Transthyretin amyloid polyneuropathy in France: A cross-sectional study with 413 patients and real-world tafamidis meglumine use (2009-2019)

OBJECTIVE

We aimed to describe characteristics of patients with ATTR variant polyneuropathy (ATTRv-PN) and ATTRv-mixed and assess the real-world use and safety profile of tafamidis meglumine 20mg.

METHODS

Thirty-eight French hospitals were invited. Patient files were reviewed to identify clinical manifestations, diagnostic methods, and treatment compliance.

RESULTS

Four hundred and thirteen patients (296 ATTRv-PN, 117 ATTRv-mixed) were analyzed. Patients were predominantly male (68.0%) with a mean age of 57.2±17.2 years. Interval between first symptom(s) and diagnosis was 3.4±4.3 years. First symptoms included sensory complaints (85.9%), dysautonomia (38.5%), motor deficits (26.4%), carpal tunnel syndrome (31.5%), shortness of breath (13.3%), and unexplained weight loss (16.0%). Mini-invasive accessory salivary gland or punch skin and nerve biopsies were most common, with a performance of 78.8-100%. TTR genetic sequencing, performed in all patients, revealed 31 TTR variants. Tafamidis meglumine was initiated in 156/214 (72.9%) ATTRv-PN patients at an early disease stage. Median treatment duration was 6.00 years in ATTRv-PN and 3.42 years in ATTRv-mixed patients. Tafamidis was well tolerated, with 20 adverse events likely related to study drug among the 336 patients.

CONCLUSION

In France, ATTRv patients are usually identified early thanks to the national network and the help of diagnosis combining genetic testing and mini-invasive biopsies.

Hypertrophic cardiomyopathy and atrial fibrillation: the Cardiomyopathy/Myocarditis registry of the EURObservational Research Programme of the European Society of Cardiology

Background

Current guidelines for AF management underline a complex approach to detecting and treating atrial fibrillation (AF). Hypertrophic cardiomyopathy (HCM) is commonly associated with AF.

Purpose

To assess the clinical characteristic and prognosis in patients with HCM and AF.

Methods and results

Overall, 1739 adult patients with HCM (711/40.9% female; median age at diagnosis: 55.5 years) were enrolled in the EURObservational Research Programme – Cardiomyopathy/Myocarditis Long-Term Registry. Baseline clinical characteristics and adverse cardiovascular endpoints at 1-year follow-up were analysed.

Results

At baseline, AF was found in 478 (27.5%) subjects (paroxysmal: 54.7%, persistent: 17.6%, permanent: 27.7%). Newly diagnosed AF was identified during 1-year follow-up in 48 (2.8%) subjects with HCM.

The presence of AF was associated with higher age (59.6±13.8 vs 50.8±16.1, p<0.001); BMI (27.7±5.1 vs 26.6±4.6 kg/m2, p<0.001); more advanced NYHA class (NYHA I/II and III/IV: 75.1 and 24.9 vs 86.2 and 13.8%, p<0.001); more frequent history of diabetes (14.6 vs 8.4%, p<0.001); arterial hypertension 43.4 vs 34.6%, p<0.001); renal impairment (15.4 vs 6.35%, p<0.001); and history of sustained VT (10.8 vs 6.35%, p<0.001). AF patients were characterized by lower left ventricular ejection fraction (LV EF) (59±12 vs 63±11%, P<0.001), left atrium (LA) dilatation (48.9±9.1 vs 42.4±7.7%, p<0.001), increased pulmonary artery systolic pressure (37.8±13.7 vs 29.6±12.6 mmHg, p<0.001), distribution of LV hypertrophy (p=0.032) and more advanced LV diastolic dysfunction (p<0.001).

On multivariate logistic regression analysis, independent predictors of AF in the HCM population were: age at enrolment (OR 1.068, P<0.001); LVEF (OR 0.978, p<0.001); and LA diameter (OR 1.094, p<0.001).

Oral anticoagulation (OAC) was administered in 69.5% of patients with AF (vitamin K antagonist: 48.5%; direct OAC: 21%). ICD was implanted in 26.8% in AF and 16.9% in non-AF subjects (p<0.001). PVI was performed in 9.9% of AF patients only.

The annual incidence of stroke/TIA was higher in AF than in the non-AF population (2.64 vs 0.85%, p=0.009). There was a trend towards increased death from any cause in the AF population (3.39 vs 1.74%, p=0.05). There were no differences in SCD-risk score between AF and non-AF subjects.

