Research priorities in advanced heart failure: James Lind alliance priority setting partnership.

OBJECTIVE: To determine research priorities in advanced heart failure (HF) for patients, carers and healthcare professionals. METHODS: Priority setting partnership using the systematic James Lind Alliance method for ranking and setting research priorities. An initial open survey of patients, carers and healthcare professionals identified respondents' questions, which were categorised to produce a list of summary research questions; questions already answered in existing literature were removed. In a second survey of patients, carers and healthcare professionals, respondents ranked the summary research questions in order of priority. The top 25 unanswered research priorities were then considered at a face-to-face workshop using nominal group technique to agree on a 'top 10'. RESULTS: 192 respondents submitted 489 responses each containing one or more research uncertainty. Out-of-scope questions (35) were removed, and collating the responses produced 80 summary questions. Questions already answered in the literature (15) were removed. In the second survey, 65 questions were ranked by 128 respondents. The top 10 priorities were developed at a consensus meeting of stakeholders and included a focus on quality of life, psychological support, the impact on carers, role of the charity sector and managing prognostic uncertainty. Ranked priorities by physicians and patients were remarkably divergent. CONCLUSIONS: Engaging stakeholders in setting research priorities led to a novel set of research questions that might not have otherwise been considered. These priorities can be used by researchers and funders to direct future research towards the areas which matter most to people living with advanced HF

Assessment of Cardiac Energy Metabolism, Function, and Physiology in Patients With Heart Failure Taking Empagliflozin : The Randomized, Controlled EMPA-VISION Trial

Acknowledgments The authors express their gratitude toward the Oxford cardiovascular magnetic resonance nursing team, specifically Judith DeLos Santos, Catherine Krasopoulos, Marion Galley, and Claudia Nunes; and the diabetes trials unit team, particularly Irene Kennedy, for her organization skills. The authors also thank the team of the computed tomography suite at the Manor Hospital Oxford as well as all patients who participated in this trial. Drs Holman and Neubauer are Emeritus National Institute for Health Research senior investigators. The views expressed are those of the author(s) and not necessarily those of the National Health Service, National Institute for Health and Care Research, or Department of Health. Sources of Funding Boehringer Ingelheim is the sponsor of the EMPA-VISION study and was involved in early stages of its study design. Boehringer Ingelheim employees (Drs Lee and Massey) also supported preparation of this manuscript. Dr Neubauer acknowledges support from the Oxford British Heart Foundation Centre of Research Excellence. Drs Holman and Neubauer were supported by the Oxford National Institute for Health Research Biomedical Research Centre. Drs Rodgers and Valkovič are funded by Sir Henry Dale Fellowships from the Wellcome Trust and the Royal Society [098436/Z/12/B and 221805/Z/20/Z, respectively]. Dr Valkovič also gratefully acknowledges support of the Slovak Grant Agencies VEGA (Vedecká grantová agentúra) [2/0003/20] and APVV (Slovak Research and Development Agency) [No. 19–0032]. Dr Miller acknowledges support from the Novo Foundation (NNF21OC0068683).Peer reviewedPublisher PD

Atlas of the clinical genetics of human dilated cardiomyopathy

[Abstract] Aim. Numerous genes are known to cause dilated cardiomyopathy (DCM). However, until now technological limitations have hindered elucidation of the contribution of all clinically relevant disease genes to DCM phenotypes in larger cohorts. We now utilized next-generation sequencing to overcome these limitations and screened all DCM disease genes in a large cohort. Methods and results. In this multi-centre, multi-national study, we have enrolled 639 patients with sporadic or familial DCM. To all samples, we applied a standardized protocol for ultra-high coverage next-generation sequencing of 84 genes, leading to 99.1% coverage of the target region with at least 50-fold and a mean read depth of 2415. In this well characterized cohort, we find the highest number of known cardiomyopathy mutations in plakophilin-2, myosin-binding protein C-3, and desmoplakin. When we include yet unknown but predicted disease variants, we find titin, plakophilin-2, myosin-binding protein-C 3, desmoplakin, ryanodine receptor 2, desmocollin-2, desmoglein-2, and SCN5A variants among the most commonly mutated genes. The overlap between DCM, hypertrophic cardiomyopathy (HCM), and channelopathy causing mutations is considerably high. Of note, we find that >38% of patients have compound or combined mutations and 12.8% have three or even more mutations. When comparing patients recruited in the eight participating European countries we find remarkably little differences in mutation frequencies and affected genes. Conclusion. This is to our knowledge, the first study that comprehensively investigated the genetics of DCM in a large-scale cohort and across a broad gene panel of the known DCM genes. Our results underline the high analytical quality and feasibility of Next-Generation Sequencing in clinical genetic diagnostics and provide a sound database of the genetic causes of DCM.Hôpitaux de Paris; PHRC AOM0414

