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Cotrim C, Palinkas ED, Cotrim N. The Importance of Left Ventricular Outflow Tract and Mid-Ventricular Gradients in Stress Echocardiography: A Narrative Review. J Clin Med 2023; 12:5292. [PMID: 37629333 PMCID: PMC10455989 DOI: 10.3390/jcm12165292] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 08/07/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023] Open
Abstract
This review aims to serve as a guide for clinical practice and to appraise the current knowledge on exercise stress echocardiography in the evaluation of intraventricular obstruction in HCM, in patients with cardiac syndrome X, in athletes with symptoms related to exercise, and in patients with normal left ventricular systolic function and exercise-related unexplained tiredness. The appearance of intraventricular obstruction while exercising is considered rare, and it usually occurs in patients with hypertrophy of the left ventricle. The occurrence of intraventricular obstruction when exercising has been evidenced in patients with hypertrophic cardiomyopathy, athletes, patients with cardiac syndrome X, patients with syncope or dizziness related to exercise, and patients with dyspnea and preserved ejection fraction. The clinical significance of this observation and the exercise modality that is most likely to trigger intraventricular obstruction remains unknown. Supine exercise and lying supine after exercise are less technically demanding, but they are also less physiologically demanding than upright exercise. Importantly, in everyday life, human beings generally do not become supine after exercise, as takes place in post-exercise treadmill stress echocardiograms in most echocardiography labs. The presence of induced intraventricular obstruction might be considered when patients have exercise-related symptoms that are not understood, and to assess prognosis in hypertrophic cardiomyopathy.
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Affiliation(s)
- Carlos Cotrim
- Heart Center do Hospital da Cruz Vermelha, 1500-048 Lisboa, Portugal
- Cardiovascular Unit (UCARDIO), 2350-325 Riachos, Portugal
- Hospital Particular do Algarve, Gambelas, 8005-226 Faro, Portugal
| | | | - Nuno Cotrim
- Santarém Hospital, 2005-177 Santarém, Portugal;
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Cotrim CA, Café H, João I, Cotrim N, Guardado J, Cordeiro P, Cotrim H, Baquero L. Exercise stress echocardiography: Where are we now? World J Cardiol 2022; 14:64-82. [PMID: 35316975 PMCID: PMC8900523 DOI: 10.4330/wjc.v14.i2.64] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 07/04/2021] [Accepted: 01/29/2022] [Indexed: 02/06/2023] Open
Abstract
Exercise stress echocardiography (ESE) is a widely used diagnostic test in cardiology departments. ESE is mainly used to study patients with coronary artery disease; however, it has increasingly been used in other clinical scenarios including valve pathology, congenital heart disease, hypertrophic and dilated cardiomyopathies, athlete evaluations, diastolic function evaluation, and pulmonary circulation study. In our laboratories, we use an established methodology in which cardiac function is evaluated while exercising on a treadmill. After completing the exercise regimen, patients remain in a standing position or lie down on the left lateral decubitus, depending on the clinical questions to be answered for further evaluation. This method increases the quality and quantity of information obtained. Here, we present the various methods of exercise stress echocardiography and our experience in many clinical arenas in detail. We also present alternatives to ESE that may be used and their advantages and disadvantages. We review recent advances in ESE and future directions for this established method in the study of cardiac patients and underline the advantage of using a diagnostic tool that is radiation-free.
