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Masri A, Lester SJ, Stendahl JC, Hegde SM, Sehnert AJ, Balaratnam G, Shah A, Fox S, Wang A. Long-Term Safety and Efficacy of Mavacamten in Symptomatic Obstructive Hypertrophic Cardiomyopathy: Interim Results of the PIONEER-OLE Study. J Am Heart Assoc 2024; 13:e030607. [PMID: 38591260 DOI: 10.1161/jaha.123.030607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 01/16/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND The phase 2 PIONEER-HCM (Phase 2 Open-label Pilot Study Evaluating Mavacamten in Subjects With Symptomatic Hypertrophic Cardiomyopathy and Left Ventricular Outflow Tract Obstruction) study showed that mavacamten improved left ventricular outflow tract gradients, exercise capacity, and symptoms in patients with obstructive hypertrophic cardiomyopathy (HCM), but the results of longer-term treatment are less well described. We report interim results from the PIONEER-OLE (PIONEER Open-Label Extension) study, the longest-term study of mavacamten in patients with symptomatic obstructive HCM. METHODS AND RESULTS Patients who previously completed PIONEER-HCM (n=20) were eligible to enroll in PIONEER-OLE. Patients received oral mavacamten, 5 mg once daily (starting dose), with individualized dose titration at week 6. Evaluations included serial monitoring of safety, echocardiography, Kansas City Cardiomyopathy Questionnaire-Overall Summary Score, and serum NT-proBNP (N-terminal pro-B-type natriuretic peptide) levels. Thirteen patients enrolled and received mavacamten (median study duration at data cutoff, 201 weeks). Most patients (92.3%) received β-blockers concomitantly. Treatment-emergent adverse events were predominantly mild/moderate. One patient had an isolated reduction in left ventricular ejection fraction to 47%, which recovered and remained normal with continued treatment at a reduced dose. At week 180, mavacamten was associated with New York Heart Association class improvements from baseline (class II to I, n=9; class III to II, n=1; and unchanged, n=2), sustained reductions in left ventricular outflow tract gradients (mean [SD] change from baseline: resting, -50 [55] mm Hg; Valsalva, -70 [41] mm Hg), and serum NT-proBNP levels (median [interquartile range] change from baseline: -498 [-2184 to -76] ng/L), and improved Kansas City Cardiomyopathy Questionnaire-Overall Summary Score (mean [SD] change from baseline: +17 [16]). CONCLUSIONS This long-term analysis supports the continued safety and effectiveness of mavacamten for >3 years in obstructive HCM. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03496168.
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Affiliation(s)
- Ahmad Masri
- Division of Cardiology, Hypertrophic Cardiomyopathy Center, School of Medicine Oregon Health & Science University Portland OR
| | - Steven J Lester
- Department of Cardiovascular Diseases Mayo Clinic Arizona Phoenix AZ
| | - John C Stendahl
- Section of Cardiovascular Medicine, Department of Internal Medicine Yale School of Medicine New Haven CT
| | - Sheila M Hegde
- Division of Cardiovascular Medicine Brigham and Women's Hospital Boston MA
| | | | | | | | | | - Andrew Wang
- Duke Cardiology Duke University Hospital Durham NC
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2
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Stepanek J, Farina JM, Mahmoud AK, Chao CJ, Alsidawi S, Ayoub C, Barry T, Pereyra M, Scalia IG, Abbas MT, Wraith RE, Brown LS, Radavich MS, Curtisi PJ, Hartzendorf PC, Lasota EM, Umetsu KN, Peterson JM, Karlson KE, Breznak K, Fortuin DF, Lester SJ, Arsanjani R. Identifying the Causes of Unexplained Dyspnea at High Altitude Using Normobaric Hypoxia with Echocardiography. J Imaging 2024; 10:38. [PMID: 38392086 PMCID: PMC10889907 DOI: 10.3390/jimaging10020038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Revised: 01/24/2024] [Accepted: 01/29/2024] [Indexed: 02/24/2024] Open
Abstract
Exposure to high altitude results in hypobaric hypoxia, leading to physiological changes in the cardiovascular system that may result in limiting symptoms, including dyspnea, fatigue, and exercise intolerance. However, it is still unclear why some patients are more susceptible to high-altitude symptoms than others. Hypoxic simulation testing (HST) simulates changes in physiology that occur at a specific altitude by asking the patients to breathe a mixture of gases with decreased oxygen content. This study aimed to determine whether the use of transthoracic echocardiography (TTE) during HST can detect the rise in right-sided pressures and the impact of hypoxia on right ventricle (RV) hemodynamics and right to left shunts, thus revealing the underlying causes of high-altitude signs and symptoms. A retrospective study was performed including consecutive patients with unexplained dyspnea at high altitude. HSTs were performed by administrating reduced FiO2 to simulate altitude levels specific to patients' history. Echocardiography images were obtained at baseline and during hypoxia. The study included 27 patients, with a mean age of 65 years, 14 patients (51.9%) were female. RV systolic pressure increased at peak hypoxia, while RV systolic function declined as shown by a significant decrease in the tricuspid annular plane systolic excursion (TAPSE), the maximum velocity achieved by the lateral tricuspid annulus during systole (S' wave), and the RV free wall longitudinal strain. Additionally, right-to-left shunt was present in 19 (70.4%) patients as identified by bubble contrast injections. Among these, the severity of the shunt increased at peak hypoxia in eight cases (42.1%), and the shunt was only evident during hypoxia in seven patients (36.8%). In conclusion, the use of TTE during HST provides valuable information by revealing the presence of symptomatic, sustained shunts and confirming the decline in RV hemodynamics, thus potentially explaining dyspnea at high altitude. Further studies are needed to establish the optimal clinical role of this physiologic method.
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Affiliation(s)
- Jan Stepanek
- Aerospace Medicine Program, Department of Internal Medicine, Mayo Clinic, Scottsdale, AZ 85054, USA
| | - Juan M Farina
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, AZ 85054, USA
| | - Ahmed K Mahmoud
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, AZ 85054, USA
| | - Chieh-Ju Chao
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Said Alsidawi
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, AZ 85054, USA
| | - Chadi Ayoub
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, AZ 85054, USA
| | - Timothy Barry
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, AZ 85054, USA
| | - Milagros Pereyra
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, AZ 85054, USA
| | - Isabel G Scalia
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, AZ 85054, USA
| | | | - Rachel E Wraith
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, AZ 85054, USA
| | - Lisa S Brown
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, AZ 85054, USA
| | - Michael S Radavich
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, AZ 85054, USA
| | - Pamela J Curtisi
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, AZ 85054, USA
| | | | - Elizabeth M Lasota
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, AZ 85054, USA
| | - Kyley N Umetsu
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, AZ 85054, USA
| | - Jill M Peterson
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, AZ 85054, USA
| | - Kristin E Karlson
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, AZ 85054, USA
| | - Karen Breznak
- Aerospace Medicine Program, Department of Internal Medicine, Mayo Clinic, Scottsdale, AZ 85054, USA
| | - David F Fortuin
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, AZ 85054, USA
| | - Steven J Lester
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, AZ 85054, USA
| | - Reza Arsanjani
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, AZ 85054, USA
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3
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Farina JM, Chao CJ, Pereyra M, Roarke M, Said EF, Barry T, Alsidawi S, Sell-Dottin K, Sweeney JP, Fortuin DF, Ayoub C, Lester SJ, Oh JK, Arsanjani R, Marcotte F. Role of lipoprotein(a) concentrations in bioprosthetic aortic valve degeneration. Heart 2024; 110:299-305. [PMID: 37643771 DOI: 10.1136/heartjnl-2023-322987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 07/24/2023] [Indexed: 08/31/2023] Open
Abstract
OBJECTIVES Lipoprotein(a) (Lp(a)) is associated with an increased incidence of native aortic stenosis, which shares similar pathological mechanisms with bioprosthetic aortic valve (bAV) degeneration. However, evidence regarding the role of Lp(a) concentrations in bAV degeneration is lacking. This study aims to evaluate the association between Lp(a) concentrations and bAV degeneration. METHODS In this retrospective multicentre study, patients who underwent a bAV replacement between 1 January 2010 and 31 December 2020 and had a Lp(a) measurement were included. Echocardiography follow-up was performed to determine the presence of bioprosthetic valve degeneration, which was defined as an increase >10 mm Hg in mean gradient from baseline with concomitant decrease in effective orifice area and Doppler Velocity Index, or new moderate/severe prosthetic regurgitation. Levels of Lp(a) were compared between patients with and without degeneration and Cox regression analysis was performed to investigate the association between Lp(a) levels and bioprosthetic valve degeneration. RESULTS In total, 210 cases were included (mean age 74.1±9.4 years, 72.4% males). Median time between baseline and follow-up echocardiography was 4.4 (IQR 3.7) years. Bioprostheses degeneration was observed in 33 (15.7%) patients at follow-up. Median serum levels of Lp(a) were significantly higher in patients affected by degeneration versus non-affected cases: 50.0 (IQR 72.0) vs 15.6 (IQR 48.6) mg/dL, p=0.002. In the regression analysis, high Lp(a) levels (≥30 mg/dL) were associated with degeneration both in a univariable analysis (HR 3.6, 95% CI 1.7 to 7.6, p=0.001) and multivariable analysis adjusted by other risk factors for bioprostheses degeneration (HR 4.4, 95% CI 1.9 to 10.4, p=0.001). CONCLUSIONS High serum Lp(a) is associated with bAV degeneration. Prospective studies are needed to confirm these findings and to investigate whether lowering Lp(a) levels could slow bioprostheses degradation.
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Affiliation(s)
- Juan M Farina
- Department of Cardiovascular Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Chieh-Ju Chao
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Milagros Pereyra
- Department of Cardiovascular Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Michael Roarke
- Department of Cardiovascular Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Ebram F Said
- Department of Cardiovascular Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Timothy Barry
- Department of Cardiovascular Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Said Alsidawi
- Department of Cardiovascular Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Kristen Sell-Dottin
- Department of Cardiovascular Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - John P Sweeney
- Department of Cardiovascular Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - David F Fortuin
- Department of Cardiovascular Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Chadi Ayoub
- Department of Cardiovascular Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Steven J Lester
- Department of Cardiovascular Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Jae K Oh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Reza Arsanjani
- Department of Cardiovascular Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Francois Marcotte
- Department of Cardiovascular Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
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4
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Jeong J, Chao CJ, Arsanjani R, Ayoub C, Lester SJ, Pereyra M, Said EF, Roarke M, Tagle-Cornell C, Koepke LM, Tsai YL, Jung-Hsuan C, Chang CC, Farina JM, Trivedi H, Patel BN, Banerjee I. Opportunistic screening for coronary artery calcium deposition using chest radiographs - a multi-objective models with multi-modal data fusion. medRxiv 2024:2024.01.10.23299699. [PMID: 38260571 PMCID: PMC10802643 DOI: 10.1101/2024.01.10.23299699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Background To create an opportunistic screening strategy by multitask deep learning methods to stratify prediction for coronary artery calcium (CAC) and associated cardiovascular risk with frontal chest x-rays (CXR) and minimal data from electronic health records (EHR). Methods In this retrospective study, 2,121 patients with available computed tomography (CT) scans and corresponding CXR images were collected internally (Mayo Enterprise) with calculated CAC scores binned into 3 categories (0, 1-99, and 100+) as ground truths for model training. Results from the internal training were tested on multiple external datasets (domestic (EUH) and foreign (VGHTPE)) with significant racial and ethnic differences and classification performance was compared. Findings Classification performance between 0, 1-99, and 100+ CAC scores performed moderately on both the internal test and external datasets, reaching average f1-score of 0.66 for Mayo, 0.62 for EUH and 0.61 for VGHTPE. For the clinically relevant binary task of 0 vs 400+ CAC classification, the performance of our model on the internal test and external datasets reached an average AUCROC of 0.84. Interpretation The fusion model trained on CXR performed better (0.84 average AUROC on internal and external dataset) than existing state-of-the-art models on predicting CAC scores only on internal (0.73 AUROC), with robust performance on external datasets. Thus, our proposed model may be used as a robust, first-pass opportunistic screening method for cardiovascular risk from regular chest radiographs. For community use, trained model and the inference code can be downloaded with an academic open-source license from https://github.com/jeong-jasonji/MTL_CAC_classification . Funding The study was partially supported by National Institute of Health 1R01HL155410-01A1 award.
