ࡱ> OQN /bjbj 4Rrr'$$$$l$$!;!=!=!=!=!=!=!$#v&Xa!a!v!6;!;!:E,Koq '!!0!{R&kv&n&;a!a!!&$ : ,The Diagnosis of Cardiomyopathy: The Cost of Lost Opportunity Mandeep R Mehra1, Lushna M. Mehra2, Patricia A. Uber3 1Brigham and Womens Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA; 2Tufts University, Boston, MA; 3University of Hawaii School of Pharmacy, Hilo, HI CORRESPONDING AUTHOR Mandeep R. Mehra, MD, Medical Director, BWH Heart and Vascular Center, Professor of Medicine, Harvard Medical School A-3, 75 Francis Street, Boston, MA 02115 E-mail mmehra@partners.org To succeed, jump as quickly at opportunities as you do at conclusions Benjamin Franklin As clinicians, we are constantly engaged in a tug of war between our penchant to be accurate in the anatomic-pathological diagnosis of a disease and the limitations of our collective diagnostic technology available to us. The clinical diagnosis and classification of cardiomyopathy assumes that we can segregate the major diagnostic buckets into those that can allow for both better therapeutic and prognostic determination. As such, we tend to intuitively separate the causes into 3 large divisions that include those etiologies emanating from disease within the coronary circulation (amenable to revascularization), those caused by mechanical aberrations leading to a pressure or volume overload (valvular heart disease) and finally those originating within the myocardial compartments (defects or dysfunction within the cardiomyocyte or its extracellular matrix). Thus, the opportunity provided by an accurate classification of causality allows for the creation of appropriate therapeutic avenues for the identified targets and may serve to elucidate the reasons for progression of disease and its collective impact upon the natural history. We now have a large armamentarium of diagnostic techniques available to us for more accurate discrimination of the underlying causes, but it can be quite daunting in its panoply of possibility. Thus, we can use multi-modality non-invasive imaging (echocardiography, magnetic resonance imaging, positron emission tomography and computerized tomography), invasive diagnostic techniques (coronary angiography, sophisticated coronary imaging methods, endomyocardial biopsy), and now, genetic studies. Despite these advanced diagnostic platforms, we remain clinically limited in our approach by a combination of imposing barriers: a) feasibility (e.g. interaction of magnetic resonance imaging with implanted devices), b) availability and cost, and c) inherent inaccuracy nested within each technique with low sensitivity (endomyocardial biopsy) or poor specificity (echocardiography). In other cases, the sheer magnitude of complexity, cost, and inadequate knowledge of appropriate use serve as major limitations as in the case of genetic testing. Several investigators have attempted to enhance our appreciation for these limitations, as well as offer solutions to the observed inaccuracy in clinical definitions and diagnosis. Early studies from pathological examination of hearts suggested that there is vast opportunity, even in the optimal discrimination between ischemic and non-ischemic causes of heart failure and more specifically determining the cause of death of these patients. At least 2 studies have demonstrated that coronary thrombosis, which is mostly silent and consequently misdiagnosed, may explain the high rate of sudden death in non-ischemic heart failure.1,2 Others have suggested that strategies to include a high use of endomyocardial biopsy may help in uncovering otherwise elusive causes of cardiomyopathy. Felker and colleagues3 performed endomyocardial biopsy in over 1200 patients with a cardiomyopathy and were able to yield a specific diagnosis in only 50% of these patients. Yet, they determined that separation of the etiology was indeed relevant in predicting prognosis and thereby guiding advanced therapy. Another study by our group led to the identification of a high rate of misclassification of significant coronary artery disease in the setting of heart disease clinically diagnosed as a non-ischemic cardiomyopathy.4 In this analysis of 112 patients with a pre-transplant diagnosis of non-ischemic cardiomyopathy, 21% were reclassified pathologically as ischemic cardiomyopathy. Of the remaining accurately classified, a third had at least moderatesevere coronary disease in 1 vessel territory, with or without infarction. In addition, 18% had areas compatible with recent ischemia, as noted by occlusive thrombus or ischemic infarction. In this issue of the journal, Constantin and colleagues5 take an important step forward by delineating the opportunities in clinical identification of the primary causes of a myocardial defect. They examined 100 patients that received a heart transplant over a 10-year period, for advanced heart failure and found critical opportunities lost in 2 specific domains in the diagnosis of a non-ischemic heart failure. First, there was a small cohort of patients with ischemic etiology on pathology that had been inappropriately misidentified as not having a coronary etiology. This is in line with prior studies in this field and point to the inaccuracy of coronary angiography, poor interpretation of the findings, or failure to revaluate over time when conditions change. The second area where there was improved reclassification from idiopathic to a specific cause comprises of 3 diagnoses including hypertrophic cardiomyopathy, lymphocytic myocarditis, and infiltrative sarcoid heart disease. One