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•Simple patient data can evaluate the probability that LVH is of hypertensive origin.•Machine learning algorithms achieve this with high accuracy.•Online calculators have been made ...publicly available.
Left ventricular hypertrophy is often associated with hypertension, which is not necessarily the cause of hypertrophy. Non-hypertension-related aetiologies often have a strong impact on patient management, and therefore require a thorough and careful workup. When considering all left ventricular hypertrophies, even the mild ones, the number of patients who need a workup increases drastically. This raises the need for a tool to evaluate the pretest probability of the origin of left ventricular hypertrophy.
To predict the hypertensive origin of left ventricular hypertrophy using machine learning on first-line clinical, laboratory and echocardiographic variables.
We used a retrospective single-centre population of 591 patients with left ventricular hypertrophy, starting at 12mm maximal left ventricular wall thickness. After splitting data in a training and testing set, we trained three different algorithms: decision tree; random forest; and support vector machine. Model performances were validated on the testing set.
All models exhibited good areas under receiver operating characteristic curves: 0.82 (95% confidence interval: 0.77–0.88) for the decision tree; 0.90 (95% confidence interval 0.85–0.94) for the random forest; and 0.90 (95% confidence interval: 0.85–0.94) for the support vector machine. After threshold selection, the last model had the best balance between its specificity of 0.96 (95% confidence interval: 0.91–0.99) and its sensitivity of 0.31 (95% confidence interval: 0.17–0.44). All algorithms relied on similar most influential predictor variables. Online calculators were developed and made publicly available.
Machine learning models were able to determine the hypertensive origin of left ventricular hypertrophy with good performances. Implementation in clinical practice could reduce the number of aetiological workups needed in patients presenting with left ventricular hypertrophy.
Towards etiological treatments in cardiomyopathies Lairez, Olivier; Fournier, Pauline; Itier, Romain ...
La Presse médicale (1983),
March 2024, 2024-Mar, 2024-03-00, 20240301, Letnik:
53, Številka:
1
Journal Article
Recenzirano
Odprti dostop
This review proposes to look at the evolution of cardiomyopathy treatments in the light of advances in diagnostic techniques, which have enabled to move from a mechanistic to a phenotypic and then ...etiological approach. The article goes beyond the ejection fraction approach, and look at new therapies that target the pathophysiological pathways of cardiomyopathies, either by targeting the phenotype, or by targeting the etiology. The evolution of HCM treatments is detailed, culminating in the latest etiological treatments such as mavacamten in sarcomeric HCM, tafamidis in transthyretin cardiac amyloidosis and migalastat in Fabry disease. Myosin stimulators are reviewed in the treatment of DCM, before opening perspectives for gene therapy, which proposes direct treatment of the culprit mutation.
Immune checkpoint inhibitors (ICIs) are approved for multiple cancers but can result in ICI-associated myocarditis, an infrequent but life-threatening condition. Elevations in cardiac biomarkers, ...specifically troponin-I (cTnI), troponin-T (cTnT), and creatine kinase (CK), are used for diagnosis. However, the association between temporal elevations of these biomarkers with disease trajectory and outcomes has not been established.
We analyzed the diagnostic accuracy and prognostic performances of cTnI, cTnT, and CK in patients with ICI myocarditis (n=60) through 1-year follow-up in 2 cardio-oncology units (APHP Sorbonne, Paris, France and Heidelberg, Germany). A total of 1751 (1 cTnT assay type), 920 (4 cTnI assay types), and 1191 CK sampling time points were available. Major adverse cardiomyotoxic events (MACE) were defined as heart failure, ventricular arrhythmia, atrioventricular or sinus block requiring pacemaker, respiratory muscle failure requiring mechanical ventilation, and sudden cardiac death. Diagnostic performance of cTnI and cTnT was also assessed in an international ICI myocarditis registry.