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5
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Siontis KC, Abreau S, Attia ZI, Barrios JP, Dewland TA, Agarwal P, Balasubramanyam A, Li Y, Lester SJ, Masri A, Wang A, Sehnert AJ, Edelberg JM, Abraham TP, Friedman PA, Olgin JE, Noseworthy PA, Tison GH. Patient-Level Artificial Intelligence-Enhanced Electrocardiography in Hypertrophic Cardiomyopathy: Longitudinal Treatment and Clinical Biomarker Correlations. JACC Adv 2023; 2:100582. [PMID: 38076758 PMCID: PMC10702858 DOI: 10.1016/j.jacadv.2023.100582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/31/2024]
Abstract
BACKGROUND Artificial intelligence (AI) applied to 12-lead electrocardiographs (ECGs) can detect hypertrophic cardiomyopathy (HCM). OBJECTIVES The purpose of this study was to determine if AI-enhanced ECG (AI-ECG) can track longitudinal therapeutic response and changes in cardiac structure, function, or hemodynamics in obstructive HCM during mavacamten treatment. METHODS We applied 2 independently developed AI-ECG algorithms (University of California-San Francisco and Mayo Clinic) to serial ECGs (n = 216) from the phase 2 PIONEER-OLE trial of mavacamten for symptomatic obstructive HCM (n = 13 patients, mean age 57.8 years, 69.2% male). Control ECGs from 2,600 age- and sex-matched individuals without HCM were obtained. AI-ECG output was correlated longitudinally to echocardiographic and laboratory metrics of mavacamten treatment response. RESULTS In the validation cohorts, both algorithms exhibited similar performance for HCM diagnosis, and exhibited mean HCM score decreases during mavacamten treatment: patient-level score reduction ranged from approximately 0.80 to 0.45 for Mayo and 0.70 to 0.35 for USCF algorithms; 11 of 13 patients demonstrated absolute score reduction from start to end of follow-up for both algorithms. HCM scores were significantly associated with other HCM-relevant parameters, including left ventricular outflow tract gradient at rest, postexercise, and with Valsalva, and NT-proBNP level, independent of age and sex (all P < 0.01). For both algorithms, the strongest longitudinal correlation was between AI-ECG HCM score and left ventricular outflow tract gradient postexercise (slope estimate: University of California-San Francisco 0.70 [95% CI: 0.45-0.96], P < 0.0001; Mayo 0.40 [95% CI: 0.11-0.68], P = 0.007). CONCLUSIONS AI-ECG analysis longitudinally correlated with changes in echocardiographic and laboratory markers during mavacamten treatment in obstructive HCM. These results provide early evidence for a potential paradigm for monitoring HCM therapeutic response.
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Affiliation(s)
| | - Sean Abreau
- Division of Cardiology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
- Cardiovascular Research Institute, San Francisco, California, USA
| | - Zachi I. Attia
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Joshua P. Barrios
- Division of Cardiology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
- Cardiovascular Research Institute, San Francisco, California, USA
| | - Thomas A. Dewland
- Division of Cardiology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Priyanka Agarwal
- MyoKardia Inc, a Wholly Owned Subsidiary of Bristol Myers Squibb, Brisbane, California, USA
| | - Aarthi Balasubramanyam
- MyoKardia Inc, a Wholly Owned Subsidiary of Bristol Myers Squibb, Brisbane, California, USA
| | - Yunfan Li
- MyoKardia Inc, a Wholly Owned Subsidiary of Bristol Myers Squibb, Brisbane, California, USA
| | - Steven J. Lester
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, Arizona, USA
| | - Ahmad Masri
- Division of Cardiovascular Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Andrew Wang
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Amy J. Sehnert
- 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
| | - Theodore P. Abraham
- Division of Cardiology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Paul A. Friedman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jeffrey E. Olgin
- Division of Cardiology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
- Cardiovascular Research Institute, San Francisco, California, USA
| | - Peter A. Noseworthy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Geoffrey H. Tison
- Division of Cardiology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
- Cardiovascular Research Institute, San Francisco, California, USA
- Bakar Computational Health Sciences Institute, University of California-San Francisco, San Francisco, California, USA
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6
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Chao CJ, Agasthi P, Girardo M, Barry T, Seri AR, Brown L, Wraith RE, Shanbhag A, Wang Y, Chen YC, Lester SJ, Alsidawi S, Freeman WK, Naqvi TZ, Eleid M, Fortuin D, Pollak P, El Sabbagh A, Sell-Dottin K, Majdalany D, Larsen C, Holmes DR, Oh JK, Appleton CP, Arsanjani R. Using Augmented Mean Arterial Pressure to Identify High Mortality Risk Patients With Moderate Aortic Stenosis. Mayo Clin Proc 2023; 98:1501-1514. [PMID: 37793726 DOI: 10.1016/j.mayocp.2023.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 02/07/2023] [Accepted: 02/17/2023] [Indexed: 10/06/2023]
Abstract
OBJECTIVE To study the usefulness of a novel echocardiographic marker, augmented mean arterial pressure (AugMAP = [(mean aortic valve gradient + systolic blood pressure) + (2 × diastolic blood pressure)] / 3), in identifying high-risk patients with moderate aortic stenosis (AS). PATIENTS AND METHODS Adults with moderate AS (aortic valve area, 1.0-1.5 cm2) at Mayo Clinic sites from January 1, 2010, through December 31, 2020, were identified. Baseline demographic, echocardiographic, and all-cause mortality data were retrieved. Patients were grouped into higher and lower AugMAP groups using a cutoff value of 80 mm Hg for analysis. Kaplan-Meier and Cox regression models were used to assess the performance of AugMAP. RESULTS A total of 4563 patients with moderate AS were included (mean ± SD age, 73.7±12.5 years; 60.5% men). Median follow-up was 2.5 years; 36.0% of patients died. The mean ± SD left ventricular ejection fraction (LVEF) was 60.1%±11.4%, and the mean ± SD AugMAP was 99.1±13.1 mm Hg. Patients in the lower AugMAP group, with either preserved or reduced LVEF, had significantly worse survival performance (all P<.001). Multivariate Cox regression showed that AugMAP (hazard ratio, 0.962; 95% CI, 0.942 to 0.981 per 5-mm Hg increase; P<.001) and AugMAP less than 80 mm Hg (hazard ratio, 1.477; 95% CI, 1.241 to 1.756; P<.001) were independently associated with all-cause mortality. CONCLUSION AugMAP is a simple and effective echocardiographic marker to identify high-risk patients with moderate AS independent of LVEF. It can potentially be used in the candidate selection process if moderate AS becomes indicated for aortic valve intervention in the future.
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Affiliation(s)
- Chieh-Ju Chao
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, Scottsdale, AZ; Department of Cardiovascular Diseases, Mayo Clinic Rochester, Rochester, MN.
| | - Pradyumma Agasthi
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, Scottsdale, AZ; Department of Cardiovascular Diseases, Mayo Clinic Rochester, Rochester, MN
| | - Marlene Girardo
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, Scottsdale, AZ
| | - Timothy Barry
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, Scottsdale, AZ
| | - Amith R Seri
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, Scottsdale, AZ
| | - Lisa Brown
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, Scottsdale, AZ
| | - Rachel E Wraith
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, Scottsdale, AZ
| | - Anusha Shanbhag
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, Scottsdale, AZ
| | - Yuxiang Wang
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, Scottsdale, AZ
| | - Yi-Chieh Chen
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, Scottsdale, AZ; Department of Pharmacy, Mayo Clinic Health System, Austin, MN
| | - Steven J Lester
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, Scottsdale, AZ
| | - Said Alsidawi
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, Scottsdale, AZ
| | - William K Freeman
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, Scottsdale, AZ
| | - Tasneem Z Naqvi
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, Scottsdale, AZ
| | - Mackram Eleid
- Department of Cardiovascular Diseases, Mayo Clinic Rochester, Rochester, MN
| | - David Fortuin
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, Scottsdale, AZ
| | - Peter Pollak
- Department of Cardiovascular Diseases, Mayo Clinic Florida, Jacksonville, FL
| | - Abdallah El Sabbagh
- Department of Cardiovascular Diseases, Mayo Clinic Florida, Jacksonville, FL
| | | | - David Majdalany
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, Scottsdale, AZ
| | - Carolyn Larsen
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, Scottsdale, AZ
| | - David R Holmes
- Department of Cardiovascular Diseases, Mayo Clinic Rochester, Rochester, MN
| | - Jae K Oh
- Department of Cardiovascular Diseases, Mayo Clinic Rochester, Rochester, MN
| | | | - Reza Arsanjani
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, Scottsdale, AZ
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7
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Mitchell CC, Frye C, Jankowski M, Symanski J, Lester SJ, Woo A, Gilliland Y, Dragulescu A, Abraham T, Desai M, Martinez MW, Nagueh SF, Phelan D. A Practical Approach to Echocardiographic Imaging in Patients With Hypertrophic Cardiomyopathy. J Am Soc Echocardiogr 2023; 36:913-932. [PMID: 37160197 DOI: 10.1016/j.echo.2023.04.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 03/31/2023] [Accepted: 04/04/2023] [Indexed: 05/11/2023]
Abstract
Hypertrophic cardiomyopathy (HCM) is frequently unrecognized or misdiagnosed. The recently published consensus recommendations from the American Society of Echocardiography provided recommendations for the utilization of multimodality imaging in the care of patients with HCM. This document provides an additional practical framework for optimal image and measurement acquisition and guidance on how to tailor the echocardiography examination for individuals with HCM. It also provides resources for physicians and sonographers to use to develop HCM imaging protocols.
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Affiliation(s)
- Carol C Mitchell
- School of Medicine and Public Health Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - Cody Frye
- Sanger Heart and Vascular Institute, Atrium Health, Charlotte, North Carolina
| | - Madeline Jankowski
- Division of Cardiology, Northwestern Memorial Hospital, Chicago, Illinois
| | - John Symanski
- Sanger Heart and Vascular Institute, Atrium Health, Charlotte, North Carolina
| | | | - Anna Woo
- Toronto General Hospital, Toronto, Ontario, Canada
| | | | | | | | | | | | | | - Dermot Phelan
- Sanger Heart and Vascular Institute, Atrium Health, Charlotte, North Carolina.
