Risk stratification in Arrhythmogenic Right Ventricular Cardiomyopathy: the impact of genotype on the 2019 ARVC risk calculator

Introduction

Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) is associated with sudden cardiac death (SCD). The 2019 ARVC risk model has been proposed as a method to quantify arrhythmic risk, but the impact of genotype its performance has not been addressed.

Purpose

To study arrhythmic outcomes in patients with ARVC and the performance of the 2019 ARVC risk model in predefined genetic subgroups.

Methods

This is an international, retrospective observational cohort study on consecutively evaluated patients with ARVC recruited from 17 centres in 7 countries. Inclusion criteria were: (i) a definite diagnosis of ARVC according to the 2010 Task Force Criteria; (ii) no history of sustained ventricular arrhythmia (VA) prior to first assessment at the participating centre; (iii) a follow up period of ≥1 month; (iv) age of diagnosis ≥14 years. Sustained ventricular arrhythmia (sustained ventricular tachycardia, appropriate implantable cardioverter defibrillator intervention, aborted SCD, or SCD) comprised the primary outcome (VA). Discriminative ability was assessed by Uno's concordance index (c-statistic) and calibration with the calibration plot slope. Fine-Gray regression was used to model the impact of clinical predictors on the arrhythmic outcome, in the context of competing risks (heart transplantation and non-arrhythmic death). The cumulative probability and 95% confidence intervals (95% CI) for the occurrence of an outcome were estimated using the Aalen-Johansen estimate in order to take into account competing risks.

Results

The study cohort comprised 554 ARVC patients. During a median follow-up of 6.0 [3.1,12.5] years, 100 patients (18%) experienced VA (Figure). Risk estimates for VA using the 2019 ARVC risk model showed good discriminative ability (c-statistic 0.75 (95% CI 0.70–0.81)) but with overestimation of risk (slope 0.46 (95% CI 0.33–0.63)). The ARVC risk model was compared in 4 gene groups: PKP2 (n=118, 21%); DSP (n=79, 14%); other desmosomal (n=59, 11%); and gene elusive (n=160, 29%). Discrimination and calibration were highest for PKP2 [c-statistic 0.83 (95% CI 0.75–0.91); calibration slope 0.67 (95% CI 0.40–1.04)] and lowest for the gene elusive group [c-statistic 0.65 (95% CI 0.57–0.74); calibration slope 0.26 (95% CI 0.06–0.49)]. Univariable analyses revealed variable performance of individual clinical risk markers in the different gene groups (see heatmap of hazard ratios and statistical significance in Figure). For example, RV dimensions and systolic function are significant risk markers in PKP2 but not in DSP patients and the opposite is true of LV systolic function (Figure).

Conclusion

The 2019 ARVC risk model performs reasonably well in gene positive ARVC, (particularly for PKP2) but is more limited in gene elusive patients. Genotype specific risk factors should be considered in ARVC patients.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation

Distribution and cardiac outcomes of neuromuscular disorders referred to an inherited cardiac disease unit

Backgroud

Neuromuscular disorders may present with varied cardiac involvement, including myocardial and conduction tissue disease. Sudden death is a common adverse event of cardiomyopathy

Purpose

The objective was to present clinical characteristics of neuromuscular disorders referred to a dedicated inherited cardiac disease unit with special interest in the mode of presentation, clinical course and cardiac complications.

Methods

Cardiological anamnesis, 12-lead electrocardiogram and bidimensional echocardiogram were performed to every individual. Gadolinium cardiac MRI/24 hour-Holter/coronariography were performed in particular cases where results of previous tests made it mandatory.

Results

199 patients (aged 43.1±18.1 years, 45.2% females, 54.8% males) with neurological disorders evaluated in an inherited cardiac disease clinic from 2003–2021 were included. There were 20 (10.1%) dystrophynopathies, 20 (10.1%) limb girdle muscular dystrophy, 14 (7.0%) other muscular dystrophies (Emery-Dreifuss, facio-scapulo-humeral, oculopharyngeal), 70 (35.2%) myotonic myopathies (Steinert myotonic dystrophy, Becker myotonia congenita, Thomsen myotonia congenita), 7 (3.5%) myofibrillar myopathies, 14 (7.0%) congenital myopathies, 18 (9.0%) metabolic myopathies, 12 (6.0%) unknown origin inherited myopathies, 24 (12.1%) non-myopathic neurological diseases. There were 44 (22.11%) patients affected with a cardiomyopathy. 51/199 (25.6%) had conduction disturbances. 33/51 had pathological cardiac findings without clinical cardiomyopathy.

