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Cui Y, Shao S, Zhang L, Tang L, Xie P, Wei L, Duan H, Hua Y, Cai X, Zhou K, Wang C. The Vectorcardiogram Characteristic and Its Predictive Value for Reduced Left Ventricular Ejection Fraction of Children with Duchenne Muscular Dystrophy. Rev Cardiovasc Med 2024; 25:309. [PMID: 39228506 PMCID: PMC11367004 DOI: 10.31083/j.rcm2508309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 03/15/2024] [Accepted: 05/27/2024] [Indexed: 09/05/2024] Open
Abstract
Background The prognosis of Duchenne muscular dystrophy (DMD) is poor once it develops to the stage of cardiac impairment. Recent studies have demonstrated that electrocardiogram (ECG), which consists of general ECG and vectorcardiogram (VCG), retains an extremely powerful role in the assessment of patients with reduced left ventricular (LV) systolic dysfunction. However, data regarding VCG recordings in DMD and its prognostic value for reduced left ventricular ejection fraction (LVEF) of DMD have never been reported. This study aims to describe the characteristics of VCG in children with DMD and to explore the predictive value of VCG for reduced LVEF in children with DMD. Methods A total of 306 patients with a known diagnosis of DMD confirmed by the genetic test were retrospectively enrolled at our hospital between August 2018 and August 2022. This resulted in a total study group of 486 VCG recordings. Among them, 75 DMD patients who underwent cardiac magnetic resonance (CMR) later after one year follow-up were prospectively enrolled. The trend of VCG parameters of DMD patients across the different age span were compared with age-matched normal children. Concordance statistic analysis was further performed to assess the validity of VCG parameters in predicting the occurrence of reduced LVEF in patients with DMD. Results DMD patients have a significantly higher heart rate, R waves in V1, QRS loop percentage in the right anterior quadrant in the horizontal plane (horizontal quadrant II) and QRS loop percentage in the anterior superior quadrant in the sagittal plane (sagittal quadrant IV) than normal children. Concordance statistic (C-statistic) showed an area under the curve of quadrant IV in the sagittal plane of baseline was 0.704. The receiver operating characteristic (ROC) curve shows that quadrant IV in the sagittal plane of 7.57% was the optimal cutoff with a sensitivity of 53.3% and a specificity of 88.3% for predicting reduced LVEF in DMD patients. Conclusions Our study firstly showed that QRS loop percentage in the right anterior quadrant in the horizontal plane (horizontal quadrant II) and QRS loop percentage in the anterior superior quadrant in the sagittal plane (sagittal quadrant IV) could be abnormal in DMD boys as early as before 5 years old. Evaluation of the myocardium by VCG in the early age to predict possible cardiac systolic dysfunction may have important implications for the ongoing management of DMD boys.
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Affiliation(s)
- Yaru Cui
- Department of Pediatric Cardiology, West China Second University Hospital,
Sichuan University, 610041 Chengdu, Sichuan, China
- West China Medical School of Sichuan University, 610041 Chengdu, Sichuan,
China
| | - Shuran Shao
- Department of Pediatric Cardiology, West China Second University Hospital,
Sichuan University, 610041 Chengdu, Sichuan, China
- West China Medical School of Sichuan University, 610041 Chengdu, Sichuan,
China
| | - Linling Zhang
- Department of Pediatric Cardiology, West China Second University Hospital,
Sichuan University, 610041 Chengdu, Sichuan, China
- West China Medical School of Sichuan University, 610041 Chengdu, Sichuan,
China
| | - Liting Tang
- Department of Pediatric Cardiology, West China Second University Hospital,
Sichuan University, 610041 Chengdu, Sichuan, China
- West China Medical School of Sichuan University, 610041 Chengdu, Sichuan,
China
| | - Peihuan Xie
- West China Medical School of Sichuan University, 610041 Chengdu, Sichuan,
China
| | - Li Wei
- Department of Pediatric Cardiology, West China Second University Hospital,
Sichuan University, 610041 Chengdu, Sichuan, China
- West China Medical School of Sichuan University, 610041 Chengdu, Sichuan,
China
| | - Hongyu Duan
- Department of Pediatric Cardiology, West China Second University Hospital,
Sichuan University, 610041 Chengdu, Sichuan, China
- The Cardiac Development and Early Intervention Unit, West China Institute
of Women and Children's Health, West China Second University Hospital, Sichuan
University, 610041 Chengdu, Sichuan, China
| | - Yimin Hua
- Department of Pediatric Cardiology, West China Second University Hospital,
Sichuan University, 610041 Chengdu, Sichuan, China
- The Cardiac Development and Early Intervention Unit, West China Institute
of Women and Children's Health, West China Second University Hospital, Sichuan
University, 610041 Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children
(Sichuan University), Ministry of Education, 610041 Chengdu, Sichuan, China
- Key Laboratory of Development and Diseases of Women and Children of
Sichuan Province, West China Second University Hospital, Sichuan University,
610041 Chengdu, Sichuan, China
| | - Xiaotang Cai
- Department of Rehabilitation Medicine, West China Second
University Hospital, Sichuan University, 610041 Chengdu, Sichuan, China
| | - Kaiyu Zhou
- Department of Pediatric Cardiology, West China Second University Hospital,
Sichuan University, 610041 Chengdu, Sichuan, China
- The Cardiac Development and Early Intervention Unit, West China Institute
of Women and Children's Health, West China Second University Hospital, Sichuan
University, 610041 Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children
(Sichuan University), Ministry of Education, 610041 Chengdu, Sichuan, China
- Key Laboratory of Development and Diseases of Women and Children of
Sichuan Province, West China Second University Hospital, Sichuan University,
610041 Chengdu, Sichuan, China
| | - Chuan Wang
- Department of Pediatric Cardiology, West China Second University Hospital,
Sichuan University, 610041 Chengdu, Sichuan, China
- The Cardiac Development and Early Intervention Unit, West China Institute
of Women and Children's Health, West China Second University Hospital, Sichuan
University, 610041 Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children
(Sichuan University), Ministry of Education, 610041 Chengdu, Sichuan, China
- Key Laboratory of Development and Diseases of Women and Children of
Sichuan Province, West China Second University Hospital, Sichuan University,
610041 Chengdu, Sichuan, China
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2
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Hakimi M, Burnham T, Ramsay J, Cheung JW, Goyal NA, Jefferies JL, Donaldson D. Electrophysiologic and cardiovascular manifestations of Duchenne and Becker muscular dystrophies. Heart Rhythm 2024:S1547-5271(24)02882-0. [PMID: 38997055 DOI: 10.1016/j.hrthm.2024.07.008] [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: 03/25/2024] [Revised: 07/01/2024] [Accepted: 07/03/2024] [Indexed: 07/14/2024]
Abstract
There have been significant advances in the diagnosis and management of the hereditary muscular disorders Duchenne and Becker muscular dystrophy (DMD and BMD). Cardiac electrophysiologic and cardiovascular involvement has long been important in the surveillance, care, and prognosis of patients with both BMD and DMD and is the leading cause of mortality in patients with DMD. With improved long-term prognosis, rhythm disorders and progressive cardiomyopathy with resultant heart failure are increasingly common. This review aimed to provide an overview to electrophysiologists and cardiologists of the cardiac electrophysiologic phenotypes and genetics of BMD and DMD and to highlight the recent discoveries that have advanced clinical course and management. A systematic review was performed of the diagnosis and management of DMD and BMD. The Cochrane Library, PubMed, MEDLINE, Europe PubMed Central, AMED, and Embase databases were accessed for available evidence. The research reported in this paper adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Evidence from randomized controlled trials and studies cited in expert consensus and practice guidelines are examined. Advanced imaging techniques and a spectrum of rhythm disorders associated with the progressive cardiomyopathy are presented. Early initiation of heart failure therapies, the role of cardiac implantable devices, and novel gene therapies approved for use with the potential to alter the disease course are discussed. When profound cardiac and cardiac electrophysiologic involvement is diagnosed and treated earlier, outcomes for DMD and BMD patients may be improved.
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Affiliation(s)
- Matthew Hakimi
- Division of Cardiology, Weill Cornell Medical, New York, New York
| | - Tyson Burnham
- Division of Cardiology, Department of Medicine, University of California at Irvine, Irvine Medical Center, Orange, California.
| | - Jay Ramsay
- Division of Cardiology, Department of Medicine, University of California at Irvine, Irvine Medical Center, Orange, California
| | - Jim W Cheung
- Division of Cardiology, Weill Cornell Medical, New York, New York
| | - Namita A Goyal
- Department of Neurology, University of California at Irvine, Irvine Medical Center, Orange, California
| | | | - David Donaldson
- Division of Cardiology, Department of Medicine, University of California at Irvine, Irvine Medical Center, Orange, California
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3
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Starnes JR, Xu M, George‐Durrett K, Crum K, Raucci FJ, Spurney CF, Hor KN, Cripe LH, Husain N, Buddhe S, Gambetta K, Tamaroff J, Slaughter JC, Markham LW, Soslow JH. Rate of Change in Cardiac Magnetic Resonance Imaging Measures Is Associated With Death in Duchenne Muscular Dystrophy. J Am Heart Assoc 2024; 13:e032960. [PMID: 38686878 PMCID: PMC11179921 DOI: 10.1161/jaha.123.032960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 03/19/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Cardiovascular disease is the leading cause of death among patients with Duchenne muscular dystrophy (DMD). Identifying patients at risk of early death could allow for increased monitoring and more intensive therapy. Measures that associate with death could serve as surrogate outcomes in clinical trials. METHODS AND RESULTS Duchenne muscular dystrophy subjects prospectively enrolled in observational studies were included. Models using generalized least squares were used to assess the difference of cardiac magnetic resonance measurements between deceased and alive subjects. A total of 63 participants underwent multiple cardiac magnetic resonance imaging and were included in the analyses. Twelve subjects (19.1%) died over a median follow-up of 5 years (interquartile range, 3.1-7.0). Rate of decline in left ventricular ejection fraction was faster in deceased than alive subjects (P<0.0001). Rate of increase in indexed left ventricular end-diastolic (P=0.0132) and systolic (P<0.0001) volumes were higher in deceased subjects. Faster worsening in midcircumferential strain was seen in deceased subjects (P=0.049) while no difference in global circumferential strain was seen. The rate of increase in late gadolinium enhancement, base T1, and mid T1 did not differ between groups. CONCLUSIONS Duchenne muscular dystrophy death is associated with the rate of change in left ventricular ejection fraction, midcircumferential strain, and ventricular volumes. Aggressive medical therapy to decrease the rate of progression may improve the mortality rate in this population. A decrease in the rate of progression may serve as a valid surrogate outcome for therapeutic trials.
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Affiliation(s)
- Joseph R. Starnes
- Division of Cardiology, Department of PediatricsVanderbilt University Medical CenterNashvilleTNUSA
| | - Meng Xu
- Department of BiostatisticsVanderbilt UniversityNashvilleTNUSA
| | - Kristen George‐Durrett
- Division of Cardiology, Department of PediatricsVanderbilt University Medical CenterNashvilleTNUSA
| | - Kimberly Crum
- Division of Cardiology, Department of PediatricsVanderbilt University Medical CenterNashvilleTNUSA
| | - Frank J. Raucci
- Division of Cardiology, Department of PediatricsChildren’s Hospital of Richmond at Virginia Commonwealth UniversityRichmondVAUSA
| | | | - Kan N. Hor
- Division of Cardiology, Department of PediatricsNationwide Children’s Hospital, Ohio State UniversityColumbusOHUSA
| | - Linda H. Cripe
- Division of Cardiology, Department of PediatricsNationwide Children’s Hospital, Ohio State UniversityColumbusOHUSA
| | - Nazia Husain
- Division of Cardiology, Department of PediatricsAnn & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of MedicineChicagoILUSA
| | - Sujatha Buddhe
- Division of Cardiology, Department of PediatricsStanford University School of MedicineStanfordCAUSA
| | - Katheryn Gambetta
- Division of Cardiology, Department of PediatricsAnn & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of MedicineChicagoILUSA
| | - Jaclyn Tamaroff
- Division of Endocrinology and Diabetes, Department of PediatricsVanderbilt University Medical CenterNashvilleTNUSA
| | | | - Larry W. Markham
- Division of Cardiology, Department of PediatricsRiley Hospital for Children at Indiana University HealthIndianapolisINUSA
| | - Jonathan H. Soslow
- Division of Cardiology, Department of PediatricsVanderbilt University Medical CenterNashvilleTNUSA
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Łoboda A, Dulak J. Cardioprotective Effects of Hydrogen Sulfide and Its Potential Therapeutic Implications in the Amelioration of Duchenne Muscular Dystrophy Cardiomyopathy. Cells 2024; 13:158. [PMID: 38247849 PMCID: PMC10814317 DOI: 10.3390/cells13020158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/10/2024] [Accepted: 01/12/2024] [Indexed: 01/23/2024] Open
Abstract
Hydrogen sulfide (H2S) belongs to the family of gasotransmitters and can modulate a myriad of biological signaling pathways. Among others, its cardioprotective effects, through antioxidant, anti-inflammatory, anti-fibrotic, and proangiogenic activities, are well-documented in experimental studies. Cardiorespiratory failure, predominantly cardiomyopathy, is a life-threatening complication that is the number one cause of death in patients with Duchenne muscular dystrophy (DMD). Although recent data suggest the role of H2S in ameliorating muscle wasting in murine and Caenorhabditis elegans models of DMD, possible cardioprotective effects have not yet been addressed. In this review, we summarize the current understanding of the role of H2S in animal models of cardiac dysfunctions and cardiac cells. We highlight that DMD may be amenable to H2S supplementation, and we suggest H2S as a possible factor regulating DMD-associated cardiomyopathy.
