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Maron MS, Mahmod M, Abd Samat AH, Choudhury L, Massera D, Phelan DMJ, Cresci S, Martinez MW, Masri A, Abraham TP, Adler E, Wever-Pinzon O, Nagueh SF, Lewis GD, Chamberlin P, Patel J, Yavari A, Dehbi HM, Sarwar R, Raman B, Valkovič L, Neubauer S, Udelson JE, Watkins H. Safety and Efficacy of Metabolic Modulation With Ninerafaxstat in Patients With Nonobstructive Hypertrophic Cardiomyopathy. J Am Coll Cardiol 2024; 83:2037-2048. [PMID: 38599256 DOI: 10.1016/j.jacc.2024.03.387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 03/18/2024] [Accepted: 03/19/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND In nonobstructive hypertrophic cardiomyopathy (nHCM), there are no approved medical therapies. Impaired myocardial energetics is a potential cause of symptoms and exercise limitation. Ninerafaxstat, a novel cardiac mitotrope, enhances cardiac energetics. OBJECTIVES This study sought to evaluate the safety and efficacy of ninerafaxstat in nHCM. METHODS Patients with hypertrophic cardiomyopathy and left ventricular outflow tract gradient <30 mm Hg, ejection fraction ≥50%, and peak oxygen consumption <80% predicted were randomized to ninerafaxstat 200 mg twice daily or placebo (1:1) for 12 weeks. The primary endpoint was safety and tolerability, with efficacy outcomes also assessed as secondary endpoints. RESULTS A total of 67 patients with nHCM were enrolled at 12 centers (57 ± 11.8 years of age; 55% women). Serious adverse events occurred in 11.8% (n = 4 of 34) in the ninerafaxstat group and 6.1% (n = 2 of 33) of patients in the placebo group. From baseline to 12 weeks, ninerafaxstat was associated with significantly better VE/Vco2 (ventilatory efficiency) slope compared with placebo with a least-squares (LS) mean difference between the groups of -2.1 (95% CI: -3.6 to -0.6; P = 0.006), with no significant difference in peak VO2 (P = 0.90). The Kansas City Cardiomyopathy Questionnaire Clinical Summary Score was directionally, though not significantly, improved with ninerafaxstat vs placebo (LS mean 3.2; 95% CI: -2.9 to 9.2; P = 0.30); however, it was statistically significant when analyzed post hoc in the 35 patients with baseline Kansas City Cardiomyopathy Questionnaire Clinical Summary Score ≤80 (LS mean 9.4; 95% CI: 0.3-18.5; P = 0.04). CONCLUSIONS In symptomatic nHCM, novel drug therapy targeting myocardial energetics was safe and well tolerated and associated with better exercise performance and health status among those most symptomatically limited. The findings support assessing ninerafaxstat in a phase 3 study.
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Affiliation(s)
- Martin S Maron
- Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA.
| | - Masliza Mahmod
- Oxford Centre for Clinical Magnetic Resonance Research, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Azlan Helmy Abd Samat
- Oxford Centre for Clinical Magnetic Resonance Research, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Lubna Choudhury
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Daniele Massera
- Hypertrophic Cardiomyopathy Program, Leon H. Charney Division of Cardiology, NYU Langone Health, New York, New York, USA
| | - Dermot M J Phelan
- Sanger Heart and Vascular Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Sharon Cresci
- Center for Cardiovascular Research, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Matthew W Martinez
- Division of Cardiology, Atlantic Health System, Morristown, New Jersey, USA
| | - Ahmad Masri
- Hypertrophic Cardiomyopathy Center, Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Theodore P Abraham
- Division of Cardiology, University of California-San Francisco, San Francisco, California, USA
| | - Eric Adler
- Division of Cardiovascular Medicine, Department of Medicine, University of California-San Diego, La Jolla, California, USA
| | - Omar Wever-Pinzon
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah and Salt Lake Veterans Affairs Medical Center, Salt Lake City, Utah, USA
| | - Sherif F Nagueh
- Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Gregory D Lewis
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Jai Patel
- Imbria Pharmaceuticals, Boston, Massachusetts, USA
| | - Arash Yavari
- Imbria Pharmaceuticals, Boston, Massachusetts, USA
| | | | | | - Betty Raman
- Oxford Centre for Clinical Magnetic Resonance Research, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Ladislav Valkovič
- Oxford Centre for Clinical Magnetic Resonance Research, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Stefan Neubauer
- Oxford Centre for Clinical Magnetic Resonance Research, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - James E Udelson
- Division of Cardiology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Hugh Watkins
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
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Ding WY, Meah MN, Stables R, Cooper RM. Interventions in Hypertrophic Obstructive Cardiomyopathy. Can J Cardiol 2024; 40:833-842. [PMID: 38070769 DOI: 10.1016/j.cjca.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 11/11/2023] [Accepted: 12/04/2023] [Indexed: 04/02/2024] Open
Abstract
Obstructive hypertrophic cardiomyopathy is the most common genetically transmitted cardiomyopathy that is associated with significant morbidity and mortality. Despite contemporary treatments and interventions, the management of patients with obstructive hypertrophic cardiomyopathy remains poorly defined compared with other branches of cardiology. In this review, we discuss established and novel therapeutic interventions in patients with obstructive hypertrophic cardiomyopathy with a focus on percutaneous and surgical strategies including surgical myectomy, mitral valve repair or replacement, percutaneous alcohol septal ablation, pacemaker and cardioverter-defibrillator implantation, septal embolization, radiofrequency endocardial catheter ablation, and percutaneous intramyocardial septal radiofrequency ablation.
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Affiliation(s)
- Wern Yew Ding
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom
| | - Mohammed N Meah
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Rodney Stables
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Robert M Cooper
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; Research Institute of Sports and Exercise Science, Liverpool John Moores University, Liverpool, United Kingdom.
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Reddy S, Varma A, Taksande A. Fever Unveiling a Hidden Cardiac Condition: A Case of Pediatric Hypertrophic Obstructive Cardiomyopathy. Cureus 2024; 16:e55823. [PMID: 38590469 PMCID: PMC10999888 DOI: 10.7759/cureus.55823] [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: 02/26/2024] [Accepted: 03/08/2024] [Indexed: 04/10/2024] Open
Abstract
This case report presents the clinical management of a 18-month-old female child who presented with fever, cough, and cold symptoms for eight days. Despite initial treatment with antipyretic syrup, the persistence of symptoms prompted further evaluation, revealing signs of hypertrophic obstructive cardiomyopathy (HOCM) on echocardiography. The patient was subsequently initiated on beta-blocker therapy and supportive care, leading to clinical improvement and eventual discharge. This case underscores the importance of considering cardiac etiologies in pediatric patients presenting with nonspecific symptoms. It highlights the role of timely diagnosis and multidisciplinary management in optimizing outcomes for affected individuals. Further research and awareness efforts are warranted to enhance diagnostic capabilities and refine treatment strategies for pediatric cardiac conditions like HOCM.
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Affiliation(s)
- Sneha Reddy
- Pediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Ashish Varma
- Pediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Amar Taksande
- Pediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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4
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Wang A, Spertus JA, Wojdyla DM, Abraham TP, Nilles EK, Owens AT, Saberi S, Cresci S, Sehnert A, Lakdawala NK. Mavacamten for Obstructive Hypertrophic Cardiomyopathy With or Without Hypertension: Post-Hoc Analysis of the EXPLORER-HCM Trial. JACC. HEART FAILURE 2024; 12:567-579. [PMID: 37855754 DOI: 10.1016/j.jchf.2023.07.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 07/19/2023] [Accepted: 07/25/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Hypertension (HTN) is common in patients with hypertrophic cardiomyopathy (HCM), but its effect on the treatment of left ventricular outflow tract (LVOT) obstruction is undefined. Although elevated systolic blood pressure (SBP) may impact dynamic LVOT gradients, its response to cardiac myosin inhibition is unknown. OBJECTIVES In a post hoc exploratory analysis of the EXPLORER-HCM trial (Clinical Study to Evaluate Mavacamten [MYK-461] in Adults With Symptomatic Obstructive Hypertrophic Cardiomyopathy), the authors examined the characteristics of patients with obstructive HCM and HTN and the associations between HTN, SBP, and the response to mavacamten treatment of LVOT obstruction. METHODS Patients were stratified by baseline history of HTN and mean SBP during 30-week treatment with mavacamten or placebo. The study estimated treatment differences and evaluated HTN and SBP groups by treatment interaction. Analysis of covariance was used to model changes in continuous endpoints, and a generalized linear model was used for binary endpoints. RESULTS HTN was present in 119 of 251 patients (47.4%), including 60 receiving mavacamten and 59 receiving placebo. Patients with HTN vs no HTN were older (63.4 vs 54.0 years; P < 0.001), had higher SBP (134 ± 15.1 mm Hg vs 123 ± 13.8 mm Hg; P < 0.001), more comorbidities, and lower peak oxygen consumption (19 ± 3 vs 20 ± 4 mL/kg/min; P = 0.021). Patients with HTN had similar NYHA functional class (NYHA functional class II, 72% vs 73%), Valsalva LVOT gradients (72 ± 34 mm Hg vs 74 ± 30 mm Hg), Kansas City Cardiomyopathy Questionnaire-Clinical Summary Scores (70.6 ± 18.8 vs 68.9 ± 23.1), and NT pro-B-type natriuretic peptide levels (geometric mean 632 ± 129 pg/mL vs 745 ± 130 pg/mL). Mavacamten-treated patients had improvement in all primary, secondary, and exploratory endpoints regardless of HTN status or mean SBP. CONCLUSIONS The clinical benefits of mavacamten in symptomatic, obstructive HCM were similar in patients with and without HTN, despite differences in baseline characteristics. (Clinical Study to Evaluate Mavacamten [MYK-461] in Adults With Symptomatic Obstructive Hypertrophic Cardiomyopathy [EXPLORER-HCM]; NCT03470545).
