1b) Our all-star distinguished faculty includes Prof Thor Edvardsen @ThorEdvardsen 🇳🇴, Assoc Prof @unimib Denisa Muraru @denisamuraru 🇮🇹, & Prof Leyla Elif Sade @leylaelifsade 🇹🇷🇺🇸#FOAMed #cardiotwitter @MedTweetorials #HCM pic.twitter.com/PCZIkPwOFs
— cardio-met (@cardiomet_CE) June 7, 2023
2) The #EACVI2023 program kicked off with @denisamuraru discussing #Echocardiographic Techniques & Tips to Optimize the #Diagnosis and #Characterization of #HCM. #Echo of course is just 1 aspect of #multi_modality #imaging, fundamental to mgmt of HCM dx, risk strat, f/u, & tx.
— cardio-met (@cardiomet_CE) June 7, 2023
4) Echocardiographic findings are then interpolated into the clinical picture to address #riskstratification for #HCM: pic.twitter.com/x6fkqDxAum
— cardio-met (@cardiomet_CE) June 7, 2023
5b) For example, which of the three echos of this patient taken during the same study do you most believe?
— cardio-met (@cardiomet_CE) June 7, 2023
This one is a 2D image from a #cardiologist in training pic.twitter.com/Li7wMWH37c
5d) . . . which of the three echos of this patient do you most believe?
— cardio-met (@cardiomet_CE) June 7, 2023
This one is a 3⃣D image from the same experienced #echocardiographer pic.twitter.com/uGkqz2cQcQ
6a) Advanced #echo offers significant advantages pic.twitter.com/231Ng1EBbC
— cardio-met (@cardiomet_CE) June 7, 2023
7a) In addition to #LV dysfunction, echo and #Doppler also identify and provide management guidance for apical aneurysms: pic.twitter.com/QCAPFC6FK8
— cardio-met (@cardiomet_CE) June 7, 2023
8a) Estimating #LV maximal gradient is essential to guide #HCM medical and/or surgical management. Echo offers such guidance, but is not without pitfalls: pic.twitter.com/Jd841cYTf7
— cardio-met (@cardiomet_CE) June 7, 2023
9b) same patient: pic.twitter.com/JAg0EM7qES
— cardio-met (@cardiomet_CE) June 7, 2023
10a) 3D echo showed diffuse “LVH” and normal LVEF with low SV: pic.twitter.com/lWMKszXaTq
— cardio-met (@cardiomet_CE) June 7, 2023
10c) However, #LVOTO may exist in other #cardiomyopathies presenting with thick #LV walls and small cavity
— cardio-met (@cardiomet_CE) June 7, 2023
12) Advances continue in echo techniques for #HCM diagnosis and management, for example: pic.twitter.com/wKpnSNVXFx
— cardio-met (@cardiomet_CE) June 7, 2023
13b) So how about a quick knowledge ✔️?
— cardio-met (@cardiomet_CE) June 7, 2023
In patients with apical #HCM, all of the following echo modalities can be useful in assessment of apical #aneurysms, EXCEPT:
a. 2DE + contrast enhancement
b. 3DE
c. Exercise echocardiography
d. Doppler echocardiography
14) So let’s take a break, and TOMORROW we’ll continue this #tweetorial and talk about #whyCMR in #HCM. On day 3, we'll review new medical treatments guided by all this imaging, and get you to your 🆓 CE/#CME certificate. pic.twitter.com/q8bWV8BK7H
— cardio-met (@cardiomet_CE) June 7, 2023
16a) So when and how do we use #CMR in the diagnosis and characterization of #HCM? pic.twitter.com/Gg5wvk1RJs
— cardio-met (@cardiomet_CE) June 8, 2023
16c) Structural abnormalities of the #papillary muscles are very frequent in #HCM. Details of abnormalities can be clearly delineated with #CMR such as abnormal chordal connections, dislocated papillary muscles, abnormal insertions, and accessory muscle bundles.