Conclusion

The study reveals a high prevalence of AF in patients with HCM that corresponds with more advanced symptoms, increased prevalence of comorbidities, structural and functional heart remodelling along with inadequate anticoagulation and a significant increase in the risk of stroke. The clinical characteristics of HCM-AF patients indicate that the ESC recommended complex AF approach “CC To ABC” is appropriate in this population.

Funding Acknowledgement

Type of funding sources: None.

Association between common cardiovascular risk factors and clinical phenotype in patients with hypertrophic cardiomyopathy from the European Society of Cardiology (ESC) EurObservational Research Programme (EORP) Cardiomyopathy/Myocarditis registry

AIMS

The interaction between common cardiovascular risk factors (CVRF) and hypertrophic cardiomyopathy (HCM) is poorly studied. We sought to explore the relation between CVRF and the clinical characteristics of patients with HCM enrolled in the EURObservational Research Programme (EORP) Cardiomyopathy registry.

METHODS AND RESULTS

1739 patients with HCM were studied. The relation between hypertension (HT), diabetes (DM), body mass index (BMI), and clinical traits was analysed. Analyses were stratified according to the presence or absence of a pathogenic variant in a sarcomere gene. The prevalence of HT, DM, and obesity (Ob) was 37, 10, and 21%, respectively. HT, DM, and Ob were associated with older age (P<0.001), less family history of HCM (HT and DM P<0.001), higher New York Heart Association (NYHA) class (P<0.001), atrial fibrillation (HT and DM P<0.001; Ob p = 0.03) and LV (left ventricular) diastolic dysfunction (HT and Ob P<0.001; DM P = 0.003). Stroke was more frequent in HT (P<0.001) and mutation-positive patients with DM (P = 0.02). HT and Ob were associated with higher provocable LV outflow tract gradients (HT P<0.001, Ob P = 0.036). LV hypertrophy was more severe in Ob (P = 0.018). HT and Ob were independently associated with NYHA class (OR 1.419, P = 0.017 and OR 1.584, P = 0.004, respectively). Other associations, including a higher proportion of females in HT and of systolic dysfunction in HT and Ob, were observed only in mutation-positive patients.

CONCLUSION

Common CVRF are associated with a more severe HCM phenotype, suggesting a proactive management of CVRF should be promoted. An interaction between genotype and CVRF was observed for some traits.

Risk of atrial fibrillation in hypertrophic cardiomyopathy: a clustering analysis based on the French registry on hypertrophic cardiomyopathy (REMY)

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): CHU Rennes, Inserm, LTSI – UMR 1099, F-35000 Rennes, France Assistance Publique-Hôpitaux de Paris-Centre Université de Paris, University of Paris

onbehalf

REMY register

Paroxysmal or chronic atrial fibrillation (AF) is frequent in hypertrophic cardiomyopathy (HCM),(20%-25% of patients), and is often considered as an important disease turning point. The aim of this study is to determine HCM-phenogroups with different risk of AF-occurrence at 5-year.

We applied the Bayesian method to differentiate phenogroups of patients with different risks of AF across a French hospital registry of adult HCM(REMY). Data were prospectively recorded on 5 years follow-up. 1431 HCM patients were recruited, including 1275 analyzed.

The population included 412 women. AF-occurred in 167 (11.6%) patients. 3 phenogroups were defined according to their common characteristics. Patients at the highest risk were more often female, with more frequent comorbidities, greatest anteroposterior LA diameter, diastolic dysfunction, outflow-tract obstruction or mitral valve abnormality, and presented higher sPAP or right ventricular dysfunction. These also had a higher risk of all-cause hospitalizations and death.

Based on a clustering analysis, 3 phenogroups of HCM according to the risk of AF occurrence can be identified. It can indicate which patients should be more monitored.

