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Ashraf I, Peck MM, Maram R, Mohamed A, Ochoa Crespo D, Kaur G, Malik BH. Association of Arrhythmias in Cardiac Amyloidosis and Cardiac Sarcoidosis. Cureus 2020; 12:e9842. [PMID: 32953349 PMCID: PMC7497218 DOI: 10.7759/cureus.9842] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Cardiac involvement in amyloidosis and sarcoidosis is poorly understood, and is associated with high morbidity and mortality. Atrial and ventricular arrhythmias, along with conduction defects, are frequent in cardiac amyloidosis and sarcoidosis. Atrial dysfunction in cardiac amyloidosis may result in atrial fibrillation and increases the risk of stroke, making anticoagulation significant and challenging. Ventricular arrhythmia and conduction defects are more common in AL amyloidosis and cardiac sarcoidosis. Premature ventricular contractions (PVCs) from Purkinje fibers trigger ventricular arrhythmias in cardiac amyloidosis, while the inflammation and scarring leading to the reentrant process is the cause in cardiac sarcoidosis. The typical treatment modalities include Class II and III antiarrhythmic drugs and ablation techniques, while corticosteroids and immunosuppressants are indicated in cardiac sarcoidosis to reduce the burden of the disease and arrhythmias. Sudden cardiac death can be a manifestation of both disorders that can be prevented by the Implantable cardioverter-defibrillator (ICD), although the predictive risk factors for primary prevention remain uncertain. In this review, we addressed the current understanding of the pathways involved in inducing arrhythmias in cardiac amyloidosis and sarcoidosis-also, the complications including sudden death and stroke associated with arrhythmia in both diseases. We have discussed other preventive steps needed to minimize arrhythmias to provide symptomatic relief and palliation to patients.
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Affiliation(s)
- Ibtisam Ashraf
- Internal Medicine, Shalamar Institute of Health Sciences, Lahore, PAK.,Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Mercedes Maria Peck
- Internal Medicine, California Institute of Behavorial Neurosciences and Psychology, Fairfield, USA
| | - Ruchira Maram
- Internal Medicine, Arogyasri Healthcare Trust, Hyderabad, IND.,Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Alaa Mohamed
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA.,Internal Medicine, Memorial Hermann Medical Center, Houston, USA
| | - Diego Ochoa Crespo
- Internal Medicine, Clinica San Martin, Azogues, ECU.,Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Gurleen Kaur
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Bilal Haider Malik
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
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Isath A, Correa A, Siroky GP, Perimbeti S, Mohammed S, Chahal CAA, Padmanabhan D, Mehta D. Trends, burden, and impact of arrhythmia on cardiac amyloid patients: A 16-year nationwide study from 1999 to 2014. J Arrhythm 2020; 36:727-734. [PMID: 32782646 PMCID: PMC7411211 DOI: 10.1002/joa3.12376] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 05/12/2020] [Accepted: 05/15/2020] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Patients with cardiac amyloidosis (CA) have increased mortality, which can be explained in part by an increased risk of arrhythmias. The burden of arrhythmias in CA, their predictors, and impact on in-hospital outcomes remains unclear. The role of implantable cardioverter-defibrillators (ICD) in this population is also uncertain. METHODS We queried the National Inpatient Sample (NIS) using ICD-9-CM codes 277.39 and 425.7 to identify CA. Twelve common arrhythmias were extracted using appropriate, validated ICD-9-CM codes. ICD implantation was identified using procedure ICD-9 codes 37.94 to 37.98, 00.51 and 00.54. RESULTS There were a total of 145,920 CA hospitalizations between 1999 and 2014 in the United States and 56,199 (38.5%) of them were associated with arrhythmias. The prevalence of arrhythmias remained relatively constant from 41.5% in 1999 to 40.2% in 2014. The most common arrhythmia was atrial fibrillation (25.4%). In-patient mortality was significantly higher in CA patients with arrhythmias (10.4% vs 6.5%, P < .001). ICD implantation was performed in 1,381 (0.94%) patients with CA and analysis revealed an incremental trend in implantation over the study period (0.48% in 1999 to 0.65% in 2014). In-hospital mortality was significantly lower in patients who underwent ICD implantation (3.7% vs 8%; P = .0078). CA patients with arrhythmias also had an increased cost of hospitalization and length of stay ($65,046 ± 1,079 vs $53,322 ± 687 and 8.3 ± 0.1 vs 7.4 ± 0.1 days, respectively; P < .0001). CONCLUSION Cardiac arrhythmias are common in patients with CA and are associated with worse in-hospital outcomes, increased length of stay, and cost of hospitalization.
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Affiliation(s)
- Ameesh Isath
- Department of MedicineMount Sinai St. Luke's and Mount Sinai WestNew YorkNYUSA
| | - Ashish Correa
- Department of CardiologyMount Sinai St. Luke'sNew YorkNYUSA
| | | | - Stuthi Perimbeti
- Department of MedicineMount Sinai St. Luke's and Mount Sinai WestNew YorkNYUSA
| | - Selma Mohammed
- Department of Cardiovascular MedicineMedStar Washington Hospital CenterWashingtonDCUSA
| | - C. Anwar A. Chahal
- Department of Cardiovascular MedicineMayo ClinicJacksonvilleFLUSA
- University of PennsylvaniaPhiladelphiaPAUSA
| | - Deepak Padmanabhan
- Department of Cardiovascular MedicineMayo ClinicJacksonvilleFLUSA
- Sri Jayadeva Institute of Cardiovascular Sciences and Research, CardiologyBengaluruKarnatakaIndia
| | - Davendra Mehta
- Department of CardiologyMount Sinai St. Luke'sNew YorkNYUSA
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53
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(Transthyretin amyloidosis). COR ET VASA 2020. [DOI: 10.33678/cor.2020.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Abstract
PURPOSE Amyloidosis represents an increasingly recognized but still frequently missed cause of heart failure. In the light of many effective therapies for light chain (AL) amyloidosis and promising new treatment options for transthyretin (ATTR) amyloidosis, awareness among caregivers needs to be raised to screen for amyloidosis as an important and potentially treatable differential diagnosis. This review outlines the diversity of cardiac amyloidosis, its relation to heart failure, the diagnostic algorithm, and therapeutic considerations that should be applied depending on the underlying type of amyloidosis. RECENT FINDINGS Non-biopsy diagnosis is feasible in ATTR amyloidosis in the absence of a monoclonal component resulting in higher detection rates of cardiac ATTR amyloidosis. Biomarker-guided staging systems have been updated to facilitate risk stratification according to currently available biomarkers independent of regional differences, but have not yet prospectively been tested. Novel therapies for hereditary and wild-type ATTR amyloidosis are increasingly available. The complex treatment options for AL amyloidosis are improving continuously, resulting in better survival and quality of life. Mortality in advanced cardiac amyloidosis remains high, underlining the importance of early diagnosis and treatment initiation. Cardiac amyloidosis is characterized by etiologic and clinical heterogeneity resulting in a frequently delayed diagnosis and an inappropriately high mortality risk. New treatment options for this hitherto partially untreatable condition have become and will become available, but raise challenges regarding their implementation. Referral to specialized centers providing access to extensive and targeted diagnostic investigations and treatment initiation may help to face these challenges.
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Gertz MA. Immunoglobulin light chain amyloidosis: 2020 update on diagnosis, prognosis, and treatment. Am J Hematol 2020; 95:848-860. [PMID: 32267020 DOI: 10.1002/ajh.25819] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 04/02/2020] [Indexed: 01/10/2023]
Abstract
DISEASE OVERVIEW Immunoglobulin light chain amyloidosis is a clonal, nonproliferative plasma cell disorder in which fragments of immunoglobulin light or heavy chain are deposited in tissues. Clinical features depend on organs involved but can include heart failure with preserved ejection fraction, nephrotic syndrome, hepatic dysfunction, peripheral/autonomic neuropathy, and "atypical smoldering multiple myeloma or monoclonal gammopathy undetermined significance (MGUS)." DIAGNOSIS Tissue biopsy stained with Congo red demonstrating amyloid deposits with apple-green birefringence is required for diagnosis. Invasive organ biopsy is not required in 85% of patients. Verification that amyloid is composed of immunoglobulin light chains is mandatory. The gold standard is laser capture mass spectroscopy. PROGNOSIS N-terminal pro-brain natriuretic peptide (NT-proBNP), serum troponin T, and difference between involved and uninvolved immunoglobulin free light chain (FLC) values are used to classify patients into four groups of similar size; median survivals are 94.1, 40.3, 14.0, and 5.8 months. THERAPY All patients with a systemic amyloid syndrome require therapy to prevent deposition of amyloid in other organs and prevent progressive organ failure. Stem cell transplant (SCT) is preferred, but only 20% of patients are eligible. Requirements for safe SCT include systolic blood pressure >90 mmHg, troponin T < 0.06 ng/mL and serum creatinine ≤1.7 mg/dL. Nontransplant candidates can be offered cyclophosphamide-bortezomib-dexamethasone or daratumumab-containing regimens as it appears to be highly active in AL amyloidosis. FUTURE CHALLENGES Delayed diagnosis remains a major obstacle to initiating effective therapy prior to the development of end-stage organ failure.
