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Abstract
PURPOSE OF REVIEW We summarize key features pertaining to the two most commonly encountered types of cardiac amyloidosis (CA), monoclonal immunoglobulin light chain (AL) and transthyretin type (ATTR), expanding upon the clinical application and utility of various imaging techniques in diagnosing CA. RECENT FINDINGS Advances in imaging have led to earlier identification, improved diagnosis of CA and higher discriminatory power to differentiate CA from other hypertrophic phenocopies. The application of cardiac magnetic resonance imaging (CMR) has led to a deeper understanding of underlying pathophysiological processes in CA, owing largely to its intrinsic tissue characterization properties. The widespread adoption of bone scintigraphy algorithms has reduced the need for cardiac biopsy and improved diagnostic confidence in ATTR CA. As new treatments for CA are rapidly developing, there will be even greater reliance on imaging, as the requirement to diagnose disease earlier, monitor response and amend treatment strategies accordingly intensifies.
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Affiliation(s)
- Liza Chacko
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, NW3 2PF, London, UK
| | - Raffaele Martone
- Tuscan Regional Amyloid Center, Careggi University Hospital, Florence, Italy
| | - Francesco Cappelli
- Tuscan Regional Amyloid Center, Careggi University Hospital, Florence, Italy
| | - Marianna Fontana
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, NW3 2PF, London, UK
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152
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Rosenblum H, Castano A, Alvarez J, Goldsmith J, Helmke S, Maurer MS. TTR (Transthyretin) Stabilizers Are Associated With Improved Survival in Patients With TTR Cardiac Amyloidosis. Circ Heart Fail 2019; 11:e004769. [PMID: 29615436 DOI: 10.1161/circheartfailure.117.004769] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 03/01/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND TTR (transthyretin) cardiac amyloidosis is caused by dissociation of TTR into monomers, which misassemble into amyloid fibrils. TTR stabilizers act at the dimer-dimer interface to prevent dissociation. We investigated differences in survival among patients with TTR cardiac amyloidosis on stabilizer medications compared with those not on stabilizers. METHODS AND RESULTS A retrospective study of patients with TTR cardiac amyloidosis presenting to a single center was conducted. Baseline characteristics were compared between those treated with stabilizers and those not treated with stabilizers. Cox proportional hazards modeling assessed for univariate predictors of the composite outcome of death or orthotopic heart transplant (OHT). Multivariable Cox proportional hazards assessed whether stabilizer treatment was independently associated with improved death or OHT after controlling for significant univariate predictors. One hundred twenty patients (mean age, 75±8, 88% male) were included: 29 patients who received stabilizers and 91 patients who did not. Stabilizer use was associated with a lower risk of the combined end point of death or OHT (hazard ratio, 0.32; 95% confidence interval, 0.18-0.58; P<0.0001). Subjects treated with stabilizers were more likely to be of White race (93% versus 55%; P<0.001), classified as New York Heart Association classes I and II (79% versus 38%; P=0.002), less likely to have a mutation (10% versus 36%; P=0.010), have lower troponin I (median 0.06 versus 0.12 ng/mL; P=0.002), and higher left ventricular ejection fraction (49% versus 40%; P=0.011), suggesting earlier stage of disease. In multivariable Cox analysis, the association between stabilizer and death or OHT persisted when adjusted for all noncollinear univariate predictors with P<0.05 (hazard ratio, 0.37; 95% confidence interval, 0.19-0.75; P=0.003). CONCLUSIONS TTR stabilizers are associated with decreased death and OHT in TTR cardiac amyloidosis. These results need to be confirmed by ongoing randomized clinical trials.
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Affiliation(s)
- Hannah Rosenblum
- Department of Medicine, Division of Cardiology, Columbia University Medical Center/New York-Presbyterian Hospital
| | - Adam Castano
- Department of Medicine, Division of Cardiology, Columbia University Medical Center/New York-Presbyterian Hospital
| | - Julissa Alvarez
- Department of Medicine, Division of Cardiology, Columbia University Medical Center/New York-Presbyterian Hospital
| | - Jeff Goldsmith
- Department of Medicine, Division of Cardiology, Columbia University Medical Center/New York-Presbyterian Hospital
| | - Stephen Helmke
- Department of Medicine, Division of Cardiology, Columbia University Medical Center/New York-Presbyterian Hospital
| | - Mathew S Maurer
- Department of Medicine, Division of Cardiology, Columbia University Medical Center/New York-Presbyterian Hospital.
