Genetics and Genomics of Hypertrophic Cardiomyopathy

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28 Genetics and Genomics of Hypertrophic Cardiomyopathy J. Martijn Bos, Steve R. Ommen and Michael J. Ackerman

INTRODUCTION Hypertrophic cardiomyopathy (HCM) is a primary disorder of the myocardium associated with increase in cardiac mass and typically, asymmetric, predominantly left ventricular hypertrophy. Affecting 1 in 500 people, HCM is a disease of profound phenotypic and genotypic heterogeneity. Clinically, HCM can be characterized by a completely asymptomatic course to severe cardiac symptoms or even sudden cardiac death (SCD). In 1989, the molecular underpinnings of HCM were exposed with the discovery of the first locus of familial HCM, which was followed in 1990 with the identification of a mutation in the MYH7-encoded beta myosin heavy chain. Since then, hundreds of mutations scattered amongst at least 10 myofilament genes confer the pathogenetic substrate for this “disease of the sarcomere/myofilament.” More recently, the genetic spectrum of HCM has expanded to encompass mutations in Z-disc–associated genes (Z-disc HCM). Furthermore, seemingly unexplained cardiac hypertrophy mimicking HCM can be the (primary) feature of some syndromes or metabolic diseases. However, the underlying genetic mechanism for approximately 30–50% of HCM remains to be elucidated and although many genotype–phenotype relationships have been observed, only few carry enough clinical significance to aid physicians predicting genotype status or course and prognosis of the disease. Current treatment for HCM is mostly aimed at symptom relief, although studies are underway to design pharmacologic

Essentials of Genomic and Personalized Medicine by Ginsburg & Willard 336

treatments for prevention of hypertrophy or individualized treatment based on one’s genetic fingerprint.

DEFINITIONS, CLINICAL PRESENTATION, AND DIAGNOSIS Background Hypertrophic cardiomyopathy is defined as unexplained left ventricular hypertrophy (LVH) in the absence of precipitating factors such as hypertension or aortic stenosis. HCM is a disease of enormous phenotypic and genotypic heterogeneity. Affecting 1 in 500 people, it is the most prevalent genetic cardiovascular disease, and more importantly the most common cause of SCD in young athletes (Maron, 2002). HCM can manifest with negligible to extreme hypertrophy, minimal to extensive fibrosis and myocyte disarray, absent to severe left ventricular outflow tract obstruction (LVOTO), and distinct patterns of hypertrophy. Nomenclature Hypertrophic cardiomyopathy was described fully for the first time by Teare in 1958 as “asymmetrical hypertrophy of the heart in young adults” (Teare, 1958). Over the past half century, HCM has since been known by a confusing array of names, reflecting its clinical heterogeneity and uncommon occurrence in daily

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Definitions, Clinical Presentation, and Diagnosis

practice. In 1968, WHO defined cardiomyopathies as “diseases of different and often unknown etiology in which the dominant feature is cardiomegaly and heart failure” (Abelmann, 1984). In 1980, cardiomyopathies were newly defined as “heart muscle diseases of unknown cause,” thereby differentiating it from specific identified heart muscle diseases of known cause such as myocarditis. Throughout the years, names such as idiopathic hypertrophic subaortic stenosis (IHSS), (Braunwald et al., 1964), muscular subaortic stenosis (Pollick et al., 1982), and hypertrophic obstructive cardiomyopathy (HOCM) (Schoendube et al., 1995) have been used widely and interchangeably to define the same disease. In 1995, the WHO/International Society and Federation of Cardiology Task Force on cardiomyopathies classified the different cardiomyopathies by dominant pathophysiology or, if possible, by etiological/pathogenetic factors (Richardson et al., 1996).The four most important cardiomyopathies – dilated cardiomyopathy (DCM), restrictive cardiomyopathy (RCM), arrhythmogenic right ventricular cardiomyopathy (ARVC), and hypertrophic cardiomyopathy (HCM) – were recognized, next to a number of specific and mostly acquired cardiomyopathies, like ischemic- and inflammatory cardiomyopathies (Richardson et al., 1996). Accordingly, HCM is described as left and/or right ventricular hypertrophy, usually asymmetric and involving the interventricular septum with predominant autosomal dominant inheritance that can be caused by mutations in sarcomeric contractile proteins (Richardson et al., 1996). On a microscopic level, HCM is characterized by the classical triad of cardiomyocyte hypertrophy, fibrosis, and myofibrillar disarray. Clinical Presentation and Diagnosis The clinical presentation of HCM is underscored by extreme variability from an asymptomatic course to that of severe heart failure, arrhythmias, and SCD. Many patients remain asymptomatic or only mildly symptomatic throughout the course of life. HCM commonly manifests between the second and the fourth decades of life but can present at the extremes of age. Infants and young children may present with severe hypertrophy leading to heart failure, and these patients have poor prognosis. More often, SCD can be the tragic sentinel event for HCM in children, adolescents, and young adults. The most common symptoms at presentation of disease are exertional dyspnea, chest pain, and syncope or presyncope. Approximately 5% of patients with HCM progress to “end-stage” disease characterized by LV dilatation and heart failure. In such cases cardiac transplantation may be considered. Other serious life-threatening complications include embolic stroke and cardiac arrhythmias. Echocardiography Conventional two-dimensional echocardiography is the diagnostic modality of choice for the clinical diagnosis of HCM. The disease is characterized by otherwise unexplained and usually asymmetric, diffuse or segmental hypertrophy associated with a non-dilated left ventricle (LV) independent of presence or absence of LV outflow obstruction. A left ventricular wall thickness of 12 mm is typically

TABLE 28.1

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Septal morphologies in HCM

Septal morphology

Description

Sigmoid septum

– Septum concave to cavity with pronounced septal bulge – Ovoid LV cavity

Reverse septal curvature

– Predominant mid-septal convexity toward LV cavity – Crescent-shaped cavity

Apical variant

– Predominant apical distribution of hypertrophy

Neutral variant

– Overall straight or variable convexity, predominantly neither convex nor concave

regarded as normal, with measurements of 13–15 mm labeled as “borderline hypertrophy.” A maximal LV end-diastolic wall thickness exceeding 15 mm represents the absolute dimension generally accepted for the clinical diagnosis of HCM in adults (in children, 2 or more standard deviations from the mean relative to body surface area) (Maron et al., 2003). Echocardiography can also provide details of location and degree of hypertrophy. In general, while there are innumerable morphologic appearances of the heart, the following four different morphological subtypes of HCM can be recognized in most cases (Table 28.1, Figure 28.1): sigmoid septum, reverse septal curvature, apical-, and neutral contour variant. Dynamic LVOTO is a common feature of HCM but is not required for the diagnosis of HCM. The existence of LVOTO is diagnosed by demonstration of a resting or provocable Doppler gradient of 30 mmHg. LVOTO is produced by the interaction of the hypertrophied septum and systolic anterior motion (SAM) of the mitral valve. The latter results from abnormal blood flow vectors across the valve, and abnormal anterior positioning of the valve and its support structures. Variable severity, posteriorly directed mitral regurgitation is a common finding. Most patients at presentation manifest some degree of impaired diastolic function ranging from abnormal relaxation to severe myocardial stiffness, elevated left ventricular end-diastolic pressure (LVEDP), elevated atrial pressure, and pulmonary congestion leading to exercise intolerance and fatigue. Systolic cardiac function, as measured by ejection fraction, is usually preserved. It is notable that more elegant measures of systolic performance, such as tissue velocity and strain imaging, suggest a decrease in systolic function in patients with HCM, and may even be present in gene-mutation carriers before hypertrophy can be detected. “End-stage disease” is characterized by LV dilatation, poor systolic function, and heart failure. Magnetic Resonance Imaging Magnetic resonance imaging (MRI) constitutes an important additional diagnostic tool especially in patients with suboptimal echocardiography or unusual segmental involvement of myocardium. Delayed gadolinium enhancement in MRI is an excellent

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Sigmoid septum (47%) 8% Myofilament Gene

Reverse septal curvature (35%) 79% Myofilament Gene

Apical (10%)

Neutral (8%)

32% Myofilament Gene

41% Myofilament Gene

Figure 28.1 Septal morphologies in HCM. Shown are the most common septal morphologies in HCM, their distribution in a large cohort of patients with HCM as well as the yield of genetic testing for each morphological subgroup.

tool to identify areas of scarring, replacement fibrosis, or irreversible myocardial injury. There are some recent reports of higher risk of SCD associated with these finding. In a cohort of 42 patients, myocardial hyper-enhancement was found in 79%. Extent of hyper-enhancement was greater in patients with progressive disease (28.5% versus 8.7%, p  0.001) and in patients with two or more risk factors for SCD (15.7% versus 8.6%, p  0.02) (Moon et al., 2003).

