Rest and Exercise Echocardiography in Hypertrophic Cardiomyopathy: Determinants of Exercise Peak Gradient and Predictors of Outcome

Transcription

1 Rest and Exercise Echocardiography in Hypertrophic Cardiomyopathy: Determinants of Exercise Peak Gradient and Predictors of Outcome G. Deswarte, AS. Polge, N. Lamblin, A. Millaire, M. Richardson, C. Bauters, G. Deklunder, T. Le Tourneau Cardiology University Hospital, Lille, France, Physiology and Cardiology Departments, Institut du Thorax, Nantes, France No Disclosure

2 Prognosis value of Rest LVOT Probability of HCM Related Death Probability of progression to NYHA class III-IV, Death from heart failure or stroke Maron and al, New Eng J Med 2003, N=1101 Years after Gradient Measurement

3 LVOT obstruction in 70 % of patients LVOT peak gradient at rest or after exercise with stopping current medications Maron, Circulation 2006

4 ESC Expert Consensus Document Ex Echo Eur Heart J 2003

5 Objectives However, determinants of exercise peak gradient in patients with HCM are incompletely understood. Moreover, beyond the assessment of obstruction and symptoms, the potential interest of exercise echocardiography remains to be addressed. Therefore, the aim of our study was to identify determinants of exercise peak gradient and to assess the potential interest of rest and exercise echocardiography in predicting outcome in patients with HCM.

6 Methods HCM patients 1.Rest and symptoms limited exercise echocardiography under current medications 2.Three groups : No obstruction at rest or exercise Baseline obstruction ( 30 mmhg at rest) Latent obstruction (peak gradient <30 mmhg at rest and 30 mmhg with EE) Follow up Composite End point 1. Cardiac death 2. Appropriate discharge by ICD or aborted sudden death 3. Unplanned hospitalization for a cardiac event related to HCM (new onset AF, heart failure, embolic event)

7 Population 154 patients No 70 patients (46%) at baseline 56 patients (36%) Latent obstruction 28 patients (18%) F-up : 2.4 ± 1.8 yrs (up to 5.5 yrs) 43 events

8 Results of Exercise Echo Rest Exercise P Heart rate, bpm < Systolic blood pressure, mmhg < Maximal Workload, watts LVEF, % Peak LVOT gradient, mmhg < PASP, mmhg <0.0001

9 Population characteristics No (54%) P Baseline Latent P groups N 70 (46%) 56 (36%) 28 (18%) Age, years Male gender, n (%) 41 (59) 41 (73) 25 (89) NYHA class III, n (%) 10 (14) 11 (20) 5 (18) Sinus Rhythm, n (%) 62 (88) 55 (98) 28 (100) Abnormal Ex SBP, n (%) 29 (41) 20 (36) 5 (18)

10 Echo characteristics No (54%) P Baseline Latent P groups N 70 (46%) 56 (36%) 28 (18%) Septal thickness, mm < LV EDD, mm Rest peak gradient, mmhg Ex peak gradient, mmhg PASP, mmhg

11 Echo systolic function pattern LVEF (%) P<0.001 Sept mitral S velocity (cm/s) P<0.05 No Baseline Latent No Baseline Latent

12 Echo diastolic function pattern LA Volume (ml/m²) Sept E/E P=0.001 P< No Baseline Latent No Baseline Latent

13 Determinants of Exercise peak gradient Multivariate analysis, R²= 0.64 β P Rest peak gradient 0.78 < Sept mitral S Multivariate analysis, R²= 0.21 Exclusion rest peak gradient β P Sinus Rhythm Sept mitral S Posterior mitral valve length 0.40 <0.0001

14 Determinants of Outcome (composite end-point) Multivariate Cox Model HR CI P NYHA class < Septum thickness Rest peak gradient Rest LVEF Exercise maximal SBP

15 Conclusion Baseline or latent obstruction is found in more than 50% of patients with HCM despite medical treatment Latent obstruction group presents better systolic and diastolic function parameters Peak gradient during exercise is strongly related to baseline peak gradient and does not appear as an independent predictor of outcome By contrast, baseline peak gradient is an independent predictor of outcome However, in this series of patients, maximal systolic blood pressure during exercise is a predictor of outcome

16 Determinants of Exercise peak gradient r= 0.78, P< Exercise peak gradient Rest peak gradient