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Affiliation(s)
- Agnieszka Łoboda
- Department of Medical Biotechnology, Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University in Krakow, Gronostajowa 7 Street, 30-387 Kraków, Poland;
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5
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Haddad CN, Ali S, Stephanou D, Assakura MS, Sahagian L, Trogkanis E. Pharmacological management of dilated cardiomyopathy in Duchenne muscular dystrophy: A systematic review. Hellenic J Cardiol 2023; 74:58-64. [PMID: 37406964 DOI: 10.1016/j.hjc.2023.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 06/10/2023] [Accepted: 06/27/2023] [Indexed: 07/07/2023] Open
Abstract
Duchenne muscular dystrophy is a fatal X-linked recessive disease affecting approximately 1 in 3500 births. It is characterized by a genetic lack of dystrophin, which is an essential protein for maintaining muscle integrity. The lack of dystrophin plays a pathophysiological role in the development of dilated cardiomyopathy in Duchenne muscular dystrophy. Currently, no consensus exists on specific pharmacological therapy guidelines for these patients; however, it centers around the guidelines for heart failure management. This systematic review investigated 12 randomized control trials dating back to 2005 in the pharmacotherapy of patients with dilated cardiomyopathy Duchenne muscular dystrophy. This review specifically included angiotensin-converting enzyme inhibitors, aldosterone receptor blockers, angiotensin receptor/neprilysin inhibitors, beta-blockers, and mineralocorticoid receptor antagonists. Despite their limitations, these studies have shown promising effects in improving the overall heart function and prognosis in patients with this condition. However, to attain higher statistical significance, future studies should investigate larger populations and for longer periods.
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Affiliation(s)
| | - Shirin Ali
- University of Nicosia Medical School, Nicosia, Cyprus
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6
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Soslow JH, Xu M, Slaughter JC, Crum K, Kaslow JA, George-Durrett K, Raucci FJ, Wilkinson JD, Cripe L, Hor K, Spurney CF, Markham LW. Cardiovascular Measures of All-Cause Mortality in Duchenne Muscular Dystrophy. Circ Heart Fail 2023; 16:e010040. [PMID: 37288563 PMCID: PMC10524475 DOI: 10.1161/circheartfailure.122.010040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 03/30/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND Cardiopulmonary failure is the leading cause of death in Duchenne muscular dystrophy (DMD). Research into DMD-specific cardiovascular therapies is ongoing, but there are no Food and Drug Administration-approved cardiac end points. To adequately power a therapeutic trial, appropriate end points must be chosen and the rate of change for these end points reported. The objective of this study was to evaluate rate of change for cardiac magnetic resonance and blood biomarkers and to determine which measures associate with all-cause mortality in DMD. METHODS Seventy-eight DMD subjects underwent 211 cardiac magnetic resonance studies analyzed for left ventricular (LV) ejection fraction, indexed LV end diastolic and systolic volumes, circumferential strain, late gadolinium enhancement presence and severity (global severity score, and full width half maximum), native T1 mapping, T2 mapping, and extracellular volume. Blood samples were analyzed for BNP (brain natriuretic peptide), NT-proBNP (N-terminal pro-B-type natriuretic peptide), and troponin I. Cox proportional hazard regression modeling was performed with all-cause mortality as the outcome. RESULTS Fifteen subjects (19%) died. LV ejection fraction, indexed end systolic volumes, global severity score, and full width half maximum worsened at 1 and 2 years while circumferential strain and indexed LV end diastolic volumes worsened at 2 years. LV ejection fraction, indexed LV end diastolic and systolic volumes, late gadolinium enhancement full width half maximum, and circumferential strain associated with all-cause mortality (P<0.05). NT-proBNP was the only blood biomarker that associated with all-cause mortality (P<0.05). CONCLUSIONS LV ejection fraction, indexed LV volumes, circumferential strain, late gadolinium enhancement full width half maximum, and NT-proBNP are associated with all-cause mortality in DMD and may be the best end points for use in cardiovascular therapeutic trials. We also report change over time of cardiac magnetic resonance and blood biomarkers.
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Affiliation(s)
- Jonathan H Soslow
- Division or Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Meng Xu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - James C Slaughter
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Kimberly Crum
- Division or Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Jacob A Kaslow
- Division of Pediatric Pulmonology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Kristen George-Durrett
- Division or Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Frank J Raucci
- Division of Pediatric Cardiology, Department of Pediatrics, Children’s Hospital of Richmond at Virginia Commonwealth University Health System, Richmond, VA 23298, USA
| | - James D Wilkinson
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Linda Cripe
- Division of Pediatric Cardiology, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH 43205 USA
| | - Kan Hor
- Division of Pediatric Cardiology, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH 43205 USA
| | - Christopher F Spurney
- Division of Cardiology, Children’s National Heart Institute, Children’s National Hospital, Washington, D.C. 20010, USA
| | - Larry W Markham
- Division of Cardiology, Department of Pediatrics, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
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7
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Chibuzo UN, Bruman M, Holguin A, Bangaru B. Duchenne Muscular Dystrophy Presenting as Incidental Hyper-Transaminasasemia in a Two-Month-Old Male. Cureus 2023; 15:e35498. [PMID: 37007358 PMCID: PMC10049938 DOI: 10.7759/cureus.35498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2023] [Indexed: 02/28/2023] Open
Abstract
Duchenne's muscular dystrophy (DMD) is a debilitating X-linked recessive disorder of dystrophin gene expression that culminates in the downregulation of dystrophin in cardiac and skeletal muscle. As a result, there is progressive muscle weakness, fibrosis, and atrophy. The skeletal and cardiac muscle degeneration rapidly progresses to the respective loss of ambulation and death from cardiac muscle failure by the second and fourth decades of life. Although muscle degeneration has been demonstrated in utero patients are initially asymptomatic. Therefore, diagnosis is typically delayed until about five years of age when proximal muscle weakness initiates a diagnostic workup that uncovers the disease. We present the rare case of an early diagnosis of DMD. A two-month-old, the only male offspring of a family with three children, was discovered to have hyper-transaminisemia during hospitalization for pneumonia. His preceding medical history was only significant for fever, cough, and rhinorrhea. The pregnancy and birth were uneventful. No abnormalities were detected on the newborn screen. Physical examination was reassuring with no peripheral stigmata of liver disease. Ultrasonographic assessments, metabolic assays, and infectious disease markers were within normal limits. Creatine kinase (CK) was markedly elevated and our patient was subsequently confirmed to be positive for a pathogenic hemizygous variant of the DMD gene. Reliance on an abnormal clinical presentation to trigger diagnostic workup for DMD has led to delays in the diagnosis of this genetic disorder. Incorporating CK analysis into newborn screening panels may enable more children to commence workup in infancy rather than at the current average age of 4.9 years. Early diagnosis is of value in the early initiation of monitoring, anticipatory guidance, and availing families' opportunities to harness current trends of care.
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Munongi L, Mawila D. Risk factors of orphan and vulnerable children in a children's home during the COVID-19 pandemic. CHILDREN AND YOUTH SERVICES REVIEW 2023; 145:106801. [PMID: 36618565 PMCID: PMC9803368 DOI: 10.1016/j.childyouth.2022.106801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/30/2022] [Accepted: 12/28/2022] [Indexed: 06/17/2023]
Abstract
Orphans and vulnerable children in children's homes are exposed to multiple psychosocial risks. This study aimed to explore the risks facing orphans and vulnerable children in a children's home in a township setting during COVID-19. Qualitative data was thematically analysed for this study. Fifty-eight female Black African children (n = 58) in a children's home were individually interviewed to ascertain the psychosocial risks that they experienced during COVID-19. The participants were orphans and vulnerable children residing in a children's home located in Johannesburg in South Africa. All children were enrolled in either primary or secondary schools located nearby the children's home. Boys were not included because the children's home only caters for females. The study found that unhealthy coping mechanisms, non-compliance with COVID-19 safety protocols, disruptive behaviour, fear of being infected and abuse by caregivers emerged as risks. We recommend that children be offered life skills such as coping mechanisms when faced with adversity, be constantly monitored to ensure adherence to safety rules and be given therapeutic interventions to deal with their fears. Furthermore, caregivers need to be psycho-educated on the giving of care to orphans and vulnerable children. The physical environment of the children's homes should be made conducive to allow healthy interactions with factors that impact on them.
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Affiliation(s)
- Lucia Munongi
- Faculty of Education, University of Johannesburg (Soweto Campus), GNA 224, Robert Sobukwe Building, 326 Chris Hani Road, Pimville 1809, South Africa
| | - Daphney Mawila
- Faculty of Education, University of Johannesburg (Soweto Campus), GNA 226, Robert Sobukwe Building, 326 Chris Hani Road, Pimville 1809, South Africa
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9
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Groh WJ, Bhakta D, Tomaselli GF, Aleong RG, Teixeira RA, Amato A, Asirvatham SJ, Cha YM, Corrado D, Duboc D, Goldberger ZD, Horie M, Hornyak JE, Jefferies JL, Kääb S, Kalman JM, Kertesz NJ, Lakdawala NK, Lambiase PD, Lubitz SA, McMillan HJ, McNally EM, Milone M, Namboodiri N, Nazarian S, Patton KK, Russo V, Sacher F, Santangeli P, Shen WK, Sobral Filho DC, Stambler BS, Stöllberger C, Wahbi K, Wehrens XHT, Weiner MM, Wheeler MT, Zeppenfeld K. 2022 HRS expert consensus statement on evaluation and management of arrhythmic risk in neuromuscular disorders. Heart Rhythm 2022; 19:e61-e120. [PMID: 35500790 DOI: 10.1016/j.hrthm.2022.04.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 04/21/2022] [Indexed: 11/04/2022]
Abstract
This international multidisciplinary document is intended to guide electrophysiologists, cardiologists, other clinicians, and health care professionals in caring for patients with arrhythmic complications of neuromuscular disorders (NMDs). The document presents an overview of arrhythmias in NMDs followed by detailed sections on specific disorders: Duchenne muscular dystrophy, Becker muscular dystrophy, and limb-girdle muscular dystrophy type 2; myotonic dystrophy type 1 and type 2; Emery-Dreifuss muscular dystrophy and limb-girdle muscular dystrophy type 1B; facioscapulohumeral muscular dystrophy; and mitochondrial myopathies, including Friedreich ataxia and Kearns-Sayre syndrome, with an emphasis on managing arrhythmic cardiac manifestations. End-of-life management of arrhythmias in patients with NMDs is also covered. The document sections were drafted by the writing committee members according to their area of expertise. The recommendations represent the consensus opinion of the expert writing group, graded by class of recommendation and level of evidence utilizing defined criteria. The recommendations were made available for public comment; the document underwent review by the Heart Rhythm Society Scientific and Clinical Documents Committee and external review and endorsement by the partner and collaborating societies. Changes were incorporated based on these reviews. By using a breadth of accumulated available evidence, the document is designed to provide practical and actionable clinical information and recommendations for the diagnosis and management of arrhythmias and thus improve the care of patients with NMDs.
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Affiliation(s)
- William J Groh
- Ralph H. Johnson VA Medical Center and Medical University of South Carolina, Charleston, South Carolina
| | - Deepak Bhakta
- Indiana University School of Medicine, Indianapolis, Indiana
| | | | | | | | - Anthony Amato
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | - Domenico Corrado
- Department of Cardiac, Thoracic, and Vascular Sciences, University of Padova, Padova, Italy
| | - Denis Duboc
- Cardiology Department, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Zachary D Goldberger
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Minoru Horie
- Shiga University of Medical Sciences, Otsu, Japan
| | | | | | - Stefan Kääb
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Jonathan M Kalman
- Royal Melbourne Hospital and University of Melbourne, Melbourne, Victoria, Australia
| | | | - Neal K Lakdawala
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Pier D Lambiase
- Barts Heart Centre, St Bartholomew's Hospital, University College London, and St Bartholomew's Hospital London, London, United Kingdom
| | | | - Hugh J McMillan
- Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | | | | | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Frederic Sacher
- Bordeaux University Hospital, LIRYC Institute, Bordeaux, France
| | | | | | | | | | - Claudia Stöllberger
- Second Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstraße, Vienna, Austria
| | - Karim Wahbi
- Cardiology Department, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
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10
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Bourke J, Turner C, Bradlow W, Chikermane A, Coats C, Fenton M, Ilina M, Johnson A, Kapetanakis S, Kuhwald L, Morley-Davies A, Quinlivan R, Savvatis K, Schiava M, Yousef Z, Guglieri M. Cardiac care of children with dystrophinopathy and females carrying DMD-gene variations. Open Heart 2022; 9:e001977. [PMID: 36252992 PMCID: PMC9577913 DOI: 10.1136/openhrt-2022-001977] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 09/26/2022] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE We provide succinct, evidence-based and/or consensus-based best practice guidance for the cardiac care of children living with Duchenne muscular dystrophy (DMD) as well as recommendations for screening and management of female carriers of mutations in the DMD-gene. METHODS Initiated by an expert working group of UK-based cardiologists, neuromuscular clinicians and DMD-patient representatives, draft guidelines were created based on published evidence, current practice and expert opinion. After wider consultation with UK-cardiologists, consensus was reached on these best-practice recommendations for cardiac care in DMD. RESULTS The resulting recommendations are presented in the form of a succinct care pathway flow chart with brief justification. The guidance signposts evidence on which they are based and acknowledges where there have been differences in opinion. Guidelines for cardiac care of patients with more advanced cardiac dystrophinopathy at any age have also been considered, based on the previous published work of Quinlivan et al and are presented here in a similar format. The recommendations have been endorsed by the British Cardiovascular Society. CONCLUSION These guidelines provide succinct, reasoned recommendations for all those managing paediatric patients with early or advanced stages of cardiomyopathy as well as females with cardiac dystrophinopathy. The hope is that this will result in more uniform delivery of high standards of care for children with cardiac dystrophinopathy, so improving heart health into adulthood through timely earlier interventions across the UK.