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Affiliation(s)
- Morie A. Gertz
- Division of HematologyMayo Clinic Rochester Minnesota USA
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56
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Halawa A, Woldu HG, Kacey KG, Alpert MA. Effect of ICD implantation on cardiovascular outcomes in patients with cardiac amyloidosis: A systematic review and meta-anaylsis. J Cardiovasc Electrophysiol 2020; 31:1749-1758. [PMID: 32391952 DOI: 10.1111/jce.14541] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 03/26/2020] [Accepted: 04/24/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Cardiac amyloidosis is associated with a high rate of sudden cardiac death (SCD). Whether implantable cardioverter-defibrillator (ICD) use in such patients prevents SCD is uncertain. This study assesses outcomes of ICD use in patients with cardiac amyloidosis. METHODS A systematic review and meta-analysis of data were performed after searching multiple databases and scientific sites pertaining to ICD use and cardiac amyloidosis. Of 8260 citations identified, six studies comprising 194 patients met inclusion criteria. RESULTS Mean values and frequencies of patient characteristics were as follows: mean NT-proBNP: 6867.9 pg/mL, mean left ventricular ejection fraction: 48.1%, heart failure: 67%, nonsustained ventricular tachycardia: 51%, syncope: 21%, and secondary prevention: 33%. During the mean follow-up period of 18.21 months, 18% of patients received appropriate ICD treatment and 5% received inappropriate ICD treatment. The mortality rate was 31%. Two studies assessed the difference between patients with appropriate ICD treatment and patients with absence of appropriate ICD treatment. There was no difference between the two groups when stratified on multiple selected third variables except for two subgroups. Male gender was associated with a higher rate of appropriate ICD treatment, whereas New York Heart Association class III or IV heart failure patients was associated with a lower rate of appropriate ICD treatment. CONCLUSION The frequency of appropriate ICD treatment in cardiac amyloidosis is low and is not predicted by nonsustained ventricular tachycardia. Male gender is associated with appropriate ICD treatment. New York Heart Association class III or IV heart failure is associated with lower rate of appropriate ICD treatment.
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Affiliation(s)
- Ahmad Halawa
- Division of Cardiovascular Medicine, University of Missouri School of Medicine, Columbia, Missouri
| | - Henok G Woldu
- Biostatistics Design Unit, University of Missouri School of Medicine, Columbia, Missouri
| | - Kristina Gifft Kacey
- Division of Cardiovascular Medicine, University of Missouri School of Medicine, Columbia, Missouri
| | - Martin A Alpert
- Division of Cardiovascular Medicine, University of Missouri School of Medicine, Columbia, Missouri
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Barrett CD, Alexander KM, Zhao H, Haddad F, Cheng P, Liao R, Wheeler MT, Liedtke M, Schrier S, Arai S, Weisshaar D, Witteles RM. Outcomes in Patients With Cardiac Amyloidosis Undergoing Heart Transplantation. JACC-HEART FAILURE 2020; 8:461-468. [DOI: 10.1016/j.jchf.2019.12.013] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 12/16/2019] [Accepted: 12/17/2019] [Indexed: 01/01/2023]
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58
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Itzhaki Ben Zadok O, Kornowski R. Cardiac Care of Patients with Cardiac Amyloidosis. Acta Haematol 2020; 143:343-351. [PMID: 32408301 DOI: 10.1159/000506919] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 02/28/2020] [Indexed: 12/20/2022]
Abstract
Cardiac amyloidosis, the majority of cases of which are due to immunoglobulin light chain amyloidosis (AL) and transthyretin amyloidosis (ATTR), affects different aspects of the heart and cardiovascular system. Amyloid-induced cardiomyopathy, clinically manifesting with heart failure and electrophysiological abnormalities, has distinct characteristics compared to non-amyloid cardiomyopathies. Accordingly, specific management strategies are required. This paper will review the cardiovascular manifestations of patients with cardiac amyloidosis and their suggested treatment strategies, emphasizing the importance of multidisciplinary care.
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Affiliation(s)
- Osnat Itzhaki Ben Zadok
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel,
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,
| | - Ran Kornowski
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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59
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Aimo A, Rapezzi C, Vergaro G, Giannoni A, Spini V, Passino C, Emdin M. Management of complications of cardiac amyloidosis: 10 questions and answers. Eur J Prev Cardiol 2020; 28:1000-1005. [PMID: 32299232 DOI: 10.1177/2047487320920756] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 03/31/2020] [Indexed: 01/15/2023]
Abstract
Amyloidosis is a systemic disorder characterized by extracellular deposition of insoluble fibrils. The most common forms are amyloid light chain and amyloid transthyretin (ATTR) amyloidoses. Cardiac involvement may be found in both these forms, and is an important cause of morbidity and mortality. The clinical presentation of cardiac amyloidosis (CA) may be represented by congestive heart failure (HF), possibly progressing to end-stage HF, as well as atrial fibrillation with possible thromboembolic events, and also conduction disturbances related to amyloid infiltration of conduction fibres. Beyond therapies targeting the blood dyscrasia or the ATTR amyloidogenic cascade, a careful choice of drug therapies, need for device implantation, and possibly treatments for advanced HF is then warranted. In the present review, we try to provide a useful guide to clinicians treating patients with CA by enucleating 10 main questions and answering them based on the evidence available as well as expert opinion and our clinical experience.
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Affiliation(s)
- Alberto Aimo
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Italy
| | | | - Giuseppe Vergaro
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Italy.,Fondazione Toscana Gabriele Monasterio, Italy
| | - Alberto Giannoni
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Italy.,Fondazione Toscana Gabriele Monasterio, Italy
| | | | - Claudio Passino
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Italy.,Fondazione Toscana Gabriele Monasterio, Italy
| | - Michele Emdin
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Italy.,Fondazione Toscana Gabriele Monasterio, Italy
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60
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Giancaterino S, Urey MA, Darden D, Hsu JC. Management of Arrhythmias in Cardiac Amyloidosis. JACC Clin Electrophysiol 2020; 6:351-361. [DOI: 10.1016/j.jacep.2020.01.004] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 12/28/2019] [Accepted: 01/09/2020] [Indexed: 12/16/2022]
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61
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Arrhythmias in Cardiac Amyloidosis: Challenges in Risk Stratification and Treatment. Can J Cardiol 2020; 36:416-423. [DOI: 10.1016/j.cjca.2019.11.039] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 11/08/2019] [Accepted: 11/18/2019] [Indexed: 12/16/2022] Open
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62
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Muchtar E, Lin G, Grogan M. The Challenges in Chemotherapy and Stem Cell Transplantation for Light-Chain Amyloidosis. Can J Cardiol 2020; 36:384-395. [DOI: 10.1016/j.cjca.2019.11.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 11/27/2019] [Accepted: 11/27/2019] [Indexed: 11/30/2022] Open
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63
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Abstract
Light chain amyloidosis is a deadly disease in which a monoclonal plasma cell dyscrasia produces misfolded immunoglobulin light chains (AL) that aggregate and form rigid amyloid fibrils. The amyloid deposits infiltrate one or more organs, leading to injury and severe dysfunction. The degree of cardiac involvement is a major driver of morbidity and mortality. Early diagnosis and treatment are crucial to prevent irreversible end-organ damage and improve overall survival. Treatment of AL cardiac amyloidosis involves eliminating the underlying plasma cell dyscrasia with chemotherapy and pursuing supportive heart failure management.
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64
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Fuchida SI, Ide D, Taminishi-Katsuragawa Y, Suga T, Matsui-Maegawa S, Maruyama N, Iwamura Y, Kitamura Y, Okawa Y, Okano A, Hatsuse M, Murakami S, Shimazaki C. A retrospective analysis of treatment outcomes in 45 patients with cardiac light-chain amyloidosis: a single-center experience in Japan. Int J Hematol 2020; 111:803-811. [PMID: 32020505 DOI: 10.1007/s12185-020-02835-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 01/21/2020] [Accepted: 01/23/2020] [Indexed: 11/27/2022]
Abstract
The prognosis of cardiac light-chain (AL) amyloidosis is considered to be very poor. We studied the treatment efficacy and outcomes by retrospectively analyzing the clinical results of 45 patients with cardiac AL amyloidosis treated at our hospital between September 2008 and March 2016. The group of patients analyzed included 29 males and 16 females with a median age of 68 years. Their baseline median NT-proBNP, cTnT, and dFLC were 3167 pg/ml, 0.080 ng/ml, and 286.17 mg/l, respectively. Twenty-eight patients were in Cardiac Stage (CS) III and 17 patients were in Revised Prognostic Stage (RPS) IV. At the median follow-up of 10 months, the median overall survival (OS) was 16 months and 3-year OS was 35.9%. The patients in CS III showed significantly poorer survival rate than those in CS I or II (3-year OS: 12.2% vs. 65.8%, p = 0.0115) and the patients in RPS IV showed significantly poorer survival rate than those in RPS I, II, or III (3-year OS: 11.0% vs. 53.3%, p = 0.000914). Regardless of the therapeutic approaches, patients who achieved hematological CR or cardiac organ response demonstrated significantly improved prognosis. Therefore, achievement of hematological and organ responses is important in the treatment of cardiac AL amyloidosis.
