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From the Department of Cardiology, Poznan University of Medical Sciences, CLINICAL MANIFESTATIONS
Poznan, Poland.
The authors declare no conflict of interest. The site and extent of LVH have a significant impact on the
Correspondence: Daria M. Adamczak, MD, Department of Cardiology, Poznan range of experienced HCM-related symptoms. Patients can develop
University of Medical Sciences, Clinical Hospital No. 1, Dluga ½, 61–848, one or more of the following structural and functional abnormali-
Poznan, Poland. E-mail: daria.m.adamczak@gmail.com.
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
ties: LVOT obstruction, diastolic dysfunction, systolic dysfunction
ISSN: 1061-5377/18/2603-0145 (so called “burned-out” phase of HCM), myocardial ischemia, and
DOI: 10.1097/CRD.0000000000000184 mitral regurgitation. These abnormalities can lead to the wide array
of symptoms experienced by patients and can be divided into 3 major of HCM, SCD, ICD, or syncope among relatives), 2D echocardiog-
groups as being related to HF, chest pain, and arrhythmias.19–22 raphy (to determine the maximal wall thickness of the LV, possible
LVOT obstruction, and systolic anterior motion), 24–48–hour ambu-
Arrhythmias latory electrocardiographic monitoring (to identify arrhythmias), and
Both supraventricular and ventricular arrhythmias are com- cardiac stress test (to assess blood pressure response). CMR may be
mon in patients with HCM; however, the spectrum of clinical mani- considered to precisely determine the maximal wall thickness of the
festations varies significantly. Patients can experience no symptoms LV and to assess for the presence and extent of myocardial fibrosis (ie,
but may also have palpitations, presyncope, syncope, or even sudden late gadolinium enhancement). The evaluation of SCD risk is not usu-
cardiac arrest. The rate of paroxysmal supraventricular arrhythmias ally repeated in patients who already have an ICD.20
among the HCM patients documented in ambulatory electrocardio-
graphic monitoring was 38%, whereas the rate of premature ven- Major (Conventional) Risk Factors
tricular beats was as high as 88%, while nonsustained ventricular The joint American College of Cardiology/European Society
tachycardia (VT), according to different studies, ranged from 15% to of Cardiology consensus document from 2003 consolidated a num-
31%.23–26 Clinically documented sustained VT is uncommon among ber of outcome studies that identified prognostic indicators with-
HCM patients. Episodes of nonsustained VT usually occur in older out regard for different effect sizes. The 2011 American College
patients and in times of heightened vagal tone. However, if they of Cardiology Foundation/American Heart Association guidelines
do happen in younger patients, they may presage potentially lethal upgraded family history of SCD, maximal LV wall thickness, and
arrhythmias such as sustained VT and ventricular fibrillation.26–28 unexplained syncope to reasonable (class IIa) indications for ICD
therapy, still recognizing the others as risk-modifying. Although
LIFE SPAN AND MORTALITY OF HCM PATIENTS the major risk factors have limited sensitivity and moderate-to-high
The majority of patients with HCM are considered to have a specificity for predicting SCD, they help identify patients who should
normal life expectancy. In a study of 312 patients, 23% lived at least receive an ICD for primary prevention. Despite their relatively low
to 75 years of age and 14% even to 80. In this group of long-term positive predictive value, their negative predicative value is high. The
survivors, 64% experienced no or only mild symptoms. Most of them most important information regarding those factors is presented in
were women.29 In a series of studies published at the end of the 20th Table 1.15,20,23,24,26,27,43,49–58
century, the annual mortality rate of HCM patients from the refer-
ral center populations was 4–6% per year30–34; however, more recent Impact of Multiple Major Risk Factors
studies of unselected patient populations demonstrated an annual Identification of ICD-eligible patients may be improved
mortality rate of approximately 1% or less.35–39 The reported annual by summation of conventional risk factors.25,59,60 A cohort of 368
morbidity in children with HCM was 2% in the community-based HCM patients demonstrated that multiple risk factors significantly
population and 6% in the tertiary referral cohorts.31,40,41 The 3 most increase the probability of SCD. Patients without any of the known
common causes of death in HCM patients are sudden cardiac death risk factors had an estimated 6-year survival rate of 95%. For 1, 2,
(SCD) (51%), HF (36%), and stroke (13%).36,42 The annual mortality and 3 factors, the survival rates were 93%, 82%, and 36%, respec-
rates are, respectively, 0.54–1%, 0.55%, and 0.07%.23,38,42–45 More- tively.25 On the other hand, data from a multicenter registry of ICDs
over, 1.8% of HCM patients per year experience life-threatening in HCM patients in primary prevention revealed that 35% of appro-
events, including appropriate implanted cardioverter defibrillator dis- priate discharges occurred in those who had only a single risk factor
charge, resuscitated sudden cardiac arrest, or heart transplant.38 SCD of SCD.61
is most common in the younger patients, whereas the fatal outcome
of HF and stroke concerns mainly the elderly. HCM Risk-SCD Calculator
In 2013, O’Mahony et al62 proposed the HCM Risk-SCD
Calculator, a novel clinical risk prediction model of SCD in HCM
SUDDEN CARDIAC DEATH derived from a retrospective, multicenter longitudinal cohort study.
