학술논문
Cardiac Remodeling in Subclinical Hypertrophic Cardiomyopathy: The VANISH Randomized Clinical Trial.
Document Type
Academic Journal
Author
Vissing CR; Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.; Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.; Axelsson Raja A; Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.; Day SM; Division of Cardiovascular Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia.; Russell MW; University of Michigan, Ann Arbor.; Zahka K; Cleveland Clinic Foundation, Cleveland, Ohio.; Lever HM; Cleveland Clinic Foundation, Cleveland, Ohio.; Pereira AC; Laboratory of Genetics and Molecular Cardiology, Heart Institute, University of São Paulo Medical School, São Paulo, Brazil.; Colan SD; Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.; Margossian R; Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.; Murphy AM; Division of Pediatric Cardiology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland.; Canter C; Washington University School of Medicine, St Louis, Missouri.; Bach RG; Washington University School of Medicine, St Louis, Missouri.; Wheeler MT; Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California.; Rossano JW; Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.; Owens AT; Division of Cardiovascular Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia.; Benson L; Toronto Hospital for Sick Children, Toronto, Ontario, Canada.; Mestroni L; University of Colorado Anschutz Medical Campus, Aurora.; Taylor MRG; University of Colorado Anschutz Medical Campus, Aurora.; Patel AR; Cardiovascular Division, Department of Medicine, University of Virginia Health System, Charlottesville.; Wilmot I; Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.; Thrush P; Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.; Soslow JH; Vanderbilt University Medical Center, Nashville, Tennessee.; Becker JR; Division of Cardiology, University of Pittsburgh School of Medicine and UPMC, Pittsburgh, Pennsylvania.; Seidman CE; Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.; Howard Hughes Medical Institute, Chevy Chase, Maryland.; Lakdawala NK; Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.; Cirino AL; Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.; McMurray JJV; British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom.; MacRae CA; Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.; Solomon SD; Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.; Bundgaard H; Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.; Orav EJ; Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.; Ho CY; Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
Source
Publisher: American Medical Association Country of Publication: United States NLM ID: 101676033 Publication Model: Print Cited Medium: Internet ISSN: 2380-6591 (Electronic) NLM ISO Abbreviation: JAMA Cardiol Subsets: MEDLINE
Subject
Language
English
Abstract
Importance: Valsartan has shown promise in attenuating cardiac remodeling in patients with early-stage sarcomeric hypertrophic cardiomyopathy (HCM). Genetic testing can identify individuals at risk of HCM in a subclinical stage who could benefit from therapies that prevent disease progression.
Objective: To explore the potential for valsartan to modify disease development, and to characterize short-term phenotypic progression in subclinical HCM.
Design, Setting, and Participants: The multicenter, double-blind, placebo-controlled Valsartan for Attenuating Disease Evolution in Early Sarcomeric Hypertrophic Cardiomyopathy (VANISH) randomized clinical trial was conducted from April 2014 to July 2019 at 17 sites in 4 countries (Brazil, Canada, Denmark, and the US), with 2 years of follow-up. The prespecified exploratory VANISH cohort studied here included sarcomere variant carriers with subclinical HCM and early phenotypic manifestations (reduced E' velocity, electrocardiographic abnormalities, or an increased left ventricular [LV] wall thickness [LVWT] to cavity diameter ratio) but no LV hypertrophy (LVH). Data were analyzed between March and December 2022.
Interventions: Treatment with placebo or valsartan (80 mg/d for children weighing <35 kg, 160 mg/d for children weighing ≥35 kg, or 320 mg/d for adults aged ≥18 years).
Main Outcomes and Measures: The primary outcome was a composite z score incorporating changes in 9 parameters of cardiac remodeling (LV cavity volume, LVWT, and LV mass; left atrial [LA] volume; E' velocity and S' velocity; and serum troponin and N-terminal prohormone of brain natriuretic peptide levels).