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Affiliation(s)
- Shin-Ichi Fuchida
- Department of Hematology, Japan Community Health Care Organization Kyoto Kuramaguchi Medical Center, 27 Shimofusa-cho, Kita-ku, Kyoto, 603-8151, Japan.
| | - Daisuke Ide
- Department of Hematology, Japan Community Health Care Organization Kyoto Kuramaguchi Medical Center, 27 Shimofusa-cho, Kita-ku, Kyoto, 603-8151, Japan
| | - Yoko Taminishi-Katsuragawa
- Department of Hematology, Japan Community Health Care Organization Kyoto Kuramaguchi Medical Center, 27 Shimofusa-cho, Kita-ku, Kyoto, 603-8151, Japan
| | - Takaomi Suga
- Department of Cardiology, Japan Community Health Care Organization Kyoto Kuramaguchi Medical Center, Kyoto, Japan
| | - Saori Matsui-Maegawa
- Department of Hematology, Japan Community Health Care Organization Kyoto Kuramaguchi Medical Center, 27 Shimofusa-cho, Kita-ku, Kyoto, 603-8151, Japan
| | - Naoki Maruyama
- Department of Cardiology, Japan Community Health Care Organization Kyoto Kuramaguchi Medical Center, Kyoto, Japan
| | - Yumi Iwamura
- Department of Cardiology, Japan Community Health Care Organization Kyoto Kuramaguchi Medical Center, Kyoto, Japan
| | - Yohei Kitamura
- Department of Cardiology, Japan Community Health Care Organization Kyoto Kuramaguchi Medical Center, Kyoto, Japan
| | - Yoshifumi Okawa
- Department of Cardiology, Japan Community Health Care Organization Kyoto Kuramaguchi Medical Center, Kyoto, Japan
| | - Akira Okano
- Department of Hematology, Japan Community Health Care Organization Kyoto Kuramaguchi Medical Center, 27 Shimofusa-cho, Kita-ku, Kyoto, 603-8151, Japan
- Department of Hematology, Omihachiman Community Medical Center, Omihachiman, Japan
| | - Mayumi Hatsuse
- Department of Hematology, Japan Community Health Care Organization Kyoto Kuramaguchi Medical Center, 27 Shimofusa-cho, Kita-ku, Kyoto, 603-8151, Japan
| | - Satoshi Murakami
- Department of Hematology, Japan Community Health Care Organization Kyoto Kuramaguchi Medical Center, 27 Shimofusa-cho, Kita-ku, Kyoto, 603-8151, Japan
| | - Chihiro Shimazaki
- Department of Hematology, Japan Community Health Care Organization Kyoto Kuramaguchi Medical Center, 27 Shimofusa-cho, Kita-ku, Kyoto, 603-8151, Japan
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El-Am EA, Dispenzieri A, Melduni RM, Ammash NM, White RD, Hodge DO, Noseworthy PA, Lin G, Pislaru SV, Egbe AC, Grogan M, Nkomo VT. Direct Current Cardioversion of Atrial Arrhythmias in Adults With Cardiac Amyloidosis. J Am Coll Cardiol 2020; 73:589-597. [PMID: 30732713 DOI: 10.1016/j.jacc.2018.10.079] [Citation(s) in RCA: 117] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Revised: 10/18/2018] [Accepted: 10/22/2018] [Indexed: 01/02/2023]
Abstract
BACKGROUND Arrhythmias, conduction abnormalities, and intracardiac thrombus are common in patients with cardiac amyloidosis (CA). Outcomes of direct-current cardioversion (DCCV) for atrial arrhythmias in patients with CA are unknown. OBJECTIVES This study sought to examine DCCV procedural outcomes in patients with CA. METHODS Patients with CA scheduled for DCCV for atrial arrhythmias from January 2000 through December 2012 were identified and matched 2:1 with control patients by age, sex, type of atrial arrhythmia, and date of DCCV. RESULTS CA patients (n = 58, mean age 69 ± 9 years, 81% male) were included. CA patients had a significantly higher cardioversion cancellation rate (28% vs. 7%; p < 0.001) compared with control patients, mainly due to intracardiac thrombus identified on transesophageal echocardiogram (13 of 16 [81%] vs. 2 of 8 [25%]; p = 0.02); 4 of 13 of the CA patients (31%) with intracardiac thrombus on transesophageal echocardiogram received adequate anticoagulation ≥3 weeks and another 2 of 13 (15%) had arrhythmia duration <48 h. DCCV success rate (90% vs. 94%; p = 0.4) was not different. Procedural complications were more frequent in CA versus control patients (6 of 42 [14%] vs. 2 of 106 [2%]; p = 0.007); complications in CA included ventricular arrhythmias in 2 and severe bradyarrhythmias requiring pacemaker implantation in 2. The only complication in the control group was self-limited bradyarrhythmias. CONCLUSIONS Patients with CA undergoing DCCV had a significantly high cancellation rate mainly due to a high incidence of intracardiac thrombus even among patients who received adequate anticoagulation. Although the success rate of restoring sinus rhythm was high, tachyarrhythmias and bradyarrhythmias complicating DCCV were significantly more frequent in CA patients compared with control patients.
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Affiliation(s)
- Edward A El-Am
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota. https://twitter.com/EdwardElAmm
| | | | - Rowlens M Melduni
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Naser M Ammash
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Roger D White
- Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota
| | - David O Hodge
- Biomedical Science and Informatics, Mayo Clinic, Jacksonville, Florida
| | - Peter A Noseworthy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Grace Lin
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Martha Grogan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota. https://twitter.com/MarthaGrogan1
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
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66
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What the Intensivists Need to Know About Critically Ill Myeloma Patients. ONCOLOGIC CRITICAL CARE 2020. [PMCID: PMC7121630 DOI: 10.1007/978-3-319-74588-6_98] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Multiple myeloma (MM) is a hematological malignancy characterized by an increase in aberrant plasma cells in the bone marrow leading to rising monoclonal protein in serum and urine. With the introduction of novel therapies with manageable side effects, this incurable disease has evolved into a chronic disease with an acceptable quality of life for the majority of patients. Accordingly, management of acute complications is fundamental in reducing the morbidity and mortality in MM. MM emergencies include symptoms and signs related directly to the disease and/or to the treatment; many organs may be involved including, but not limited to, renal, cardiovascular, neurologic, hematologic, and infectious complications. This review will focus on the numerous approaches that are aimed at managing these complications.
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67
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Bart NK, Thomas L, Korczyk D, Atherton JJ, Stewart GJ, Fatkin D. Amyloid Cardiomyopathy. Heart Lung Circ 2019; 29:575-583. [PMID: 32001152 DOI: 10.1016/j.hlc.2019.11.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 11/23/2019] [Accepted: 11/29/2019] [Indexed: 01/15/2023]
Abstract
Amyloid cardiomyopathy is emerging as an important and under-recognised cause of heart failure and cardiac arrhythmias, especially in older adults. This disorder is characterised by extracellular deposition of amyloid fibrils that form due to misfolding of secreted light chains (AL) or transthyretin protein (ATTR). In ATTR, amyloid aggregates typically result from excessive accumulation of wild-type transthyretin (ATTRwt) or from protein structural defects caused by TTR gene variants (ATTRv). Amyloid fibril deposition may predominantly affect the heart or show multi-system involvement. Previously considered to be rare and inexorably progressive with no specific therapy, there has been enormous recent interest in ATTR cardiomyopathy due to upwardly-revised estimates of disease prevalence together with development of disease-modifying interventions. Because of this, there is a clinical imperative to have a high index of suspicion to identify potential cases and to be aware of contemporary diagnostic methods and treatment options. Genetic testing should be offered to all patients with proven ATTR to access the benefits of new therapies specific to ATTRv and allow predictive testing of family members. With heightened awareness of amyloid cardiomyopathy and expanded use of genetic testing, a substantial rise in the numbers of asymptomatic individuals who are carriers of pathogenic variants is expected, and optimal strategies for monitoring and treatment of these individuals at risk need to be determined. Pre-emptive administration of fibril-modifying therapies provides an unprecedented opportunity for disease prevention and promises to change amyloid cardiomyopathy from being a fatal to a treatable disorder.
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Affiliation(s)
- Nicole K Bart
- Cardiology Department, St. Vincent's Hospital, Sydney NSW, Australia; Molecular Cardiology Division, Victor Chang Cardiac Research Institute, Sydney NSW, Australia; St. Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney NSW, Australia
| | - Liza Thomas
- Cardiology Department, Westmead Hospital, Sydney NSW, Australia; Westmead Clinical School, University of Sydney, Sydney NSW, Australia; South Western Clinical School, University of NSW, Sydney NSW, Australia
| | - Dariusz Korczyk
- Cardiology Department, Princess Alexandra Hospital, Brisbane Qld, Australia; University of Queensland, Brisbane Qld, Australia
| | - John J Atherton
- University of Queensland, Brisbane Qld, Australia; Cardiology Department, Royal Brisbane and Women's Hospital, Brisbane Qld, Australia
| | - Graeme J Stewart
- Westmead Clinical School, University of Sydney, Sydney NSW, Australia; Clinical Immunology Department & Westmead Amyloidosis Centre, Westmead Hospital, Sydney, NSW, Australia
| | - Diane Fatkin
- Cardiology Department, St. Vincent's Hospital, Sydney NSW, Australia; Molecular Cardiology Division, Victor Chang Cardiac Research Institute, Sydney NSW, Australia; St. Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney NSW, Australia.
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John RM, Stern DL. Use of Implantable Electronic Devices in Patients With Cardiac Amyloidosis. Can J Cardiol 2019; 36:408-415. [PMID: 32037105 DOI: 10.1016/j.cjca.2019.12.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 12/03/2019] [Accepted: 12/03/2019] [Indexed: 10/25/2022] Open
Abstract
Arrhythmias are a major cause of morbidity and mortality in the course of cardiac amyloidosis (CA). Less commonly, they may be the initial manifestation that lead to the diagnosis. With improved therapeutic interventions for amyloidosis, it is no longer considered to be a terminal untreatable condition, and there is increasing recognition of the role of implantable electronic devices in CA. The frequency and nature of arrhythmias are largely determined by the type of amyloidosis. Bradyarrhythmias are more common in the transthyretin form of amyloidosis, and risk for ventricular arrhythmias is higher in the light-chain form. Pacemaker implantation is often required and effective for alleviation of symptoms. The role of implantable cardioverter-defibrillators (ICDs) remains controversial, especially for primary prevention of sudden death. Traditional risk stratification tools for sudden death do not appear to be applicable to CA, because decline of left ventricular (LV) systolic dysfunction to the point of the usual indication for an ICD implant in other cardiomyopathies, ie, LV ejection fraction ≤ 35%, usually marks end-stage disease in CA when pump failure becomes the predominant cause of death. The challenge remains the identification of markers for sudden death in early stages of the disease. Included in this review is a general overview of available data on the nature of bradycardia and ventricular arrhythmias, including the role of implantable electronic devices for the treatment of these conditions. Published series of ICD use in CA are summarized and the role of newer pacing techniques, including biventricular pacing, is discussed.
