Post on 25-May-2018
transcript
©2011 MFMER | slide-1
Hypertrophic Cardiomyopathy:What’s new in the Guidelines and how does it impact clinical practice
Steve R. Ommen, MDDirector, Mayo Hypertrophic Cardiomyopathy ClinicProfessor of Medicine
©2011 MFMER | slide-3
Guideline
• Advice
• Recommendation, but not mandatory
As opposed to “policy” which is meant to ensure compliance
©2011 MFMER | slide-4
An expert is a person who has made all the mistakes which can be made in a very narrow field.
-paraphrased from Neils Bohr
©2011 MFMER | slide-5
ACC/AHA & ESC Guideline Comparison
• What is the same?
• Families need to be screened
• Standard testing includes
• ECG, Holter, Transthoracic echo +/- MRI
• Medications first for obstruction
• SCD risk needs to be assessed in every patient
• VKA for atrial fibrillation
• Follow up with prudent testing
©2011 MFMER | slide-6
ACC/AHA & ESC Guideline Comparison
What is the same?
Centers with experience / expertise should be involved:
specialized imaging
therapeutic procedures
©2011 MFMER | slide-7
ACC/AHA & ESC Guideline Comparison
What is different in ESC?
• More specific details
• No preference regarding septal reduction therapy
• New SCD risk prediction tool
©2011 MFMER | slide-9
How do we know which patients will
need a defibrillator?
05
1015202530
Cu
mu
lati
ve %
(3.7
+/-
2.8
years
)
©2011 MFMER | slide-10
Nonsustained
Ventricular
Tachycardia
• Rest
• Exercise
Severity of LVH
Abnormal Exercise
BP
Response
Unexplained
Syncope
Family History of
Sudden Death
Fibrosis or scar
Role of Isolated
Myofilament
Mutations
Outflow
Obstruction
SCD In HCM
©2011 MFMER | slide-11
Which HCM Pt needs ICD?Risk Factors Recommendation
0 Reassurance
1 Individualize
2+ Recommend ICD
Prior SCD Recommend ICD
Sustained VT Recommend ICD
©2011 MFMER | slide-12
Young age
MLVWT approaching 30 mm
Remote or Unclear FHSCD
LVOTO and no planned intervention
Delayed enhancement
Septal Ablation
Known specific mutations
Syncope in past 5 years
©2011 MFMER | slide-13
Receiver operating characteristic (ROC(t)) curves for the American College of Cardiology/European
Society of Cardiology (ACC/ESC) and ACC Foundation/American Heart Association (ACCF/AHA)
guidelines.
O'Mahony C et al. Heart 2013;99:534-541
Copyright © BMJ Publishing Group Ltd & British Cardiovascular Society. All rights reserved.
©2011 MFMER | slide-15
49 yo male
Echo
Wall thickness = 21 mm
Non-obstructive
Exercise Test
121% FAC
©2011 MFMER | slide-16
Recommended (4/28/2008):
24 Hour Holter Monitor
Continue current meds
No competitive sports
49 yo male
7/26/2008
Died,
Hiking
©2011 MFMER | slide-19
Risk Stratification is Imperfect
…if we expect to tell us yes or no for any individual patient
©2011 MFMER | slide-20
Change the Mindset
Risk Stratification helps contextualize
risk
We help patients make decisions
©2011 MFMER | slide-23
Help Patients Make Decisions
The decision for placement of an ICD in HCM patients should include prudent application of
individual clinical judgment, as well as thorough discussion of the strength of evidence, benefits,
and risks to allow active participation of the informed patient in decision-making
“…other clinical features that are of potential prognostic importance and when the likely benefit
is greater than the lifelong risk of complications and the impact of an ICD on lifestyle, socioeconmic
status and psychological health”
©2011 MFMER | slide-24
Advocate, counsel, inform…..
If the patient is going to leave the office afraid to live because they might
die…then that’s the patient who should
strongly consider ICD