Results: This study included 34 participants, with a mean (SD) age of 16 (5) years (all were White). A total of 18 participants (8 female [44%] and 10 male [56%]) were randomized to valsartan and 16 (9 female [56%] and 7 male [44%]) were randomized to placebo. No statistically significant effects of valsartan on cardiac remodeling were detected (mean change in composite z score compared with placebo: -0.01 [95% CI, -0.29 to 0.26]; P = .92). Overall, 2-year phenotypic progression was modest, with only a mild increase in LA volume detected (increased by 3.5 mL/m2 [95% CI, 1.4-6.0 mL/m2]; P = .002). Nine participants (26%) had increased LVWT, including 6 (18%) who developed clinically overt HCM. Baseline LA volume index (LAVI; 35 vs 28 mL/m2; P = .01) and average interventricular septum thickness (8.5 vs 7.0 mm; P = .009) were higher in participants who developed HCM.
Conclusions and Relevance: In this exploratory cohort, valsartan was not proven to slow progression of subclinical HCM. Minimal changes in markers of cardiac remodeling were observed, although nearly one-fifth of patients developed clinically overt HCM. Transition to disease was associated with greater baseline interventricular septum thickness and LAVI. These findings highlight the importance of following sarcomere variant carriers longitudinally and the critical need to improve understanding of factors that drive disease penetrance and progression.
Trial Registration: ClinicalTrials.gov Identifier: NCT01912534.
Objective: To explore the potential for valsartan to modify disease development, and to characterize short-term phenotypic progression in subclinical HCM.
Design, Setting, and Participants: The multicenter, double-blind, placebo-controlled Valsartan for Attenuating Disease Evolution in Early Sarcomeric Hypertrophic Cardiomyopathy (VANISH) randomized clinical trial was conducted from April 2014 to July 2019 at 17 sites in 4 countries (Brazil, Canada, Denmark, and the US), with 2 years of follow-up. The prespecified exploratory VANISH cohort studied here included sarcomere variant carriers with subclinical HCM and early phenotypic manifestations (reduced E' velocity, electrocardiographic abnormalities, or an increased left ventricular [LV] wall thickness [LVWT] to cavity diameter ratio) but no LV hypertrophy (LVH). Data were analyzed between March and December 2022.
Interventions: Treatment with placebo or valsartan (80 mg/d for children weighing <35 kg, 160 mg/d for children weighing ≥35 kg, or 320 mg/d for adults aged ≥18 years).
Main Outcomes and Measures: The primary outcome was a composite z score incorporating changes in 9 parameters of cardiac remodeling (LV cavity volume, LVWT, and LV mass; left atrial [LA] volume; E' velocity and S' velocity; and serum troponin and N-terminal prohormone of brain natriuretic peptide levels).
Results: This study included 34 participants, with a mean (SD) age of 16 (5) years (all were White). A total of 18 participants (8 female [44%] and 10 male [56%]) were randomized to valsartan and 16 (9 female [56%] and 7 male [44%]) were randomized to placebo. No statistically significant effects of valsartan on cardiac remodeling were detected (mean change in composite z score compared with placebo: -0.01 [95% CI, -0.29 to 0.26]; P = .92). Overall, 2-year phenotypic progression was modest, with only a mild increase in LA volume detected (increased by 3.5 mL/m2 [95% CI, 1.4-6.0 mL/m2]; P = .002). Nine participants (26%) had increased LVWT, including 6 (18%) who developed clinically overt HCM. Baseline LA volume index (LAVI; 35 vs 28 mL/m2; P = .01) and average interventricular septum thickness (8.5 vs 7.0 mm; P = .009) were higher in participants who developed HCM.
Conclusions and Relevance: In this exploratory cohort, valsartan was not proven to slow progression of subclinical HCM. Minimal changes in markers of cardiac remodeling were observed, although nearly one-fifth of patients developed clinically overt HCM. Transition to disease was associated with greater baseline interventricular septum thickness and LAVI. These findings highlight the importance of following sarcomere variant carriers longitudinally and the critical need to improve understanding of factors that drive disease penetrance and progression.
Trial Registration: ClinicalTrials.gov Identifier: NCT01912534.