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Affiliation(s)
| | - Hugo Café
- Faculdade de Medicina, Algarve University, Faro 8005-139, Portugal
| | - Isabel João
- Department of Cardiology, Garcia de Orta Hospital, Almada 2805-267, Portugal
| | - Nuno Cotrim
- Department of Medicine, Garcia de Orta Hospital, Almada 2805-267, Portugal
| | - Jorge Guardado
- Cardiovascular Unit, UCARDIO, Centro Clinico, Riachos 2350-325, Portugal
| | - Pedro Cordeiro
- Department of Cardiology, Hospital Particular do Algarve, Faro 8005-226, Portugal
| | - Hortense Cotrim
- Faculdade de Medicina, Algarve University, Faro 8005-139, Portugal
| | - Luis Baquero
- Heart Center, Hospital da Cruz Vermelha Portuguesa, Lisboa 1549-008, Portugal
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Kossaify A, Bassil E, Kossaify M. Stress Echocardiography: Concept and Criteria, Structure and Steps, Obstacles and Outcomes, Focused Update and Review. Cardiol Res 2020; 11:89-96. [PMID: 32256915 PMCID: PMC7092766 DOI: 10.14740/cr851] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 01/28/2020] [Indexed: 01/06/2023] Open
Abstract
Stress echocardiography (SEC) is a technique established more than 35 years ago; however, it is still poorly implemented in many countries and institutions, and this reluctance may be related to many obstacles such as operator skills, lack of awareness or institutional policy. Stress echo was initially used for assessing coronary artery disease (CAD), with respect to myocardial viability, using wall motion response; however, current use of stress echo extends beyond CAD, such as valvular heart disease and diastolic stress test. Dobutamine is a commonly used agent when pharmaceutical approach is implemented. With regard to CAD, there are four stress responses: normal, ischemic, viable and necrotic. A low dose dobutamine protocol is recommended in patients with baseline wall motion abnormalities, and a very low dose dobutamine is used in low flow low gradient aortic stenosis in order to check the flow and contractility reserve. Of note, respecting protocols, indications and contraindications are important to avoid or minimize risks of complications during the procedure. This article presents a focused update and review regarding SEC, along with an overview of the different indications, structures and steps, and obstacles and outcomes; also the article aims to highlight more awareness and sensitization on this useful technique.
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Affiliation(s)
- Antoine Kossaify
- Cardiology Division, Echocardiology Unit, University Hospital Notre Dame des Secours, PO Box 3, Byblos, Lebanon.,Holy Spirit University of Kaslik (USEK), School of Medicine, St Charbel Street, Byblos, Lebanon
| | - Elie Bassil
- Cardiology Division, Echocardiology Unit, University Hospital Notre Dame des Secours, PO Box 3, Byblos, Lebanon.,Holy Spirit University of Kaslik (USEK), School of Medicine, St Charbel Street, Byblos, Lebanon
| | - Mikhael Kossaify
- Cardiology Division, Echocardiology Unit, University Hospital Notre Dame des Secours, PO Box 3, Byblos, Lebanon.,Holy Spirit University of Kaslik (USEK), School of Medicine, St Charbel Street, Byblos, Lebanon
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Elevated Level of Troponin but Not N-Terminal Probrain Natriuretic Peptide Is Associated with Increased Risk of Sudden Cardiac Death in Hypertrophic Cardiomyopathy Calculated According to the ESC Guidelines 2014. DISEASE MARKERS 2017; 2017:9417908. [PMID: 29358842 PMCID: PMC5735689 DOI: 10.1155/2017/9417908] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 09/08/2017] [Accepted: 09/26/2017] [Indexed: 01/06/2023]
Abstract
The aim of this study was to assess the relationship between biomarkers (high-sensitive troponin I [hs-TnI], N-Terminal probrain natriuretic peptide [NT-proBNP]) and calculated 5-year percentage risk score of sudden cardiac death (SCD) in hypertrophic cardiomyopathy (HCM). Methods. In 46 HCM patients (mean age 39 ± 7 years, 24 males and 22 females), echocardiographic examination, including the stimulating maneuvers to provoke maximized LVOT gradient, had been performed and next ECG Holter was immediately started. After 24 hours, the ECG Holter was finished and the hs-TnI and NT-proBNP have been measured. Patients were divided according to 1/value of both biomarkers (hs-TnI-positive and hs-TnI-negative subgroups) and 2/(NT-proBNP lower and higher subgroup divided by median). Results. In comparison between 19 patients (hs-TnI positive) versus 27 patients (hs-TnI negative), the calculated 5-year percentage risk of SCD in HCM was significantly greater (6.38 ± 4.17% versus 3.81 ± 3.23%, P < 0.05). In comparison between higher NT-proBNP versus lower NT-proBNP subgroups, the calculated 5-year percentage risk of SCD in HCM was not significantly greater (5.18 ± 3.63% versus 4.14 ± 4.18%, P > 0.05). Conclusions. Patients with HCM and positive hs-TnI test have a higher risk of SCD estimated according to SCD calculator recommended by the ESC Guidelines 2014 than patients with negative hs-TnI test.
