NON-INVASIVE TREATMENT OPTIONS IN HYPERTROPHIC CARDIOMYOPATHY
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1 NON-INVASIVE TREATMENT OPTIONS IN HYPERTROPHIC CARDIOMYOPATHY SGK, 2015 Christiane Gruner University Heart Center, Zurich Department of Cardiology
2 NONINVASIVE TREATMENT OPTIONS: TOPICS 1. LVOT obstruction 2. microvascular dysfunction myocardial ischema 3. arrhythmias atrial fibrillation ventricular SCD
3 NONINVASIVE TREATMENT OPTIONS: BASIS 45 studies 2121 HCM patiens Spoladore R et al, EHJ, 2012;33:
4 NONINVASIVE TREATMENT OPTIONS: BASIS Spoladore R et al, EHJ, 2012;33:
5 NONINVASIVE TREATMENT OPTIONS: TOPICS 1. LVOT obstruction 2. microvascular dysfunction myocardial ischema 3. arrhythmias atrial fibrillation ventricular SCD
6 NONINVASIVE TREATMENT OPTIONS: LVOT OBSTRUCTION Septal hypertrophy Mitral valve anomalies Papillary muscle anomalies Geometry basis heart Contractility Drag forces SAM Mitral regurgitation LVOT obstruction
7 NONINVASIVE TREATMENT OPTIONS: LVOT OBSTRUCTION NEGATIVE CHRONOTROPE NEGATIVE INOTROPE BETA BLOCKERS DISOPYRAMIDE (VERAPAMIL) AHAACC Guidelines, Circulation 2011;124: ESC Guidelines, EHJ 2014;35(39):
8 NONINVASIVE TREATMENT OPTIONS: LVOT OBSTRUCTION NEGATIVE CHRONOTROPE NEGATIVE INOTROPE BETA BLOCKERS DISOPYRAMIDE (VERAPAMIL) AHAACC Guidelines, Circulation 2011;124: ESC Guidelines, EHJ 2014;35(39):
9 NONINVASIVE TREATMENT OPTIONS: LVOT OBSTRUCTION NEGATIVE CHRONOTROPE NEGATIVE INOTROPE BETA BLOCKERS DISOPYRAMIDE (VERAPAMIL) Class 1A antiarrhythmic, sodium channel blocker Negative inotrope In combination with beta blocker (prevent 1:1 conduction) QT interval prolongation check QT interval 7-10 days after initiation Anticholinergic side effects AHAACC Guidelines, Circulation 2011;124: ESC Guidelines, EHJ 2014;35(39):
10 NONINVASIVE TREATMENT OPTIONS: LVOT OBSTRUCTION NEGATIVE CHRONOTROPE NEGATIVE INOTROPE BETA BLOCKERS DISOPYRAMIDE (VERAPAMIL) AVOID ACE-inhibitors Nitro Volume depletion AHAACC Guidelines, Circulation 2011;124: ESC Guidelines, EHJ 2014;35(39):
11 NONINVASIVE TREATMENT OPTIONS: LVOT OBSTRUCTION PATIENT EXAMPLE: 44 YEARS OLD MALE No treatment, heart rate 95 bpm Bisoprolol 5mg od, disopyramide 100mg tid, heart rate 68 bpm
12 NONINVASIVE TREATMENT OPTIONS: LVOT OBSTRUCTION PATIENT EXAMPLE: 44 YEARS OLD MALE No treatment, heart rate 95 bpm Bisoprolol 5mg od, disopyramide 100mg tid, heart rate 68 bpm
13 NONINVASIVE TREATMENT OPTIONS: TOPICS 1. LVOT obstruction 2. microvascular dysfunction myocardial ischema 3. arrhythmias atrial fibrillation ventricular SCD