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153
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Lane T, Fontana M, Martinez-Naharro A, Quarta CC, Whelan CJ, Petrie A, Rowczenio DM, Gilbertson JA, Hutt DF, Rezk T, Strehina SG, Caringal-Galima J, Manwani R, Sharpley FA, Wechalekar AD, Lachmann HJ, Mahmood S, Sachchithanantham S, Drage EP, Jenner HD, McDonald R, Bertolli O, Calleja A, Hawkins PN, Gillmore JD. Natural History, Quality of Life, and Outcome in Cardiac Transthyretin Amyloidosis. Circulation 2019; 140:16-26. [DOI: 10.1161/circulationaha.118.038169] [Citation(s) in RCA: 168] [Impact Index Per Article: 33.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Thirusha Lane
- National Amyloidosis Centre, Division of Medicine, University College London, United Kingdom (T.H., M.F., A.M.-N., C.C.Q., C.J.W., D.M.R., J.A.G., D.F.H., T.R., S.G.S., J.C.-G., R. Manwani, F.A.S., A.D.W., H.J.L., S.M., S.S., P.N.H., J.D.G.)
| | - Marianna Fontana
- National Amyloidosis Centre, Division of Medicine, University College London, United Kingdom (T.H., M.F., A.M.-N., C.C.Q., C.J.W., D.M.R., J.A.G., D.F.H., T.R., S.G.S., J.C.-G., R. Manwani, F.A.S., A.D.W., H.J.L., S.M., S.S., P.N.H., J.D.G.)
| | - Ana Martinez-Naharro
- National Amyloidosis Centre, Division of Medicine, University College London, United Kingdom (T.H., M.F., A.M.-N., C.C.Q., C.J.W., D.M.R., J.A.G., D.F.H., T.R., S.G.S., J.C.-G., R. Manwani, F.A.S., A.D.W., H.J.L., S.M., S.S., P.N.H., J.D.G.)
| | - Candida Cristina Quarta
- National Amyloidosis Centre, Division of Medicine, University College London, United Kingdom (T.H., M.F., A.M.-N., C.C.Q., C.J.W., D.M.R., J.A.G., D.F.H., T.R., S.G.S., J.C.-G., R. Manwani, F.A.S., A.D.W., H.J.L., S.M., S.S., P.N.H., J.D.G.)
| | - Carol J. Whelan
- National Amyloidosis Centre, Division of Medicine, University College London, United Kingdom (T.H., M.F., A.M.-N., C.C.Q., C.J.W., D.M.R., J.A.G., D.F.H., T.R., S.G.S., J.C.-G., R. Manwani, F.A.S., A.D.W., H.J.L., S.M., S.S., P.N.H., J.D.G.)
| | - Aviva Petrie
- National Amyloidosis Centre, Division of Medicine, University College London, United Kingdom (T.H., M.F., A.M.-N., C.C.Q., C.J.W., D.M.R., J.A.G., D.F.H., T.R., S.G.S., J.C.-G., R. Manwani, F.A.S., A.D.W., H.J.L., S.M., S.S., P.N.H., J.D.G.)
| | - Dorota M. Rowczenio
- National Amyloidosis Centre, Division of Medicine, University College London, United Kingdom (T.H., M.F., A.M.-N., C.C.Q., C.J.W., D.M.R., J.A.G., D.F.H., T.R., S.G.S., J.C.-G., R. Manwani, F.A.S., A.D.W., H.J.L., S.M., S.S., P.N.H., J.D.G.)
| | - Janet A. Gilbertson
- National Amyloidosis Centre, Division of Medicine, University College London, United Kingdom (T.H., M.F., A.M.-N., C.C.Q., C.J.W., D.M.R., J.A.G., D.F.H., T.R., S.G.S., J.C.-G., R. Manwani, F.A.S., A.D.W., H.J.L., S.M., S.S., P.N.H., J.D.G.)
| | - David F. Hutt
- National Amyloidosis Centre, Division of Medicine, University College London, United Kingdom (T.H., M.F., A.M.-N., C.C.Q., C.J.W., D.M.R., J.A.G., D.F.H., T.R., S.G.S., J.C.-G., R. Manwani, F.A.S., A.D.W., H.J.L., S.M., S.S., P.N.H., J.D.G.)
| | - Tamer Rezk
- National Amyloidosis Centre, Division of Medicine, University College London, United Kingdom (T.H., M.F., A.M.-N., C.C.Q., C.J.W., D.M.R., J.A.G., D.F.H., T.R., S.G.S., J.C.-G., R. Manwani, F.A.S., A.D.W., H.J.L., S.M., S.S., P.N.H., J.D.G.)
| | - Svetla G. Strehina
- National Amyloidosis Centre, Division of Medicine, University College London, United Kingdom (T.H., M.F., A.M.-N., C.C.Q., C.J.W., D.M.R., J.A.G., D.F.H., T.R., S.G.S., J.C.-G., R. Manwani, F.A.S., A.D.W., H.J.L., S.M., S.S., P.N.H., J.D.G.)