SCD refers to the unexpected cessation of cardiac activity, The cohort consisted of 3675 patients from 6 centers in the European
with hemodynamic collapse and death within 1 hour from the onset Union. The aim of the study was to derive and validate a new SCD
of symptoms in a person without any prior condition that would seem model assessing an individualized 5-year risk of SCD and to improve
fatal. The direct cause of death is usually ventricular tachyarrhyth- ICD therapy in patients with HCM. The abnormal blood pressure
mia. It is estimated that the incidence of SCD worldwide may be as response to exercise was excluded from the model, whereas maximal
high as 1/1000 per year. SCD usually occurs in those with previously LVOT gradient at rest or during the Valsalva maneuver (formerly an
known or latent structural heart disease, and the most common cause ancillary risk factor) was upgraded. There were also 2 additions: age
of SCD in the general population is coronary artery disease. Nev- and left atrial diameter. The 5-year risk of SCD < 4% was classified
ertheless, HCM is the most frequent cause of SCD in young people as low risk without indication for an ICD. An ICD may be considered
and competitive athletes.46–48 Therefore, for medical, social, and eco- if the risk is intermediate, namely 4 to < 6%. Finally, a risk ≥ 6% was
nomic reasons, it is important to identify people who are at increased considered high and a clear indication for ICD. Patients who did not
risk of sudden death. reach the SCD endpoint had a mean calculated 5-year risk of 3.7%.
The model predicts that for every 16 ICDs, 1 patient will be saved
Risk Stratification from SCD at 5 years (number needed to treat = 16 over 5 years).62
Clinical Evaluation The calculator was implemented into the 2014 ESC Guidelines on the
Risk stratification should be performed in all patients with HCM diagnosis and management of HCM. Independent validation studies
regardless of their symptoms, hemodynamic status, or the severity of revealed mixed results, but most of them suggest that the HCM SCD-
the hypertrophy. Because the disease can evolve over time, all patients Risk Calculator outperforms algorithms from 2003 and 2011. In a ter-
with known or suspected HCM should undergo serial assessments tiary center cohort study of 706 HCM patients, the C-statistics for the
every 12–24 months, especially those potentially eligible for implanted 2003, 2011, and 2014 algorithms were 0.55, 0.60, and 0.69, respec-
cardioverter defibrillator (ICD) use. The evaluation should include his- tively.63–65 The achievement of the new model lies in the shift from
tory and physical examination, family history (with emphasis on cases relative to absolute risk estimation.66 Nevertheless, it also has some
146 | www.cardiologyinreview.com © 2017 Wolters Kluwer Health, Inc. All rights reserved.
TABLE 1. Major Risk Factors of Sudden Cardiac Death in Hypertrophic Cardiomyopathy
Risk Factor Comment
Family history of SCD An increased risk if the deceased close relative was < 40 years old or had confirmed
hypertrophic cardiomyopathy.
Unexplained syncope An increased risk of SCD if the syncope appears to be due to arrhythmia, particularly
in younger patients, and if it is relatively close (< 6 mo) to evaluation.
