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THE NATURAL HISTORY OF DILATED CARDIOMYOPATHY (DCM)Thomas Zegkos
Cardiomyopathies Lab
AHEPA University Hospital
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DEFINITION OF DILATED CARDIOMYOPATHY
“The presence of left ventricular dilatation and left ventricular systolic dysfunction in the absence of abnormal loading conditions (hypertension, valve disease) or coronary artery disease sufficient to cause global systolic impairment”.
Elliot P et al. EHJ 2008
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CAUSES OF DCM
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CAUSES OF DCM IN PATIENTS WITH INITIALLY UNEXPLAINED CARDIOMYOPATHY
Felker et al NEJM 2000
Disorder05
101520253035404550
IDCM
Myocarditis
Ischmic CM
Infiltrative disease
Peripartum CM
Hypertension
HIV
CTD
Substance abuse
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EPIDEMIOLOGY OF IDCM
ANNUAL INCIDENCE 5-8/100,000
PREVALENCE 36/ 100,000
INCREASED RISK ASSOCIATED WITH: MALE GENDER BLACK RACE CHRONIC BETA-AGONIST USE
Dec GW, Fuster V. NEJM 1994;331:1564-75
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FAMILIAR DCM
Over 20-50% of patients with IDCM Over 30 genes responsible have been discovered
GENESLamin A/Cδ-sarcoglycanDystrophinDesminVinculinTitinTroponin-Tα-tropomyosinß-myosin heavy chainActinMitochondrial DNA mutations
Fatkin D, et al. NEJM 1999;341
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LAMINOPATHIES
6% of all DCM patients 7.5% of familiar forms 33% of DCM patients with conduction disturbances
Parks S, et al, Am Heart J 2008
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CLINICAL PRESENTATION OF DCM
Heart failure symptoms 75%-85%
Chest angina 8%-20%
Emboli (systemic or pulmonary) 1%-4%
Syncope <1%
Sudden cardiac death <1%
Dec GW, Fuster V. NEJM 1994;331:1564-75
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DCM EVALUATION
Detailed family history and screening of first degree relatives if necessary Complete blood count Metabolic panel Thyroid function tests Cardiac biomarkers B-type natriuretic peptide assay Chest radiography Echocardiography Cardiac magnetic resonance imaging (MRI) Electrocardiography (ECG) Endomyocardial biopsy may be useful in case of:
Recent onset of rapidly deteriorating cardiac function Patients receiving chemotherapy with doxorubicin Patients with systemic diseases with possible cardiac involvement (eg,
hemochromatosis, sarcoidosis, amyloidosis, Löffler endocarditis, endomyocardial fibroelastosis)
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NATURAL HISTORY OF DCM
HEART FAILURE AND FUNCTIONAL STATUS
SUR
VIV
AL
Asymptomatic
100%
0Mild Moderate Severe
ANNUAL MORTALITY
< 5% 10% 20 - 30 % 30 - 80%
CAUSE OF DEATHΥ
SUDDEN DEATH 40%CONGESTIVE HEART FAILURE 40%
OTHER CAUSES 20%
Acute event
V McMurray JJ, et al. Lancet 2005
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CAUSES OF DEATH BASED ON NYHA CLASS
MERIT-HF study group. LANCET 1999
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DIFFERENCES IN NATURAL HISTORY OF DCM ETIOLOGIES
Felker et al NEJM 2000
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SURVIVAL IN IDCM VERSUS MYOCARDITIS
0
20
40
60
80
100
0 2 4 6Years
Surv
ival
(%
)
Myocarditis (n=27)IDCM (n=58)
Grogan, et al JACC 1995
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SURVIVAL IN IDCM VERSUS ALCOHOLIC DCM
Merello G, et al JACC: HEART FAILURE 2015
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SURVIVAL IN IDCM VERSUS SARCOIDOSIS CARDIOMYOPATHY
Yazaki Y, et al. Am J Cardiol 1998
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NATURAL HISTORY OF LAMINOPATHIES
Age related penetrance with early onset atrial arrhythmias followed by conduction disease, often with mild LV dilatation and systolic dysfunction.
Over 60% of patients experience cardiovascular death or major cardiovascular events by the age of 45
46% of mortality of carriers due to sudden death
Taylor G, et al. JACC 2003Van Berlo J, et al. J Mol Med 2005
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PROGNOSTIC FACTORS OF DCM
ECHOCARDIOGRAPHIC FINDINGS Degree of impairment in LVEF Extent of left ventricular enlargement Diastolic dysfunction Coexistent right ventricular dysfunction
CLINICAL FINDINGS Favorable prognosis: NYHA < IV, younger age,
female sex Poor prognosis: Syncope, persistent S3 gallop, right-
sided heart failure, atrial fibrillation, AV or bundle branch block, hyponatremia, troponin elevation, increased BNP, maximum oxygen uptake < 12 mg/kg/min
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AHA/ACC 2013 AND ESC 2015 INDICATIONS FOR ICD IMPLANTATION IN DCM
Predictors of SCD used in the guidelines also predict overall mortality and simply reflect severity of disease.
