Symptomatic Obstructive Hypertrophic Cardiomyopathy: Diagnostic Strategies to Improve Outcomes
Hypertrophic cardiomyopathy (HCM) is a relatively common disorder estimated to affect between 0.2% and 0.5% of the global population.1 The condition is characterized by abnormal thickening of the cardiac walls that leads to heart failure, atrial fibrillation, and sudden death due to ventricular arrhythmias. HCM has an autosomal-dominant etiology and results from a mutation in genes that encode for 1 of the 9 sarcomere proteins, leading to structural and functional abnormalities in myofibril and myocytes.2,3
The common presentation types include obstructive HCM, which manifests as thickening of the interventricular septum, and nonobstructive HCM, which is characterized by thickening of the left ventricle. Both presentation types produce the same net effect of reduced blood flow from the heart to the rest of the body. Symptoms of both HCM types include dyspnea, angina, and syncope, and there is often a family history of sudden cardiac death.
HCM is highly heterogeneous with diverse pathophysiologies and clinical courses. In most patients, the presentation can be asymptomatic.1
Given the availability of improved treatment options for symptomatic obstructive and nonobstructive HCM,5,6 accurate diagnosis is critical. Several tools can be used for the diagnosis of HCM, but understanding of this disease is poor. Significant disparities in diagnosis reported across various demographic and socioeconomic groups may reflect a low index of suspicion for HCM in certain populations, resulting in missed opportunities for accurate diagnosis and treatment of this disease.7
Clinical Manifestation and Prevalence
Although the majority of patients with obstructive HCM are asymptomatic, a minority of patients experience symptoms and have clinical presentations that include chest pain, shortness of breath, fatigue, arrhythmias, dizziness, lightheadedness, swelling, and syncope.8
The symptoms result from increased demand for blood flow to the body as a result of the thickened heart muscle and alterations in the cardiac conduction system.5
A study by Maron and colleagues reported a prevalence of HCM of 2 per 1000 in the general adult population.9 This prevalence is consistent with reported estimates that in the United States, HCM affects between 600,000 and 1.5 million people.10 Although most patients present with HCM in their second or third decade of life, some may present between their fourth and sixth decades.3
Studies conducted in Germany and Korea show that the prevalence of HCM increases with age and that its incidence increases over time.11,12 The study conducted in Germany used data from the Institute for Applied Health Research and found the prevalence of HCM among patients aged 0 to 9 years to be lower than that in patients 80 years of age and older (7.4 per 100,000 persons vs 298.7 per 100,000 persons). In all age categories, the prevalence of HCM was higher in men compared with women (Figure 1).11
The study conducted in Korea, which evaluated data from the National Health Insurance Services database, found that among patients with newly diagnosed HCM, the total incidence rate increased steadily from 4.15 per 100,000 person-years in 2010 to 5.6 per 100,000 person-years in 2016; the incidence rate was approximately 1.7-fold higher in males throughout the study period compared with females (Figure 2).12
In the United States, although rates of diagnosis of obstructive HCM are higher among men (specifically White men), there are data supporting increased prevalence in women. There are also data indicating that women often present at an older age with worse symptoms and a higher risk of disease progression to heart failure or death.7 Traditionally, HCM was considered a condition most commonly responsible for sudden cardiac death in young athletes.13 Given that HCM can be asymptomatic during childhood, the diagnosis can be missed and individuals may die by sudden cardiac death.6
Patients diagnosed with HCM during childhood have been reported to have a higher annual mortality rate compared with patients diagnosed as older children or during middle or old age.7,14,15 In one study, the annual sudden death mortality average in patients with HCM aged between 9 and 13.9 years was 7.2% compared with 1.7% in patients aged 16 years and older.14 Diagnosis of HCM in older children, young adults, or older individuals is associated with lower rates of sudden death.7
Although information from the HCM database in the United States suggests a lower rate of obstructive HCM among African American men (presumably because of lower rates of diagnosis), data from the National Collegiate Athletic Association (NCAA) show that African American basketball players who are men represent the most likely demographic to be affected by, and die from, obstructive HCM. Authors of a recent study suggest that there is a higher overall incidence of obstructive HCM among African Americans.7 The social determinants of health and healthcare — including income, education, insurance, and geography — may hinder access to services such as routine screening, diagnostic evaluation, and long-term follow-up.7
The healthcare cost of HCM is enormous. A study conducted in the United States using real-world population claims data found that the mean annual cost of healthcare resource utilization was approximately $20,000 higher for patients with obstructive HCM and approximately $35,000 higher for patients with symptomatic obstructive HCM compared with that of matched control groups without HCM.16 Over a 1-year follow-up period, mean healthcare costs for patients with HCM were nearly $37,000 higher than those of matched controls due predominantly to inpatient costs.16 Early diagnosis can reduce the economic burden of obstructive HCM.