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Affiliation(s)
- Andrew Wang
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.
| | - John A Spertus
- Departments of Internal Medicine and Biomedical and Health Informatics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Daniel M Wojdyla
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Theodore P Abraham
- Division of Cardiology, Department of Medicine, University of San Francisco School of Medicine, San Francisco, California, USA
| | - Ester Kim Nilles
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Anjali Tiku Owens
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sara Saberi
- Division of Cardiovascular Medicine, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Sharon Cresci
- Cardiovascular Division, John T. Milliken Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Amy Sehnert
- Bristol Myers Squibb, Princeton, New Jersey, USA
| | - Neal K Lakdawala
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Desai MY, Hajj-Ali A, Rutkowski K, Ospina S, Gaballa A, Emery M, Asher C, Xu B, Thamilarasan M, Popovic ZB. Real-world experience with mavacamten in obstructive hypertrophic cardiomyopathy: Observations from a tertiary care center. Prog Cardiovasc Dis 2024:S0033-0620(24)00022-7. [PMID: 38354765 DOI: 10.1016/j.pcad.2024.02.001] [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: 02/11/2024] [Accepted: 02/11/2024] [Indexed: 02/16/2024]
Abstract
BACKGROUND In symptomatic obstructive hypertrophic cardiomyopathy (oHCM) patients, mavacamten is commercially approved to help improve left ventricular (LV) outflow tract (LVOT) gradients, symptoms, and reduce eligibility for septal reduction therapy (SRT) under the risk evaluation and mitigation strategy (REMS) program. We sought to prospectively report the initial real-world clinical experience with the use of commercially available mavacamten in a multi-hospital tertiary healthcare system. METHODS We studied the first 150 consecutive oHCM patients (mean age 65 years, 53% women, 83% on betablockers and 61% in New York Heart Association [NYHA] class III) who were initiated on 5 mg of mavacamten with dose titrations using symptom assessment and echocardiographic measurements of LVOT gradient and LV ejection fraction (LVEF) measurements. We measured changes in NYHA class, LVEF, LVOT gradients (resting and Valsalva) at baseline, 4, 8 and 12 weeks. RESULTS At 261 ± 143 days (range of 31-571 days), 69 (46%) patients had ≥1 NYHA class, and 27 (18%) additional patients had ≥2 NYHA class improvement. The mean Valsalva LVOT gradient decreased from 72 ± 43 mmHg at baseline to 29 ± 31 mmHg at 4 weeks, 29 ± 28 mmHg at 8 weeks and 30 ± 29 mmHg at 12 weeks (p < 0.001). At baseline, 100% patients had Valsalva LVOT gradients ≥30 mmHg, which reduced to 29% at 4 weeks, 28% at 8 weeks and 30% at 12 weeks. In 40 patients who reported no symptomatic improvement, the mean Valsalva LVOT gradient decreased from 73 ± 39 mmHg at baseline to 34 ± 27 mmHg at 4 weeks, 35 ± 28 mmHg at 8 weeks and 30 ± 24 mmHg at 12 weeks (P < 0.001). The mean LVEF at baseline was 66 ± 6% and changed to 64 ± 5% at 4 weeks, 63 ± 5% at 8 weeks and 62 ± 7% at 12 weeks (p < 0.0001). No patient underwent SRT, developed LVEF ≤30% or developed heart failure requiring admission. Three (2%) patients needed temporary interruption of mavacamten due to LVEF<50%. CONCLUSIONS In a real-world study in symptomatic oHCM patients at a multi-hospital tertiary care referral center, we demonstrate the efficacy and safety, along with the logistic feasibility of prescribing mavacamten under the REMS program.
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Affiliation(s)
- Milind Y Desai
- From the Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, Weston, Cleveland, OH, USA.
| | - Adel Hajj-Ali
- From the Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, Weston, Cleveland, OH, USA
| | - Katy Rutkowski
- From the Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, Weston, Cleveland, OH, USA
| | - Susan Ospina
- From the Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, Weston, Cleveland, OH, USA
| | - Andrew Gaballa
- From the Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, Weston, Cleveland, OH, USA
| | - Michael Emery
- From the Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, Weston, Cleveland, OH, USA
| | - Craig Asher
- From the Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, Weston, Cleveland, OH, USA
| | - Bo Xu
- From the Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, Weston, Cleveland, OH, USA
| | - Maran Thamilarasan
- From the Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, Weston, Cleveland, OH, USA
| | - Zoran B Popovic
- From the Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, Weston, Cleveland, OH, USA
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6
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Cui H, Schaff HV, Olson TP, Geske JB, Dearani JA, Nishimura RA, Sun D, Ommen SR. Cardiopulmonary exercise test in patients with obstructive hypertrophic cardiomyopathy. J Thorac Cardiovasc Surg 2024; 167:701-710.e3. [PMID: 35798610 DOI: 10.1016/j.jtcvs.2022.05.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 04/26/2022] [Accepted: 05/06/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The study objective was to analyze performance on cardiopulmonary exercise testing and its prognostic value in patients with obstructive hypertrophic cardiomyopathy undergoing septal myectomy. METHODS We reviewed patients with obstructive hypertrophic cardiomyopathy who had cardiopulmonary exercise testing before septal myectomy from 2005 to 2016. Causes of functional impairment and their impact on survival were analyzed. RESULTS A total of 752 patients had cardiopulmonary exercise testing at a median of 16 days (interquartile range, 2-56) before myectomy. The median exercise time was 6.6 (5.3-8.0) minutes. Functional aerobic capacity was 64% (53%-75%) of predicted, and metabolic equivalent of task was 5.2 (4.1-6.4). The peak oxygen consumption was 18.0 (14.2-21.9) mL/kg/min, which was 60% (49%-72%) of the predicted value. The primary causes for low peak oxygen consumption were impaired cardiac output (73.7%), limited heart rate reserve (52.0%), and obesity (48.2%). Resting outflow tract gradient correlated poorly to peak oxygen consumption, but the use of beta-blockers was associated with reduced peak oxygen consumption. During a median (interquartile range) of 9.0 (6.8-11.7) years of follow-up, the estimated 5- and 10-year survivals were 97% and 91%, respectively. Greater adjusted peak oxygen consumption (hazard ratio, 0.98; P = .011) and abnormal pulse oxygen increase (hazard ratio, 0.44; P = .003) were independently associated with better long-term survival after myectomy. CONCLUSIONS Among patients with hypertrophic cardiomyopathy undergoing septal myectomy, functional capacity is severely impaired despite receiving optimal medical treatment. We identified risk factors of reduced long-term survival from preoperative cardiopulmonary exercise testing that may aid risk stratification in patients undergoing septal myectomy.
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Affiliation(s)
- Hao Cui
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | | | - Thomas P Olson
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn
| | - Jeffrey B Geske
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Rick A Nishimura
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn
| | - Daokun Sun
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Steve R Ommen
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn
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Guo G, Wang L, Li X, Fu W, Cao J, Zhang J, Liu Y, Liu M, Wang M, Zhao G, Zhao X, Zhou Y, Niu S, Liu G, Zhang Y, Dong J, Tao H, Zhao X. Enhanced myofilament calcium sensitivity aggravates abnormal calcium handling and diastolic dysfunction in patient-specific induced pluripotent stem cell-derived cardiomyocytes with MYH7 mutation. Cell Calcium 2024; 117:102822. [PMID: 38101154 DOI: 10.1016/j.ceca.2023.102822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 10/04/2023] [Accepted: 11/06/2023] [Indexed: 12/17/2023]
Abstract
Hypertrophic cardiomyopathy (HCM), the most common inherited heart disease, is frequently caused by mutations in the β-cardiac myosin heavy chain gene (MYH7). Abnormal calcium handling and diastolic dysfunction are archetypical features of HCM caused by MYH7 gene mutations. However, the mechanism of how MYH7 mutations leads to these features remains unclear, which inhibits the development of effective therapies. Initially, cardiomyocytes were generated from induced pluripotent stem cells from an eight-year-old girl diagnosed with HCM carrying a MYH7(C.1063 G>A) heterozygous mutation(mutant-iPSC-CMs) and mutation-corrected isogenic iPSCs(control-iPSC-CMs) in the present study. Next, we compared phenotype of mutant-iPSC-CMs to that of control-iPSC-CMs, by assessing their morphology, hypertrophy-related genes expression, calcium handling, diastolic function and myofilament calcium sensitivity at days 15 and 40 respectively. Finally, to better understand increased myofilament Ca2+ sensitivity as a central mechanism of central pathogenicity in HCM, inhibition of calcium sensitivity with mavacamten can improveed cardiomyocyte hypertrophy. Mutant-iPSC-CMs exhibited enlarged areas, increased sarcomere disarray, enhanced expression of hypertrophy-related genes proteins, abnormal calcium handling, diastolic dysfunction and increased myofilament calcium sensitivity at day 40, but only significant increase in calcium sensitivity and mild diastolic dysfunction at day 15. Increased calcium sensitivity by levosimendan aggravates cardiomyocyte hypertrophy phenotypes such as expression of hypertrophy-related genes, abnormal calcium handling and diastolic dysfunction, while inhibition of calcium sensitivity significantly improves cardiomyocyte hypertrophy phenotypes in mutant-iPSC-CMs, suggesting increased myofilament calcium sensitivity is the primary mechanisms for MYH7 mutations pathogenesis. Our studies have uncovered a pathogenic mechanism of HCM caused by MYH7 gene mutations through which enhanced myofilament calcium sensitivity aggravates abnormal calcium handling and diastolic dysfunction. Correction of the myofilament calcium sensitivity was found to be an effective method for treating the development of HCM phenotype in vitro.