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Affiliation(s)
- Roy M John
- Center for Advanced Management of Ventricular Arrhythmias, Department of Cardiology, Northshore University Hospital, Manhasset, New York, USA.
| | - David L Stern
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA; Department of Cardiology, North Shore University Hospital, Manhasset, New York, USA
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Dorbala S, Ando Y, Bokhari S, Dispenzieri A, Falk RH, Ferrari VA, Fontana M, Gheysens O, Gillmore JD, Glaudemans AWJM, Hanna MA, Hazenberg BPC, Kristen AV, Kwong RY, Maurer MS, Merlini G, Miller EJ, Moon JC, Murthy VL, Quarta CC, Rapezzi C, Ruberg FL, Shah SJ, Slart RHJA, Verberne HJ, Bourque JM. ASNC/AHA/ASE/EANM/HFSA/ISA/SCMR/SNMMI expert consensus recommendations for multimodality imaging in cardiac amyloidosis: Part 1 of 2-evidence base and standardized methods of imaging. J Nucl Cardiol 2019; 26:2065-2123. [PMID: 31468376 DOI: 10.1007/s12350-019-01760-6] [Citation(s) in RCA: 205] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Sharmila Dorbala
- Cardiac Amyloidosis Program, Cardiovascular Imaging Program, Departments of Radiology and Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA.
| | - Yukio Ando
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Sabahat Bokhari
- Columbia University Medical Center/New York Presbyterian Hospital, Columbia University, New York, NY, USA
| | - Angela Dispenzieri
- Division of Hematology, Division of Cardiovascular Diseases, and Department of Radiology, Division of Nuclear Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Rodney H Falk
- Cardiac Amyloidosis Program, Cardiovascular Imaging Program, Departments of Radiology and Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | - Victor A Ferrari
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Marianna Fontana
- Division of Medicine, National Amyloidosis Centre, University College London, London, UK
| | - Olivier Gheysens
- Nuclear Medicine and Molecular Imaging, University Hospitals Leuven, Leuven, Belgium
| | - Julian D Gillmore
- Division of Medicine, National Amyloidosis Centre, University College London, London, UK
| | - Andor W J M Glaudemans
- Department of Nuclear Medicine and Molecular Imaging, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Mazen A Hanna
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Bouke P C Hazenberg
- Department of Rheumatology & Clinical Immunology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Arnt V Kristen
- Department of Cardiology, University of Heidelberg, Heidelberg, Germany
| | - Raymond Y Kwong
- Cardiac Amyloidosis Program, Cardiovascular Imaging Program, Departments of Radiology and Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | - Mathew S Maurer
- Columbia University Medical Center/New York Presbyterian Hospital, Columbia University, New York, NY, USA
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Center, Foundation Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, Pavia, Italy
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Edward J Miller
- Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - James C Moon
- Division of Medicine, National Amyloidosis Centre, University College London, London, UK
| | | | - C Cristina Quarta
- Division of Medicine, National Amyloidosis Centre, University College London, London, UK
| | - Claudio Rapezzi
- Cardiology Unit, Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater-University of Bologna, Bologna, Italy
| | - Frederick L Ruberg
- Amyloidosis Center and Section of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA, USA
| | - Sanjiv J Shah
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Riemer H J A Slart
- Department of Nuclear Medicine and Molecular Imaging, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Hein J Verberne
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jamieson M Bourque
- Departments of Medicine and Radiology, Cardiovascular Imaging Center, University of Virginia, Charlottesville, VA, USA
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Vaxman I, Dispenzieri A, Muchtar E, Gertz M. New developments in diagnosis, risk assessment and management in systemic amyloidosis. Blood Rev 2019; 40:100636. [PMID: 31706583 DOI: 10.1016/j.blre.2019.100636] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 09/19/2019] [Accepted: 10/29/2019] [Indexed: 12/12/2022]
Abstract
Amyloidosis is a group of disorders characterized by a misfolded protein that deposits in organs and compromise their function. Clinician should have a high index of suspicion because in most cases, the clinical picture is non-specific. Typing of amyloid is of utmost importance and should be an integral part of accurately diagnosing a patient. AL amyloidosis is the most common systemic amyloidosis in the western world in which the misfolded proteins are immunoglobulin light chains secreted by clonal plasma cells. New data about prognostication of AL amyloidosis patients are accumulating. The treatment goal is to eradicate the amyloidogenic plasma cell clone, by using high dose melphalan and/or novel agents (proteasome inhibitors, immunomodulatory drugs, monoclonal antibodies against CD38). Early diagnosis is important for effectively treating the patient as late diagnosis hampers chances for organ recovery. ATTR amyloidosis is less recognized but is increasingly seen due to better recognition and improved diagnostic tools. New data about treatment options (patisiran, inotersen and tafamidis) have recently been published and are discussed.
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Affiliation(s)
- Iuliana Vaxman
- Division of Hematology, Mayo Clinic, Rochester, MN, USA; Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva, Israel; Israel Sackler Faculty of Medicine Tel-Aviv University, Tel-Aviv, Israel
| | | | - Eli Muchtar
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Morie Gertz
- Division of Hematology, Mayo Clinic, Rochester, MN, USA.
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Dorbala S, Ando Y, Bokhari S, Dispenzieri A, Falk RH, Ferrari VA, Fontana M, Gheysens O, Gillmore JD, Glaudemans AWJM, Hanna MA, Hazenberg BPC, Kristen AV, Kwong RY, Maurer MS, Merlini G, Miller EJ, Moon JC, Murthy VL, Quarta CC, Rapezzi C, Ruberg FL, Shah SJ, Slart RHJA, Verberne HJ, Bourque JM. ASNC/AHA/ASE/EANM/HFSA/ISA/SCMR/SNMMI Expert Consensus Recommendations for Multimodality Imaging in Cardiac Amyloidosis: Part 1 of 2-Evidence Base and Standardized Methods of Imaging. J Card Fail 2019; 25:e1-e39. [PMID: 31473268 DOI: 10.1016/j.cardfail.2019.08.001] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Sharmila Dorbala
- Cardiac Amyloidosis Program, Cardiovascular Imaging Program, Departments of Radiology and Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts.