Age of diagnosis of neurological and cardiomyopathy conditions were 28.4±20.4 and 40.6±18.4 years old respectively. Reasons for diagnosis were symptoms (164, 82.4%), family screening (27, 13.6%), incidental finding (7, 3.5%), sudden death (1, 0.5%). 31 (15.6%) had atrial fibrillation, 17 (8.5%) required pacemaker and 15 (7.5%) ICD implantation. 32 (16.1%) patients died or had severe cardiac outcome. 7 (3.5%) had sudden death or equivalent, 3 (1.5%) heart-failure-death, 1 (0.5%) received cardiac transplantation, 18 (9.1%) had other-disease-related-death and 3 (1.5%) other disease non-cadiac-related-death).

Conclusion

Neuromuscular diseases require periodic cardiac evaluation. Despite onset of neurological symptoms usually precede cardiac involvement, the burden of cardiac involvement and complications is highly significant. Cause of death in neurological conditions with cardiac involvement is mostly driven by the severity of the cardiomyopathy.

Funding Acknowledgement

Type of funding sources: None.

Influence of sex on cardiovascular outcomes in RBM20 variant carriers

Background

Variants in the RBM20 gene cause dilated cardiomyopathy and may be associated with a poor prognosis.

Objectives

To determine disease penetrance, the risk of adverse events and the influence of sex on outcomes in RBM20 variant carriers.

Methods

Consecutive probands and relatives carrying pathogenic or likely pathogenic RBM20 variants were retrospectively recruited from 12 cardiomyopathy units. The primary endpoint was a composite of malignant ventricular arrhythmia (MVA) and end-stage heart failure (ESHF). MVA and ESHF endpoints were also analysed separately and males and females compared.

Results

Longitudinal follow-up data were available for 163 RBM20 variant carriers (82 male, median age 36.5 years, median follow-up 77.6 months). 10/163 had an MVA event at baseline. 30/153 without baseline MVA (19.6%) reached the primary endpoint with a trend towards worse outcomes in males (p=0.08). 16/153 (10.5%) had new MVA with no difference between males and females (p=0.92). 20/163 (12.2%) developed ESHF (17 males and 3 females; p<0.001).

By the end of follow-up, 114 patients (70%) had either left ventricular systolic dysfunction (LVSD) or had experienced MVA. 22 patients received a first diagnosis of LVSD during follow-up. Disease penetrance in individuals over 40 years of age was 78.5% by last evaluation.

Eleven patients that reached the MVA endpoint had a left ventricular ejection fraction (LVEF) available within 6 months of the event. Median [IQR] contemporary LVEF was 30% [23.75, 40%]. 5/11 patients had a contemporary LVEF >35%. 1/11 had a contemporary LVEF >45% (a female, 1st degree relative presenting with sustained ventricular tachycardia and an LVEF of 65%).

Conclusions

RBM20 variants are highly penetrant. The risk of MVA in male and female RBM20 variant carriers is similar but male sex is strongly associated with ESHF. MVA events occur in patients with LVEF >35%.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation Clinical Research Training Fellowship

Prognosis of left ventricular noncompaction with preserved ejection fraction

Introduction

Left ventricular noncompaction (LVNC) is a poorly defined entity with heterogeneous prognosis. LV ejection fraction (LVEF) is one of the main predictors of major adverse cardiovascular events (MACE). However, outcomes of LVNC patients with preserved LVEF (pEF) remain uncertain.

Purpose

The aim of our study was to determine the incidence and predictors of MACE in LVNC patients with pEF as well as to assess the evolution of LVEF throughout follow-up.

Methods

We conducted a retrospective, longitudinal, multicentre cohort study. Consecutive patients with transthoracic echocardiography (TTE) and/or cardiac magnetic resonance (CMR) diagnostic criteria for LVNC and initially pEF (LVEF≥50%) were recruited. MACE were defined as a composite of heart failure (HF), ventricular arrhythmias (VA), systemic embolisms (SE) and/or all-cause mortality. Progressive systolic dysfunction was defined as an LVEF<50% at last TTE and/or an absolute ≥10-point decrease in LVEF from first to last TTE. Lower limit of LVEF values were considered 50–53% for TTE and 50–57% for CMR, according to current recommendations.