3 different AF-risk groups Intermediate risk group n = 524 High-risk group n= 207 Low-risk group n = 544 P Gender = Males (%) 338 (64.5) 103 (49.8) 422 (77.6) &lt;0.001 Age (median [IQR]) 59.00 [47.00, 66.00] 63.00 [54.00, 74.00] 50.00 [38.00, 60.00] &lt;0.001 Stroke (%) 29 (5.5) 44 (21.3) 5 (0.9) &lt;0.001 Right ventricular failure (%) 10 (1.9) 41 (19.8) 0 (0.0) &lt;0.001 None Mitral regurgitation (%) 207 (42.2) 25 (12.6) 416 (81.2) &lt;0.001 Moderate to severe mitral regurgitation (%) 258 (52.6) 143 (72.3) 92 (18) &lt;0.001 Mitral Valve elongation (%) 113 (23.5) 48 (24.9) 62 (12.1) Abnormal insertion of a papillary muscle (%) 13 (2.7) 12 (6.2) 6 (1.2) Mitral valve SAM (%) 214 (40.8) 115 (55.6) 77 (14.2) &lt;0.001 Basal obstruction (%) 196 (37.4) 119 (57.5) 54 (9.9) &lt;0.001 Anteroposterior LA diameter (mm) (median [IQR]) 44.00 [38.00, 49.00] 47.00 [42.00, 51.00] 39.00 [33.00, 43.00] &lt;0.001 Mitral E/e’ Lateral (median [QR]) 10.00 [8.00, 13.53] 15.00 [10.11, 20.00] 7.50 [5.80, 10.00] &lt;0.001 Mitral E/e’ Septal (median [QR]) 15.00 [11.18, 19.55] 18.40 [14.20, 23.50] 10.50 [8.33, 13.88] &lt;0.001 Normal sPAP (%) 354 (82.1) 74 (39.6) 435 (98.0) &lt;0.001 Event AF (%) 80 (15.3) 60 (29.0) 27 (5.0) &lt;0.001 Any cause death (%) 29 (5.5) 36 (17.4) 7 (1.3) &lt;0.001 Any cause hospitalization (%) 174 (33.2) 113 (54.6) 56 (10.3) &lt;0.001 3 different groups on their caracteristics and AF-risk Abstract Figure.

Genetic counselling and testing of adult patients with cardiomyopathies: insight from the EORP cardiomyopathy and myocarditis registry of the European Society of Cardiology

Introduction

Cardiomyopathies comprise a heterogeneous group of diseases, often of genetic origin.

Purpose

We assessed the current practice of genetic counselling and testing of adult cardiomyopathy patients in the prospective ESC EORP cardiomyopathy registry.

Methods

3 208 adult patients from sixty-nine centres in 18 countries were enrolled. Clinical data on genetic counselling and testing and on the presentation of cardiomyopathies were gathered.

Results

Genetic counselling was performed in 60.8% of all patients (75.4% in hypertrophic (HCM), 39.2% in dilated (DCM), 70.8% in arrhythmogenic right ventricular (ARVC) and 49.2% in restrictive cardiomyopathy (RCM), p&lt;0.001). Comparing European geographical areas, genetic counselling was performed from 42.4% to 83.3% (p&lt;0.001). It was provided by a cardiologist (85.3%), geneticist (15.1%), genetic counsellor (11.3%), or a nurse (7.5%), (p&lt;0.001). Genetic testing was performed in 37.3% of all patients (48.8% in HCM, 18.6% in DCM, 55.6% % in ARVC and 43.6% in RCM, p&lt;0.001). Index patients with genetic testing were younger at diagnosis, had more familial disease, family history of sudden cardiac death or implanted cardioverter defibrillators but less comorbidities than those not tested (p&lt;0.001 for each comparison). At least 1 disease causing variant was found in 41.7% of index patients with genetic testing (43.3% in HCM, 33.3% in DCM, 51.4% in ARVC and 42.9% in RCM, p=0.13).

Conclusion

We report on the practice of genetic counselling and testing in cardiomyopathies in Europe. Genetic counselling and testing were performed in a substantial proportion of patients but less often than recommended by European guidelines, and much less in DCM than in HCM and ARVC, despite evidence for genetic background.

Funding Acknowledgement

Type of funding source: None

High prevalence of familial and genetic disease in children with cardiomyopathies: baseline paediatric data from the ESC EORP Cardiomyopathy and Myocarditis registry

Background

Previous studies on paediatric cardiomyopathies have provided useful information on their epidemiology and clinical presentation but have been limited by a lack of detailed data on genetic testing and aetiology.

Purpose

The purpose of this study was to examine the frequency of familial and genetic disease among children with cardiomyopathy enrolled in the European Society of Cardiology (ESC) Cardiomyopathy and Myocarditis EORP Long-Term Registry (CMY-LT).