Diagnosis of HCM
Early screening, prompt diagnosis, and ongoing monitoring of individuals with or at risk for obstructive HCM can improve health outcomes. In the United States, approximately 13% of an estimated 750,000 cases of HCM have been diagnosed.1 Sometimes, diagnoses are incidentally being made after a heart murmur is detected during a physical examination or in a patient with abnormal findings on electrocardiogram (ECG) or a family history suggestive of the condition. Given that HCM is an inherited disorder, current evidence-based recommendations support genetic testing, including cascade testing of relatives. Individuals who are affected should be offered genetic counseling.1
A diagnosis of HCM is based on medical and family history, physical examination, and diagnostic tests. The physical examination and family history are essential first steps in determining HCM signs, symptoms, or risk for HCM, with level of risk evaluated by identification of relatives who have HCM or associated conditions such as heart failure or cardiac arrest. The American Heart Association identifies several diagnostic tests for HCM.8
HCM is typically diagnosed using an echocardiogram to measure the thickness of the heart muscle and blood flow from the heart. Transesophageal echocardiogram may also be used, although this minimally invasive procedure involves insertion of a probe in the throat while the patient is under sedation.8
It is essential to determine whether obstruction is present in symptomatic patients, either at rest or during exertion. Comprehensive 2-dimensional and Doppler echocardiography are needed to identify the presence of an obstruction, as well as its location and severity.
A diagnosis of HCM is confirmed if left ventricular wall thickness is at least 15 mm and this thickness cannot be explained by other conditions such as hypertension, valvular problems, congenital disease, or infiltrative cardiomyopathies. The diagnosis can also be confirmed if left ventricular wall thickness is at least 13 mm in patients who are genotype-positive or are relatives of individuals with HCM.1 It should be noted that although abnormal results seen on a 12-lead ECG are not specific for HCM, certain findings such as localized or widespread repolarization changes, prominent precordial voltages and left axis deviation, P-wave abnormalities, and inferior and/or lateral Q waves should raise suspicion for the disorder.1 Cardiac magnetic resonance imaging (MRI) can provide superior morphologic and tissue characterization and volumetric assessment compared with ECG. Use of MRI may help to differentiate myocardial thickening due to HCM from thickening due to other causes, thereby guiding appropriate management.17 Cardiac MRI is recommended for18:
- Patients with ECG results that are inconclusive for a diagnosis of HCM; and
- Patients with known HCM for whom clinicians require additional information about the magnitude and distribution of hypertrophy or the anatomy of the mitral valve apparatus to inform decision-making regarding septal reduction therapy.
