HCM Treatment: The View from OHSU

If you are looking for a good survey of current practices in the treatment of HCM, a recent article published in the journal Structural Heart by Dr. Ahmad Masri and the team at Oregon Health and Sciences University (OHSU) provides an informative overview of thirty controversies and considerations in the treatment of HCM. This article explains in some detail how the doctors at this HCM Center approach these situations. 

This article, along with the brand new 2020 AHA/ACC HCM Guidelines, will tell you everything there is to know about the contemporary treatment of HCM.  For a short summary of all things HCM, you can also visit the page on this website entitled “Hypertrophic Cardiomyopathy-HCM for Short.”

The issues and concepts discussed in this article are as follows:

SCREENING OF HCM FAMILY MEMBERS:

  • How often should HCM family members be screened? 
  • Do children under 12 need to be screened?
  • What are the clinical implications of obstruction?
  • Are deformation imaging and strain analysis meaningful on echocardiogram?
  • How often should cardiac MRI be repeated?
  • What is the utility of cardiopulmonary exercise testing?
  • What are the implications of HCM genotype?
  • Do gene negative relatives need further screening?

QUESTIONS ABOUT DRUGS USED IN HCM TREATMENT:

  • Can disopyramide (Norpace) be started on outpatient basis?
  • Is ranolazine (Ranexa) useful in HCM?
  • Are anticoagulants needed in HCM patients with apical aneurysm?
  • Are anti-arrhythmics drugs useful in the treatment of HCM?

RISK STRATIFICATION (OR WHO NEEDS AN ICD?):

ELECTROPHYSIOLOGY ISSUES IN HCM

  • Is rhythm control better than rate control for atrial fibrillation?
  • Is catheter ablation preferable to anti-arrhythmic drugs in atrial fibrillation?
  • Is the S-ICD a good option for HCM patients?
  • Should patients at lower risk of sudden death with A-V block get a pacemaker or ICD?
  • Is there a role for the CHA2DS2-VASc score for HCM patients with atrial fibrillation?
  • What is the role of ventricular tachycardia ablation in HCM?

MANAGEMENT OF PATIENTS WHO DON’T RESPOND TO MEDICATION:

  • Which is preferable, myectomy or alcohol septal ablation?
  • Should additional surgical procedures be used to reduce outflow tract obstruction and systolic anterior motion of the mitral valve?
  • Are there any consequences resulting from left branch bundle block after myectomy?
  • Should transapical myectomy be a treatment option?
  • What is the role of the mitral valve repair via MitraClip in HCM?

Click here to access the article.

Atrial Fibrillation May Cause Negative Outcomes in HCM

 

A recent study published in Clinical Research in Cardiology  found that atrial fibrillation is a frequent complication of HCM and can be an important predictor of negative outcomes.

These findings suggest that practitioners should aggressively screen for and treat atrial fibrillation in HCM patients to improve long term outcomes.

Atrial Fibrillation? Try Giving Up Alcohol

A recent study published in the New England Journal of Medicine found that drinkers suffering from atrial fibrillation who stopped drinking for the period of the study significantly reduced episodes of atrial fibrillation. 

According to doctors, alcohol consumption appears to be a significant risk factor and trigger for atrial fibrillation, while teetotaling appears to have a profound impact.

Dr. John Osborne, an American Heart Association spokesperson, said the benefit from giving up drinking was similar to results seen from drugs used to treat atrial fibrillation.  Even if patients are not able to completely abstain from alcohol, Osborne advised cutting back significantly. “It costs nothing and led to a substantial reduction in hospital rates. People in the abstinence group also lost an average of 3.8 kilograms [8.4 pounds] in six months,” he said.

Not everyone thinks that teetotaling is a workable treatment for afib, however. Critics say that encouraging abstinence is unrealistic and is not a permanent solution to the problem.  In fact, a planned follow-up study had to be shortened due the difficulty of finding participants willing to abstain from drinking for a whole year.

 

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Apple Watch Spots AFib

The software update which allows the Apple Watch 4 to take an EKG and to detect atrial fibrillation went live last week. In anticipation of the availability of these functions, I purchased an Apple Watch 4.  As soon as the software was available, I downloaded it and have used it every day since. So far, I am quite pleased with my purchase.  The technology works very well, even despite the fact that I have an implantable pacemaker/defibrillator.

The strip it takes looks like this:

EKG Picture Apple WAtch

You can send a strip via email to your doctor, and all are saved for posterity on your Iphone.  (NOTE:  YOU MUST HAVE AN IPHONE CAPABLE OF RUNNING THE SOFTWARE IN ORDER TO USE THE WATCH).

And, as long as you tell the software that you have never been diagnosed with atrial fibrillation, if it detects atrial fibrillation while you wearing the watch, it will send you an alert.  I haven’t gotten such an alert yet and hope not to!

This article provides a pretty accurate history of handheld consumer EKG devices along with a description of what it is like to download and use the Apple software.