Methods

633 individuals aged &lt;18 years with hypertrophic cardiomyopathy [HCM; n=387 (61%)], dilated cardiomyopathy (DCM; n=205 (33%)], restrictive cardiomyopathy [RCM; n=28 (4%)] and arrhythmogenic right ventricular cardiomyopathy [ARVC; n=11 (2%)] were enrolled by 26 centres from 14 countries. Mean age at diagnosis was 5.2 (±5.4) years and there was a male predominance [n=372 (59%)] across all cardiomyopathy subtypes, with the exception of DCM in those diagnosed &lt;10 years of age (p=0.005). 541 (87%) were probands compared to 83 (13%) first-degree relatives.

Results

Overall, 253 patients (47% of those reported) had familial disease; in those diagnosed between 10 and 18 years of age, familial disease was most frequent in HCM and least frequent in DCM [57 (55%) vs 12 (32%); p=0.046]. Genetic testing was performed in 414 (68%) patients. In those diagnosed &lt;10 years, genetic testing was more frequently performed in HCM [128 (67%) vs 33 (37%) in DCM, 10 (56%) in RCM and 1 (50%) in ARVC; p=0.008]; in those aged 10–18, genetic testing was most frequent in ARVC [n=8 (89%)] followed by HCM [n=81 (69%)], RCM [n=1 (50%)] and DCM [n=22 (46%); p=0.007]. A causative mutation was reported in 250 patients (60%), with a higher yield in those aged 10–18 vs &lt;10 years [77 (69%) vs 172 (57%), p=0.032]. In those &lt;10 years, the prevalence of reported causative mutations was highest in HCM [128 (67%) vs 10 (56%) in RCM, 1 (50%) in ARVC and 33 (37%) in DCM; p&lt;0.001]; in those 10–18 years, there was no significant difference in prevalence of reported causative variants between cardiomyopathy subtypes. Rare disease phenocopies were reported in 171 patients (27%): malformation syndromes [n=75 (12%)]; neuromuscular disorders [n=49 (8%)]; inborn errors of metabolism [n=20 (3%)]; mitochondrial [n=18 (3%)]; and chromosomal [n=15 (2%)]. Phenocopies were reported most frequently in patients &lt;10 years [135 (30%) vs 35 (20%) in those aged 10–18 years; p=0.008], particularly in HCM in those &lt;10 years [n=110 (41%); p&lt;0.001 vs other subtypes] and DCM in those aged 10–18 years [n=18 (38%); p=0.03 vs other subtypes].

Conclusion

This study confirms the heterogeneous aetiology of childhood cardiomyopathies and demonstrate a higher prevalence of familial disease than previously reported in paediatric populations. Genetic testing is performed in a high proportion of patients, with a high yield of reported causative variants.

Funding Acknowledgement

Type of funding source: None

Genome wide association analysis in dilated cardiomyopathy revealed two new susceptibility loci for systolic heart failure

 

We conducted the largest Genome Wide Association Study performed so far in Dilated Cardiomyopathy (DCM), a leading cause of systolic heart failure and cardiovascular death. Using a discovery phase of 2,719 cases and 4,440 controls and a replication phase of 584 independent cases and 966 controls, we identified and replicated two new DCM-associated loci, one on chromosome 3p (meta-analysis OR = 1.36 [1.25 - 1.48], p=5.3 10–13) and the second on chromosome 22q (meta-analysis OR = 1.33 [1.22 - 1.46], p=5.0 10–10), while confirming the two previously identified DCM loci on chromosome 10 and 1, BAG3 and HSPB7. We estimated the global heritability to 31% ± 8%. The genetic risk score constructed from the number of lead risk-alleles at these 4 loci revealed a 27% risk increased in individuals with 8 risk-alleles compared to the 5 risk alleles reference group (OR = 1.27 [1.14–1.42]).

The two association signals were then fine-mapped by combining in silico and functional genomics investigations (as 4C-sequencing on iPSC-derived cardiomyocytes). While a few genes remain candidates at the second locus and deserve further investigations, our work clearly identified one gene as responsible for the association at the first locus whose role in the pathophysiology of DCM is supported by recent observations in human and mice. As the biological pathway in which this gene is involved is a potential target for pharmacological agents, our finding opens novel therapeutic perspectives for treating or preventing heart failure.