| | - Joan Caringal-Galima
- National Amyloidosis Centre, Division of Medicine, University College London, United Kingdom (T.H., M.F., A.M.-N., C.C.Q., C.J.W., D.M.R., J.A.G., D.F.H., T.R., S.G.S., J.C.-G., R. Manwani, F.A.S., A.D.W., H.J.L., S.M., S.S., P.N.H., J.D.G.)
| | - Richa Manwani
- National Amyloidosis Centre, Division of Medicine, University College London, United Kingdom (T.H., M.F., A.M.-N., C.C.Q., C.J.W., D.M.R., J.A.G., D.F.H., T.R., S.G.S., J.C.-G., R. Manwani, F.A.S., A.D.W., H.J.L., S.M., S.S., P.N.H., J.D.G.)
| | - Faye A. Sharpley
- National Amyloidosis Centre, Division of Medicine, University College London, United Kingdom (T.H., M.F., A.M.-N., C.C.Q., C.J.W., D.M.R., J.A.G., D.F.H., T.R., S.G.S., J.C.-G., R. Manwani, F.A.S., A.D.W., H.J.L., S.M., S.S., P.N.H., J.D.G.)
| | - Ashutosh D. Wechalekar
- National Amyloidosis Centre, Division of Medicine, University College London, United Kingdom (T.H., M.F., A.M.-N., C.C.Q., C.J.W., D.M.R., J.A.G., D.F.H., T.R., S.G.S., J.C.-G., R. Manwani, F.A.S., A.D.W., H.J.L., S.M., S.S., P.N.H., J.D.G.)
| | - Helen J. Lachmann
- National Amyloidosis Centre, Division of Medicine, University College London, United Kingdom (T.H., M.F., A.M.-N., C.C.Q., C.J.W., D.M.R., J.A.G., D.F.H., T.R., S.G.S., J.C.-G., R. Manwani, F.A.S., A.D.W., H.J.L., S.M., S.S., P.N.H., J.D.G.)
| | - Shameem Mahmood
- National Amyloidosis Centre, Division of Medicine, University College London, United Kingdom (T.H., M.F., A.M.-N., C.C.Q., C.J.W., D.M.R., J.A.G., D.F.H., T.R., S.G.S., J.C.-G., R. Manwani, F.A.S., A.D.W., H.J.L., S.M., S.S., P.N.H., J.D.G.)
| | - Sajitha Sachchithanantham
- National Amyloidosis Centre, Division of Medicine, University College London, United Kingdom (T.H., M.F., A.M.-N., C.C.Q., C.J.W., D.M.R., J.A.G., D.F.H., T.R., S.G.S., J.C.-G., R. Manwani, F.A.S., A.D.W., H.J.L., S.M., S.S., P.N.H., J.D.G.)
| | - Edmund P.S. Drage
- Eastman Dental Institute, University College London, United Kingdom (A.P.). IQVIA, London, United Kingdom (E.P.S.D., H.D.J., R. McDonald, O.B., A.C.)
| | - Harvey D. Jenner
- Eastman Dental Institute, University College London, United Kingdom (A.P.). IQVIA, London, United Kingdom (E.P.S.D., H.D.J., R. McDonald, O.B., A.C.)
| | - Rosie McDonald
- Eastman Dental Institute, University College London, United Kingdom (A.P.). IQVIA, London, United Kingdom (E.P.S.D., H.D.J., R. McDonald, O.B., A.C.)
| | - Ottavia Bertolli
- Eastman Dental Institute, University College London, United Kingdom (A.P.). IQVIA, London, United Kingdom (E.P.S.D., H.D.J., R. McDonald, O.B., A.C.)
| | - Alan Calleja
- Eastman Dental Institute, University College London, United Kingdom (A.P.). IQVIA, London, United Kingdom (E.P.S.D., H.D.J., R. McDonald, O.B., A.C.)
| | - Philip N. Hawkins
- National Amyloidosis Centre, Division of Medicine, University College London, United Kingdom (T.H., M.F., A.M.-N., C.C.Q., C.J.W., D.M.R., J.A.G., D.F.H., T.R., S.G.S., J.C.-G., R. Manwani, F.A.S., A.D.W., H.J.L., S.M., S.S., P.N.H., J.D.G.)
| | - Julian D. Gillmore
- National Amyloidosis Centre, Division of Medicine, University College London, United Kingdom (T.H., M.F., A.M.-N., C.C.Q., C.J.W., D.M.R., J.A.G., D.F.H., T.R., S.G.S., J.C.-G., R. Manwani, F.A.S., A.D.W., H.J.L., S.M., S.S., P.N.H., J.D.G.)