could argue, of course, that the frequency of these observations or the cost of this lost opportunity were not excessive, since the patients clinical course may not have been altered in terms of the trajectory and need for heart transplantation. However, a closer look at the data may argue otherwise. In many cases of hypertrophic cardiomyopathy, the disease burden is not just shared by the patient but also by the family and early detection of disease in siblings or family members may be particularly rewarding. In others, therapy directed to the primary etiology may attenuate the progression (steroids in sarcoidosis). One area of opportunity is in familial cardiomyopathy, now determined to be a more common diagnosis than previously considered.6 Although this was not directly evaluated in the Constantine study, it is very possible that many idiopathic cardiomyopathy patients had a specific genetic cause that was clustered in their families. To this end, Arbustini and colleagues7 have proposed the MOGE(S) classification for the phenotype-genotype associations in an effort to better classify the underlying disorders. This classification system encourages the combined clinical use of the Morphology (M), Organ involvement (O), Genetic defects (G), specific Etiology (E) and the Stage of heart failure (S). We would posit that a substantial number of patients in the current study may have been classified into this category had a detailed family history been obtained, genotyping for selected cases been conducted, and pathological assessments using higher resolution systems such as electron microscopy been employed. What then are the lessons to be learned from this important study? First, we believe that a detailed 3-generation family history should be obtained in all patients presenting with idiopathic cardiomyopathy; second, we endorse the more frequent use of multi-modality non-invasive imaging and, when indicated, an endomyocardial biopsy should be performed. In this regard, it is essential for central core labs that have experience and technical expertise in the pathological assessment of cardiomyopathy, including electron microscopy, be available. Furthermore, genetic testing may be appropriately applied in highly selective cases, though we admit the literature is still uncertain for non-hypertrophic forms of myocardial disease in this regard. Finally, we also believe that anchoring to an old evaluation should be a pitfall avoided. In such cases, one should not assume that a previously normal angiogram should deter re-evaluation. We note that only half of the patients in the Constantine series underwent an angiogram within 6 months of the transplant operation, which points to a lower frequency of use of this otherwise worthwhile testing modality, especially when the clinical condition takes a steep decline. While these solutions will not entirely rectify the problem(s) of misclassification, we believe that these are steps in the right direction to develop organized and standardized approaches to identification and assessment of disease diagnosis. As Albert Einstein remarked, Once we accept our limits, we go beyond them. REFERENCES Uretsky BF, Thygesen K, Armstrong PW, Cleland JG, Horowitz JD, Massie BM, et al. Acute coronary findings at autopsy in heart failure patients with sudden death: results from the assessment of treatment with lisinopril and survival (ATLAS) trial. Circulation. 2000;102:611-6. Orn S, Cleland JG, Romo M, Kjekshus J, Dickstein K. Recurrent infarction causes the most deaths following myocardial infarction with left ventricular dysfunction. Am J Med. 2005;118:752-8. Felker GM, Thompson RE, Hare JM, Hruban RH, Clemetson DE, Howard DL, et al. Underlying causes and long-term survival in patients with initially unexplained cardiomyopathy. N Engl J Med. 2000;342:1077-84. Mehra LM, Uber PA. Preponderance and implications of etiologic misclassification in advanced heart failure: a clinical-pathologic investigation. J Heart Lung Transplant. 2013;32:268-9. Constantin I, Del Castillo SL, Vita T, Iaciano M, Valle Raleigh JM, Pizarro R, et al. Etiologic Diagnosis of Cardiomyopathy in Heart Transplant Recipients. Agreement Between Pretransplant Clinical Diagnosis and Pathology. Rev Argent Cardiol 2014;82:xxx-xxx. Hershberger RE, Hedges DJ, Morales A. Dilated cardiomyopathy: the complexity of a diverse genetic architecture. Nat Rev Cardiol. 2013;10:531-47. Arbustini E, Narula N, Tavazzi L, Serio A, Grasso M, Favalli V, et al. The MOGE(S) classification of cardiomyopathy for clinicians. 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L^`LhH. ^`hH. ^`hH. PL^P`LhH.^`o(. ^`hH. pL^p`LhH. @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PL^P`LhH.Xi                  [6m?^,eV )SA` |utF5Y Yw PdPkJn1k$,$LN%J&]*1[/$g0{2V35-5U>#?\?JBeQFHGxNGrQLR9T_h*vjk:nhp uq`r(#s3u!w.exyiyy+zl{nHzRXHs:b~,rm ko|WC%vNPz=wK]kBIvGA(@x 6-y"2%m|?iz$*aD2Gu:,ZS}rAPA>4HVJvvi"ufUzVd&>''@'''''@UnknownG*Ax Times New Roman5Symbol3. *Cx Arial?= *Cx Courier New7@CambriaG=  jMS Mincho-3 fgO PLucida GrandeArialA$BCambria Math qhѳ)'ѳ)'$!H$!H20'' K#QHX $P'+z2!xx , Mandeep Mehra sacrevista  Oh+'0$ px   Mandeep MehraNormal sacrevista2Microsoft Office Word@F#@f@f$!՜.+,0 hp  Harvard Medical SchoolH'  TtuloTitle  !"#$%&'()+,-./0123456789:;<=?@ABCDEGHIJKLMPRoot Entry FoR1Table*&WordDocument4RSummaryInformation(>DocumentSummaryInformation8FCompObjv  F$Documento de Microsoft Word 97-2003 MSWordDocWord.Document.89q El diagnóstico de la miocardiopatía hipertrófica en un hospital universitario - Archivo PPCT

