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      Clinical Care Recommendations for Cardiologists Treating Adults With Myotonic Dystrophy

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          Abstract

          Myotonic dystrophy is an inherited systemic disorder affecting skeletal muscle and the heart. Genetic testing for myotonic dystrophy is diagnostic and identifies those at risk for cardiac complications. The 2 major genetic forms of myotonic dystrophy, type 1 and type 2, differ in genetic etiology yet share clinical features. The cardiac management of myotonic dystrophy should include surveillance for arrhythmias and left ventricular dysfunction, both of which occur in progressive manner and contribute to morbidity and mortality. To promote the development of care guidelines for myotonic dystrophy, the Myotonic Foundation solicited the input of care experts and organized the drafting of these recommendations. As a rare disorder, large scale clinical trial data to guide the management of myotonic dystrophy are largely lacking. The following recommendations represent expert consensus opinion from those with experience in the management of myotonic dystrophy, in part supported by literature‐based evidence where available.

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          Most cited references51

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          Aberrant regulation of insulin receptor alternative splicing is associated with insulin resistance in myotonic dystrophy.

          Myotonic dystrophy type 1 (DM1) is caused by a CTG trinucleotide expansion in the 3' untranslated region of the DM protein kinase gene. People with DM1 have an unusual form of insulin resistance caused by a defect in skeletal muscle. Here we demonstrate that alternative splicing of the insulin receptor (IR) pre-mRNA is aberrantly regulated in DM1 skeletal muscle tissue, resulting in predominant expression of the lower-signaling nonmuscle isoform (IR-A). IR-A also predominates in DM1 skeletal muscle cultures, which exhibit a decreased metabolic response to insulin relative to cultures from normal controls. Steady-state levels of CUG-BP, a regulator of pre-mRNA splicing proposed to mediate some aspects of DM1 pathogenesis, are increased in DM1 skeletal muscle; overexpression of CUG-BP in normal cells induces a switch to IR-A. The CUG-BP protein mediates this switch through an intronic element located upstream of the alternatively spliced exon 11, and specifically binds within this element in vitro. These results support a model in which increased expression of a splicing regulator contributes to insulin resistance in DM1 by affecting IR alternative splicing.
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            2012 ACCF/AHA/HRS focused update incorporated into the ACCF/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.

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              Effect of perindopril on the onset and progression of left ventricular dysfunction in Duchenne muscular dystrophy.

              The aim of this research was to examine the effects of perindopril on cardiac function in patients with Duchenne muscular dystrophy (DMD). Duchenne muscular dystrophy, an inherited X-linked disease, is characterized by progressive muscle weakness and myocardial involvement. In phase I, 57 children with DMD and a left ventricular ejection fraction (LVEF) >55% (mean 65.0 +/- 5.4%), 9.5 to 13 years of age (mean 10.7 +/- 1.2 years), were enrolled in a three-year multicenter, randomized, double-blind trial of perindopril, 2 to 4 mg/day (group 1), versus placebo (group 2). In phase II, all patients received open-label perindopril for 24 more months; LVEF was measured at 0, 36, and 60 months. Phase I was completed by 56 (27 in group 1 and 29 in group 2) and phase II by 51 patients (24 in group 1 and 27 in group 2). There was no difference in baseline characteristics between the treatment groups. At the end of phase I, mean LVEF was 60.7 +/- 7.6% in group 1 versus 64.4 +/- 9.8% in group 2, and was <45% in a single patient in each group (p = NS). At 60 months, LVEF was 58.6 +/- 8.1% in group 1 versus 56.0 +/- 15.5% in group 2 (p = NS). A single patient had an LVEF <45% in group 1 versus eight patients in group 2 (p = 0.02). Early treatment with perindopril delayed the onset and progression of prominent left ventricle dysfunction in children with DMD.
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                Author and article information

                Contributors
                elizabeth.mcnally@northwestern.edu
                Journal
                J Am Heart Assoc
                J Am Heart Assoc
                10.1002/(ISSN)2047-9980
                JAH3
                ahaoa
                Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease
                John Wiley and Sons Inc. (Hoboken )
                2047-9980
                06 February 2020
                18 February 2020
                : 9
                : 4 ( doiID: 10.1002/jah3.v9.4 )
                : e014006
                Affiliations
                [ 1 ] Northwestern University Feinberg School of Medicine Chicago IL
                [ 2 ] Washington University in St. Louis MO
                [ 3 ] University of Amsterdam Amsterdam The Netherlands
                [ 4 ] Indiana University School of Medicine Indianapolis IN
                [ 5 ] Albert Einstein College of Medicine Bronx NY
                [ 6 ] University of Pennsylvania Philadelphia PA
                [ 7 ] Medical University of South Carolina Charleston SC
                [ 8 ] National Hospital Organization Higashisaitama National Hospital Saitama Japan
                [ 9 ] Hopital Cochin Universite Paris Descartes Paris France
                [ 10 ] Shiga University of Medical Science Shiga Japan
                [ 11 ] Myotonic Foundation San Francisco CA
                [ 12 ] University of Texas Southwestern Medical Center Dallas TX
                Author notes
                [*] [* ] Correspondence to: Elizabeth M. McNally, MD, PhD, Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, 303 E. Superior St., Chicago IL 60611. E‐mail: elizabeth.mcnally@ 123456northwestern.edu
                Article
                JAH34773
                10.1161/JAHA.119.014006
                7070199
                32067592
                57bc3302-ce35-41af-b24a-ee85613afc9a
                © 2020 The Authors and Myotonic. Published on behalf of the American Heart Association, Inc., by Wiley.

                This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

                History
                : 19 July 2019
                : 10 December 2019
                Page count
                Figures: 0, Tables: 0, Pages: 7, Words: 6262
                Funding
                Funded by: National Institutes of Health , open-funder-registry 10.13039/100000002;
                Award ID: AR052646
                Award ID: HD087351
                Categories
                Special Report
                Special Report
                Custom metadata
                2.0
                18 February 2020
                Converter:WILEY_ML3GV2_TO_JATSPMC version:5.7.6.1 mode:remove_FC converted:04.03.2020

                Cardiovascular Medicine
                arrhythmias,conduction system disease,heart failure,management,myotonic dystrophy,genetics

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