MOLECULAR GENETICS OF HCM Sarcomeric/Myofilament HCM Since the sentinel discovery of the first locus for familial HCM on chromosome 14 (1989) and first mutations involving the MYH7-encoded beta myosin heavy chain (1990) as the pathogenic basis for HCM (Geisterfer-Lowrance et al., 1990; Jarcho et al., 1989), over 400 mutations scattered among at least 24 genes encoding various sarcomeric proteins (myofilaments and Z-disc– associated proteins) and calcium-handling proteins have been identified (Table 28.2, Figure 28.2). The most common genetically mediated form of HCM is myofilament HCM, with hundreds of disease-associated mutations in eight genes-encoding proteins critical to the sarcomere’s thick myofilament (beta myosin heavy chain [MYH7] [Geisterfer-Lowrance et al., 1990]; regulatory myosin light chain [MYL2] and essential myosin light chain [MYL3] [Poetter et al., 1996]), intermediate myofilament (myosin-binding protein C [MYBPC3] [Watkins et al., 1995]), and thin myofilament (cardiac troponin T [TNNT2], alphatropomyosin [TPM1] [Thierfelder et al., 1994], cardiac troponin I [TNNI3] [Kimura et al., 1997]), troponin C [TNNC1] [Landstorm et al., 2008] and actin ([ACTC] [Mogensen et al., 1999; Olson et al., 2002a]). Targeted screening of giant sarcomeric TTN-encoded titin, which extends throughout half of the sarcomere, has thus far revealed only one mutation (Satoh et al. 1999). More recently, mutations have been described in the myofilament protein alpha myosin heavy chain encoded by MYH6

(Niimura et al., 2002). The prevalence of mutations in the eight most common myofilament-associated genes, currently comprising the commercially available HCM genetic tests in different international cohorts, ranges from 30% to 61%, leaving still a large number of patients with genetically unexplained disease (Van Driest et al., 2005a). Z-disc and Calcium-Handling HCM Over the last few years, the spectrum of HCM-associated genes has expanded outside the myofilament to encompass additional subgroups that could be classified as “Z-disc HCM” and “calcium-handling HCM.” Due to its close proximity to the contractile apparatus of the myofilaments and its specific structure–function relationship with regard to cyto-architecture, as well as its role in the stretch-sensor mechanism of the sarcomere, recent attention has been focused on the proteins that comprise the cardiac Z-disc. Initial mutations were described in CSRP3-encoded muscle LIM protein (Geier et al., 2003) and TCAP-encoded telethonin (Hayashi et al., 2004), an observation replicated in a large cohort of unrelated patients with HCM (Bos et al., 2006). Recently, mutations in patients with HCM have been reported in LDB3-encoded LIM domain binding 3, ACTN2-encoded alpha-actinin-2, and VCL-encoded vinculin/ metavinculin (Theis et al., 2006). Interestingly, although the first HCM-associated mutation in vinculin was found in the cardiacspecific insert of the gene, yielding the protein called metavinculin (Vasile et al., 2006a), the follow-up study also identified a mutation in the ubiquitously expressed protein vinculin (Vasile et al., 2006b). In 2007, a mutation in the Z-disc–associated MYOZ2-encoded myozenin 2 was reported as a novel gene for HCM (Osio et al., 2007). As the critical ion in the excitation–contraction coupling of the cardiomyocyte, calcium and proteins involved in calciuminduced calcium release (CICR) have always been of high interest in the pathogenesis of HCM. Although with very low frequency, mutations have been described in the promoter – and coding region of PLN-encoded phospholamban – an important

Molecular Genetics of HCM

TABLE 28.2

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Summary of HCM susceptibility genes Gene

Locus

Protein

Estimated frequency (%)

2q24.3

Titin

1

Myofilament HCM Giant filament

TTN

Thick filament

MYH7 MYH6 MYL2a MYL3a

14q11.2–q12 14q11.2–q12 12q23–q24.3 3p21.2–p21.3

-myosin heavy chain

-myosin heavy chain Ventricular regulatory myosin light chain Ventricular essential myosin light chain

15–25 1 2 1

Intermediate filament

MYBPC3a

11p11.2

Cardiac myosin-binding protein C

15–25

Thin filament

TNNT2a TNNI3a TPM1a ACTCa TNNC1a

1q32 19p13.4 15q22.1 15q14 3p21.3–p14.3

Cardiac troponin T Cardiac troponin I

-tropomyosin

-cardiac actin Cardiac troponin C

5 5 5 1 1

LBD3 CSRP3 TCAP VCL ACTN2 MYOZ2

10q22.2–q23.3 11p15.1 17q12–q21.1 10q22.1–q23 1q42–q43 4q26–q27

LIM binding domain 3 (alias: ZASP) Muscle LIM protein Telethonin Vinculin/metavinculin

-actinin 2 Myozenin 2

1–5 1 1 1 1 1

RYR2 JPH2 PLN

1q42.1–q43 20q12 6q22.1

Cardiac ryanodine receptor Junctophilin-2 Phospholamban

1 1 1

a

Z-disc HCM

Calcium-handling HCM

a

Available as part of commercially available genetic test for HCM.

inhibitor of cardiac muscle sarcoplasmic reticulum Ca(2)ATPase (SERCA) (Haghighi et al., 2006; Minamisawa et al., 2003), the RyR2-encoded cardiac ryanodine receptor (Fujino et al., 2006), and the JPH2-encoded type 2 junctophilin (Landstrom et al., 2007). Metabolic and Syndromal HCM-mimicry The last genetic subgroup of unexplained cardiac hypertrophy is the one comprising metabolic and syndromal HCM-mimickers – in which cardiomyopathy is a sometimes sole presenting feature (Table 28.3). In 2001, the first mutations in PRKAG2-encoded AMP-activated protein kinase gamma 2, a protein involved in the energy homeostasis of the heart, were described in two families with severe HCM and aberrant AV-conduction in some individuals (Blair et al., 2001). Further studies showed that patients with mutations in this gene lack the HCM characteristics of myocyte – and myofibrillar disarray – but show newly formed vacuoles filled with glycogen-associated granules. This glycogen storage disease therefore seemed to mimic HCM, distinguishing itself by electrophysiological abnormalities, particularly ventricular pre-excitation (Arad et al., 2002, 2005). In 2005, Arad et al. described mutations in lysosome-associated membrane protein2 encoded by LAMP2 (Danon’s syndrome) and protein kinase gamma 2 encoded by PRKAG2 in glycogen storage disease-associated genes mimicking

the clinical phenotype of HCM (Arad et al., 2005). A recent community-based study showed that in 50 healthy individuals with idiopathic LVH, participants with sarcomere gene protein and storage mutations essentially were indistinguishable clinically from those without mutations (Morita et al., 2006). In 2005, a mutation in FXN-encoded frataxin associated with Friedrich ataxia was described in a patient with HCM. Although this patient also harbored a myofilament mutation in MYBPC3-encoded myosin binding protein C, functional characterization showed significant influence of the FXN-mutant on the phenotype, suggesting that the observed alterations in energetics may act in synergy with the present myofilament mutation (Van Driest et al., 2005b). Akin to PRKAG2 and LAMP2, Fabry’s disease can express predominant cardiac features of seemingly unexplained LVH. Over the years, mutations in GLAencoded alpha-galactosidose A have been found in patients with this multisystem disorder (Nakao et al., 1995; Sachdev et al., 2002; Sakuraba et al., 1990). Genotype–Phenotype Relationships in HCM For over the past decade, multiple studies have tried to identify phenotypic characteristics most indicative of myofilament HCM to facilitate genetic counseling and strategically direct clinical genetic testing (Ackerman et al., 2002; Richard et al.,

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Metabolic HCM (1%)

Calcium-handling HCM (1–5%)

SR ATP

Ca2+

Frataxin

Lysosome

Tropomyosin Troponin

Myosinbinding protein C

ADP

I-Band

Actin

CapZ

Tropomyosin

Z-Disc Desmin

Ankyrin Obscurin

S100 Myopalladin CARP

MLP

Nebulette

β-myosin heavy chain

Myosin light chain

Myofilament HCM (40–70%)

m

Calsarcin gamma-Filamin

PKC ZASP Calcineurin

Myopodin ALP MinK T-Cap Myostatin alpha-Actinin

Tiltin

Z-disc HCM (1–5%)

Figure 28.2 Subgroups of genetic HCM. Shown are the most important functional subgroups of genetically mediated HCM. Blue arrows indicate the functional relationship between the different elements.

2003; Van Driest et al., 2002, 2003, 2004a, b; Woo et al., 2003). Up until 2001, it was thought that specific mutations in these myofilament genes were inherently “benign” or “malignant” (Anan et al., 1994; Coviello et al., 1997; Elliott et al., 2000; Moolman et al., 1997; Niimura et al., 2002; Seidman et al., 2001; Varnava et al., 1999; Watkins et al., 1992). However, these studies were based on highly penetrant, single families with HCM, and later genotype–phenotype studies involving a large cohort of unrelated patients have indicated that great caution must

be exercised with assigning particular prognostic significance to any particular mutation (Ackerman et al., 2002; Van Driest et al., 2002, 2004b). Furthermore, these studies demonstrated that the two most common forms of genetically mediated HCM – MYH7-HCM and MYBPC3-HCM – were phenotypically indistinguishable (Van Driest et al., 2004b). While several phenotype–genotype relationships have emerged to enrich the yield of genetic testing, these patient profiles have not been particularly clinically informative on an individual level.