Results

A total of 305 patients from 12 centres were included from 2000 to 2018. Age was 38±19 years, 165 (54%) were men and 185 (61%) were probands. LVEF was 62±8% and 8% had late gadolinium enhancement (LGE). During a median follow-up of 4.7 (IQR 2.1–7.4) years, MACE occurred in 40 (13%) patients with an incidence rate of 2.96 (95% CI 2.17–4.04) events per 100 person-years: 8 HF, 27 VA, 3 SE and 5 deaths. LVEF by TTE (HR 0.95, 95% CI 0.90–0.99, p=0.035) and age (HR 1.02, 95% CI 1.01–1-04, p=0.04) were the only variables independently associated with the endpoint. Patients with lower limit LVEF values showed an increased risk of MACE (Figure 1). Among probands, those with family aggregation presented a higher incidence of MACE compared to nonfamilial cases (HR 2.74, p=0.043). A positive genotype was not associated.

Sixty-one (21%) patients experienced progressive systolic dysfunction: 31 (11%) had an LVEF<50% and 48 (17%) an absolute ≥10-point decrease in LVEF at last follow-up. On multivariate analysis, LVEF by CMR was the only independent predictor (HR 0.96, 95% CI 0.92–0.99, p=0.031). Patients with lower limit LVEF values had an increased risk (Figure 2). In this subgroup, LGE was also associated with the endpoint (HR 3.52, p=0.011). Family aggregation was not associated, while a positive genotype correlated with lower risk (HR 0.52, p=0.029).

Conclusions

Patients with left ventricular noncompaction and preserved ejection fraction carry a moderate risk of major adverse cardiovascular events and progressive systolic dysfunction. LVEF remains the main predictor of outcomes in this subgroup. Patients with lower limit LVEF values are at increased risk, probably suggesting subclinical systolic dysfunction. Therefore, they should be carefully monitored.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Long term outcomes in left ventricular noncompaction

Funding Acknowledgements

Type of funding sources: None.

Background

Left ventricular noncompaction (LVNC) is a heterogeneous entity with a wide phenotypic expression. Risk factors have not been well established and prognostic stratification remains challenging.

Objectives

Describe long term outcomes of LVNC patients and determine predictors of cardiovascular events. 

Methods

 

Prospective multicentric study of consecutive patients fulfilling imaging diangostic criteria for LVNC (Jenni echo criteria and Petersen CMR criteria). Demographic, ECG, imaging and genetic variables were collected. End points were heart failure (HF), ventricular arrhythmias (VA), systemic embolisms (SE) and all-cause death. Major adverse cardiovascular events (MACE) was the combination of the four previous end points.

Results

585 patients from 12 referral centres were included from 2000 to 2018. Age at diagnosis was 45 ± 20 years, 334 (57%) were male, baseline LVEF was 48 ± 17% and 18% presented late gadolinium enhancement (LGE). During a median follow-up of 5.1 years (IQR 2.3-8.1), 110 (19%) patients presented HF, 87 (15%) VA, 18 (3%) SE and 34 (6%) died. MACE occurred in 223 (38%) patients.

LVEF was independently associated with HF, VA, SE and MACE: HR were 1.08, 1.02, 1.04 and 1.02 respectively (all p < 0.05). LGE was more frequent in patients with reduced LVEF (39 Vs 53%, p < 0.001) and was associated with higher HF and VA risk in patients with LVEF > 35% (HR 2.69 and 2.48 respectively, p < 0.05) (Figure 1). Patients with a normal ECG, LVEF≥50%, no LGE and no family aggregation presented no MACE (0%) at long term follow-up.

Among patients who underwent genetic testing (354, 61%), TTN variants and complex genotype (more than one variant) presented lower LVEF and higher HF risk. ACTC1 variants were associated with VA.

Conclusions

LVNC carries a high long term risk of heart faliure and ventricular arrhythmias. LVEF is the most important predictor and myocardial fibrosis is associated with increased risk in patients without severe systolic dysfunction. Genotype is a modifier of outcomes. These factors might be used to risk stratify LVNC patients.

Abstract Figure. Kaplan Meier survival curves

P1441 Predictors of systemic embolisms in a large cohort of left ventricular noncompaction patients

BACKGROUND

Left ventricular noncompaction (LVNC) is associated with an increased risk of systemic embolisms (SE). However, incidence and risk factors are not well established.