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Affiliation(s)
- John Bourke
- Department of Cardiology, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
- John Walton Muscular Dystrophy Research Centre, Newcastle University, Newcastle upon Tyne, UK
| | - Cathy Turner
- John Walton Muscular Dystrophy Research Centre, Newcastle University, Newcastle upon Tyne, UK
| | - William Bradlow
- Department of Paediatric Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ashish Chikermane
- Department of Cardiology, Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Caroline Coats
- Department of Cardiology, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Matthew Fenton
- Department of Paediatric Cardiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Maria Ilina
- Scottish Paediatric Cardiac Services, Royal Hospital for Children, Glasgow, UK
| | | | - Stam Kapetanakis
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Adrian Morley-Davies
- Department of Cardiology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Ros Quinlivan
- Department of Neuromuscular Disease, National Hospital for Neurology and Neurosurgery, London, UK
- Institute of Neurology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Konstantinos Savvatis
- Institute of Neurology, University College London Hospitals NHS Foundation Trust, London, UK
- Barts Heart Centre, Saint Bartholomew's Hospital Barts Heart Centre, London, UK
| | - Marianela Schiava
- John Walton Muscular Dystrophy Research Centre, Newcastle University, Newcastle upon Tyne, UK
| | - Zaheer Yousef
- Department of Cardiology, Cardiff and Vale University Health Board, Cardiff, UK
| | - Michela Guglieri
- John Walton Muscular Dystrophy Research Centre, Newcastle University, Newcastle upon Tyne, UK
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11
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Batra A, Barnard AM, Lott DJ, Willcocks RJ, Forbes SC, Chakraborty S, Daniels MJ, Arbogast J, Triplett W, Henricson EK, Dayan JG, Schmalfuss C, Sweeney L, Byrne BJ, McDonald CM, Vandenborne K, Walter GA. Longitudinal changes in cardiac function in Duchenne muscular dystrophy population as measured by magnetic resonance imaging. BMC Cardiovasc Disord 2022; 22:260. [PMID: 35681116 PMCID: PMC9185987 DOI: 10.1186/s12872-022-02688-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 05/19/2022] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND The lack of dystrophin in cardiomyocytes in Duchenne muscular dystrophy (DMD) is associated with progressive decline in cardiac function eventually leading to death by 20-40 years of age. The aim of this prospective study was to determine rate of progressive decline in left ventricular (LV) function in Duchenne muscular dystrophy (DMD) over 5 years. METHODS Short axis cine and grid tagged images of the LV were acquired in individuals with DMD (n = 59; age = 5.3-18.0 years) yearly, and healthy controls at baseline (n = 16, age = 6.0-18.3 years) on a 3 T MRI scanner. Grid-tagged images were analyzed for composite circumferential strain (ℇcc%) and ℇcc% in six mid LV segments. Cine images were analyzed for left ventricular ejection fraction (LVEF), LV mass (LVM), end-diastolic volume (EDV), end-systolic volume (ESV), LV atrioventricular plane displacement (LVAPD), and circumferential uniformity ratio estimate (CURE). LVM, EDV, and ESV were normalized to body surface area for a normalized index of LVM (LVMI), EDV (EDVI) and ESV (ESVI). RESULTS At baseline, LV ℇcc% was significantly worse in DMD compared to controls and five of the six mid LV segments demonstrated abnormal strain in DMD. Longitudinal measurements revealed that ℇcc% consistently declined in individuals with DMD with the inferior segments being more affected. LVEF progressively declined between 3 to 5 years post baseline visit. In a multivariate analysis, the use of cardioprotective drugs trended towards positively impacting cardiac measures while loss of ambulation and baseline age were associated with negative impact. Eight out of 17 cardiac parameters reached a minimal clinically important difference with a threshold of 1/3 standard deviation. CONCLUSION The study shows a worsening of circumferential strain in dystrophic myocardium. The findings emphasize the significance of early and longitudinal assessment of cardiac function in DMD and identify early biomarkers of cardiac dysfunction to help design clinical trials to mitigate cardiac pathology. This study provides valuable non-invasive and non-contrast based natural history data of cardiac changes which can be used to design clinical trials or interpret the results of current trials aimed at mitigating the effects of decreased cardiac function in DMD.
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Affiliation(s)
- Abhinandan Batra
- Department of Physical Therapy, University of Florida, Gainesville, FL, 32610, USA
| | - Alison M Barnard
- Department of Physical Therapy, University of Florida, Gainesville, FL, 32610, USA
| | - Donovan J Lott
- Department of Physical Therapy, University of Florida, Gainesville, FL, 32610, USA
| | - Rebecca J Willcocks
- Department of Physical Therapy, University of Florida, Gainesville, FL, 32610, USA
| | - Sean C Forbes
- Department of Physical Therapy, University of Florida, Gainesville, FL, 32610, USA
| | | | - Michael J Daniels
- Department of Statistics, University of Florida, Gainesville, FL, 32610, USA
| | - Jannik Arbogast
- Department of Physiology and Functional Genomics, University of Florida, 1600 SW Archer RD, M552, P.O. Box 1002754, Gainesville, FL, 32610, USA
| | - William Triplett
- Department of Physical Therapy, University of Florida, Gainesville, FL, 32610, USA
| | - Erik K Henricson
- Department of Physical Medicine and Rehabilitation, University of California, Davis, Sacramento, CA, 95817, USA
| | | | - Carsten Schmalfuss
- Department of Medicine, Cardiology, University of Florida, Gainesville, FL, 32610, USA
| | - Lee Sweeney
- Department of Pharmacology and Therapeutics, University of Florida, Gainesville, FL, 32610, USA
| | - Barry J Byrne
- Department of Pediatrics, University of Florida, Gainesville, FL, 32610, USA
| | - Craig M McDonald
- Department of Physical Medicine and Rehabilitation, University of California, Davis, Sacramento, CA, 95817, USA
| | - Krista Vandenborne
- Department of Physical Therapy, University of Florida, Gainesville, FL, 32610, USA
| | - Glenn A Walter
- Department of Physiology and Functional Genomics, University of Florida, 1600 SW Archer RD, M552, P.O. Box 1002754, Gainesville, FL, 32610, USA.
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12
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Landfeldt E, Ferizović N, Buesch K. Timing of Clinical Interventions in Patients With Duchenne Muscular Dystrophy: A Systematic Review and Grading of Evidence. J Neuromuscul Dis 2022; 9:353-364. [DOI: 10.3233/jnd-220804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Clinical medical management guidelines of Duchenne muscular dystrophy (DMD) emphasize prevention and early identification and treatment. Objective: The objective of our study was to review, synthesize, and grade published evidence of the impact of the timing of clinical interventions in DMD. Methods: We searched PubMed, Embase, and the Cochrane Library for records published from inception up until November 19, 2021, reporting evidence of the impact of the timing of clinical interventions in DMD. We assessed the quality of evidence using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework. Results: We included 12 publications encompassing 1,623 patients with DMD from seven countries (Australia, France, Germany, Italy, Japan, the United Kingdom, and the United States of America). Six (50%) studies reported evidence of an impact of the timing of initiation of glucocorticoids on loss of ambulation, cardiomyopathy, fractures, forced vital capacity, and height and BMI; four (33%) of cardiac medication (i.e., angiotensin-converting enzyme inhibitors, β-blockers, and eplerenone) on left ventricular size and function and survival; one (8%) of lower limb surgery on motor quotient and loss of ambulation; and one (8%) of ataluren on lower extremity and motor function. The overall quality of the body of evidence was low. Conclusion: While there is a clinical rationale for anticipatory diagnostic and therapeutic strategies, evidence of the impact of the timing of initiation of treatments in patients with DMD is still emerging. Further research of this topic is warranted to inform treatment guidelines in this indication.
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Affiliation(s)
| | | | - K. Buesch
- PTC Therapeutics Switzerland GmbH, Zug, Switzerland
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13
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Birnkrant DJ, Bello L, Butterfield RJ, Carter JC, Cripe LH, Cripe TP, McKim DA, Nandi D, Pegoraro E. Cardiorespiratory management of Duchenne muscular dystrophy: emerging therapies, neuromuscular genetics, and new clinical challenges. THE LANCET RESPIRATORY MEDICINE 2022; 10:403-420. [DOI: 10.1016/s2213-2600(21)00581-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 11/01/2021] [Accepted: 12/14/2021] [Indexed: 01/06/2023]
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14
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Morris CE, Wheeler JJ, Joos B. The Donnan-dominated resting state of skeletal muscle fibers contributes to resilience and longevity in dystrophic fibers. J Gen Physiol 2022; 154:212743. [PMID: 34731883 PMCID: PMC8570295 DOI: 10.1085/jgp.202112914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 09/30/2021] [Indexed: 11/28/2022] Open
Abstract
Duchenne muscular dystrophy (DMD) is an X-linked dystrophin-minus muscle-wasting disease. Ion homeostasis in skeletal muscle fibers underperforms as DMD progresses. But though DMD renders these excitable cells intolerant of exertion, sodium overloaded, depolarized, and spontaneously contractile, they can survive for several decades. We show computationally that underpinning this longevity is a strikingly frugal, robust Pump-Leak/Donnan (P-L/D) ion homeostatic process. Unlike neurons, which operate with a costly “Pump-Leak–dominated” ion homeostatic steady state, skeletal muscle fibers operate with a low-cost “Donnan-dominated” ion homeostatic steady state that combines a large chloride permeability with an exceptionally small sodium permeability. Simultaneously, this combination keeps fiber excitability low and minimizes pump expenditures. As mechanically active, long-lived multinucleate cells, skeletal muscle fibers have evolved to handle overexertion, sarcolemmal tears, ischemic bouts, etc.; the frugality of their Donnan dominated steady state lets them maintain the outsized pump reserves that make them resilient during these inevitable transient emergencies. Here, P-L/D model variants challenged with DMD-type insult/injury (low pump-strength, overstimulation, leaky Nav and cation channels) show how chronic “nonosmotic” sodium overload (observed in DMD patients) develops. Profoundly severe DMD ion homeostatic insult/injury causes spontaneous firing (and, consequently, unwanted excitation–contraction coupling) that elicits cytotoxic swelling. Therefore, boosting operational pump-strength and/or diminishing sodium and cation channel leaks should help extend DMD fiber longevity.
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Affiliation(s)
- Catherine E Morris
- Neuroscience, Ottawa Hospital Research Institute, Ottawa, Canada.,Center for Neural Dynamics, University of Ottawa, Ottawa, Canada
| | | | - Béla Joos
- Center for Neural Dynamics, University of Ottawa, Ottawa, Canada.,Department of Physics, University of Ottawa, Ottawa, Canada
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15
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Cardiac Complications of Neuromuscular Disorders. Neuromuscul Disord 2022. [DOI: 10.1016/b978-0-323-71317-7.00003-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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16
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Grigoratos C, Aimo A, Barison A, Castiglione V, Todiere G, Ricci G, Siciliano G, Emdin M. Cardiac magnetic resonance in patients with muscular dystrophies. Eur J Prev Cardiol 2021; 28:1526-1535. [PMID: 32418485 DOI: 10.1177/2047487320923052] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 04/10/2020] [Indexed: 01/15/2023]
Abstract
Muscular dystrophies are inherited disorders sharing similar clinical features and dystrophic changes on muscle biopsy. Duchenne muscular dystrophy is the most common inherited muscle disease of childhood, and Becker muscular dystrophy is a milder allelic variant with a slightly lower prevalence. Myotonic dystrophy is the most frequent form in adults. Cardiac magnetic resonance is the gold standard technique for the quantification of cardiac chamber volumes and function, and also enables a characterisation of myocardial tissue. Most cardiac magnetic resonance studies in the setting of muscular dystrophy were carried out at single centres, evaluated small numbers of patients and used widely heterogeneous protocols. Even more importantly, those studies analysed more or less extensively the patterns of cardiac involvement, but usually did not try to establish the added value of cardiac magnetic resonance to standard echocardiography, the evolution of cardiac disease over time and the prognostic significance of cardiac magnetic resonance findings. As a result, the large and heterogeneous amount of information on cardiac involvement in muscular dystrophies cannot easily be translated into recommendations on the optimal use of cardiac magnetic resonance. In this review, whose targets are cardiologists and neurologists who manage patients with muscular dystrophy, we try to summarise cardiac magnetic resonance findings in patients with muscular dystrophy, and the results of studies evaluating the role of cardiac magnetic resonance as a tool for diagnosis, risk stratification and follow-up. Finally, we provide some practical recommendations about the need and timing of cardiac magnetic resonance examination for the management of patients with muscular dystrophy.
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Affiliation(s)
| | - Alberto Aimo
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Italy
| | - Andrea Barison
- Fondazione Toscana Gabriele Monasterio, Italy
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Italy
| | | | | | - Giulia Ricci
- Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Gabriele Siciliano
- Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Michele Emdin
- Fondazione Toscana Gabriele Monasterio, Italy
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Italy
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17
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Blaszczyk E, Gröschel J, Schulz-Menger J. Role of CMR Imaging in Diagnostics and Evaluation of Cardiac Involvement in Muscle Dystrophies. Curr Heart Fail Rep 2021; 18:211-224. [PMID: 34319529 PMCID: PMC8342365 DOI: 10.1007/s11897-021-00521-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/19/2021] [Indexed: 11/18/2022]
Abstract
PURPOSE OF REVIEW This review aims to outline the utility of cardiac magnetic resonance (CMR) in patients with different types of muscular dystrophies for the assessment of myocardial involvement, risk stratification and in guiding therapeutic decisions. RECENT FINDINGS In patients suffering from muscular dystrophies (MD), even mild initial dysfunction may lead to severe heart failure over a time course of years. CMR plays an increasing role in the diagnosis and clinical care of these patients, mostly due to its unique capability to precisely characterize subclinical and progressive changes in cardiac geometry, function in order to differentiate myocardial injury it allows the identification of inflammation, focal and diffuse fibrosis as well as fatty infiltration. CMR may provide additional information in addition to the physical examination, laboratory tests, ECG, and echocardiography. Further trials are needed to investigate the potential impact of CMR on the therapeutic decision-making as well as the assessment of long-term prognosis in different forms of muscular dystrophies. In addition to the basic cardiovascular evaluation, CMR can provide a robust, non-invasive technique for the evaluation of subclinical myocardial tissue injury like fat infiltration and focal and diffuse fibrosis. Furthermore, CMR has a unique capability to detect the progression of myocardial tissue damage in patients with a preserved systolic function.