El diagnóstico de la miocardiopatía hipertrófica en un hospital universitario;
The Diagnosis of Cardiomyopathy: The Cost of Lost Opportunity

Creators:Mehra, Mandeep R.; Medical Director, BWH Heart and Vascular Center, Professor of Medicine, Harvard Medical School, Mehra, Lushna M., Uber, Patricia A.
2014-10-07

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Metadatos destacados

Colecciones
Argentine Journal of Cardiology

Editor

Sociedad Argentina de Cardiología

Fuente

Revista Argentina de Cardiología; Vol 82, No 5 (2014); 364-365, Argentine Journal of Cardiology; Vol 82, No 5 (2014); 364-365

Citación

Mehra, Mandeep R.; Medical Director, BWH Heart and Vascular Center, Professor of Medicine, Harvard Medical School, Mehra, Lushna M., y Uber, Patricia A., “El diagnóstico de la miocardiopatía hipertrófica en un hospital universitario,” Archivo PPCT, consulta 2 de abril de 2026, http://archivoppct.caicyt.gov.ar/items/show/8849.

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Autor

Mehra, Mandeep R.; Medical Director, BWH Heart and Vascular Center, Professor of Medicine, Harvard Medical School
Mehra, Lushna M.
Uber, Patricia A.

Fuente

Revista Argentina de Cardiología; Vol 82, No 5 (2014); 364-365
Argentine Journal of Cardiology; Vol 82, No 5 (2014); 364-365

Editor

Sociedad Argentina de Cardiología

Fecha

2014-10-07

Derechos

Los que firman al pié, certificamos que tenemos total responsabilidad por la conducción de este estudio y por el diseño y la interpretación de los datos. Nosotros escribimos el manuscrito y somos responsables por la decisión acerca del mismo. Cada uno de nosotros cumple la definición de autor como se afirma en el Comité Internacional de Editores de Revistas Médicas (International Committee of Medical Journal Editors, ver www.icmje.org). Nosotros hemos visto y aprobado el manuscrito final. Ni el artículo, ni ninguna parte esencial del mismo, incluido las tablas y las figuras, será publicado o admitido para arbitrar a otra parte antes de aparecer en la Revista.También notificamos haber leído la sección “conflicto de intereses”, y revelaríamos cualquiera que existiera. Dejamos constancia que si nuestro artículo se publicara en la RAC, cederíamos los derechos (copyright) a la Revista.Los documentos publicados en esta revista están bajo la licencia Creative Commons Atribución-NoComercial-Compartir-Igual 2.5 Argentina.
Those signing below certify that we have full responsibility for the conduction of this study and for the design and interpretation of the information. We wrote the manuscript and are responsible for its decision. Each of us fulfills the definition of authorship as stated by the International Committee of Medical Journal Editors ( www.icmje.org). We have signed and approved the final manuscript. Neither the manuscript, nor any essential part thereof, including tables and figures, will be published or accepted for refereeing elsewhere before being published in the Journal. We have also read the "Conflict of Interest" section and would disclose any existing. We state that if our manuscript is published in the RAC, we shall transfer the copyright to the Journal.

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eng
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info:eu-repo/semantics/article
info:eu-repo/semantics/publishedVersion