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8
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Arnaout R, Hahn RT, Hung JW, Jone PN, Lester SJ, Little SH, Mackensen GB, Rigolin V, Sachdev V, Saric M, Sengupta PP, Strom JB, Taub CC, Thamman R, Abraham T. The (Heart and) Soul of a Human Creation: Designing Echocardiography for the Big Data Age. J Am Soc Echocardiogr 2023; 36:800-801. [PMID: 37191597 PMCID: PMC10913146 DOI: 10.1016/j.echo.2023.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 04/16/2023] [Indexed: 05/17/2023]
Affiliation(s)
- Rima Arnaout
- University of California, San Francisco, San Francisco, California.
| | | | - Judy W Hung
- Massachusetts General Hospital, Boston, Massachusetts
| | - Pei-Ni Jone
- Lurie Children's Hospital, Chicago, Illinois; Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | | | - Vera Rigolin
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Vandana Sachdev
- National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Muhamed Saric
- New York University Langone Health, New York, New York
| | | | - Jordan B Strom
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Cynthia C Taub
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Ritu Thamman
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Theodore Abraham
- University of California, San Francisco, San Francisco, California
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Chao CJ, Agasthi P, Seri AR, Barry T, Shanbhag A, Wang Y, Eleid MF, Fortuin D, Sweeney JP, Pollak P, El Sabbagh A, Lester SJ, Freeman WK, Naqvi TZ, Holmes DR, Appleton CP, Arsanjani R. Transcatheter Aortic Valve Replacement Prognostication with Augmented Mean Arterial Pressure. J Cardiovasc Dev Dis 2023; 10:jcdd10050192. [PMID: 37233159 DOI: 10.3390/jcdd10050192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 04/19/2023] [Accepted: 04/21/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Post-transcatheter aortic valve replacement (TAVR) patient outcome is an important research topic. To accurately assess post-TAVR mortality, we examined a family of new echo parameters (augmented systolic blood pressure (AugSBP) and arterial mean pressure (AugMAP)) derived from blood pressure and aortic valve gradients. METHODS Patients in the Mayo Clinic National Cardiovascular Diseases Registry-TAVR database who underwent TAVR between 1 January 2012 and 30 June 2017 were identified to retrieve baseline clinical, echocardiographic and mortality data. AugSBP, AugMAP and valvulo-arterial impedance (Zva) (Zva) were evaluated using Cox regression. Receiver operating characteristic curve analysis and the c-index were used to assess the model performance against the Society of Thoracic Surgeons (STS) risk score. RESULTS The final cohort contained 974 patients with a mean age of 81.4 ± 8.3 years old, and 56.6% were male. The mean STS risk score was 8.2 ± 5.2. The median follow-up duration was 354 days, and the one-year all-cause mortality rate was 14.2%. Both univariate and multivariate Cox regression showed that AugSBP and AugMAP parameters were independent predictors for intermediate-term post-TAVR mortality (all p < 0.0001). AugMAP1 < 102.5 mmHg was associated with a 3-fold-increased risk of all-cause mortality 1-year post-TAVR (hazard ratio 3.0, 95%confidence interval 2.0-4.5, p < 0.0001). A univariate model of AugMAP1 surpassed the STS score model in predicting intermediate-term post-TAVR mortality (area under the curve: 0.700 vs. 0.587, p = 0.005; c-index: 0.681 vs. 0.585, p = 0.001). CONCLUSIONS Augmented mean arterial pressure provides clinicians with a simple but effective approach to quickly identify patients at risk and potentially improve post-TAVR prognosis.
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Affiliation(s)
- Chieh-Ju Chao
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, Scottsdale, AZ 85259, USA
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Rochester, MN 55905, USA
| | - Pradyumna Agasthi
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, Scottsdale, AZ 85259, USA
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Rochester, MN 55905, USA
| | - Amith R Seri
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, Scottsdale, AZ 85259, USA
| | - Timothy Barry
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, Scottsdale, AZ 85259, USA
| | - Anusha Shanbhag
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, Scottsdale, AZ 85259, USA
| | - Yuxiang Wang
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, Scottsdale, AZ 85259, USA
| | - Mackram F Eleid
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Rochester, MN 55905, USA
| | - David Fortuin
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, Scottsdale, AZ 85259, USA
| | - John P Sweeney
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, Scottsdale, AZ 85259, USA
| | - Peter Pollak
- Department of Cardiovascular Diseases, Mayo Clinic Florida, Jacksonville, FL 32224, USA
| | - Abdallah El Sabbagh
- Department of Cardiovascular Diseases, Mayo Clinic Florida, Jacksonville, FL 32224, USA
| | - Steven J Lester
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, Scottsdale, AZ 85259, USA
| | - William K Freeman
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, Scottsdale, AZ 85259, USA
| | - Tasneem Z Naqvi
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, Scottsdale, AZ 85259, USA
| | - David R Holmes
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Rochester, MN 55905, USA
| | | | - Reza Arsanjani
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, Scottsdale, AZ 85259, USA
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Masri A, Lester SJ, Stendahl J, Hegde SM, Sehnert A, Balaratnam G, Fox S, Wang A. LONG-TERM SAFETY AND EFFICACY OF MAVACAMTEN IN PATIENTS (PTS) WITH SYMPTOMATIC OBSTRUCTIVE HYPERTROPHIC CARDIOMYOPATHY (HCM): UPDATED RESULTS FROM THE PIONEER-OLE STUDY. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)00790-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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11
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Chao C, Seri A, Fortuin FD, Sweeney JP, Thaden JJ, Eleid M, Alkhouli M, Rihal CR, Holmes DR, Pollak PM, Elsabbagh A, Lester SJ, Oh JK, Banerjee I, Arsanjani R. Topological data analysis identified prognostically-distinct phenotypes in MitraClip patients. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Topological data analysis (TDA) is the state-of-the-art unsupervised machine learning framework that can provide insight into the dataset and visualize condensed information via the topological network graph. This robust approach was never used to assess the heterogeneous MitraClip population.
Purpose
We aim to develop a TDA model that will identify prognostically-distinct phenogroups in MitraClip patients without a priori knowledge of the population and their outcomes.
Method
Patients who underwent MitraClip (June 2014-September 2020) at Mayo Clinic sites were identified from the institutional database for baseline and follow-up data. Thirteen variables were used for TDA. The topological network graph was created using the Python Scikit-TDA Kepler-Mapper package (v. 2.0.1), and clustering was performed at the graph level with Louvain's modularity method. Kaplan-Meier survival analysis was used to assess the all-cause mortality endpoint of each cluster identified in an unsupervised manner. The dataset with cluster labels was also used to train a Light Gradient Boosted Machine model, and SHapley Additive exPlanations (SHAP) analysis was applied to determine the feature importance.
Results
A total of 389 consecutive patients were included in the final analysis and two major clusters consisting of 384 patients were identified. The mean age was 80.3±8.7 years; 256 (65.8%) were male. The mean Society of Thoracic Surgeons Mitral Valve Replacement risk score was 9.6±6.9%. Fifty-five (14.5%) patients died during the mean follow duration (185 days). Kaplan-Meier analysis showed significant survival differences among the two clusters (HR: 2.38; 95% CI: 1.39–4.06, p=0.001; Figure 1). Clusters 1 (n=195) was associated with > mild residual mitral regurgitation and worse survival performance and was characterized with worse tricuspid regurgitation severity, a higher proportion of patients with atrial fibrillation/flutter, anterior leaflet prolapse, and mitral annular/leaflet calcification, as summarized in Table 1.
Conclusion
TDA can identify distinct phenotype clusters with prognostic significance in MitraClip patients based on mitral valve morphology and clinical risk factors. This simple model can facilitate clinical risk stratification for MitraClip patients regarding procedural success and survival performance.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- C Chao
- Mayo Clinic, Cardiovascular Diseases , Rochester , United States of America
| | - A Seri
- Mayo Clinic Arizona , Scottsdale , United States of America
| | - F D Fortuin
- Mayo Clinic Arizona , Scottsdale , United States of America
| | - J P Sweeney
- Mayo Clinic Arizona , Scottsdale , United States of America
| | - J J Thaden
- Mayo Clinic, Cardiovascular Diseases , Rochester , United States of America
| | - M Eleid
- Mayo Clinic, Cardiovascular Diseases , Rochester , United States of America
| | - M Alkhouli
- Mayo Clinic, Cardiovascular Diseases , Rochester , United States of America
| | - C R Rihal
- Mayo Clinic, Cardiovascular Diseases , Rochester , United States of America
| | - D R Holmes
- Mayo Clinic, Cardiovascular Diseases , Rochester , United States of America
| | - P M Pollak
- Mayo Clinic , Jacksonville , United States of America
| | - A Elsabbagh
- Mayo Clinic , Jacksonville , United States of America
| | - S J Lester
- Mayo Clinic Arizona , Scottsdale , United States of America
| | - J K Oh
- Mayo Clinic, Cardiovascular Diseases , Rochester , United States of America
| | - I Banerjee
- Mayo Clinic Arizona , Scottsdale , United States of America
| | - R Arsanjani
- Mayo Clinic Arizona , Scottsdale , United States of America
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12
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Nagueh SF, Phelan D, Abraham T, Armour A, Desai MY, Dragulescu A, Gilliland Y, Lester SJ, Maldonado Y, Mohiddin S, Nieman K, Sperry BW, Woo A. Recommendations for Multimodality Cardiovascular Imaging of Patients with Hypertrophic Cardiomyopathy: An Update from the American Society of Echocardiography, in Collaboration with the American Society of Nuclear Cardiology, the Society for Cardiovascular Magnetic Resonance, and the Society of Cardiovascular Computed Tomography. J Am Soc Echocardiogr 2022; 35:533-569. [PMID: 35659037 DOI: 10.1016/j.echo.2022.03.012] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Hypertrophic cardiomyopathy (HCM) is defined by the presence of left ventricular hypertrophy in the absence of other potentially causative cardiac, systemic, syndromic, or metabolic diseases. Symptoms can be related to a range of pathophysiologic mechanisms including left ventricular outflow tract obstruction with or without significant mitral regurgitation, diastolic dysfunction with heart failure with preserved and heart failure with reduced ejection fraction, autonomic dysfunction, ischemia, and arrhythmias. Appropriate understanding and utilization of multimodality imaging is fundamental to accurate diagnosis as well as longitudinal care of patients with HCM. Resting and stress imaging provide comprehensive and complementary information to help clarify mechanism(s) responsible for symptoms such that appropriate and timely treatment strategies may be implemented. Advanced imaging is relied upon to guide certain treatment options including septal reduction therapy and mitral valve repair. Using both clinical and imaging parameters, enhanced algorithms for sudden cardiac death risk stratification facilitate selection of HCM patients most likely to benefit from implantable cardioverter-defibrillators.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Saidi Mohiddin
- Inherited/Acquired Myocardial Diseases, Barts Health NHS Trust, St Bartholomew's Hospital, London, UK
| | - Koen Nieman
- Cardiovascular Medicine and Radiology (CV Imaging), Stanford University Medical Center, CA
| | - Brett W Sperry
- Saint Luke's Mid America Heart Institute, Kansas City, MO
| | - Anna Woo
- Toronto General Hospital, Toronto, Canada
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13
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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: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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14
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Affiliation(s)
- Daniel Jacoby
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University, New Haven, CT, USA
| | - Carolyn Y Ho
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Steven J Lester
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Andrew Wang
- Duke University School of Medicine, Durham, NC, USA
| | - Iacopo Olivotto
- Cardiomyopathy Unit, Azienda Ospedaliera Universitaria Careggi, Florence 50134, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
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15
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Ho CY, Mealiffe ME, Bach RG, Bhattacharya M, Choudhury L, Edelberg JM, Hegde SM, Jacoby D, Lakdawala NK, Lester SJ, Ma Y, Marian AJ, Nagueh SF, Owens A, Rader F, Saberi S, Sehnert AJ, Sherrid MV, Solomon SD, Wang A, Wever-Pinzon O, Wong TC, Heitner SB. Evaluation of Mavacamten in Symptomatic Patients With Nonobstructive Hypertrophic Cardiomyopathy. J Am Coll Cardiol 2021; 75:2649-2660. [PMID: 32466879 DOI: 10.1016/j.jacc.2020.03.064] [Citation(s) in RCA: 158] [Impact Index Per Article: 52.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 03/26/2020] [Accepted: 03/29/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Patients with nonobstructive hypertrophic cardiomyopathy (nHCM) often experience a high burden of symptoms; however, there are no proven pharmacological therapies. By altering the contractile mechanics of the cardiomyocyte, myosin inhibitors have the potential to modify pathophysiology and improve symptoms associated with HCM. OBJECTIVES MAVERICK-HCM (Mavacamten in Adults With Symptomatic Non-Obstructive Hypertrophic Cardiomyopathy) explored the safety and efficacy of mavacamten, a first-in-class reversible inhibitor of cardiac-specific myosin, in nHCM. METHODS The MAVERICK-HCM trial was a multicenter, double-blind, placebo-controlled, dose-ranging phase II study in adults with symptomatic nHCM (New York Heart Association functional class II/III), left ventricular ejection fraction (LVEF) ≥55%, and N-terminal pro-B-type natriuretic peptide (NT-proBNP) ≥300 pg/ml. Participants were randomized 1:1:1 to mavacamten at a pharmacokinetic-adjusted dose (targeting plasma levels of 200 or 500 ng/ml), or placebo for 16 weeks, followed by an 8-week washout. Initial dose was 5 mg daily with 1 dose titration at week 6. RESULTS Fifty-nine participants were randomized (19, 21, 19 patients to 200 ng/ml, 500 ng/ml, placebo, respectively). Their mean age was 54 years, and 58% were women. Serious adverse events occurred in 10% of participants on mavacamten and in 21% participants on placebo. Five participants on mavacamten had reversible reduction in LVEF ≤45%. NT-proBNP geometric mean decreased by 53% in the pooled mavacamten group versus 1% in the placebo group, with geometric mean differences of -435 and -6 pg/ml, respectively (p = 0.0005). Cardiac troponin I (cTnI) geometric mean decreased by 34% in the pooled mavacamten group versus a 4% increase in the placebo group, with geometric mean differences of -0.008 and 0.001 ng/ml, respectively (p = 0.009). CONCLUSIONS Mavacamten, a novel myosin inhibitor, was well tolerated in most subjects with symptomatic nHCM. Furthermore, treatment was associated with a significant reduction in NT-proBNP and cTnI, suggesting improvement in myocardial wall stress. These results set the stage for future studies of mavacamten in this patient population using clinical parameters, including LVEF, to guide dosing. (A Phase 2 Study of Mavacamten in Adults With Symptomatic Non-Obstructive Hypertrophic Cardiomyopathy [MAVERICK-HCM]; NCT03442764).