14 NONINVASIVE TREATMENT OPTIONS: MICROVASCULAR DYSFUNCTION Spoladore R et al, EHJ, 2012;33: Olivotto I, JACC, 2011;58(8): Olivotto I, JACC, 2006;47(5):1043-8
15 NONINVASIVE TREATMENT OPTIONS: MICROVASCULAR DYSFUNCTION SYMPTOMATIC HCM PATIENT LVEF <50% HEART FAILURE MANAGEMENT OBSTRUCTIVE PHYSIOLOGY YES NO SYSTOLIC LV FUNCTION BETA BLOCKER VERAPAMIL DRUGS SEA MYECTOMY LVEF 50% DIURETICS ACE INHIBITORS ARBs AHAACC Guidelines, Circulation 2011;124: ESC Guidelines, EHJ 2014;35(39):
16 NONINVASIVE TREATMENT OPTIONS: TOPICS 1. LVOT obstruction 2. microvascular dysfunction myocardial ischema 3. arrhythmias atrial fibrillation ventricular SCD
17 NONINVASIVE TREATMENT OPTIONS: ATRIAL FIBRILLATION LEFT ATRIAL SIZE FIBROSISSCARRING IN THE LEFT ATRIUM (SURGERIES) 25% of HCM PATIENTS
18 NONINVASIVE TREATMENT OPTIONS: ATRIAL FIBRILLATION RHYTHM CONTROL >>>>> RATE CONTROL DRUGS Beta blockers Calcium channel blockers (verapamil-type) Amiodarone, NO DRONEDARONE No class 1C anti-arrhythmic agents ELECTRIC DC CARDIOVERSION RELIEF OF LVOT OBSTRUCTION PULMONARY VEIN ISOLATION NO EXOTIC ANTI- ARRHYTHMIC AGENTS ORAL ANTICOAGULATION INDEPENDENT OF CHADS2Vasc SCORE
19 ATRIAL FIBRILLATION: RELIEF OF LVOT OBSTRUCTION PRE MYECTOMY POST MYECTOMY AHAACC Guidelines, Circulation 2011;124:
20 ATRIAL FIBRILLATION: PULMONARY VEIN ISOLATION overall lower success rate (50%) frequently: >1 intervention required Di Donna P et al, Europace, 2010;12:347-55
21 NONINVASIVE TREATMENT OPTIONS: VENTRICULAR ARRHYTHMIAS FIBROSISSCAR ISCHEMIA
22 NONINVASIVE TREATMENT OPTIONS: VENTRICULAR ARRHYTHMIAS
23 NONINVASIVE TREATMENT OPTIONS: VENTRICULAR ARRHYTHMIAS Maron BJ, JAMA 2002;287: Melacini P, Heart 2007;93:
24 NONINVASIVE TREATMENT OPTIONS: BASIS 217 patients 391 patients Spoladore R et al, EHJ, 2012;33:
25 NONINVASIVE TREATMENT OPTIONS: VENTRICULAR ARRHYTHMIAS RISK STRATIFICATION FOR SCD AHAACC Guidelines, Circulation 2011;124: ESC Guidelines, EHJ 2014;35(39):
26 NONINVASIVE TREATMENT OPTIONS: SUMMARY 1. LVOT OBSTRUCTION MEDICAL TREATMENT OPTIONS BETA BLOCKER +- DISOPYRAMIDE (VERAPAMIL) AVOID VOLUME DEPLETION AND DRUGS REDUCING AFTERLOAD AND PRELOAD INVASIVE PROCEDURES 2. MICROVASCULAR DYSFUNCTION BETA BLOCKER VERAPAMIL DIURETICS ACE INHIBITORS ARBs
27 NONINVASIVE TREATMENT OPTIONS: SUMMARY 3. ARRHYTHMIAS ATRIAL FIBRILLATION TRY TO ACHIEVE SINUS RHYTHM BETA BLOCKER AMIODARONE ORAL ANTICOAGULATION PULMONARY VEIN ISOLATION WITH LOWER SUCCESS RATE VENTRICULAR ARRHYTHMIAS NO MEDICAL THERAPY RISK STRATIFICATION FOR SCD AICD INSERTION
28 Thank you hypertrophic cardiomyopathy clinic
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