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Affiliation(s)
- Guangli Guo
- Department of Cardiology, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, 450000, China
| | - Lu Wang
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Xiaowei Li
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China; Henan Key Laboratory of Hereditary Cardiovascular Diseases, Zhengzhou, 450052, China
| | - Wanrong Fu
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Jinhua Cao
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Jianchao Zhang
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Yangyang Liu
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China; Henan Key Laboratory of Hereditary Cardiovascular Diseases, Zhengzhou, 450052, China
| | - Mengduan Liu
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China; Henan Key Laboratory of Hereditary Cardiovascular Diseases, Zhengzhou, 450052, China
| | - Mengyu Wang
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China; Henan Key Laboratory of Hereditary Cardiovascular Diseases, Zhengzhou, 450052, China
| | - Guojun Zhao
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Xi Zhao
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China; Henan Key Laboratory of Hereditary Cardiovascular Diseases, Zhengzhou, 450052, China
| | - Yangfan Zhou
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China; Henan Key Laboratory of Hereditary Cardiovascular Diseases, Zhengzhou, 450052, China
| | - Shaohui Niu
- Department of Cardiology, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, 450000, China
| | - Gangqiong Liu
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Yanzhou Zhang
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Jianzeng Dong
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China; Henan Key Laboratory of Hereditary Cardiovascular Diseases, Zhengzhou, 450052, China; Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, No. 2 Beijing Anzhen Road, Chaoyang District, Beijing 100029, China.
| | - Hailong Tao
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China.
| | - Xiaoyan Zhao
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China; Henan Key Laboratory of Hereditary Cardiovascular Diseases, Zhengzhou, 450052, China.
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8
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Desai MY, Owens A, Wolski K, Geske JB, Saberi S, Wang A, Sherrid M, Cremer PC, Lakdawala NK, Tower-Rader A, Fermin D, Naidu SS, Smedira NG, Schaff H, McErlean E, Sewell C, Mudarris L, Gong Z, Lampl K, Sehnert AJ, Nissen SE. Mavacamten in Patients With Hypertrophic Cardiomyopathy Referred for Septal Reduction: Week 56 Results From the VALOR-HCM Randomized Clinical Trial. JAMA Cardiol 2023; 8:968-977. [PMID: 37639243 PMCID: PMC10463171 DOI: 10.1001/jamacardio.2023.3342] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 08/07/2023] [Indexed: 08/29/2023]
Abstract
Importance There is an unmet need for novel medical therapies before recommending invasive therapies for patients with severely symptomatic obstructive hypertrophic cardiomyopathy (HCM). Mavacamten has been shown to improve left ventricular outflow tract (LVOT) gradient and symptoms and may thus reduce the short-term need for septal reduction therapy (SRT). Objective To examine the cumulative longer-term effect of mavacamten on the need for SRT through week 56. Design, Setting, and Participants This was a double-blind, placebo-controlled, multicenter, randomized clinical trial with placebo crossover at 16 weeks, conducted from July 2020 to November 2022. Participants were recruited from 19 US HCM centers. Included in the trial were patients with obstructive HCM (New York Heart Association class III/IV) referred for SRT. Study data were analyzed April to August 2023. Interventions Patients initially assigned to mavacamten at baseline continued the drug for 56 weeks, and patients taking placebo crossed over to mavacamten from week 16 to week 56 (40-week exposure). Dose titrations were performed using echocardiographic LVOT gradient and LV ejection fraction (LVEF) measurements. Main Outcome and Measure Proportion of patients undergoing SRT, remaining guideline eligible or unevaluable SRT status at week 56. Results Of 112 patients with highly symptomatic obstructive HCM, 108 (mean [SD] age, 60.3 [12.5] years; 54 male [50.0%]) qualified for the week 56 evaluation. At week 56, 5 of 56 patients (8.9%) in the original mavacamten group (3 underwent SRT, 1 was SRT eligible, and 1 was not SRT evaluable) and 10 of 52 patients (19.2%) in the placebo crossover group (3 underwent SRT, 4 were SRT eligible, and 3 were not SRT evaluable) met the composite end point. A total of 96 of 108 patients (89%) continued mavacamten long term. Between the mavacamten and placebo-to-mavacamten groups, respectively, after 56 weeks, there was a sustained reduction in resting (mean difference, -34.0 mm Hg; 95% CI, -43.5 to -24.5 mm Hg and -33.2 mm Hg; 95% CI, -41.9 to -24.5 mm Hg) and Valsalva (mean difference, -45.6 mm Hg; 95% CI, -56.5 to -34.6 mm Hg and -54.6 mm Hg; 95% CI, -66.0 to -43.3 mm Hg) LVOT gradients. Similarly, there was an improvement in NYHA class of 1 or higher in 51 of 55 patients (93%) in the original mavacamten group and in 37 of 51 patients (73%) in the placebo crossover group. Overall, 12 of 108 patients (11.1%; 95% CI, 5.87%-18.60%), which represents 7 of 56 patients (12.5%) in the original mavacamten group and 5 of 52 patients (9.6%) in the placebo crossover group, had an LVEF less than 50% (2 with LVEF ≤30%, one of whom died), and 9 of 12 patients (75%) continued treatment. Conclusions and Relevance Results of this randomized clinical trial showed that in patients with symptomatic obstructive HCM, mavacamten reduced the need for SRT at week 56, with sustained improvements in LVOT gradients and symptoms. Although this represents a useful therapeutic option, given the potential risk of LV systolic dysfunction, there is a continued need for close monitoring. Trial Registration ClinicalTrials.gov Identifier: NCT04349072.
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Affiliation(s)
- Milind Y. Desai
- The Hypertrophic Cardiomyopathy Center, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- Coordinating Center for Clinical Research Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Anjali Owens
- Division of Cardiology, University of Pennsylvania, Philadelphia
| | - Kathy Wolski
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- Coordinating Center for Clinical Research Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jeffrey B. Geske
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Sara Saberi
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Andrew Wang
- Department of Cardiology, Duke University, Durham, North Carolina
| | - Mark Sherrid
- Department of Cardiology, New York University, New York
| | - Paul C. Cremer
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- Coordinating Center for Clinical Research Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Neal K. Lakdawala
- Division of Cardiology, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - David Fermin
- Department of Cardiology, Corewell Health, Grand Rapids, Michigan
| | - Srihari S. Naidu
- Department of Cardiology, Westchester Medical Center, Valhalla, New York
| | - Nicholas G. Smedira
- The Hypertrophic Cardiomyopathy Center, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- Department of Cardiothoracic Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Hartzell Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Ellen McErlean
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- Coordinating Center for Clinical Research Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Christina Sewell
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- Coordinating Center for Clinical Research Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | | | | | | | | | - Steven E. Nissen
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- Coordinating Center for Clinical Research Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
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9
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Nag S, Gollapudi SK, Del Rio CL, Spudich JA, McDowell R. Mavacamten, a precision medicine for hypertrophic cardiomyopathy: From a motor protein to patients. SCIENCE ADVANCES 2023; 9:eabo7622. [PMID: 37506209 DOI: 10.1126/sciadv.abo7622] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 06/23/2023] [Indexed: 07/30/2023]
Abstract
Hypertrophic cardiomyopathy (HCM) is a primary myocardial disorder characterized by left ventricular hypertrophy, hyperdynamic contraction, and impaired relaxation of the heart. These functional derangements arise directly from altered sarcomeric function due to either mutations in genes encoding sarcomere proteins, or other defects such as abnormal energetics. Current treatment options do not directly address this causal biology but focus on surgical and extra-sarcomeric (sarcolemmal) pharmacological symptomatic relief. Mavacamten (formerly known as MYK-461), is a small molecule designed to regulate cardiac function at the sarcomere level by selectively but reversibly inhibiting the enzymatic activity of myosin, the fundamental motor of the sarcomere. This review summarizes the mechanism and translational progress of mavacamten from proteins to patients, describing how the mechanism of action and pharmacological characteristics, involving both systolic and diastolic effects, can directly target pathophysiological derangements within the cardiac sarcomere to improve cardiac structure and function in HCM. Mavacamten was approved by the Food and Drug Administration in April 2022 for the treatment of obstructive HCM and now goes by the commercial name of Camzyos. Full information about the risks, limitations, and side effects can be found at www.accessdata.fda.gov/drugsatfda_docs/label/2022/214998s000lbl.pdf.
