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Cardiopulmonary exercise test and sudden cardiac death risk in hypertrophic cardiomyopathy
Damiano Magrì1, Giuseppe Limongelli2, Federica Re3
1Department of Clinical and Molecular Medicine, University of Rome "La Sapienza", Rome, Italy.
Insights
The ventilation/carbon dioxide relation (VE/VCO2) slope during exercise testing can improve sudden cardiac death (SCD) risk stratification in hypertrophic cardiomyopathy (HCM) patients. This cardiopulmonary exercise test metric offers valuable insights beyond current risk scores.
Area of Science:
- Cardiology
- Exercise Physiology
- Sudden Cardiac Death Research
Background:
- Hypertrophic cardiomyopathy (HCM) presents complex risks for sudden cardiac death (SCD).
- Factors influencing SCD risk in HCM often overlap with exercise limitation pathophysiology.
- Current SCD risk stratification strategies in HCM require refinement.
Purpose of the Study:
- To evaluate the utility of cardiopulmonary exercise testing (CPET) in enhancing SCD risk stratification for HCM patients.
- To determine if the ventilation/carbon dioxide relation (VE/VCO2) slope improves upon existing risk assessment models.
Main Methods:
- A prospective, multicentre study followed 623 consecutive HCM outpatients from 2007 to 2015.
- The composite endpoint included SCD, aborted SCD, and appropriate implantable cardioverter-defibrillator (ICD) interventions.
- Multivariate analysis assessed the VE/VCO2 slope's association with the study endpoint, comparing it with established guideline-derived scores.
Main Results:
- During a median follow-up of 3.7 years, 25 patients reached the composite endpoint.
- The VE/VCO2 slope independently predicted the study endpoint, showing high concordance indices (0.748-0.750) with guideline scores.
- A VE/VCO2 slope cut-off of 31 demonstrated good accuracy (AUC 0.72) for predicting SCD events.
Conclusions:
- The VE/VCO2 slope shows potential to augment SCD risk stratification in HCM, especially for low-intermediate risk patients.
- This CPET-derived metric may offer incremental value beyond current risk stratification guidelines.
- Further validation in larger, independent cohorts is warranted to confirm these findings.
Background:
In hypertrophic cardiomyopathy (HCM), most of the factors associated with the risk of sudden cardiac death (SCD) are also involved in the pathophysiology of exercise limitation. The present multicentre study investigated possible ability of cardiopulmonary exercise test in improving contemporary strategies for SCD risk stratification.
Methods:
A total of 623 consecutive outpatients with HCM, from five tertiary Italian HCM centres, were recruited and prospectively followed, between September 2007 and April 2015. The study composite end point was SCD, aborted SCD and appropriate implantable cardioverter defibrillator (ICD) interventions.
Results:
During a median follow-up of 3.7 years (25th-75th centile: 2.2-5.1 years), 25 patients reached the end point at 5 years (3 SCD, 4 aborted SCD, 18 appropriate ICD interventions). At multivariate analysis, ventilation versus carbon dioxide relation during exercise (VE/VCO2 slope) remains independently associated to the study end point either when challenged with the 2011 American College of Cardiology Foundation/American Heart Association guidelines-derived score (C index 0.748) or with the 2014 European Society of Cardiology guidelines-derived score (C index 0.750). A VE/VCO2 slope cut-off value of 31 showed the best accuracy in predicting the SCD end point within the entire HCM study cohort (sensitivity 64%, specificity 72%, area under the curve 0.72).
Conclusions:
Our data suggest that the VE/VCO2 slope might improve SCD risk stratification, particularly in those HCM categories classified at low-intermediate SCD risk according to contemporary guidelines. There is a need for further larger studies, possibly on independent cohorts, to confirm our preliminary findings.
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