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Lu DY, Hailesealassie B, Ventoulis I, Liu H, Liang HY, Nowbar A, Pozios I, Canepa M, Cresswell K, Luo HC, Abraham MR, Abraham TP. Impact of peak provoked left ventricular outflow tract gradients on clinical outcomes in hypertrophic cardiomyopathy. Int J Cardiol 2018; 243:290-295. [PMID: 28747034 DOI: 10.1016/j.ijcard.2017.04.039] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Revised: 03/23/2017] [Accepted: 04/10/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Hypertrophic cardiomyopathy (HCM) is traditionally classified based on a left ventricular outflow tract (LVOT) pressure gradient of 30mmHg at rest or with provocation. There are no data on whether 30mmHg is the most informative cut-off value and whether provoked gradients offer any information regarding outcomes. METHODS Resting and provoked peak LVOT pressure gradients were measured by Doppler echocardiography in patients fulfilling guidelines criteria for HCM. A composite clinical outcome including new onset atrial fibrillation, ventricular tachycardia/fibrillation, heart failure, transplantation, and death was examined over a median follow-up period of 2.1years. RESULTS Among 536 patients, 131 patients had resting LVOT gradients greater than 30mmHg. Subjects with higher resting gradients were older with more cardiovascular events. For provoked gradients, a bi-modal risk distribution was found. Patients with provoked gradients >90mmHg (HR 3.92, 95% CI 1.97-7.79) or <30mmHg (HR 2.15, 95% CI 1.08-4.29) have more events compared to those with gradients between 30 and 89mmHg in multivariable analysis. The introduction of two cut-off points for provoked gradients allowed HCM to be reclassified into four groups: patients with "benign" latent HCM (provoked gradient 30-89mmHg) had the best prognosis, whereas those with persistent obstructive HCM had the worst outcome. CONCLUSIONS Provoked LVOT pressure gradients offer additional information regarding clinical outcomes in HCM. Applying cut-off points at 30 and 90mmHg to provoked LVOT pressure gradients further classifies HCM patients into low-, intermediate- and high-risk groups.
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Affiliation(s)
- Dai-Yin Lu
- Johns Hopkins Hypertrophic Cardiomyopathy Center of Excellence, Baltimore, MD, United States; Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Bereketeab Hailesealassie
- Johns Hopkins Hypertrophic Cardiomyopathy Center of Excellence, Baltimore, MD, United States; Division of Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Johns Hopkins University, Baltimore, MD, United States
| | - Ioannis Ventoulis
- Johns Hopkins Hypertrophic Cardiomyopathy Center of Excellence, Baltimore, MD, United States
| | - Hongyun Liu
- Johns Hopkins Hypertrophic Cardiomyopathy Center of Excellence, Baltimore, MD, United States
| | - Hsin-Yueh Liang
- Johns Hopkins Hypertrophic Cardiomyopathy Center of Excellence, Baltimore, MD, United States; Division of Cardiology, Department of Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Alexandra Nowbar
- Johns Hopkins Hypertrophic Cardiomyopathy Center of Excellence, Baltimore, MD, United States
| | - Iraklis Pozios
- Johns Hopkins Hypertrophic Cardiomyopathy Center of Excellence, Baltimore, MD, United States
| | - Marco Canepa
- Johns Hopkins Hypertrophic Cardiomyopathy Center of Excellence, Baltimore, MD, United States
| | - Kenneth Cresswell
- Johns Hopkins Hypertrophic Cardiomyopathy Center of Excellence, Baltimore, MD, United States
| | - Hong-Chang Luo
- Johns Hopkins Hypertrophic Cardiomyopathy Center of Excellence, Baltimore, MD, United States
| | - M Roselle Abraham
- Johns Hopkins Hypertrophic Cardiomyopathy Center of Excellence, Baltimore, MD, United States
| | - Theodore P Abraham
- Johns Hopkins Hypertrophic Cardiomyopathy Center of Excellence, Baltimore, MD, United States.