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Affiliation(s)
- Carolyn Y Ho
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
| | | | - Richard G Bach
- Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri
| | | | - Lubna Choudhury
- Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Chicago, Illinois
| | | | - Sheila M Hegde
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Daniel Jacoby
- Department of Internal Medicine, Section of Cardiovascular Diseases, Yale University School of Medicine, New Haven, Connecticut
| | - Neal K Lakdawala
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Steven J Lester
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, Phoenix, Arizona
| | - Yanfei Ma
- MyoKardia, Inc., Brisbane, California
| | - Ali J Marian
- Center for Cardiovascular Genetics, Institute of Molecular Medicine, University of Texas Health Sciences Center at Houston, Houston, Texas
| | - Sherif F Nagueh
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Anjali Owens
- Heart and Vascular Center, Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Florian Rader
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Sara Saberi
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan
| | | | - Mark V Sherrid
- Hypertrophic Cardiomyopathy Program, New York University School of Medicine, New York, New York
| | - Scott D Solomon
- Department of Internal Medicine, Section of Cardiovascular Diseases, Yale University School of Medicine, New Haven, Connecticut
| | - Andrew Wang
- Duke Cardiology, Duke Health Center at Southpoint, Durham, North Carolina
| | - Omar Wever-Pinzon
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah
| | - Timothy C Wong
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Stephen B Heitner
- Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
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16
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Olivotto I, Oreziak A, Barriales-Villa R, Abraham TP, Masri A, Garcia-Pavia P, Saberi S, Lakdawala NK, Wheeler MT, Owens A, Kubanek M, Wojakowski W, Jensen MK, Gimeno-Blanes J, Afshar K, Myers J, Hegde SM, Solomon SD, Sehnert AJ, Zhang D, Li W, Bhattacharya M, Edelberg JM, Waldman CB, Lester SJ, Wang A, Ho CY, Jacoby D. Mavacamten for treatment of symptomatic obstructive hypertrophic cardiomyopathy (EXPLORER-HCM): a randomised, double-blind, placebo-controlled, phase 3 trial. Lancet 2020; 396:759-769. [PMID: 32871100 DOI: 10.1016/s0140-6736(20)31792-x] [Citation(s) in RCA: 420] [Impact Index Per Article: 105.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 08/02/2020] [Accepted: 08/04/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND Cardiac muscle hypercontractility is a key pathophysiological abnormality in hypertrophic cardiomyopathy, and a major determinant of dynamic left ventricular outflow tract (LVOT) obstruction. Available pharmacological options for hypertrophic cardiomyopathy are inadequate or poorly tolerated and are not disease-specific. We aimed to assess the efficacy and safety of mavacamten, a first-in-class cardiac myosin inhibitor, in symptomatic obstructive hypertrophic cardiomyopathy. METHODS In this phase 3, randomised, double-blind, placebo-controlled trial (EXPLORER-HCM) in 68 clinical cardiovascular centres in 13 countries, patients with hypertrophic cardiomyopathy with an LVOT gradient of 50 mm Hg or greater and New York Heart Association (NYHA) class II-III symptoms were assigned (1:1) to receive mavacamten (starting at 5 mg) or placebo for 30 weeks. Visits for assessment of patient status occurred every 2-4 weeks. Serial evaluations included echocardiogram, electrocardiogram, and blood collection for laboratory tests and mavacamten plasma concentration. The primary endpoint was a 1·5 mL/kg per min or greater increase in peak oxygen consumption (pVO2) and at least one NYHA class reduction or a 3·0 mL/kg per min or greater pVO2 increase without NYHA class worsening. Secondary endpoints assessed changes in post-exercise LVOT gradient, pVO2, NYHA class, Kansas City Cardiomyopathy Questionnaire-Clinical Summary Score (KCCQ-CSS), and Hypertrophic Cardiomyopathy Symptom Questionnaire Shortness-of-Breath subscore (HCMSQ-SoB). This study is registered with ClinicalTrials.gov, NCT03470545. FINDINGS Between May 30, 2018, and July 12, 2019, 429 adults were assessed for eligibility, of whom 251 (59%) were enrolled and randomly assigned to mavacamten (n=123 [49%]) or placebo (n=128 [51%]). 45 (37%) of 123 patients on mavacamten versus 22 (17%) of 128 on placebo met the primary endpoint (difference +19·4%, 95% CI 8·7 to 30·1; p=0·0005). Patients on mavacamten had greater reductions than those on placebo in post-exercise LVOT gradient (-36 mm Hg, 95% CI -43·2 to -28·1; p<0·0001), greater increase in pVO2 (+1·4 mL/kg per min, 0·6 to 2·1; p=0·0006), and improved symptom scores (KCCQ-CSS +9·1, 5·5 to 12·7; HCMSQ-SoB -1·8, -2·4 to -1·2; p<0·0001). 34% more patients in the mavacamten group improved by at least one NYHA class (80 of 123 patients in the mavacamten group vs 40 of 128 patients in the placebo group; 95% CI 22·2 to 45·4; p<0·0001). Safety and tolerability were similar to placebo. Treatment-emergent adverse events were generally mild. One patient died by sudden death in the placebo group. INTERPRETATION Treatment with mavacamten improved exercise capacity, LVOT obstruction, NYHA functional class, and health status in patients with obstructive hypertrophic cardiomyopathy. The results of this pivotal trial highlight the benefits of disease-specific treatment for this condition. FUNDING MyoKardia.
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Affiliation(s)
- Iacopo Olivotto
- Cardiomyopathy Unit, Azienda Ospedaliera Universitaria Careggi, Florence, Italy; University of Florence, Florence, Italy.
| | - Artur Oreziak
- 1st Department of Arrhythmia, National Institute of Cardiology, Warsaw, Poland
| | - Roberto Barriales-Villa
- Unidad de Cardiopatías Familiares, Instituto de Investigación Biomédica de A Coruña, A Coruña, Spain; Complexo Hospitalario Universitario de A Coruña, A Coruña, Spain; Servizo Galego de Saúde, A Coruña, Spain; Universidade da Coruña, A Coruña, Spain; Centro de Investigación Biomédica en Red, Madrid, Spain
| | - Theodore P Abraham
- Division of Cardiology, University of California San Francisco, San Francisco, CA, USA
| | - Ahmad Masri
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Pablo Garcia-Pavia
- Centro de Investigación Biomédica en Red, Madrid, Spain; Department of Cardiology, Hospital Universitario Puerta de Hierro, Madrid, Spain; Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain
| | - Sara Saberi
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Neal K Lakdawala
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Matthew T Wheeler
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Anjali Owens
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Milos Kubanek
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Wojciech Wojakowski
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Morten K Jensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Juan Gimeno-Blanes
- Inherited Cardiac Disease Unit, University Hospital Virgen de la Arrixaca, Murcia, Spain
| | - Kia Afshar
- Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, UT, USA
| | - Jonathan Myers
- Division of Cardiology, Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA, USA; Stanford University, Palo Alto, CA, USA
| | - Sheila M Hegde
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | | | | | | | | | | | | | - Steven J Lester
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Andrew Wang
- Duke University School of Medicine, Durham, NC, USA
| | - Carolyn Y Ho
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Daniel Jacoby
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University, New Haven, CT, USA
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Ho CY, Olivotto I, Jacoby D, Lester SJ, Roe M, Wang A, Waldman CB, Zhang D, Sehnert AJ, Heitner SB. Study Design and Rationale of EXPLORER-HCM: Evaluation of Mavacamten in Adults With Symptomatic Obstructive Hypertrophic Cardiomyopathy. Circ Heart Fail 2020; 13:e006853. [PMID: 32498620 DOI: 10.1161/circheartfailure.120.006853] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Obstructive hypertrophic cardiomyopathy (oHCM) is characterized by unexplained left ventricular (LV) hypertrophy associated with dynamic LV outflow tract obstruction. Current medical therapies are nonspecific and have limited efficacy in relieving symptoms. Mavacamten is a first-in-class targeted inhibitor of cardiac myosin, which has been shown to reduce LV outflow tract obstruction, improve exercise capacity, and relieve symptoms of oHCM in the PIONEER-HCM phase 2 study. METHODS EXPLORER-HCM is a multicenter, phase 3, randomized, double-blind, placebo-controlled trial to investigate the efficacy and safety of mavacamten in treating symptomatic oHCM. Eligible adults with oHCM and New York Heart Association Functional Class II or III are randomized 1:1 to receive once-daily, oral mavacamten, or matching placebo for 30 weeks. The primary composite functional end point is clinical response at week 30 compared to baseline defined as either (1) an increase in peak oxygen consumption ≥1.5 mL/kg/min and reduction of at least one New York Heart Association class; or (2) an improvement of ≥3.0 mL/kg/min in peak oxygen consumption with no worsening of New York Heart Association class. Secondary end points include change in postexercise LV outflow tract gradient, New York Heart Association class, peak oxygen consumption, and patient-reported outcomes assessed by the Kansas City Cardiomyopathy Questionnaire and a novel HCM-specific instrument. Exploratory end points aim to characterize the effect of mavacamten on multiple aspects of oHCM pathophysiology. CONCLUSIONS EXPLORER-HCM is a phase 3 trial in oHCM testing a first-in-class, targeted strategy of myosin inhibition to improve symptom burden and exercise capacity through reducing LV outflow tract obstruction. Results of this trial will provide evidence to support the first disease-specific treatment for HCM. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03470545.
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Affiliation(s)
- Carolyn Y Ho
- Brigham and Women's Hospital, Boston, MA (C.Y.H.)
| | | | | | | | - Matthew Roe
- Duke Clinical Research Institute, Durham, NC (M.R.)
| | - Andrew Wang
- Duke University School of Medicine, Durham, NC (A.W.)
| | | | | | | | - Stephen B Heitner
- Knight Cardiovascular Institute, Oregon Health and Sciences University, Portland (S.B.H.)