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Affiliation(s)
- Suman Nag
- MyoKardia Inc., a wholly owned subsidiary of Bristol Myers Squibb, Brisbane, CA 94005, USA
| | - Sampath K Gollapudi
- MyoKardia Inc., a wholly owned subsidiary of Bristol Myers Squibb, Brisbane, CA 94005, USA
| | - Carlos L Del Rio
- MyoKardia Inc., a wholly owned subsidiary of Bristol Myers Squibb, Brisbane, CA 94005, USA
- Cardiac Consulting, 1630 S Delaware St. #56426, San Mateo, CA 94403, USA
| | | | - Robert McDowell
- MyoKardia Inc., a wholly owned subsidiary of Bristol Myers Squibb, Brisbane, CA 94005, USA
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10
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Desai MY, Owens A, Geske JB, Wolski K, Saberi S, Wang A, Sherrid M, Cremer PC, Naidu SS, Smedira NG, Schaff H, McErlean E, Sewell C, Balasubramanyam A, Lampl K, Sehnert AJ, Nissen SE. Dose-Blinded Myosin Inhibition in Patients With Obstructive Hypertrophic Cardiomyopathy Referred for Septal Reduction Therapy: Outcomes Through 32 Weeks. Circulation 2023; 147:850-863. [PMID: 36335531 DOI: 10.1161/circulationaha.122.062534] [Citation(s) in RCA: 35] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Septal reduction therapy (SRT) in patients with intractable symptoms from obstructive hypertrophic cardiomyopathy (oHCM) is associated with variable morbidity and mortality. The VALOR-HCM trial (A Study to Evaluate Mavacamten in Adults with Symptomatic Obstructive Hypertrophic Cardiomyopathy Who Are Eligible for Septal Reduction Therapy) examined the effect of mavacamten on the need for SRT through week 32 in oHCM. METHODS A double-blind randomized placebo-controlled multicenter trial at 19 US sites included patients with oHCM on maximal tolerated medical therapy referred for SRT with left ventricular outflow tract gradient ≥50 mm Hg at rest or provocation (enrollment, July 2020-October 2021). The group initially randomized to mavacamten continued the drug for 32 weeks, and the placebo group crossed over to dose-blinded mavacamten from week 16 to week 32. Dose titrations were based on investigator-blinded echocardiographic assessment of left ventricular outflow tract gradient and left ventricular ejection fraction. The principal end point was the proportion of patients proceeding with SRT or remaining guideline eligible at 32 weeks in both treatment groups. RESULTS From the 112 randomized patients with oHCM, 108 (mean age, 60.3 years; 50% men; 94% in New York Heart Association class III/IV) qualified for week 32 evaluation (56 in the original mavacamten group and 52 in the placebo cross-over group). After 32 weeks, 6 of 56 patients (10.7%) in the original mavacamten group and 7 of 52 patients (13.5%) in the placebo cross-over group met SRT guideline criteria or elected to undergo SRT. After 32 weeks, a sustained reduction in resting left ventricular outflow tract gradient (-33.0 mm Hg [95% CI, -41.1 to -24.9]) and Valsalva left ventricular outflow tract gradient (-43.0 mm Hg [95% CI, -52.1 to -33.9]) was observed in the original mavacamten group. A similar reduction in resting (-33.7 mm Hg [95% CI, -42.2 to -25.2]) and Valsalva (-52.9 mm Hg [95% CI, -63.2 to -42.6]) gradients was quantified in the cross-over group after 16 weeks of mavacamten. After 32 weeks, improvement by ≥1 New York Heart Association class was observed in 48 of 53 patients (90.6%) in the original mavacamten group and 35 of 50 patients (70%) after 16 weeks in the cross-over group. CONCLUSIONS In severely symptomatic patients with oHCM, 32 weeks of mavacamten treatment showed sustained reduction in the proportion proceeding to SRT or remaining guideline eligible, with similar effects observed in patients who crossed over from placebo after 16 weeks. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT04349072.
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Affiliation(s)
- Milind Y Desai
- From the Hypertrophic Cardiomyopathy Center (M.Y.D., N.G.S.), Heart Vascular and Thoracic Institute, Cleveland Clinic, OH.,Department of Cardiovascular Medicine (M.Y.D., K.W., P.C.C., E.M., C.S., S.E.N.), Heart Vascular and Thoracic Institute, Cleveland Clinic, OH.,Cleveland Clinic Coordinating Center for Clinical Research (M.Y.D., K.W., P.C.C., E.M., C.S., S.E.N.), Heart Vascular and Thoracic Institute, Cleveland Clinic, OH
| | - Anjali Owens
- Division of Cardiology, University of Pennsylvania, Philadelphia (A.O.)
| | - Jeffrey B Geske
- Departments of Cardiovascular Diseases (J.B.G.), Mayo Clinic, Rochester, MN
| | - Kathy Wolski
- Department of Cardiovascular Medicine (M.Y.D., K.W., P.C.C., E.M., C.S., S.E.N.), Heart Vascular and Thoracic Institute, Cleveland Clinic, OH.,Cleveland Clinic Coordinating Center for Clinical Research (M.Y.D., K.W., P.C.C., E.M., C.S., S.E.N.), Heart Vascular and Thoracic Institute, Cleveland Clinic, OH
| | - Sara Saberi
- Department of Internal Medicine, University of Michigan, Ann Arbor (S.S.)
| | - Andrew Wang
- Department of Cardiology, Duke University, Durham, NC (A.W.)
| | - Mark Sherrid
- Department of Cardiology, New York University, NY (M.S.)
| | - Paul C Cremer
- Department of Cardiovascular Medicine (M.Y.D., K.W., P.C.C., E.M., C.S., S.E.N.), Heart Vascular and Thoracic Institute, Cleveland Clinic, OH.,Cleveland Clinic Coordinating Center for Clinical Research (M.Y.D., K.W., P.C.C., E.M., C.S., S.E.N.), Heart Vascular and Thoracic Institute, Cleveland Clinic, OH
| | - Srihari S Naidu
- Department of Cardiology, Westchester Medical Center, Valhalla, NY (S.S.N.)
| | - Nicholas G Smedira
- From the Hypertrophic Cardiomyopathy Center (M.Y.D., N.G.S.), Heart Vascular and Thoracic Institute, Cleveland Clinic, OH.,Department of Cardiothoracic Surgery (N.G.S.), Heart Vascular and Thoracic Institute, Cleveland Clinic, OH
| | | | - Ellen McErlean
- Department of Cardiovascular Medicine (M.Y.D., K.W., P.C.C., E.M., C.S., S.E.N.), Heart Vascular and Thoracic Institute, Cleveland Clinic, OH.,Cleveland Clinic Coordinating Center for Clinical Research (M.Y.D., K.W., P.C.C., E.M., C.S., S.E.N.), Heart Vascular and Thoracic Institute, Cleveland Clinic, OH
| | - Christina Sewell
- Department of Cardiovascular Medicine (M.Y.D., K.W., P.C.C., E.M., C.S., S.E.N.), Heart Vascular and Thoracic Institute, Cleveland Clinic, OH.,Cleveland Clinic Coordinating Center for Clinical Research (M.Y.D., K.W., P.C.C., E.M., C.S., S.E.N.), Heart Vascular and Thoracic Institute, Cleveland Clinic, OH
| | - Aarthi Balasubramanyam
- MyoKardia, Inc, a wholly owned subsidiary of Bristol Myers Squibb, Brisbane, CA (A.B., K.L., A.J.S.)
| | - Kathy Lampl
- MyoKardia, Inc, a wholly owned subsidiary of Bristol Myers Squibb, Brisbane, CA (A.B., K.L., A.J.S.)
| | - Amy J Sehnert
- MyoKardia, Inc, a wholly owned subsidiary of Bristol Myers Squibb, Brisbane, CA (A.B., K.L., A.J.S.)