Molecular Genetics of HCM

TABLE 28.3 Gene

Metabolic and Syndromal-HCM-mimickers

Locus

Protein

Syndrome

7q35-q36.36

AMP-activated protein kinase

WPW/HCM

LAMP2a

Xq24

Lysosome-associated membrane protein 2

Danon’s syndrome

GAA

17q25.2-q25.3 Alpha-1,4-glucosidase Pompe’s deficiency disease

GLAa

Xq22

Alphagalactosidase A

Fabry’s disease

FXN

9q13

Frataxin

Friedrich’s ataxia

PTPN11b

12q24.1

Protein tyrosine phosphatase, nonreceptor type 11

Noonan’s syndrome

PRKAG2

a

Note: In patients with cardiac hypertrophy secondary to Noonan’s syndrome, PTPN11 mutations are quite uncommon (10%) compared to 50% yield expected for Noonan’s syndrome without LVH. a Available as part of commercially available genetic testing. b PTPN11 is also associated with LEOPARD syndrome and is allelic to Noonan’s syndrome.

Recently, an important discovery, linking the echocardiographically determined septal morphology to the underlying genetic substrate, was made (Binder et al., 2006). The first link to be drawn between septal morphologies was a result of a HCM study by Lever and colleagues in the 1980s, where septal contour (Table 28.1) was found to be age-dependent with a predominance of sigmoidal-HCM noted in the elderly (Lever et al., 1989). In the early 1990s, an early genotype–phenotype observation involving a small number of patients and family members showed that patients with mutations in the beta myosin heavy chain (MYH7-HCM) generally had reversed curvature septal contours (reverse curve-HCM) (Solomon et al., 1993). Analysis of the echocardiograms of 382 previously genotyped and published patients (Van Driest et al., 2003, 2004b, c), revealed that sigmoidal-HCM (47% of cohort) and reverse curve-HCM (35% of cohort) were the two most prevalent anatomical subtypes of HCM and that the septal contour was the strongest predictor for the presence of a myofilament mutation, regardless of age (Binder et al., 2006). In fact, multivariate analysis in this cohort demonstrated that septal morphology was the only, independent predictor of myofilament HCM with an odds ratio of 21 (p  0.001) when reverse curve morphology was present (Figure 28.1; Binder et al., 2006). The yield from the commercially equivalent HCM genetic research test for myofilament HCM was 79% in reverse curveHCM but only 8% in patients with sigmoidal-HCM. Of the smaller subgroup of patients with apical HCM, 32% had a mutation in one of the elements of the cardiac myofilament (Binder et al.,

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2006). These observations may facilitate echo-guided genetic testing by enabling informed genetic counseling about the a priori probability of a positive genetic test based on the patient’s expressed anatomical phenotype of HCM (Figure 28.1). With the majority of known myofilament proteins studied, except for a complete analysis of the giant protein TTNencoded titin, recent research has focused on proteins beyond the cardiac myofilaments, especially proteins involved in the cytoarchitecture and cardiac stretch-sensor mechanism of the cardiomyocyte localized to the cardiac Z-disc (Figure 28.2). The Z-disc is an intricate assembly of proteins at the Z-line of the cardiomyocyte sarcomere. Proteins of the Z-disc are important in the structural and mechanical stability of the sarcomere as they appear to serve as a docking station for transcription factors, Ca2 signaling proteins, kinases, and phosphatases (Frank et al., 2006; Pyle et al., 2004). In addition, this assembly of proteins seems to serve as a way station for proteins that regulate transcription by aiding in their controlled translocation between the nucleus and the Z-disc (Frank et al., 2006; Pyle et al., 2004). A main implication for the Z-disc is its involvement in the cardiomyocyte stretch sensing and response systems (Knoll et al., 2002). Mutations in these proteins have been implicated as HCM (Bos et al., 2006; Geier et al., 2003; Hayashi et al., 2004; Vasile et al., 2006a, b) and DCM susceptibility genes (Bos et al., 2006; Geier et al., 2003; Hayashi et al., 2004; Mohapatra et al., 2003; Olson et al., 2002b; Vasile et al., 2006a). Additionally, it has become appreciated that these divergent cardiomyopathic phenotypes of HCM and DCM are partially allelic disorders with ACTC, MYH7, TNNT2, TPM1, MYBPC3, TTN, MLP, TCAP, and VCL established as both HCM and DCM susceptibility genes (Daehmlow et al., 2002; Geier et al., 2003; Gerull et al., 2002; Hayashi et al., 2004; Kamisago et al., 2000; Mohapatra et al., 2003; Olson et al., 2000, 2001;Vasile et al., 2006a). Recently, mutations in ACTN2-encoded alpha-actinin-2 (ACTN2) and LDB3-encoded LIM domain binding 3 (LDB3) as novel HCM susceptibility genes (Theis et al., 2006) were described. Linking reverse curve-HCM to the presence of myofilament mutation, and recognizing that the Z-disc may transduce multiple-signaling pathways during stress, translating into hypertrophic responses, cell growth and remodeling (Frey et al., 2004), it was observed that Z-disc HCM, in contrast to myofilament HCM, is preferentially sigmoidal. In fact, 11 out of 13 patients with Z-disc HCM had a sigmoidal septal contour and no reverse septal curvatures were seen (Theis et al., 2006). It is speculated that Z-disc HCM leads to a hypertrophic response that is expressed in the areas of highest stress (i.e., LVOT) and therefore predisposes to a sigmoidal septal contour. New Insights and Approaches to Genomics of HCM Not only in molecular genetics but also in other fields of “-omics,” novel pathways underlying the pathophysiology of this heterogeneous disease have been identified using several new techniques to study large-scale transcriptional changes (Churchill, 2002; Holland, 2002;Velculescu et al., 1997). A transcriptomic approach

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Clinic HCM proband

Genetics-based screening A priori chance of positive genetic test based on septal contour Reverse septal curvature Neutral Apical Sigmoidal

Echocardiography-based screening Screen first-degree relatives and athletic second-degree relatives

79% 41% 32% 8%

Genetic testing performed ?

No

Yes

Positive echocardiogram ?

No

Yes Mutation identified?

No Repeat echocardiogram every 5 years

Yes Confirm mutation in first-degree relatives

Mutation identified?

No

HCM confirmed Perform annual clinical and echocardiographic exam

(annual for young adults and athletes)

Yes No further screening

Figure 28.3 Genetic- and echocardiographic-based screening in HCM. Flow-chart showing decision to follow in genetic- and echocardiography-based screening in HCM. Noted are the a priori chances for a positive genetic test result based on the echocardiographic-scored septal contour, as well as the steps to follow if a patient chooses not to pursue genetic testing.

using microarray, a technique that enables one to give a snapshot view of gene expression, combined with complex analytic tools, can identify genes that seem to be co-regulated and thereby form a transcriptional network of genes and pathways. Microarray chips can hold over 10,000 genes and can be utilized to compare expression levels in certain disease states with healthy controls. In 2002, Hwang et al. studied RNA from heart failure patients with either HCM or DCM and found 192 genes to be upregulated in both, as well as several genes differentially expressed between the two diseases providing information on different pathways and genes involved in the pathogenesis (Hwang et al., 2002). More recently, Rajan et al. performed microarray analysis on ventricular tissue of two previously developed transgenic HCM mice carrying mutations in alpha-tropomyosin (TPM1). Studying 22,600 genes, they discovered 754 differentially expressed genes between transgenic and non-transgenic mice, of which 266 were differentially regulated between the two different mutant hearts showing most significant changes in genes belonging to the “secreted/ extracellular matrix” (upregulation) and “metabolic enzymes” (downregulation) (Rajan et al., 2006). Microarray techniques were also used by Sayed et al. when they studied the effect of aortic constriction on expression of microRNAs, fundamental regulators consisting of non-coding RNA molecules that silence genes through post-transcriptional regulation first described by Lee et al. in 1993 (Lee et al., 1993). In this recent study, they found that microRNAs, especially

microRNA-1 (miR-1), play an important role in the development of cardiac hypertrophy, where downregulation of miR-1 leads to relief of its growth-related target genes, protein synthesis, and increased cell size showing a completely new approach to the -omics of HCM (Sayed et al., 2007). In 2007, a novel-sensitive messenger RNA (mRNA) profiling technology, PMAGE (polony multiplex analysis of gene expression), which detects mRNAs as rare as one transcript per three cells, was developed (Kim et al., 2007). Using this new technique, early transcriptional changes preceding pathological manifestations were identified in mice with HCM-causing mutations, including low-abundance mRNA encoding signaling molecules and transcription factors that participate in the disease pathogenesis (Kim et al., 2007).

