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Abstract

Taking into account the complexity and limitations of clinical assessment in hypertrophic cardiomyopathy (HCM), imaging techniques play an essential role in the evaluation of patients with this disease. Thus, in HCM patients, imaging provides solutions for most clinical needs, from diagnosis to prognosis and risk stratification, from anatomical and functional assessment to ischaemia detection, from metabolic evaluation to monitoring of treatment modalities, from staging and clinical profiles to follow-up, and from family screening and preclinical diagnosis to differential diagnosis. Accordingly, a multimodality imaging (MMI) approach (including echocardiography, cardiac magnetic resonance, cardiac computed tomography, and cardiac nuclear imaging) is encouraged in the assessment of these patients. The choice of which technique to use should be based on a broad perspective and expert knowledge of what each technique has to offer, including its specific advantages and disadvantages. Experts in different imaging techniques should collaborate and the different methods should be seen as complementary, not as competitors. Each test must be selected in an integrated and rational way in order to provide clear answers to specific clinical questions and problems, trying to avoid redundant and duplicated information, taking into account its availability, benefits, risks, and cost.

Hypertrophic cardiomyopathy, Left ventricular hypertrophy, Echocardiography, Cardiac magnetic resonance, Cardiac computed tomography, Cardiac nuclear imaging, Multimodality imaging
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: [email protected].
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2 Comments
Comments (2)
"Re:""Role of multimodality cardiac imaging in the management of patients with hypertrophic cardiomyopathy: an expert consensus of the European Association of Cardiovascular Imaging Endorsed by the Saudi Heart Association""Cardim, et al., 16 (3): 280-280 doi:10.1093/ehjci/jeu291"
24 March 2015
Nuno Cardim , Chair
Role of multimodality cardiac imaging in the management of patients with HCM:an expert consensus of the EACVI
We are grateful to Dr. Barriales-Villa and colleagues for their interest and insights regarding the assessment of left atrial (LA) dimensions in hypertrophic cardiomyopathy patients in our consensus paper. (1)
We absolutely agree (on-line with the ESC guidelines) (2), that the antero-posterior LA (AP-LA) diameter should be used in the assessment of SCD risk using the 5 years SCD risk prediction model. This evidence-based data is clearly stated in the text (section “MMI according to clinical evolution profiles: Profile SCD”) and shown in Figure 23, where the AP-LA is used (1). The same measurement may also be selected, as stated, to predict atrial fibrillation (AF) in HCM.
The time-honored linear AP-LA diameter (measured in the parasternal long-axis view using M-mode or 2D echocardiography) continues to be widely used in clinical practice to assess LA size, However, it is well known (as Dr. Barriales-Villa and colleagues also state), that it does not represent an accurate picture of LA size because it assumes that when the LA enlarges, all its dimensions change similarly, which is often not the case in LA remodeling.
Therefore, when assessing the LA size and remodeling in every heart disease, the measurement of LA volume index is recommended. This is emphasized even in the 2015 EACVI/ASE recommendations on chamber quantification (3). Evaluation of volume takes into account alterations in LA chamber size in all directions and LA volume has been shown to be a powerful prognostic variable in a variety of cardiac disease states. Compared with AP diameter, LA volume has a stronger association with outcomes in cardiac patients. (4,5)
LA volume index can be easily assessed from the apical view and its normal range, reproducibility and clinical role have been determined, in a number of cardiac diseases, including HCM, where this measurement should be used, in the assessment of diastolic function according to the EACVI/ASE recommendations (6), in the prediction of AF (7) and in defining prognosis. (8)
Nuno Cardim and Maurizio Galderisi
Chair and Co-chair of the Role of multimodality cardiac imaging in the management of patients with HCM: an expert consensus of the European Association of Cardiovascular Imaging. European Heart Journal
1-Cardim N, Galderisi M, Edvardsen T, Plein S, Popescu BA, D’Andrea A et al. Role of multimodality cardiac imaging in the management of patients with HCM: an expert consensus of the European Association of Cardiovascular Imaging. European Heart Journal – Cardiovascular Imaging 2015; 16:280
2-2014 ESC Guidelines on diagnosis and management of HCM. The Task Force for the Diagnosis and Management of HCM of the European Society of Cardiology. European Heart Journal 2014;35, 2733–2779
