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Time-trends in the decision of a primary prevention strategy implementation in patients with hypertrophic cardiomyopathy
Session:
Sessão de Posters 45 - Miocardiopatia hipertrófica
Speaker:
Miguel Marques Antunes
Congress:
CPC 2024
Topic:
F. Valvular, Myocardial, Pericardial, Pulmonary, Congenital Heart Disease
Theme:
17. Myocardial Disease
Subtheme:
17.4 Myocardial Disease – Treatment
Session Type:
Cartazes
FP Number:
---
Authors:
Miguel Marques Antunes; Inês Ferreira Neves; Pedro Garcia Brás; Inês Gracio Almeida; José Viegas; Isabel Cardoso; André Ferreira; Guilherme Portugal; Pedro Silva Cunha; Rui Cruz Ferreira; Mário Martins Oliveira; Sílvia Aguiar Rosa
Abstract
<p><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><strong>Background:</strong> Hypertrophic cardiomyopathy (HCM) is a prevalent and potentially life-threatening condition. While the body of knowledge on this disease has progressed substantially, sudden cardiac death (SCD) prediction remains sub-optimal. Implantable cardioverter-defibrillators (ICD) have robust evidence supporting prevention of SCD in patients (P) in secondary prevention. However, the clinical decision on the use of these devices in primary prevention remains a matter of debate. From 2014 to 2023, the European Society of Cardiology (ESC) has emanated several recommendations regarding ICD implantation in primary prevention in P with HCM. </span></span></p> <p><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><strong>Objective</strong>: To evaluate time trends in the decision-making process of ICD implantation in primary prevention for P with HCM. </span></span></p> <p><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><strong>Methods:</strong> We retrospectively analyzed data from P followed in a Cardiomyopathy Clinic. P characteristics, remote monitoring information, echocardiographic, and magnetic resonance imaging (CMR) data were recorded. We then classified P according to 3 groups (ICD not recommended, ICD may be considered, ICD should be considered) - in line with the 2014, 2022 and 2023 ESC Guidelines (GL). Classification into these groups started with the use of the HCM Risk SCD calculator (high >6%, intermediate 4-6% and low <4% 5-year risk). Significant late gadolinium enhancement (LGE) at CMR (≥15% of LV mass), LVEF <50%, left ventricular apical aneurysm (AA) and sarcomeric pathogenic mutations were effect modifiers for P in the intermediate risk group for the 2022 SCD GL. LGE, LVEF <50% and AA were considered risk-enhancers for the low-risk group in the 2022 SCD GL, while only the first two were considered in the 2023 GL (Table 1). </span></span></p> <p><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><strong>Results:</strong> 42 P with a median age of 56 [46-67] years, 26 (46%) of which male, were included (Table 2) - amounting a total of 26 568 days (72 years) at risk, averaging 1.7 patient/years. Median HCM SCD risk score was 4.75 [3.33-5.9] - classifying as an intermediate risk. There were no downgrades in the strength of recommendation since the 2014 HCM GL (Figure 1). The 2022 SCD GL had the highest number of P (52%) in the strongest recommendation group, with the main driver for upgrade being the presence of LGE >15%. The 2023 Cardiomyopathy GL had the highest number of P in the intermediate recommendation group – 27 (64%). There were 4 ICD-appropriate therapies – 3 shocks and 1 anti-tachycardia pacing. Of these, 2 happened in the high-risk group (1 ventricular fibrillation and 1 ventricular tachycardia (VT)), 1 in the intermediate-risk group and 1 in the low-risk group, both for VT. </span></span></p> <p><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><strong>Conclusion:</strong> GL recommendations have generally increased the strength of recommendation for ICD implantation in recent years, with varying degrees of certainty regarding risk modifiers. ICD implantation in primary prevention remains a matter of debate and risk-prediction models are still sub-optimal.</span></span></p>
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