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Heitner SB, Jacoby D, Lester SJ, Owens A, Wang A, Zhang D, Lambing J, Lee J, Semigran M, Sehnert AJ. Mavacamten Treatment for Obstructive Hypertrophic Cardiomyopathy: A Clinical Trial. Ann Intern Med 2019; 170:741-748. [PMID: 31035291 DOI: 10.7326/m18-3016] [Citation(s) in RCA: 163] [Impact Index Per Article: 32.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Mavacamten, an orally administered, small-molecule modulator of cardiac myosin, targets underlying biomechanical abnormalities in obstructive hypertrophic cardiomyopathy (oHCM). OBJECTIVE To characterize the effect of mavacamten on left ventricular outflow tract (LVOT) gradient. DESIGN Open-label, nonrandomized, phase 2 trial. (ClinicalTrials.gov: NCT02842242). SETTING 5 academic centers. PARTICIPANTS 21 symptomatic patients with oHCM. INTERVENTION Patients in cohort A received mavacamten, 10 to 20 mg/d, without background medications. Those in cohort B received mavacamten, 2 to 5 mg/d, with β-blockers allowed. MEASUREMENTS The primary end point was change in postexercise LVOT gradient at 12 weeks. Secondary end points included changes in peak oxygen consumption (pVO2), resting and Valsalva LVOT gradients, left ventricular ejection fraction (LVEF), and numerical rating scale dyspnea score. RESULTS In cohort A, mavacamten reduced mean postexercise LVOT gradient from 103 mm Hg (SD, 50) at baseline to 19 mm Hg (SD, 13) at 12 weeks (mean change, -89.5 mm Hg [95% CI, -138.3 to -40.7 mm Hg]; P = 0.008). Resting LVEF was also reduced (mean change, -15% [CI, -23% to -6%]). Peak VO2 increased by a mean of 3.5 mL/kg/min (CI, 1.2 to 5.9 mL/kg/min). In cohort B, the mean postexercise LVOT gradient decreased from 86 mm Hg (SD, 43) to 64 mm Hg (SD, 26) (mean change, -25.0 mm Hg [CI, -47.1 to -3.0 mm Hg]; P = 0.020), and mean change in resting LVEF was -6% (CI, -10% to -1%). Peak VO2 increased by a mean of 1.7 mL/kg/min (SD, 2.3) (CI, 0.03 to 3.3 mL/kg/min). Dyspnea scores improved in both cohorts. Mavacamten was well tolerated, with mostly mild (80%), moderate (19%), and unrelated (79%) adverse events. The most common adverse events definitely or possibly related to mavacamten were decreased LVEF at higher plasma concentrations and atrial fibrillation. LIMITATION Small size; open-label design. CONCLUSION Mavacamten can reduce LVOT obstruction and improve exercise capacity and symptoms in patients with oHCM. PRIMARY FUNDING SOURCE MyoKardia.
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Affiliation(s)
| | - Daniel Jacoby
- Yale New Haven Hospital, New Haven, Connecticut (D.J.)
| | | | - Anjali Owens
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania (A.O.)
| | - Andrew Wang
- Duke University Medical Center, Durham, North Carolina (A.W.)
| | - David Zhang
- MyoKardia, South San Francisco, California (D.Z., J.L., J.L., M.S., A.J.S.)
| | - Joseph Lambing
- MyoKardia, South San Francisco, California (D.Z., J.L., J.L., M.S., A.J.S.)
| | - June Lee
- MyoKardia, South San Francisco, California (D.Z., J.L., J.L., M.S., A.J.S.)
| | - Marc Semigran
- MyoKardia, South San Francisco, California (D.Z., J.L., J.L., M.S., A.J.S.)
| | - Amy J Sehnert
- MyoKardia, South San Francisco, California (D.Z., J.L., J.L., M.S., A.J.S.)
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Patel SI, Ackerman MJ, Shamoun FE, Geske JB, Ommen SR, Love WT, Cha SS, Bos JM, Lester SJ. QT prolongation and sudden cardiac death risk in hypertrophic cardiomyopathy. Acta Cardiol 2019; 74:53-58. [PMID: 29513133 DOI: 10.1080/00015385.2018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
INTRODUCTION Risk assessment for sudden cardiac death (SCD) in hypertrophic cardiomyopathy (HCM) remains complex. The goal of this study was to assess electrocardiogram (ECG)-derived risk factors on SCD in a large HCM population Methods: Retrospective review of adults with HCM evaluated at Mayo Clinic, Rochester, MN from 1 December 2002 to 31 December 2012 was performed. Data inclusive of ECG and 24-hour ambulatory Holter monitor were assessed. SCD events were documented by ventricular fibrillation (VF) noted on implantable cardioverter defibrillator (ICD), or appropriate VT or VF-terminating ICD shock. RESULTS Overall, 1615 patients (mean age 53.7 ± 15.2 years; 943 males, 58.4%) were assessed, with mean follow-up 2.46 years and 110 SCD events. Via logistic regression (n = 820), the odds of SCD increased with increasing number of conventional risk factors. With one risk factor the OR was 4.88 (p < .0001; CI 2.22-10.74), two risk factors the OR was 6.922 (p < .0001; CI 2.94-16.28) and three or more risk factors, the OR was 13.997 (p < .0001; CI 5.649-34.68). Adding QTc > 450 to this logistic regression model had OR 1.722 (p = .04, CI 1.01-2.937) to predict SCD. QTc ≥ 450 was a significant predictor for death (HR 1.88, p = .021, CI 1.10-3.20). There was no correlation between sinus bradycardia, sinus tachycardia, first degree AV block, atrial fibrillation, left bundle branch block, right bundle branch block, premature atrial complexes, premature ventricular complexes, supraventricular tachycardia, PR interval, QRS interval and SCD. CONCLUSIONS Prolonged QTc was a risk factor for SCD and death even when controlling for typical risk factors.
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Affiliation(s)
- Salma I Patel
- a Center for Sleep Medicine , Mayo Clinic , Rochester , MN , USA
| | - Michael J Ackerman
- b Department of Cardiovascular Diseases , Mayo Clinic , Rochester , MN , USA
| | - Fadi E Shamoun
- c Division of Cardiovascular Diseases , Mayo Clinic , Scottsdale , AZ , USA
| | - Jeffrey B Geske
- b Department of Cardiovascular Diseases , Mayo Clinic , Rochester , MN , USA
| | - Steve R Ommen
- b Department of Cardiovascular Diseases , Mayo Clinic , Rochester , MN , USA
| | - William T Love
- d Department of Internal Medicine , Mayo Clinic , Scottsdale , AZ , USA and
| | - Stephen S Cha
- e Department of Health Science Research , Mayo Clinic , Scottsdale , AZ , USA
| | - Johan M Bos
- b Department of Cardiovascular Diseases , Mayo Clinic , Rochester , MN , USA
| | - Steven J Lester
- c Division of Cardiovascular Diseases , Mayo Clinic , Scottsdale , AZ , USA
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20
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Patel SI, Ackerman MJ, Shamoun FE, Geske JB, Ommen SR, Love WT, Cha SS, Bos JM, Lester SJ. QT prolongation and sudden cardiac death risk in hypertrophic cardiomyopathy. Acta Cardiol 2019. [PMID: 29513133 DOI: 10.1080/00015385.2018.1440905] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Risk assessment for sudden cardiac death (SCD) in hypertrophic cardiomyopathy (HCM) remains complex. The goal of this study was to assess electrocardiogram (ECG)-derived risk factors on SCD in a large HCM population Methods: Retrospective review of adults with HCM evaluated at Mayo Clinic, Rochester, MN from 1 December 2002 to 31 December 2012 was performed. Data inclusive of ECG and 24-hour ambulatory Holter monitor were assessed. SCD events were documented by ventricular fibrillation (VF) noted on implantable cardioverter defibrillator (ICD), or appropriate VT or VF-terminating ICD shock. RESULTS Overall, 1615 patients (mean age 53.7 ± 15.2 years; 943 males, 58.4%) were assessed, with mean follow-up 2.46 years and 110 SCD events. Via logistic regression (n = 820), the odds of SCD increased with increasing number of conventional risk factors. With one risk factor the OR was 4.88 (p < .0001; CI 2.22-10.74), two risk factors the OR was 6.922 (p < .0001; CI 2.94-16.28) and three or more risk factors, the OR was 13.997 (p < .0001; CI 5.649-34.68). Adding QTc > 450 to this logistic regression model had OR 1.722 (p = .04, CI 1.01-2.937) to predict SCD. QTc ≥ 450 was a significant predictor for death (HR 1.88, p = .021, CI 1.10-3.20). There was no correlation between sinus bradycardia, sinus tachycardia, first degree AV block, atrial fibrillation, left bundle branch block, right bundle branch block, premature atrial complexes, premature ventricular complexes, supraventricular tachycardia, PR interval, QRS interval and SCD. CONCLUSIONS Prolonged QTc was a risk factor for SCD and death even when controlling for typical risk factors.
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Affiliation(s)
- Salma I. Patel
- Center for Sleep Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Fadi E. Shamoun
- Division of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ, USA
| | - Jeffrey B. Geske
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Steve R. Ommen
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - William T. Love
- Department of Internal Medicine, Mayo Clinic, Scottsdale, AZ, USA and
| | - Stephen S. Cha
- Department of Health Science Research, Mayo Clinic, Scottsdale, AZ, USA
| | - Johan M. Bos
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Steven J. Lester
- Division of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ, USA
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21
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Rudski LG, Gargani L, Armstrong WF, Lancellotti P, Lester SJ, Grünig E, D'Alto M, Åström Aneq M, Ferrara F, Saggar R, Saggar R, Naeije R, Picano E, Schiller NB, Bossone E. Stressing the Cardiopulmonary Vascular System: The Role of Echocardiography. J Am Soc Echocardiogr 2018; 31:527-550.e11. [PMID: 29573927 DOI: 10.1016/j.echo.2018.01.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Indexed: 01/06/2023]
Abstract
The cardiopulmonary vascular system represents a key determinant of prognosis in several cardiorespiratory diseases. Although right heart catheterization is considered the gold standard for assessing pulmonary hemodynamics, a comprehensive noninvasive evaluation including left and right ventricular reserve and function and cardiopulmonary interactions remains highly attractive. Stress echocardiography is crucial in the evaluation of many cardiac conditions, typically coronary artery disease but also heart failure and valvular heart disease. In stress echocardiographic applications beyond coronary artery disease, the assessment of the cardiopulmonary vascular system is a cornerstone. The possibility of coupling the left and right ventricles with the pulmonary circuit during stress can provide significant insight into cardiopulmonary physiology in healthy and diseased subjects, can support the diagnosis of the etiology of pulmonary hypertension and other conditions, and can offer valuable prognostic information. In this state-of-the-art document, the topic of stress echocardiography applied to the cardiopulmonary vascular system is thoroughly addressed, from pathophysiology to different stress modalities and echocardiographic parameters, from clinical applications to limitations and future directions.