We are convinced that these results provide new findings that add both on the understanding of the genetic architecture of heart failure and on potential new players involved in the pathophysiology of this devastating disease.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): GENMED Laboratory of Excellence on Medical Genomics, DETECTIN-HF project (ERA-CVD framework), Assistance Publique-Hôpitaux de Paris, Délégation à la recherche clinique, the “Fondation LEDUCQ”, the PROMEX charitable foundation, the Société Française de Cardiologie/Fédération Française de Cardiologie, the Deutsche Forschungsgemeinschaft, The Federal Ministry of Education and Research and the Ministry of Cultural Affairs and the Social Ministry of the Federal State of Mecklenburg-West Pomerania, The German Center for Cardiovascular Research (DZHK), Hospitals NIHR Biomedical Research Centre, NWO VENI grant (no. 016.176.136)

Availability and applicability of cardiac magnetic resonance imaging in diagnosis in cardiomyopathies: the Cardiomyopathy/Myocarditis registry of the EURObservational Research Programme of the ESC

Background

Cardiac magnetic resonance (CMR) constitutes a gold standard in the diagnosis of cardiomyopathies. Regardless of CMR advantages, the method is time-consuming, high-cost, with limited availability in some European regions.

Purpose

To assess the availability and applicability of CMR for establishing the diagnosis in different populations of patients with cardiomyopathies.

Methods

Overall, 3208 adult patients with cardiomyopathy (1119 / 34.9% females; median age at diagnosis: 49.0 years): 1260 with dilated (DCM), 1739 with hypertrophic (HCM), 66 with restrictive (RCM) and 143 with arrhythmogenic right ventricular cardiomyopathy (ARVC) enrolled in EURObservational Research Programme (EORP) – Cardiomyopathy/Myocarditis Long-Term Registry were analysed.

Results

CMR scan was performed as a baseline diagnostic method in 29.4% of patients; CMR was a single diagnostic method in 0.9% of patients and in 28.6% of patients CMR was used along with transthoracic echocardiography (TTE). In 67.6% of patients TTE was at the baseline the single diagnostic imaging method. Prevalence of CMR use in different cardiomyopathies was as follows: 20.6% in DCM, 33.8% in HCM, 36.4% in RCM and 51.1% in ARVC (p&lt;0.001). Range of CMR applicability in different European regions was diverse from 0% up to 63.2%.

The population with CMR use was younger, less symptomatic, with decreased prevalence of other cardiovascular risk factors and of associated cardiovascular diseases as compared to the population diagnosed without CMR scanning (p&lt;0.001).

Abnormal CMR results were present in 93.4% of patients with the highest percentage in RCM (95.8%) and HCM (94.9%) followed by DCM (91.5%) and the lowest abnormal CMR scan ratio in ARVC (87.7%) (p=0.030). The majority of CMR examinations comprised the assessment of late gadolinium enhancement (LGE, 93.3% at baseline). Presence of CMR LGE was observed in 69.3% of all patients: 59.1% in DCM, 73.8% in HCM, in 63.9% in ARVC and with the highest prevalence in RCM (83.3%) (p&lt;0.001).

Conclusion

The study reveals real-life data on the low availability and applicability of CMR in adult patients with cardiomyopathies. The analysis shows the advantages of CMR imaging but also identifies the gaps between recommendations and clinical practice. Improvement regarding access, training and reimbursement is necessary to offer CMR to cardiomyopathy patients in accordance with the ESC guidelines.

Funding Acknowledgement

Type of funding source: None

P1494Usefulness of longitudinal strain adjusted to regional thickness in hypertrophic cardiomyopathy

Background

In hypertrophic cardiomyopathy (HCM), longitudinal strain analysis allows to early detect left ventricular (LV) contraction abnormalities despite preserved LV ejection fraction. In current software, the width of the region of interest (ROI) is the same over the entire myocardial wall, and might analyze partially LV hypertrophic segments.

Purpose

The aim of this study is to evaluate a novel software for strain analysis with an adjustable ROI according to each segment thickness.

Methods

We included 110 patients: 55 patients with HCM (HCM group) and 55 healthy subjects (age- and sex-matched control group). All patients underwent echocardiography using a Vivid 9 GE system and measurements were performed using EchoPAC software. Global longitudinal strain (GLS) and regional strain for each of the 17 segments was calculated with standard software (for 2 groups) and with software adjusted to the myocardial wall thickness (for HCM group).