SCREENING AND TREATMENT FOR HCM Family Screening in HCM Genetic and clinical screening of family members with HCM plays an important role in the early diagnosis of HCM. Figure 28.3 shows one possible algorithm to follow after diagnosis of a proband with HCM. In general, all first-degree relatives and probably “athletic” second-degree relatives of an index case of HCM

Screening and Treatment for HCM

should be screened by an ECG and an echocardiogram. Annual screenings are recommended for young persons (12–25 years) and athletes and thereafter every 5 years. If the HCM-causing mutation is known, first-degree relatives should have confirmatory genetic testing of the mutation in addition to the screening ECG and echocardiogram. Depending on the established familial versus sporadic pattern, confirmatory genetic testing should proceed in concentric circles of relatedness. For example, if the mutation is established in the patient’s father, the patient’s paternal grandparents should be tested, and if necessary, the paternal aunts and uncles and so forth. If the putative HCM-associated mutation is not found in a phenotype-negative family member, screening can be stopped. However, a decision to cease surveillance for HCM in a relative hinges critically on the certainty of the identified gene/ mutation and its causative link as well as the complete absence of any traditional evidence used to diagnose HCM clinically (i.e., asymptomatic and normal echo). Follow-up and Sports Participation Intense physical exertion can potentially trigger SCD in individuals with HCM. According to the 2005 Bethesda Conference recommendations, athletes with HCM should be excluded from participation in contact sports as well as most organized competitive sports, with the possible exception of low-intensity sports classified as class IA sports (i.e., golf, bowling, cricket, billiards, and riflery) (Maron et al., 2005). Per the guidelines, the presence of an implantable cardioverter defibrillator (ICD) does not alter these recommendations. This restrictive approach is loosened for the patient with genotype-positive but phenotype-negative HCM. All patients with HCM should undergo, on an annual basis, careful personal and family history record, two-dimensional echocardiography, 12-lead ECG, 24–48-h ambulatory Holter electrocardiogram, and exercise stress testing (for evaluation of exercise tolerance, blood pressure, and ventricular tachyarrhythmias). Pharmacological Therapy for Obstructive HCM The primary goal of pharmacologic therapy in obstructive HCM is to decrease symptoms. Understanding the pathophysiology of the LVOTO is crucial to devising appropriate medication recommendations. The LVOTO in HCM is dynamic and highly load-dependent. The obstruction is augmented with decreases in preload (volume status) and afterload (vasodilation) and with increases in contractility. Simple physical exertion such as walking can cause all of these to occur simultaneously. As patients with HCM typically only have symptoms with effort, the goal of medical therapy is to decrease the effort-related augmentation of LVOTO. Beta Blockers Due to negative inotropic and negative chronotropic effects, beta blockers are the traditional mainstay of HCM therapy. Beta blockers are used in symptomatic patients with or without obstruction to control heart failure and anginal chest pain. The dose–response relationship of these medications varies

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significantly from patient to patient. Commonly used beta blockers include propranolol, atenolol, metoprolol, and nadolol (Elliott et al., 2004; Spirito et al., 2006). Calcium-Blocker Therapy The calcium channel antagonist verapamil is another drug used in HCM for its negative inotropic effect. It should be avoided in infants and used with caution in patients with heart failure and/or very significant obstruction (Maron et al., 2003). While both verapamil and diltiazem have negative inotropic and negative chronotropic effects, in some patients, vasodilatory action can predominate and paradoxically increase the severity of symptoms. Dihydropyridine-type calcium antagonists are pure vasodilators that should be avoided in patients with HCM. Disopyramide Disopyramide is a negative inotrope and type 1-A antiarrhythmic agent, which may help some patients with obstruction. It decreases cardiac output in nonobstructive HCM and is used primarily in patients not responding to beta blocker and/or calcium channel blocker therapy. There are no data that beta blockers, calcium channel blockers, or disopyramide alter the risk of sudden death (Maron et al., 2003). Drugs to Be Used with Caution in HCM Angiotensin-converting enzymes inhibitors (ACE inhibitors), angiotensin II blockers, nifedipine, and other pure afterload reducing agents should be used with caution, as afterload reduction may worsen LVOTO (Roberts et al., 2005; Spirito et al., 2006). Beta adrenergic agents like dopamine, dobutamine, or epinephrine and agents with increased inotropic activity may worsen LVOTO (Maron et al., 2003). Likewise, rapid or aggressive diuresis can decrease preload and worsen LVOTO. Pharmacogenomics Currently, there is no therapy available specifically designed for specific gene mutations underlying the disease nor a therapy that has been shown to reverse the hypertrophic process. Although polymorphisms in the renin-angiotensin-aldosterone system (RAAS) modify the phenotype of HCM, particularly MYBPC3-HCM (Perkins et al., 2005), a direct correlation with genotype-specific drug treatment has not been shown. However, with growing evidence that ACE inhibitors especially combined with low doses of aldosterone receptor blockers can prevent the progression of hypertrophy and fibrosis (Fraccarollo et al., 2003, 2005; Kalkman et al., 1999; Kambara et al., 2003; Monteiro de Resende et al., 2006), one can envision that, with increasing knowledge of the genomic background of HCM, specific therapies will emerge in the near future. In other cases for example, the proper and prompt recognition of an HCM phenocopy such as cardiac Fabry’s disease can facilitate gene-specific pharmacotherapy including in this particular example, enzyme-replacement therapy. Albeit rare, such clinical sleuthing can enable early treatment and prevent the progression of the disease.

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The Role and Impact of Non-Pharmacological Therapy Septal Myectomy Surgery Ventricular septal myectomy remains the gold standard for treating drug refractory, symptomatic obstructive HCM; a procedure during which a piece of hypertrophied septum is removed in order to relieve the obstruction (Maron et al., 2004; Nishimura et al., 2004; Spirito et al., 2006). Surgery is usually indicated in patients with peak instantaneous LVOT Doppler gradient of 50 mmHg or higher under rest or provocation and/or severely symptomatic patients (NYHA class 3 or 4, (Maron et al., 2003, 2004; Spirito et al., 2006). This profile represents approximately 5% of patients with HCM (Elliott et al., 2004). More extensive, extended septal myectomy involving the anterolateral papillary muscle and mitral valvuloplasty may be needed in patients with abnormal papillary muscle apparatus and mitral valve abnormalities (Ommen et al., 2005). The surgical mortality is 1% in most major centers (Maron et al., 2004; Poliac et al., 2006). Long-term survival after surgical myectomy is equal to that observed in the general population (Ommen et al., 2005). Surgery provides long-term improvement in LVOT gradient, mitral valve regurgitation, and symptomatic improvement (Maron et al., 2004; Ommen et al., 2005; Poliac et al., 2006). Septal Ablation Alcohol septal ablation technique using ethanol (95% alcohol 1–3 ml) is injected in specific septal branches of the left anterior descending artery producing a controlled septal infarction often

providing dramatic symptomatic improvement in some patients (Faber et al., 1998; Gietzen et al., 1999; Kimmelstiel et al., 2004; Knight et al., 1997; Lakkis et al., 1998). The criteria for patient selection for alcohol septal ablation are similar to myectomy with the following caveat – the impact of alcohol septal ablation on SCD risk is unknown. Scarring associated with alcohol septal ablation may create a permanent arrhythmogenic substrate (Maron et al., 2003). Complications include complete atrioventricular block requiring permanent pacemakers (5–10% of patients), large myocardial infarction, acute mitral valve regurgitation, ventricular fibrillation (VF), and death (2–4%, Nishimura et al., 2004; Roberts et al., 2005; Spirito et al., 2006). Alcohol septal ablation is not suitable for patients with LVOTO secondary to abnormal mitral valve apparatus and unusual location of hypertrophy away from the area supplied by septal perforator. Given the unknown future risks of alcohol septal ablation, it is not recommended in children or young adults (Maron et al., 2003). Implantable Cardioverter Defibrillator The implantable cardiac defibrillator (ICD) plays an important role in primary and secondary prevention of sudden death of patient with HCM. The three main functions of the ICD are detection of arrhythmia; delivery of appropriate electrical therapy; and storage of diagnostic information, including electrocardiograms and details of treated episodes. In a multicenter study of ICDs in patients with HCM, the device intervened appropriately, terminating VT/VF, at a rate of

Secondary prevention For all patients with a history of OHCA, documented sustained VT or VF

Primary prevention Two or more major risk factors Individualized consideration with only one major risk factor

Major risk factors • Abnormal blood pressure response during exercise • Extreme hypertrophy (30 mm) • Family history of sudden cardiac death • Non-sustained ventricular tachycardia • Unexplained syncope (exercise-induced)

Possible Modifiers • Gadolinium hyper-enhancement on CMR • LVOTO

Figure 28.4 The major indications for implantation of an ICD in HCM: secondary prevention or primary prevention, and major risk factors. CMR, cardiac magnetic resonance; LVOTO, left ventricular outflow tract obstruction; OHCA, out of hospital cardiac arrest; VF, ventricular fibrillation; VT, ventricular tachycardia.

2009 Update

5% per year for those patients implanted as primary prevention and 11% per year for secondary prevention, over an average follow-up of 3 years (Maron et al., 2000). The indications for implantation of an ICD are listed in Figure 28.4 and can be summarized as secondary prevention for all patients with a history of out of hospital cardiac arrest (OHCA), documented sustained VT or VF, or as primary prevention in patients with two or more major risk factors. Dual-Chamber Pacing There has been a great deal of debate surrounding the use of pacing as a means of relieving ventricular obstruction. Some studies have shown a beneficial effect, while others demonstrated significant placebo effect (Maron et al., 2003). The average decrease in LVOTO gradient with pacing ranged from a modest 25% to 40% and varied substantially (Maron et al., 2003). There

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is evidence to suggest that appropriately used dual-chamber pacing may decrease LVOT gradient and provide symptomatic relief (Maron et al., 1999). Thus, there may be a limited role of dual-chamber pacing in a select group of patients, for example patients with advanced age (65 years) and higher surgical risk. There is no evidence to suggest any change in SCD risk or disease progression (Boriani et al., 2004). Maze Procedures Surgical Maze procedure combined with myectomy may be a feasible therapeutic option in HCM with LVOTO and atrial fibrillation (AF). There are small case series reporting low operative mortality and morbidity and a high likelihood of patients remaining in sinus rhythm post procedure (Chen et al., 2004). Larger studies with longer follow-up are needed to better define the risks and benefits of surgical Maze procedure in HCM.

