ESC Guidelines Hypertrophic Cardiomyopathy | Cardiac Arrest | Heart

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  ESC GUIDELINES 2014ESCGuidelinesondiagnosisandmanagementofhypertrophiccardiomyopathy  The Task Force for the Diagnosis and Management of HypertrophicCardiomyopathy of the European Society of Cardiology (ESC) Authors/Task Force members: Perry M. Elliott* (Chairperson) (UK) Aris Anastasakis(Greece),MichaelA.Borger(Germany),MartinBorggrefe(Germany),FrancoCecchi(Italy), Philippe Charron (France), Albert Alain Hagege (France), Antoine Lafont(France),GiuseppeLimongelli(Italy),HeikoMahrholdt(Germany),WilliamJ.McKenna (UK), Jens Mogensen (Denmark), Petros Nihoyannopoulos (UK), Stefano Nistri (Italy),Petronella G. Pieper (Netherlands),Burkert Pieske (Austria),Claudio Rapezzi (Italy),Frans H.Rutten (Netherlands),Christoph Tillmanns (Germany), Hugh Watkins (UK). Additional Contributor: Constantinos O’Mahony (UK).ESC Committee for Practice Guidelines (CPG): Jose Luis Zamorano (Chairperson) (Spain), Stephan Achenbach(Germany), Helmut Baumgartner (Germany), Jeroen J. Bax (Netherlands), He´ctor Bueno (Spain), Veronica Dean(France), Christi Deaton (UK), Çetin Erol (Turkey), Robert Fagard (Belgium), Roberto Ferrari (Italy), David Hasdai(Israel), Arno W. Hoes (Netherlands), Paulus Kirchhof (Germany/UK), Juhani Knuuti (Finland), Philippe Kolh(Belgium), Patrizio Lancellotti (Belgium), Ales Linhart (Czech Republic), Petros Nihoyannopoulos (UK),Massimo F. Piepoli (Italy), Piotr Ponikowski (Poland), Per Anton Sirnes (Norway), Juan Luis Tamargo (Spain),Michal Tendera (Poland), Adam Torbicki (Poland), William Wijns (Belgium), Stephan Windecker (Switzerland).Document Reviewers: David Hasdai (Israel) (CPG Review Coordinator), Piotr Ponikowski (Poland) (CPG Review Coordinator),StephanAchenbach(Germany),FernandoAlfonso(Spain),CristinaBasso(Italy),NunoMiguelCardim(Portugal), Juan Ramo´nGimeno (Spain), Stephane Heymans (Netherlands), PerJohan Holm (Sweden), Andre Keren * Corresponding author: Perry M. Elliott, Cardiology Department, The Heart Hospital, 16-18 Westmoreland Street, London W1G 8PH, United Kingdom, Tel:  + 44 203 456 7898,Email: perry.elliott@ucl.ac.uk  † Other ESC entities having participated in the development of this document:Associations:  European Association of Cardiovascular Imaging (EACVI), European Association of Percutaneous Cardiovascular Interventions (EAPCI), European Heart RhythmAssociation (EHRA), Heart Failure Association of the ESC (HFA).  WorkingGroups: CardiovascularPharmacologyandDrugTherapy,WorkingGrouponCardiovascularSurgery,WorkingGrouponDevelopmentalAnatomyandPathology,WorkingGroup on Grown-up Congenital Heart Disease, Working Group on Myocardial and Pericardial Diseases. Councils:  Cardiology Practice, Cardiovascular Primary Care.The content of these EuropeanSocietyof Cardiology (ESC) Guidelines has been published forpersonaland educationaluse only.No commercial use is authorized. No part of the ESCGuidelinesmaybetranslatedorreproducedinanyformwithoutwrittenpermissionfromtheESC.PermissioncanbeobtaineduponsubmissionofawrittenrequesttoOxfordUniversityPress, the publisher of the European Heart Journal and the party authorized to handle such permissions on behalf of the ESC. Disclaimer: TheESCGuidelinesrepresenttheviewsoftheESCandwereproducedaftercarefulconsiderationofthescientificandmedicalknowledgeandtheevidenceavailableatthe time of their dating.TheESCisnotresponsibleintheeventofanycontradiction,discrepancyand/orambiguitybetweentheESCGuidelinesandanyotherofficialrecommendationsorguidelinesissuedby therelevantpublichealthauthorities,inparticularinrelationshiptogooduseofhealthcareortherapeuticstrategies.HealthprofessionalsareencouragedtotaketheESCGuidelinesfullyintoaccountwhenexercisingtheirclinicaljudgment,aswellasinthedeterminationandtheimplementationofpreventive,diagnosticortherapeuticmedicalstrategies.However,theESCGuidelinesdonotoverride,inanywaywhatsoever,theindividualresponsibilityofhealthprofessionalstomakeappropriateandaccuratedecisionsinconsiderationofeachpatient’shealthconditionandinconsultationwiththatpatientand,whereappropriateand/ornecessary,thepatient’scaregiver.NordotheESCGuidelinesexempthealthprofessionalsfromtakingcarefulandfullconsiderationoftherelevantofficialupdatedrecommendationsorguidelinesissuedbythecompetentpublichealthauthoritiesinordertomanageeachpatient’scaseinlightofthescientifically