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Affiliation(s)
- Lawrence G Rudski
- Azrieli Heart Center and Center for Pulmonary Vascular Diseases, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Luna Gargani
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | - William F Armstrong
- Department of Internal Medicine, Division of Cardiovascular Disease, University of Michigan Medical Center, Ann Arbor, Michigan
| | - Patrizio Lancellotti
- Department of Cardiology, University of Liège Hospital, GIGA-Cardiovascular Sciences, Liège, Belgium
| | - Steven J Lester
- Division of Cardiovascular Diseases, Mayo Clinic, Scottsdale, Arizona
| | - Ekkehard Grünig
- Centre for Pulmonary Hypertension, University Hospital Heidelberg, Heidelberg, Germany
| | - Michele D'Alto
- Department of Cardiology, Second University of Naples-Monaldi Hospital, Naples, Italy
| | - Meriam Åström Aneq
- Department of Clinical Physiology, Institution of Medicine and Health Sciences, Linköping University, Linköping, Sweden
| | | | - Rajeev Saggar
- Lung Institute, Banner University Medical Center-Phoenix, University of Arizona, Phoenix, Arizona
| | - Rajan Saggar
- Lung & Heart-Lung Transplant and Pulmonary Hypertension Programs, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | | | - Eugenio Picano
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | - Nelson B Schiller
- Cardiovascular Research Institute, Health eHeart Study, Division of Cardiology, Department of Medicine, University of California, San Francisco, San Francisco, California
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22
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Abbas AE, Khoury Abdulla R, Aggrawal A, Crile J, Lester SJ, Boura J. A novel echocardiographic hemodynamic classification of heart failure based on stroke volume index and left atrial pressure. Echocardiography 2017; 34:1417-1425. [DOI: 10.1111/echo.13642] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Amr E. Abbas
- Department of Cardiovascular Medicine; Beaumont Health; Royal Oak MI USA
- Oakland University William Beaumont School of Medicine; Auburn Hills MI USA
| | | | - Anshul Aggrawal
- Department of Cardiovascular Medicine; Beaumont Health; Royal Oak MI USA
| | - Jason Crile
- Department of Cardiovascular Medicine; Beaumont Health; Royal Oak MI USA
| | - Steven J. Lester
- Division of Cardiovascular Diseases; Mayo Clinic; Phoenix AZ, USA
| | - Judy Boura
- Oakland University William Beaumont School of Medicine; Auburn Hills MI USA
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Nasr SH, Dasari S, Mills JR, Theis JD, Zimmermann MT, Fonseca R, Vrana JA, Lester SJ, McLaughlin BM, Gillespie R, Highsmith WE, Lee JJ, Dispenzieri A, Kurtin PJ. Hereditary Lysozyme Amyloidosis Variant p.Leu102Ser Associates with Unique Phenotype. J Am Soc Nephrol 2017; 28:431-438. [PMID: 28049649 PMCID: PMC5280032 DOI: 10.1681/asn.2016090951] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Lysozyme amyloidosis (ALys) is a rare form of hereditary amyloidosis that typically manifests with renal impairment, gastrointestinal (GI) symptoms, and sicca syndrome, whereas cardiac involvement is exceedingly rare and neuropathy has not been reported. Here, we describe a 40-year-old man with renal impairment, cardiac and GI symptoms, and peripheral neuropathy. Renal biopsy specimen analysis revealed amyloidosis with extensive involvement of glomeruli, vessels, and medulla. Amyloid was also detected in the GI tract. Echocardiographic and electrocardiographic findings were consistent with cardiac involvement. Proteomic analysis of Congo red-positive renal and GI amyloid deposits detected abundant lysozyme C protein. DNA sequencing of the lysozyme gene in the patient and his mother detected a heterozygous c.305T>C alteration in exon 3, which causes a leucine to serine substitution at codon 102 (Human Genome Variation Society nomenclature: p.Leu102Ser; legacy designation: L84S). We also detected the mutant peptide in the proband's renal and GI amyloid deposits. PolyPhen analysis predicted that the mutation damages the encoded protein. Molecular dynamics simulations suggested that the pathogenesis of ALys p.Leu102Ser is mediated by shifting the position of the central β-hairpin coordinated with an antiparallel motion of the C-terminal helix, which may alter the native-state structural ensemble of the molecule, leading to aggregation-prone intermediates.
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Affiliation(s)
- Samih H Nasr
- Departments of Laboratory Medicine and Pathology
| | | | - John R Mills
- Departments of Laboratory Medicine and Pathology
| | | | | | - Rafael Fonseca
- Department of Internal Medicine, Mayo Clinic in Arizona, Phoenix, Arizona
| | | | - Steven J Lester
- Department of Internal Medicine, Mayo Clinic in Arizona, Phoenix, Arizona
| | - Brooke M McLaughlin
- Department of Clinical Genomics, Mayo Clinic in Arizona, Scottsdale, Arizona
| | - Robert Gillespie
- Department of Cardiology, Sharp Rees-Stealy Medical Group, San Diego, California; and
| | | | - John J Lee
- Department of Pathology, Sharp Memorial Hospital, San Diego, California
| | - Angela Dispenzieri
- Departments of Laboratory Medicine and Pathology
- Medicine, Mayo Clinic, Rochester, Minnesota
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Vucicevic D, Lester SJ, Appleton CP, Panse PM, Schleifer JW, Wilansky S. The Incremental Value of Magnetic Resonance Imaging for Identification of Apical Pouch in Patients with Apical Variant of Hypertrophic Cardiomyopathy. Echocardiography 2015; 33:572-8. [DOI: 10.1111/echo.13118] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Darko Vucicevic
- Division of Cardiovascular Diseases; Mayo Clinic; Scottsdale Arizona
| | - Steven J. Lester
- Division of Cardiovascular Diseases; Mayo Clinic; Scottsdale Arizona
| | | | | | | | - Susan Wilansky
- Division of Cardiovascular Diseases; Mayo Clinic; Scottsdale Arizona
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25
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Abudiab MM, Wilansky S, Lester SJ, Yousefzai R, Tyler R, Tajik AJ. Transient Apical Thickening Following Apical Ballooning Syndrome: A Case Series. Echocardiography 2015; 32:1723-7. [DOI: 10.1111/echo.13001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Muaz M. Abudiab
- Division of Cardiovascular Diseases; Department of Internal Medicine; Mayo Clinic; Scottsdale Arizona
| | - Susan Wilansky
- Division of Cardiovascular Diseases; Department of Internal Medicine; Mayo Clinic; Scottsdale Arizona
| | - Steven J. Lester
- Division of Cardiovascular Diseases; Department of Internal Medicine; Mayo Clinic; Scottsdale Arizona
| | - Rayan Yousefzai
- Aurora Cardiovascular Services; Aurora Sinai/Aurora St. Luke's Medical Centers; University of Wisconsin School of Medicine and Public Health; Milwaukee Wisconsin
| | - Rochelle Tyler
- Division of Cardiovascular Diseases; Department of Internal Medicine; Mayo Clinic; Scottsdale Arizona
| | - A. Jamil Tajik
- Aurora Cardiovascular Services; Aurora Sinai/Aurora St. Luke's Medical Centers; University of Wisconsin School of Medicine and Public Health; Milwaukee Wisconsin
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Roy RR, Hurst RT, Lester SJ, Kendall C, Baxter C, Wu Q, Borovansky J, Files J, Panse P, Wilansky S. Risk Stratification for Cardiovascular Disease in Women in the Primary Care Setting. J Am Soc Echocardiogr 2015; 28:1232-9. [PMID: 26243701 DOI: 10.1016/j.echo.2015.06.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Indexed: 10/23/2022]
Abstract
BACKGROUND Traditional risk assessment tools classify the majority of middle-aged women at low risk despite cardiovascular (CV) disease's affecting >50% of women and remaining the leading cause of death. Ultrasound-determined carotid intima-media thickness (CIMT) and/or computed tomographic coronary artery calcium score (CACS) quantify subclinical atherosclerosis and add incremental prognostic value. The aim of this study was to assess the utility of CIMT and CACS to detect subclinical atherosclerosis in younger women. METHODS Asymptomatic women aged 50 to 65 years with at least one CV risk factor and low Framingham risk scores were identified prospectively at primary care and cardiology clinics. Mean intimal thickness, plaque on CIMT, and Agatston calcium score for CACS were obtained. RESULTS Of 86 women (mean age, 58 ± 4.6 years; mean Framingham risk score, 1.9 ± 1.2; mean low-density lipoprotein cholesterol level, 138.9 ± 37.0 mg/dL), 53 (62%) had high-risk CIMT (51% plaque, 11% CIMT > 75th percentile). In contrast, three women (3.5%) had CACS > 100, all of whom had plaque by CIMT. Of the 58 women with CACS of 0, 32 (55%) had high-risk CIMT (48% plaque, 7% CIMT > 75th percentile). CONCLUSIONS In patients referred by their physicians for assessment of CV risk, CIMT in asymptomatic middle-aged women with at least one CV risk factor and low risk by the Framingham risk score identified a large number with advanced subclinical atherosclerosis despite low CACS. Our results suggest that CIMT may be a more sensitive method for CV risk assessment than CACS or traditional risk tools in this population. Further studies are needed to determine if earlier detection would be of clinical benefit.
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Affiliation(s)
- Ranjini R Roy
- Division of Cardiovascular Diseases, Department of Internal Medicine, University of Arizona College of Medicine, Maricopa Medical Center, Phoenix, Arizona
| | - R Todd Hurst
- Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, Scottsdale, Arizona
| | - Steven J Lester
- Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, Scottsdale, Arizona
| | - Christopher Kendall
- Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, Scottsdale, Arizona
| | - Christy Baxter
- Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, Scottsdale, Arizona
| | - Qing Wu
- College of Medicine, Biostatistics, Division of Health Sciences Research, Mayo Clinic College of Medicine, Scottsdale, Arizona
| | - Jill Borovansky
- Department of Internal Medicine, Mayo Clinic College of Medicine, Scottsdale, Arizona
| | - Julia Files
- Department of Internal Medicine, Mayo Clinic College of Medicine, Scottsdale, Arizona
| | - Prasad Panse
- Department of Radiology, Mayo Clinic College of Medicine, Scottsdale, Arizona
| | - Susan Wilansky
- Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, Scottsdale, Arizona.
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Affiliation(s)
- Amr E Abbas
- Department of Cardiology, Beaumont Health System, Royal Oak, Michigan
| | - Laura M Franey
- Department of Cardiology, Beaumont Health System, Royal Oak, Michigan
| | - Steven J Lester
- Division of Cardiovascular Diseases, Mayo Clinic, Scottsdale, Arizona
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28
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Abbas AE, Franey LM, Marwick T, Maeder MT, Kaye DM, Vlahos AP, Serra W, Al-Azizi K, Schiller NB, Lester SJ. Noninvasive Assessment of Pulmonary Vascular Resistance by Doppler Echocardiography. J Am Soc Echocardiogr 2013; 26:1170-1177. [DOI: 10.1016/j.echo.2013.06.003] [Citation(s) in RCA: 100] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Indexed: 01/08/2023]
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Harold JG, Bass TA, Bashore TM, Brindiss RG, Brush JE, Burke JA, Dehmers GJ, Deychak YA, Jneids H, Jolliss JG, Landzberg JS, Levine GN, McClurken JB, Messengers JC, Moussas ID, Muhlestein JB, Pomerantz RM, Sanborn TA, Sivaram CA, Whites CJ, Williamss ES, Halperin JL, Beckman JA, Bolger A, Byrne JG, Lester SJ, Merli GJ, Muhlestein JB, Pina IL, Wang A, Weitz HH. ACCF/AHA/SCAI 2013 Update of the Clinical Competence Statement on Coronary Artery Interventional Procedures. Catheter Cardiovasc Interv 2013; 82:E69-111. [DOI: 10.1002/ccd.24985] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | - John G. Harold
- American College of Cardiology Foundation representative
| | - Theodore A. Bass
- Society for Cardiovascular Angiography and Interventions representative
| | | | | | | | | | | | | | | | | | | | | | | | | | - Issam D. Moussas
- Society for Cardiovascular Angiography and Interventions representative
| | | | | | | | | | | | | | | | - Joshua A. Beckman
- Former Task Force member during the writing effort; Authors with no symbol by their name were included to provide additional content expertise
| | | | | | | | | | | | - Ileana L. Pina
- Former Task Force member during the writing effort; Authors with no symbol by their name were included to provide additional content expertise
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Nelson MR, Hurst RT, Raslan SF, Cha S, Wilansky S, Lester SJ. Echocardiographic measures of myocardial deformation by speckle-tracking technologies: the need for standardization? J Am Soc Echocardiogr 2012; 25:1189-94. [PMID: 22981227 DOI: 10.1016/j.echo.2012.08.006] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Multiple vendor-specific two-dimensional speckle-tracking echocardiographic algorithms with which to characterize myocardial mechanics are commercially available. The purpose of this study was to compare global longitudinal strain (GLS) results between two independent software vendors using a neutral image platform. METHODS A convenience sample of 100 prospectively collected patients was evaluated. Subjects with more than two left ventricular endocardial segments poorly delineated were excluded. GLS was obtained from the apical four-chamber, three-chamber, and two-chamber views using two independent speckle-tracking echocardiographic software packages (EchoInsight version 1.5.0 and Image-Arena version 4.5). Linear regression analysis and paired t tests were used to compare GLS results. Intraclass correlation coefficients and Bland-Altman plots were used for assessments of reliability. RESULTS The "out-of-the-box" mean GLS was -12.99 ± 2.38% using EchoInsight and -16.87 ± 2.84% using Image-Arena (mean difference, 3.87 ± 2.42%; P = .0001). Agreement between the software packages was moderate (intraclass correlation coefficient, 0.43; 95% confidence interval, 0.32-0.55). Using uniform variables to derive GLS (Lagrangian strain measured in systole and diastole at the endocardium and averaging the peak segmental strain curves), EchoInsight GLS was -16.17 ± 2.90% and Image-Arena GLS was -16.87 ± 2.84% (mean difference, 0.70 ± 2.75%; P = .02), with an intraclass correlation coefficient of 0.70 (95% confidence interval, 0.52-0.79). CONCLUSIONS Image-Arena GLS results were consistently different (more negative) than EchoInsight measures out of the box but became similar when information used to derive GLS was uniform. The evolution of measures of myocardial mechanics into routine clinical practice will require vigilance and standardization of the various techniques, necessitating independent validation of commercially available speckle-tracking echocardiographic products.
