Hypertrophic Cardiomyopathy: basics and management

Transcription

1 Hypertrophic Cardiomyopathy: basics and management Bette Kim, MD Program Director, Cardiomyopathy Program Director, Roosevelt Hospital Echocardiography Lab Assistant Professor of Clinical Medicine Mount Sinai Roosevelt Hospital

2 HCM is relatively common 1:500 in general population have HCM 20,000,000 in tri-state NY metropolitan area 40,000 individuals with HCM

3 Genetics Mutations in genes encoding proteins of the sarcomere 11 or more known sarcomeric mutations Autosomal dominant transmission with variable penetrance

4 Maron, B. JACC 2014; 64:83-99

5 Watkins H, NEJM 2011

6 Anatomic Diversity!

7 Diversity of HCM phenotype by cmri Maron, B. JACC 2014; 64:83-99

8 Severe asymmetric hypertrophy

9 Preop resting LVOT gradient

10 Minimal LVH but SAM

11 Post-exercise

12 Post-exercise LVOT gradient

13 Nonobstructive HCM

14 Mid ventricular obstruction Apical akinesis

15 Findings associated with HCM Small vessel coronary artery disease Replacement fibrosis Apical aneurysm?small vessel disease?mid ventricular obstruction Mitral valve abnormalities Long mitral valve leaflets Papillary muscle abnormalities

16 Stained to detect fibrosis Shirani JACC 2000

17 Maron, M. JACC 2009;54:866-75

18 HCM in women Olivotto, et al, JACC 2005; 46:480-7

19 Women diagnosed later Olivotto, et al, JACC 2005; 46:480-7

20 Worsening HF and stroke Olivotto, et al, JACC 2005; 46:480-7

21 Women and myectomy Woo et al, Circulation 2005; 111:

22 Five Aspects of HCM Treatment 1. Treatment of symptoms. 2. Risk stratification and sudden death prevention with ICD, if indicated. 3. Advice to avoid competitive athletics and extremes of strenuous exertion. 4. Test first degree relatives: echo, ECG! or genotype paradigm. 5. Test for, and treat hyperlipidemia.

23 Stress echocardiogram Obstructive or nonobstructive Asymptomatic Mildly symptomatic Drug refractory severely symptomatic Surveillance Maron, B. JACC 2014; 64:83-99 Medical therapy Obstructive: septal myectomy (or ASA) Nonobstructive : transplant

24 Mitral Valve Area is Increased in HCM Klues HG Circ 1992

25 Normal Klues HG Circ 1992

26 Anatomic Substrate Septal bulge Mitral valve papillary muscles and leaflets are anteriorly positioned. MV relatively large. Residual portions of the leaflets extend past the coaptation point and protrude into the outflow tract.

27 Levine R, Circulation 1995 Sherrid M, JACC 1993, 2000, Circ 1998

28 LV Ao LA SAM begins

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30 Reflections of Inflections. JACC 2009

31 All patients with HCM Pharmacologic therapy Myectomy, Ablation ACC/ESC Guidelines

32 Treatment of Symptoms from Obstruction: The Basics Obstruction worsens with! inotropy " afterload " preload exercise postprandial standing or Valsalva

33 Treat obstruction " inotropy! afterload! preload beta blockers, verapamil, diltiazem, disopyramide Avoid vasodilators Hydration Avoiding high dose diuretics

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35 Drugs to avoid in obstructive HCM Nitrates ACE, ARB;!.prils and!.sartans Dihydropyridine CaCB: Nifedipine, Amlodipine;!.pines Alpha blockers: Terazosin (Hytrin), Tamsulosin (Flomax), Doxazosin (Cardura),!.sins PDE5 inhibitors: Sildenafil (Viagra), Vardenafil (Levitra)!.enafils Dobutamine, Dopamine Digoxin Sympathomimetics: Pseudophedrine, Ritalin, Concerta

36 How should we treat symptoms and gradient in obstructive HCM patients who do not respond to beta-blockade or verapamil?

37 Therapeutic Options Disopyramide Surgical septal myectomy Alcohol septal ablation (DDD pacing with short AV delay)

38 Disopyramide for Symptomatic OHCM Disopyramide, a type I antiarrhythmic drug with strong negative inotropic effect, decreases resting LVOT gradients and is efficacious in relieving symptoms in 2/3 of patients with severe obstruction. The optimum starting dose is 500 mg/day, using the controlled release preparation to allow twice a day dosing. ACC/AHA Guidelines 2011: IIa recommendation ESC Guidelines 2014: Ib recommendation

39 Multicenter Study of Disopyramide in OHCM 118 patients treated with HCM treated with disopyramide from 1990 to 1999 from 4 HCM centers were followed for mean 3.1 years. Mortality was compared to 373 obstructive patients from the same centers not treated with disopyramide. JACC 2005

40 JACC 2005

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42 Responders (n=54) to disopyramide trial (grad <30 mm Hg) have lower gradients and shorter mitral anterior leaflets than non-responders (n=19) p= p=0.07 p= Age (yrs) Gradient (mmhg) Anterior Leaf Length (mm) Alviar C, Musat D et al. ESC Congress 2013

43 Drug dosages in OHCM Beta-blocker increased till resting heart rate bpm. Disopyramide CR 250 mg BID or 300 mg BID, or Disopyramide regular release mg QID. Verapamil SR 240mg-360 mg/day. Mestinon Timespan 180 mg once or twice daily or regular release 60mg TID

44 Annals of Thoracic Surgery 2003

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46 Mitral valve plication

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48 Residual leaflet excision

49 Survival of patients post myectomy vs agematched US expected survival Ommen S et al. JACC 2005;46:470.

50 Alcohol Ablation C Knight, Circ 1997

51 Complication Rates after ASA Are As High As after Myectomy Sorajja P, Circulation 2008

52 Septal Scar is larger after ASA Post-ablation Post-myectomy Transmural Scar NO Scar Valenti et al. JACC

53 Sudden Cardiac Death in HCM Sudden death in young, relatively asymptomatic patients was part of the modern description of HCM. Ventricular fibrillation is the cause. Occurs in 1.0%/ year in non-referred patients. Mean age of sudden death, 44 years. In subgroups, SCD may occur in 3-4%/year. Effort to ascertain which patients are at high risk.

54 Stratification of Risk for Sudden Death in HCM Massive LV segmental wall thickness > 30 mm. First degree relative with SCD. Unexplained syncope especially recurrent, within 6 months of evaluation. Remote syncope less significant.

55 End stage EF<50% LV apical aneurysm LGE > 15% Marked LVOT gradient at rest **Age > 60 y

56 LGE on cmri Chan RH, Circ 2014; 130:

57 SCD and Extent of LGE in 1293 HCM patients Chan RH, Circ 2014; 130:

58 Conclusions HCM is a prevalent yet treatable genetic disease HCM is underdiagnosed and delayed in women. Women have more severe symptoms upon diagnosis and worse outcomes compared with men. Pharmacologic therapy for patients with obstructive HCM is often effective. Surgery is successful for obstruction when medications fail. Alcohol ablation should be reserved for patients who cannot have surgery because of other illness or age.

59 HCM trials HCMR cmri, biomarkers, genetic testing and outcomes LIBERTY-HCM Phase 2/3 trial of effect of GS-6615 on exercise capacity in symptomatic HCM Contact me with questions