2009 UPDATE With research ongoing and recognizing that approximately 20% of reverse curve-HCM and over 80% of sigmoidal-HCM remains genetically unexplained, novel HCM-susceptibility genes have been discovered recently. In 2007, Arimura et al. found two mutations in one patient with HCM in OBSCNencoded obscurin that altered interaction with the giant myofilament protein titin (Arimura et al., 2007). In a larger study, 3 of 384 patients with HCM were mutation-positive in the ANKRD1-encoded cardiac ankyrin repeat protein (Arimura et al., 2009). The release of the complete human genome sequence and the enormity of variation in individuals show a growing role for modifier genes and the search for effect by genomewide studies. In 2007, Daw et al. identified multiple loci with suggestive linkage for modifying cardiac hypertrophy. Effect sizes on left ventricular mass on this cohort of 100 patients ranged from an ⬃8 g shift attributed to one locus for the common allele to 90 g shift for another locus’ uncommon allele (Daw et al., 2007). In 2008, sex hormone polymorphisms were shown to modify the HCM phenotype (Lind et al., 2008). Fewer CAG repeats in AR-encoded androgen receptor were associated with greater myocardial wall thickness in males (p0.008), and male carriers of the A-allele in the promoter of ESR1-encoded estrogen receptor 1 (SNP rs6915267) exhibited a 11% decrease in LV wall thickness (p0.047) compared to GG-homozygote males (Lind et al., 2008). HCM modifier polymorphisms like these could contribute to the clinical differences observed between men and women with HCM (Bos et al., 2008; Olivotto et al., 2005).

A recent longitudinal study in a large cohort of Italian patients with HCM has shown an increased risk of cardiovascular death, nonfatal stroke, or progression to NYHA class III/ IV among patients with a positive HCM genetic test involving any of the myofilament genes compared to those patients with a negative genetic test (25% versus 7%, respectively; p0.002). Multivariate analysis showed that myofilament positive HCM (i.e., a positive genetic test) was the strongest predictor of an adverse outcome (hazard ratio 4.27 (CI 1.43 – 12.48, p0.008, Olivotto et al., 2008). Furthermore, patients with a positive genetic test had greater probability of developing severe LV systolic dysfunction (p0.021) and restrictive LV filling (p0.018, Olivotto et al., 2008). In the emerging field of microRNA’s (miR’s) and their role in cardiac development and (hypertrophic) heart disease, several new studies linking miR’s and hypertrophy have been published. Utilizing two mouse models of pathological hypertrophy – transverse aortic constriction (TAC) and calcineurin transgenic mice – 6 miR’s were up-regulated, which in vitro, were sufficient to induce hypertrophic growth of cardiomyocytes (van Rooij et al., 2006). A transgenic mouse model over-expressing miR195 showed that a single miRNA could induce pathological hypertrophy and heart failure (van Rooij et al., 2006). Multiple studies have since been published with miRNA expression profiles in different settings, in vivo and in vitro, of cardiac hypertrophy demonstrating the potential role of miR’s in (hypertrophic) heart disease and possibly HCM (Ikeda et al., 2007; Sayed et al., 2007; Tatsuguchi et al., 2007; Thum et al., 2007; van Rooij et al., 2006, 2007).

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2009 UPDATE REFERENCES Arimura, T., Bos, J.M., Sato, A., Kubo, T., Okamoto, H., Nishi, H., Harada, H., Koga, Y., Moulik, M., Doi, Y. et al. (2009). Ankrd1encoded cardiac ankyrin repeat protein mutations in hypertrophic cardiomyopathy. J Am Coll Cardiol. Arimura, T., Matsumoto, Y., Okazaki, O., Hayashi, T., Takahashi, M., Inagaki, N., Hinohara, K., Ashizawa, N., Yano, K. and Kimura, A. (2007). Structural analysis of obscurin gene in hypertrophic cardiomyopathy. Biochem Biophys Res Commun 362(2), 281–287. Bos, J.M.,Theis, J.L.,Tajik, A.J., Gersh, B.J., Ommen, S.R. and Ackerman, M.J. (2008). Relationship between sex, shape, and substrate in hypertrophic cardiomyopathy. Am Heart J 155(6), 1128–1134. Daw, E.W., Chen, S.N., Czernuszewicz, G., Lombardi, R., Lu,Y., Ma, J., Roberts, R., Shete, S. and Marian, A.J. (2007). Genome-wide mapping of modifier chromosomal loci for human hypertrophic cardiomyopathy. Hum Mol Genet 16(20), 2463–2471. Ikeda, S., Kong, S.W., Lu, J., Bisping, E., Zhang, H., Allen, P.D., Golub,T.R., Pieske, B. and Pu, W.T. (2007). Altered microRNA expression in human heart disease. Physiol Genomics 31(3), 367–373. Lind, J.M., Chiu, C., Ingles, J.,Yeates, L., Humphries, S.E., Heather, A.K. and Semsarian, C. (2008). Sex hormone receptor gene variation associated with phenotype in male hypertrophic cardiomyopathy patients. J Mol Cell Cardiol 45(2), 217–222. Olivotto, I., Girolami, F.,Ackerman, M.J., Nistri, S., Bos, J.M., Zachara, E., Ommen, S.R., Theis, J.L., Vaubel, R.A., Re, F. et al. (2008). Myofilament protein gene mutation screening and outcome of

patients with hypertrophic cardiomyopathy. Mayo Clin Proc 83(6), 630–638. Olivotto, I., Maron, M.S., Adabag, A.S., Casey, S.A., Vargiu, D., Link, M.S., Udelson, J.E., Cecchi, F. and Maron, B.J. (2005). Genderrelated differences in the clinical presentation and outcome of hypertrophic cardiomyopathy. J Am Coll Cardiol 46(3), 480–487. Sayed, D., Hong, C., Chen, I.Y., Lypowy, J. and Abdellatif, M. (2007). MicroRNAs play an essential role in the development of cardiac hypertrophy. Circ Res 100(3), 416–424. Tatsuguchi, M., Seok, H.Y., Callis, T.E., Thomson, J.M., Chen, J.F., Newman, M., Rojas, M., Hammond, S.M. and Wang, D.Z. (2007). Expression of micrornas is dynamically regulated during cardiomyocyte hypertrophy. J Mol Cell Cardiol 42(6), 1137–1141. Thum, T., Galuppo, P., Wolf, C., Fiedler, J., Kneitz, S., van Laake, L.W., Doevendans, P.A., Mummery, C.L., Borlak, J., Haverich, A. et al. (2007). Micrornas in the human heart: A clue to fetal gene reprogramming in heart failure. Circulation 116(3), 258–267. van Rooij, E., Sutherland, L.B., Liu, N., Williams, A.H., McAnally, J., Gerard, R.D., Richardson, J.A. and Olson, E.N. (2006). A signature pattern of stress-responsive micrornas that can evoke cardiac hypertrophy and heart failure. Proc Natl Acad Sci USA 103(48), 18255–18260. van Rooij, E., Sutherland, L.B., Qi, X., Richardson, J.A., Hill, J. and Olson, E.N. (2007). Control of stress-dependent cardiac growth and gene expression by a microrna. Science 316(5824), 575–579.

REFERENCES Abelmann, W.H. (1984). Classification and natural history of primary myocardial disease. Prog Cardiovasc Dis 27(2), 73–94. Ackerman, M.J., Van Driest, S.V., Ommen, S.R., Will, M.L., Nishimura, R.A., Tajik, A.J. and Gersh, B.J. (2002). Prevalence and age-dependence of malignant mutations in the beta-myosin heavy chain and troponin T gene in hypertrophic cardiomyopathy: A comprehensive outpatient perspective. J Am Coll Cardiol 39(12), 2042–2048. Anan, R., Greve, G., Thierfelder, L., Watkins, H., McKenna, W.J., Solomon, S., Vecchio, C., Shono, H., Nakao, S., Tanaka, H. et al. (1994). Prognostic implications of novel beta cardiac myosin heavy chain gene mutations that cause familial hypertrophic cardiomyopathy. J Clin Invest 93(1), 280–285. Arad, M., Benson, D.W., Perez-Atayde,A.R., McKenna,W.J., Sparks, E.A., Kanter, R.J., McGarry, K., Seidman, J.G. and Seidman, C.E. (2002). Constitutively active AMP kinase mutations cause glycogen storage disease mimicking hypertrophic cardiomyopathy. J Clin Invest 109(3), 357–362. Arad, M., Maron, B.J., Gorham, J.M., Johnson, W.H., Jr, Saul, J.P., Perez-Atayde, A.R., Spirito, P., Wright, G.B., Kanter, R.J., Seidman, C.E. et al. (2005). Glycogen storage diseases presenting as hypertrophic cardiomyopathy. N Engl J Med 352(4), 362–372. Binder, J., Ommen, S.R., Gersh, B.J.,Van Driest, S.L.,Tajik, A.J., Nishimura, R.A. and Ackerman, M.J. (2006). Echocardiography-guided genetic testing in hypertrophic cardiomyopathy: septal morphological features predict the presence of myofilament mutations. Mayo Clin Proc 81(4), 459–467.

