Arabadjian, Milla, FNP

Chaudhry, Farooq, MD

Feiner, Ellina C, MD

Kim, Bette, MD

Sherrid, Mark V, MD

Winson, Glenda, RN

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health Network LVHN Scholarly Works Department of Medicine Post-Prandial Upright Exercise Echocardiography in Hypertrophic Cardiomyopathy Ellina C. Feiner MD Lehigh Valley Health Network, Ellina_C.Feiner@lvhn.org Milla Arabadjian FNP Glenda Winson RN Bette Kim MD Farooq Chaudhry MD See next page for additional authors Follow this and additional works at: https://scholarlyworks.lvhn.org/medicine  Part of the Cardiology Commons, and the Medical Sciences Commons Published In/Presented At Feiner, E., Arabadjian, M., Winson, G., Kim, B., Chaudhry, F., & Sherrid, M. (2013). Post-prandial upright exercise echocardiography in hypertrophic cardiomyopathy. Journal Of The American College Of Cardiology, 61(24), 2487-2488. doi:10.1016/j.jacc.2013.02.079 This Letter to the Editor is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by an authorized administrator. For more information, please contact LibraryServices@lvhn.org. Authors Ellina C. Feiner MD, Milla Arabadjian FNP, Glenda Winson RN, Bette Kim MD, Farooq Chaudhry MD, and Mark V. Sherrid MD This letter to the editor is available at LVHN Scholarly Works: https://scholarlyworks.lvhn.org/medicine/342 CORRESPONDENCEResearchCorrespondence Post-Prandial Upright Exercise Echocardiography inHypertrophic CardiomyopathyTo the Editor: Approximately one-third of patients with hypertro-phic cardiomyopathy (HCM) experience symptom exacerbationafter a meal, and the post-prandial (PP) state has been associatedwith an increase in left ventricular outflow tract (LVOT) gradients(1). Also, LVOT gradients are higher when measured in theupright posture (2). We evaluated standing post-exercise PP(SPEPP) echocardiography for detection of latent obstruction insymptomatic patients who were not obstructed after conventionalprovocations and after exercise echocardiography.For clinical indications, selected symptomatic patients withHCM without previous detection of LVOT obstruction at rest,standing, or after Valsalva first performed fasting symptom-limitedmaximal exercise stress test using the Bruce protocol with gradientacquired supine within 30 to 60 s of terminating exercise. Selectedpatients were chosen for SPEPP on the same day because theHCM clinician suspected they might have LVOT obstruction(described below), despite gradients 45 mm Hg demonstratedafter routine stress. Meal size was not standardized; patients wereinstructed to eat a “moderate-sized lunch.” On the same day 1 hourafter lunch, within 3 h of the first test, they underwent exercisetesting with the post-exercise gradient acquired standing, SPEPP,after the same symptom-limited protocol.In 13 of 20 patients, gradients due to new mitral-septal contactwere much higher after SPEPP than after the fasting supineexercise test, with a median 83 mm Hg versus 34 mm Hg (Fig. 1).The remaining 7 patients were nonobstructed with an SPEPPmedian gradient of 18 mm Hg. The percent target heart rateachieved did not differ between the 2 groups, 83% versus 79%. Inthe whole group of 20 patients, post-exercise gradients were higherafter a meal, with a median 61 mm Hg (interquartile range [IQR]:20 to 85 mm Hg) versus 25 mm Hg (IQR: 17 to 37 mm Hg)(p  0.03). Heart rate when gradients were measured did not differFigure 1 Gradients Revealed by SPEPP(Upper) In fasting state, no outflow gradients were shown supine, standing, and post-exercise. (Lower) Post-prandial resting gradient was 58 mm Hg, standing 92 mm Hg, andstanding post-exercise post-prandial (SPEPP) 161 mm Hg. The patient had surgical relief of obstruction with improvement in symptoms. LVOT  left ventricular outflow tract.Journal of the American College of Cardiology Vol. 61, No. 24, 2013© 2013 by the American College of Cardiology Foundation ISSN 0735-1097/$36.00Published by Elsevier Inc.Downloaded for library services (libraryservices@lvhn.org) at Lehigh Valley Health Network from ClinicalKey.com by Elsevier on August 26, 2022. For personal use only. No other uses without permission. Copyright ©2022. Elsevier Inc. All rights reserved.between the 2 tests: 122  15 beats/min versus 121  16beats/min.Patients with SPEPP latent obstruction more frequentlyreported PP symptoms: 92% versus 29% (p  0.007). At rest, theyhad longer posterior mitral leaflets: 1.7  0.3 cm versus 1.2  0.3cm (p  0.002). Initial post-exercise gradients were mildly higherin patients who ultimately were SPEPP: median 34 mm Hgversus 16 mm Hg (p  0.008). Overall, in 9 of 13 SPEPPpatients, there was a change in therapy to relieve obstruction.Patients with SPEPP latent obstruction were more frequentlytreated with beta-blockade: 100% versus 43%; 5 patients receiveddisopyramide and 3 underwent septal myectomy. In patients withgradient-lowering therapy because of SPEPP, Minnesota qualityof life decreased from 29  19 to 12  19 (p  0.02), but therewas no change in SPEPP patients.We selected patients with HCM whom we suspected hadLVOT obstruction as the cause of their symptoms, despite nosignificant obstruction with standard provocations and aftersymptom-limited conventional stress exercise. In these