| | - Yukio Ando
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Sabahat Bokhari
- Columbia University Medical Center/New York Presbyterian Hospital, Columbia University, New York, New York
| | - Angela Dispenzieri
- Division of Hematology, Division of Cardiovascular Diseases, and Department of Radiology, Division of Nuclear Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Rodney H Falk
- Cardiac Amyloidosis Program, Cardiovascular Imaging Program, Departments of Radiology and Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Victor A Ferrari
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marianna Fontana
- Division of Medicine, National Amyloidosis Centre, University College London, London, United Kingdom
| | - Olivier Gheysens
- Nuclear Medicine and Molecular Imaging, University Hospitals Leuven, Leuven, Belgium
| | - Julian D Gillmore
- Division of Medicine, National Amyloidosis Centre, University College London, London, United Kingdom
| | - Andor W J M Glaudemans
- Department of Nuclear Medicine and Molecular Imaging, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Mazen A Hanna
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Bouke P C Hazenberg
- Department of Rheumatology & Clinical Immunology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Arnt V Kristen
- Department of Cardiology, University of Heidelberg, Heidelberg, Germany
| | - Raymond Y Kwong
- Cardiac Amyloidosis Program, Cardiovascular Imaging Program, Departments of Radiology and Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Mathew S Maurer
- Columbia University Medical Center/New York Presbyterian Hospital, Columbia University, New York, New York
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Center, Foundation Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, Pavia, Italy; Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Edward J Miller
- Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - James C Moon
- Division of Medicine, National Amyloidosis Centre, University College London, London, United Kingdom
| | | | - C Cristina Quarta
- Division of Medicine, National Amyloidosis Centre, University College London, London, United Kingdom
| | - Claudio Rapezzi
- Cardiology Unit, Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater-University of Bologna, Bologna, Italy
| | - Frederick L Ruberg
- Amyloidosis Center and Section of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Sanjiv J Shah
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Riemer H J A Slart
- Department of Nuclear Medicine and Molecular Imaging, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Hein J Verberne
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jamieson M Bourque
- Departments of Medicine and Radiology, Cardiovascular Imaging Center, University of Virginia, Charlottesville, Virginia
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Donnellan E, Wazni OM, Saliba WI, Baranowski B, Hanna M, Martyn M, Patel D, Trulock K, Menon V, Hussein A, Aagaard P, Jaber W, Kanj M. Cardiac devices in patients with transthyretin amyloidosis: Impact on functional class, left ventricular function, mitral regurgitation, and mortality. J Cardiovasc Electrophysiol 2019; 30:2427-2432. [DOI: 10.1111/jce.14180] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 09/05/2019] [Accepted: 09/07/2019] [Indexed: 01/10/2023]
Affiliation(s)
- Eoin Donnellan
- Department of Cardiovascular Medicine Cleveland Clinic Cleveland Ohio
| | - Oussama M. Wazni
- Department of Cardiovascular Medicine Cleveland Clinic Cleveland Ohio
| | - Walid I. Saliba
- Department of Cardiovascular Medicine Cleveland Clinic Cleveland Ohio
| | - Bryan Baranowski
- Department of Cardiovascular Medicine Cleveland Clinic Cleveland Ohio
| | - Mazen Hanna
- Department of Cardiovascular Medicine Cleveland Clinic Cleveland Ohio
| | - Michael Martyn
- Department of Cardiovascular Medicine Cleveland Clinic Cleveland Ohio
| | - Divyang Patel
- Department of Cardiovascular Medicine Cleveland Clinic Cleveland Ohio
| | - Kevin Trulock
- Department of Cardiovascular Medicine Cleveland Clinic Cleveland Ohio
| | - Venu Menon
- Department of Cardiovascular Medicine Cleveland Clinic Cleveland Ohio
| | - Ayman Hussein
- Department of Cardiovascular Medicine Cleveland Clinic Cleveland Ohio
| | - Philip Aagaard
- Department of Cardiovascular Medicine Cleveland Clinic Cleveland Ohio
| | - Wael Jaber
- Department of Cardiovascular Medicine Cleveland Clinic Cleveland Ohio
| | - Mohamed Kanj
- Department of Cardiovascular Medicine Cleveland Clinic Cleveland Ohio
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Yamamoto H, Yokochi T. Transthyretin cardiac amyloidosis: an update on diagnosis and treatment. ESC Heart Fail 2019; 6:1128-1139. [PMID: 31553132 PMCID: PMC6989279 DOI: 10.1002/ehf2.12518] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 08/19/2019] [Accepted: 08/25/2019] [Indexed: 12/14/2022] Open
Abstract
Transthyretin cardiac amyloidosis (ATTR‐CA) demonstrates progressive, potentially fatal, and infiltrative cardiomyopathy caused by extracellular deposition of transthyretin‐derived insoluble amyloid fibrils in the myocardium. Two distinct types of transthyretin (wild type or variant) become unstable, and misfolding forms aggregate, resulting in amyloid fibrils. ATTR‐CA, which has previously been underrecognized and considered to be rare, has been increasingly recognized as a cause of heart failure with preserved ejection fraction among elderly persons. With the advanced technology, the diagnostic tools have been improving for cardiac amyloidosis. Recently, the efficacy of several disease‐modifying agents focusing on the amyloidogenic process has been demonstrated. ATTR‐CA has been changing from incurable to treatable. Nevertheless, there are still no prognostic improvements due to diagnostic delay or misdiagnosis because of phenotypic heterogeneity and co‐morbidities. Thus, it is crucial for clinicians to be aware of this clinical entity for early diagnosis and proper treatment. In this mini‐review, we focus on recent advances in diagnosis and treatment of ATTR‐CA.
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Affiliation(s)
- Hiroyuki Yamamoto
- Department of Cardiovascular Medicine, Narita-Tomisato Tokushukai Hospital, 1-1-1 Hiyoshidai, Tomisato, Chiba, 286-0201, Japan
| | - Tomoki Yokochi
- Department of Clinical Research, Chiba Tokushukai Hospital, Chiba, Japan
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Witteles RM, Liedtke M. AL Amyloidosis for the Cardiologist and Oncologist: Epidemiology, Diagnosis, and Management. JACC CardioOncol 2019; 1:117-130. [PMID: 34396169 PMCID: PMC8352106 DOI: 10.1016/j.jaccao.2019.08.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Revised: 08/09/2019] [Accepted: 08/11/2019] [Indexed: 02/07/2023] Open
Abstract
AL amyloidosis results from clonal production of immunoglobulin light chains, most commonly arising from a clonal plasma cell disorder. Once considered a nearly uniformly fatal disease, prognosis has improved markedly over the past 15 years, predominantly because of advances in light chain suppressive therapies. Cardiac deposition of amyloid fibrils is common, and the severity of cardiac involvement remains the primary driver of prognosis. Improvements in chemotherapy/immunotherapy have prompted a reassessment of the role of advanced cardiac therapies previously considered contraindicated in most patients, including the role of implantable cardioverter-defibrillators and cardiac transplantation. This state-of-the-art review highlights the current state of the field, including diagnosis, prognosis, and hematologic- and cardiac-specific therapies.
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Key Words
- AL amyloidosis
- ASCT, autologous stem cell transplantation
- BNP, B-type natriuretic peptide
- CyBorD, cyclophosphamide, bortezomib, and dexamethasone
- FLC, free light chain
- ICD, implantable cardioverter-defibrillator
- MGUS, monoclonal gammopathy of undetermined significance
- NT-proBNP, N-terminal pro–B-type natriuretic peptide
- SAP, serum amyloid P
- SPIE, serum protein electrophoresis with immunofixation
- UPIE, urine protein electrophoresis with immunofixation
- amyloidosis
- diagnosis
- drug therapy
- heart failure
- imaging
- treatment
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Affiliation(s)
- Ronald M. Witteles
- Division of Cardiovascular Medicine, Stanford Amyloid Center, Stanford University School of Medicine, Stanford, California, USA
| | - Michaela Liedtke
- Division of Hematology, Stanford Amyloid Center, Stanford University School of Medicine, Stanford, California, USA
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76
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Manolis AS, Manolis AA, Manolis TA, Melita H. Cardiac amyloidosis: An underdiagnosed/underappreciated disease. Eur J Intern Med 2019; 67:1-13. [PMID: 31375251 DOI: 10.1016/j.ejim.2019.07.022] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 07/15/2019] [Accepted: 07/23/2019] [Indexed: 12/14/2022]
Abstract
Cardiac amyloidosis or amyloid cardiomyopathy (ACM), commonly resulting from extracellular deposition of amyloid fibrils consisted of misfolded immunoglobulin light chain (AL) or transthyretin (TTR) protein, is an underestimated cause of heart failure and cardiac arrhythmias. Among the three types of cardiac amyloidosis (wild-type or familial TTR and light-chain), the wild-type (Wt) TTR-related amyloidosis (ATTR) is an increasingly recognized cause of heart failure with preserved ejection fraction (HFpEF), and amyloidosis should be considered in the differential diagnosis of this heart failure group of patients. Recent advances in the diagnosis and drug treatment of ACM have ushered in a new era in early disease detection and better management of these patients. Certain clues in cardiac and extracardiac manifestations of ACM may heighten clinical suspicion and guide further confirmatory testing. Newer noninvasive imaging methods (strain echocardiography, cardiac magnetic resonance and bone scintigraphy) may obviate the need for endomyocardial biopsy in ATTR patients, while newer targeted therapies may alter the adverse prognosis in these patients. Early recognition of ACM is crucial in halting the disease process before irreversible organ damage occurs. Chemotherapy and stem-cell transplantation combined with immunomodulatory therapy may also favorably affect the course and prognosis of light chain ACM. Finally, in select patients with end-stage disease, heart transplantation may render results comparable to non-ACM patients. All these issues are herein reviewed.
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Affiliation(s)
- Antonis S Manolis
- Third Department of Cardiology, Athens University School of Medicine, Athens, Greece.
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Lee C, Chau E, Patel S, Zhao D, Yang AH, Lee BT, Alexander J, Ostrzega E, Sarte P. A rare systemic etiology of heart failure and liver dysfunction. Clin Case Rep 2019; 7:1355-1357. [PMID: 31360486 PMCID: PMC6637331 DOI: 10.1002/ccr3.2229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 04/11/2019] [Accepted: 05/10/2019] [Indexed: 11/20/2022] Open
Abstract
Systemic amyloidosis is a rare condition that can manifest with cardiomyopathy, hepatic dysfunction, and renal disease. Diagnosis is often missed and/or delayed due to chronic multi-system involvement and indeterminate signs and symptoms. Treatment generally involves systemic therapy and autologous stem-cell transplantation.
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Affiliation(s)
| | - Edward Chau
- University of Southern CaliforniaLos AngelesCalifornia
| | - Sumit Patel
- University of Southern CaliforniaLos AngelesCalifornia
| | - Diana Zhao
- University of Southern CaliforniaLos AngelesCalifornia
| | | | - Brian T. Lee
- University of Southern CaliforniaLos AngelesCalifornia
| | | | | | - Patrick Sarte
- University of Southern CaliforniaLos AngelesCalifornia
- Internal MedicineKeck School of Medicine of the University of Southern CaliforniaLos AngelesCalifornia
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79
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Ruberg FL, Grogan M, Hanna M, Kelly JW, Maurer MS. Transthyretin Amyloid Cardiomyopathy: JACC State-of-the-Art Review. J Am Coll Cardiol 2019; 73:2872-2891. [PMID: 31171094 PMCID: PMC6724183 DOI: 10.1016/j.jacc.2019.04.003] [Citation(s) in RCA: 551] [Impact Index Per Article: 110.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 04/03/2019] [Accepted: 04/09/2019] [Indexed: 12/16/2022]
Abstract
Transthyretin amyloid cardiomyopathy (ATTR-CM) is an under-recognized cause of heart failure (HF) in older adults, resulting from myocardial deposition of misfolded transthyretin (TTR) or pre-albumin. Characteristic patterns of echocardiography and cardiac magnetic resonance can strongly suggest the disease but are not diagnostic. The diagnosis can be made with noninvasive nuclear imaging when there is no evidence of a monoclonal protein. Amyloid fibril formation results from a destabilizing mutation in hereditary ATTR amyloidosis (hATTR) or from an aging-linked process in wild-type ATTR amyloidosis (wtATTR). Recent studies have suggested that up to 10% to 15% of older adults with HF may have unrecognized wtATTR. Associated features, including carpal tunnel syndrome and lumbar spinal stenosis, raise suspicion and may afford a means for early diagnosis. Previously treatable only by organ transplantation, pharmaceutical therapy that slows or halts ATTR-CM progression and favorably affects clinical outcomes is now available. Early recognition remains essential to afford the best treatment efficacy.