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Affiliation(s)
- Edyta Blaszczyk
- Working Group on Cardiovascular Magnetic Resonance, Experimental and Clinical Research Center a joint cooperation between the Charité – Universitätsmedizin Berlin, Department of Internal Medicine and Cardiology and the Max-Delbrueck Center for Molecular Medicine, and HELIOS Klinikum Berlin Buch, Department of Cardiology and Nephrology, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Berlin, Germany
| | - Jan Gröschel
- Working Group on Cardiovascular Magnetic Resonance, Experimental and Clinical Research Center a joint cooperation between the Charité – Universitätsmedizin Berlin, Department of Internal Medicine and Cardiology and the Max-Delbrueck Center for Molecular Medicine, and HELIOS Klinikum Berlin Buch, Department of Cardiology and Nephrology, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Berlin, Germany
| | - Jeanette Schulz-Menger
- Working Group on Cardiovascular Magnetic Resonance, Experimental and Clinical Research Center a joint cooperation between the Charité – Universitätsmedizin Berlin, Department of Internal Medicine and Cardiology and the Max-Delbrueck Center for Molecular Medicine, and HELIOS Klinikum Berlin Buch, Department of Cardiology and Nephrology, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Berlin, Germany
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18
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Stalens C, Motté L, Béhin A, Ben Yaou R, Leturcq F, Bassez G, Laforêt P, Fontaine B, Ederhy S, Masingue M, Saadi M, Louis SL, Berber N, Stojkovic T, Duboc D, Wahbi K. Improved Cardiac Outcomes by Early Treatment with Angiotensin-Converting Enzyme Inhibitors in Becker Muscular Dystrophy. J Neuromuscul Dis 2021; 8:495-502. [PMID: 33814458 PMCID: PMC8385526 DOI: 10.3233/jnd-200620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background: The latest practice guidelines from the American College of Cardiology/American Heart Association recommend the prescription of an ACE-i for patients presenting with non-ischemic cardiomyopathy when left ventricular ejection fraction (LVEF) falls below 40%. Objective: To determine if the initiation of treatment with an angiotensin-converting enzyme inhibitor (ACE-i) earlier than recommended by practice guidelines issued by professional societies improves the long-term cardiac outcomes of patients presenting with Becker muscular dystrophy (MD) cardiomyopathy. Methods: From a multicenter registry of Becker MD, we selected retrospectively patients presenting between January 1990 and April 2019 with a LVEF ≥40 and ≤49%. We used a propensity score analysis to compare the risk of a) hospitalization for management of heart failure (HF), and b) a decrease in LVEF to <35% in patients who received an ACE-i when LVEF fell below 40% (conventional treatment), versus below 50% (early treatment). Results: From the 183 patients entered in our registry, we identified 85 whose LVEF was between 40 and 49%, 51 of whom received early and 34 received conventional ACE-i treatment. Among patients with early versus conventional treatments, 2 (3.9%) versus 4 (11.8%) were hospitalized for management of HF [hazard ratio (HR) 0.151; 95% confidence interval (CI) 0.028 to 0.822; p = 0.029], and 9 (17.6%) versus 10 (29.4%) had a decrease in LVEF below 35% (HR 0.290; 95% CI 0.121 to 0.694; p = 0.005). Conclusions: The long-term cardiac outcome of patients presenting with Becker MD was significantly better when treatment with ACE-i was introduced after a decrease in LVEF below 50%, instead of below 40% as recommended in the current practice guidelines issued by professional societies.
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Affiliation(s)
- Caroline Stalens
- Medical Affairs Department, AFM-Téléthon, Evry, France.,INSERM Unit 970, Paris Cardiovascular Research Centre (PARCC), Paris, France
| | - Leslie Motté
- AP-HP, Cochin Hospital, Cardiology Department, Paris, France
| | - Anthony Béhin
- AP-HP, Pitié-Salpêtrière Hospital, Reference Center for Muscle Diseases Paris-Est, Myology Institute, Paris, France
| | - Rabah Ben Yaou
- AP-HP, Pitié-Salpêtrière Hospital, Reference Center for Muscle Diseases Paris-Est, Myology Institute, Paris, France
| | - France Leturcq
- AP-HP, Cochin Hospital, Department of Genetics and Molecular Biology, Paris, France
| | - Guillaume Bassez
- AP-HP, Pitié-Salpêtrière Hospital, Reference Center for Muscle Diseases Paris-Est, Myology Institute, Paris, France
| | - Pascal Laforêt
- Neurology Department, CHU Paris IdF Ouest-Hôpital Raymond Poincaré, Garches, France
| | - Bertrand Fontaine
- AP-HP, Pitié-Salpêtrière Hospital, Reference Center for Muscle Diseases Paris-Est, Myology Institute, Paris, France
| | - Stéphane Ederhy
- AP-HP, Saint Antoine Hospital, Cardiology Department, Paris, France
| | - Marion Masingue
- AP-HP, Pitié-Salpêtrière Hospital, Reference Center for Muscle Diseases Paris-Est, Myology Institute, Paris, France
| | - Malika Saadi
- AP-HP, Cochin Hospital, Cardiology Department, Paris, France
| | - Sarah Leonard Louis
- AP-HP, Pitié-Salpêtrière Hospital, Reference Center for Muscle Diseases Paris-Est, Myology Institute, Paris, France
| | - Nawal Berber
- AP-HP, Pitié-Salpêtrière Hospital, Reference Center for Muscle Diseases Paris-Est, Myology Institute, Paris, France
| | - Tanya Stojkovic
- AP-HP, Pitié-Salpêtrière Hospital, Reference Center for Muscle Diseases Paris-Est, Myology Institute, Paris, France
| | - Denis Duboc
- AP-HP, Cochin Hospital, Cardiology Department, Paris, France.,Université Paris Descartes-Sorbonne Paris Cité, Paris, France
| | - Karim Wahbi
- AP-HP, Cochin Hospital, Cardiology Department, Paris, France.,Université Paris Descartes-Sorbonne Paris Cité, Paris, France.,Inserm, UMRS, Paris, France
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19
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Laskary A, Fonfara S, Chambers H, O'Sullivan ML. Prospective clinical trial evaluating spironolactone in Doberman pinschers with congestive heart failure due to dilated cardiomyopathy. J Vet Cardiol 2021; 40:84-98. [PMID: 34315691 DOI: 10.1016/j.jvc.2021.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 06/08/2021] [Accepted: 06/10/2021] [Indexed: 01/29/2023]
Abstract
INTRODUCTION/OBJECTIVES Whether the aldosterone antagonist spironolactone has beneficial survival effects in dogs with dilated cardiomyopathy (DCM) is not known. The primary objective of the study was to evaluate the effect of spironolactone, when added to conventional therapy, on survival time in Doberman pinschers with congestive heart failure (CHF) due to DCM. ANIMALS Sixty-seven client-owned Doberman pinschers with CHF due to DCM. MATERIALS AND METHODS The trial design was prospective, randomized, blinded, and placebo controlled. Dogs were randomized to receive 50-75 mg of spironolactone twice daily (n = 34) or a placebo (n = 33), in addition to standard CHF therapy. Follow-up visits were targeted every 1-6 weeks until endpoint. Quality-of-life questionnaire and physical examination were performed at every visit, while renal biochemistry, ECG, echocardiography, and thoracic radiography were reassessed as needed. The primary endpoint was time to cardiac death, defined as death or euthanasia from CHF or sudden death. RESULTS Median time to primary endpoint in the spironolactone group (183 days) was not statistically significantly different than that for the placebo group (124 days) (p = 0.254). The development of atrial fibrillation (AF) was significantly less frequent in the spironolactone group (n = 7) than the placebo group (n = 15, p = 0.037). CONCLUSIONS While median time to cardiac death in the spironolactone group was not statistically significantly different than that in the placebo group, adding spironolactone to conventional therapy resulted in reduced occurrence of AF.
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Affiliation(s)
- A Laskary
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, 28 College Ave W, Guelph, Ontario, N1G 2W1, Canada
| | - S Fonfara
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, 28 College Ave W, Guelph, Ontario, N1G 2W1, Canada
| | - H Chambers
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, 28 College Ave W, Guelph, Ontario, N1G 2W1, Canada
| | - M L O'Sullivan
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, 28 College Ave W, Guelph, Ontario, N1G 2W1, Canada.
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20
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Ellwood RA, Piasecki M, Szewczyk NJ. Caenorhabditis elegans as a Model System for Duchenne Muscular Dystrophy. Int J Mol Sci 2021; 22:ijms22094891. [PMID: 34063069 PMCID: PMC8125261 DOI: 10.3390/ijms22094891] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 04/26/2021] [Accepted: 04/26/2021] [Indexed: 02/07/2023] Open
Abstract
The nematode worm Caenorhabditis elegans has been used extensively to enhance our understanding of the human neuromuscular disorder Duchenne Muscular Dystrophy (DMD). With new arising clinically relevant models, technologies and treatments, there is a need to reconcile the literature and collate the key findings associated with this model.
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Affiliation(s)
- Rebecca A. Ellwood
- Medical Research Council (MRC) Versus Arthritis, Centre for Musculoskeletal Ageing Research, Royal Derby Hospital, University of Nottingham, Derby DE22 3DT, UK; (R.A.E.); (M.P.)
- National Institute for Health Research, Nottingham Biomedical Research Centre, Derby DE22 3DT, UK
| | - Mathew Piasecki
- Medical Research Council (MRC) Versus Arthritis, Centre for Musculoskeletal Ageing Research, Royal Derby Hospital, University of Nottingham, Derby DE22 3DT, UK; (R.A.E.); (M.P.)
- National Institute for Health Research, Nottingham Biomedical Research Centre, Derby DE22 3DT, UK
| | - Nathaniel J. Szewczyk
- Medical Research Council (MRC) Versus Arthritis, Centre for Musculoskeletal Ageing Research, Royal Derby Hospital, University of Nottingham, Derby DE22 3DT, UK; (R.A.E.); (M.P.)
- National Institute for Health Research, Nottingham Biomedical Research Centre, Derby DE22 3DT, UK
- Ohio Musculoskeletal and Neurologic Institute, Ohio University, Athens, OH 45701, USA
- Department of Biomedical Sciences, Heritage College of Osteopathic Medicine, Ohio University, Athens, OH 45701, USA
- Correspondence:
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21
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Hayes EA, Nandi D. Is there a future for the use of left ventricular assist devices in Duchenne muscular dystrophy? Pediatr Pulmonol 2021; 56:753-759. [PMID: 33245216 DOI: 10.1002/ppul.25181] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 10/05/2020] [Accepted: 11/12/2020] [Indexed: 01/14/2023]
Abstract
Duchenne muscular dystrophy (DMD) is the most common form of childhood muscular dystrophy resulting in progressive muscle wasting and weakness. With advancements in respiratory care and the use of glucocorticoids, cardiomyopathy has surpassed respiratory compromise as the leading cause of morbidity and mortality in this patient population. As muscular dystrophy remains a relative contraindication to heart transplantation, end-stage heart failure management represents a major therapeutic challenge. Long-term left ventricular assist device (LVAD) therapy has emerged as a promising management strategy to improve the survival and quality of life in DMD cardiomyopathy. Preoperative planning, optimal patient selection, aggressive postoperative rehabilitation, and continued discussion of goals of care are critical considerations for the appropriate use of LVAD in DMD patients with cardiomyopathy.
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Affiliation(s)
- Emily A Hayes
- Division of Cardiology, The Heart Center, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | - Deipanjan Nandi
- Division of Cardiology, The Heart Center, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
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22
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Bennett J, Kertesz NJ. Management of rhythm disorders in Duchenne muscular dystrophy: Is sudden death a cardiac or pulmonary problem? Pediatr Pulmonol 2021; 56:760-765. [PMID: 33651920 DOI: 10.1002/ppul.25205] [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: 08/12/2020] [Revised: 10/28/2020] [Accepted: 11/12/2020] [Indexed: 11/06/2022]
Abstract
Dystrophin deficiency results in the cardiomyopathy of variable onset and deficiency. Myocardial scarring commonly results in cardiac dysfunction, with both atrial and ventricular dysrhythmias. Heart failure, rather than arrhythmia burden, remains the strongest cardiac predictor of mortality in this patient population. Current data suggest the overall rate of sudden cardiac death in pediatric dilated cardiomyopathy is significantly lower than in adults. Specifically, in the Duchenne cardiomyopathy population, sudden death from an arrhythmic cause appears to be rare, even in patients with previously diagnosed arrhythmias. Despite this, recommendations for implantable cardioverter-defibrillator (ICD) placement in patients with Duchenne cardiomyopathy has traditionally been extrapolated from adult heart failure recommendations based on decreased left ventricular ejection fraction <35%. Early involvement of the cardiologist in the care for patients with dystrophin-deficient cardiomyopathy is recommended for this reason. The indications for ICD placement to prevent sudden death in patients with Duchenne cardiomyopathy are not well defined. There is little evidence to suggest that placement meaningfully prolongs life in this population, and should be carefully considered in accordance with the care goals of the patient and his family.
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Affiliation(s)
- Jeffrey Bennett
- The Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Naomi J Kertesz
- The Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA
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Lee S, Lee M, Hor KN. The role of imaging in characterizing the cardiac natural history of Duchenne muscular dystrophy. Pediatr Pulmonol 2021; 56:766-781. [PMID: 33651923 DOI: 10.1002/ppul.25227] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 10/19/2020] [Accepted: 11/12/2020] [Indexed: 01/11/2023]
Abstract
Duchene muscular dystrophy (DMD) is a rare but devastating disease resulting in progressive loss of ambulation, respiratory failure, DMD-associated cardiomyopathy (DMD-CM), and premature death. The use of corticosteroids and supportive respiratory care has improved outcomes, such that DMD-CM is now the leading cause of death. Historically, most programs have focused on skeletal myopathy with less attention to the cardiac phenotype. This omission is rather astonishing since patients with DMD possess an absolute genetic risk of developing cardiomyopathy. Unfortunately, heart failure signs and symptoms are vague due to skeletal muscle myopathy leading to limited ambulation. Traditional assessment of cardiac symptoms by the New York Heart Association American College of Cardiology/American Heart Association Staging (ACC/AHA) classification is of limited utility, even in advanced stages. Echocardiographic assessment can detect cardiac dysfunction late in the disease course, but this has proven to be a poor surrogate marker of early cardiovascular disease and an inadequate predictor of DMD-CM. Indeed, one explanation for the paucity of cardiac therapeutic trials for DMD-CM has been the lack of a suitable end-point. Improved outcomes require a better proactive treatment strategy; however, the barrier to treatment is the lack of a sensitive and specific tool to assess the efficacy of treatment. The use of cardiac imaging has evolved from echocardiography to cardiac magnetic resonance imaging to assess cardiac performance. The purpose of this article is to review the role of cardiac imaging in characterizing the cardiac natural history of DMD-CM, highlighting the prognostic implications and an outlook on how this field might evolve in the future.