Blair, E., Redwood, C., Ashrafian, H., Oliveira, M., Broxholme, J., Kerr, B., Salmon, A., Ostman-Smith, I. and Watkins, H. (2001). Mutations in the gamma(2) subunit of AMP-activated protein kinase cause familial hypertrophic cardiomyopathy: Evidence for the central role of energy compromise in disease pathogenesis. Hum Mol Genet 10(11), 1215–1220. Boriani, G., Maron, B.J., Shen, W.K. and Spirito, P. (2004). Prevention of sudden death in hypertrophic cardiomyopathy: But which defibrillator for which patient? Circulation 110(15), e438–e442. Bos, J.M., Poley, R.N., Ny, M., Tester, D.J., Xu, X., Vatta, M., Towbin, J.A., Gersh, B.J., Ommen, S.R. and Ackerman, M.J. (2006). Genotype-phenotype relationships involving hypertrophic cardiomyopathy-associated mutations in titin, muscle Lim protein, and telethonin. Mol Genet Metab 88(1), 78–85. Braunwald, E., Lambrew, C.T., Rockoff, S.D., Ross, J., Jr and Morrow, A.G. (1964). Idiopathic hypertrophic subaortic stenosis. I. A description of the disease based upon an analysis of 64 patients. Circulation 30(Suppl 4), 3–119. Chen, M.S., McCarthy, P.M., Lever, H.M., Smedira, N.G. and Lytle, B.L. (2004). Effectiveness of atrial fibrillation surgery in patients with hypertrophic cardiomyopathy. Am J Cardiol 93(3), 373–375. Churchill, G.A. (2002). Fundamentals of experimental design for cDNA microarrays. Nat Genet 32(Suppl), 490–495. Coviello, D.A., Maron, B.J., Spirito, P.,Watkins, H.,Vosberg, H.P.,Thierfelder, L., Schoen, F.J., Seidman, J.G. and Seidman, C.E. (1997). Clinical features of hypertrophic cardiomyopathy caused by mutation of a hot spot in the alpha-tropomyosin gene. J Am Coll Cardiol 29(3), 635–640.

References

Daehmlow, S., Erdmann, J., Knueppel, T., Gille, C., Froemmel, C., Hummel, M., Hetzer, R. and Regitz-Zagrosek, V. (2002). Novel mutations in sarcomeric protein genes in dilated cardiomyopathy. Biochem Biophys Res Commun 298(1), 116–120. Elliott, P. and McKenna, W.J. (2004). Hypertrophic cardiomyopathy. Lancet 363(9424), 1881–1891. Elliott, P.M., Poloniecki, J., Dickie, S., Sharma, S., Monserrat, L., Varnava, A., Mahon, N.G. and McKenna, W.J. (2000). Sudden death in hypertrophic cardiomyopathy: Identification of high risk patients. J Am Coll Cardiol 36(7), 2212–2218. Faber, L., Seggewiss, H. and Gleichmann, U. (1998). Percutaneous transluminal septal myocardial ablation in hypertrophic obstructive cardiomyopathy: Results with respect to intraprocedural myocardial contrast echocardiography. Circulation 98(22), 2415–2421. Fraccarollo, D., Galuppo, P., Hildemann, S., Christ, M., Ertl, G. and Bauersachs, J. (2003). Additive improvement of left ventricular remodeling and neurohormonal activation by aldosterone receptor blockade with eplerenone and ACE inhibition in rats with myocardial infarction. J Am Coll Cardiol 42(9), 1666–1673. Fraccarollo, D., Galuppo, P., Schmidt, I., Ertl, G. and Bauersachs, J. (2005). Additive amelioration of left ventricular remodeling and molecular alterations by combined aldosterone and angiotensin receptor blockade after myocardial infarction. Cardiovasc Res 67(1), 97–105. Frank, D., Kuhn, C., Katus, H.A. and Frey, N. (2006). The sarcomeric Z-disc: A nodal point in signalling and disease. J Mol Med, 1–23. Frey, N., Katus, H.A., Olson, E.N. and Hill, J.A. (2004). Hypertrophy of the heart: A new therapeutic target?. Circulation 109(13), 1580–1589. Fujino, N., Ino, H., Hayashi, K., Uchiyama, K., Nagata, M., Konno, T., Katoh, H., Sakamoto, Y. and Tsubokawa, T. (2006). A novel missense mutation in cardiac ryanodine receptor gene as a possible cause of hypertrophic cardiomyopathy: Evidence from familial analysis. Circulation 114(18). II-165–915. Geier, C., Perrot, A., Ozcelik, C., Binner, P., Counsell, D., Hoffmann, K., Pilz, B., Martiniak, Y., Gehmlich, K., van der Ven, P.F. et al. (2003). Mutations in the human muscle Lim protein gene in families with hypertrophic cardiomyopathy. Circulation 107(10), 1390–1395. Geisterfer-Lowrance, A.A., Kass, S., Tanigawa, G., Vosberg, H., McKenna, W., Seidman, C.E. and Seidman, J.G. (1990). A molecular basis for familial hypertrophic cardiomyopathy: A beta cardiac myosin heavy chain gene missense mutation. Cell 62, 999–1006. Gerull, B., Gramlich, M., Atherton, J., McNabb, M., Trombitas, K., SasseKlaassen, S., Seidman, J.G., Seidman, C., Granzier, H., Labeit, S. et al. (2002). Mutations of TTN, encoding the giant muscle filament titin, cause familial dilated cardiomyopathy. Nat Genet 30(2), 201–204. Gietzen, F.H., Leuner, C.J., Raute-Kreinsen, U., Dellmann, A., Hegselmann, J., Strunk-Mueller, C. and Kuhn, H.J. (1999). Acute and long-term results after transcoronary ablation of septal hypertrophy (TASH). Catheter interventional treatment for hypertrophic obstructive cardiomyopathy. Eur Heart J 20(18), 1342–1354. Haghighi, K., Kolokathis, F., Gramolini, A.O., Waggoner, J.R., Pater, L., Lynch, R.A., Fan, G.C., Tsiapras, D., Parekh, R.R., Dorn, G.W., 2nd et al. (2006). A mutation in the human phospholamban gene, deleting arginine 14, results in lethal, hereditary cardiomyopathy. Proc Natl Acad Sci USA 103(5), 1388–1393. Hayashi,T., Arimura,T., Itoh-Satoh, M., Ueda, K., Hohda, S., Inagaki, N., Takahashi, M., Hori, H., Yasunami, M., Nishi, H. et al. (2004). TCAP gene mutations in hypertrophic cardiomyopathy and dilated cardiomyopathy. J Am Coll Cardiol 44(11), 2192–2201.

■

347

Holland, M.J. (2002). Transcript abundance in yeast varies over six orders of magnitude. J Biol Chem 277(17), 14363–14366. Hwang, J.J., Allen, P.D.,Tseng, G.C., Lam, C.W., Fananapazir, L., Dzau,V.J. and Liew, C.C. (2002). Microarray gene expression profiles in dilated and hypertrophic cardiomyopathic end-stage heart failure. Physiol Genomics 10(1), 31–44. Jarcho, J.A., McKenna, W., Pare, J.A., Solomon, S.D., Holcombe, R.F., Dickie, S., Levi, T., Donis-Keller, H., Seidman, J.G. and Seidman, C.E. (1989). Mapping a gene for familial hypertrophic cardiomyopathy to chromosome 14q1. N Engl J Med 321(20), 1372–1378. Kalkman, E.A., van Haren, P., Saxena, P.R. and Schoemaker, R.G. (1999). Early captopril prevents myocardial infarction-induced hypertrophy but not angiogenesis. Eur J Pharmacol 369(3), 339–348. Kambara, A., Holycross, B.J., Wung, P., Schanbacher, B., Ghosh, S., McCune, S.A., Bauer, J.A. and Kwiatkowski, P. (2003). Combined effects of low-dose oral spironolactone and captopril therapy in a rat model of spontaneous hypertension and heart failure. J Cardiovasc Pharmacol 41(6), 830–837. Kamisago, M., Sharma, S.D., DePalma, S.R., Solomon, S., Sharma, P., McDonough, B., Smoot, L., Mullen, M.P., Woolf, P.K., Wigle, E.D. et al. (2000). Mutations in sarcomere protein genes as a cause of dilated cardiomyopathy. N Engl J Med 343(23), 1688–1696. Kim, J.B., Porreca, G.J., Song, L., Greenway, S.C., Gorham, J.M., Church, G.M., Seidman, C.E. and Seidman, J.G. (2007). Polony multiplex analysis of gene expression (PMAGE) in mouse hypertrophic cardiomyopathy. Science 316(5830), 1481–1484. Kimmelstiel, C.D. and Maron, B.J. (2004). Role of Percutaneous Septal Ablation in Hypertrophic Obstructive Cardiomyopathy. Circulation 109(4), 452–456. Kimura, A., Harada, H., Park, J.E., Nishi, H., Satoh, M., Takahashi, M., Hiroi, S., Sasaoka, T., Ohbuchi, N., Nakamura, T. et al. (1997). Mutations in the cardiac troponin I gene associated with hypertrophic cardiomyopathy. Nat Genet 16(4), 379–382. Knight, C., Kurbaan, A.S., Seggewiss, H., Henein, M., Gunning, M., Harrington, D., Fassbender, D., Gleichmann, U. and Sigwart, U. (1997). Nonsurgical septal reduction for hypertrophic obstructive cardiomyopathy: Outcome in the first series of patients. Circulation 95(8), 2075–2081. Knoll, R., Hoshijima, M., Hoffman, H.M., Person, V., LorenzenSchmidt, I., Bang, M.L., Hayashi, T., Shiga, N., Yasukawa, H., Schaper, W. et al. (2002). The cardiac mechanical stretch sensor machinery involves a Z disc complex that is defective in a subset of human dilated cardiomyopathy. Cell 111(7), 943–955. Lakkis, N.M., Nagueh, S.F., Kleiman, N.S., Killip, D., He, Z.X., Verani, M.S., Roberts, R. and Spencer, W.H., 3rd (1998). Echocardiography-guided ethanol septal reduction for hypertrophic obstructive cardiomyopathy. Circulation 98(17), 1750–1755. Landstrom, A.P., Parvatiyar, M.S., Pinto, J.R., Marquardt, M.L., Bos, J.M., Ommen, S.R., Potter, J.D., Ackerman, M.J. (2008). Defining TNNC1-encoded cardiac Troponin C as novel target gene for hypertrophic cardiomyopathy. J Mol Cell Cardiol In Press. Landstrom, A., Batalden, K.B., Weisleder, N., Bos, J.M., Tester, D.J., Ommen, S.R., Wehrens, X.H.T., Claycomb, W.C., Ko, J., Hwang, M. et al. (2007). Mutations in JPH2-encoded junctophilin-2 associated with hypertrophic cardiomyopathy in humans. J Mol Cell Cardiol 42, 1026–1035. Lee, R.C., Feinbaum, R.L. and Ambros, V. (1993). The C. elegans heterochronic gene lin-4 encodes small RNAs with antisense complementarity to lin-14. Cell 75(5), 843–854.