accepted data pursuant to their respective ethical and professional obligations. It is also the health professional’s responsibility to verify the applicable rules and regulationsrelating to drugs and medical devices at the time of prescription. National Cardiac Societies document reviewers:  listed in Appendix 1 & The European Society of Cardiology 2014. All rights reserved. For permissions please email: journals.permissions@oup.com. European Heart Journal (2014)  35 , 2733–2779doi:10.1093/eurheartj/ehu284  (Israel),PaulusKirchhof(Germany/UK),PhilippeKolh(Belgium),ChristosLionis(Greece),ClaudioMuneretto(Italy),Silvia Priori (Italy), Maria Jesus Salvador (Spain), Christian Wolpert (Germany), Jose Luis Zamorano (Spain). The disclosure forms of the authors and reviewers are available on the ESC website www.escardio.org/guidelines Online publish-ahead-of-print 29 August 2014 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Keywords  Guideline  †  Diagnosis  †  Cardiacimaging  †  Genetics  †  Symptoms  †  Heartfailure  †  Arrhythmia  †  Leftventricular outflow tract obstruction  †  Sudden cardiac death  †  Implantable cardioverter defibrillators  † Pregnancy  †  Athletes  †  Hypertension  †  Valve disease Table of Contents Abbreviations and acronyms . . . . . . . . . . . . . . . . . . . . . . . .27351. Preamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27362. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27372.1 Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27372.2 Scope of Guidelines . . . . . . . . . . . . . . . . . . . . . . . .27373. Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27384. Aetiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27384.1 Sarcomere protein gene mutations . . . . . . . . . . . . . . .27384.2 Metabolic disorders . . . . . . . . . . . . . . . . . . . . . . . .27384.3 Mitochondrial cardiomyopathies . . . . . . . . . . . . . . . .27384.4 Neuromuscular disease . . . . . . . . . . . . . . . . . . . . . .27384.5 Malformation syndromes . . . . . . . . . . . . . . . . . . . . .27384.6 Infiltrative disease/inflammation . . . . . . . . . . . . . . . . .27384.7 Endocrine disorders . . . . . . . . . . . . . . . . . . . . . . . .27384.8 Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27395. Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27395.1 Diagnostic criteria. . . . . . . . . . . . . . . . . . . . . . . . . .27395.1.1 Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27395.1.2 Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27395.1.3 Relatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27405.2 History and physical examination . . . . . . . . . . . . . . . .27405.3 Resting and ambulatory electrocardiography . . . . . . . . .27425.4 Echocardiography . . . . . . . . . . . . . . . . . . . . . . . . . .27425.4.1 Assessment of left ventricular wall thickness . . . . . .27425.4.2 Associated abnormalities of the mitral valve and leftventricular outflow tract . . . . . . . . . . . . . . . . . . . . . . .27425.4.3 Assessment of latent obstruction . . . . . . . . . . . . .27435.4.4 Left atrial enlargement . . . . . . . . . . . . . . . . . . . .27435.4.5 Assessment of diastolic function . . . . . . . . . . . . . .27445.4.6 Systolic function . . . . . . . . . . . . . . . . . . . . . . . .27445.4.7 Value of echocardiography in differential diagnosis . .27445.4.8 Contrast echocardiography . . . . . . . . . . . . . . . . .27445.4.9 Transoesophageal echocardiography . . . . . . . . . . .27445.5 Cardiovascular magnetic resonance imaging . . . . . . . . .27455.5.1 Assessment of ventricular morphology andfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27455.5.2 Myocardial fibrosis . . . . . . . . . . . . . . . . . . . . . .27465.5.3 Late Gadolinium Enhancement and Prognosis . . . . .27465.5.4 Differential diagnosis . . . . . . . . . . . . . . . . . . . . .27465.6 Nuclear imaging and computerized tomography . . . . . .27475.7 Endomyocardial biopsy . . . . . . . . . . . . . . . . . . . . . .27475.8 Laboratory tests . . . . . . . . . . . . . . . . . . . . . . . . . . .27476. Genetic testing and family screening . . . . . . . . . . . . . . . . . .27476.1 Counselling in probands . . . . . . . . . . . . . . . . . . . . . .27486.2 Methods for molecular genetic screening in probands . . .27486.3 Indications for genetic testing in probands . . . . . . . . . .27486.4 Genetic and clinical screening