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Affiliation(s)
- Frederick L Ruberg
- Section of Cardiovascular Medicine, Department of Medicine, Amyloidosis Center, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Martha Grogan
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Mazen Hanna
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Jeffery W Kelly
- Departments of Chemistry and Molecular Medicine, Scripps Research Institute, La Jolla, California
| | - Mathew S Maurer
- Division of Cardiology, Department of Medicine, Center for Advanced Cardiac Care, Columbia University Medical Center, New York, New York.
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80
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Leung N. DSMA Renal Scan in Cardiac Amyloidosis: Are We Missing Something? Mayo Clin Proc 2019; 94:936-938. [PMID: 31171128 DOI: 10.1016/j.mayocp.2019.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 04/23/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Nelson Leung
- Division of Nephrology and Hypertension, Division of Hematology, Mayo Clinic, Rochester, MN.
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81
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Abstract
Background Cardiac amyloidosis (CA) is an underappreciated cause of morbidity and mortality. Light-chain (AL) and transthyretin (ATTR) amyloidosis have different disease trajectories. No data are available on subtype-specific modes of death (MOD) in patients with CA. Methods and results We retrospectively investigated 66 with AL and 48 with wild-type ATTR amyloidosis (ATTRwt) from 2000 to 2018. ATTRwt differed from AL by age (74.6 ± 5.4 years vs. 63 ± 10.8 years), posterior wall thickness (16.8 ± 3.3 mm vs. 14.3 ± 2.2 mm), left ventricular mass index (180.7 ± 63.2 g/m2 vs. 133.5 ± 42.2 g/m2), and the proportions of male gender (91.7% vs. 59.1%), atrial enlargement (92% vs. 68.2%) and atrial fibrillation (50% vs. 12.1%). In AL NYHA Functional Class and proteinuria (72.7% vs. 39.6%) were greater; mean arterial pressure (84.4 ± 13.5 mmHg vs. 90.0 ± 11.3 mmHg) was lower. Unadjusted 5-year mortality rate was 65% in AL-CA vs. 44% in the ATTRwt group. Individuals with AL-CA were 2.28 times ([95%CI 1.27–4.10]; p = 0.006) more likely to die than were individuals with ATTRwt-CA. Information on MOD was available in 56 (94.9%) of 59 deceased patients. MOD was cardiovascular in 40 (66.8%) and non-cardiovascular in 16 (27.1%) patients. Cardiovascular [28 (68.3%) vs. 13 (80%)] death events were distributed equally between AL and ATTRwt (p = 0.51). Conclusion Our data indicate no differences in MOD between patients with AL and ATTRwt cardiac amyloidosis despite significant differences in clinical presentation and disease progression. Cardiovascular events account for more than two-thirds of fatal casualties in both groups. Graphic abstract ![]()
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82
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Taiwo AA, Alapati L, Movahed A. Cardiac amyloidosis: A case report and review of literature. World J Clin Cases 2019; 7:742-752. [PMID: 30968039 PMCID: PMC6448069 DOI: 10.12998/wjcc.v7.i6.742] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 02/12/2019] [Accepted: 02/18/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Cardiac amyloidosis, a disease caused by the precipitation of amyloid proteins in the myocardial extracellular matrix has been historically difficult to diagnose due to lack of specific clinical manifestations and necessity of biopsy to demonstrate amyloid deposition. However, advances in cardiovascular imaging techniques have facilitated earlier recognition of this disease. In addition, while once thought of as incurable, treatment strategies are emerging for cardiac amyloidosis, making early diagnosis essential.
CASE SUMMARY We outline the case of a 73 years old African American female who was admitted with sudden onset shortness of breath and found to be in cardiogenic shock. Cardiac amyloidosis was suspected due to discordance between electrocardiogram and echocardiogram findings and this was subsequently confirmed with the aid of scintigraphy and an endomyocardial biopsy.
CONCLUSION Our objective is to highlight the diagnostic evaluation and clinical implications of cardiac amyloidosis.
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Affiliation(s)
- Adeyemi Adedamola Taiwo
- Department of Internal Medicine, East Carolina University, Greenville, NC 27834, United States
| | - Lavanya Alapati
- Department of Cardiovascular Sciences, East Carolina Heart Institute, East Carolina University, Greenville, NC 27834, United States
| | - Assad Movahed
- Department of Cardiovascular Sciences, East Carolina Heart Institute, East Carolina University, Greenville, NC 27834, United States
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Correction to: Reference Ranges for the Size of the Fetal Cardiac Outflow Tracts From 13 to 36 Weeks Gestation: A Single-Center Study of Over 7000 Cases. Circ Cardiovasc Imaging 2019; 12:e000025. [PMID: 30866649 DOI: 10.1161/hci.0000000000000025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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84
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Sidana S, Tandon N, Brady PA, Grogan M, Gertz MA, Dispenzieri A, Lin G, Dingli D, Buadi FK, Lacy MQ, Kapoor P, Gonsalves WI, Muchtar E, Warsame R, Kumar SK, Kourelis TV. Prognostic Significance of Holter Monitor Findings in Patients With Light Chain Amyloidosis. Mayo Clin Proc 2019; 94:455-464. [PMID: 30718070 DOI: 10.1016/j.mayocp.2018.08.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 08/04/2018] [Accepted: 08/10/2018] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To evaluate the prognostic impact of Holter findings in patients with light chain amyloidosis. PATIENTS AND METHODS We evaluated 239 patients in whom light chain amyloidosis was diagnosed from January 1, 2010, through December 31, 2015, who underwent 24-hour Holter monitoring. RESULTS Holter testing was done before stem cell transplant evaluation in 183 of the 239 patients (76.6%) and at diagnosis in 50 (20.9%). Holter findings were nonsustained ventricular tachycardia (NSVT) in 60 patients (25.1%), ventricular couplets in 103 (43.1)%, accelerated idioventricular rhythm in 32 (13.4%), and atrial fibrillation (AF) in 18 (7.5%). Overall survival (OS) at 3 and 6 months after Holter monitoring in patients with AF vs without AF was 78% (95% CI, 54%-91%) vs 96% (95% CI, 92%-98%) (P=.002) and 61% (95% CI, 38%-80%) vs 92% (95% CI, 87%-95%), (P<.001), respectively. In patients with and without NSVT, 3- and 6-month OS after Holter testing was 90% (95% CI, 80%-94%) vs 96% (95% CI, 91%-98%) (P=.12) and 77% (95% CI, 64%-85%) vs 94% (95% CI, 89%-97%) (P<.001), respectively. For patients with and without ventricular couplets, 3- and 6-month OS was 94% (95% CI, 88%-97%) vs 94% (95% CI, 89%-97%) (P=.98) and 84% (95% CI, 75%-89%) vs 94% (95% CI, 89%-97%) (P=.01), respectively. Atrial fibrillation (hazard ratio, 2.5; 95% CI, 1.2-5.0; P=.02) and NSVT (hazard ratio, 2.0; 95% CI, 1.1-3.5; P=.02) were independent predictors for OS after accounting for age and Mayo stage. For patients undergoing routine testing before stem cell transplant, AF (P=.002) and NSVT (P=.02) were associated with inferior OS at 6 months but did not retain statistical significance after adjusting for Mayo stage (P=.10 and P=.54, respectively). CONCLUSION Atrial fibrillation and NSVT on 24-hour Holter monitoring are associated with inferior short-term OS outcomes but do not impact peritransplant mortality.
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Affiliation(s)
- Surbhi Sidana
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Nidhi Tandon
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Peter A Brady
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN Dr Brady is now with the Iowa Heart Center, Iowa City, IA
| | - Martha Grogan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN Dr Brady is now with the Iowa Heart Center, Iowa City, IA
| | - Morie A Gertz
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Angela Dispenzieri
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Grace Lin
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN Dr Brady is now with the Iowa Heart Center, Iowa City, IA
| | - David Dingli
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Francis K Buadi
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Martha Q Lacy
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Prashant Kapoor
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Wilson I Gonsalves
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Eli Muchtar
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Rahma Warsame
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Shaji K Kumar
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Taxiarchis V Kourelis
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN.
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High-dose melphalan and autologous peripheral blood stem cell transplantation in patients with AL amyloidosis and cardiac defibrillators. Bone Marrow Transplant 2019; 54:1304-1309. [DOI: 10.1038/s41409-019-0440-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 12/19/2018] [Accepted: 12/22/2018] [Indexed: 11/08/2022]
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86
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Vaxman I, Gertz M. Recent Advances in the Diagnosis, Risk Stratification, and Management of Systemic Light-Chain Amyloidosis. Acta Haematol 2019; 141:93-106. [PMID: 30650422 DOI: 10.1159/000495455] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 11/15/2018] [Indexed: 12/19/2022]
Abstract
The term amyloidosis refers to a group of disorders in which protein fibrils accumulate in certain organs, disrupt their tissue architecture, and impair the function of the effected organ. The clinical manifestations and prognosis vary widely depending on the specific type of the affected protein. Immunoglobulin light-chain (AL) amyloidosis is the most common form of systemic amyloidosis, characterized by deposition of a misfolded monoclonal light-chain that is secreted from a plasma cell clone. Demonstrating amyloid deposits in a tissue biopsy stained with Congo red is mandatory for the diagnosis. Novel agents (proteasome inhibitors, immunomodulatory drugs, monoclonal antibodies, venetoclax) and autologous stem cell transplantation, used for eliminating the underlying plasma cell clone, have improved the outcome for low- and intermediate-risk patients, but the prognosis for high-risk patients is still grave. Randomized studies evaluating antibodies that target the amyloid deposits (PRONTO, VITAL) were recently stopped due to futility and currently there is an intensive search for novel treatment approaches to AL amyloidosis. Early diagnosis is of paramount importance for effective treatment and prognosis, due to the progressive nature of this disease.