| | - Steven E Nissen
- Department of Cardiovascular Medicine (M.Y.D., K.W., P.C.C., E.M., C.S., S.E.N.), Heart Vascular and Thoracic Institute, Cleveland Clinic, OH.,Cleveland Clinic Coordinating Center for Clinical Research (M.Y.D., K.W., P.C.C., E.M., C.S., S.E.N.), Heart Vascular and Thoracic Institute, Cleveland Clinic, OH
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11
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Maron MS, Masri A, Choudhury L, Olivotto I, Saberi S, Wang A, Garcia-Pavia P, Lakdawala NK, Nagueh SF, Rader F, Tower-Rader A, Turer AT, Coats C, Fifer MA, Owens A, Solomon SD, Watkins H, Barriales-Villa R, Kramer CM, Wong TC, Paige SL, Heitner SB, Kupfer S, Malik FI, Meng L, Wohltman A, Abraham T. Phase 2 Study of Aficamten in Patients With Obstructive Hypertrophic Cardiomyopathy. J Am Coll Cardiol 2023; 81:34-45. [PMID: 36599608 DOI: 10.1016/j.jacc.2022.10.020] [Citation(s) in RCA: 66] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 09/12/2022] [Accepted: 10/12/2022] [Indexed: 01/03/2023]
Abstract
BACKGROUND Left ventricular outflow tract (LVOT) obstruction is a major determinant of heart failure symptoms in obstructive hypertrophic cardiomyopathy (oHCM). Aficamten, a next-in-class cardiac myosin inhibitor, may lower gradients and improve symptoms in these patients. OBJECTIVES This study aims to evaluate the safety and efficacy of aficamten in patients with oHCM. METHODS Patients with oHCM and LVOT gradients ≥30 mm Hg at rest or ≥50 mm Hg with Valsalva were randomized 2:1 to receive aficamten (n = 28) or placebo (n = 13) in 2 dose-finding cohorts. Doses were titrated based on gradients and ejection fraction (EF). Safety and changes in gradient, EF, New York Heart Association functional class, and cardiac biomarkers were assessed over a 10-week treatment period and after a 2-week washout. RESULTS From baseline to 10 weeks, aficamten reduced gradients at rest (mean difference: -40 ± 27 mm Hg, and -43 ± 37 mm Hg in Cohorts 1 and 2, P = 0.0003 and P = 0.0004 vs placebo, respectively) and with Valsalva (-36 ± 27 mm Hg and -53 ± 44 mm Hg, P = 0.001 and <0.0001 vs placebo, respectively). There were modest reductions in EF (-6% ± 7.5% and -12% ± 5.9%, P = 0.007 and P < 0.0001 vs placebo, respectively). Symptomatic improvement in ≥1 New York Heart Association functional class was observed in 31% on placebo, and 43% and 64% on aficamten in Cohorts 1 and 2, respectively (nonsignificant). With aficamten, N-terminal pro-B-type natriuretic peptide was reduced (62% relative to placebo, P = 0.0002). There were no treatment interruptions and adverse events were similar between treatment arms. CONCLUSIONS Aficamten resulted in substantial reductions in LVOT gradients with most patients experiencing improvement in biomarkers and symptoms. These results highlight the potential of sarcomere-targeted therapy for treatment of oHCM.
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Affiliation(s)
- Martin S Maron
- Lahey Hospital and Medical Center, Burlington, Massachusetts, USA.
| | - Ahmad Masri
- Oregon Health & Science University, Portland, Oregon, USA
| | | | | | - Sara Saberi
- University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Andrew Wang
- Duke University Hospital, Durham, North Carolina, USA
| | - Pablo Garcia-Pavia
- Hospital Universitario Puerta de Hierro de Majadahonda, IDIPHISA, CIBERCV, Madrid, Spain; Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain
| | | | - Sherif F Nagueh
- Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Florian Rader
- Cedars Sinai Medical Center, Los Angeles, California, USA
| | | | | | | | | | - Anjali Owens
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | | | | | | | | | - Timothy C Wong
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Sharon L Paige
- Cytokinetics Incorporated, South San Francisco, California, USA
| | | | - Stuart Kupfer
- Cytokinetics Incorporated, South San Francisco, California, USA
| | - Fady I Malik
- Cytokinetics Incorporated, South San Francisco, California, USA
| | - Lisa Meng
- Cytokinetics Incorporated, South San Francisco, California, USA
| | - Amy Wohltman
- Cytokinetics Incorporated, South San Francisco, California, USA
| | - Theodore Abraham
- University of California, San Francisco, San Francisco, California, USA
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12
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Dong T, Nissen S, Ospina S, Desai MY. An evaluation of mavacamten for the treatment of symptomatic obstructive hypertrophic cardiomyopathy in adults. Expert Rev Cardiovasc Ther 2023; 21:5-13. [PMID: 36522857 DOI: 10.1080/14779072.2023.2159811] [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] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Hypertrophic cardiomyopathy (HCM) is a genetic cardiac disorder leading to hypertrophy of the left ventricle excluding other etiologies. Patients can experience exertional chest pain, dyspnea, syncope or even sudden cardiac death (SCD). Traditional medical management consists of beta blockers (BB), nondihydropyridine calcium channel blockers and disopyramide. Mavacamten, a novel cardiac myosin inhibitor, has recently been shown to improve both quantitative and qualitative measures of obstructive HCM allowing some patients to defer septal reduction therapy. AREAS COVERED This review delves into the pharmacotherapy of mavacamten, the evidence behind this first-in-class drug for HCM, guidance for clinical usage, and possible future uses for cardiac myosin inhibitors. EXPERT OPINION Mavacamten should be incorporated into the standard armamentarium of medications used to treat obstructive HCM. PIONEER-HCM, EXPLORER-HCM and VALOR-HCM demonstrated improvements in peak LVOT gradient both at rest and post-exercise, cardiac biomarkers, New York Heart Association (NYHA) functional class and Kansas City Cardiomyopathy Questionnaire (KCCQ) scores. Unlike other medications utilized for treatment, mavacamten can delay or even obviate the need for septal reduction therapy.
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Affiliation(s)
- Tiffany Dong
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Steven Nissen
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Susan Ospina
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Milind Y Desai
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
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13
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Packard E, de Feria A, Peshin S, Reza N, Owens AT. Contemporary Therapies and Future Directions in the Management of Hypertrophic Cardiomyopathy. Cardiol Ther 2022; 11:491-507. [PMID: 36243823 PMCID: PMC9652179 DOI: 10.1007/s40119-022-00283-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 10/06/2022] [Indexed: 11/26/2022] Open
Abstract
Hypertrophic cardiomyopathy (HCM) is a genetic disorder caused by pathogenic variants in sarcomeric genes, leading to left ventricular hypertrophy and complex phenotypic heterogeneity. While HCM is the most common inherited cardiomyopathy, pharmacological treatment options have previously been limited and were predominantly directed towards symptom control owing to left ventricular outflow obstruction. These therapies, including beta blockers, calcium channel blockers, and disopyramide, have not been shown to affect the natural history of the disease, which is of particular concern for younger patients who have an increased lifetime risk of experiencing arrhythmias, heart failure, and sudden cardiac death. Increased knowledge of the genetic mechanisms underlying this disease in recent years has led to the development of targeted, potentially disease-modifying therapies for both obstructive and nonobstructive phenotypes that may help to prevent or ameliorate left ventricular hypertrophy. In this review article, we will define the etiology and clinical phenotypes of HCM, summarize the conventional therapies for obstructive HCM, discuss the emerging targeted therapies as well as novel invasive approaches for obstructive HCM, describe the therapeutic advances for nonobstructive HCM, and outline the future directions for the treatment of HCM.
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Affiliation(s)
- Elizabeth Packard
- Division of Cardiovascular Medicine, Department of Medicine, Perelman Center for Advanced Medicine, Perelman School of Medicine at the University of Pennsylvania, 11th Floor South Tower, Philadelphia, PA, 19104, USA
| | - Alejandro de Feria
- Division of Cardiovascular Medicine, Department of Medicine, Perelman Center for Advanced Medicine, Perelman School of Medicine at the University of Pennsylvania, 11th Floor South Tower, Philadelphia, PA, 19104, USA
| | - Supriya Peshin
- Division of Cardiovascular Medicine, Department of Medicine, Perelman Center for Advanced Medicine, Perelman School of Medicine at the University of Pennsylvania, 11th Floor South Tower, Philadelphia, PA, 19104, USA
| | - Nosheen Reza
- Division of Cardiovascular Medicine, Department of Medicine, Perelman Center for Advanced Medicine, Perelman School of Medicine at the University of Pennsylvania, 11th Floor South Tower, Philadelphia, PA, 19104, USA
| | - Anjali Tiku Owens
- Division of Cardiovascular Medicine, Department of Medicine, Perelman Center for Advanced Medicine, Perelman School of Medicine at the University of Pennsylvania, 11th Floor South Tower, Philadelphia, PA, 19104, USA.
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14
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Topriceanu CC, Moon JC, Captur G, Perera B. The use of attention-deficit hyperactivity disorder medications in cardiac disease. Front Neurosci 2022; 16:1020961. [PMID: 36340760 PMCID: PMC9626759 DOI: 10.3389/fnins.2022.1020961] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/03/2022] [Indexed: 09/02/2023] Open
Abstract
Attention-deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder with onset usually in childhood characterized by inattention, impulsivity, and hyperactivity causing a functional impairment. Untreated ADHD, or treatment delay is associated with adverse outcomes and poor quality of life. Although conservative management strategies such as behavioral and psychological interventions are important, pharmacological treatment has a strong evidence base with improved outcomes. ADHD medications are broadly divided into stimulant and non-stimulant medications. Stimulant medications are generally more effective than non-stimulants. Cardiovascular safety of ADHD medication has been a matter of debate for decades. Treatment guidelines advise the careful consideration of risks and benefits in people with cardiovascular diseases such as congenital heart disease or cardiomyopathy. Although stimulants can increase systemic blood pressure and heart rate, no significant associations were found between their use and serious cardiovascular events. Concerns regarding QT effects and attendant sudden cardiac death risks deter clinicians from initiating much-needed ADHD medications in patients with heart disease. This overly cautious approach is potentially depriving low-risk individuals from significant benefits associated with timely ADHD drug treatment. This review discusses the cardiovascular risks reportedly associated with ADHD medications, the evidence base for their safe usage in persons with established cardiovascular disease, and highlights future research directions.