348

CHAPTER 28

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Genetics and Genomics of Hypertrophic Cardiomyopathy

Lever, H.M., Karam, R.F., Currie, P.J. and Healy, B.P. (1989). Hypertrophic cardiomyopathy in the elderly. Distinctions from the young based on cardiac shape. Circulation 79(3), 580–589. Maron, B.J. (2002). Hypertrophic cardiomyopathy: A systematic review. JAMA 287(10), 1308–1320. Maron, B.J., Nishimura, R.A., McKenna, W.J., Rakowski, H., Josephson, M.E. and Kieval, R.S. (1999). Assessment of permanent dual-chamber pacing as a treatment for drug-refractory symptomatic patients with obstructive hypertrophic cardiomyopathy. A randomized, double-Blind, crossover study (M-PATHY). Circulation 99(22), 2927–2933. Maron, B.J., Shen, W.K., Link, M.S., Epstein, A.E., Almquist, A.K., Daubert, J.P., Bardy, G.H., Favale, S., Rea, R.F., Boriani, G. et al. (2000). Efficacy of implantable cardioverter-defibrillators for the prevention of sudden death in patients with hypertrophic cardiomyopathy [See Comments]. N Engl J Med 342(6), 365–373. Maron, B.J., McKenna, W.J., Danielson, G.K., Kappenberger, L.J., Kuhn, H.J., Seidman, C.E., Shah, P.M., Spencer, W.H., 3rd, Spirito, P., Ten Cate, F.J. et al. (2003). American College of Cardiology/European Society of Cardiology clinical expert consensus document on hypertrophic cardiomyopathy. A Report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents and the European Society of Cardiology Committee for Practice Guidelines. J Am Coll Cardiol 42(9), 1687–1713. Maron, B.J., Dearani, J.A., Ommen, S.R., Maron, M.S., Schaff, H.V., Gersh, B.J. and Nishimura, R.A. (2004). The case for surgery in obstructive hypertrophic cardiomyopathy. J Am Coll Cardiol 44(10), 2044–2053. Maron, B.J., Ackerman, M.J., Nishimura, R.A., Pyeritz, R.E., Towbin, J.A. and Udelson, J.E. (2005). Task Force 4: HCM and other cardiomyopathies, mitral valve prolapse, myocarditis, and Marfan syndrome. J Am Coll Cardiol 45(8), 1340–1345. Minamisawa, S., Sato, Y., Tatsuguchi, Y., Fujino, T., Imamura, S., Uetsuka, Y., Nakazawa, M. and Matsuoka, R. (2003). Mutation of the phospholamban promoter associated with hypertrophic cardiomyopathy. Biochem Biophys Res Commun 304(1), 1–4. Mogensen, J., Klausen, I.C., Pedersen, A.K., Egeblad, H., Bross, P., Kruse, T.A., Gregersen, N., Hansen, P.S., Daandrup, U. and Borglum, A.D. (1999). Alpha-cardiac cctin is a novel disease gene in familial hypertrophic cardiomyopathy. J Clin Invest 103(10), R39–R43. Mohapatra, B., Jimenez, S., Lin, J.H., Bowles, K.R., Coveler, K.J., Marx, J.G., Chrisco, M.A., Murphy, R.T., Lurie, P.R., Schwartz, R.J. et al. (2003). Mutations in the muscle Lim protein and alphaactinin-2 genes in dilated cardiomyopathy and endocardial fibroelastosis. Mol Genet Metab 80(1-2), 207–215. Monteiro de Resende, M., Kriegel, A.J. and Greene, A.S. (2006). Combined effects of low-dose spironolactone and captopril therapy in a rat model of genetic hypertrophic cardiomyopathy. J Cardiovasc Pharmacol 48(6), 265–273. Moolman, J.C., Corfield, V.A., Posen, B., Ngumbela, K., Seidman, C., Brink, P.A. and Watkins, H. (1997). Sudden death due to troponin T mutations. J Am Coll Cardiol 29(3), 549–555. Moon, J.C., McKenna, W.J., McCrohon, J.A., Elliott, P.M., Smith, G.C. and Pennell, D.J. (2003). Toward clinical risk assessment in hypertrophic cardiomyopathy with gadolinium cardiovascular magnetic resonance. J Am Coll Cardiol 41(9), 1561–1567. Morita, H., Larson, M.G., Barr, S.C., Vasan, R.S., O’Donnell, C.J., Hirschhorn, J.N., Levy, D., Corey, D., Seidman, C.E., Seidman, J.G.

et al. (2006). Single-gene mutations and increased left ventricular wall thickness in the community: The framingham heart study. Circulation 113(23), 2697–2705. Nakao, S., Takenaka, T., Maeda, M., Kodama, C., Tanaka, A., Tahara, M., Yoshida, A., Kuriyama, M., Hayashibe, H., Sakuraba, H. et al. (1995). An atypical variant of Fabry’s disease in men with left ventricular hypertrophy. N Engl J Med 333(5), 288–293. Niimura, H., Patton, K.K., McKenna, W.J., Soults, J., Maron, B.J., Seidman, J.G. and Seidman, C.E. (2002). Sarcomere protein gene mutations in hypertrophic cardiomyopathy of the elderly. Circulation 105(4), 446–451. Nishimura, R.A. and Holmes, D.R., Jr (2004). Clinical practice. Hypertrophic obstructive cardiomyopathy. N Engl J Med 350(13), 1320–1327. Olson, T.M., Doan, T.P., Kishimoto, N.Y., Whitby, F.G., Ackerman, M.J. and Fananapazir, L. (2000). Inherited and de novo mutations in the cardiac actin gene cause hypertrophic cardiomyopathy. J Mol Cell Cardiol 32, 1687–1694. Olson, T.M., Illenberger, S., Kishimoto, N.Y., Huttelmaier, S., Keating, M.T. and Jockusch, B.M. (2002a). Metavinculin mutations alter actin interaction in dilated cardiomyopathy. Circulation 105(4), 431–437. Olson, T.M., Karst, M.L., Whitby, F.G. and Driscoll, D.J. (2002b). Myosin light chain mutation causes autosomal recessive cardiomyopathy with mid-cavitary hypertrophy and restrictive physiology. Circulation 105(20), 2337–2340. Olson, T.M., Kishimoto, N.Y., Whitby, F.G. and Michels, V.V. (2001). Mutations that alter the surface charge of alpha-tropomyosin are associated with dilated cardiomyopathy. J Mol Cell Cardiol 33(4), 723–732. Ommen, S.R., Maron, B.J., Olivotto, I., Maron, M.S., Cecchi, F., Betocchi, S., Gersh, B.J., Ackerman, M.J., McCully, R.B., Dearani, J.A. et al. (2005). Long-term effects of surgical septal myectomy on survival in patients with obstructive hypertrophic cardiomyopathy. J Am Coll Cardiol 46(3), 470–476. Osio, A., Tan, L., Chen, S.N., Lombardi, R., Nagueh, S.F., Shete, S., Roberts, R., Willerson, J.T. and Marian, A.J. (2007). Myozenin 2 is a novel gene for human hypertrophic cardiomyopathy. Circ Res. Perkins, M.J., Van Driest, S.L., Ellsworth, E.G., Will, M.L., Gersh, B.J., Ommen, S.R. and Ackerman, M.J. (2005). Gene-specific modifying effects of pro-LVH polymorphisms involving the reninangiotensin-aldosterone system among 389 unrelated patients with hypertrophic cardiomyopathy. Eur Heart J 26(22), 2457–2462. Poetter, K., Jiang, H., Hassanzadeh, S., Master, S.R., Chang, A., Dalakas, M.C., Rayment, I., Sellers, J.R., Fananapazir, L. and Epstein, N.D. (1996). Mutations in either the essential or regulatory light chains of myosin are associated with a rare myopathy in human heart and skeletal muscle. Nat Genet 13(1), 63–69. Poliac, L.C., Barron, M.E. and Maron, B.J. (2006). Hypertrophic cardiomyopathy. Anesthesiology 104(1), 183–192. Pollick, C., Morgan, C.D., Gilbert, B.W., Rakowski, H. and Wigle, E.D. (1982). Muscular subaortic stenosis: The temporal relationship between systolic anterior motion of the anterior mitral leaflet and the pressure gradient. Circulation 66(5), 1087–1094. Pyle, W.G. and Solaro, R.J. (2004). At the crossroads of myocardial signaling: The role of Z-discs in intracellular signaling and cardiac function. Circ Res 94(3), 296–305. Rajan, S., Williams, S.S., Jagatheesan, G., Ahmed, R.P., Fuller-Bicer, G., Schwartz, A., Aronow, B.J. and Wieczorek, D.F. (2006). Microarray analysis of gene expression during early stages of mild and severe cardiac hypertrophy. Physiol Genomics 27(3), 309–317.