PURPOSE

To evaluate the rate of SE in LVNC and describe risk factors.

METHODS

LNVC patients were included in a multicentric registry. Those with SE were considered for the analysis.

RESULTS

514 patients with LVNC from 10 Spanish centres were recruited from 2000 to 2018. During a median follow-up of 4.2 years (IQR 1.9-7.1), 23 patients (4.5%) had a SE. Patients with SE (Table 1) were older at diagnosis, with no differences in gender and had similar cardiovascular risk factors. They were more frequently under oral anticoagulation (OAC). Besides, they had a more reduced LVEF, and more dilated LV and left atrium (LA). Late gadolinium enhancement (LGE) was more frequent, altogether suggesting a more severe phenotype.

Patients with SE had non-significantly higher rates of hospitalization for heart failure (33% Vs 24%, p = 0.31) and atrial fibrillation (35% Vs 19%, p = 0.10). In multivariate analysis, only LA diameter was an independent predictor of SE (OR 1.04, p = 0.04). A LA diameter > 45 mm had an independent 3 fold increased risk of SE (OR 3.04, p = 0.02) (Image 1).

CONCLUSIONS

LVNC carries a moderate mid-term risk of SE, which appears to be irrespective of atrial fibrillation and associated with age, LV dilatation and systolic dysfunction and mainly LA dilatation. This subgroup of patients should be considered for oral anticoagulation in primary prevention.

Table 1 Systemic embolisms (n = 23) No systemic embolisms (n = 491) p Men, n (%) 15 (65) 289 (56) 0.52 Median age at diagnosis (IQR) - yr 60 (48-76) 48 (30-64) 0.02 Median follow up (IQR) - yr 5.9 (3.1-7.8) 4.2 (1.8-7.1) 0.18 OAC, n (%) 19 (83) 118 (24) 0.01 LVEF (SD) - % 37 (15) 48 (17) 0.01 LVEDD (SD) - mm 58 (11) 54 (10) 0.04 LA diameter (SD) - mm 46 (9) 39 (9) 0.01 Characteristics of patients with and without systemic embolisms

Abstract P1441 Figure. Image 1

P1442 Outcomes of patients with left ventricular noncompaction and preserved ejection fraction

CONCLUSIONS

Patients with LVNC and pEF have an overall excellent prognosis, which is markedly better than those with rEF. However, there is progressive decrease in LVEF, associated with heart failure, and moderate risk of life threatening arrhythmias. Therefore, periodic follow-up should be promoted.

Table 1 LVNC pEF (n = 239) LVNC rEF (n = 252) p Men, n (%) 131 (55) 146 (58) 0.65 Median age at diagnosis (IQR) - yr 38 (23-54) 58 (42-72) 0.01 Median follow up (IQR) - yr 4.9 (2.1-7.3) 3.9 (1.4-7.9) 0.04 QRS (SD) - ms 93 (18) 117 (32) 0.01 LGE, n (%) 18 (9) 52 (30) 0.01

Abstract P1442 Figure. Image 1

A study of the SCN5A gene in a cohort of 76 patients with Brugada syndrome

We aim to study the SCN5A gene in a cohort of Brugada syndrome (BS) patients and evaluate the genotype-phenotype correlation. BS is caused by mutations in up to 10 different genes, SCN5A being the most frequently involved. Large genomic rearrangements in SCN5A have been associated with conduction disease, but its prevalence in BS is unknown. Seventy-six non-related patients with BS were studied. Clinical characteristics and family risk profile were recorded. Direct sequencing and multiplex ligation-dependent probe amplification (MLPA) of the SCN5A gene for identification of mutations and larger rearrangements were performed, respectively. Eight patients (10.5%) had point mutations (R27H, E901K, G1743R (detected in three families), V728I, N1443S and E1152X). Patients with mutations had a trend toward a higher proportion of spontaneous type I Brugada electrocardiogram (ECG) (87.5% vs 52.9%, p = 0.06) and had evidence of familial disease (62.5%, vs 23.5%, p = 0.03). The symptoms and risk profile of the carriers were not different from wild-type probands. There were non-significant differences in the prevalence of type I ECG, syncope and history of arrhythmia in carriers of selected polymorphisms. None of the patients had any deletion/duplication in the SCN5A gene. In conclusion, 10.5% of our patients had mutations in the SCN5A gene. Patients with mutations seemed to have more spontaneous type I ECG, but no differences in syncope or arrhythmic events compared with patients without mutations. Larger studies are needed to evaluate the role of polymorphisms in the SCN5A in the expression of the phenotype and prognosis. Large rearrangements were not identified in the SCN5A gene using the MLPA technique.