In patients with obstructive HCM, the classic finding highly suggestive of obstruction is a loud systolic ejection murmur that increases in intensity when the patient moves from a squatting to a standing position or during the strain phase of the Valsalva maneuver.2 If HCM is suspected and a murmur is not present at rest or when moving from a squatting to a standing position, auscultation should be repeated during exercise or immediately afterward. Clinically important obstruction should be questioned in the continued absence of a murmur.2
The ECG of a patient with obstructive HCM will show left ventricular hypertrophy.19 A peak instantaneous continuous-wave Doppler gradient of 30 mm Hg or greater at rest indicates obstructive HCM, and a gradient of at least 50 mm Hg, either at rest or with exertion, is considered the threshold for septal reduction surgery in symptomatic patients.1
Myocardial thickening due to many causes may mimic HCM phenotypes. Systemic hypertension and aortic stenosis are the most common causes of acquired left ventricular hypertrophy that can be confused with HCM. Physiologic remodeling due to physical fitness can also manifest with left ventricular wall thickening; however, wall thickness rarely exceeds 15 mm in this setting. Furthermore, in physiologic remodeling, diastolic function is normal and left ventricular cavity sizes are generally larger compared with typical left ventricular cavity sizes in HCM.1
Several conditions can mimic HCM (Table 1).17 The use of heart murmurs to differentiate HCM from non-HCM-related conditions is outlined in Table 2.17,20
Although genetic testing is not required for the diagnosis of HCM, testing for disease-associated genetic variants should be offered to patients who have an atypical presentation on screening or when another genetic condition is suspected. Genetic testing can also facilitate the identification of first-degree family members who may be at risk of developing HCM.1 Next-generation sequencing technologies, despite their limitations, allow faster and increasingly affordable gene-based diagnostic tests that may help clinicians to differentiate HCM from mimics of the condition and thus potentially facilitate early identification of at-risk individuals for clinical evaluation and surveillance prior to disease onset.1,21
Addressing Disparities in the Diagnosis of Obstructive HCM
Early diagnosis and management of obstructive HCM improves health outcomes and reduces the incidence of sudden cardiac death. The previously mentioned racial and gender disparities are rooted in the lack of robust data to confirm anecdotal evidence of higher rates of sudden cardiac death among African American men and other minority populations, as well as the worse HCM outcomes observed among women.6 Clinicians should have a high index of suspicion for an increased risk of obstructive HCM in specific populations and are recommended to increase the level of screening and diagnostic evaluations accordingly.
HCM is an inherited disorder, current evidence-based recommendations support genetic testing, and affected individuals should be offered genetic counseling.
The symptoms of obstructive HCM — including dyspnea, angina, and syncope — are associated with suboptimal left ventricular blood flow due to thickening of the ventricular wall. For diagnostic evaluation, it is essential to obtain a family history and perform a physical examination that includes echocardiography and an ECG. In some patients, cardiac MRI can provide additional diagnostic information to guide appropriate management.
1. Owens AT, Nosheen Reza N. Diagnosis of hypertrophic cardiomyopathy: what every cardiologist needs to know. American College of Cardiology. Published online Feb 27, 2020. Accessed January 4, 2022. https://www.acc.org/latest-in-cardiology/articles/2020/02/25/06/34/diagnosis-of-hypertrophic-cardiomyopathy
2. Nishimura RA, Seggewiss H, Schaff HV. Hypertrophic obstructive cardiomyopathy: surgical myectomy and septal ablation. Circ Res. 2017;121(7):771-783. doi:10.1161/CIRCRESAHA.116.309348