Results

GLS was significantly decreased in the HCM group as compared to the control group (−15.1±4.8% versus −20.5±4.3%, p<0.0001). In HCM group, GLS (standard method versus adjusted to thickness) were not significantly different (p=0.34). Interestingly, regional strain adjusted to thickness was significantly lower than standard strain in hypertrophic segments, especially in basal inferoseptal segment (p=0.0002), median inferoseptal segment (p<0.001) and median anteroseptal segment (p=0.02). Strain adjusted to thickness was still significantly lower in the most hypertrophic segments (≥20 mm) (−3.7±3%, versus −5.9±4.4%, p=0.049 in the basal inferoseptal segment and −5.7±3.5% versus −8.3±4.5%, p=0.0007 in the median inferoseptal segment). Analysis of strain adjusted to thickness had a better feasibility (97.5% versus 99%, p=0.01).

Conclusion

Analysis of longitudinal strain adjusted to regional thickness is feasible in HCM and allows a better evaluation of myocardial deformation, especially in the most LV hypertrophic segments.

P1247FLNC pathogenic variants in patients with various cardiomyopathies:prevalence and genotype-phenotype correlations

Background/Introduction

Pathogenic variants FLNC encoding filamin C have been firstly reported to cause myopathies, and were recently linked to isolated cardiac phenotypes.However, few data on phenotype-genotype correlation are available.

Purpose

Our aim was to estimate the prevalence of FLNC pathogenic variants in cardiomyopathies and to study the relations between phenotype and genotype.

Methods

DNAs from a cohort of 1150 unrelated index-patients with an isolated cardiomyopathy (700 hypertrophic, 300 dilated, 50 restrictive cardiomyopathies, and 100 left ventricle non-compactions) have been sequenced on a custom panel of 52 cardiomyopathy disease-causing genes.

Results

A FLNC pathogenic variant was identified in 28 patients corresponding to a prevalence ranging from 1 to 8% depending on the cardiomyopathy subtypes. Truncating variants were always identified in patients with dilated cardiomyopathy, while missense or in-frame variants were found in other phenotypes. This work reported for the first time a left ventricular non-compaction associated with FLNC pathogenic variant.

In the cohort, nine patients (32%) were implanted with an automatic defibrillator. In 7 families (25%), history of sudden cardiac death (SCD) before 50 years was reported. A personal or family history of sudden cardiac death (SCD) was significantly higher in patients with truncating variants than in patients carrying missense variants (p=0.01). Four patients died of cardiac cause including 3 from SCD and 1 from heart failure.

Conclusion

This work highlights the role of FLNC in cardiomyopathies. A correlation between the type of the variant and the cardiomyopathy subtype was observed as well as with SCD risk. These new data should be taken into consideration for patient's management and primary prevention of sudden cardiac death.

Acknowledgement/Funding

La ligue contre la Cardiomyopathie

5163Predictors of adverse cardiovascular events in patients with truncating variants in the filamin c (flnc) gene

Background

Truncating variants in Filamin C (FLNCtv) are associated with arrhythmogenic (AC) and dilated cardiomyopathies (DCM). Affected patients are reported to demonstrate a high incidence of arrhythmic and heart-failure related cardiovascular events. The aim of this study was to determine factors that predict adverse events in mutation carriers.

Methods

The study cohort comprised 168 FLNCtv carriers followed at 19 European centres. Baseline and longitudinal follow-up clinical data were collected. The primary endpoint was a composite of sudden cardiac death (SCD), aborted SCD, appropriate implantable cardioverter-defibrillator (ICD) shock, cardiac transplantation (HTx) and mortality from end-stage heart failure (ESHF).

Results

47 different pathogenic or likely-pathogenic FLNCtv were identified in 60 unrelated probands. In those with baseline and longitudinal data (160 patients; 57 probands), 114 (71.3%) patients exhibited evidence of cardiac disease at initial evaluation. Gene penetrance was 85% by the age of 40 years. During a median follow-up of 1.5 years (IQR 4.1), 24 individuals (15%) reached the primary endpoint – 16 arrhythmic (SCD/aborted SCD/ICD shock) and 8 heart failure (ESHF/HTx) related-events. Univariable predictors at baseline evaluation of the composite primary endpoint included proband status (HR 4.0, 95% CI: 1.5–10.9, p=0.01), symptoms of dyspnoea (HR 2.8, 95% CI: 1.2–6.4, p=0.02), LV systolic dysfunction (LVSD) (HR 12.4, 95% CI: 2.9–53.2, p=0.001), frequent ventricular ectopy (VE>500) on 24-hour Holter (HR 9.3, 95% CI: 1.2–74.7, p=0.04) and the presence of late gadolinium enhancement on CMR (HR 8.9, 95% CI: 1.2–68.5, p=0.04).