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Dimitrow PP, Sorysz D, Hładij R, Chyrchel B, Dudzik B, Sułowicz W, Surdacki A. Patient after renal transplantation with syncope: Role of echocardiography in upright position. JOURNAL OF CLINICAL ULTRASOUND : JCU 2017; 45:616-620. [PMID: 28271534 DOI: 10.1002/jcu.22465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Revised: 01/13/2017] [Accepted: 01/24/2017] [Indexed: 06/06/2023]
Abstract
In Doppler echocardiography, testing left ventricular outflow tract (LVOT) gradient in the supine position (as is done in everyday practice) does not reflect the pathophysiology of this dynamic abnormality during the daily activities that trigger the symptoms (eg, syncope). LVOT obstruction is a dynamic phenomenon, strongly dependent on the left ventricular cavity size, geometric configuration of hypertrophy, load variability, contractility, and mitral apparatus abnormalities. LVOT gradient may develop not only in hypertrophic cardiomyopathy but also in various heart diseases. Recent investigations show that LVOT gradient should be measured also in the standing position. Here, we report the case of patient after renal transplantation, who developed LVOT gradient during orthostatic test. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 45:616-620, 2017.
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Affiliation(s)
- Paweł Petkow Dimitrow
- 2nd Department of Cardiology, Jagiellonian University Medical College, ul. Kopernika 17, 31-501, Kraków, Polska
| | - Danuta Sorysz
- 2nd Department of Cardiology, Jagiellonian University Medical College, ul. Kopernika 17, 31-501, Kraków, Polska
| | - Rafał Hładij
- 2nd Department of Cardiology, Jagiellonian University Medical College, ul. Kopernika 17, 31-501, Kraków, Polska
| | - Bernadeta Chyrchel
- 2nd Department of Cardiology, Jagiellonian University Medical College, ul. Kopernika 17, 31-501, Kraków, Polska
| | - Barbara Dudzik
- Chair and Department of Nephrology, Jagiellonian University Medical College, Kraków, Poland
| | - Władysław Sułowicz
- Chair and Department of Nephrology, Jagiellonian University Medical College, Kraków, Poland
| | - Andrzej Surdacki
- 2nd Department of Cardiology, Jagiellonian University Medical College, ul. Kopernika 17, 31-501, Kraków, Polska
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Hładij R, Rajtar-Salwa R, Dimitrow PP. Troponin as ischemic biomarker is related with all three echocardiographic risk factors for sudden death in hypertrophic cardiomyopathy (ESC Guidelines 2014). Cardiovasc Ultrasound 2017; 15:24. [PMID: 28903763 PMCID: PMC5598038 DOI: 10.1186/s12947-017-0115-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Accepted: 09/06/2017] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Sudden cardiac death (SCD) risk stratification is the most important preventive action in patients with hypertrophic cardiomyopathy (HCM). The identification of the ischemia biomarker high sensitive troponin I (hs-TnI) role for this arrhythmic disease may provide additional information for SCD risk stratification. The aim of the study was to compare echocardiographic parameters (prognostic for risk stratification of SCD in HCM) among two subgroups of HCM patients: with elevated hs-TnI versus non-elevated hs-TnI level. METHODS In 51 HCM patients (mean age 39 ± 8 years, 31 males and 20 females) an echocardiographic examination, including the stimulating maneuvers to provoke maximized LVOT gradient, was performed. The hs-TnI was measured 24 h later. RESULTS By comparing two subgroups of patients, 26 members with hs-TnI positive versus 25 with hs-TnI negative, the study showed that the values of all three parameters were greater: provocable left ventricular outflow tract gradient (LVOTG) - 49.1 ± 45.9 vs 25.5 ± 24.8 mmHg, p = 0.019; left atrial diameter - 50.1 ± 9.6 vs 43.9 ± 9.8 mmHg, p = 0.041; maximal LV thickness - 22.1 ± 5.3 vs 19.9 ± 34 mm, p = 0.029. CONCLUSION The increased value of all three echocardiographic parameters used as risk factors for SCD (ESC Guidelines) is related to the elevated level of hs-TnI in HCM. Due to the high LVOTG - great hs-TnI relationship, exercise stress, both diagnostic and even rehabilitation/training, should be monitored by biomarker control.