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Affiliation(s)
- Constantin-Cristian Topriceanu
- Barnet, Enfield and Haringey Mental Health Trust, London, United Kingdom
- UCL Institute of Cardiovascular Science, University College London, London, United Kingdom
- UCL MRC Unit for Lifelong Health and Ageing, University College London, London, United Kingdom
- Cardiac MRI Unit, Barts Heart Centre, London, United Kingdom
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital, London, United Kingdom
| | - James C. Moon
- UCL Institute of Cardiovascular Science, University College London, London, United Kingdom
- Cardiac MRI Unit, Barts Heart Centre, London, United Kingdom
| | - Gabriella Captur
- UCL Institute of Cardiovascular Science, University College London, London, United Kingdom
- UCL MRC Unit for Lifelong Health and Ageing, University College London, London, United Kingdom
- Department of Cardiology, Centre for Inherited Heart Muscle Conditions, The Royal Free Hospital, London, United Kingdom
| | - Bhathika Perera
- Barnet, Enfield and Haringey Mental Health Trust, London, United Kingdom
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15
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Javidgonbadi D, Schaufelberger M, Östman-Smith I. Factors associated with excess female mortality in obstructive hypertrophic cardiomyopathy. Eur J Prev Cardiol 2022; 29:1545-1556. [PMID: 35512246 DOI: 10.1093/eurjpc/zwac078] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 03/21/2022] [Accepted: 04/13/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Several studies have reported excess female mortality in patients with hypertrophic cardiomyopathy, but the cause is unknown. AIMS To compare risk-factors for disease-related death in both sexes in a geographical cohort of patients with obstructive hypertrophic cardiomyopathy (oHCM). METHODS AND RESULTS Data-bases in all ten hospitals within West Götaland Region yielded 250 oHCM-patients (123 females, 127 males). Mean follow-up was 18.1 y. Risk-factors for disease-related death were evaluated by Cox-hazard regression and Kaplan-Meier survival-curves, with sex-comparisons of distribution of risk-factors and therapy in total and age-matched (n = 166) groups. At diagnosis females were older, median 62 y vs. 51 y, (P < 0.001), but not different in outflow-gradients and median NYHA-class. However, septal hypertrophy was more advanced: 10.6 [IQR = 3.2] vs. 9.6 [2.5] mm/m2 BSA; P = 0.002. Females had higher disease-related mortality than males (P = <0.001), with annual mortality 2.9% vs. 1.5% in age-matched groups (P = 0.010 log-rank). For each risk-category identified (NYHA-class ≥ III, outflow-gradient ≥50 mmHg), a higher proportion of females died (P = 0.0004; P = 0.001). Calcium-blocker therapy was a risk-factor (P = 0.005) and was used more frequently in females (P = 0.034). A beta-blocker dose above cohort-median reduced risk for disease-related death in both males (HR = 0.32; P = 0.0040) and in females (HR = 0.49; P = 0.020). Excess female deaths occurred in chronic heart-failure (P = 0.001) and acute myocardial infarctions (P = 0.015). Fewer females received beta-blocker therapy after diagnosis (64% vs. 78%, P = 0.018), in a smaller dose (P = 0.007), and less frequently combined with disopyramide (7% vs. 16%, P = 0.048). CONCLUSION Addressing sex-disparities in the timing of diagnosis and pharmacological therapy has the potential to improve the care of females with oHCM.
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Affiliation(s)
- Davood Javidgonbadi
- Department of Cardiology, Northern Älvsborg County Hospital, Trollhättan, Sweden
| | - Maria Schaufelberger
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ingegerd Östman-Smith
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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16
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Desai MY, Owens A, Geske JB, Wolski K, Naidu SS, Smedira NG, Cremer PC, Schaff H, McErlean E, Sewell C, Li W, Sterling L, Lampl K, Edelberg JM, Sehnert AJ, Nissen SE. Myosin Inhibition in Patients With Obstructive Hypertrophic Cardiomyopathy Referred for Septal Reduction Therapy. J Am Coll Cardiol 2022; 80:95-108. [PMID: 35798455 DOI: 10.1016/j.jacc.2022.04.048] [Citation(s) in RCA: 135] [Impact Index Per Article: 67.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 04/08/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Septal reduction therapy (SRT), surgical myectomy or alcohol ablation, is recommended for obstructive hypertrophic cardiomyopathy (oHCM) patients with intractable symptoms despite maximal medical therapy, but is associated with morbidity and mortality. OBJECTIVES This study sought to determine whether the oral myosin inhibitor mavacamten enables patients to improve sufficiently to no longer meet guideline criteria or choose to not undergo SRT. METHODS Patients with left ventricular (LV) outflow tract (LVOT) gradient ≥50 mm Hg at rest/provocation who met guideline criteria for SRT were randomized, double blind, to mavacamten, 5 mg daily, or placebo, titrated up to 15 mg based on LVOT gradient and LV ejection fraction. The primary endpoint was the composite of the proportion of patients proceeding with SRT or who remained guideline-eligible after 16 weeks' treatment. RESULTS One hundred and twelve oHCM patients were enrolled, mean age 60 ± 12 years, 51% men, 93% New York Heart Association (NYHA) functional class III/IV, with a mean post-exercise LVOT gradient of 84 ± 35.8 mm Hg. After 16 weeks, 43 of 56 placebo patients (76.8%) and 10 of 56 mavacamten patients (17.9%) met guideline criteria or underwent SRT, difference (58.9%; 95% CI: 44.0%-73.9%; P < 0.001). Hierarchical testing of secondary outcomes showed significant differences (P < 0.001) favoring mavacamten, mean differences in post-exercise peak LVOT gradient -37.2 mm Hg; ≥1 NYHA functional class improvement 41.1%; improvement in patient-reported outcome 9.4 points; and NT-proBNP and cardiac troponin I between-groups geometric mean ratio 0.33 and 0.53. CONCLUSIONS In oHCM patients with intractable symptoms, mavacamten significantly reduced the fraction of patients meeting guideline criteria for SRT after 16 weeks. Long-term freedom from SRT remains to be determined. (A Study to Evaluate Mavacamten in Adults With Symptomatic Obstructive HCM Who Are Eligible for Septal Reduction Therapy [VALOR-HCM]; NCT04349072).
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Affiliation(s)
- Milind Y Desai
- Hypertrophic Cardiomyopathy Center, Cleveland Clinic, Cleveland, Ohio, USA; Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA; Cleveland Clinic Coordinating Center for Clinical Research, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Anjali Owens
- Division of Cardiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jeffrey B Geske
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Kathy Wolski
- Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA; Cleveland Clinic Coordinating Center for Clinical Research, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Srihari S Naidu
- Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | - Nicholas G Smedira
- Hypertrophic Cardiomyopathy Center, Cleveland Clinic, Cleveland, Ohio, USA; Department of Cardiothoracic Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Paul C Cremer
- Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA; Cleveland Clinic Coordinating Center for Clinical Research, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Hartzell Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Ellen McErlean
- Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA; Cleveland Clinic Coordinating Center for Clinical Research, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Christina Sewell
- Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA; Cleveland Clinic Coordinating Center for Clinical Research, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Wanying Li
- MyoKardia, Inc, a wholly owned subsidiary of Bristol Myers Squibb, Brisbane, California, USA
| | - Lulu Sterling
- MyoKardia, Inc, a wholly owned subsidiary of Bristol Myers Squibb, Brisbane, California, USA
| | - Kathy Lampl
- MyoKardia, Inc, a wholly owned subsidiary of Bristol Myers Squibb, Brisbane, California, USA
| | - Jay M Edelberg
- MyoKardia, Inc, a wholly owned subsidiary of Bristol Myers Squibb, Brisbane, California, USA
| | - Amy J Sehnert
- MyoKardia, Inc, a wholly owned subsidiary of Bristol Myers Squibb, Brisbane, California, USA
| | - Steven E Nissen
- Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA; Cleveland Clinic Coordinating Center for Clinical Research, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA.