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Affiliation(s)
- Iuliana Vaxman
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Morie Gertz
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA,
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Abstract
Systemic immunoglobulin light chain amyloidosis is a protein misfolding disease caused by the conversion of immunoglobulin light chains from their soluble functional states into highly organized amyloid fibrillar aggregates that lead to organ dysfunction. The disease is progressive and, accordingly, early diagnosis is vital to prevent irreversible organ damage, of which cardiac damage and renal damage predominate. The development of novel sensitive biomarkers and imaging technologies for the detection and quantification of organ involvement and damage is facilitating earlier diagnosis and improved evaluation of the efficacy of new and existing therapies. Treatment is guided by risk assessment, which is based on levels of cardiac biomarkers; close monitoring of clonal and organ responses guides duration of therapy and changes in regimen. Several new classes of drugs, such as proteasome inhibitors and immunomodulatory drugs, along with high-dose chemotherapy and autologous haematopoietic stem cell transplantation, have led to rapid and deep suppression of amyloid light chain production in the majority of patients. However, effective therapies for patients with advanced cardiac involvement are an unmet need. Passive immunotherapies targeting clonal plasma cells and directly accelerating removal of amyloid deposits promise to further improve the overall outlook of this increasingly treatable disease.
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89
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Gertz MA. Immunoglobulin light chain amyloidosis: 2018 Update on diagnosis, prognosis, and treatment. Am J Hematol 2018; 93:1169-1180. [PMID: 30040145 DOI: 10.1002/ajh.25149] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 05/11/2018] [Accepted: 05/11/2018] [Indexed: 11/10/2022]
Abstract
DISEASE OVERVIEW Immunoglobulin light chain amyloidosis is a clonal, nonproliferative plasma cell disorder in which fragments of immunoglobulin light or heavy chain are deposited in tissues. Clinical features depend on organs involved but can include restrictive cardiomyopathy, nephrotic syndrome, hepatic dysfunction, peripheral/autonomic neuropathy, and "atypical multiple myeloma." DIAGNOSIS Tissue biopsy stained with Congo red demonstrating amyloid deposits with apple-green birefringence is required for diagnosis. Invasive organ biopsy is not required because amyloid deposits can be found in bone marrow, salivary gland, or subcutaneous fat aspirate in 85% of patients. Verification that amyloid is composed of immunoglobulin light chains is mandatory. The gold standard is laser capture mass spectroscopy. PROGNOSIS N-terminal pro-brain natriuretic peptide (NT-proBNP), serum troponin T, and difference between involved and uninvolved immunoglobulin free light chain values are used to classify patients into four groups of similar size; median survivals are 94.1, 40.3, 14.0, and 5.8 months. THERAPY All patients with a systemic amyloid syndrome require therapy to prevent deposition of amyloid in other organs and prevent progressive organ failure. Stem cell transplant (SCT) is preferred, but only 20% of patients are eligible. Requirements for safe SCT include systolic blood pressure >90 mm Hg, troponin T < 0.06 ng/mL, age < 70 years, and serum creatinine ≤1.7 mg/dL. Nontransplant candidates can be offered melphalan-dexamethasone or cyclophosphamide-bortezomib-dexamethasone. Daratumumab appears to be highly active in AL amyloidosis. Antibodies designed to dissolve existing amyloid deposits are under study. FUTURE CHALLENGES Delayed diagnosis remains a major obstacle to initiating effective therapy. EDUCATIONAL OBJECTIVES Upon completion of this educational activity, participants will be better able to: Master recognition of clinical presentations that should raise suspicion of amyloidosis. Understand simple techniques for confirming the diagnosis and providing material to classify the protein subunit. Recognize that a tissue diagnosis of amyloidosis does not indicate whether the amyloid is systemic or of immunoglobulin light chain origin. Understand the roles of the newly introduced chemotherapeutic and investigational antibody regimens for the therapy of light chain amyloidosis.
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Affiliation(s)
- Morie A. Gertz
- Division of Hematology; Mayo Clinic; Rochester Minnesota
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90
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91
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Tuzovic M, Yang EH, Baas AS, Depasquale EC, Deng MC, Cruz D, Vorobiof G. Cardiac Amyloidosis: Diagnosis and Treatment Strategies. Curr Oncol Rep 2018; 19:46. [PMID: 28528458 DOI: 10.1007/s11912-017-0607-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Cardiac amyloidosis in the United States is most often due to myocardial infiltration by immunoglobulin protein, such as in AL amyloidosis, or by the protein transthyretin, such as in hereditary and senile amyloidosis. Cardiac amyloidosis often portends a poor prognosis especially in patients with systemic AL amyloidosis. Despite better understanding of the pathophysiology of amyloid, many patients are still diagnosed late in the disease course. This review investigates the current understanding and new research on the diagnosis and treatment strategies in patients with cardiac amyloidosis. Myocardial amyloid infiltration distribution occurs in a variety of patterns. Structural and functional changes on echocardiography can suggest presence of amyloid, but CMR and nuclear imaging provide important complementary information on amyloid burden and the amyloid subtype, respectively. While for AL amyloid, treatment success largely depends on early diagnosis, for ATTR amyloid, new investigational agents that reduce production of transthyretin protein may have significant impact on clinical outcomes. Advancements in the non-invasive diagnostic detection and improvements in early disease recognition will undoubtedly facilitate a larger proportion of patients to receive early therapy when it is most effective.
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Affiliation(s)
- Mirela Tuzovic
- Division of Cardiology, Department of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Eric H Yang
- Division of Cardiology, Department of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Arnold S Baas
- Ahmanson-UCLA Cardiomyopathy Center, Department of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Eugene C Depasquale
- Ahmanson-UCLA Cardiomyopathy Center, Department of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Mario C Deng
- Ahmanson-UCLA Cardiomyopathy Center, Department of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Daniel Cruz
- Ahmanson-UCLA Cardiomyopathy Center, Department of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Gabriel Vorobiof
- Division of Cardiology, Department of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA. .,Cardiovascular Center, 100 Medical Plaza, Suite 545, 100 UCLA Medical Plaza, Los Angeles, CA, 90095, USA.
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92
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John RM. Arrhythmias in Cardiac Amyloidosis. J Innov Card Rhythm Manag 2018; 9:3051-3057. [PMID: 32477799 PMCID: PMC7252761 DOI: 10.19102/icrm.2018.090301] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 09/28/2017] [Indexed: 01/11/2023] Open
Abstract
Arrhythmias are common in cardiac amyloidosis and vary based on the amyloidosis type. Conduction defects and atrial arrhythmias are more prevalent in transthyretin amyloidosis compared with light chain amyloidosis, and this difference might be a reflection of the longer survival time in the former. This review summarizes the available literature on arrhythmias in this increasingly recognized form of cardiomyopathy and raises the importance of performing systematic data collection to improve outcomes.
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Affiliation(s)
- Roy M John
- Department of Medicine, Cardiology Division, Vanderbilt University, Nashville, TN, USA
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93
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Milani P, Palladini G, Merlini G. New concepts in the treatment and diagnosis of amyloidosis. Expert Rev Hematol 2018; 11:117-127. [DOI: 10.1080/17474086.2018.1424534] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Paolo Milani
- Amyloidosis Research and Treatment Center, Foundation ‘Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo’, and Department of Molecular Medicine, University of Pavia, Pavia, Italy
- PhD program in Experimental Medicine, University of Pavia, Pavia, Italy
| | - Giovanni Palladini
- Amyloidosis Research and Treatment Center, Foundation ‘Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo’, and Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Center, Foundation ‘Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo’, and Department of Molecular Medicine, University of Pavia, Pavia, Italy
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Abstract
The heart and the kidneys are the most commonly involved organs in systemic amyloidosis. Cardiac involvement is associated with an increased morbidity, treatment intolerance, and poorer overall survival. The most common types of amyloidosis that are associated with cardiac involvement include light chain (AL) amyloidosis and transthyretin (TTR) amyloidosis (both mutant and wild type). The traditional first-line treatment for AL amyloidosis includes alkylator-based chemotherapy or high-dose melphalan followed by autologous stem cell transplantation (ASCT). Novel agents, including proteasome inhibitors, immunomodulators, and monoclonal antibodies, have shown promising activity in both frontline and relapsed settings. Orthotopic heart transplantation (OHT) followed by ASCT has led to superior outcomes compared to OHT alone. Orthotopic liver transplantation (OLT) is the first-line treatment for TTR amyloidosis. However, progression of cardiac amyloidosis after OLT is often noted due to deposition of wild TTR. Combined OLT and OHT also has a role in treatment and leads to superior outcomes in carefully selected candidates. Pharmacologic agents, including diflunisal, tafamidis, small interfering ribonucleic acid, and doxycycline, have shown promising activity in stabilizing TTR from misfolding into fibrils and are being actively investigated. Best supportive care and management of heart failure symptoms with diuretics are a mainstay of treatment in all cardiac amyloidosis subtypes. Robust data on the benefit of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or beta blockers in amyloid cardiomyopathy is lacking.