Neuropsychiatric risk in children with intellectual disability of genetic origin: IMAGINE, a UK national cohort study

Background Children with intellectual disability frequently have multiple co-morbid neuropsychiatric conditions and poor physical health. Genomic testing is increasingly recommended as a first-line investigation for these children. We aim to determine the effect of genomics, inheritance, and socioeconomic deprivation on neuropsychiatric risk in children with intellectual disability of genetic origin as compared with the general population. Methods IMAGINE is a prospective cohort study using online mental health and medical assessments in a cohort of 3407 UK participants with intellectual disability and pathogenic genomic variants as identified by the UK's National Health Service (NHS). Our study is on a subset of these participants, including all children aged 4–19 years. We collected diagnostic genomic reports from NHS records and asked primary caregivers to provide an assessment of their child using the Development and Well-Being Assessment (DAWBA), the Strengths and Difficulties Questionnaire (SDQ), the Adaptive Behaviour Assessment System 3 (ABAS-3), and a medical history questionnaire. Each child was assigned a rank based on their postcode using the index of multiple deprivation (IMD). We compared the IMAGINE cohort with the 2017 National Survey of Children's Mental Health in England. The main outcomes of interest were mental health and neurodevelopment according to the DAWBA and SDQ. Findings We recruited 2770 children from the IMAGINE study between Oct 1, 2014 and June 30, 2019, of whom 2397 (86·5%) had a basic assessment of their mental health completed by their families and 1277 (46·1%) completed a medical history questionnaire. The mean age of participants was 9·2 years (SD 3·9); 1339 (55·9%) were boys and 1058 (44·1%) were girls. 355 (27·8%) of 1277 reported a seizure disorder and 814 (63·7%) reported movement or co-ordination problems. 1771 (73·9%) of 2397 participants had a pathogenic copy number variant (CNV) and 626 (26·1%) had a pathogenic single nucleotide variant (SNV). Participants were representative of the socioeconomic spectrum of the UK general population. The relative risk (RR) of co-occurring neuropsychiatric diagnoses, compared with the English national population, was high: autism spectrum disorder RR 29·2 (95% CI 23·9–36·5), ADHD RR 13·5 (95% CI 11·1–16·3). In children with a CNV, those with a familial variant tended to live in more socioeconomically deprived areas than those with a de novo variant. Both inheritance and socioeconomic deprivation contributed to neuropsychiatric risk in those with a CNV. Interpretation Children with genomic variants and intellectual disability are at an increased risk of neuropsychiatric difficulties. CNV variant inheritance and socioeconomic deprivation also contribute to the risk. Early genomic investigations of children with intellectual disability could facilitate the identification of the most vulnerable children. Additionally, harnessing parental expertise using online DAWBA assessments could rapidly identify children with exceptional needs to child mental health services

Neuropsychiatric risk in children with intellectual disability of genetic origin: IMAGINE - The UK National Cohort Study

Background: Children with intellectual disability (ID) frequently have multiple co-morbid neuropsychiatric conditions and poor physical health. Genomic testing is increasingly recommended as a first-line investigation for these children. We aimed to determine the impact of genomics, inheritance and socioeconomic deprivation on neuropsychiatric risk in children with intellectual disability of genetic origin as compared to the general population. Methods: IMAGINE is a prospective study using online mental health and medical assessments in a cohort of 2770 children with ID and pathogenic genomic variants, identified by the UK’s National Health Service. Outcomes: Assessments completed on 2397 young people with ID (4-19 years, M 9·2, SD 3·9) with a rare pathogenic genomic variant. 1339 (55·9%) were male. 1771 (73·9%) of participants had a pathogenic copy number variant (CNV), 626 (26·1%) a pathogenic single nucleotide variant (SNV). Participants were representative of the socioeconomic spectrum of the UK general population. The relative risk of co-occurring neuropsychiatric diagnoses, compared with the UK national population, was high: Autism Spectrum Disorder 29·2 (95% CI 23·9 to 36·5), Attention Deficit Hyperactivity Disorder 13·5 (95% CI 11·1 to 16·3). In children with a CNV, those with a familial variant tended to live in more socioeconomically deprived areas. Both inheritance and socioeconomic deprivation contributed to neuropsychiatric risk in those with a CNV. Interpretation: Children with genomic variants and ID are at a greatly enhanced risk of neuropsychiatric difficulties. CNV variant inheritance and socioeconomic deprivation also contribute to the risk