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17
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Dong T, Zhao Y, Jin HF, Shen L, Lin Y, Si LL, Chen L, Liu JC. SNTA1-deficient human cardiomyocytes demonstrate hypertrophic phenotype and calcium handling disorder. Stem Cell Res Ther 2022; 13:288. [PMID: 35773684 PMCID: PMC9248201 DOI: 10.1186/s13287-022-02955-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 05/07/2022] [Indexed: 11/13/2022] Open
Abstract
Background α-1-syntrophin (SNTA1), a protein encoded by SNTA1, is highly expressed in human cardiomyocytes. Mutations in SNTA1 are associated with arrhythmia and cardiomyopathy. Previous research on SNTA1 has been based on non-human cardiomyocytes. This study was designed to identify the phenotype of SNTA1-deficiency using human cardiomyocytes. Methods SNTA1 was knocked out in the H9 embryonic stem cell line using the CRISPR-Cas9 system. H9SNTA1KO cells were then induced to differentiate into cardiomyocytes using small molecule inhibitors. The phenotypic discrepancies associated with SNTA1-deficient cardiomyocytes were investigated. Results SNTA1 was truncated at the 149th amino acid position of PH1 domain by a stop codon (TGA) using the CRISPR-Cas9 system. SNTA1-deficiency did not affect the pluripotency of H9SNTA1KO, and they retain their in vitro ability to differentiate into cardiomyocytes. However, H9SNTA1KO derived cardiomyocytes exhibited hypertrophic phenotype, lower cardiac contractility, weak calcium transient intensity, and lower level of calcium in the sarcoplasmic reticulum. Early treatment of SNTA1-deficient cardiomyocytes with ranolazine improved the calcium transient intensity and cardiac contractility. Conclusion SNTA1-deficient cardiomyocytes can be used to research the etiology, pathogenesis, and potential therapies for myocardial diseases. The SNTA1-deficient cardiomyocyte model suggests that the maintenance of cardiac calcium homeostasis is a key target in the treatment of myocardial-related diseases. Supplementary Information The online version contains supplementary material available at 10.1186/s13287-022-02955-4.
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Affiliation(s)
- Tao Dong
- Basic Medicine School, Qiqihar Medical University, 333 Bukui Street, Qiqihar, 161006, Heilongjiang, China.
| | - Yan Zhao
- College of Life Science and Agroforestry, Qiqihar University, Qiqihar, 161006, Heilongjiang, China
| | - Hai-Feng Jin
- Basic Medicine School, Qiqihar Medical University, 333 Bukui Street, Qiqihar, 161006, Heilongjiang, China
| | - Lei Shen
- Basic Medicine School, Qiqihar Medical University, 333 Bukui Street, Qiqihar, 161006, Heilongjiang, China
| | - Yan Lin
- Basic Medicine School, Qiqihar Medical University, 333 Bukui Street, Qiqihar, 161006, Heilongjiang, China
| | - Long-Long Si
- CAS Key Laboratory of Quantitative Engineering Biology, Shenzhen Institute of Synthetic Biology, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, China
| | - Li Chen
- CAS Key Laboratory of Quantitative Engineering Biology, Shenzhen Institute of Synthetic Biology, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, China
| | - Ji-Cheng Liu
- Qiqihar Institute of Medical and Pharmaceutical Sciences, Qiqihar Medical University, 333 Bukui Street, Qiqihar, 161006, Heilongjiang, China.
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18
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Hegde SM, Lester SJ, Solomon SD, Michels M, Elliott PM, Nagueh SF, Choudhury L, Zemanek D, Zwas DR, Jacoby D, Wang A, Ho CY, Li W, Sehnert AJ, Olivotto I, Abraham TP. Effect of Mavacamten on Echocardiographic Features in Symptomatic Patients With Obstructive Hypertrophic Cardiomyopathy. J Am Coll Cardiol 2021; 78:2518-2532. [PMID: 34915982 DOI: 10.1016/j.jacc.2021.09.1381] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 08/27/2021] [Accepted: 09/28/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND EXPLORER-HCM (Clinical Study to Evaluate Mavacamten [MYK-461] in Adults With Symptomatic Obstructive Hypertrophic Cardiomyopathy) demonstrated that mavacamten, a cardiac myosin inhibitor, improves symptoms, exercise capacity, and left ventricular outflow tract (LVOT) obstruction in patients with obstructive hypertrophic cardiomyopathy (oHCM). OBJECTIVES The purpose of this study was to evaluate mavacamten's effect on measures of cardiac structure and function and its association with changes in other clinical measures. METHODS Key echocardiographic parameters from serial echocardiograms over 30 weeks from 251 symptomatic oHCM patients (mavacamten [n = 123], placebo [n = 128]) were assessed in a core laboratory. RESULTS More patients on mavacamten (80.9%; n = 76 of 94) vs placebo (34.0%; n = 33 of 97) showed complete resolution of mitral valve systolic anterior motion after 30 weeks (difference, 46.8%; P < 0.0001). Mavacamten also improved measures of diastolic function vs placebo, including left atrial volume index (LAVI) (mean ± SD baseline: 40 ± 12 mL/m2 vs 41 ± 14 mL/m2; mean change from baseline of -7.5 mL/m2 [95% CI: -9.0 to -6.1 mL/m2] vs -0.09 mL/m2 [95% CI: -1.6 to 1.5 mL/m2]; P < 0.0001) and lateral E/e' (baseline, 15 ± 6 vs 15 ± 8; change of -3.8 [95% CI: -4.7 to -2.8] vs 0.04 [95% CI: -0.9 to 1.0]; P < 0.0001). Among mavacamten-treated patients, improvement in resting, Valsalva, and post-exercise LVOT gradients, LAVI, and lateral E/e' was associated with reduction in N-terminal pro-B-type natriuretic peptide (P ≤ 0.03 for all). Reduction in LAVI was associated with improved peak exercise oxygen consumption (P = 0.04). CONCLUSIONS Mavacamten significantly improved measures of left ventricular diastolic function and systolic anterior motion. Improvement in LVOT obstruction, LAVI, and E/e' was associated with reduction in a biomarker of myocardial wall stress (N-terminal pro-B-type natriuretic peptide). These findings demonstrate improvement in important markers of the pathophysiology of oHCM with mavacamten. (Clinical Study to Evaluate Mavacamten [MYK-461] in Adults With Symptomatic Obstructive Hypertrophic Cardiomyopathy; NCT03470545).
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Affiliation(s)
- Sheila M Hegde
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.
| | - Steven J Lester
- Department of Cardiovascular Diseases, Mayo Clinic, Phoenix, Arizona, USA
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michelle Michels
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Perry M Elliott
- Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Sherif F Nagueh
- Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Lubna Choudhury
- Bluhm Cardiovascular Institute, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - David Zemanek
- 2nd Department of Internal Medicine-Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Donna R Zwas
- Heart Institute, Hadassah University Medical Center, Jerusalem, Israel
| | - Daniel Jacoby
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University, New Haven, Connecticut, USA
| | - Andrew Wang
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Carolyn Y Ho
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Wanying Li
- MyoKardia, Inc, a wholly owned subsidiary of Bristol Myers Squibb, Brisbane, California, USA
| | - Amy J Sehnert
- MyoKardia, Inc, a wholly owned subsidiary of Bristol Myers Squibb, Brisbane, California, USA
| | - Iacopo Olivotto
- Cardiomyopathy Unit, Azienda Ospedaliera Universitaria Careggi and the University of Florence, Florence, Italy
| | - Theodore P Abraham
- UCSF HCM Center of Excellence, University of California San Francisco, San Francisco, California, USA
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19
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Novel therapies in inherited cardiomyopathies. PROGRESS IN PEDIATRIC CARDIOLOGY 2021. [DOI: 10.1016/j.ppedcard.2021.101444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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20
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Rodriguez-Gonzalez M, Pérez-Reviriego ÁA, Castellano-Martinez A, Cascales-Poyatos HM. Disopyramide as coadjuvant treatment in obstructive hypertrophic cardiomyopathy. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2021. [DOI: 10.1016/j.anpede.2020.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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21
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Rodriguez-Gonzalez M, Pérez-Reviriego ÁA, Castellano-Martinez A, Cascales-Poyatos HM. [Disopyramide as coadjuvant treatment in obstructive hypertrophic cardiomyopathy]. An Pediatr (Barc) 2020; 94:253-256. [PMID: 32646796 DOI: 10.1016/j.anpedi.2020.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 04/05/2020] [Accepted: 04/22/2020] [Indexed: 11/18/2022] Open
Affiliation(s)
- Moisés Rodriguez-Gonzalez
- Sección de Cardiología Pediátrica, Unidad de Gestión Clínica de Pediatría, Hospital Universitario Puerta del Mar, Cádiz, España; Unidad de Investigación, Instituto de Investigación Biomédica e Innovación de Cádiz (INiBICA), Hospital Universitario Puerta del Mar, Cádiz, España.
