode sarcomeric structures, are associated with the HCM phenotype. Thus, HCM can be thought of as a sarcomeric disease, with myocardial fiber disarray as its histological hallmark. There are two types of HCM, a more common, obstructive type (HOCM, 70%) and a less common, non-obstructive type (HNCM; in all cases of HCM, testing should be performed to detect outflow obstruction at rest and/or on provocation, and to thereby determine whether HOCM or HNCM is present. The symptoms of HCM include dyspnea, angina pectoris, palpitations, dizziness, and occasionally syncope. Because sudden cardiac death is the most serious complication of HCM, particularly in young and asymptomatic patients, it follows that correct diagnosis, followed by risk stratification of patients with regard to the need for prophylactic implantation of an implantable cardiac defibrillator (ICD), can be of life-saving importance. The pharmacotherapy of symptomatic HNCM consists of the treatment of heart failure with a normal ejection fraction (HFNEF). In HOCM, the patient's symptoms and the obstructive gradient are the guide to treatment with beta-blockers or verapamil. For patients with drug-resistant disease, surgical myectomy and percutaneous septal ablation are now standard treatments. CONCLUSION A near-normal life expectancy and a highly satisfactory quality of life are now realistic treatment goals for patients with HCM.
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Affiliation(s)
- Christian Prinz
- Kardiologische Klinik, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen.
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Rinaldi CA, Bucknall CA, Gill JS. Beneficial effects of biventricular pacing in a patient with hypertrophic cardiomyopathy and intraventricular conduction delay. Heart 2002; 87:e6. [PMID: 12010954 PMCID: PMC1767121 DOI: 10.1136/heart.87.6.e6] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The beneficial use of biventricular pacing is reported in a patient with hypertrophic cardiomyopathy and intraventricular conduction delay. This resulted in improvements in symptomatic status and exercise tolerance that may be related to cardiac resynchronisation. The improvement in symptoms by biventricular pacing in a patient with hypertrophic cardiomyopathy and intraventricular conduction delay is previously undocumented and requires further investigation.
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Affiliation(s)
- C A Rinaldi
- Cardiothoracic Centre, Guys and St Thomas's NHS Trust, St Thomas's Hospital, London, SE1 7EH, UK.
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Abstract
Hypertrophic cardiomyopathy is a primary disease of the cardiac muscle characterized by a hypertrophied and nondilated left ventricle in the absence of other cardiac or systemic disease. The disorder occurs twice as often in men than in women and is relatively more common in young adults. Early treatment of symptoms may improve hemodynamic benefits and prevent complications, including sudden death. This case illustrates various treatment modalities used to manage symptoms and describes the challenges in effectively maintaining hemodynamic stability.
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Affiliation(s)
- L S Evangelista
- Department of Nursing, California State University, Los Angeles, USA
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Abstract
This review focuses on recent developments in the field of pacing in hypertrophic cardiomyopathy (HCM). Regarding mechanisms of action, recent data indicates that pacing acts by inducing dysynchronous left ventricular activation, thus reducing contractility and increasing end-systolic volume. Following several positive uncontrolled studies, three randomized crossover trials, with a total of approximately 140 patients, have now confirmed that gradients are on average halved with pacing but the reduction in symptoms has been modest and maximum exercise capacity has not been improved. These studies have identified a placebo effect from pacemaker implantation in HCM and have questioned the efficacy of pacing as a symptomatic therapy for HCM. There is probably a subgroup of patients with HCM who respond to permanent dual-chamber pacing but their precise identification is not yet clear. Permanent pacing should continue to be considered as one option in the management of the patient with drug refractory, symptomatic obstructive HCM.
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Affiliation(s)
- D M Gilligan
- Cardiology Section (111J-3), Veterans Affairs Medical Center, 1201 Broad Rock Boulevard, Richmond, VA 23249, USA. gilligan.
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Abstract
Current recommendations in favor of dual-chamber over single-chamber ventricular pacing for patients with sinus node dysfunction or AV conduction disorders were made largely based on observational data and expert opinions. The first randomized pacing mode selection study was relatively small and suggested survival advantage with physiologic pacing only after an extended follow-up duration of 5.5 years. Preliminary results of the first large-scale multicenter randomized pacing mode selection trial revealed only modest reduction in atrial fibrillation without survival advantage after 3 years of physiologic pacing. Two other large-scale multicenter randomized trials comparing physiologic versus ventricular pacing are currently ongoing. They may provide further scientific evidence based on which more objective recommendations can be made with respect to pacing mode selection.
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Affiliation(s)
- C Y Tang
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minnesota, USA.
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