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Affiliation(s)
| | - Eli Muchtar
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Morie A Gertz
- Division of Hematology, Mayo Clinic, Rochester, MN, USA.
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95
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How to Evaluate for and Manage Inflammatory and Infiltrative Cardiomyopathies that Require Ventricular Tachycardia Ablation. CURRENT CARDIOVASCULAR RISK REPORTS 2017. [DOI: 10.1007/s12170-017-0563-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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96
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Abstract
Restrictive cardiomyopathy (RCM) is characterized by nondilated left or right ventricle with diastolic dysfunction. The restrictive cardiomyopathies are a heterogenous group of myocardial diseases that vary according to pathogenesis, clinical presentation, diagnostic evaluation and criteria, treatment, and prognosis. In this review, an overview of RCMs will be presented followed by a detailed discussion on 3 major causes of RCM, for which tailored interventions are available: cardiac amyloidosis, cardiac sarcoidosis, and cardiac hemochromatosis. Each of these 3 RCMs is challenging to diagnose, and recognition of each disease entity is frequently delayed. Clinical clues to promote recognition of cardiac amyloidosis, cardiac sarcoidosis, and cardiac hemochromatosis and imaging techniques used to facilitate diagnosis are discussed. Disease-specific therapies are reviewed. Early recognition remains a key barrier to improving survival in all RCMs.
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Affiliation(s)
- Eli Muchtar
- From the Division of Hematology (E.M., M.A.G.) and Department of Cardiovascular Medicine (L.A.B.), Mayo Clinic, Rochester, MN
| | - Lori A. Blauwet
- From the Division of Hematology (E.M., M.A.G.) and Department of Cardiovascular Medicine (L.A.B.), Mayo Clinic, Rochester, MN
| | - Morie A. Gertz
- From the Division of Hematology (E.M., M.A.G.) and Department of Cardiovascular Medicine (L.A.B.), Mayo Clinic, Rochester, MN
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97
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Abstract
PURPOSE OF REVIEW Transthyretin (TTR)-related cardiac amyloidosis is a progressive infiltrative cardiomyopathy that mimics hypertensive, hypertrophic heart disease and may go undiagnosed. Transthyretin-derived amyloidosis accounts for 18% of all cases of cardiac amyloidosis. Thus, the study's purpose is to provide a comprehensive review of transthyretin cardiac amyloidosis. RECENT FINDINGS Wild-type transthyretin (ATTRwt) protein causes cardiac amyloidosis sporadically, with 25 to 36% of the population older than 80 years of age are at risk to develop a slowly progressive, infiltrative amyloid cardiomyopathy secondary to ATTRwt. In contrast, hereditary amyloidosis (ATTRm) is an autosomal dominant inherited disease associated with more than 100 point mutations in the transthyretin gene and has a tendency to affect the heart and nervous system. Up to 4% of African-Americans carry the Val122Ile mutation in the transthyretin gene, the most prevalent cause of hereditary cardiac amyloidosis in the USA. Identifying transthyretin cardiac amyloidosis requires increased awareness of the prevalence, signs and symptoms, and diagnostic tools available for discrimination of this progressive form of cardiomyopathy associated with left ventricular hypertrophy. While there are no FDA-approved medical treatments, investigation is underway on agents to reduce circulating mutated transthyretin.
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Affiliation(s)
- Anit K Mankad
- Division of Cardiology, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA, USA.
| | - Keyur B Shah
- The Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
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98
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Avula SR, Handa R, Balakrishnan B, Girard S. Missed opportunity for anticoagulation in a patient with AL cardiac amyloidosis and rapidly progressive heart failure. BMJ Case Rep 2017; 2017:bcr-2017-220538. [PMID: 28784887 PMCID: PMC5623239 DOI: 10.1136/bcr-2017-220538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2017] [Indexed: 11/04/2022] Open
Abstract
A previously healthy 65-year-old woman presented with progressive symptoms of heart failure. Low-voltage ECG and findings on echocardiography were concerning for infiltrative cardiomyopathy. Cardiac MRI showed biventricular late gadolinium enhancement, and endomyocardial biopsy confirmed monoclonal immunoglobulin light-chain (AL) amyloidosis. Bortezomib-based chemotherapy was initiated, but the patient continued to clinically deteriorate. She required hospital readmission after resuscitated out-of-hospital cardiac arrest attributed to progressive conduction disease, and a permanent pacemaker was implanted. Chest CT angiography showed a small subsegmental pulmonary embolism (PE), but anticoagulation was withheld as her lower extremity Doppler was negative. One month later, another pulseless electrical arrest occurred, due to massive PE. Thereafter, she had refractory class IV congestive heart failure with severe right ventricular dysfunction, and was deemed unsuitable for stem-cell or heart transplantation. This case highlights the predilection for thromboembolism in AL cardiac amyloidosis.
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Affiliation(s)
- Sindhu Reddy Avula
- Department of Internal Medicine, Saint Joseph Mercy Ann Arbor Hospital, Ypsilanti, Michigan, USA
| | - Rishin Handa
- Department of Internal Medicine, Saint Joseph Mercy Ann Arbor Hospital, Ypsilanti, Michigan, USA
| | - Bathmapriya Balakrishnan
- Department of Internal Medicine, Saint Joseph Mercy Ann Arbor Hospital, Ypsilanti, Michigan, USA
| | - Steven Girard
- Department of Cardiovascular Medicine, Saint Joseph Mercy Ann Arbor Hospital, Ypsilanti, Michigan, USA
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99
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Zipse MM, Tzou WS. Sudden cardiac death in nonischemic cardiomyopathy: Refining risk assessment. J Cardiovasc Electrophysiol 2017; 28:1361-1366. [PMID: 28670752 DOI: 10.1111/jce.13284] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 06/17/2017] [Accepted: 06/23/2017] [Indexed: 12/12/2022]
Abstract
Sudden cardiac death (SCD) risk assessment among patients with nonischemic cardiomyopathy (NICM) has been has been less straightforward than for patients with ischemic cardiomyopathy. The common surrogate that has been associated with highest SCD risk for all cardiomyopathies, and which has been universally used to guide implantation of primary-prevention implantable cardioverter-defibrillators (ICDs), is left ventricular ejection fraction (LVEF) ≤35%. However, this practice has been called into question, especially in light of recent trials suggesting that ICD treatment may not be of additional survival benefit among those with NICM treated with optimal medical therapy. This Clinical Review attempts to offer refinements to the current practice of SCD risk assessment among patients with NICM, with specific focus on importance of NICM etiology and efforts to identify myocardial scarring and arrhythmogenic substrate, both of which may provide greater information about SCD risk than the LVEF alone. These concepts are illustrated further as they apply to hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, and cardiac sarcoidosis, all of which are increasingly recognized NICM substrates associated with SCD and for which refinements for assessing risk are lacking in conventional guidelines.
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Affiliation(s)
- Matthew M Zipse
- University of Colorado, Section of Cardiac Electrophysiology, Aurora, CO, USA
| | - Wendy S Tzou
- University of Colorado, Section of Cardiac Electrophysiology, Aurora, CO, USA
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100
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Siddiqi OK, Ruberg FL. Cardiac amyloidosis: An update on pathophysiology, diagnosis, and treatment. Trends Cardiovasc Med 2017; 28:10-21. [PMID: 28739313 DOI: 10.1016/j.tcm.2017.07.004] [Citation(s) in RCA: 187] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 07/06/2017] [Accepted: 07/07/2017] [Indexed: 12/20/2022]
Abstract
The amyloidoses are a group of systemic diseases characterized by organ deposition of misfolded protein fragments of diverse origins. The natural history of the disease, involvement of other organs, and treatment options vary significantly based on the protein of origin. In AL amyloidosis, amyloid protein is derived from immunoglobulin light chains, and most often involves the kidneys and the heart. ATTR amyloidosis is categorized as mutant or wild-type depending on the genetic sequence of the transthyretin (TTR) protein produced by the liver. Wild-type ATTR amyloidosis mainly involves the heart, although the reported occurrence of bilateral carpal tunnel syndrome, spinal stenosis and biceps tendon rupture in these patients speaks to more generalized protein deposition. Mutant TTR is marked by cardiac and/or peripheral nervous system involvement. Cardiac involvement is associated with symptoms of heart failure, and dictates the clinical course of the disease. Cardiac amyloidosis can be diagnosed noninvasively by echocardiography, cardiac MRI, or nuclear scintigraphy. Endomyocardial biopsy may be needed in the case of equivocal imaging findings or discordant data. Treatment is aimed at relieving congestive symptoms and targeting the underlying amyloidogenic process. This includes anti-plasma cell therapy in AL amyloidosis, and stabilization of the TTR tetramer or inhibition of TTR protein production in ATTR amyloidosis. Cardiac transplantation can be considered in highly selected patients in tandem with therapy aimed at suppressing the amyloidogenic process, and appears associated with durable long-term survival.
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Affiliation(s)
- Omar K Siddiqi
- Section of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, 88 East Newton Street, Boston, MA; Amyloidosis Center, Boston University School of Medicine, Boston Medical Center, Boston, MA
| | - Frederick L Ruberg
- Section of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, 88 East Newton Street, Boston, MA; Amyloidosis Center, Boston University School of Medicine, Boston Medical Center, Boston, MA; Department of Radiology, Boston University School of Medicine, Boston Medical Center, Boston, MA.
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