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Affiliation(s)
- Rafał Hładij
- 2nd Department of Cardiology, Jagiellonian University Medical College, Kraków, Poland
| | - Renata Rajtar-Salwa
- 2nd Department of Cardiology, Jagiellonian University Medical College, Kraków, Poland
| | - Paweł Petkow Dimitrow
- 2nd Department of Cardiology, Jagiellonian University Medical College, Kraków, Poland. .,II Klinika Kardiologii CMUJ, ul. Kopernika 17, 31-501, Kraków, Poland.
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7
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Giacomelli R, Di Cesare E, Cipriani P, Ruscitti P, Di Sibio A, Liakouli V, Gennarelli A, Carubbi F, Splendiani A, Berardicurti O, Di Benedetto P, Ciccia F, Guggino G, Radchenko G, Triolo G, Masciocchi C. Pharmacological stress, rest perfusion and delayed enhancement cardiac magnetic resonance identifies very early cardiac involvement in systemic sclerosis patients of recent onset. Int J Rheum Dis 2017; 20:1247-1260. [DOI: 10.1111/1756-185x.13107] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Roberto Giacomelli
- Division of Rheumatology; Department of Biotechnological and Applied Clinical Science; School of Medicine; University of L'Aquila; L'Aquila Italy
| | - Ernesto Di Cesare
- Department of Biotechnological and Applied Clinical Sciences; Division of Cardiac Radiology; Laboratory of Radiobiology; University of L'Aquila; L'Aquila Italy
| | - Paola Cipriani
- Division of Rheumatology; Department of Biotechnological and Applied Clinical Science; School of Medicine; University of L'Aquila; L'Aquila Italy
| | - Piero Ruscitti
- Division of Rheumatology; Department of Biotechnological and Applied Clinical Science; School of Medicine; University of L'Aquila; L'Aquila Italy
| | - Alessandra Di Sibio
- Department of Biotechnological and Applied Clinical Sciences; Division of Radiology; Laboratory of Radiobiology; University of L'Aquila; L'Aquila Italy
| | - Vasiliki Liakouli
- Division of Rheumatology; Department of Biotechnological and Applied Clinical Science; School of Medicine; University of L'Aquila; L'Aquila Italy
| | - Antonio Gennarelli
- Department of Biotechnological and Applied Clinical Sciences; Division of Radiology; Laboratory of Radiobiology; University of L'Aquila; L'Aquila Italy
| | - Francesco Carubbi
- Division of Rheumatology; Department of Biotechnological and Applied Clinical Science; School of Medicine; University of L'Aquila; L'Aquila Italy
| | - Alessandra Splendiani
- Department of Biotechnological and Applied Clinical Sciences; Division of Radiology; Laboratory of Radiobiology; University of L'Aquila; L'Aquila Italy
| | - Onorina Berardicurti
- Division of Rheumatology; Department of Biotechnological and Applied Clinical Science; School of Medicine; University of L'Aquila; L'Aquila Italy
| | - Paola Di Benedetto
- Division of Rheumatology; Department of Biotechnological and Applied Clinical Science; School of Medicine; University of L'Aquila; L'Aquila Italy
| | - Francesco Ciccia
- Division of Rheumatology; Department of Internal Medicine; University of Palermo; Palermo Italy
| | - Giuliana Guggino
- Division of Rheumatology; Department of Internal Medicine; University of Palermo; Palermo Italy
| | - Ganna Radchenko
- Institute of Cardiology of Ukrainian National Academy of Medical Science; Kyiv Ukraine
| | - Giovanni Triolo
- Division of Rheumatology; Department of Internal Medicine; University of Palermo; Palermo Italy
| | - Carlo Masciocchi
- Department of Biotechnological and Applied Clinical Sciences; Division of Radiology; Laboratory of Radiobiology; University of L'Aquila; L'Aquila Italy
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Exercise stress echocardiography in hypertrophic cardiomyopathy. J Echocardiogr 2017; 15:110-117. [PMID: 28501918 DOI: 10.1007/s12574-017-0338-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 04/19/2017] [Accepted: 04/28/2017] [Indexed: 01/06/2023]
Abstract
In this review, we make a comprehensive summary of exercise stress echocardiography in hypertrophic cardiomyopathy (HCM) and practical tips used in our hospital. The main objective of performing exercise stress echocardiography in patients with HCM is to evaluate left ventricular outflow tract obstruction, mitral regurgitation, left ventricular asynergy, and diastolic function during exercise. There are limitations to the explanations that can be provided for exertional symptoms when resting echocardiography is performed in patients with HCM. In contrast, exercise stress echocardiography causes the manifestation of findings that are latent at rest, which possibly provides the elucidation of symptom etiology. In this article, we focus on the usefulness of exercise stress echocardiography in HCM.