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Affiliation(s)
- Matthew R Nelson
- Division of Cardiovascular Diseases, Mayo Clinic, Scottsdale, Arizona, USA
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Hurst RT, Nelson MR, Kendall CB, Cha SS, Ressler SW, Lester SJ. Carotid intimal-medial thickness in active professional American football players aged 23 to 35 years. Am J Cardiol 2012; 109:897-900. [PMID: 22196775 DOI: 10.1016/j.amjcard.2011.10.052] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2011] [Revised: 10/27/2011] [Accepted: 10/27/2011] [Indexed: 11/24/2022]
Abstract
Risk of cardiovascular disease and death in retired professional American football players may be higher than that in the general population. Previously published data have demonstrated that American football players have less glucose intolerance, less smoking, similar lipid profiles, and higher blood pressure despite a much larger body compared to the general population, although the presence of subclinical atherosclerosis in these subjects has not been evaluated. This study compared the prevalence of subclinical atherosclerosis in active professional American football players to that in age-, gender-, and race-matched controls derived from the Bogalusa Heart Study. Carotid intimal-medial thickness (CIMT) was used as an indicator of subclinical atherosclerosis in 75 active American football players (23 to 35 years old, 31 white, 44 African-American) as measured by B-mode ultrasonography at Mayo Clinic, Scottsdale, Arizona, on September 13 and 14, 2009. CIMT measurements of 75 athletes were compared to those of 518 matched controls who had CIMT determinations in 1995 and 1996. Two-group t tests determined population similarities between groups. In a generalized linear model, players (overall and by race) had lower CIMT values than controls after age and race adjustment (p <0.001 for all comparisons). Nonlinemen and linemen had lower CIMT values than controls (p < 0.001 and p = 0.004, respectively). In conclusion, active professional American football players, regardless of position, had mean CIMT values similar to or lower than those in a matched general population cohort, suggesting that if the prevalence of subclinical atherosclerosis is increased in retired professional American football players, this occurs after retirement.
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Fan P, Bhagirath KM, Lester SJ, Humphries J, Hentz JG, Hurst RT. Continuing Medical Education Activity in Echocardiography. Echocardiography 2012. [DOI: 10.1111/j.1540-8175.2012.01677.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Bhagirath KM, Lester SJ, Humphries J, Hentz JG, Hurst RT. Carotid Intima-Media Thickness Measurements Are Not Affected by the Ultrasound Frequency. Echocardiography 2011; 29:354-7. [DOI: 10.1111/j.1540-8175.2011.01557.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Abstract
Cardiovascular risk factors have utility in risk prediction but have limitations in predicting individual risk. Identifying an individual's risk remains a challenge. Emerging technologies such as carotid artery ultrasonography and measures of carotid intima-media thickness (CIMT) may be useful in identifying the susceptible patient who may benefit from more aggressive preventive therapy. This screening test is noninvasive, reproducible, inexpensive, and radiation-free. Recent data have improved our understanding of the application of CIMT as a screening tool for cardiovascular disease. CIMT measurement may place an individual into a higher- or lower-risk category, allowing for appropriate institution of preventive strategies.
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Affiliation(s)
- Farouk Mookadam
- Department of Cardiovascular Diseases, Mayo Clinic Scottsdale, Scottsdale, AZ, USA.
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Abstract
Changes in the plasma concentrations of cortisol were recorded in 5-6 weeks-old lambs during the first 480 minutes after surgical castration and tailing in order to define the full post-treatment cortisol response and to determine whether or not the handling associated with repeated blood sampling delayed the return of cortisol concentrations to pretreatment values. Four groups of six or seven lambs were studied: One group was bled regularly throughout the 480 minutes of the study, and in the other three post-treatment blood sampling began at 90, 240 or 480 minutes. Plasma cortisol concentrations increased after treatment and returned to or approached pretreatment values by 480 minutes. No significant differences in mean cortisol concentrations were observed between the groups at any stage. It is concluded that the acute distress response of these lambs to surgical castration and tailing lasted about 8 hours and that repeated handling for blood sampling did not contribute significantly to this distress.
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Affiliation(s)
- S J Lester
- Department of Physiology and Anatomy, Massey University, Private Bag 11-222, Palmerston North, New Zealand
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Nelson MR, Mookadam F, Thota V, Emani U, Al Harthi M, Lester SJ, Cha S, Stepanek J, Hurst RT. Epicardial fat: an additional measurement for subclinical atherosclerosis and cardiovascular risk stratification? J Am Soc Echocardiogr 2010; 24:339-45. [PMID: 21185148 DOI: 10.1016/j.echo.2010.11.008] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2010] [Indexed: 12/13/2022]
Abstract
BACKGROUND The value of epicardial adipose tissue (EAT) thickness as determined by echocardiography in cardiovascular risk assessment is not well understood. The aim of this study was to determine the associations between EAT thickness and Framingham risk score, carotid intima media thickness, carotid artery plaque, and computed tomographic coronary calcium score in a primary prevention population. METHODS Patients presenting for cardiovascular preventive care (n = 356) who underwent echocardiography as well as carotid artery ultrasound and/or coronary calcium scoring were included. RESULTS EAT thickness was weakly correlated with Framingham risk score. The prevalence of carotid plaque was significantly greater in those with EAT thickness ≥ 5.0 mm who either had low Framingham risk scores or had body mass indexes ≥ 25 kg/m(2), compared with those with EAT thickness <5.0 mm. No significant association between EAT thickness and carotid intima-media thickness or coronary calcium score existed. CONCLUSION EAT thickness ≥ 5.0 mm may identify an individual with a higher likelihood of having detectable carotid atherosclerosis.
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Eleid MF, Lester SJ, Wiedenbeck TL, Patel SD, Appleton CP, Nelson MR, Humphries J, Hurst RT. Carotid Ultrasound Identifies High Risk Subclinical Atherosclerosis in Adults with Low Framingham Risk Scores. J Am Soc Echocardiogr 2010; 23:802-8. [DOI: 10.1016/j.echo.2010.06.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2010] [Indexed: 10/19/2022]
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Hurst RT, Burke RF, Wissner E, Roberts A, Kendall CB, Lester SJ, Somers V, Goldman ME, Wu Q, Khandheria B. Incidence of subclinical atherosclerosis as a marker of cardiovascular risk in retired professional football players. Am J Cardiol 2010; 105:1107-11. [PMID: 20381661 DOI: 10.1016/j.amjcard.2009.12.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2009] [Revised: 12/03/2009] [Accepted: 12/03/2009] [Indexed: 10/19/2022]
Abstract
The purpose of this study was to evaluate subclinical atherosclerosis in retired professional football players. Two hundred one healthy former professional football players (mean age 50.8 years; mean body mass index 31.5 kg/m(2)) were screened for the prevalence of cardiovascular risk factors, metabolic syndrome, and subclinical atherosclerosis by carotid artery ultrasound and compared with a cohort of men of similar body mass index referred for the assessment of subclinical atherosclerosis by carotid ultrasound. The prevalence of carotid artery plaque in the players was not significantly different from that of the body mass index-matched patients (33.3% vs 29.3%, p = 0.45). For the 2 groups, the prevalence of carotid artery plaque was >3 times higher than that reported in general population studies of patients with the same age range, gender, and exclusions. Metabolic syndrome prevalence was higher in linemen than in nonlinemen (45.8% vs 22.5%, p = 0.001), but there was no statistical difference in plaque presence between linemen and nonlinemen (27.1% vs 35.9%, p = 0.23). In conclusion, despite their elite athletic histories, former professional football players have a similar prevalence of advanced subclinical atherosclerosis as a clinically referred population of overweight and obese men.
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Lester SJ, Eleid MF, Khandheria BK, Hurst RT. Carotid intima-media thickness and coronary artery calcium score as indications of subclinical atherosclerosis. Mayo Clin Proc 2009; 84:229-33. [PMID: 19252109 PMCID: PMC2664607 DOI: 10.1016/s0025-6196(11)61139-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To determine the ability of carotid intima-media thickness (CIMT) and coronary artery calcium score (CACS) to detect subclinical atherosclerosis in a young to middle-aged, low-risk, primary-prevention population. PATIENTS AND METHODS Patients aged 36 to 59 years who underwent determination of CIMT and CACS at our institution between May 1, 2004, and April 1, 2008, were included in the study. Those with diabetes mellitus or a history of coronary, peripheral, or cerebral vascular disease were excluded. Other information, such as Framingham risk score (FRS), was obtained by a review of clinical and laboratory data. RESULTS Of 118 patients, 89 (75%) had a CACS of zero and 94 (80%) were men; mean +/- SD age was 48.9+/-5.7 years. The mean FRS of this group was 4.0; 86 patients (97%) were considered at low risk (<1% annualized rate) of cardiovascular events. Evidence of carotid atherosclerosis was found in 42 (47%; 95% confidence interval, 37%-58%) of these 89 patients; carotid plaque was found in 30 (34%); and CIMT above the 75th percentile was found in 12 (13%) of age-, sex-, and race-matched control patients. Of the 40 patients with low-risk CIMT (below the 50th percentile), 4 (10%) had a CACS at or above the 50th percentile. CONCLUSION Subclinical vascular disease can be detected by CIMT evaluation in young to middle-aged patients with a low FRS and a CACS of zero. These findings have important implications for vascular disease screening and the implementation of primary-prevention strategies.
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Affiliation(s)
- Steven J Lester
- Division of Cardiovascular Diseases, Mayo Clinic Arizona, 13400 E Shea Blvd, Scottsdale, AZ 85259, USA.
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40
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Lester SJ, Eleid MF, Khandheria BK, Hurst RT. Carotid intima-media thickness and coronary artery calcium score as indications of subclinical atherosclerosis. Mayo Clin Proc 2009; 84:229-33. [PMID: 19252109 PMCID: PMC2664607 DOI: 10.4065/84.3.229] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
OBJECTIVE To determine the ability of carotid intima-media thickness (CIMT) and coronary artery calcium score (CACS) to detect subclinical atherosclerosis in a young to middle-aged, low-risk, primary-prevention population. PATIENTS AND METHODS Patients aged 36 to 59 years who underwent determination of CIMT and CACS at our institution between May 1, 2004, and April 1, 2008, were included in the study. Those with diabetes mellitus or a history of coronary, peripheral, or cerebral vascular disease were excluded. Other information, such as Framingham risk score (FRS), was obtained by a review of clinical and laboratory data. RESULTS Of 118 patients, 89 (75%) had a CACS of zero and 94 (80%) were men; mean +/- SD age was 48.9+/-5.7 years. The mean FRS of this group was 4.0; 86 patients (97%) were considered at low risk (<1% annualized rate) of cardiovascular events. Evidence of carotid atherosclerosis was found in 42 (47%; 95% confidence interval, 37%-58%) of these 89 patients; carotid plaque was found in 30 (34%); and CIMT above the 75th percentile was found in 12 (13%) of age-, sex-, and race-matched control patients. Of the 40 patients with low-risk CIMT (below the 50th percentile), 4 (10%) had a CACS at or above the 50th percentile. CONCLUSION Subclinical vascular disease can be detected by CIMT evaluation in young to middle-aged patients with a low FRS and a CACS of zero. These findings have important implications for vascular disease screening and the implementation of primary-prevention strategies.