— cardio-met (@cardiomet_CE) June 8, 2023
17b) #whyCMR is helpful to decipher all the components of atrial remodeling in the course of #HCM: dilatation, impaired contraction, and fibrosis.
— cardio-met (@cardiomet_CE) June 8, 2023
19) Late #gadolinium enhancement on CMR #LGE_CMR in a pt with #HCM provides important info about localized fibrosis.
— cardio-met (@cardiomet_CE) June 8, 2023
See 🔓 https://t.co/zhjnbjLSKX for recent review. pic.twitter.com/JZLiGMOmHZ
21) #CMR can also assess extracellular volume in #HCM and in other #sarcomere mutations carriers pic.twitter.com/g8TxQcOJnj
— cardio-met (@cardiomet_CE) June 8, 2023
23) #CMR can also be used to evaluate microvascular perfusion quantitatively: pic.twitter.com/Xq83bDBajX
— cardio-met (@cardiomet_CE) June 8, 2023
25) #HCM #phenocopies are clinical conditions that are phenotypically undistinguishable from HCM, but with a different underlying etiology. #CMR is helpful in separating things out. pic.twitter.com/mb28GtgbPY
— cardio-met (@cardiomet_CE) June 8, 2023
26b) Athlete's 🫀, continued
— cardio-met (@cardiomet_CE) June 8, 2023
Athletes heart is one of the most frequent challenges in the differential diagnosis #DDx of #HCM. #CMRtypically shows no late gadolinium hyperenhancement in athlete’s heart despite LV hypertrophy.
(Courtesy of Dr Ozge Ozgen) pic.twitter.com/7Xk3PSLRck
26d) Typically #CMR T1 mapping shows ⬇️ ECV & T1 time in athlete’s 🫀 vs #HCM. In athlete’s heart the main mechanism is hypertrophy of myocytes that shrinks the interstitial space; in #HCM either replacement fibrosis or profibrotic activity act to expand the interstitial space.
— cardio-met (@cardiomet_CE) June 8, 2023
28) Again, additive to info obtained by #echo, #CMR in #HCM helps define therapeutic targets: pic.twitter.com/8bkUl5lVU2
— cardio-met (@cardiomet_CE) June 8, 2023
30a) So what have you learned about #CMR?
— cardio-met (@cardiomet_CE) June 8, 2023
What is the added value of CMR to #echocardiography in the diagnosis of #HCM?
a. Computation of LV mass
b. Quantification of mitral regurgitation
c. Tissue characterization
d. Assessment of dynamic outflow tract obstruction
31) WELCOME BACK! Thank you for hanging with us—your reward is in sight! Expert authors @ThorEdvardsen 🇳🇴, @denisamuraru 🇮🇹, & @leylaelifsade 🇹🇷🇺🇸 are presenting the highlights of their outstanding symposium at #EACVI23 on optimizing imaging for #HCM!#FOAMed #CardioTwitter
— cardio-met (@cardiomet_CE) June 9, 2023
33) There are established resources to #riskstratify for, & help prevent, sudden cardiac death #SCD in #HCM.