Within 72 hours of admission, cTnT, cTnI, and CK were increased compared with upper reference limits (URLs) in 56 of 57 (98%), 37 of 42 (88%
=0.03 versus cTnT), and 43 of 57 (75%
<0.001 versus cTnT), respectively. This increased rate of positivity for cTnT (93%) versus cTnI (64%
<0.001) on admission was confirmed in 87 independent cases from an international registry. In the Franco-German cohort, 24 of 60 (40%) patients developed ≥1 MACE (total, 52; median time to first MACE, 5 interquartile range, 2-16 days). The highest value of cTnT:URL within the first 72 hours of admission performed best in terms of association with MACE within 90 days (area under the curve, 0.84) than CK:URL (area under the curve, 0.70). A cTnT:URL ≥32 within 72 hours of admission was the best cut-off associated with MACE within 90 days (hazard ratio, 11.1 95% CI, 3.2-38.0;
<0.001), after adjustment for age and sex. cTnT was increased in all patients within 72 hours of the first MACE (23 of 23 100%), whereas cTnI and CK values were less than the URL in 2 of 19 (11%) and 6 of 22 (27%) of patients (
<0.001), respectively.
cTnT is associated with MACE and is sensitive for diagnosis and surveillance in patients with ICI myocarditis. A cTnT:URL ratio <32 within 72 hours of diagnosis is associated with a subgroup at low risk for MACE. Potential differences in diagnostic and prognostic performances between cTnT and cTnI as a function of the assays used deserve further evaluation in ICI myocarditis.
Background:Wild-type transthyretin-related amyloidosis (ATTRwt) and degenerative aortic stenosis (AS) are both age-related. Diagnosis of cardiac amyloidosis (CA) among patients with AS may be ...difficult due to overlapping morphological and functional criteria. The aim of this study was to describe an echocardiographic longitudinal strain (LS) pattern among patients with AS with and without ATTRwt.Methods and Results:Patients who have AS with ATTRwt (n=30), AS without ATTRwt (n=50) and ATTRwt without AS (n=31) underwent two-dimensional speckle-tracking echocardiography. Transthyretin CA was based on positive bone scintigraphy without monoclonal gammopathy. All patients showed a gradual decrease in LS from the base to the apex resulting in a decrease of the global LS. A cut-off value of 1.0 for relative apical LS (average apical LS/average basal LS+mid-LS) was sensitive (88%) but less specific (68%) in differentiating ATTRwt among patients with severe AS. The best cut-off value for relative apical LS for identifying patients with ATTRwt among the whole population was 0.9 (sensitivity 74%, specificity 66%); however, 35%, 25% and 11% of patients who have ATTRwt without AS, with moderate AS and with severe AS, respectively, did not reach this threshold.Conclusions:A decrease of global and relative apical LS is common in patients with AS, even in the absence of ATTRwt. ATTRwt CA can be present even in the absence of relative apical sparing of LS.
Abstract
Aims
Hypertrophic cardiomyopathy (HCM) may be associated with very narrow QRS, while left ventricular hypertrophy (LVH) may increase QRS duration. We investigated the relationships between ...QRS duration and LV mass (LVM) in subtypes of abnormal LV wall thickness.
Methods and results
Automated measurement of LVM on MRI was correlated to automated measurement of QRS duration on ECG in HCM, left ventricular non compaction (LVNC), left ventricular hypertrophy (LVH), and controls with healthy hearts. Uni and multivariate analyses were performed between groups including explanatory variables expected to influence LVM and QRS duration. The relationships between QRS duration and LVM were further studied within each group. Two hundred and twenty-one HCM, 28 LVNC, 16 LVH, and 40 controls were retrospectively included. Mean QRS duration was 92 ms for HCM, 104 for LVNC, 110 for LVH, and 92 for controls (P < 0.01). Mean LVM was 100, 90, 108, and 68 g/m2 (P < 0.01). QRS duration, LVM, hypertension, maximal wall thickness, and late gadolinium enhancement were significantly linked to HCM in multivariate analysis (w/wo bundle branch block). An independent negative correlation was found between LVM and QRS duration in the HCM group, while the relationship was reverse in LVNC, LVH, and controls.
Conclusion
QRS duration increases with LVM in LVNC, LVH, or in healthy hearts, while reverse relationship is present in HCM. These relationships were independent from other parameters. These results warrant additional investigations for refining diagnosis criteria for HCM in the future.
Background
The sustainability of the results of Mitraclip procedures is a source of concern.
Aims
To investigate risk factors of severe mitral regurgitation (MR) recurrence after Mitraclip in primary ...MR.
