Time to consider atrial and diastolic function as key drivers of major adverse cardiovascular events in hypertrophic cardiomyopathy
A Martins, J Pereira, M Amado, A Vazao, M Cabral, C Domingues, C Ruivo, D DuraoAbstract
Introduction
Hypertrophic cardiomyopathy (HCM) is a heritable heart disease characterized by left ventricular hypertrophy and fibrosis, with an increased risk of major adverse cardiovascular events (MACE). Identifying reliable predictors of MACE is essential for early risk stratification and guiding patient management.
Objectives
To evaluate predictors of extended MACE in patients with HCM followed at a Cardiomyopathy Clinic in a regional hospital in Portugal.
Methods
Retrospective, single-center study of patients diagnosed with HCM between 2018 and 2024. Patients with a history of uncontrolled hypertension or significant valvular disease were excluded. Clinical, laboratory, and echocardiographic data were collected at baseline (table 1). The occurrence of extended MACE at follow-up, defined as cardiovascular (CV) mortality, myocardial infarction, stroke and heart failure (HF) hospitalizations, was assessed. Patients who experienced MACE (group 1) were compared with those who did not (group 2).
Results
165 patients were included; median age was 64 years (IQR 13) and 64% were male. The median follow-up was 39 months (IQR 29), during which 25 patients (15%) experienced extended MACE (group 1). Group 1 patients more frequently had NYHA class ≥ II (68 vs 31%, p<0.001) and atrial fibrillation (AF) (52 vs 11%, p<0.001). Regarding echocardiographic variables, group 1 patients showed higher E/e’ ratio (18.7 vs 12.0, p=0.005), PSAP (35.0 vs 31.0 mmHg, p=0.010), and left atrial (LA) volume index (55.8 vs 50.1 ml/m², p=0.013), along with lower TAPSE (21.9 vs 23.1 mm, p=0.033), right ventricular global longitudinal strain (RV GLS, -18.2 vs -20.4%, p=0.008), LA reservoir strain (LASr, 12.0 vs 19.0%, p<0.001), and LA contractile strain (LASct, -5.3 vs -10.1%, p<0.001). Additionally, group 1 had higher NT-proBNP levels (1380 vs 576.5 pg/ml, p<0.001). ROC analysis identified cut-off values for continuous variables, and only those with AUC > 0.650 were included in the multivariate analysis. After multivariate logistic regression E/e’ ratio, AF, and LASct remained independent predictors of extended MACE (Table 1B). The primary driver of extended MACE was HF hospitalizations (72%), followed by myocardial infarction (12%), stroke (12%), and CV mortality (4%).
Conclusions
In this cohort of HCM patients, LASct, AF, and elevated filling pressures were independent predictors of extended MACE, supporting the integration of atrial functional assessment into HCM risk stratification.Table 1For image description, please refer to the figure legend and surrounding text.Figure 1For image description, please refer to the figure legend and surrounding text.