[Results of 125-iodine seed implant with preplanning system in 250 patients with prostate cancer]

INTRODUCTION

We review the experience with prostate carcinoma patients treated with permanent implants of 125-I seeds and the outcome eight years after the beginning of this technique.

MATERIAL AND METHODS

From 2002 to 2007 we have performed 250 implants with LDR brachytherapy with RapidStrand(®) and preplanning system. Mean age was 68 (49-78). Mean PSA was 7.32 (2.31 - 14.6). T1-T2a was the stage in 98%, and Gleason ≤ 6 in 96%. Low risk cases were 81% and intermediate risk 19% (ten of them received 46 Gy EBRT). Hormonal treatment was used in 42%.

RESULTS

With a mean follow-up of 48 months, 14 patients (5.7%) showed biochemical failure (BF). Eleven patients (4.5%) with theoretical BF were observed and PSA decreased without treatment. Actuarial PSA relapse-free survival at 5 years was 91%, (92% low risk, 86% intermediate cases), and 92% vs 81% with PSA <10 vs >10 (p<0.05). Rectum complications were G2 in 0.6%. A urinary catheter was necessary in 6.5%. Sexual function was conserved in 60%. Mean V100 was 89% and D90 143 Gy.

CONCLUSION

The outcome of patients with low risk prostate carcinoma treated with I-125 seed is very good with very low complications rate. Cases with PSA bounces should be controlled before starting a salvage treatment.

Radiation transmission data for radionuclides and materials relevant to brachytherapy facility shielding

To address the limited availability of radiation shielding data for brachytherapy as well as some disparity in existing data, Monte Carlo simulation was used to generate radiation transmission data for 60Co, 137CS, 198Au, 192Ir 169Yb, 170Tm, 131Cs, 125I, and 103pd photons through concrete, stainless steel, lead, as well as lead glass and baryte concrete. Results accounting for the oblique incidence of radiation to the barrier, spectral variation with barrier thickness, and broad beam conditions in a realistic geometry are compared to corresponding data in the literature in terms of the half value layer (HVL) and tenth value layer (TVL) indices. It is also shown that radiation shielding calculations using HVL or TVL values could overestimate or underestimate the barrier thickness required to achieve a certain reduction in radiation transmission. This questions the use of HVL or TVL indices instead of the actual transmission data. Therefore, a three-parameter model is fitted to results of this work to facilitate accurate and simple radiation shielding calculations.

Insights into the role of microRNAs in cardiac diseases: from biological signalling to therapeutic targets

microRNAs have recently opened new pathways to explain gene expression and disease biology in many scenarios, including cardiac diseases. microRNAs are endogenous small non-coding RNAs that mediate post-transcriptional repression or messenger RNA degradation. By annealing to inexactly complementary sequences in the 3' untranslated region of the target messenger RNA, protein level is down-regulated. Several microRNAs appear to act cooperatively through multiple target sites in one gene and, conversely, most microRNAs can target several genes. miR-133 and miR-1 are specifically expressed in cardiac and skeletal muscle and control myogenesis, cardiac development, cardiac performance and cardiomyocyte hypertrophy (mainly by tuning transcription factors and other growth-related targets). They also modulate the expression of certain cardiac ion channels and related proteins with proarrhythmic effect. Besides them, other microRNAs have been shown to exert influence on the myocardial growth, the electrical balance and the angiogenesis processes that take place in the heart. Bioinformatics is a useful tool to identify potential targets of a given microRNA, although there is still substantial concern about their reliability. Experimental manipulation of microRNAs has provided a tantalizing basis to speculate that future research on microRNAs may yield important progress in the prevention of sudden cardiac death and in the treatment of cardiac heart failure. However, the final effect of the blockage of microRNAs in vivo remains unclear, since each of them can target hundreds of genes with different intensity. The era of the microRNAs in cardiovascular diseases has just started.

[Ophthalmological manifestations in Fabry's disease. Four clinical cases showing deficient alpha-galactosidase-A activity]

CASE REPORT

Fabry's disease is an illness produced by an alteration in the catabolism of the glycosphingolipids. We report ophthalmologic findings in 4 people, detected after 113 patient evaluations from an analytical, cardiological and genetic point of view.