References

Richard, P., Charron, P., Carrier, L., Ledeuil, C., Cheav, T., Pichereau, C., Benaiche, A., Isnard, R., Dubourg, O., Burban, M. et al. (2003). Hypertrophic cardiomyopathy: Distribution of disease genes, spectrum of mutations, and implications for a molecular diagnosis strategy. Circulation 107(17), 2227–2232. Richardson, P., McKenna, W., Bristow, M., Maisch, B., Mautner, B., O’Connell, J., Olsen, E., Thiene, G., Goodwin, J., Gyarfas, I. et al. (1996). Report of the 1995 World Health Organization/International Society and Federation of Cardiology Task Force on the Definition and Classification of Cardiomyopathies. Circulation 93(5), 841–842. Roberts, R. and Sigwart, U. (2005). Current concepts of the pathogenesis and treatment of hypertrophic cardiomyopathy. Circulation 112(2), 293–296. Sachdev, B., Takenaka, T., Teraguchi, H., Tei, C., Lee, P., McKenna, W.J. and Elliott, P.M. (2002). Prevalence of AndersonFabry disease in male patients with late onset hypertrophic cardiomyopathy. Circulation 105(12), 1407–1411. Sakuraba, H., Oshima, A., Fukuhara,Y., Shimmoto, M., Nagao,Y., Bishop, D.F., Desnick, R.J. and Suzuki, Y. (1990). Identification of point mutations in the alpha-galactosidase a gene in classical and atypical hemizygotes with Fabry disease. Am J Hum Genet 47(5), 784–789. Satoh, M., Takahashi, M., Sakamoto, T., Hiroe, M., Marumo, F. and Kimura, A. (1999). Structural analysis of the titin gene in hypertrophic cardiomyopathy: Identification of a novel disease gene. Biochem Biophys Res Commun 262, 411–417. Sayed, D., Hong, C., Chen, I.Y., Lypowy, J. and Abdellatif , M. (2007). Micrornas play an essential role in the development of cardiac hypertrophy. Circ Res 100(3), 416–424. Schoendube, F.A., Klues, H.G., Reith, S., Flachskampf , F.A., Hanrath, P. and Messmer, B.J. (1995). Long-term clinical and echocardiographic follow-up after surgical correction of hypertrophic obstructive cardiomyopathy with extended myectomy and reconstruction of the subvalvular mitral apparatus. Circulation 92(9 Suppl), II122–II127. Seidman, J.G. and Seidman, C. (2001). The genetic basis for cardiomyopathy: From mutation identification to mechanistic paradigms. Cell 104(4), 557–567. Solomon, S.D., Wolff , S., Watkins, H., Ridker, P.M., Come, P., McKenna, W.J., Seidman, C.E. and Lee, R.T. (1993). Left ventricular hypertrophy and morphology in familial hypertrophic cardiomyopathy associated with mutations of the beta-myosin heavy chain gene. J Am Coll Cardiol 22(2), 498–505. Spirito, P. and Autore, C. (2006). Management of hypertrophic cardiomyopathy. BMJ 332(7552), 1251–1255. Teare, D. (1958). Asymmetrical hypertrophy of the heart in young adults. Br Heart J 20(1), 1–8. Theis, J.L., Martijn Bos, J., Bartleson, V.B., Will, M.L., Binder, J., Vatta, M., Towbin, J.A., Gersh, B.J., Ommen, S.R. and Ackerman, M.J. (2006). Echocardiographic-determined septal morphology in Z-disc hypertrophic cardiomyopathy. Biochem Biophys Res Commun 351(4), 896–902. Thierfelder, L., Watkins, H., MacRae, C., Lamas, R., McKenna, W., Vosberg, H.P., Seidman, J.G. and Seidman, C.E. (1994). Alphatropomyosin and cardiac troponin T mutations cause familial hypertrophic cardiomyopathy: A disease of the sarcomere. Cell 77(5), 701–712. Van Driest, S.V., Ackerman, M.J., Ommen, S.R., Shakur, R., Will, M.L., Nishimura, R.A., Tajik, A.J. and Gersh, B.J. (2002). Prevalence and

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severity of “Benign” mutations in the beta myosin heavy chain, cardiac troponin-T, and alpha tropomyosin genes in hypertrophic cardiomyopathy. Circulation 106, 3085–3090. Van Driest, S.L., Ellsworth, E.G., Ommen, S.R., Tajik, A.J., Gersh, B.J. and Ackerman, M.J. (2003). Prevalence and spectrum of thin filament mutations in an outpatient referral population with hypertrophic cardiomyopathy. Circulation 108, 445–451. Van Driest, S.L., Jaeger, M.A., Ommen, S.R., Will, M.L., Gersh, B.J., Tajik, A.J. and Ackerman, M.J. (2004). Comprehensive analysis of the beta-myosin heavy chain gene in 389 unrelated patients with hypertrophic cardiomyopathy. J Am Coll Cardiol 44(3), 602–610. Van Driest, S.L., Maron, B.J. and Ackerman, M.J. (2004). From malignant mutations to malignant domains: The continuing search for prognostic significance in the mutant genes causing hypertrophic cardiomyopathy. [Comment]. Heart (British Cardiac Society) 90(1), 7–8. Van Driest, S.L., Vasile, V.C., Ommen, S.R., Will, M.L., Gersh, B.J., Nishimura, R.A., Tajik, A.J. and Ackerman, M.J. (2004). Myosin binding protein C mutations and compound herterozygosity in hypertrophic cardiomyopathy. J Am Coll Cardiol 44(9), 1903–1910. Van Driest, S.L., Ommen, S.R., Tajik, A.J., Gersh, B.J. and Ackerman, M.J. (2005). Sarcomeric genotyping in hypertrophic cardiomyopathy. Mayo Clin Proc 80(4), 463–469. Van Driest, S.L., Gakh, O., Ommen, S.R., Isaya, G. and Ackerman, M.J. (2005). Molecular and functional characterization of a human frataxin mutation found in hypertrophic cardiomyopathy. Mol Genet Metab 2, 1096–7192. Varnava, A., Baboonian, C., Davison, F., de Cruz, L., Elliott, P.M., Davies, M.J. and McKenna, W.J. (1999). A new mutation of the cardiac troponin T gene causing familial hypertrophic cardiomyopathy without left ventricular hypertrophy. Heart 82(5), 621–624. Vasile, V.C., Will, M.L., Ommen, S.R., Edwards, W.D., Olson, T.M. and Ackerman, M.J. (2006a). Identification of a metavinculin missense mutation, R975w, associated with both hypertrophic and dilated cardiomyopathy. Mol Genet Metab 87(2), 169–174. Vasile, V.C., Ommen, S.R., Edwards, W.D. and Ackerman, M.J. (2006b). A missense mutation in a ubiquitously expressed protein, vinculin, confers susceptibility to hypertrophic cardiomyopathy. Biochem Biophys Res Commun 345(3), 998–1003. Velculescu, V.E., Zhang, L., Zhou, W., Vogelstein, J., Basrai, M.A., Bassett, D.E., Jr, Hieter, P., Vogelstein, B. and Kinzler, K.W. (1997). Characterization of the yeast transcriptome. Cell 88(2), 243–251. Watkins, H., Rosenzweig, A., Hwang, D.S., Levi, T., McKenna, W., Seidman, C.E. and Seidman, J.G. (1992). Characteristics and prognostic implications of myosin missense mutations in familial hypertrophic cardiomyopathy. N Engl J Med 326(17), 1108–1114. Watkins, H., Conner, D., Thierfelder, L., Jarcho, J.A., MacRae, C., McKenna, W.J., Maron, B.J., Seidman, J.G. and Seidman, C.E. (1995). Mutations in the cardiac myosin binding protein-C gene on chromosome 11 cause familial hypertrophic cardiomyopathy. Nat Genet 11, 434–437. Woo, A., Rakowski, H., Liew, J.C., Zhao, M.S., Liew, C.C., Parker, T.G., Zeller, M., Wigle, E.D. and Sole, M.J. (2003). Mutations of the beta myosin heavy chain gene in hypertrophic cardiomyopathy: Critical functional sites determine prognosis. Heart (British Cardiac Society) 89(10), 1179–1185.