Multivariable analysis identified LVSD (LVEF <50%) at baseline as an independent predictor of the primary endpoint with a hazard ratio of 8.6 (95% CI: 1.8–41.5, p=0.007). ROC analysis using LV systolic dysfunction to predict the primary endpoint demonstrated an area under the curve of 0.84 (95% CI: 0.76–0.91, p<0.001) and identified an optimal LVEF “cut-off” of 47% for predicting adverse events with a Youden's index of 0.61 (sensitivity 0.91; specificity 0.70).

Kaplan-Meier plot to demonstrate freedom

Conclusions

LVSD is associated with an over 8-fold increase in the hazard of a primary endpoint event in FLNCtv gene carriers indicating that these patients should be considered for implantable cardioverter-defibrillator (ICD) implantation, optimal heart failure medical therapy and close clinical follow-up.

Acknowledgement/Funding

NIHR Biomedical Research Centre; Instituto de Salud Carlos III; DETECTIN-HF project; Wellcome Trust;CIBERCV; EU Regional Development Fund; FEDER.

P886Exercise left ventricular outflow track obstruction in hypertrophic cardiomyopathy: peak exercise or post-exercise pressure gradients?

Background

Left ventricular outflow track obstruction (LVOTO) is a key feature of hypertrophic cardiomyopathy (HCM), associated with poor prognosis and requiring specific management in symptomatic patients. Furthermore, new drugs targeting LVOTO are under investigation. Exercise echocardiography is the more relevant test to unmask latent obstruction in patients with HCM and to link obstruction to symptoms during physical activity. However, little is known about the role and impact of obstruction according to the precise time of occurrence during exercise or immediate recovery.

Objective

We hypothesized that LVOT pressure gradients could be enhanced during immediate recovery after exercise compared to peak exercise in patients with HCM.

Methods

We conducted an observational, single center and retrospective study and included all the patients with HCM referred to our department between 2010 and 2018 for an exercise echocardiography. All exercises were performed on a bicycle in a semi-supine position and LVOT pressure gradient were recorded continuously during and immediately after exercise in the same position.

Results

121 patients with HCM were included (age 49±16 y, 64% male, 59% NYHA 2 and 3, LV ejection fraction 66±7%, max LV wall thickness 19±5 mm, 69% receiving betablockers). Exercise was performed until exhaustion at a mean workload of 118±58 Watts. Overall, the maximal LVOT gradients increased from rest, to peak exercise and recovery (respectively 17±18, 39±43 and 55±60 mmHg, p<0,0001). More than half of the patients (52%) had a gradient ≥30 mmHg at least in one phase, but a maximal gradient ≥50 mmHg (threshold for invasive treatment in symptomatic patients) was observed in only 7% of the population at rest, 25% at peak exercise and 37% at recovery (p<0.001). Finally, a maximal gradient ≥50 mmHg was recorded only during immediate recovery (69±25 mmHg) and not during exercise in 16 patients (13%). None of them experienced post-exercise syncope.

Conclusion

The time course of significant LVOTO during exercise in HCM should be evaluated carefully. LVOTO is more severe and more prevalent during immediate recovery. Some patients exhibit only significant post-exercise LVOT pressure gradients, which therefore cannot explain limitation during exercise.

5164New risk prediction score for life-threatening ventricular tachyarrhythmias in laminopathies

Background

An accurate estimation of the risk of life-threatening (LT) ventricular tachyarrhythmia (VTA) in patients with LMNA mutations is crucial to select candidates for implantable cardioverter defibrillator (ICD) implantation.

Methods

We included 839 adult patients with LMNA mutations, including 660 from a French nationwide registry in the development sample, and 179 from other countries, referred to 5 tertiary centers for cardiomyopathies, in the validation sample. LTVTA was defined as a) sudden cardiac death or b) ICD-treated or hemodynamically unstable VTA. The prognostic model was derived using Fine-Gray's regression model. The net reclassification was compared with current clinical practice guidelines. The results are presented as means (standard deviation) or medians [interquartile range].

