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Value of a comprehensive exercise echocardiography assessment for patients with hypertrophic cardiomyopathy
Jesus Peteiro1, Roberto Barriales-Villa2, José M Larrañaga-Moreira2
1Laboratory of Stress Echocardiography, Department of Cardiology, Complejo Hospitalario Universitario de A Coruña (CHUAC), CIBER-CV, Universidad de A Coruña, As Xubias, 84, 15006 A Coruña, Spain.
Insights
Exercise echocardiography (ExE) provides valuable prognostic information in hypertrophic cardiomyopathy (HCM) patients. Combining ExE findings with elevated filling pressures during exercise predicts adverse events in HCM.
Area of Science:
- Cardiology
- Echocardiography
- Cardiovascular Imaging
Background:
- Hypertrophic cardiomyopathy (HCM) is a genetic heart disease characterized by abnormal thickening of the heart muscle.
- Assessing left ventricular (LV) function and identifying potential complications like outflow tract obstruction and mitral regurgitation is crucial for managing HCM.
- Exercise echocardiography (ExE) offers a dynamic method to evaluate these parameters under stress.
Purpose of the Study:
- To evaluate the prognostic value of exercise echocardiography (ExE) assessments in patients with hypertrophic cardiomyopathy (HCM).
- To determine if LV systolic and diastolic function, LV outflow tract (LVOT) obstruction, and mitral regurgitation (MR) during exercise predict clinical outcomes in HCM patients with preserved ejection fraction.
Main Methods:
- Prospective evaluation of 285 HCM patients with preserved LV ejection fraction (≥50%) using treadmill ExE.
- Measurements included LV systolic function, LV-derived filling pressures (E/e´), LVOT gradients, and mitral regurgitation (MR) at rest and during/post-exercise.
- Clinical events (hard events, combined events, interventions) were tracked over a mean follow-up of 3.9 years.
Main Results:
- Exercise-induced LVOT obstruction developed in 27% of patients; new wall motion abnormalities in 13%.
- Elevated E/e´ (≥14) was common at rest (45%) and post-exercise (47%). Significant MR was less frequent.
- Exercise electrocardiography, exercise LVEF, and positive ExE combined with increased post-exercise E/e´ were significant predictors of adverse events, with the worst outcome in this subgroup (5.9% annualized hard event rate).
Conclusions:
- Comprehensive assessment using ExE is feasible and provides significant incremental prognostic information in HCM patients with preserved LV systolic function.
- ExE parameters, particularly elevated filling pressures during exercise, are important for risk stratification in HCM.
- This dynamic assessment aids in identifying high-risk individuals who may benefit from closer monitoring or intervention.
Background:
Exercise echocardiography (ExE) may assess left ventricular (LV) systolic and diastolic function, LV outflow tract (LVOT) obstruction, and mitral regurgitation (MR). We aimed to evaluate the prognostic value of these assessments during exercise in patients with hypertrophic cardiomyopathy (HCM).
Methods:
LV systolic function, LV-derived filling pressures, LVOT gradients, and MR were prospectively evaluated during treadmill ExE in 285 patients with HCM and preserved LV ejection fraction (EF) (≥50%). Recordings were obtained at rest and peak exercise for LV systolic function and at rest and post-exercise for LVOT gradients, MR, and ratio of early LV inflow velocity to early tissue Doppler annulus velocity (E/e´).
Results:
Thirty-seven patients (13%) had LVOT obstruction at rest, and 76 (27%) developed exercise-induced LVOT obstruction. New wall motion abnormalities were detected in 38 patients (13%). E/e´>14 was observed in 129 patients at rest (45%) and in 134 at post-exercise (47%). Corresponding figures for significant MR (moderate or severe) were 21 (7%) and 17 (6%). During follow-up (3.9 ± 2.5 years), 27 patients had a hard event, 39 a combined event (hard plus new atrial fibrillation or syncope), and 58 a combined event or intervention. Exercise electrocardiographic testing, exercise LVEF, and the combination of positive ExE and increased E/e´ with exercise predicted outcome. The worst event rate corresponded to patients with raised E/e' values at post-exercise and positive ExE (annualized hard event-rate of 5.9%).
Conclusions:
A comprehensive assessment during ExE is feasible for patients with HCM and preserved LV systolic function, and provides significant incremental prognostic information.