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Affiliation(s)
- Simon Lee
- Department of Pediatrics, The Heart Center, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio, USA
| | - Marc Lee
- Department of Pediatrics, The Heart Center, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio, USA
| | - Kan N Hor
- Department of Pediatrics, The Heart Center, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio, USA
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24
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Wittekind SG, Villa CR. Cardiac medication management in Duchenne muscular dystrophy. Pediatr Pulmonol 2021; 56:747-752. [PMID: 33647187 DOI: 10.1002/ppul.25175] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 09/24/2020] [Accepted: 10/30/2020] [Indexed: 12/21/2022]
Abstract
There have been significant improvements in the skeletal muscle and respiratory care for patients with Duchenne muscular dystrophy (DMD) over the last two decades. This has resulted in longer expected survival as many patients will live into their 20s and 30s. This timeline has resulted in a greater proportion of patients experiencing heart failure and cardiac-related mortality. Herein, we describe the current indications for medical therapy for patients with DMD.
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Affiliation(s)
- Samuel G Wittekind
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Chet R Villa
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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25
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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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26
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Spurney CF, Ascheim D, Charnas L, Cripe L, Hor K, King N, Kinnett K, McNally EM, Sauer JM, Sweeney L, Villa C, Markham LW. Current state of cardiac troponin testing in Duchenne muscular dystrophy cardiomyopathy: review and recommendations from the Parent Project Muscular Dystrophy expert panel. Open Heart 2021; 8:openhrt-2021-001592. [PMID: 33762424 PMCID: PMC7993361 DOI: 10.1136/openhrt-2021-001592] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/17/2021] [Accepted: 03/05/2021] [Indexed: 01/06/2023] Open
Abstract
Cardiac disease is now the leading cause of death in Duchenne muscular dystrophy (DMD). Clinical evaluations over time have demonstrated asymptomatic cardiac troponin elevations and acute elevations are associated with symptoms and cardiac dysfunction in DMD. Clinicians require a better understanding of the relationship of symptoms, troponin levels and progression of cardiac disease in DMD. As clinical trials begin to assess novel cardiac therapeutics in DMD, troponin levels in DMD are important for safety monitoring and outcome measures. The Parent Project Muscular Dystrophy convened an expert panel of cardiologists, scientists, and regulatory and industry specialists on 16 December 2019 in Silver Spring, Maryland and reviewed published and unpublished data from their institutions. The panel recommended retrospective troponin data analyses, prospective longitudinal troponin collection using high-sensitivity cardiac troponin I assays, inclusion of troponin in future clinical trial outcomes and future development of clinical guidelines for monitoring and treating troponin elevations in DMD.
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Affiliation(s)
- Christopher F Spurney
- Children's National Heart Institute, Children's National Hospital, Washington, District of Columbia, USA
| | | | - Lawrence Charnas
- Clinical Research Rare Neurology Disease, Pfizer, Cambridge, Massachusetts, USA
| | - Linda Cripe
- The Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Kan Hor
- The Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA
| | | | - Kathi Kinnett
- Parent Project Muscular Dystrophy, Hackensack, New Jersey, USA
| | | | | | - Lee Sweeney
- Department of Pharmacology and Therapeutics, University of Florida, Gainesville, Florida, USA
| | - Chet Villa
- Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Larry W Markham
- Pediatrics, Division of Pediatric Cardiology, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana, USA
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27
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Rodriguez-Gonzalez M, Lubian-Gutierrez M, Cascales-Poyatos HM, Perez-Reviriego AA, Castellano-Martinez A. Role of the Renin-Angiotensin-Aldosterone System in Dystrophin-Deficient Cardiomyopathy. Int J Mol Sci 2020; 22:ijms22010356. [PMID: 33396334 PMCID: PMC7796305 DOI: 10.3390/ijms22010356] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 12/27/2020] [Accepted: 12/28/2020] [Indexed: 12/16/2022] Open
Abstract
Dystrophin-deficient cardiomyopathy (DDC) is currently the leading cause of death in patients with dystrophinopathies. Targeting myocardial fibrosis (MF) has become a major therapeutic goal in order to prevent the occurrence of DDC. We aimed to review and summarize the current evidence about the role of the renin-angiotensin-aldosterone system (RAAS) in the development and perpetuation of MF in DCC. We conducted a comprehensive search of peer-reviewed English literature on PubMed about this subject. We found increasing preclinical evidence from studies in animal models during the last 20 years pointing out a central role of RAAS in the development of MF in DDC. Local tissue RAAS acts directly mainly through its main fibrotic component angiotensin II (ANG2) and its transducer receptor (AT1R) and downstream TGF-b pathway. Additionally, it modulates the actions of most of the remaining pro-fibrotic factors involved in DDC. Despite limited clinical evidence, RAAS blockade constitutes the most studied, available and promising therapeutic strategy against MF and DDC. Conclusion: Based on the evidence reviewed, it would be recommendable to start RAAS blockade therapy through angiotensin converter enzyme inhibitors (ACEI) or AT1R blockers (ARBs) alone or in combination with mineralocorticoid receptor antagonists (MRa) at the youngest age after the diagnosis of dystrophinopathies, in order to delay the occurrence or slow the progression of MF, even before the detection of any cardiovascular alteration.
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Affiliation(s)
- Moises Rodriguez-Gonzalez
- Pediatric Cardiology Division of Puerta del Mar University Hospital, University of Cadiz, 11009 Cadiz, Spain
- Biomedical Research and Innovation Institute of Cadiz (INiBICA), Research Unit, Puerta del Mar University Hospital, University of Cadiz, 11009 Cadiz, Spain;
- Correspondence: ; Tel.: +34-956002700
| | - Manuel Lubian-Gutierrez
- Pediatric Neurology Division of Puerta del Mar University Hospital, University of Cadiz, 11009 Cadiz, Spain;
- Pediatric Division of Doctor Cayetano Roldan Primary Care Center, 11100 San Fernando, Spain
| | | | | | - Ana Castellano-Martinez
- Biomedical Research and Innovation Institute of Cadiz (INiBICA), Research Unit, Puerta del Mar University Hospital, University of Cadiz, 11009 Cadiz, Spain;
- Pediatric Nephrology Division of Puerta del Mar University Hospital, University of Cadiz, 11009 Cadiz, Spain
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28
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de Souza F, Bittar Braune C, Dos Santos Nucera APC. Duchenne muscular dystrophy: an overview to the cardiologist. Expert Rev Cardiovasc Ther 2020; 18:867-872. [PMID: 32985912 DOI: 10.1080/14779072.2020.1828065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Duchenne muscular dystrophy (DMD) is the most common form of muscular dystrophy in children, affecting approximately one in 3,500-5,000 liveborn boys. The main signs and symptoms include gait disturbances beginning in early childhood, with later onset of respiratory and cardiac function disorders, both directly affecting the prognosis. AREAS COVERED The recent improvement of mechanical ventilation increased the mean DMD survival age; however, there has been little progress in the treatment and prevention of cardiac complications, which currently predominantly impact survival. Cardiological evaluation with imaging methods, such as echocardiography and magnetic resonance imaging, can improve the understanding and detect changes in cardiac function early. EXPERT OPINION Close monitoring by the cardiologists and early treatment, with adequate heart disease stratification, may be the key to prolong the lives of these patients until more promising therapies are available and can predict DMD prognosis and progression more accurately. The objective of this brief review is to update the cardiologists by highlighting the most relevant aspects of treatment and follow-up, in a practical and concise way.
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Affiliation(s)
- Fabio de Souza
- Cardiology Section, Department of Specialized Medicine, School of Medicine and Surgery, Federal University of the State of Rio De Janeiro , Rio de Janeiro, Brazil
| | | | - Ana Paula Cassetta Dos Santos Nucera
- Cardiology Section, Department of Specialized Medicine, School of Medicine and Surgery, Federal University of the State of Rio De Janeiro , Rio de Janeiro, Brazil
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29
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Lowe J, Kolkhof P, Haupt MJ, Peczkowski KK, Rastogi N, Hauck JS, Kadakia FK, Zins JG, Ciccone PC, Smart S, Sandner P, Raman SV, Janssen PML, Rafael-Fortney JA. Mineralocorticoid receptor antagonism by finerenone is sufficient to improve function in preclinical muscular dystrophy. ESC Heart Fail 2020; 7:3983-3995. [PMID: 32945624 PMCID: PMC7754779 DOI: 10.1002/ehf2.12996] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 07/29/2020] [Accepted: 08/17/2020] [Indexed: 01/11/2023] Open
Abstract
Aims Duchenne muscular dystrophy (DMD) is an X‐linked inherited disease due to dystrophin deficiency causing skeletal and cardiac muscle dysfunction. Affected patients lose ambulation by age 12 and usually die in the second to third decades of life from cardiac and respiratory failure. Symptomatic treatment includes the use of anti‐inflammatory corticosteroids, which are associated with side effects including weight gain, osteoporosis, and increased risk of cardiovascular disease. Novel treatment options include blockade of the renin–angiotensin–aldosterone system, because angiotensin as well as aldosterone contribute to persistent inflammation and fibrosis, and aldosterone blockade represents an efficacious anti‐fibrotic approach in cardiac failure. Recent preclinical findings enabled successful clinical testing of a combination of steroidal mineralocorticoid receptor antagonists (MRAs) and angiotensin converting enzyme inhibitors in DMD boys. The efficacy of MRAs alone on dystrophic skeletal muscle and heart has not been investigated. Here, we tested efficacy of the novel non‐steroidal MRA finerenone as a monotherapy in a preclinical DMD model. Methods and results The dystrophin‐deficient, utrophin haploinsufficient mouse model of DMD was treated with finerenone and compared with untreated dystrophic and wild‐type controls. Grip strength, electrocardiography, cardiac magnetic resonance imaging, muscle force measurements, histological quantification, and gene expression studies were performed. Finerenone treatment alone resulted in significant improvements in clinically relevant functional parameters in both skeletal muscle and heart. Normalized grip strength in rested dystrophic mice treated with finerenone (40.3 ± 1.0 mN/g) was significantly higher (P = 0.0182) compared with untreated dystrophic mice (35.2 ± 1.5 mN/g). Fatigued finerenone‐treated dystrophic mice showed an even greater relative improvement (P = 0.0003) in normalized grip strength (37.5 ± 1.1 mN/g) compared with untreated mice (29.7 ± 1.1 mN/g). Finerenone treatment also led to significantly lower (P = 0.0075) susceptibility to limb muscle damage characteristic of DMD measured during a contraction‐induced injury protocol. Normalized limb muscle force after five lengthening contractions resulted in retention of 71 ± 7% of baseline force in finerenone‐treated compared with only 51 ± 4% in untreated dystrophic mice. Finerenone treatment also prevented significant reductions in myocardial strain rate (P = 0.0409), the earliest sign of DMD cardiomyopathy. Moreover, treatment with finerenone led to very specific cardiac gene expression changes in clock genes that might modify cardiac pathophysiology in this DMD model. Conclusions Finerenone administered as a monotherapy is disease modifying for both skeletal muscle and heart in a preclinical DMD model. These findings support further evaluation of finerenone in DMD clinical trials.
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Affiliation(s)
- Jeovanna Lowe
- Department of Physiology and Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, 43210, USA
| | - Peter Kolkhof
- R&D Preclinical Research Cardiovascular, Bayer AG, Wuppertal, Germany
| | - Michael J Haupt
- Department of Physiology and Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, 43210, USA
| | - Kyra K Peczkowski
- Department of Physiology and Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, 43210, USA
| | - Neha Rastogi
- Department of Physiology and Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, 43210, USA
| | - J Spencer Hauck
- Department of Physiology and Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, 43210, USA
| | - Feni K Kadakia
- Department of Physiology and Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, 43210, USA
| | - Jonathan G Zins
- Department of Physiology and Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, 43210, USA
| | - Pierce C Ciccone
- Department of Physiology and Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, 43210, USA
| | - Suzanne Smart
- Davis Heart and Lung Research Institute, College of Medicine, The Ohio State University, Columbus, OH, 43210, USA
| | - Peter Sandner
- R&D Preclinical Research Cardiovascular, Bayer AG, Wuppertal, Germany.,Department of Pharmacology, Hannover Medical School, Hannover, Germany
| | - Subha V Raman
- Davis Heart and Lung Research Institute, College of Medicine, The Ohio State University, Columbus, OH, 43210, USA
| | - Paul M L Janssen
- Department of Physiology and Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, 43210, USA
| | - Jill A Rafael-Fortney
- Department of Physiology and Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, 43210, USA
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30
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Himelman E, Lillo MA, Nouet J, Gonzalez JP, Zhao Q, Xie LH, Li H, Liu T, Wehrens XH, Lampe PD, Fishman GI, Shirokova N, Contreras JE, Fraidenraich D. Prevention of connexin-43 remodeling protects against Duchenne muscular dystrophy cardiomyopathy. J Clin Invest 2020; 130:1713-1727. [PMID: 31910160 PMCID: PMC7108916 DOI: 10.1172/jci128190] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 12/18/2019] [Indexed: 12/11/2022] Open
Abstract
Aberrant expression of the cardiac gap junction protein connexin-43 (Cx43) has been suggested as playing a role in the development of cardiac disease in the mdx mouse model of Duchenne muscular dystrophy (DMD); however, a mechanistic understanding of this association is lacking. Here, we identified a reduction of phosphorylation of Cx43 serines S325/S328/S330 in human and mouse DMD hearts. We hypothesized that hypophosphorylation of Cx43 serine-triplet triggers pathological Cx43 redistribution to the lateral sides of cardiomyocytes (remodeling). Therefore, we generated knockin mdx mice in which the Cx43 serine-triplet was replaced with either phospho-mimicking glutamic acids (mdxS3E) or nonphosphorylatable alanines (mdxS3A). The mdxS3E, but not mdxS3A, mice were resistant to Cx43 remodeling, with a corresponding reduction of Cx43 hemichannel activity. MdxS3E cardiomyocytes displayed improved intracellular Ca2+ signaling and a reduction of NADPH oxidase 2 (NOX2)/ROS production. Furthermore, mdxS3E mice were protected against inducible arrhythmias, related lethality, and the development of cardiomyopathy. Inhibition of microtubule polymerization by colchicine reduced both NOX2/ROS and oxidized CaMKII, increased S325/S328/S330 phosphorylation, and prevented Cx43 remodeling in mdx hearts. Together, these results demonstrate a mechanism of dystrophic Cx43 remodeling and suggest that targeting Cx43 may be a therapeutic strategy for preventing heart dysfunction and arrhythmias in DMD patients.