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Imaging assessment of cardiovascular disease in systemic lupus erythematosus. Clin Dev Immunol 2011; 2012:694143. [PMID: 22110536 PMCID: PMC3202117 DOI: 10.1155/2012/694143] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2011] [Revised: 08/26/2011] [Accepted: 08/26/2011] [Indexed: 11/17/2022]
Abstract
Systemic lupus erythematosus is a multisystem, autoimmune disease known to be one of the strongest risk factors for atherosclerosis. Patients with SLE have an excess cardiovascular risk compared with the general population, leading to increased cardiovascular morbidity and mortality. Although the precise explanation for this is yet to be established, it seems to be associated with the presence of an accelerated atherosclerotic process, arising from the combination of traditional and lupus-specific risk factors. Moreover, cardiovascular-disease associated mortality in patients with SLE has not improved over time. One of the main reasons for this is the poor performance of standard risk stratification tools on assessing the cardiovascular risk of patients with SLE. Therefore, establishing alternative ways to identify patients at increased risk efficiently is essential. With recent developments in several imaging techniques, the ultimate goal of cardiovascular assessment will shift from assessing symptomatic patients to diagnosing early cardiovascular disease in asymptomatic patients which will hopefully help us to prevent its progression. This review will focus on the current status of the imaging tools available to assess cardiac and vascular function in patients with SLE.
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Ashrafi R, Garg P, McKay E, Gosney J, Chuah S, Davis G. Aggressive cardiac involvement in systemic lupus erythematosus: a case report and a comprehensive literature review. Cardiol Res Pract 2011; 2011:578390. [PMID: 21350606 PMCID: PMC3042616 DOI: 10.4061/2011/578390] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2010] [Revised: 12/24/2010] [Accepted: 01/07/2011] [Indexed: 11/20/2022] Open
Abstract
Background. We present the case of a 35-year-old gentleman who presented with an aggressive cardiomyopathy with normal coronary arteries. He was later diagnosed with systemic lupus-related cardiomyopathy. Methods. We undertook an extensive review of the literature regarding cardiac manifestations of lupus and used over 100 journals to identify the key points in pathology, diagnosis, and treatment. Results. We have shown that cardiac lupus can be rapidly progressive and, unless treated early, can have severe consequences. The predominant pathologies are immune complex and accelerated atherosclerosis drive. Treatment comprised of high-level immunosuppression.
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Affiliation(s)
- Reza Ashrafi
- Aintree Cardiac Centre, University Hospital Aintree, Lower Lane, Liverpool L9 7AL, UK
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Schotte H, Becker H, Domschke W, Gaubitz M. [Cardiovascular monitoring of patients with systemic lupus erythematosus]. Z Rheumatol 2005; 64:564-75. [PMID: 16328762 DOI: 10.1007/s00393-005-0668-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2004] [Accepted: 10/05/2004] [Indexed: 11/28/2022]
Abstract
Accelerated atherosclerotic cardiovascular disease is increasingly recognized as a major cause of morbidity and mortality in patients with systemic lupus erythematosus (SLE). Cardiac manifestations of SLE are frequent and can involve almost all components of the heart. Pulmonary hypertension often develops during the course of SLE. The high incidence of cardiovascular complications may justify a screening of SLE patients in order to ensure early diagnosis and therapy. Results of diagnostic procedures that detect coronary insufficiency, surrogates of atherosclerotic burden and echocardiographic findings are often abnormal in SLE. However, evidence to support a routine screening for cardiovascular disease is currently not available. Therefore, based on the recommendations that have been proposed for other conditions associated with cardiovascular disease, we suggest assessment of risk factors and the performance of echocardiography at least annually in asymptomatic SLE patients. If two or more risk factors are present, an exercise ECG is recommended. The benefit, however, of screening SLE patients for cardiovascular disease has to be confirmed in prospective studies.
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Affiliation(s)
- H Schotte
- Medizinische Klinik und Poliklinik B, Universitätsklinikum Münster, Albert-Schweitzer-Str. 33, 48129 Münster, Germany.
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