of relatives . . . . . . . . . . .27496.4.1 Familieswithdefinitediseasecausinggeneticmutations27496.4.2 Families without definite disease causing geneticmutations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27496.5 Clinical and genetic screening of children . . . . . . . . . . .27506.6 Follow-up of mutation carriers without a phenotype. . . .27516.7 Pre-implantation and pre-natal genetic testing . . . . . . . .27517. Delivery of care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27517.1 Education and training . . . . . . . . . . . . . . . . . . . . . . .27528. Assessment of symptoms . . . . . . . . . . . . . . . . . . . . . . . .27528.1 Chest pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27528.2 Heart failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27528.2.1 Invasive pressure studies . . . . . . . . . . . . . . . . . . .27538.2.2 Cardiopulmonary exercise testing. . . . . . . . . . . . .27538.3 Syncope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27538.4 Palpitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27548.5 Role of electrophysiological testing . . . . . . . . . . . . . . .27549. Management of symptoms and complications . . . . . . . . . . . .27559.1 Left ventricular outflow tract obstruction . . . . . . . . . . .27559.1.1 General measures . . . . . . . . . . . . . . . . . . . . . . .27559.1.2 Drug therapy . . . . . . . . . . . . . . . . . . . . . . . . . .27559.1.3 Invasive treatment of left ventricular outflow tractobstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27569.1.3.1 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . .27569.1.3.2 Septal alcohol ablation . . . . . . . . . . . . . . . . .27569.1.3.3 Surgery vs. alcohol ablation . . . . . . . . . . . . . .27579.1.3.4 Minimum activity requirements . . . . . . . . . . . .27579.1.3.5 Dual chamber pacing . . . . . . . . . . . . . . . . . .27589.2 Left ventricular mid-cavity obstruction and apicalaneurysms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27599.3 Management of symptoms in patients without leftventricular outlow tract obstruction . . . . . . . . . . . . . . . . .27599.3.1 Heart failure . . . . . . . . . . . . . . . . . . . . . . . . . .27599.3.1.1 Drug therapy . . . . . . . . . . . . . . . . . . . . . . .27599.3.1.2 Cardiac resynchronization therapy . . . . . . . . . .27609.3.1.3 Cardiac transplantation . . . . . . . . . . . . . . . . .27609.3.1.4 Left ventricular assist devices . . . . . . . . . . . . .27609.3.2 Angina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2760ESC Guidelines 2734  9.4 Atrial tachyarrhythmia . . . . . . . . . . . . . . . . . . . . . . .27619.4.1 Acute treatment . . . . . . . . . . . . . . . . . . . . . . . .27629.4.2 Thromboembolism prophylaxis . . . . . . . . . . . . . .27629.4.3 Ventricular rate control . . . . . . . . . . . . . . . . . . .27629.4.4 Rhythm control . . . . . . . . . . . . . . . . . . . . . . . .27629.5 Sudden cardiac death . . . . . . . . . . . . . . . . . . . . . . . .27639.5.1 Clinical risk assessment . . . . . . . . . . . . . . . . . . .27639.5.2 Models for estimating sudden cardiac death risk . . . .27649.5.3 Prevention of sudden cardiac death . . . . . . . . . . . .27659.5.3.1 Exercise restriction . . . . . . . . . . . . . . . . . . .27659.5.3.2 Anti-arrhythmic drugs . . . . . . . . . . . . . . . . . .27659.5.3.3 Implantable cardioverter defibrillators . . . . . . .27659.5.3.3.1 Secondary prophylaxis . . . . . . . . . . . . . . .27659.5.3.3.2 Primary prophylaxis. . . . . . . . . . . . . . . . .27659.5.3.3.3 Practical aspects of ICD therapy . . . . . . . . .27679.5.4 Risk of sudden death in children . . . . . . . . . . . . . .27679.6 Symptomatic bradycardia and atrioventricular block . . . .27689.7 Ventricular tachycardia . . . . . . . . . . . . . . . . . . . . . .276810. Recommendations for routine follow-up . . . . . . . . . . . . . .276811. Reproduction and contraception . . . . . . . . . . . . . . . . . . .276911.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . .276911.2 Contraception and termination of pregnancy. . . . . . . .276911.3 Infertility treatment . . . . . . . . . . . . . . . . . . . . . . . .276911.4. Pre-conception counselling . . . . . . . . . . . . . . . . . . .276911.5 Management of pregnancy and delivery . . . . . . . . . . .277012. Special issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .277112.1. Diagnosis of hypertrophic cardiomyopathy in athletes .277112.2 Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . .277112.2.1 Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . .277112.2.2 Electrocardiogram . . . . . . . . . . . . . . . . . . . . . .277112.3 Isolated basal septal hypertrophy (sigmoid septum) inelderly people . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .277112.4 Diagnosis and management of valve disease in patientswith hypertrophic cardiomyopathy. . . . . . . . . . . . . . . . . .277212.4.1 Aortic valve disease . . . . . . . . . . . . . . . . . . . . .277212.4.2 Mitral valve disease . . . . . . . . . . . . . . . . . . . . .277212.4.3 Endocarditis prophylaxis . . . . . . . . . . . . . . . . . .277213. Living with cardiomyopathy: advice to patients . . . . . . . . . .277314. Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2773References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2774 Abbreviations and acronyms 2D two-dimensional99mTc-DPD 99mTechnetium-3,3-diphosphono-1,2-propanodi-carboxylic acidACE angiotensin-converting enzymeAF atrial fibrillationAL amyloid light chainAR aortic regurgitationARB angiotensin receptor blocker ATTR amyloidosis-transthyretin typeAV atrioventricular BiVAD biventricular assist deviceBNP brain natriuretic peptideBPM Beats per minuteCCS Canadian Cardiovascular SocietyCFC cardiofacialcutaneousCHA 2 DS 2 -VASc Congestive Heart failure, hypertension,Age ≥ 75 (doubled), Diabetes, Stroke(doubled), Vascular disease, Age 65–74, andSex (female)CMR cardiac magnetic resonanceCRT cardiac resynchronization therapyCRT-D cardiac resynchronization therapy-defibrillator CRT-P Cardiac resynchronization therapy with apacemaker CT computed tomographyDC direct currentDNA deoxyribonucleic acidE/A ratio of mitral peak velocity of early filling (E) to mitral peak velocity of late filling (A)E/e’ ratio of early transmitral flow velocity (E) to early mitral annulus velocity (e’)EACTS EuropeanAssociationforCardio-ThoracicSurgeryECG electrocardiogramEF ejection fractionEPS electrophysiological studyESC European Society of CardiologyFDA (US) Food and Drug AdministrationFHL1 four and a half LIM domains 1HAS-BLED hypertension, abnormal renal/liver function,stroke, bleeding history or predisposition, labileINR, elderly ( . 65 years), drugs/alcoholconcomitantlyHCM hypertrophic cardiomyopathyhs-cTnT high sensitivity cardiac troponin THTS high throughput sequencingICD implantable cardioverter defibrillator ILR implantable loop recorder INR international normalized ratioIUD intrauterine deviceLA left atriumLAMP-2 lysosome-associated membrane protein 2LBBB left bundle branch block LEOPARD Lentigines, ECG abnormalities, Ocular hyperte-lorism, Pulmonary stenosis, Abnormal genitalia,Retardation of growth, and sensory-neuralDeafnessLGE late gadolinium enhancementLV left ventricular LVAD left ventricular assist deviceLVH left ventricular hypertrophyLVOTO left ventricular outlow tract obstructionMADIT-RIT Multicenter Automatic Defibrillator ImplantationTrial—Reduce Inappropriate TherapyMAPK mitogen activated protein kinaseMELAS mitochondrialencephalomyopathy,lacticacidosis,and stroke-like episodesMERFF myoclonic epilepsy with ragged red fibres ESC Guidelines  2735  MRA mineralocorticoid receptor antagonistMYBPC3 myosin-binding protein C, cardiac-typeMYH7 myosin-7 (ß-myosin heavy chain)MYL3 myosin light chain 3NOAC new oral anticoagulantsNSVT non-sustained ventricular tachycardiaNT-proBNP N-terminal pro brain natriuretic peptideNYHA New York Heart AssociationOAC oral anticoagulantso.d. omni die (every day)PC-CMR phase contrast cardiac magnetic resonancePDE 5  phosphodiesterase type 5PET positron emission tomographyPRKAG2 gamma-2 sub-unit of the adenosinemonophosphate-activated protein kinaseRAAS renin angiotensin aldosterone systemRV right ventricular SAM systolic anterior motionSCD sudden cardiac deathSAA septal alcohol ablationS-ICD TM Subcutaneous lead implantable cardioverter defibrillator SPECT single photon emission computed tomographySSFP steady-state free precessionSVT supraventricular tachycardiaTOE transoesophageal echocardiographyTNNI3 troponin I, cardiac muscleTNNT2 troponin T, cardiac muscleTPM1 tropomyosin alpha-1 chainTTE transthoracic echocardiographyTTR transthyretinVF ventricular fibrillationVKA vitamin K antagonistVT ventricular tachycardia WHO World Health Organization 1. Preamble Guidelines summarize and