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Affiliation(s)
| | | | - Julie Nouet
- Department of Cell Biology and Molecular Medicine
| | | | - Qingshi Zhao
- Department of Cell Biology and Molecular Medicine
| | - Lai-Hua Xie
- Department of Cell Biology and Molecular Medicine
| | - Hong Li
- Center for Advanced Proteomics Research, New Jersey Medical School, Rutgers Biomedical and Health Sciences, Newark, New Jersey, USA
| | - Tong Liu
- Center for Advanced Proteomics Research, New Jersey Medical School, Rutgers Biomedical and Health Sciences, Newark, New Jersey, USA
| | - Xander H.T. Wehrens
- Department of Molecular Physiology and Biophysics, Medicine, Neuroscience, and Pediatrics, Cardiovascular Research Institute, Baylor College of Medicine, Houston, Texas, USA
| | - Paul D. Lampe
- Fred Hutchinson Cancer Research Center, Translational Research Program, Public Health Sciences Division, Seattle, Washington, USA
| | - Glenn I. Fishman
- Leon H. Charney Division of Cardiology, New York University Langone Health, New York, New York, USA
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31
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Hauck JS, Lowe J, Rastogi N, McElhanon KE, Petrosino JM, Peczkowski KK, Chadwick AN, Zins JG, Accornero F, Janssen PML, Weisleder NL, Rafael-Fortney JA. Mineralocorticoid receptor antagonists improve membrane integrity independent of muscle force in muscular dystrophy. Hum Mol Genet 2020; 28:2030-2045. [PMID: 30759207 DOI: 10.1093/hmg/ddz039] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 02/04/2019] [Accepted: 02/07/2019] [Indexed: 12/15/2022] Open
Abstract
Mineralocorticoid receptor (MR) drugs have been used clinically for decades to treat cardiovascular diseases. MR antagonists not only show preclinical efficacy for heart in Duchenne muscular dystrophy (DMD) models but also improve skeletal muscle force and muscle membrane integrity. The mechanisms of action of MR antagonists in skeletal muscles are entirely unknown. Since MR are present in many cell types in the muscle microenvironment, it is critical to define cell-intrinsic functions in each cell type to ultimately optimize antagonist efficacy for use in the widest variety of diseases. We generated a new conditional knockout of MR in myofibers and quantified cell-intrinsic mechanistic effects on functional and histological parameters in a DMD mouse model. Skeletal muscle MR deficiency led to improved respiratory muscle force generation and less deleterious fibrosis but did not reproduce MR antagonist efficacy on membrane susceptibility to induced damage. Surprisingly, acute application of MR antagonist to muscles led to improvements in membrane integrity after injury independent of myofiber MR. These data demonstrate that MR antagonists are efficacious to dystrophic skeletal muscles through both myofiber intrinsic effects on muscle force and downstream fibrosis and extrinsic functions on membrane stability. MR antagonists may therefore be applicable for treating more general muscle weakness and possibly other conditions that result from cell injuries.
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Affiliation(s)
| | | | | | - Kevin E McElhanon
- Department of Physiology and Cell Biology.,Dorothy M. Davis Heart and Lung Research Institute, College of Medicine, The Ohio State University, Columbus, OH USA
| | - Jennifer M Petrosino
- Department of Physiology and Cell Biology.,Dorothy M. Davis Heart and Lung Research Institute, College of Medicine, The Ohio State University, Columbus, OH USA
| | | | | | | | - Federica Accornero
- Department of Physiology and Cell Biology.,Dorothy M. Davis Heart and Lung Research Institute, College of Medicine, The Ohio State University, Columbus, OH USA
| | | | - Noah L Weisleder
- Department of Physiology and Cell Biology.,Dorothy M. Davis Heart and Lung Research Institute, College of Medicine, The Ohio State University, Columbus, OH USA
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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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Hauck JS, Howard ZM, Lowe J, Rastogi N, Pico MG, Swager SA, Petrosino JM, Gomez-Sanchez CE, Gomez-Sanchez EP, Accornero F, Rafael-Fortney JA. Mineralocorticoid Receptor Signaling Contributes to Normal Muscle Repair After Acute Injury. Front Physiol 2019; 10:1324. [PMID: 31736768 PMCID: PMC6830343 DOI: 10.3389/fphys.2019.01324] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 10/03/2019] [Indexed: 01/11/2023] Open
Abstract
Acute skeletal muscle injury is followed by a temporal response of immune cells, fibroblasts, and muscle progenitor cells within the muscle microenvironment to restore function. These same cell types are repeatedly activated in muscular dystrophy from chronic muscle injury, but eventually, the regenerative portion of the cycle is disrupted and fibrosis replaces degenerated muscle fibers. Mineralocorticoid receptor (MR) antagonist drugs have been demonstrated to increase skeletal muscle function, decrease fibrosis, and directly improve membrane integrity in muscular dystrophy mice, and therefore are being tested clinically. Conditional knockout of MR from muscle fibers in muscular dystrophy mice also improves skeletal muscle function and decreases fibrosis. The mechanism of efficacy likely results from blocking MR signaling by its endogenous agonist aldosterone, being produced at high local levels in regions of muscle damage by infiltrating myeloid cells. Since chronic and acute injuries share the same cellular processes to regenerate muscle, and MR antagonists are clinically used for a wide variety of conditions, it is crucial to define the role of MR signaling in normal muscle repair after injury. In this study, we performed acute injuries using barium chloride injections into tibialis anterior muscles both in myofiber MR conditional knockout mice on a wild-type background (MRcko) and in MR antagonist-treated wild-type mice. Steps of the muscle regeneration response were analyzed at 1, 4, 7, or 14 days after injury. Presence of the aldosterone synthase enzyme was also assessed during the injury repair process. We show for the first time aldosterone synthase localization in infiltrating immune cells of normal skeletal muscle after acute injury. MRcko mice had an increased muscle area infiltrated by aldosterone synthase positive myeloid cells compared to control injured animals. Both MRcko and MR antagonist treatment stabilized damaged myofibers and increased collagen infiltration or compaction at 4 days post-injury. MR antagonist treatment also led to reduced myofiber size at 7 and 14 days post-injury. These data support that MR signaling contributes to the normal muscle repair process following acute injury. MR antagonist treatment delays muscle fiber growth, so temporary discontinuation of these drugs after a severe muscle injury could be considered.
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Affiliation(s)
- J. Spencer Hauck
- Department of Physiology and Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, United States
| | - Zachary M. Howard
- Department of Physiology and Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, United States
| | - Jeovanna Lowe
- Department of Physiology and Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, United States
| | - Neha Rastogi
- Department of Physiology and Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, United States
| | - Madison G. Pico
- Department of Physiology and Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, United States
| | - Sarah A. Swager
- Department of Physiology and Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, United States
| | - Jennifer M. Petrosino
- Department of Physiology and Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, United States
- Dorothy M. Davis Heart and Lung Research Institute, College of Medicine, The Ohio State University, Columbus, OH, United States
| | - Celso E. Gomez-Sanchez
- Department of Internal Medicine, University of Mississippi Medical Center, Jackson, MS, United States
| | - Elise P. Gomez-Sanchez
- Department of Pharmacology and Toxicology, University of Mississippi Medical Center, Jackson, MS, United States
| | - Federica Accornero
- Department of Physiology and Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, United States
- Dorothy M. Davis Heart and Lung Research Institute, College of Medicine, The Ohio State University, Columbus, OH, United States
| | - Jill A. Rafael-Fortney
- Department of Physiology and Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, United States
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Raman SV, Hor KN, Mazur W, Cardona A, He X, Halnon N, Markham L, Soslow JH, Puchalski MD, Auerbach SR, Truong U, Smart S, McCarthy B, Saeed IM, Statland JM, Kissel JT, Cripe LH. Stabilization of Early Duchenne Cardiomyopathy With Aldosterone Inhibition: Results of the Multicenter AIDMD Trial. J Am Heart Assoc 2019; 8:e013501. [PMID: 31549577 PMCID: PMC6806050 DOI: 10.1161/jaha.119.013501] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background Duchenne muscular dystrophy incurs nearly universal dilated cardiomyopathy by the third decade of life, preceded by myocardial damage and impaired left ventricular strain by cardiac magnetic resonance. It has been shown that (1) mineralocorticoid receptor antagonist therapy with spironolactone attenuated damage while maintaining function when given early in a mouse model and (2) low-dose eplerenone stabilized left ventricular strain in boys with Duchenne muscular dystrophy and evident myocardial damage but preserved ejection fraction. We hypothesized that moderate-dose spironolactone versus eplerenone would provide similar cardioprotection in this first head-to-head randomized trial of available mineralocorticoid receptor antagonists, the AIDMD (Aldosterone Inhibition in Duchenne Muscular Dystrophy) trial. Methods and Results This was a multicenter, double-blind, randomized, noninferiority trial. Subjects were randomized to eplerenone, 50 mg, or spironolactone, 50 mg, orally once daily for 12 months. The primary outcome was change in left ventricular systolic strain at 12 months. Among 52 enrolled male subjects, aged 14 (interquartile range, 12-18) years, spironolactone was noninferior to eplerenone (∆strain, 0.4 [interquartile range, -0.4 to 0.6] versus 0.2 [interquartile range, -0.2 to 0.7]; P=0.542). Renal and pulmonary function remained stable in both groups, and no subjects experienced serious hyperkalemia. Infrequent adverse events included gynecomastia in one subject in the spironolactone arm and facial rash in one subject in the eplerenone arm. Conclusions In boys with Duchenne muscular dystrophy and preserved left ventricular ejection fraction, spironolactone added to background therapy is noninferior to eplerenone in preserving contractile function. These findings support early mineralocorticoid receptor antagonist therapy as effective and safe in a genetic disease with high cardiomyopathy risk. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT02354352.
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Affiliation(s)
- Subha V Raman
- Ohio State University Wexner Medical Center Columbus OH
| | - Kan N Hor
- Nationwide Children's Hospital Columbus OH
| | - Wojciech Mazur
- The Christ Hospital Heart and Vascular Center Cincinnati OH
| | | | - Xin He
- Department of Epidemiology and Biostatistics University of Maryland College Park MD
| | - Nancy Halnon
- University of California, Los Angeles Los Angeles CA
| | | | | | | | | | | | - Suzanne Smart
- Ohio State University Wexner Medical Center Columbus OH
| | - Beth McCarthy
- Ohio State University Wexner Medical Center Columbus OH
| | | | | | - John T Kissel
- Department of Neurology Ohio State University Columbus OH
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35
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Meyers TA, Townsend D. Cardiac Pathophysiology and the Future of Cardiac Therapies in Duchenne Muscular Dystrophy. Int J Mol Sci 2019; 20:E4098. [PMID: 31443395 PMCID: PMC6747383 DOI: 10.3390/ijms20174098] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 08/12/2019] [Accepted: 08/19/2019] [Indexed: 12/25/2022] Open
Abstract
Duchenne muscular dystrophy (DMD) is a devastating disease featuring skeletal muscle wasting, respiratory insufficiency, and cardiomyopathy. Historically, respiratory failure has been the leading cause of mortality in DMD, but recent improvements in symptomatic respiratory management have extended the life expectancy of DMD patients. With increased longevity, the clinical relevance of heart disease in DMD is growing, as virtually all DMD patients over 18 year of age display signs of cardiomyopathy. This review will focus on the pathophysiological basis of DMD in the heart and discuss the therapeutic approaches currently in use and those in development to treat dystrophic cardiomyopathy. The first section will describe the aspects of the DMD that result in the loss of cardiac tissue and accumulation of fibrosis. The second section will discuss cardiac small molecule therapies currently used to treat heart disease in DMD, with a focus on the evidence supporting the use of each drug in dystrophic patients. The final section will outline the strengths and limitations of approaches directed at correcting the genetic defect through dystrophin gene replacement, modification, or repair. There are several new and promising therapeutic approaches that may protect the dystrophic heart, but their limitations suggest that future management of dystrophic cardiomyopathy may benefit from combining gene-targeted therapies with small molecule therapies. Understanding the mechanistic basis of dystrophic heart disease and the effects of current and emerging therapies will be critical for their success in the treatment of patients with DMD.
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Affiliation(s)
- Tatyana A Meyers
- Department of Integrative Biology and Physiology, Medical School, University of Minnesota, Minneapolis, MN 55455, USA
| | - DeWayne Townsend
- Department of Integrative Biology and Physiology, Medical School, University of Minnesota, Minneapolis, MN 55455, USA.
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37
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Abstract
Heritable cardiomyopathies are a class of heart diseases caused by variations in a number of genetic loci. Genetic variants on one allele lead to either a degraded protein, which causes a haploinsufficiency of that protein, or a nonfunctioning protein that subverts the molecular system within which the protein works. Over years, both of these mechanisms eventually lead to diseased heart tissue and symptoms of a failing heart. Most cardiomyopathy treatments repurpose heart failure drugs to manage these symptoms and avoid adverse outcomes. There are few therapies that correct the underlying pathogenic genetic or molecular mechanism. This review will reflect on this unmet clinical need in genetic cardiomyopathies and consider a variety of therapies that address the mechanism of disease rather than patient symptoms. These therapies are genetic, targeting a defective gene or transcript, or ameliorating a genetic insufficiency. However, there are also a number of small molecules under exploration that modulate downstream faulty protein products affected in cardiomyopathies.
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Affiliation(s)
- Giuliana G Repetti
- From the Department of Genetics, Harvard Medical School, Boston, MA (G.G.R., C.N.T., J.G.S., C.E.S.)
| | - Christopher N Toepfer
- From the Department of Genetics, Harvard Medical School, Boston, MA (G.G.R., C.N.T., J.G.S., C.E.S.)
- Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, United Kingdom (C.N.T.)
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (C.N.T., C.E.S.)
| | - Jonathan G Seidman
- From the Department of Genetics, Harvard Medical School, Boston, MA (G.G.R., C.N.T., J.G.S., C.E.S.)
| | - Christine E Seidman
- From the Department of Genetics, Harvard Medical School, Boston, MA (G.G.R., C.N.T., J.G.S., C.E.S.)
- Howard Hughes Medical Institute, Chevy Chase, MD (C.E.S.)
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38
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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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Heier CR, Yu Q, Fiorillo AA, Tully CB, Tucker A, Mazala DA, Uaesoontrachoon K, Srinivassane S, Damsker JM, Hoffman EP, Nagaraju K, Spurney CF. Vamorolone targets dual nuclear receptors to treat inflammation and dystrophic cardiomyopathy. Life Sci Alliance 2019; 2:2/1/e201800186. [PMID: 30745312 PMCID: PMC6371196 DOI: 10.26508/lsa.201800186] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 01/25/2019] [Accepted: 01/28/2019] [Indexed: 12/25/2022] Open
Abstract
Cardiomyopathy is a leading cause of death for Duchenne muscular dystrophy. Here, we find that the mineralocorticoid receptor (MR) and glucocorticoid receptor (GR) can share common ligands but play distinct roles in dystrophic heart and skeletal muscle pathophysiology. Comparisons of their ligand structures indicate that the Δ9,11 modification of the first-in-class drug vamorolone enables it to avoid interaction with a conserved receptor residue (N770/N564), which would otherwise activate transcription factor properties of both receptors. Reporter assays show that vamorolone and eplerenone are MR antagonists, whereas prednisolone is an MR agonist. Macrophages, cardiomyocytes, and CRISPR knockout myoblasts show vamorolone is also a dissociative GR ligand that inhibits inflammation with improved safety over prednisone and GR-specific deflazacort. In mice, hyperaldosteronism activates MR-driven hypertension and kidney phenotypes. We find that genetic dystrophin loss provides a second hit for MR-mediated cardiomyopathy in Duchenne muscular dystrophy model mice, as aldosterone worsens fibrosis, mass and dysfunction phenotypes. Vamorolone successfully prevents MR-activated phenotypes, whereas prednisolone activates negative MR and GR effects. In conclusion, vamorolone targets dual nuclear receptors to treat inflammation and cardiomyopathy with improved safety.
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Affiliation(s)
- Christopher R Heier
- Department of Genomics and Precision Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA .,Center for Genetic Medicine Research, Children's National Medical Center, Washington, DC, USA
| | - Qing Yu
- Center for Genetic Medicine Research, Children's National Medical Center, Washington, DC, USA
| | - Alyson A Fiorillo
- Department of Genomics and Precision Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA.,Center for Genetic Medicine Research, Children's National Medical Center, Washington, DC, USA
| | - Christopher B Tully
- Center for Genetic Medicine Research, Children's National Medical Center, Washington, DC, USA
| | - Asya Tucker
- Center for Genetic Medicine Research, Children's National Medical Center, Washington, DC, USA
| | - Davi A Mazala
- Center for Genetic Medicine Research, Children's National Medical Center, Washington, DC, USA
| | | | | | | | - Eric P Hoffman
- AGADA Biosciences Incorporated, Halifax, Nova Scotia, Canada.,ReveraGen BioPharma, Incorporated, Rockville, MD, USA.,School of Pharmacy and Pharmaceutical Sciences, Binghamton University-State University of New York (SUNY), Binghamton, NY, USA
| | - Kanneboyina Nagaraju
- AGADA Biosciences Incorporated, Halifax, Nova Scotia, Canada.,ReveraGen BioPharma, Incorporated, Rockville, MD, USA.,School of Pharmacy and Pharmaceutical Sciences, Binghamton University-State University of New York (SUNY), Binghamton, NY, USA
| | - Christopher F Spurney
- Department of Genomics and Precision Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA.,Center for Genetic Medicine Research, Children's National Medical Center, Washington, DC, USA.,Division of Cardiology, Children's National Heart Institute, Children's National Medical Center, Washington, DC, USA
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40
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Amedro P, Vincenti M, De La Villeon G, Lavastre K, Barrea C, Guillaumont S, Bredy C, Gamon L, Meli AC, Cazorla O, Fauconnier J, Meyer P, Rivier F, Adda J, Mura T, Lacampagne A. Speckle-Tracking Echocardiography in Children With Duchenne Muscular Dystrophy: A Prospective Multicenter Controlled Cross-Sectional Study. J Am Soc Echocardiogr 2019; 32:412-422. [PMID: 30679141 DOI: 10.1016/j.echo.2018.10.017] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Prognosis of Duchenne muscular dystrophy (DMD) is related to cardiac dysfunction. Speckle-tracking echocardiographic (STE) imaging is emerging as a noninvasive functional biomarker to consider in the early detection of DMD-related cardiomyopathy. However, STE analysis has not been assessed in a prospectively controlled study, especially in presymptomatic children with DMD, and no study has used STE analysis in all three displacements (longitudinal, radial, and circumferential) and for both ventricles. METHODS This prospective controlled study enrolled 108 boys, 36 of whom had DMD (mean age, 11 ± 3.8 years) and 72 of whom were age-matched control subjects in a 1:2 case-control design. Conventional echocardiographic variables were collected for the left and right ventricles. STE analyses were performed in the longitudinal, radial, and circumferential displacements for the left ventricle and in the free wall longitudinal displacement for the right ventricle. The effect of age on the evolution of two-dimensional strain in children with DMD was studied by adding an interaction term, DMD × age, in the models. RESULTS Conventional echocardiographic measures were normal in both groups. Left ventricular (LV) ejection fraction ranged from 45% to 76% (mean, 63 ± 6%) in the DMD group and from 55% to 76% (mean, 64 ± 5%) in the control group. Global LV strain mean measures were significantly worse in the DMD group for the longitudinal (-16.8 ± 3.9% vs -20.6 ± 2.6%, P < .0001), radial (22.7 ± 11.3% vs 31.7 ± 14%, P = .002), and circumferential (-16.5 ± 3.8% vs -20.3 ± 3.1%, P < .0001) displacements. The decrease of global LV longitudinal strain with age in children with DMD was 0.34% per year more marked than that in control subjects. The LV inferolateral and anterolateral segments were specifically impaired, especially in the basal area. Right ventricular function evaluated using conventional echocardiography and STE analysis was normal and not different between children with DMD and control subjects. CONCLUSIONS The existence of altered LV strain despite normal LV function in children with DMD represents an important perspective for future pediatric drug trials in DMD-related cardiomyopathy prevention.
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Affiliation(s)
- Pascal Amedro
- Pediatric and Congenital Cardiology Department, M3C Regional Reference CHD Center, CHU Montpellier, Montpellier, France; PHYMEDEXP, University of Montpellier, CNRS, INSERM, CHU Montpellier, Montpellier, France.
| | - Marie Vincenti
- Pediatric and Congenital Cardiology Department, M3C Regional Reference CHD Center, CHU Montpellier, Montpellier, France; PHYMEDEXP, University of Montpellier, CNRS, INSERM, CHU Montpellier, Montpellier, France; Pediatric Cardiology and Rehabilitation Unit, St-Pierre Institute, Palavas-Les-Flots, France
| | - Gregoire De La Villeon
- Pediatric and Congenital Cardiology Department, M3C Regional Reference CHD Center, CHU Montpellier, Montpellier, France; Pediatric Cardiology and Rehabilitation Unit, St-Pierre Institute, Palavas-Les-Flots, France
| | - Kathleen Lavastre
- Pediatric and Congenital Cardiology Department, M3C Regional Reference CHD Center, CHU Montpellier, Montpellier, France
| | - Catherine Barrea
- Pediatric and Congenital Cardiology Department, Cliniques Universitaires Saint-Luc, UCL University, Brussels, Belgium
| | - Sophie Guillaumont
- Pediatric and Congenital Cardiology Department, M3C Regional Reference CHD Center, CHU Montpellier, Montpellier, France; Pediatric Cardiology and Rehabilitation Unit, St-Pierre Institute, Palavas-Les-Flots, France
| | - Charlene Bredy
- Pediatric and Congenital Cardiology Department, M3C Regional Reference CHD Center, CHU Montpellier, Montpellier, France; Department of Cardiology, CHU Montpellier, Montpellier, France
| | - Lucie Gamon
- Epidemiology and Clinical Research Department, CHU Montpellier, Montpellier, France
| | - Albano C Meli
- PHYMEDEXP, University of Montpellier, CNRS, INSERM, CHU Montpellier, Montpellier, France
| | - Olivier Cazorla
- PHYMEDEXP, University of Montpellier, CNRS, INSERM, CHU Montpellier, Montpellier, France
| | - Jeremy Fauconnier
- PHYMEDEXP, University of Montpellier, CNRS, INSERM, CHU Montpellier, Montpellier, France
| | - Pierre Meyer
- PHYMEDEXP, University of Montpellier, CNRS, INSERM, CHU Montpellier, Montpellier, France; Pediatric Neurology, National Reference Centre for Neuromuscular Diseases, CHU Montpellier, Montpellier, France
| | - François Rivier
- PHYMEDEXP, University of Montpellier, CNRS, INSERM, CHU Montpellier, Montpellier, France; Pediatric Neurology, National Reference Centre for Neuromuscular Diseases, CHU Montpellier, Montpellier, France
| | - Jerome Adda
- Department of Cardiology, CHU Montpellier, Montpellier, France
| | - Thibault Mura
- Epidemiology and Clinical Research Department, CHU Montpellier, Montpellier, France; Clinical Investigation Center, University of Montpellier, INSERM, CHU Montpellier, Montpellier, France
| | - Alain Lacampagne
- PHYMEDEXP, University of Montpellier, CNRS, INSERM, CHU Montpellier, Montpellier, France
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Speckle tracking echocardiography in healthy children: comparison between the QLAB by Philips and the EchoPAC by General Electric. Int J Cardiovasc Imaging 2019; 35:799-809. [DOI: 10.1007/s10554-018-01516-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Accepted: 12/15/2018] [Indexed: 11/26/2022]
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Lamacie MM, Warman-Chardon J, Crean AM, Florian A, Wahbi K. The Added Value of Cardiac Magnetic Resonance in Muscular Dystrophies. J Neuromuscul Dis 2019; 6:389-399. [PMID: 31561382 PMCID: PMC6918915 DOI: 10.3233/jnd-190415] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Muscular dystrophies (MD) represent a heterogeneous group of rare genetic diseases that often lead to significant weakness due to progressive muscle degeneration. In many forms of MD, cardiac manifestations including heart failure, atrial and ventricular arrhythmias and conduction abnormalities can occur and may be a predominant feature of the disease. Cardiac magnetic resonance (CMR) can assess cardiac anatomy, global and regional ventricular function, volumes and mass as well as presence of myocardial inflammation, infiltration or fibrosis. The role for cardiac MRI has been well-established in a wide range of muscular dystrophies related cardiomyopathies. CMR is a more sensitive technique than echocardiography for early diagnosis of cardiac involvement. It has also great potential to improve the prediction of long-term outcome, particularly the development of heart failure and arrhythmic events; however it still has to be validated by longitudinal studies including large populations. This review will outline the utility of CMR in patients with muscular dystrophies for assessment of myocardial involvement, risk stratification, and in guiding therapeutic management.
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Affiliation(s)
- Mariana M. Lamacie
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ontario, Canada
| | - Jodi Warman-Chardon
- Division of Neurology, Department of Medicine, University of Ottawa, Ontario, Canada
| | - Andrew M. Crean
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ontario, Canada
| | - Anca Florian
- Department of Cardiology I, University Hospital Muenster, Muenster, Germany
| | - Karim Wahbi
- APHP, Cochin Hospital, Cardiology Department, FILNEMUS, Centre de Référence de Pathologie Neuromusculaire Nord/Est/Ile de France, Paris-Descartes, Sorbonne Paris Cité University, Paris, France; INSERM Unit, Paris Cardiovascular Research Centre (PARCC), Paris, France
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Lowe J, Kadakia FK, Zins JG, Haupt M, Peczkowski KK, Rastogi N, Floyd KT, Gomez-Sanchez EP, Gomez-Sanchez CE, Elnakish MT, Rafael-Fortney JA, Janssen PML. Mineralocorticoid Receptor Antagonists in Muscular Dystrophy Mice During Aging and Exercise. J Neuromuscul Dis 2018; 5:295-306. [PMID: 30010143 DOI: 10.3233/jnd-180323] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Mineralocorticoid receptor antagonists added to angiotensin converting enzyme inhibitors have shown preclinical efficacy for both skeletal and cardiac muscle outcomes in young sedentary dystrophin-deficient mdx mice also haploinsufficient for utrophin, a Duchenne muscular dystrophy (DMD) model. The mdx genotypic DMD model has mild pathology, making non-curative therapeutic effects difficult to distinguish at baseline. Since the cardiac benefit of mineralocorticoid receptor antagonists has been translated to DMD patients, it is important to optimize potential advantages for skeletal muscle by further defining efficacy parameters. OBJECTIVE We aimed to test whether therapeutic effects of mineralocorticoid receptor antagonists added to angiotensin converting enzyme inhibitors are detectable using three different reported methods of exacerbating the mdx phenotype. METHODS We tested treatment with lisinopril and the mineralocorticoid receptor antagonist spironolactone in: 10 week-old exercised, 1 year-old sedentary, and 5 month-old isoproterenol treated mdx mice and performed comprehensive functional and histological measurements. RESULTS None of the protocols to exacerbate mdx phenotypes resulted in dramatically enhanced pathology and no significant benefit was observed with treatment. CONCLUSIONS Since endogenous mineralocorticoid aldosterone production from immune cells in dystrophic muscle may explain antagonist efficacy, it is likely that these drugs work optimally during the narrow window of peak inflammation in mdx mice. Exercised and aged mdx mice do not display prolific damage and inflammation, likely explaining the absence of continued efficacy of these drugs. Since inflammation is more prevalent in DMD patients, the therapeutic window for mineralocorticoid receptor antagonists in patients may be longer.