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Reant P, Dufour M, Peyrou J, Reynaud A, Rooryck C, Dijos M, Vincent C, Cornolle C, Roudaut R, Lafitte S. Upright treadmill vs. semi-supine bicycle exercise echocardiography to provoke obstruction in symptomatic hypertrophic cardiomyopathy: a pilot study. Eur Heart J Cardiovasc Imaging 2017; 19:31-38. [DOI: 10.1093/ehjci/jew313] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 11/28/2016] [Indexed: 02/06/2023] Open
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Obstructive Form of Hypertrophic Cardiomyopathy-Left Ventricular Outflow Tract Gradient: Novel Methods of Provocation, Monitoring of Biomarkers, and Recent Advances in the Treatment. BIOMED RESEARCH INTERNATIONAL 2016; 2016:1575130. [PMID: 27247935 PMCID: PMC4877458 DOI: 10.1155/2016/1575130] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Revised: 03/17/2016] [Accepted: 04/06/2016] [Indexed: 02/07/2023]
Abstract
Dynamic (latent or/and labile) obstruction of left ventricular outflow (LVOT) was recognized from the earliest clinical descriptions of hypertrophic cardiomyopathy (HCM) and has proved to be a complex phenomenon, as well as arguably the most audible (“visible”) pathophysiological hallmark of this heterogeneous disease. The aim of the current review is focused on two novel issues in a subgroup of obstructive HCM. Firstly, the important methodological problem in HCM is the examination of a subgroup of patients with nonobstructive hypertrophy in resting conditions and hard, but possible provoking obstruction. Recently, investigators have proposed physiological stress test (with double combined stimuli) to disclose such type of patients. The upright exercise is described in the ESC guideline on hypertrophic cardiomyopathy from 2014 and may appear as a candidate for gold standard provocation test. The second novel area of interest is associated with elevated level of signaling biomarkers: hypercoagulation, hemolysis, acquired von Willebrand 2A disease, and enhanced oxidative stress. The accelerated and turbulent flow within narrow LVOT may be responsible for these biochemical disturbances. The most recent advances in the treatment of obstructive HCM are related to nonpharmacological methods of LVOT gradient reduction. This report extensively discusses novel methods.
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Dimitrow PP, Cheng TO. WITHDRAWN: Hypertrophic cardiomyopathy: Genotype-positive, phenotype-“almost” negative. Diagnostic role of exercise in provocation of left ventricular outflow tract gradient. Int J Cardiol 2015; 191:323. [DOI: 10.1016/j.ijcard.2014.09.137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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12
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Dimitrow PP, Cheng TO. Hypertrophic cardiomyopathy: genotype-positive, phenotype-"almost" negative. Diagnostic role of exercise in provocation of left ventricular outflow tract gradient. Int J Cardiol 2014; 177:736-7. [PMID: 25449499 DOI: 10.1016/j.ijcard.2014.09.159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 09/27/2014] [Indexed: 11/17/2022]
Abstract
It has been proposed to use exercise stress echocardiography in the upright position with left ventricular outflow tract gradient monitoring both during and after exercise as a marker of genotype-positive/phenotype negative hypertrophic cardiomyopathy (HCM). Doppler measurement of gradient has been a very helpful and diagnostic examination in several subgroups of subjects (especially in young persons, athletes). Recently, many noninvasive (bio)markers have been found to be very helpful in screening patients suspected of HCM before full expression of phenotype.
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Affiliation(s)
| | - Tsung O Cheng
- Department of Medicine, The George Washington University Medical Center, 2150 Pennsylvania Avenue NW, Washington, DC 20037, USA.
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