evaluate all available evidence atthe timeof the writing process, on a particular issue with the aim of assistinghealth professionals in selecting the best management strategies for an individual patient, with a given condition, taking into account theimpactonoutcome,aswellastherisk-benefit-ratioofparticulardiag-nostic or therapeutic means. Guidelines and recommendationsshould help the health professionals to make decisions in their dailypractice. However, the final decisions concerning an individualpatient must be made by the responsible health professional(s) inconsultation with the patient and caregiver as appropriate.A great numberof Guidelines havebeen issued in recent years by the European Society of Cardiology (ESC) as well as by other soci-eties and organisations. Because of the impact on clinical practice,quality criteria for the development of guidelines have beenestablished in order to make all decisions transparent to the user.The recommendations for formulating and issuing ESC Guidelinescan be found on the ESC website (http://www.escardio.org/guidelines-surveys/esc-guidelines/about/Pages/rules-writing.aspx).ESC Guidelines represent the official position of the ESC on a given topic and are regularly updated.MembersofthisTaskForcewereselectedbytheESCtorepresentprofessionals involved with the medical care of patients with thispathology. Selectedexpertsinthefieldundertookacomprehensivereviewofthepublishedevidenceformanagement (includingdiagno-sis, treatment, prevention and rehabilitation) of a given conditionaccording to ESC Committee for Practice Guidelines (CPG) policy.A critical evaluation of diagnostic and therapeutic procedures wasperformed including assessment of the risk-benefit-ratio. Estimatesof expected health outcomes for larger populations were included,where data exist. The level of evidence and the strength of recom-mendation of particular management options were weighed andgraded according to predefined scales, as outlined in  Tables 1  and  2 .The experts of the writing and reviewing panels filled in declara- tions of interest forms which might be perceived as real or potentialsourcesofconflictsofinterest.Theseformswerecompiledintoonefile and can be found on the ESC website (http://www.escardio.org/guidelines). Any changes in declarations of interest that arise during thewritingperiodmustbenotifiedtotheESCandupdated.TheTask Forcereceivedits entire financialsupport fromtheESC withoutanyinvolvement from healthcare industry.TheESCCPGsupervisesandcoordinatesthepreparationofnewGuidelines produced by Task Forces, expert groups or consensuspanels. The Committee is also responsible for the endorsementprocess of these Guidelines. The ESC Guidelines undergo extensivereviewbytheCPGandexternalexperts.Afterappropriaterevisionsit is approved byall the experts involvedin the Task Force. The fina-lized document is approved by the CPG for publication in the Euro-pean Heart Journal. It was developed after careful consideration of  the scientific and medical knowledge and the evidence available at the time of their dating.ThetaskofdevelopingESCGuidelinescoversnotonlytheintegra- tionofthemostrecentresearch,butalsothecreationofeducational tools and implementation programmes for the recommendations.To implement the guidelines, condensed pocket guidelines ver-sions, summary slides, booklets with essential messages, summarycards for non-specialists, electronic version for digital applications(smartphones etc) are produced. These versions are abridgedand, thus, if needed, one should always refer to the full textversion which is freely available on the ESC website. The NationalSocieties of the ESC are encouraged to endorse, translate and im-plement the ESC Guidelines. Implementation programmes areneeded because it has been shown that the outcome of diseasemaybefavourablyinfluencedbythethoroughapplicationofclinicalrecommendations.Surveysandregistriesareneededtoverifythatreal-lifedailyprac- tice is in keeping with what is recommended in the guidelines, thuscompleting the loop between clinical research, writing of guidelines,disseminating them and implementing them into clinical practice.Health professionals are encouraged to take the ESC Guidelinesfully into account when exercising their clinical judgment as well asin the determination and the implementation of preventive, ESC Guidelines 2736
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