And here is a story about a man whose watch spotted his previously undiagnosed Afib. After a trip to the emergency room, he was able to receive proper treatment and avert a potential health crisis.

 

HCM Researchers Put their Heads Together to Improve Lives of HCM Patients

A recent paper published in the journal Circulation looked at the clinical course of approximately 4,600 HCM patients over the course of more than 24,000 clinical years, which the paper describes as the largest comprehensive cohort of HCM patients ever studied.

This study examined patients from eight high volume HCM centers which aggregated their institutional data into a database known as the Sarcomere Human Cardiomyopathy Registry (or the acronym the “SHaRe” for short). The results of the study showed that, in general, HCM patients are at substantially elevated risk for atrial fibrillation and heart failure, and have significantly higher mortality rates than that of the general U.S. population.

Continue reading “HCM Researchers Put their Heads Together to Improve Lives of HCM Patients”

Atrial Fibrillation: Treatable HCM Complication

A recent paper by doctors at Tufts University’s HCM Center found that transient episodes of atrial fibrillation (AF) are treatable and do not often progress to permanent AF.

This study found that AF was not a frequent cause of death by heart failure or sudden cardiac arrest.  However, the researchers identified AF as an important cause of stroke in HCM patients.  Therefore, they recommend a low threshold for starting HCM patients on anti-coagulants following an initial AF episode.

Researchers in this study analyzed statistics from 1558 HCM patients, 20% of whom experienced AF.  74% experienced only sporadic episodes, while 26% went on to develop permanent AF.

At the time of publication, 91% of the 277 of the patients included in the sample were still alive and between the ages 49 and 75 years old.

According to an accompanying editorial by Italian HCM expert Dr. Paolo Spirito, the outlook for HCM patients with atrial fibrillation has improved over the last twenty years due to significant advances in HCM treatment over that time period such as ICD implantation and myectomy, along with aggressive anti-coagulation for atrial fibrillation patients.

Spirito also noted that it is difficult to predict whether a given HCM patient will go on to develop permanent Afib after a single episode since many will not.  Additionally, permanent afib can be well tolerated when there is contemporaneous control of heart rate.  Therefore,  anti-arrhythmic medications, which can cause unpleasant side effects, may not be necessary for HCM patients with afib as long as anti-coagulation measures are taken.

 

 

 

Could Your Fitbit Detect AFib?

The same Fitbit you wear to count your steps may soon have an additional purpose:  it could detect atrial fibrillation.

Atrial fibrillation is an irregular heartbeat which could cause a stroke if not properly treated.  Yet, it often goes unnoticed by a person experiencing it.

According to this story in Time, Fitbit is  developing software which would enable its existing trackers to detect afib, and thus allow time for appropriate action before it is too late.

This technology could be of great benefit to heart patients.  Not only does the Fitbit encourage you to exercise, it might just save your life!

Aspirin May Cause More Harm than Good in Afib

According to new research presented at last week’s meeting of the Heart Rhythm Society, aspirin is not effective in preventing strokes in patients with atrial fibrillation, and in some instances may actually do more harm than good.

Note that previous studies have demonstrated that aspirin is not effective in preventing strokes from Afib.

In fact, the study, led by Dr. Jared Bunch from Intermountain Healthcare system, Salt Lake City, UT, found that patients who were prescribed aspirin following catheter ablation procedures to treat atrial fibrillation were significantly more likely to suffer gastrointestinal or genitourinary bleeding than those who took other anticoagulants like warfarin, or those who received no treatment at all.

For more, see these articles from  Medical News Today  and Science Times (with link to video).

 

Can Your Apple Watch Spot Afib?

According to preliminary data presented this week at the Heart Rhythm Society’s annual meeting, the Apple watch. together with an app called Cardiogram, spots atrial fibrillation with 97% accuracy. 

Start-up tech company Cardiogram paired up with electrophysiologists at the University of California, San Francisco to try out the technology on patients awaiting cardioversion for atrial fibrillation.  51 patients at UCSF agreed to wear Apple Watches during their cardioversion procedures.

Heart rate samples were obtained before the procedure, when the patient was in atrial fibrillation, and again afterward when heart rhythm had been restored to normal. The researchers found that the Apple Watches were able to detect afib 97% of the time.

The Cardiogram and UCSF teams hope to publish their findings in a peer-reviewed journal while Cardiogram hopes it can make this information useful to consumers.  One possibility would be to have the watch send a notification to the wearer that s/he appears to be in afib should contact her/his care provider immediately.

If you are interested in participating in this research, click here.

Read more about it at TechCrunch, BuzzFeedApple Insider and CNET,

Catheter ablation useful for AFib in HCM

A recent article published in Heart looked at the safety and effectiveness of catheter ablation for the treatment of Atrial Fibrillation in patients with HCM by performing a systematic review of prior publications on the subject.

The researchers concluded that even though the success rate for HCM patients was approximately half that of patients who suffered from AFib but did not have HCM, catheter ablation is still an effective treatment for HCM patients;  especially for those HCM patients who suffer from paroxysmal AFib and who have smaller atria.