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Effects of Metoprolol on Exercise Hemodynamics in Patients With Obstructive Hypertrophic Cardiomyopathy
Anne M Dybro1, Torsten B Rasmussen1, Roni R Nielsen1
1Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark; Department of Clinical Medicine, Health, Aarhus University, Aarhus, Denmark.
Insights
Metoprolol did not significantly alter exercise pulmonary capillary wedge pressure in obstructive hypertrophic cardiomyopathy (HCM). However, it improved stroke volume and reduced left ventricular outflow tract gradients at rest and during exercise.
Area of Science:
- Cardiology
- Pharmacology
- Exercise Physiology
Background:
- Obstructive hypertrophic cardiomyopathy (HCM) presents complex challenges regarding exercise hemodynamics, loading conditions, and treatment efficacy.
- The precise impact of medical interventions on exercise physiology in obstructive HCM remains incompletely understood.
Purpose of the Study:
- To evaluate the effects of metoprolol on invasive hemodynamic parameters during rest and exercise in patients with obstructive HCM.
- To assess metoprolol's influence on pulmonary capillary wedge pressure (PCWP) and other key cardiovascular metrics.
Main Methods:
- A randomized, double-blind, placebo-controlled crossover trial involving 28 patients with obstructive HCM (NYHA class ≥II).
- Patients received either metoprolol 150 mg or placebo for two 2-week periods.
- Right-heart catheterization and echocardiography were performed at rest and during peak exercise.
Main Results:
- Metoprolol did not significantly affect the change in PCWP from rest to peak exercise (ΔPCWP).
- At rest, metoprolol reduced heart rate and LVOT gradient, while increasing end-diastolic volume and stroke volume.
- During exercise, metoprolol lowered heart rate and LVOT gradient, decreased mitral regurgitation, and increased stroke volume.
Conclusions:
- Exercise in obstructive HCM is linked to abnormal PCWP increases, which metoprolol did not mitigate.
- Metoprolol enhanced stroke volume at rest and during exercise, associated with improved LV filling, reduced LVOT obstruction, and less mitral regurgitation.
Background:
The relationship between exercise hemodynamics, loading conditions, and medical treatment in patients with obstructive hypertrophic cardiomyopathy (HCM) is incompletely understood.
Objectives:
This study aimed to investigate the effect of metoprolol on invasive hemodynamic parameters at rest and during exercise in patients with obstructive HCM.
Methods:
This randomized, double-blind, placebo-controlled crossover trial enrolled 28 patients with obstructive HCM and New York Heart Association functional class ≥II. Patients were randomized to initiate either metoprolol 150 mg or placebo for 2 consecutive 2-week periods. Right-heart catheterization and echocardiography were performed at rest and during exercise at the end of each treatment period. The primary outcome was the difference in pulmonary capillary wedge pressure (ΔPCWP) between peak exercise and rest.
Results:
No treatment effect on ΔPCWP was observed between metoprolol and placebo treatment (21 ± 9 mm Hg vs 23 ± 9 mm Hg; P = 0.12). At rest, metoprolol lowered heart rate (P < 0.0001), left ventricular outflow tract (LVOT) gradient (P = 0.01), and increased left ventricular end-diastolic volume (P = 0.02) and stroke volume (SV) (+6.4; 95% CI: 0.02-17.7; P = 0.049). During peak exercise, metoprolol was associated with a lower heart rate (P < 0.0001), a lower LVOT gradient (P = 0.0005), lesser degree of mitral regurgitation (P = 0.004), and increased SV (+9 mL; 95% CI: 2-15 mL; P = 0.008).
Conclusions:
In patients with obstructive HCM, exercise was associated with an abnormal rise in PCWP, which was unaffected by metoprolol. However, metoprolol increased SV at rest and peak exercise following changes in end-diastolic volume, LVOT gradient, and degree of mitral regurgitation. (The Effect of Metoprolol in Patients With Hypertrophic Obstructive Cardiomyopathy [TEMPO]; NCT03532802).
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