patients, 13of 20 (65%) were found to have substantial LVOT gradients afterSPEPP, which led to an alteration in treatment for 9 of 13patients.Treatment choices for relief of limiting symptoms in HCMdepend heavily on the presence of LVOT obstruction. Patients’severe symptoms and outflow obstruction may be treated success-fully by addition of medications or septal reduction. In contrast,there are limited options for patients who are nonobstructed. Exerciseechocardiography is an excellent modality for provocation in patientswho might otherwise be categorized as nonobstructed (2).However, even after a stress exercise echocardiogram that doesnot provoke gradient, the clinician may still suspect obstruction incertain patients. It is our current clinical practice to employ SPEPPafter conventional stress echocardiography for patients with puta-tive nonobstructive HCM who have: 1) New York Heart Associ-ation 3 symptoms, especially PP worsening, who otherwise wouldhave limited treatment options; 2) long leaflets or mild systolicanterior motion but no demonstrable gradients; and 3) syncope butwhere arrhythmias cannot be detected, even after prolongedmonitoring.Valsalva and standing increase gradient due to a reduction invenous return, a decrease in LV volume, and an increase in theoverlap between LV inflow and outflow (2). Consequent decreasein stroke volume increases sympathetic activity, augmenting ob-struction. In healthy individuals after a meal, peripheral vascularresistance decreases because of mesenteric vasodilation, with asecondary increase in stroke volume. In HCM, deleterious hemo-dynamic effects of a meal include limited rise of stroke volume,greater elevation in right heart pressures, and provocation ofLVOT gradients (1). During exercise alone, augmented contrac-tility increases obstruction. We have shown that selected patientswho have no obstruction after conventional stress echocardiogra-phy performed fasting and imaged supine may develop largegradients (median 83 mm Hg) when exercised after eating andwhen the gradient is acquired upright. We posit that SPEPP moreprofoundly alters load and contractility than conventional stressechocardiography.The diagnosis of latent obstruction altered therapy in 9 of 13(69%) of our patients. Five received disopyramide and 3 hadsurgical septal myectomy. Patients who received new therapybecause of SPEPP latent obstruction experienced a dramaticreduction in symptoms. A limitation of the study is that LVOTgradients after stress were not interpreted blindly. Because studypatients were selected by clinical suspicion, detection rates may notbe generalizable.Not infrequently, findings in a symptomatic patient with HCMwill raise the clinical suspicion that the patient is suffering fromLVOT obstruction, even if routine stress echocardiography isnegative. Performing stress echocardiography in the PP state withgradient acquired in the upright posture (SPEPP) correctly diag-noses latent obstruction and thus focuses management on gradientreduction.Ellina Feiner, MDMilla Arabadjian, FNPGlenda Winson, RNBette Kim, MDFarooq Chaudhry, MD*Mark V. Sherrid, MD*Division of CardiologySt. Luke’s–Roosevelt Hospital Center1000 10th AvenueNew York, New York 10019E-mail: msherrid@chpnet.orghttp://dx.doi.org/10.1016/j.jacc.2013.02.079From the Division of Cardiology, St. Luke’s—Roosevelt HospitalCenter, Columbia University, New York, New York.Please note: Dr. Chaudhry has served on Speakers, Bureau for Lantheus MedicalImaging and GE Medical Imaging. All other authors have reported that they have norelationships relevant to the contents of this paper to disclose.REFERENCES1. Gilligan DM, Marsonis A, Joshi J, et al. Cardiovascular and hormonalresponses to a meal in hypertrophic cardiomyopathy: a comparison ofpatients with and without postprandial exacerbation of symptoms. ClinCardiol 1996;19:129–35.2. Joshi S, Patel UK, Yao SS, et al. Standing and exercise Dopplerechocardiography in obstructive hypertrophic cardiomyopathy: therange of gradients with upright activity. J Am Soc Echocardiogr2011;24:75–82.Letters to the EditorDo Work Accidents Play AnyRole in the Increased Risk ofDeath Observed in 25- to 44-Year-Old Patients After Syncope?We read with great interest the paper by Ruwald et al. (1) dealingwith the prognosis of healthy individuals discharged from theemergency department or hospital after a syncope episode.Surprisingly, fainters 25 to 44 years of age had a risk of deathhigher than that of subjects older than 75 years of age, differingfrom what was previously reported (2). Moreover, in individuals 25to 44 years of age with syncope, the long-term all-cause mortality2488 Correspondence JACC Vol. 61, No. 24, 2013June 18, 2013:2487–93Downloaded for library services (libraryservices@lvhn.org) at Lehigh Valley Health Network from ClinicalKey.com by Elsevier on August 26, 2022. For personal use only. No other uses without permission. Copyright ©2022. Elsevier Inc. All rights reserved.

Post-Prandial Upright Exercise Echocardiography in Hypertrophic Cardiomyopathy

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Post-Prandial Upright Exercise Echocardiography in Hypertrophic Cardiomyopathy

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