DISCUSSION

Fabry's disease is uncommon and shows variable ophthalmologic affectation. Some patients with Fabry's disease do not present ocular affectation, while, on the other hand, healthy carriers with important ocular alterations have been described. The deposit of glycosphingolipids produces affectation at the corneal, crystalline, vascular and retinal levels. The vascular alterations affect not only the veins but also the arteries, as we report in our patients.

Design and evaluation of a HDR skin applicator with flattening filter

The purposes of this study are: (i) to design field flattening filters for the Leipzig applicators of 2 and 3 cm of inner diameter with the source traveling parallel to the applicator contact surface, which are accessories of the microSelectron-HDR afterloader (Nucletron, Veenendaal, The Netherlands). These filters, made of tungsten, aim to flatten the heterogeneous dose distribution obtained with the Leipzig applicators. (ii) To estimate the dose rate distributions for these Leipzig+filter applicators by means of the Monte Carlo (MC) method. (iii) To experimentally verify these distributions for prototypes of these new applicators, and (iv) to obtain the correspondence factors to measure the output of the applicators by the user using an insert into a well chamber. The MC GEANT4 code has been used to design the filters and to obtain the dose rate distributions in liquid water for the two Leipzig+filter applicators. In order to validate this specific application and to guarantee that realistic source-applicator geometry has been considered, an experimental verification procedure was implemented in this study, in accordance with the updated recommendations of the American Association of Physicists in Medicine Task Group No. 43 U1 Report. Thermoluminescent dosimeters, radiochromic film, and a pin-point ionization chamber in a plastic [polymethylmethacrylate (PMMA)] phantom were used to verify the MC results for the two applicators of a microSelectron-HDR afterloader with the mHDR-v2 source. To verify the output of the Leipzig +filter applicators, correspondence factors were deduced for the well chambers HDR100-plus (Standard Imaging, Inc., Middleton, WI) and TM33004 (PTW, Freiburg, Germany) using a specific insert for both applicators. The doses measured in the PMMA phantom agree within experimental uncertainties with the dose obtained by the MC calculations. Percentage depth dose and off-axis profiles were obtained normalized at a depth of 3 mm along the central applicator axis in a cylindrical 20 x 20 cm water phantom. A table of output factors, normalized to 1 U of source air kerma strength at this depth, is presented. Correspondence factors were obtained for the two well chambers considered. The matrix data obtained in the MC simulation with a grid separation of 0.5 mm has been used to build a data set in a convenient format to model these distributions for routine use with a brachytherapy treatment planning system.

Historical trends in reported survival rates in patients with hypertrophic cardiomyopathy

OBJECTIVE

To determine the range of survival rates of patients with hypertrophic cardiomyopathy (HCM) by comparing and contrasting the natural history of a cohort of patients seen between 1988 and 2002 with that of other published series.

METHODS

956 adult (> or = 16 years old) patients with HCM (572 men, mean (SD) age 42 (15) years, range 16-88) were evaluated by ECG, Holter, exercise testing, and echocardiography. Patient characteristics and survival data were compared with those in natural history studies from referral and non-referral centres published between 1960 and January 2003.

RESULTS

The duration of follow up was 69 (45) months. 120 (12.6%) patients died or underwent cardiac transplantation. Sudden cardiac death (n = 48) was the most common mode of death. The annual rate of sudden death or implantable cardioverter-defibrillator discharge was 1.02 (95% confidence interval (CI) 0.76 to 1.26). Annual rates for heart failure death or transplantation and stroke related death were 0.55% (95% CI 0.37% to 0.78%) and 0.07% (95% CI 0.02% to 0.19%), respectively. When studies published within the last 10 years of the study period were compared with earlier reports, the size of individual study cohorts was larger (309 (240.6) v 136.5 (98.8), p = 0.058) and the proportion with severe functional limitation NYHA class III/IV lower (12.4% v 24.8%, p < 0.0001), and fewer patients underwent septal myotomy-myectomy (5.2% v 18.7%, p < 0.0001). Published sudden death rates over the last 10 years were lower than previously published figures (median 1.0% (range 0.1-1.7) v 2.0% (0-3.5)).

CONCLUSION

Published survival rates in HCM cohorts have improved progressively over the past 40 years. In the modern era the prevalence of disease related complications is similar in all reporting centres.