| | - Álvaro Antonio Pérez-Reviriego
- Sección de Cardiología Pediátrica, Unidad de Gestión Clínica de Pediatría, Hospital Universitario Puerta del Mar, Cádiz, España; Unidad de Investigación, Instituto de Investigación Biomédica e Innovación de Cádiz (INiBICA), Hospital Universitario Puerta del Mar, Cádiz, España
| | - Ana Castellano-Martinez
- Sección de Cardiología Pediátrica, Unidad de Gestión Clínica de Pediatría, Hospital Universitario Puerta del Mar, Cádiz, España; Unidad de Investigación, Instituto de Investigación Biomédica e Innovación de Cádiz (INiBICA), Hospital Universitario Puerta del Mar, Cádiz, España
| | - Helena María Cascales-Poyatos
- Sección de Cardiología Pediátrica, Unidad de Gestión Clínica de Pediatría, Hospital Universitario Puerta del Mar, Cádiz, España; Unidad de Investigación, Instituto de Investigación Biomédica e Innovación de Cádiz (INiBICA), Hospital Universitario Puerta del Mar, Cádiz, España
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22
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Wieruszewski PM, Sims CR, Daly RC, Taner T, Wittwer ED. Use of Angiotensin II for Vasoplegic Shock in a Combined Heart and Liver Transplant Recipient with Systolic Anterior Motion Physiology. J Cardiothorac Vasc Anesth 2019; 33:2366-2367. [DOI: 10.1053/j.jvca.2019.03.054] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 03/24/2019] [Indexed: 11/11/2022]
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23
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Li J, Wu Z, Zheng D, Sun Y, Wang S, Yan Y. Bioinformatics analysis of the regulatory lncRNA‑miRNA‑mRNA network and drug prediction in patients with hypertrophic cardiomyopathy. Mol Med Rep 2019; 20:549-558. [PMID: 31180540 PMCID: PMC6579968 DOI: 10.3892/mmr.2019.10289] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 04/25/2019] [Indexed: 01/10/2023] Open
Abstract
Hypertrophic cardiomyopathy (HCM) is a complex inherited cardiovascular disease. The present study investigated the long noncoding (lnc)RNA/microRNA (mi)RNA/mRNA expression pattern of patients with HCM and aimed to identify key molecules involved in the development of this condition. An integrated strategy was conducted to identify differentially expressed miRNAs (DEmiRs), differentially expressed lncRNAs (DElncs) and differentially expressed genes (DEGs) based on the GSE36961 (mRNA), GSE36946 (miRNA), GSE68316 (lncRNA/mRNA) and GSE32453 (mRNA) expression profiles downloaded from the Gene Expression Omnibus datasets. Bioinformatics tools were employed to perform function and pathway enrichment analysis, protein-protein interaction, lncRNA-miRNA-mRNA and hub gene networks. Subsequently, DEGs were used as targets to predict drugs. The results indicated that a total of 2,234 DElncs (1,120 upregulated and 1,114 downregulated), 5 DEmiRs (2 upregulated and 3 downregulated) and 42 DEGs (35 upregulated and 7 downregulated) were identified in 4 microarray profiles. Gene ontology analysis revealed that DEGs were mainly involved in actin filament and stress fiber formation and in calcium ion binding, whereas Kyoto Encyclopedia of Genes and Genomes pathway analysis identified the hypoxia inducible factor-1, transforming growth factor-β and tumor necrosis factor signaling pathways as the main pathways involved in these processes. The hub genes were screened using cytoHubba. A total of 1,086 lncRNA-miRNA-mRNA interactions including 67 lncRNAs, 5 miRNAs and 25 mRNAs were mined in the present study based on prediction websites. Drug prediction indicated that the targeted drugs mainly included angiotensin converting enzyme inhibitors or β-blockers. A comprehensive bioinformatics analysis of the molecular regulatory lncRNA-miRNA-mRNA network was performed and potential therapeutic applications of drugs were predicted in HCM patients. The data may unravel the future molecular mechanism of HCM.
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Affiliation(s)
- Jiajianghui Li
- Department of Epidemiology and Biostatistics, School of Public Health, Capital Medical University, Beijing 100069, P.R. China
| | - Zining Wu
- Beijing Laboratory for Cardiovascular Precision Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing 100069, P.R. China
| | - Deqiang Zheng
- Department of Epidemiology and Biostatistics, School of Public Health, Capital Medical University, Beijing 100069, P.R. China
| | - Yue Sun
- Department of Epidemiology and Biostatistics, School of Public Health, Capital Medical University, Beijing 100069, P.R. China
| | - Sisi Wang
- Department of Epidemiology and Biostatistics, School of Public Health, Capital Medical University, Beijing 100069, P.R. China
| | - Yuxiang Yan
- Department of Epidemiology and Biostatistics, School of Public Health, Capital Medical University, Beijing 100069, P.R. China
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Ferrantini C, Pioner JM, Mazzoni L, Gentile F, Tosi B, Rossi A, Belardinelli L, Tesi C, Palandri C, Matucci R, Cerbai E, Olivotto I, Poggesi C, Mugelli A, Coppini R. Late sodium current inhibitors to treat exercise-induced obstruction in hypertrophic cardiomyopathy: an in vitro study in human myocardium. Br J Pharmacol 2018; 175:2635-2652. [PMID: 29579779 PMCID: PMC6003658 DOI: 10.1111/bph.14223] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 03/07/2018] [Accepted: 03/08/2018] [Indexed: 12/19/2022] Open
Abstract
Background and Purpose In 30–40% of hypertrophic cardiomyopathy (HCM) patients, symptomatic left ventricular (LV) outflow gradients develop only during exercise due to catecholamine‐induced LV hypercontractility (inducible obstruction). Negative inotropic pharmacological options are limited to β‐blockers or disopyramide, with low efficacy and tolerability. We assessed the potential of late sodium current (INaL)‐inhibitors to treat inducible obstruction in HCM. Experimental Approach The electrophysiological and mechanical responses to β‐adrenoceptor stimulation were studied in human myocardium from HCM and control patients. Effects of INaL‐inhibitors (ranolazine and GS‐967) in HCM samples were investigated under conditions simulating rest and exercise. Key Results In cardiomyocytes and trabeculae from 18 surgical septal samples of patients with obstruction, the selective INaL‐inhibitor GS‐967 (0.5 μM) hastened twitch kinetics, decreased diastolic [Ca2+] and shortened action potentials, matching the effects of ranolazine (10μM). Mechanical responses to isoprenaline (inotropic and lusitropic) were comparable in HCM and control myocardium. However, isoprenaline prolonged action potentials in HCM myocardium, while it shortened them in controls. Unlike disopyramide, neither GS‐967 nor ranolazine reduced force at rest. However, in the presence of isoprenaline, they reduced Ca2+‐transient amplitude and twitch tension, while the acceleration of relaxation was maintained. INaL‐inhibitors were more effective than disopyramide in reducing contractility during exercise. Finally, INaL‐inhibitors abolished arrhythmias induced by isoprenaline. Conclusions and Implications Ranolazine and GS‐967 reduced septal myocardium tension during simulated exercise in vitro and therefore have the potential to ameliorate symptoms caused by inducible obstruction in HCM patients, with some advantages over disopyramide and β‐blockers.
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Affiliation(s)
- Cecilia Ferrantini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.,Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Josè Manuel Pioner
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Luca Mazzoni
- Department NeuroFarBa, University of Florence, Florence, Italy
| | - Francesca Gentile
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Benedetta Tosi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Alessandra Rossi
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | | | - Chiara Tesi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Chiara Palandri
- Department NeuroFarBa, University of Florence, Florence, Italy
| | - Rosanna Matucci
- Department NeuroFarBa, University of Florence, Florence, Italy
| | | | - Iacopo Olivotto
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Corrado Poggesi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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25
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Hidalgo LF, Naidu SS, Aronow WS. Pharmacological and non-pharmacological treatment of obstructive hypertrophic cardiomyopathy. Expert Rev Cardiovasc Ther 2018; 16:21-26. [PMID: 29231770 DOI: 10.1080/14779072.2018.1417038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Luis F. Hidalgo
- Department of Medicine, Division of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Srihari S. Naidu
- Department of Medicine, Division of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Wilbert S. Aronow
- Department of Medicine, Division of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
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26
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Veselka J, Anavekar NS, Charron P. Hypertrophic obstructive cardiomyopathy. Lancet 2017; 389:1253-1267. [PMID: 27912983 DOI: 10.1016/s0140-6736(16)31321-6] [Citation(s) in RCA: 167] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 07/22/2016] [Accepted: 08/02/2016] [Indexed: 12/23/2022]
Abstract
Hypertrophic obstructive cardiomyopathy is an inherited myocardial disease defined by cardiac hypertrophy (wall thickness ≥15 mm) that is not explained by abnormal loading conditions, and left ventricular obstruction greater than or equal to 30 mm Hg. Typical symptoms include dyspnoea, chest pain, palpitations, and syncope. The diagnosis is usually suspected on clinical examination and confirmed by imaging. Some patients are at increased risk of sudden cardiac death, heart failure, and atrial fibrillation. Patients with an increased risk of sudden cardiac death undergo cardioverter-defibrillator implantation; in patients with severe symptoms related to ventricular obstruction, septal reduction therapy (myectomy or alcohol septal ablation) is recommended. Life-long anticoagulation is indicated after the first episode of atrial fibrillation.
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Affiliation(s)
- Josef Veselka
- Department of Cardiology, 2nd Medical School, Charles University and Motol University Hospital, Prague, Czech Republic.
| | - Nandan S Anavekar
- Departments of Cardiology and Radiology, Mayo Clinic, Rochester, MN, USA
| | - Philippe Charron
- Université Paris Sud, UVSQ, INSERM U1018, CESP, Boulogne-Billancourt, France; APHP, ICAN, Hôpital de la Pitié Salpêtrière, Paris, France
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