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Affiliation(s)
- Steven J Lester
- Division of Cardiovascular Diseases, Mayo Clinic Arizona, 13400 E Shea Blvd, Scottsdale, AZ 85259, USA.
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42
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Lester SJ, Tajik AJ, Nishimura RA, Oh JK, Khandheria BK, Seward JB. Unlocking the Mysteries of Diastolic Function. J Am Coll Cardiol 2008; 51:679-89. [PMID: 18279730 DOI: 10.1016/j.jacc.2007.09.061] [Citation(s) in RCA: 268] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2007] [Revised: 09/20/2007] [Accepted: 09/24/2007] [Indexed: 01/19/2023]
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Abstract
Echocardiography is a most useful bedside tool to help in the diagnosis and subsequent management of patients with infective endocarditis. Transesophageal echocardiography provides complementary and often incremental information necessary in making a diagnosis, and in identifying associated intracardiac complications. This chapter will focus on the role of echocardiography in the diagnosis and management of infective endocarditis.
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Abstract
Echocardiography is a most useful bedside tool to help in the diagnosis and management of critically ill patients after acute myocardial infarction. In most instances, the mechanism of unexplained shock will be elucidated. Transesophageal echocardiography can further delineate the mechanical complications of myocardial infarction when the transthoracic echocardiogram may not be adequate. This article will focus on the mechanical complications of myocardial infarction in patients who most often present with cardiogenic shock or acute pulmonary edema. Each clinical entity is discussed, and illustrative echocardiograms are provided.
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Affiliation(s)
- Susan Wilansky
- Division of Cardiovascular Diseases, Mayo Clinic Arizona, Scottsdale, AZ, USA.
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45
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Jiamsripong P, Honda T, Reuss CS, Hurst RT, Chaliki HP, Grill DE, Schneck SL, Tyler R, Khandheria BK, Lester SJ. Three methods for evaluation of left atrial volume. European Journal of Echocardiography 2007; 9:351-5. [PMID: 17658300 DOI: 10.1016/j.euje.2007.05.004] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
AIM To compare and contrast 3 different echocardiographic methods used to measure left atrial (LA) volume: biplane area length (AL), biplane modified Simpson (SIMP), and prolate ellipse (PE) methods. METHODS AND RESULTS A review of consecutive patients who presented to our outpatient echocardiography laboratory for a resting transthoracic study between April 2006 and May 2006 was performed. Echocardiograms were reexamined and LA volume measured using the AL, SIMP, and PE methods. Of 102 consecutive patients evaluated, 97 had a measure of LA volume using all 3 methods. A significant difference in the measurement of mean +/- SD LA volume was noted among the 3 different methods: 37 +/- 16 mL/m(2) for AL, 34 +/- 14 mL/m(2) for SIMP, and 27 +/- 12 mL/m(2) for PE. The PE method yielded routinely smaller values compared with either the AL or SIMP method (P < 0.001). Differences increased with increased LA volume. The SIMP method derived consistently smaller (<5 mL/m(2)) values than those of the AL method, consistent across the full range of LA volumes. CONCLUSION Significant differences exist among these 3 commonly used methods for measuring LA volume. Standardization of the measurement of LA volume is recommended.
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Affiliation(s)
- Panupong Jiamsripong
- Division of Cardiovascular Diseases, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ 85259, USA
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46
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Sengupta PP, Krishnamoorthy VK, Korinek J, Narula J, Vannan MA, Lester SJ, Tajik JA, Seward JB, Khandheria BK, Belohlavek M. Left ventricular form and function revisited: applied translational science to cardiovascular ultrasound imaging. J Am Soc Echocardiogr 2007; 20:539-51. [PMID: 17485001 PMCID: PMC1951787 DOI: 10.1016/j.echo.2006.10.013] [Citation(s) in RCA: 228] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2006] [Indexed: 02/08/2023]
Abstract
Doppler tissue imaging (DTI) and DTI-derived strain imaging are robust physiologic tools used for the noninvasive assessment of regional myocardial function. As a result of high temporal and spatial resolution, regional function can be assessed for each phase of the cardiac cycle and within the transmural layers of the myocardial wall. Newer techniques that measure myocardial motion by speckle tracking in gray-scale images have overcome the angle dependence of DTI strain, allowing for measurement of 2-dimensional strain and cardiac rotation. DTI, DTI strain, and speckle tracking may provide unique information that deciphers the deformation sequence of complexly oriented myofibers in the left ventricular wall. The data are, however, limited. This review examines the structure and function of the left ventricle relative to the potential clinical application of DTI and speckle tracking in assessing the global mechanical sequence of the left ventricle in vivo.
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Affiliation(s)
- Partho P Sengupta
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
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47
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Abstract
Echocardiography is currently the primary clinical method for the noninvasive measurement of right heart hemodynamic parameters and is an indispensable tool for the initial assessment, diagnosis, longitudinal follow-up, and prognostication of patients with abnormal right heart function. This review will discuss the echocardiographic methods used to estimate right heart hemodynamic parameters.
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Affiliation(s)
- Kwan S Lee
- Division of Cardiovascular Diseases, Mayo Clinic Scottsdale, Scottsdale, Arizona 85259, USA
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Reuss CS, Lester SJ, Hurst RT, Askew JW, Nager P, Lusk J, Altemose GT, Tajik AJ. Isolated left ventricular basal ballooning phenotype of transient cardiomyopathy in young women. Am J Cardiol 2007; 99:1451-3. [PMID: 17493478 DOI: 10.1016/j.amjcard.2006.12.078] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2006] [Revised: 12/21/2006] [Accepted: 12/21/2006] [Indexed: 12/16/2022]
Abstract
This report describes a variant of transient regional left ventricular dysfunction in which isolated basal left ventricular akinesia with normal mid-ventricular (papillary-level) wall motion and apical hypercontractility were noted in young women (mean age 31 years). This finding was demonstrated in 3 consecutive patients; the first patient was experiencing emotional life-altering events, and the second presented with an acute flare of multiple sclerosis. The third patient presented < 24 hours after methamphetamine use. Coronary angiography demonstrated normal epicardial coronary arteries in all patients. Wall motion abnormalities resolved within 2 to 6 weeks. In conclusion, the entity described in this report is reminiscent of apical ballooning ("Tako-Tsubo"), mid-ventricular ballooning, and apical sparing syndromes; however, isolated basal left ventricular involvement has not been previously described and is a newer variant in the spectrum of transient cardiomyopathies. The pathophysiology of this entity has not been elucidated. A unifying feature between the transient cardiomyopathic syndromes most likely is in the concentration, distribution, and activity of cardiac adrenergic receptors.
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MESH Headings
- Adrenergic beta-Antagonists/therapeutic use
- Adult
- Angiotensin-Converting Enzyme Inhibitors/therapeutic use
- Cardiomyopathy, Dilated/diagnostic imaging
- Cardiomyopathy, Dilated/drug therapy
- Cardiomyopathy, Dilated/etiology
- Cardiomyopathy, Dilated/physiopathology
- Dilatation, Pathologic/complications
- Dilatation, Pathologic/drug therapy
- Dilatation, Pathologic/physiopathology
- Echocardiography
- Female
- Humans
- Stroke Volume/drug effects
- Ventricular Dysfunction, Left/complications
- Ventricular Dysfunction, Left/diagnostic imaging
- Ventricular Dysfunction, Left/drug therapy
- Ventricular Dysfunction, Left/physiopathology
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Affiliation(s)
- Christina S Reuss
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Scottsdale, Arizona, USA.
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Bidart CM, Abbas AE, Parish JM, Chaliki HP, Moreno CA, Lester SJ. The Noninvasive Evaluation of Exercise-induced Changes in Pulmonary Artery Pressure and Pulmonary Vascular Resistance. J Am Soc Echocardiogr 2007; 20:270-5. [PMID: 17336753 DOI: 10.1016/j.echo.2006.08.032] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2006] [Indexed: 12/16/2022]
Abstract
BACKGROUND During exercise, pulmonary artery systolic pressure (PASP) may increase. The purpose of this study was to examine the responses of PASP and pulmonary vascular resistance by Doppler echocardiography during exercise in conditioned athletes and in patients with pulmonary disease. METHODS Fifteen participants in each group were evaluated using Doppler echocardiography at rest and during recumbent bicycle exercise. PASP was calculated using 4 times the tricuspid regurgitant velocity squared (TRV)2 and a surrogate for pulmonary vascular resistance was calculated using the equation: pulmonary vascular resistance = TRV/right ventricular outflow tract time-velocity integral. RESULTS During exercise, PASP increased in both groups with higher values achieved by patients with pulmonary conditions (54.8 vs 70.6 mm Hg, P = .009). At baseline the ratio TRV/right ventricular outflow tract time-velocity integral was 0.2 or less in both the athlete and pulmonary groups. During exercise, the ratio of TRV/right ventricular outflow tract time-velocity integral remained less than 0.2 in the athletes and increased more than 0.2 in the pulmonary group. CONCLUSION Doppler echocardiography can be used to discriminate a flow- versus resistance-mediated mechanism for exercised-induced increase in PASP.
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Affiliation(s)
- Chad M Bidart
- Division of Cardiovascular Disease, Mayo Clinic Arizona, Scottsdale, Arizona, USA
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50
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Lee KS, Appleton CP, Lester SJ, Adam TJ, Hurst RT, Moreno CA, Altemose GT. Relation of electrocardiographic criteria for left atrial enlargement to two-dimensional echocardiographic left atrial volume measurements. Am J Cardiol 2007; 99:113-8. [PMID: 17196473 DOI: 10.1016/j.amjcard.2006.07.073] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2006] [Revised: 07/19/2006] [Accepted: 07/25/2006] [Indexed: 11/20/2022]
Abstract
Left atrial (LA) enlargement by 2-dimensional (2-D) echocardiography predicts adverse cardiovascular outcomes. Electrocardiographic (ECG) criteria for LA enlargement are based on M-mode echocardiographic LA diameter, which is inferior to 2-D-derived LA volumes. This study compared established ECG criteria for LA enlargement with atrial volume obtained by 2-D echocardiography to determine if traditional ECG criteria accurately represent LA chamber enlargement, therefore offering a low-cost screening tool. A total of 261 randomly selected patients who underwent electrocardiography and 2-D echocardiography were enrolled. ECG parameters and electronically derived P-wave medians were analyzed with electronic calipers for maximal accuracy. LA volumes by 2-D echocardiography were measured with Simpson's method of discs, with enlargement defined as 32 ml/m(2). Sensitivity and specificity tables and receiver-operating characteristic curves were constructed for each criterion. Univariate and multivariate analyses were performed for predictors of 2-D echocardiographic LA enlargement. LA enlargement was present in 43% of patients. ECG P-wave duration was the most sensitive for the detection of LA enlargement (69%) but had low specificity (49%). Conversely, a biphasic P wave was the most specific (92%) but had low sensitivity (12%). The maximum area under the receiver-operating characteristic curve for any criterion was 0.64, too low to be of clinical utility. In conclusion, established ECG criteria for LA enlargement do not reliably reflect LA enlargement and lack sufficient predictive value to be useful clinically. These results suggest that P-wave abnormalities should be noted as nonspecific LA abnormalities, with the term "LA enlargement" no longer used.
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Affiliation(s)
- Kwan S Lee
- Division of Cardiovascular Diseases, Mayo Clinic Arizona, Scottsdale, AZ, USA
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