3-Lang R, Badano L, Mor-Avi, V,Afilalo J ,Armstrong A, Ernande L et al. Eur Heart J -Cardiovasc Imaging 2015: 233–271
4-Tsang TS, Barnes ME, Bailey KR, Leibson CL, Montgomery SC, Takemoto Y et al. Left trial volume: Important risk marker of incident atrial fibrillation in 1655 older men and women. Mayo Clin Proc 2001:467–475
5-Pritchett AM, Jacobsen SJ, Mahoney DW, Rodeheffer RJ, Bailey KR, Redfield MM. Left atrial volume as an index of left atrial size: a population-based study. J Am
Coll Cardiol 2003:036–1043
6-Nagueh S, Appleton C, Gillebert T, Marino P, Oh J, Smiseth O et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography. Eur J  Echocardiogr 2009:  165–193
7-Losi M, Betocchi S, Aversa M, Lombardi R, Miranda M, D'Alessandro G, et al.Determinants of atrial fibrillation development in patients with hypertrophic cardiomyopathy.Am J Cardiol. 2004 Oct 1;94(7):895-900
8-Yang H, Woo A, Monakier D, Jamorski M, Fedwick K, Wigle ED et al. Enlarged left atrial volume in hypertrophic cardiomyopathy: a marker for disease severity. J Am Soc Echocardiogr 2005:1074 – 82
Submitted on 24/03/2015 8:00 PM GMT
Re: " Role of multimodality cardiac imaging in the management of patients with hypertrophic cardiomyopathy: an expert consensus of the European Association of Cardiovascular Imaging Endorsed by the Saudi Heart Association " Cardim, et al., 16 (3): 280-280 doi:10.1093/ehjci/jeu291
3 March 2015
Roberto Barriales-Villa , Inhertited Cardiovascular Disease Unit , Ruth Pérez-Fernández , Stress Echocardiography Unit , Jesús Peteiro , Stress Echocardiography Unit
Department of Cardiology, Complexo Hospitalario Universitario de A Coruña(Spain)
We congratulate the authors of the expert consensus on the role of multimodality cardiac imaging in the management of patients with hypertrophic cardiomyopathy (HCM)(1), but we would like to make a comment to this position paper, as they state that left atrium (LA) volume need to be assessed during a comprehensive echocardiographic examination in these patients. Prediction of sudden cardiac death (SCD) is the most controversial issue in HCM. In the new ESC HCM Guidelines (2), it is recommended that patients undergo a standardized clinical evaluation that records a predefined set of prognostic variables, which are then used to estimate the 5-year risk of SCD using the HCM Risk-SCD model (Recommendation IB). The new SCD risk model helps clinicians to simplify this controversial aspect and in a head to head comparison with a model using four major risk factors, the performance of the prediction model improved substantially (C-index from 0.54 to 0.7)(2). The problem is that in this SCD prediction model, only the antero-posterior left atrium (AP-LA) diameter is considered, not the volume. We can be critic with this inclusion, but the current evidence supports it. Two studies have reported a positive association between LA diameter and SCD (3,4). However, there are no data on the association between SCD and LA area and volume. Probably in future the LA volume will be included, but until this occur the AP-LA diameter is crucial when you want to predict SCD in these patients. Moreover, the new ESC guidelines, consider that LA size is a consistent predictor for atrial fibrillation and stroke in patients with HCM, and recommend (IIa) that patients in sinus rhythm with LA diameter ≥45mm should undergo 6–12 monthly 48-hour ambulatory ECG monitoring to detect atrial fibrillation (2). Although it has been shown that LA volume offers higher prognostic information than LA diameter in different cardiac diseases (5), we think that due to the above mentioned evidence with LA diameter, this measurement should be included in this consensus References (1) Cardim N, Galderisi M, Edvardsen T, Plein S, Popescu BA, D’Andrea A et al. Role of multimodality cardiac imaging in the management of patients with HCM: an expert consensus of the European Association of Cardiovascular Imaging Endorsed by the Saudi Heart Association. European Heart Journal – Cardiovascular Imaging 2015;16:280 (2) 2014 ESC Guidelines on diagnosis and management of HCM. The Task Force for the Diagnosis and Management of HCM of the European Society of Cardiology. European Heart Journal 2014;35, 2733–2779 (3) O’Mahony C, Jichi F, Pavlou M, Monserrat L, Anastasakis A, Rapezzi C et al. A novel clinical risk prediction model for sudden cardiac death in hypertrophic cardiomyopathy. Eur Heart J 2014;35:2010–2020. (4) Spirito P, Autore C, Rapezzi C, Bernabo P, Badagliacca R, Maron MS et al  Syncope and risk of sudden death in HCM. Circulation 2009;119:1703–1710. (5) Moller JE, Hillis GS, Oh JK, Seward JB, Reeder GS, Wright RS, et al. Left atrial volume A powerful predictor of survival after acute myocardial infarction. Circulation 2003;107:2207-12
Submitted on 03/03/2015 12:00 AM GMT