3. Raj MA, Ranka S, Goyal A. Hypertrophic obstructive cardiomyopathy. StatPearls. Last update November 4, 2021. Accessed January 19, 2022. https://www.ncbi.nlm.nih.gov/books/NBK430820/
4. Ho CY, Mealiffe ME, Bach RG, et al. Evaluation of mavacamten in symptomatic patients with nonobstructive hypertrophic cardiomyopathy. J Am Coll Cardiol. 2020;75(21):2649-2660. doi:10.1016/j.jacc.2020.03.064
5. Harris C, Croce B, Munkholm-Larsen S. Hypertrophic obstructive cardiomyopathy. Ann Cardiothorac Surg. 2017;6(4):429. doi:10.21037/acs.2017.07.06
6. Olivotto I, Oreziak A, Barriales-Villa R, et al; on behalf of EXPLORER-HCM study investigators. Mavacamten for treatment of symptomatic obstructive hypertrophic cardiomyopathy (EXPLORER-HCM): a randomised, double-blind, placebo-controlled, phase 3 trial. Lancet. 2020;396(10253):759-769. doi:10.1016/S0140-6736(20)31792-X
7. Burns J, Jean-Pierre P. Disparities in the diagnosis of hypertrophic obstructive cardiomyopathy: a narrative review of current literature. Cardiol Res Pract. 2018;2018:3750879. doi:10.1155/2018/3750879
8. Hypertrophic cardiomyopathy (HCM). American Heart Association. Last Updated November 17, 2020. Accessed January 4, 2022. https://www.heart.org/en/health-topics/cardiomyopathy/what-is-cardiomyopathy-in-adults/hypertrophic-cardiomyopathy
9. Maron BJ, Gardin JM, Flack JM, Gidding SS, Kurosaki TT, Bild DE. Prevalence of hypertrophic cardiomyopathy in a general population of young adults. Echocardiographic analysis of 4111 subjects in the CARDIA Study. Circulation. 1995;92(4):785-789. doi: 10.1161/01.cir.92.4.785
10. Hypertrophic cardiomyopathy. Cleveland Clinic. Accessed January 13, 2022. https://my.clevelandclinic.org/health/diseases/17116-hypertrophic-cardiomyopathy
11. Husser D, Ueberham L, Jacob J, et al. Prevalence of clinically apparent hypertrophic cardiomyopathy in Germany-an analysis of over 5 million patients. PLoS One. 2018;13(5):e0196612. doi:10.1371/journal.pone.0196612
12. Moon I, Lee SY, Kim HK, et al. Trends of the prevalence and incidence of hypertrophic cardiomyopathy in Korea: a nationwide population-based cohort study. PLoS One. 2020;15(1):e0227012. doi:10.1371/journal.pone.0227012
13. Malhotra A, Sharma S. Hypertrophic cardiomyopathy in athletes. Eur Cardiol. 2017;12(2):80-82. doi:10.15420/ecr.2017:12:1
14. Ostman-Smith I, Wettrell G, Keeton B, et al. Age- and gender-specific mortality rates in childhood hypertrophic cardiomyopathy. Eur Heart J. 2008;29(9):1160-7. doi:10.1093/eurheartj/ehn122
15. Kalra A, Maron BJ. Hypertrophic cardiomyopathy in patients of advanced age. American College of Cardiology. Published online August 18, 2015. Accessed January 13, 2022. https://www.acc.org/latest-in-cardiology/articles/2015/08/17/13/12/hypertrophic-cardiomyopathy-in-patients-of-advanced-age
16. Jain SS, Li SS, Xie J, et al. Clinical and economic burden of obstructive hypertrophic cardiomyopathy in the United States. J Med Econ. 2021;24(1):1115-1123. doi:10.1080/13696998.2021.1978242
17. Méndez C, Soler R, Rodríguez E, Barriales R, Ochoa JP, Monserrat L. Differential diagnosis of thickened myocardium: an illustrative MRI review. Insights Imaging. 2018;9(5):695-707. doi:10.1007/s13244-018-0655-9
18. Gersh BJ, Maron BJ, Bonow RO, et al.; American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. 2011 ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2011;58(25):e212-e260. doi:10.1016/j.jacc.2011.06.011
19. Antunes MO, Scudeler TL. Hypertrophic cardiomyopathy. Int J Cardiol Heart Vasc. 2020;27:100503. doi:10.1016/j.ijcha.2020.100503.
20. Biniwale N, Hoefen R, Baibhav B. Hypertrophic cardiomyopathy. Visual Dx. Last updated July 12, 2018. Accessed January 4, 2022. https://www.visualdx.com/visualdx/diagnosis/hypertrophic+cardiomyopathy?diagnosisId=54614&moduleId=101
21. Teekakirikul P, Zhu W, Huang HC, Fung E. Hypertrophic cardiomyopathy: an overview of genetics and management. Biomolecules. 2019;9(12):878. doi:10.3390/biom9120878
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Reviewed January 2022