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45 studies. 6088 DCM patients enrolled
Goldberger J, et al. JACC 2014
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SYNCOPE IN DCM
Syncopal events imply a higher risk of SCD regardless of the proven etiology of the syncope.
These patients with ICD implantation receive similar clinical benefits to secondary prevention cases.
Knight B, et al. JACC 1999
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LATE GADOLINIUM ENHANCEMENT
Gulati A, et al. JAMA 2013
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LAMINOPATHIES RISK FACTORS FOR MAJOR EVENTS IN 269
PATIENTS Baseline LVEF < 45% Non-sustained ventricular tachycardia Male gender
van Rijsingen IA, et al. JACC 2012
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373 patients with an evaluation consistent with IDCM or myocarditis
Fewer than 6 months of symptom duration
McNamara D et al. JACC 2011
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LVEF IMPROVEMENT IN IDCM AFTER OMT (IMAC2 STUDY)
Solid bars: lvedd <6,00 cm
Shaded bars: lvedd 6,00 to 7,00 cm
Open bars: lvedd >7,00 cm
McNamara D et al. JACC 2011
• 70% demonstrated an increase of 10 ejection fraction units,• 39% demonstrated an increase of 20 U or more.• In 25% the LVEF had normalized (0.50 or more).
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LVEF IMPROVEMENT IN ALCOHOLIC DCM
Merello G, et al JACC: HEART FAILURE 2015
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LVEF IMPROVEMENT IN CHEMOTHERAPY INDUCED DCM
Cardinale D, et al JACC 2010
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LVEF IMPROVEMENT IN CARDIAC SARCOIDOSIS
Chou CZ, et al. Am J Cardiol 2004
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ROLE OF LVEF IMPROVEMENT ON THE NATURAL HISTORY OF DCM
Steimle AE, et al. JACC 1994;23:553-9
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SURVIVAL IN IDCM (1975-2000)
25-30% annual mortality 50% five-year mortality
Dec GW, Fuster V. NEJM 1994;331:1564-75
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SURVIVAL IN IMAC2 (2011)
94% transplant free survival at 1st year
88% at 4 years
McNamara D et al. JACC 2011
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603 patients with IDCM 4 enrollment periods:
Castelli G, et al. Circ Heart Fail. 2013
1977-1984: pre ACEI
1985-1990: ACEI introduction
1991-2000: B-blockers introduction
2001-2011: Devices introduction
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CHANGES IN MANAGEMENT OF DCM
Castelli G, et al. Circ Heart Fail. 2013
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CHANGES IN MANAGEMENT OF DCM
Castelli G, et al. Circ Heart Fail. 2013
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CARDIOVASCULAR AND HEART FAILURE MORTALITY REDUCTION
HF mortality decreased: 53% for period 2 74% for period 3 90% for period 4compared to period 1
5 year event-free rate: 62% for period 1 74% for period 2 84% for period 3 93% for period 4
Castelli G, et al. Circ Heart Fail. 2013
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SUDDEN DEATH RATE REDUCTION
87% risk reduction in period 2000-2010 compared to period 1977-1984
Castelli G, et al. Circ Heart Fail. 2013
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AHEPA CARDIOMYOPATHIES CENTER COHORT
183 DCM patients
Idiopathic Familiar Myocarditis Alcoholic Chemotherapy Other0
5
10
15
20
25
30
35
40 37.7
24
10.4 9.8
0.5
17.6
%
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AHEPA CARDIOMYOPATHIES CENTER COHORT
183 DCM patients
CEI/ARB B-Blocker Diuretics MRA0
10
20
30
40
50
60
70
80
77.6 75.4
64.5
44.3
%
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AHEPA CARDIOMYOPATHIES CENTER COHORT
After a mean follow up of 6±4 years, 9,8% died NYHA class and LVEF were independent predictors
P=0,02 P=0,009
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AHEPA CARDIOMYOPATHIES CENTER COHORT
1,6% suffered SCD 18% of the patients received ICD
Primary prevention Secondary prevention0
10
20
30
40
50
60
70
80
78.8
21.2
ICD %
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AHEPA CARDIOMYOPATHIES CENTER COHORT
21% of ICD patients received appropriate interventions
Primary Prevention Secondary prevention0
10
20
30
40
50
60
11.5
57.1
Appropriate interventions %
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CONCLUSIONS
DCM is an heterogeneous disease with variable natural history.
The natural history of DCM has changed substantially over the last decades.
The prognostic factors of DCM, especially for SCD, still remain a subject of controversy.
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THANK YOU