Results

We included 444 patients 40.6 (14.1) years of age in the derivation sample and 145 patients 38.2 (15.0) years in the validation sample, of whom 86 (19.3%) and 34 (23.4%) suffered LTVTA over 3.6 [1.0–7.2] and 5.1 [2.0–9.3] years of follow-up, respectively. Predictors of LTVTA in the derivation sample were: male sex, non-missense LMNA mutation, 1st degree and higher atrioventricular block, non-sustained ventricular tachycardia, and left ventricular ejection fraction. In the derivation sample, C-index (95% CI) of the model was 0.776 (0.711–0.842). In the external validation sample, the C-index was 0.800 (0.642–0.959) and calibration slope 1.082 (95% CI, 0.643–1.522). A 5-year estimated risk threshold ≥7% predicted 96.2% of LTVTA and net reclassified 28.8% of patients with LTVTA compared with the guidelines-based approach.

Conclusions

Compared to the current standard of care, this risk prediction model for LTVTA in laminopathies facilitated significantly the choice of ICD candidates.

Acknowledgement/Funding

AFM Téléthon

P891Psycho-social impact of predictive genetic testing in hereditary heart diseases (PREDICT Study)

Introduction

Hereditary heart diseases are most often characterized by autosomal dominant inheritance and delayed cardiac expression. Predictive genetic testing is offered to asymptomatic relatives to allow targeted medical care with early therapeutics in order to reduce the risk of complications. Psychological issues and socio-professional impact of predictive testing are complex and have been poorly studied. The aim of this study was to evaluate the psychological and socio-professional impact of predictive genetic testing in hereditary heart diseases through a prospective and retrospective study.

Patients and methods

This multicentric French study involved 20 expert centers in hereditary heart diseases. We included 517 adult relatives (42.3±16.7 years, 60.6% females) who performed predictive genetic testing (prospective study: N=264, retrospective study: N=253). The opinion and experience were collected via auto-questionnaires, at various moments in the prospective study, with different items and validated scales (STAI: score for anxiety and IES: impact of event).

Results

In the prospective study, family history was characterized by cardiomyopathy (88.4%) and channelopathies (11.6%). The main motivations for performing the test were: “to remove doubt” (65.3%), “for children” (64.0%), “to benefit from medical supervision” (34.9%). A mutation was present in 39.4% of relatives. No regret was expressed after testing (only 2.3% regrets). The result did not lead to a socio-professional change or family relationship change in 60.7%. Among those who had a change, it was perceived as unfavorable for only 3%. A change in socio-professional status and/or family relationship was mainly related to the result of genetic testing (p<0.0001). The level of anxiety (STAI scale) increased before the test result but then decreased and returned to baseline. Subjects with depression history were more likely to develop anxiety at long term after multivariate analyses (p=0.004). Quite similar results were observed in the retrospective study.

Conclusions

Our results show that contrary to a widespread opinion, the medical benefit was not the main motivation for predictive genetic testing. In most cases, no or marginal adverse psychological and socio-professional impact of genetic testing was observed when performed by a team expert in predictive testing. However careful management is required to identify and manage subjects at risk for increased anxiety or socio-professional change.

Secondary findings from next generation sequencing: Psychological and ethical issues. Family and patient perspectives

Access to active search for actionable secondary findings (SF) in diagnostic practice is a major psychological and ethical issue for genomic medicine. In this study, we analyzed the preferences of patients and their families regarding SF and identified the reporting procedures necessary for informed consent. We interviewed parents of patients with undiagnosed rare diseases potentially eligible for exome sequencing and patients affected by the diseases listed in the ACMG recommendations. Four focus groups (FG) were formed: parents of patients with undiagnosed rare diseases (FG1, n = 5); patients with hereditary cancers (FG2, n = 10); patients with hereditary cardiac conditions (FG3, n = 3); and patients with metabolic diseases (FG4, n = 3). Psychologists presented three broad topics for discussion: 1. Favorable or not to SF access, 2. Reporting procedures, 3. Equity of access. Discussions were recorded and analyzed using simplified Grounded Theory. Overall, 8 participants declared being favorable to SF because of the medical benefit (mainly FG1); 11 were unfavorable because of the psychological consequences (mainly FG2, FG3, FG4); 2 were ambivalent. The possibility of looking for SF in minors was debated. The 4 key information-based issues for participants ranked as follows: explanation of SF issues, autonomy of choice, importance of a reflection period, and quality of interactions between patients and professionals. Examining equity of access to SF led to philosophical discussions on quality of life. In conclusion, individual experience and life context (circumstances) were decisive in participants' expectations and fears regarding access to SF. Additional longitudinal studies based on actual SF disclosure announcements are needed to establish future guidelines.