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Published on: March 21, 2013
Orthostatic blood pressure test for risk stratification in patients with hypertrophic cardiomyopathy
Julia Münch1, Ali Aydin2, Anna Suling3
1Klinik und Poliklinik für Allgemeine und Interventionelle Kardiologie, Universitäres Herzzentrum Hamburg, Martinistr. 52, 20246, Hamburg, Germany.
Insights
In hypertrophic cardiomyopathy (HCM) patients, an orthostatic blood pressure test effectively identifies syncope causes, particularly in older adults. This aids risk stratification and may prevent unnecessary implantable cardioverter-defibrillator (ICD) implantations.
Area of Science:
- Cardiology
- Electrophysiology
- Internal Medicine
Background:
- Hypertrophic cardiomyopathy (HCM) is a leading cause of sudden cardiac death (SCD) in young adults, often linked to ventricular tachycardia (VT).
- Identifying the cause of syncope (pre-syncope) is crucial for SCD risk stratification and deciding on implantable cardioverter-defibrillator (ICD) implantation in HCM patients.
- Evidence of VT during syncope is frequently absent, necessitating alternative diagnostic methods.
Purpose of the Study:
- To evaluate the utility of an orthostatic blood pressure test in identifying the cause of syncope and pre-syncope in patients with HCM.
- To determine if orthostatic dysregulation is a significant factor in syncope among HCM patients, especially older individuals.
- To assess the correlation between orthostatic test results, prolonged QTc interval, and the occurrence of syncope/pre-syncope in HCM.
Main Methods:
- A cohort of 100 HCM patients experiencing syncope or pre-syncope within the last five years were evaluated over 15 months.
- Patients underwent assessment for syncope and VT, including 24-hour ECGs and device interrogation.
- Eighty patients completed an orthostatic blood pressure test, and logistic regression models were used for statistical analysis.
Main Results:
- A positive orthostatic test significantly increased the likelihood of syncope/pre-syncope by 63-fold in patients over 40 years old (93% sensitivity, 74% specificity).
- No correlation was found between orthostatic test results and the occurrence of VT.
- A prolonged QTc interval also independently increased the likelihood of syncope/pre-syncope by 6.6-fold.
Conclusions:
- The orthostatic blood pressure test is a valuable tool for evaluating syncope and pre-syncope in HCM patients, particularly older individuals.
- Orthostatic syncope may be more prevalent in HCM than previously recognized.
- This simple test can provide crucial information for risk stratification, potentially avoiding unnecessary ICD implantations in older HCM patients.
Background:
Hypertrophic cardiomyopathy (HCM) is the most common cause of sudden cardiac death (SCD) in young adults, mainly ascribed to ventricular tachycardia (VT). Assuming that VT is the major cause of (pre-) syncope in HCM patients, its occurrence is essential for SCD risk stratification and primarily preventive ICD-implantation. However, evidence of VT during syncope is often missing. As the differentiation of potential lethal causes for syncope such as VT from more harmless reasons is crucial, HCM patients were screened for orthostatic dysregulation by using a simple orthostatic blood pressure test.
Methods:
Over 15 months (IQR [9;20]) 100 HCM patients (55.8±16.2 yrs, 61% male) were evaluated for (pre-)syncope and VT (24h-ECGs, device-memories) within the last five years. Eighty patients underwent an orthostatic blood pressure test. Logistic regression models were used for statistical analysis.
Results:
In older patients (>40 yrs) a positive orthostatic test result increased the chance of (pre-) syncope by a factor of 63 (95%-CI [8.8; 447.9], p<0.001; 93% sensitivity, 95%-CI [76; 99]; 74% specificity, 95%-CI [58; 86]). No correlation with VT was shown. A prolonged QTc interval also increased the chance of (pre-) syncope by a factor of 6.6 (95%-CI [2.0; 21.7]; p=0.002).
Conclusions:
The orthostatic blood pressure test is highly valuable for evaluation of syncope and presyncope especially in older HCM patients, suggesting that orthostatic syncope might be more relevant than previously assumed. Considering the high complication rates due to ICD therapies, this test may provide useful information for the evaluation of syncope in individual risk stratification and may help to prevent unnecessary device implantations, especially in older HCM patients.
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