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Affiliation(s)
- Jeovanna Lowe
- Department of Physiology & Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Feni K Kadakia
- Department of Physiology & Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Jonathan G Zins
- Department of Physiology & Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Michael Haupt
- Department of Physiology & Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Kyra K Peczkowski
- Department of Physiology & Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Neha Rastogi
- Department of Physiology & Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Kyle T Floyd
- Department of Physiology & Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Elise P Gomez-Sanchez
- Department of Pharmacology & Toxicology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Celso E Gomez-Sanchez
- Department of Internal Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Mohammad T Elnakish
- Department of Physiology & Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, USA.,Department of Pharmacology & Toxicology, Faculty of Pharmacy, Helwan University, Cairo, Egypt
| | - Jill A Rafael-Fortney
- Department of Physiology & Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Paul M L Janssen
- Department of Physiology & Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, USA
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Cardona A, Baker P, Kahwash R, Smart S, Phay JE, Basso C, Raman SV. Evidence of aldosterone synthesis in human myocardium in acute myocarditis. Int J Cardiol 2018; 275:114-119. [PMID: 30384979 DOI: 10.1016/j.ijcard.2018.10.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 09/17/2018] [Accepted: 10/02/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Myocarditis may be self-limited but has been identified as an important contributor to downstream cardiomyopathy. Aldosterone mediates myocardial damage in various conditions, but has not been considered specifically as a therapeutic target for inflammatory damage in acute myocarditis. We sought to demonstrate local aldosterone synthesis in human myocardium affected by acute myocarditis. METHODS We evaluated myocardial samples obtained via endomyocardial biopsy (EMB) for expression of CYP11B2, the final and key enzyme for aldosterone synthesis, from patients with acute myocarditis and from stable heart transplant recipients with no evidence of rejection as negative controls. Excised adrenal glands from patients with aldosterone-secreting adenomas were used as positive controls. An experienced cardiovascular pathologist blinded to clinical information rated CYP11B2 stains as negative, positive, or borderline, also recording location of any CYP11B2-positivity. RESULTS Sixteen patients' EMB samples showing definite acute myocarditis were identified (50% female). CYP11B2 was positive in 13/16 cases (81%), typically showing diffuse intracardiomyocyte cytoplasmic staining, vs. 2/16 borderline stains in transplant controls (p < 0.001 myocarditis vs. negative controls). All 3 adrenalectomy samples stained positive for CYP11B2 (diffuse intracellular staining). Importantly, no myocarditis or transplant patients were on aldosterone antagonist therapy at the time of biopsy. CONCLUSIONS In this proof-of-concept study, myocardium from patients with acute myocarditis demonstrates evidence and high prevalence of local aldosterone synthesis by immunohistochemistry that showed high accuracy, specificity, and sensitivity. Aldosterone warrants consideration as a specific target for therapy in patients with myocardial damage due to inflammation towards strategies that reduce downstream complications.
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Affiliation(s)
- Andrea Cardona
- Ohio State University, Heart and Vascular Center, Columbus, OH, USA; Division of Cardiology, University of Perugia, School of Medicine, Perugia, Italy
| | - Peter Baker
- Nationwide Children's Hospital, Anatomic Pathology, Columbus, OH, USA
| | - Rami Kahwash
- Ohio State University, Heart and Vascular Center, Columbus, OH, USA
| | - Suzanne Smart
- Ohio State University, Heart and Vascular Center, Columbus, OH, USA
| | - John E Phay
- Ohio State University, Surgical Oncology, Columbus, OH, USA
| | - Cristina Basso
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Subha V Raman
- Ohio State University, Heart and Vascular Center, Columbus, OH, USA.
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45
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Leigh F, Ferlini A, Biggar D, Bushby K, Finkel R, Morgenroth LP, Wagner KR. Neurology Care, Diagnostics, and Emerging Therapies of the Patient With Duchenne Muscular Dystrophy. Pediatrics 2018; 142:S5-S16. [PMID: 30275245 DOI: 10.1542/peds.2018-0333c] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/26/2018] [Indexed: 11/24/2022] Open
Abstract
Duchenne muscular dystrophy is the most common form of childhood muscular dystrophy. A mutation in the DMD gene disrupts dystrophin (protein) production, causing damage to muscle integrity, weakness, loss of ambulation, and cardiopulmonary compromise by the second decade of life. Life expectancy has improved from mid-teenage years to mid-20s with the use of glucocorticoids and beyond the third decade with ventilator support and multidisciplinary care. However, Duchenne muscular dystrophy is associated with comorbidities and is a fatal disease. Glucocorticoids prolong ambulation, but their side effects are significant. Emerging investigational therapies have surfaced over the past decade and have rapidly been tested in clinical trials. Gene-specific strategies include nonsense readthrough, exon skipping, gene editing, utrophin modulation, and gene replacement. Other mechanisms include muscle regeneration, antioxidants, and antifibrosis and anti-inflammatory pathways. With potential therapies emerging, early diagnosis is needed to initiate treatment early enough to minimize morbidity and mortality. Newborn screening can be used to significantly improve early diagnosis, especially for gene-specific therapeutics.
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Affiliation(s)
- Fawn Leigh
- Massachusetts General Hospital and Harvard Medical School, Harvard University, Cambridge, Massachusetts; .,Seattle Children's Hospital, University of Washington, Seattle, Washington
| | | | - Doug Biggar
- Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada
| | - Katharine Bushby
- John Walton Centre for Muscular Dystrophy Research, Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | | | | | - Kathryn R Wagner
- Kennedy Krieger Institute, Baltimore, Maryland; and.,School of Medicine, Johns Hopkins University, Baltimore, Maryland
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46
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Buddhe S, Cripe L, Friedland-Little J, Kertesz N, Eghtesady P, Finder J, Hor K, Judge DP, Kinnett K, McNally EM, Raman S, Thompson WR, Wagner KR, Olson AK. Cardiac Management of the Patient With Duchenne Muscular Dystrophy. Pediatrics 2018; 142:S72-S81. [PMID: 30275251 PMCID: PMC6566852 DOI: 10.1542/peds.2018-0333i] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/26/2018] [Indexed: 12/11/2022] Open
Abstract
Duchenne muscular dystrophy (DMD) results in a progressive cardiomyopathy that produces significant morbidity and mortality. To improve the quality of life in patients with DMD, cardiac care is focused on surveillance and management, with the goal of slowing the onset and progression of heart failure complications. The current article is intended to be an expanded review on the cardiac management data used to inform the 2018 DMD Care Considerations recommendations as well as be a discussion on clinical controversies and future management directions. The new cardiac guidance includes changes regarding noninvasive imaging surveillance of cardiac function and pharmacologic therapy. Many emerging therapies lack sufficient evidence-based data to be recommended in the 2018 DMD Care Considerations. These are discussed in the present article as clinical controversies and future directions. Important emerging therapies include new heart failure medications, mechanical circulatory support with ventricular assist devices, heart transplantation, and internal cardiac defibrillators. Future research studies should be focused on the risks and benefits of these advanced therapies in patients with DMD. We conclude this review with a brief discussion on the relationship between the heart and the recently developed medications that are used to directly target the absence of dystrophin in DMD.
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Affiliation(s)
- Sujatha Buddhe
- Seattle Children’s Hospital and School of Medicine, University of Washington, Seattle, Washington
| | - Linda Cripe
- Nationwide Children’s Hospital, Columbus, Ohio;,The Ohio State University, Columbus, Ohio
| | - Joshua Friedland-Little
- Seattle Children’s Hospital and School of Medicine, University of Washington, Seattle, Washington
| | - Naomi Kertesz
- Nationwide Children’s Hospital, Columbus, Ohio;,The Ohio State University, Columbus, Ohio
| | - Pirooz Eghtesady
- St Louis Children’s Hospital and School of Medicine, Washington University, St Louis, Missouri
| | - Jonathan Finder
- Children’s Hospital of Pittsburgh and School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kan Hor
- Nationwide Children’s Hospital, Columbus, Ohio;,The Ohio State University, Columbus, Ohio
| | - Daniel P. Judge
- Medical University of South Carolina, Charleston, South Carolina
| | - Kathi Kinnett
- Parent Project Muscular Dystrophy, Hackensack, New Jersey
| | | | | | | | - Kathryn R. Wagner
- Kennedy Krieger institute, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Aaron K. Olson
- Seattle Children’s Hospital and School of Medicine, University of Washington, Seattle, Washington
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47
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Hor KN, Mah ML, Johnston P, Cripe TP, Cripe LH. Advances in the diagnosis and management of cardiomyopathy in Duchenne muscular dystrophy. Neuromuscul Disord 2018; 28:711-716. [PMID: 30064893 DOI: 10.1016/j.nmd.2018.06.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Revised: 06/28/2018] [Accepted: 06/28/2018] [Indexed: 02/07/2023]
Abstract
Patients with Duchenne muscular dystrophy suffer debilitating muscle destruction, resulting in loss of ambulation, diminished respiratory function, gastrointestinal disturbances and cardiomyopathy. Although it is the most common cause of death in these patients, cardiomyopathy is poorly understood in terms of distinct pathogenesis, natural history, and specific, effective therapeutic interventions. We review the state-of-the-art knowledge of Duchenne muscular dystrophy-associated cardiomyopathy including clinical evaluation, imaging, medical and perioperative management, and prospects for gene therapy. We also review cardiomyopathy in heterozygote carriers. By describing our current understanding and best practices, we hope to improve harmonization of care across institutions and identify collective knowledge gaps to guide future research efforts.
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Affiliation(s)
- Kan N Hor
- The Department of Pediatrics, Ohio State University College of Medicine, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - May Ling Mah
- The Department of Pediatrics, Ohio State University College of Medicine, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Pace Johnston
- The Department of Pediatrics, Ohio State University College of Medicine, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Timothy P Cripe
- The Department of Pediatrics, Ohio State University College of Medicine, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Linda H Cripe
- The Department of Pediatrics, Ohio State University College of Medicine, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA.
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48
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Wittlieb-Weber CA, Pantea C, Krikov S, Westfield C, Fox DJ, Pandya S, Bounsanga J, Johnson NE, Butterfield RJ, Venkatesh YS, Ciafaloni E. Cardiovascular health supervision for Duchenne Muscular Dystrophy; data from the MD STARnet. PROGRESS IN PEDIATRIC CARDIOLOGY 2018. [DOI: 10.1016/j.ppedcard.2018.01.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Birnkrant DJ, Bushby K, Bann CM, Alman BA, Apkon SD, Blackwell A, Case LE, Cripe L, Hadjiyannakis S, Olson AK, Sheehan DW, Bolen J, Weber DR, Ward LM. Diagnosis and management of Duchenne muscular dystrophy, part 2: respiratory, cardiac, bone health, and orthopaedic management. Lancet Neurol 2018; 17:347-361. [PMID: 29395990 DOI: 10.1016/s1474-4422(18)30025-5] [Citation(s) in RCA: 572] [Impact Index Per Article: 95.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 10/30/2017] [Accepted: 01/12/2018] [Indexed: 02/07/2023]
Abstract
A coordinated, multidisciplinary approach to care is essential for optimum management of the primary manifestations and secondary complications of Duchenne muscular dystrophy (DMD). Contemporary care has been shaped by the availability of more sensitive diagnostic techniques and the earlier use of therapeutic interventions, which have the potential to improve patients' duration and quality of life. In part 2 of this update of the DMD care considerations, we present the latest recommendations for respiratory, cardiac, bone health and osteoporosis, and orthopaedic and surgical management for boys and men with DMD. Additionally, we provide guidance on cardiac management for female carriers of a disease-causing mutation. The new care considerations acknowledge the effects of long-term glucocorticoid use on the natural history of DMD, and the need for care guidance across the lifespan as patients live longer. The management of DMD looks set to change substantially as new genetic and molecular therapies become available.
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Affiliation(s)
- David J Birnkrant
- Department of Pediatrics, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA.
| | - Katharine Bushby
- John Walton Muscular Dystrophy Research Centre, Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Carla M Bann
- RTI International, Research Triangle Park, NC, USA
| | - Benjamin A Alman
- Department of Orthopaedic Surgery, Duke University School of Medicine and Health System, Durham, NC, USA
| | - Susan D Apkon
- Department of Rehabilitation Medicine, Seattle Children's Hospital, Seattle, WA, USA
| | | | - Laura E Case
- Doctor of Physical Therapy Division, Department of Orthopaedics, Duke University School of Medicine, Durham, NC, USA
| | - Linda Cripe
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Stasia Hadjiyannakis
- Division of Endocrinology and Metabolism, Children's Hospital of Eastern Ontario, and University of Ottawa, Ottawa, ON, Canada
| | - Aaron K Olson
- Department of Pediatrics, Seattle Children's Hospital, Seattle, WA, USA
| | - Daniel W Sheehan
- John R Oishei Children's Hospital, University at Buffalo, The State University of New York, Buffalo, NY, USA
| | - Julie Bolen
- Rare Disorders and Health Outcomes Team, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - David R Weber
- Division of Endocrinology and Diabetes, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Leanne M Ward
- Division of Endocrinology and Metabolism, Children's Hospital of Eastern Ontario, and University of Ottawa, Ottawa, ON, Canada
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50
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Crispi V, Matsakas A. Duchenne muscular dystrophy: genome editing gives new hope for treatment. Postgrad Med J 2018; 94:296-304. [DOI: 10.1136/postgradmedj-2017-135377] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 01/03/2018] [Accepted: 01/13/2018] [Indexed: 12/20/2022]
Abstract
Duchenne muscular dystrophy (DMD) is a progressive wasting disease of skeletal and cardiac muscles, representing one of the most common recessive fatal inherited genetic diseases with 1:3500–1:5000 in yearly incidence. It is caused by mutations in the DMD gene that encodes the membrane-associated dystrophin protein. Over the years, many have been the approaches to management of DMD, but despite all efforts, no effective treatment has yet been discovered. Hope for the development of potential therapeutics has followed the recent advances in genome editing and gene therapy. This review gives an overview to DMD and summarises current lines of evidence with regard to treatment and disease management alongside the appropriate considerations.
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