The technical development, diagnostic accuracy and prognostic value of multimodality imaging in cardiac sarcoidosis and myocarditis

Cardiac sarcoidosis (CS) and myocarditis are potentially fatal inflammatory heart muscle conditions that are under-diagnosed in everyday clinical practice. A scarcity of data and lack of consensus on the most appropriate methods for detecting, monitoring and treating these inflammatory cardiomyopathies presents a significant diagnostic and therapeutic challenge. Moreover, whether inflammation plays a role in arrhythmogenic cardiomyopathy (AC) in-vivo remains unknown. This thesis describes the novel technical development of the hybrid imaging technique positron emission tomography and magnetic resonance imaging (PET/MRI) in cardiovascular imaging. It validates the use of this technique in imaging CS and explores its wider utility within routine clinical practice. It confirms that novel hybrid PET/MRI multimodality imaging improves the diagnostic accuracy for detecting CS and suggests that each imaging component provides complimentary information on disease pathophysiology. Furthermore, it establishes that abnormalities detected on PET/MRI provide additive clinical value in predicting adverse disease-related outcomes. Given the demonstrated value of PET/MRI in CS, the diagnostic and prognostic utility of multimodality imaging using PET and MRI is sequentially evaluated in myocarditis and elucidates similar findings to those found in CS, highlighting the critical clinical role of PET and MRI in the evaluation of myocarditis. Extrapolating the concept of imaging inflammation even further to those with AC, a retrospective analysis of those who underwent a PET scan confirms the in-vivo hypothesis that inflammation is involved in the pathophysiology of AC. Consequently, a standardised, systematic diagnostic pathway is defined for use in the diagnostic and prognostic evaluation of patients with inflammatory heart muscle disease. Translated directly into clinical practice, these data offer enormous opportunities for cardiomyopathy services and patients by enabling earlier diagnoses and the institution of therapies to reduce morbidity and mortality. Finally, illustrative case studies demonstrate the wider utility and clinical application of multiparametric, multimodality imaging offered by PET and MRI across cardiovascular disease and future translational and innovative opportunities are proposed

Design and rationale of the EMPA-VISION trial: investigating the metabolic effects of empagliflozin in patients with heart failure.

AIMS: Despite substantial improvements over the last three decades, heart failure (HF) remains associated with a poor prognosis. The sodium-glucose co-transporter-2 inhibitor empagliflozin demonstrated significant reductions of HF hospitalization in patients with HF independent of the presence or absence of type 2 diabetes mellitus in the EMPEROR-Reduced trial and cardiovascular mortality in the EMPA-REG OUTCOME trial. To further elucidate the mechanisms behind these positive outcomes, this study aims to determine the effects of empagliflozin treatment on cardiac energy metabolism and physiology using magnetic resonance spectroscopy (MRS) and cardiovascular magnetic resonance (CMR). METHODS AND RESULTS: The EMPA-VISION trial is a double-blind, randomized, placebo-controlled, mechanistic study. A maximum of 86 patients with HF with reduced ejection fraction (n = 43, Cohort A) or preserved ejection fraction (n = 43, Cohort B), with or without type 2 diabetes mellitus, will be enrolled. Participants will be randomized 1:1 to receive either 10 mg of empagliflozin or placebo for 12 weeks. Eligible patients will undergo cardiovascular magnetic resonance, resting and dobutamine stress MRS, echocardiograms, cardiopulmonary exercise tests, serum metabolomics, and quality of life questionnaires at baseline and after 12 weeks. The primary endpoint will be the change in resting phosphocreatine-to-adenosine triphosphate ratio, as measured by 31 Phosphorus-MRS. CONCLUSIONS: EMPA-VISION is the first clinical trial assessing the effects of empagliflozin treatment on cardiac energy metabolism in human subjects in vivo. The results will shed light on the mechanistic action of empagliflozin in patients with HF and help to explain the results of the safety and efficacy outcome trials (EMPEROR-Reduced and EMPEROR-Preserved).Boehringer Ingelheim is the sponsor of the EMPA-VISION study and was involved in its study design. Boehringer Ingelheim also supported the preparation of this article. S.N. acknowledges support from the Oxford British Heart Foundation (BHF) Centre of Research Excellence. R.R.H. and S.N. were supported by the Oxford National Institute for Health Research (NIHR) Biomedical Research Centre (BRC). C.T.R. is funded by a Sir Henry Dale Fellowship from the Wellcome Trust and the Royal Society [098436/Z/12/B]. L.V. gratefully acknowledges support of the Slovak Grant Agencies VEGA [2/0001/17] and APVV [#15–0029]