EH@ESC_2015

CARDIOLOGY EUROPEAN HOSPITAL  Vol 24 Issue 4/15 6 Hypertrophic cardiomyopathy The British Cardiovascular Society Conference Experts: Echocardiography is an invaluable tool Music reaches the heart The challenges and advantages of using echocardiography as an inval- uable tool in the assessment of Hypertrophic Cardiomyopathy have been highlighted at a major UK cardiology conference. A key ben- efit of echocardiography is its abil- ity to accurately measure important aspects of cardiac structure and function related to hypertrophic cardiomyopathy (HCM), explained cardiac physiologist Dr Martin Stout. Speaking at the British Cardiovascular Society Conference, held in Manchester this June, during a session that examined the use of cardiac ultrasound in diagnosis, Dr Stout looked at the advantages, chal- lenges and factors in using echocar- diography to assess HCM. A primary disease of the myo- cardium, where a portion becomes abnormally thickened and fibrosed, HCM has a prevalence of 0.02-0.23% in adults and, in children, preva- lence estimates are 0.3-0.5 per 1,000 – although data is more limited in this population. Dr Stout: ‘Diagnosis in adults is a wall thickness of 15mm or above in one or more myocardial segments. Echocardiography plays a central role in diagnosis but both cardiac MR and cardiac CT may also be relevant.’ Giving examples of different phenotypic patterns of HCM, Stout explained the importance of using contrast media in patients where diagnosis with echocardiography alone was difficult, particularly for a better view of the apex in potential apical HCM. ‘It’s very important in Report: Mark Nicholls Innovative presentations, ground- breaking science and inspirational lectures underlined the diversity of sessions at the British Cardiovascular Society 2015 conference held in Manchester this June. Professor Cliff Garratt, the confer- ence programme committee chair, pointed to an evolving programme as key in the event’s success. ‘From my point of view it has been very exciting and energising to see so many people in the cardiovascular community involved in various ways in the meeting.’ Renowned scientist and TV per- sonality Professor Robert Winston set the tone during the open- ing ceremony, with his presentation ‘Where are we going with molecular medicine?’ With the conference theme “Hearts to Genes” a number of ses- sions focused on new genetic tests for cardiac disease and how these are being applied. Among research presented was the discovery of a faulty gene that can cause fatal abnormal heart rhythms that are brought on by exercise, while another session sug- gested that fat surrounding blood vessels may actually help fight heart disease to reduce the risk of a car- diac attack. The conference also offered unusual sessions, notably one by Professor Peter Sleight, from the University of Oxford, on music and the cardiovascular system, high- lighting the therapeutic potential of music on the heart rate, blood pres- sure and wider well-being. This ses- sion attracted widespread national media interest in the UK. Professor Garratt, who is also BCS vice president (education and research), said the increasing involvement of the British Heart Foundation (BHF) in the meeting was pivotal in its success and devel- opment: ‘The BHF is a key support- er of the meeting and had a number of sessions devoted to research that it funds,’ he pointed out. This included a highlight session of hypertrophic cardiomyopathy, which focused on research from a single clinical research depart- ment, showing how it works in terms of vision and scope. ‘For that reason we were keen that the cardiology trainees who attend the meeting went along because soon they will be looking to see whether they are interested in cardiovascu- lar research as a career, or part of their career, and the session gave them an insight into what might be involved,” Garratt added. The UK Genetic Testing Network (UKGTN) was involved in a ses- sion on the new genetic tests for cardiovascular disease that helps cardiologists to treat inherited con- ditions more effectively while the Strickland Goodall Lecture, topic “wellness and its causes”, was given by Sir Harry Burns, profes- sor of global public health at the University of Strathclyde and former Chief Medical Officer for Scotland. Other highlight lectures covered issues such as the transplant cycle, the medico-legal minefield. There were also hands-on interactive train- ing, popular hot topic sessions, a strong focus on cardiac imaging and exhibitors. One of the more popular sessions, said Professor Garratt, was the 2015 hypertension update for cardiolo- gists, which drew a large audience with discussions outlining why car- diologists should be interested in hypertension. ‘The aim of the British Cardiovascular Society Conference is to deliver the best basic and clinical science sessions in such a way that is relevant to everyone,’ Garratte concluded. ‘We think we have achieved it, but will continue to build on that for 2016*.’ *For the diary: 6-8 June 2016 BCS conference. Manchester, UK these cases to use contrast to aid diagnosis and there’s real benefit in patients with apical HCM,’ he added. Viewing from different imaging planes Working with current ESC 2014 guidelines on HCM, he stressed the importance of viewing from differ- ent imaging planes and the particu- lar need to assess for right ventri- cle (RV) involvement and measure left atrial (LA) dimensions /volume (a particularly powerful indictor of prognosis). With echocardiography in HCM, he pointed out, factors also to be aware of include mitral valve abnor- malities and left ventricular outflow tract obstruction (LVOTO). He also added the importance of assess- ing LVOTO at rest, during valsalva manoeuvre (exhalation against a closed airway), and during exercise. ‘The problem,’ Stout warned, ‘is that not everyone will have outflow tract obstruction at rest: only one third of patients with HCM will have outflow obstruction at rest, and another third will have obstruc- tion during provocative manoeu- vres.’ However, he stressed that not only SAM (systolic anterior motion) might result in LVOTO in HCM. Other factors to consider are papil- lary muscle abnormalities and MV leaflet or apparatus abnormalities; so it remains important to rule out other causes of LVOTO. According to Stoute, there are Moores University, in Liverpool, dis- cussed echocardiographic assess- ment of ARVC, a genetically deter- mined heart disease. He said ECG is crucial for this diagnosis and stressed the importance of multi- angle views. additional challenges in using echo- cardiography for HCM. ‘Monitoring LV diastolic func- tion in HCM is not always that straightforward either, it’s difficult because of the phenotypic variation of hypertrophy and fibrosis. You must use all available technologies including LA volume and assess- ment of PA systolic pressure.’ LV systolic function in HCM can be monitored using advanced strain technology to look at subtle aspects of LV mechanics, which he said was particularly important when ejection fraction is usually normal or supra- normal in these patients. ‘Strain imaging can help in the clinical management of a patient and is also useful in patients with apical HCM,’ he said. His Echo HCM “checklist” includes: assess pres- ence and distribution of hypertro- phy; think about use of contrast agents; assess for RV involvement; assess LV systolic function in detail; LV diastolic function; LA volume; PA systolic pressure; LVOTO, MV, and the extent of MR and papillary evaluation. The session also heard from Paediatric Echo Cardiographer Dr Saleha Kabir, from the Evelina London Children’s Hospital, who highlighted the role of echocar- diography in inherited conditions, in particular left ventricular non- compaction, which, although rare, is increasingly recognised primarily through advances in imaging tech- nology. Dr David Oxborough, reader in cardiovascular physiology at John Echocardiography: Ultrasound examination of the heart Dr Martin Stout is Clinical Researcher in Cardiac Physiology at University Hospital South Manchester Cardiology Department and at the Manchester Metropolitan University School of Healthcare Science, where he performs advanced echocardiography techniques, physiologist- led exercises and dobutamine stress echo services for routine and more complex cases. He is also programme director for the modernisation of scientific careers, academic pathways in cardiac, critical care, vascular and respiratory and sleep sciences. An active member of the British Society of Echocardiography Education and Research he also takes part in Audit committees and is a regular presenter at national and international conferences. Cliff Garratt is Professor of Cardiology at the Institute of Cardiovascular Sciences, Professor of Cardiology at Manchester University and Hon Consultant Cardiologist at Central Manchester University Foundation Trust. His research and clinical interests focus on the mechanisms and management of atrial fibrillation and familial sudden cardiac death syndromes. He is co-chair of the Heart Rhythm UK Working group on Clinical Management of Familial Sudden Death syndromes and Vice- President (Education and Research) of the British Cardiovascular Society

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