Cardiological aspects of Fabry disease: from diagnosis to therapeutic efficacy assessment.

backgroundFabry disease (FD) is a rare inborn error of metabolism in which absent or deficient activity of α-galactosidase A leads to lysosomal dysfunction and globotriaosylceramide accumulation in different organs, including the heart. FD is characterized by a broad clinical spectrum, but Fabry cardiomyopathy represents the leading cause of morbidity and mortality. Electrocardiogram (ECG), echocardiography, and cardiac magnetic resonance (CMR) imaging are the cornerstones to suspect and diagnose cardiac involvement and to monitor it. Cardiac biomarkers such as troponin and N-terminal pro-B-type natriuretic peptide are also used to ascertain the degree of cardiac involvement. However, definitive data are lacking on how to plan the follow-up of patients with or without cardiac involvement, when to initiate specific therapy, and when to switch from one treatment to another. Current proposals suggest initiating treatment when there is evidence of left ventricular hypertrophy but before fibrosis develops. MAIN BODY: Ten experts on FD met in Milan on March 8, 2024. The panel of experts was selected based on their expertise and contribution to the literature on FD. The group deliberated on appropriate parameters for cardiac assessment at diagnosis and during follow-up. The panel discussed developing a multiparametric cardiac assessment system (including ECG, laboratory biomarkers, echocardiographic and CMR parameters) to be used in clinical practice to guide management and monitor treatment response. The authors defined the requirements of such a system and advocate for the research needed to build and validate it. The experts also proposed a multiparametric clinical pathway for cardiac assessment, treatment initiation, and follow-up, designed to support routine clinical decisions. This was intended as general guidance, acknowledging that clinicians should tailor management to the individual patient's specific characteristics - a principle of particular importance in rare diseases such as FD, where organ involvement and treatment response can differ substantially among individuals.

conclusionSince cardiovascular disease is a leading cause of death in FD, an agreed staging system for evaluating cardiac progression is urgently needed. Further research should be carried out to confirm the criteria of a cardiac assessment system, evaluate its prognostic and predictive validity, and ensure its reliability and reproducibility.