— cardio-met (@cardiomet_CE) June 9, 2023
See 🔓 https://t.co/Of5xl51EWt pic.twitter.com/swwgS0m968
35) It seems we have entered a new era of #HCM management with the development of #sarcomeric contractile inhibitors and approval of the first such agent, #mavacamten. pic.twitter.com/FkjSaa8XEn
— cardio-met (@cardiomet_CE) June 9, 2023
36b) #Mavacamten doses 2.5, 5, 10, or 15mg given PO to ➡️target ⤵️ in #LVOT gradient < 30mm Hg + mavacamten plasma concentration 350-700ng/mL. 75% of pts taking beta-blockers & 18.7% taking #CCBs at enrollment. pic.twitter.com/1HE6LIt3d7
— cardio-met (@cardiomet_CE) June 9, 2023
36d) Pts on #mavacamten had
— cardio-met (@cardiomet_CE) June 9, 2023
🫀 greater ⬇️ vs placebo in post-exercise #LVOT gradient
🫀 greater ⬆️ in pVO2
🫀 improved symptom scores
Improvement by at least 1⃣NYHA class in 34% more patients in the mavacamten group. pic.twitter.com/7XkVXkwUAX
37) Pertinent to our #imaging discussion, a #CMR substudy of EXPLORER-HCM showed that #mavacamten favorably impacted cardiac structure in obstructive #HCM:
— cardio-met (@cardiomet_CE) June 9, 2023
🔓 https://t.co/eHAFGuBgJi pic.twitter.com/swK5PJb1k7
38b)
— cardio-met (@cardiomet_CE) June 9, 2023
🫀 resting or provoked #LVOT gradient ≥ 50 mmHg
🫀 LVEF ≥ 60%
In this trial, use of disopyramide at baseline allowed. Pts randomized to an escalating dose of #mavacamtenor placebo, followed 16 weeks:
🔓 https://t.co/5DIfYsAxSZ pic.twitter.com/GJuinLITTj
39) There were 2⃣ key differences in #VALOR_HCM from #EXPLORER:
— cardio-met (@cardiomet_CE) June 9, 2023
🔑 NYHA III at baseline—sicker patients!
🔑 Echo based dosing—back to our #imaging 🩻 theme! pic.twitter.com/QXr4sfnnVM
41) Finally, there is an emerging treatment for #HCM.
— cardio-met (@cardiomet_CE) June 9, 2023
🫀 #Aficamten is 2nd in class selective inhibitor of cardiac #myosin that acts by binding directly at a distinct allosteric binding site ➡️⬇️number of actin–myosin cross-bridges causing #HCM hypercontractility. pic.twitter.com/jHNrFo8KWH
42b) Primary objective: determine safety & tolerability of various doses #aficamten.
— cardio-met (@cardiomet_CE) June 9, 2023
🔑secondary EPs:
🫀 change from baseline resting & Valsalva #LVOT gradients over 10 weeks
🫀 % w/ complete hemodynamic response
🫀 change from baseline #LVEF, #biomarkers, #NYHA functional class pic.twitter.com/XFc8FSGXJl
43a) Given results of #REDWOOD_HCM, #aficamten was tested for 12 weeks in a 4th cohort of pts w/ non-obstructive #HCM.
— cardio-met (@cardiomet_CE) June 9, 2023
🆕Results were presented at #ACC23 by @cardiomet_ce expert faculty @MasriAhmadMD: pic.twitter.com/W6pWrdkpu9
44) More to come as new studies follow. Meanwhile:
— cardio-met (@cardiomet_CE) June 9, 2023
• #Mavacamten approved in US
• Safe
• Cardiac #imaging is crucial
• Impact on arrhythmias is not known
• Several next in class drugs in testing
44c) Your choices:
— cardio-met (@cardiomet_CE) June 9, 2023
a. ⬇️mavacamten to next lower dose, reeval in 4w
b. 🛑mavacamten, reeval in 4w
c. ⬇️mavacamten to next lower dose, reeval in 2w
d. 🛑mavacamten, reeval in 2w
45) And as a 🏆 for following this 🧵and to commemorate ALL your learning, you can now go to https://t.co/GiznO0WsdM and claim ONE HOUR 🆓CE/#CME 🇺🇸🇬🇧🇪🇺🇨🇦 #physicians #physicianassociates #nurses #nursepractitioners #pharmacists pic.twitter.com/bmccRJO1X6
— cardio-met (@cardiomet_CE) June 9, 2023
46) Expert authors Prof Thor Edvardsen @ThorEdvardsen 🇳🇴, Assoc Prof @unimib Denisa Muraru @denisamuraru 🇮🇹, & Prof Leyla Elif Sade @leylaelifsade 🇹🇷🇺🇸 all 🙏for joining us and encourage you to FOLLOW @cardiomet_ce for more expert #cardiometabolic #MedEd right here on Twitter!
— cardio-met (@cardiomet_CE) June 9, 2023