Methods and results
Eighty‐three patients undergoing successful Mitraclip procedures were retrospectively included. Valve anatomy and Mitraclips placement were comprehensively analyzed by post‐processing 3D echocardiographic acquisition. The primary composite endpoint was the recurrence of severe MR. The average age was 83±7 years‐old, 37 (44%) were female. Median follow‐up was 381 days (IQR 195–717) and 17 (20%) patients reached the primary endpoint. Main causes of recurrence of severe MR were relapse of a prolapse (64%) and single leaflet detachment (23%). Posterior coaptation line length (HR 1.06 95%CI 1.01–1.12 p = 0.02), poor imaging quality (HR 3.84, 95%CI 1.12–13.19; p = 0.03), and inter‐clip distance (HR 1.60, 95%CI 1.27–2.02; p < 0.01) were associated with the occurrence of the primary endpoint.
Conclusions
Recurrence of severe MR after a MitraClip procedure for primary MR results from a complex interplay between anatomical (tissue excess) and procedural criteria (quality of ultrasound guidance and MitraClips spacing).
Le diagnostic d’insuffisance cardiaque est trop tardif.
Les symptômes d’insuffisance cardiaque sont aspécifiques.
Les peptides natriurétiques de type B, avec un seuil de 35pg/mL pour le BNP et de ...125pg/mL pour le NT-proBNP, permettent le diagnostic d’insuffisance cardiaque chez les patients paucisymptomatiques.
La dysfonction ventriculaire gauche, diastolique ou systolique, reste longtemps asymptomatique.
Chez les patients diabétiques et/ou hypertendus, les peptides natriurétiques, avec un seuil de NT-proBNP de 125pg/mL, pourraient permettre le diagnostic des dysfonctions ventriculaires gauches asymptomatiques.
Un traitement bloquant le système rénine-angiotensine-aldostérone chez les patients diabétiques présentant des taux de NT-proBNP≥125pg/mL pourrait permettre d’éviter l’apparition d’une insuffisance cardiaque.
Un dépistage des sujets à risque d’insuffisance cardiaque (diabétiques, hypertendus) semble envisageable grâce aux peptides natriurétiques.
Diagnosis of heart failure is too late.
Symptoms of heart failure are non-specific.
Brain natriuretic peptides allow the diagnosis of heart failure in pauci-symptomatic patients, with a threshold of 35pg/mL for BNP and 125pg/mL for NT-proBNP.
Left ventricular dysfunction, either diastolic or systolic, remains asymptomatic for a long time.
In diabetic and/or hypertensive patients, natriuretic peptides, can be used to diagnose asymptomatic left ventricular dysfunction, with a threshold of 125pg/mL NT-proBNP.
Treatment blocking the renin-angiotensin-aldosterone system in diabetic patients with NT-proBNP levels of 125pg/mL can prevent onset of heart failure.
Screening of subjects at risk of heart failure (diabetics, hypertensive) is possible thanks to natriuretic peptides.
Background: Among diagnosis associated with left ventricular hypertrophy (LVH), cardiac amyloidosis (CA) is a progressive disease with poor prognosis. Early noninvasive identification is of growing ...clinical importance. The objective of our study was to integrate clinical, biologic, electrocardiographic and echocardiographic parameters to build a diagnostic score in patients with LVH.
Methods and results: One hundred and fourteen patients with LVH underwent a cardiac magnetic resonance (CMR) and a
99m
Tc-hydroxymethylene-diphosphonate scintigraphy (
99m
Tc-HMDP) allowing to discriminate three groups of diagnoses: CA (n = 50 including 31, 18 and 1 ATTR, AL and AA amyloidosis), hypertrophic cardiomyopathy (n = 19) and unspecific cardiomyopathy (n = 45). Seven continuous variables associated with CA (systolic arterial pressure <130 mmHg; PR duration >200 ms; Sokolow index <12 mV; diastolic left ventricular posterior thickness >13 mm; E/Ea ratio >10; global longitudinal strain > −12% and sum of basal longitudinal strain > −47%) were selected and dichotomized according to the best cutoff value to build the diagnostic score, which was validated in an independent cohort of 34 patients with LVH from aortic stenosis. The area under the ROC curve for the diagnosis of CA using the score was 0.933 (95%CI 0.889-0.978). The best cut off value for the score was 3 leading to a sensitivity of 90% and specificity of 81%. Area under the ROC curve for the score was 0.932 in the validation cohort. A diagnostic score >3 was associated with a poorest prognosis.
Conclusion: An integrated evaluation of 6 diagnostic factors including arterial blood pressure, ECG and echocardiographic parameters to build a diagnostic score is a simple and easily method to discriminate the 3 main CA in patients with LVH.
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