Maximal LV wall thickness > 30 mm An inverted U-shaped relation between maximal LV wall thickness and the estimated
5-year risk of SCD. The incidence of SCD almost doubles for each 5-mm increase
in wall thickness. Patients with wall thickness 30–34 mm have the greatest risk of
SCD. The extreme hypertrophy ≥ 35 mm is very rare, and there is a lacking body of
evidence regarding the risk of SCD in such patients.
Abnormal BP response to exercise (failure to increase systolic An increased risk of SCD in patients < 40 years old or with family history of SCD.
BP by at least 20 mm Hg from rest to peak exercise or a fall of
>20 mm Hg from the peak exercise BP during ongoing exercise)
Nonsustained ventricular tachycardia (VT; ≥ 3 consecutive Conflicting data. It is reasonable to assume an increased risk if nonsustained VT occurs
ventricular beats at 120 beats per minute lasting < 30 sec) in the young and if the episodes are prolonged, fast, repetitive, or associated with
impaired consciousness.
SCD indicates sudden cardiac death; LV, left ventricular; BP, blood pressure.
limitations. It should not be used in pediatric patients < 16 years old, prevention). However, there are many complications after device
elite or competitive athletes, HCM associated with metabolic diseases therapy, for example, inappropriate ICD discharges (25%), lead
and genetic syndromes, and in patients for whom ICD is an option for dysfunction (6–13%), infection (4–5%), bleeding or thrombosis
secondary prevention. The most important information regarding the (2–3%).96–98 Therefore, it is of utmost importance to carefully choose
risk factors used in the HCM SCD-Risk Calculator are presented in those patients in whom the benefits of ICD therapy outweigh the
Table 2.44,62,65,67–72 risks. It is recommended that patients who have ≥ 4% risk in the
HCM Risk-SCD Calculator, at least 2 major risk factors, LV api-
Low-Risk Patient Profile cal aneurysm, or end-stage HCM undergo ICD. Additionally, pri-
Limited data suggest that a patient with the features listed in mary prevention may be reasonable in patients with moderate risk
Table 3 may have an incidence of SCD 0.2–0.4% per year.15,20,73 and massive LVH ≥ 30 mm, family history of SCD due to HCM,
or recent unexplained syncope. The presence of extensive late gad-
Other Potential Prognostic Factors
olinium enhancement on CMR may be useful to make a decision
Although the SCD risk stratification algorithms are getting with patients having 1 major factor and otherwise uncertain risk
more accurate, there are still a number of factors worth considering. stratification.25,49,50,61,62,76
The potentially prognostic features collected in Table 4 may be use-
ful in resolving often difficult and uncertain decisions concerning Pharmacologic Treatment
implementation of an ICD.2,3,22,25,36,74–95 There is no evidence that pharmacologic therapy provides
any protection against SCD due to malignant ventricular arrhyth-
THE PREVENTION OF SUDDEN CARDIAC DEATH mias in patients with HCM.99 Therefore, there are no recommen-
dations to suppress arrhythmia in the asymptomatic patient with
Cardioverter Defibrillator Implantation premature ventricular beats or nonsustained VT.50,100 Neverthe-
The ICD is the best available therapy for HCM patients who less, symptomatic patients are usually treated with amiodarone
have survived sudden cardiac arrest (secondary prevention) or who and a beta blocker (eg, a nonvasodilating one, or if a patient has
are at high risk of potentially lethal ventricular arrhythmias (primary an ICD, use sotalol).
148 | www.cardiologyinreview.com © 2017 Wolters Kluwer Health, Inc. All rights reserved.
ACKNOWLEDGMENTS 23. Adabag AS, Casey SA, Kuskowski MA, et al. Spectrum and prognostic sig-
nificance of arrhythmias on ambulatory Holter electrocardiogram in hypertro-
The authors thank Dr. Margarita Lianeri for her editorial assistance. phic cardiomyopathy. J Am Coll Cardiol. 2005;45:697–704.
24. Monserrat L, Elliott PM, Gimeno JR, et al. Non-sustained ventricular tachy-
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