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154
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Yunis A, Doros G, Luptak I, Connors LH, Sam F. Use of Ventilatory Efficiency Slope as a Marker for Increased Mortality in Wild-Type Transthyretin Cardiac Amyloidosis. Am J Cardiol 2019; 124:122-130. [PMID: 31053293 DOI: 10.1016/j.amjcard.2019.03.035] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 03/13/2019] [Accepted: 03/19/2019] [Indexed: 01/21/2023]
Abstract
Wild-type transthyretin amyloidosis (ATTRwt) results in an infiltrative cardiomyopathy often culminating in symptomatic heart failure. The use of cardiopulmonary exercise testing (CPET) in determining outcomes in ATTRwt cardiac amyloidosis is unknown. Given the emergence of novel therapies to treat transthyretin amyloidosis, we sought to investigate the utility of CPET on outcomes in patients with ATTRwt cardiomyopathy. Fifty-six patients, with biopsy and immunohistochemically proved ATTRwt, were enrolled between 2005 and 2015, as part of an NIH ATTRwt substudy at the Boston University Amyloidosis Center. Patients were prospectively studied, which included laboratory tests, electrocardiogram, echocardiography, in addition to CPET. In this cohort of ATTRwt patients who performed CPET were elderly, all were male, and predominantly white (69.9%). The overall median survival was 59.01 months (95% confidence interval [CI] 49.29 to 88.69). By multivariate analysis, C-reactive protein (CRP; hazard ratio [HR] 1.10 [1.03 to 1.18]), decreased sodium (HR 0.75 [0.58 to 0.97]), creatinine (HR 7.48 [2.44 to 22.98]) and VE/VCO2 (HR 1.10 [1.05 to 1.16]) were significant risk factors for mortality (p <0.05). Peak VO2 was insignificant by both univariate and multivariate analyses. ATTRwt patients with VE/VCO2 >40 had a worse median survival of 38.54 months (95% CI 32.63 to 51.47) versus 88.69 months (95% CI 56.26 to 89.49) than patients with VE/VCO2 slope ≤40. Receiver-operating characteristic curve showed that the combination of VE/VCO2, CRP, sodium, and creatinine (Area under the ROC Curve [AUC], 0.89) predicted 1-year mortality in ATTRwt cardiac amyloidosis. In conclusion, increased VE/VCO2, in combination with CRP, sodium, and creatinine, may identify patients at increased risk of death in ATTRwt cardiomyopathy. VE/VCO2 might have a role in objectively assessing therapeutic response in ATTRwt cardiac amyloidosis.
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Affiliation(s)
- Adil Yunis
- Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Gheorge Doros
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Ivan Luptak
- Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts; Cardiovascular Section, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts; Evans Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Lawreen H Connors
- Alan and Sandra Gerry Amyloid Research Laboratory in the Amyloidosis Center, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Flora Sam
- Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts; Cardiovascular Section, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts; Evans Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts.
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155
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Trenkwalder T, Schunkert H, Reinhard W. [Cardiac involvement in storage diseases : Role of genetic diagnostics]. Herz 2019; 44:461-474. [PMID: 31236604 DOI: 10.1007/s00059-019-4824-5] [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] [Indexed: 11/26/2022]
Abstract
In clinical practice cardiac involvement in patients with storage disorders is often diagnosed at a late and advanced stage of the disease with pronounced organ damage. As the currently available targeted therapies can only stop the progress of the disease, a timely diagnosis is of particular relevance. Genetic testing has become increasingly more important in cases of suspected cardiac manifestation in storage disorders. Thereby, diagnostic genetic testing can help to confirm the diagnosis and may also be relevant for therapeutic decision making. In relatives of affected patients predictive genetic testing provides the opportunity for an early therapeutic intervention.
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Affiliation(s)
- T Trenkwalder
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Fakultät für Medizin, Technische Universität München, Lazarettstr. 36, 80636, München, Deutschland
| | - H Schunkert
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Fakultät für Medizin, Technische Universität München, Lazarettstr. 36, 80636, München, Deutschland
- Partner Site Munich Heart Alliance, Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), München, Deutschland
| | - W Reinhard
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Fakultät für Medizin, Technische Universität München, Lazarettstr. 36, 80636, München, Deutschland.
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156
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Marume K, Takashio S, Nishi M, Hirakawa K, Yamamoto M, Hanatani S, Oda S, Utsunomiya D, Shiraishi S, Ueda M, Yamashita T, Sakamoto K, Yamamoto E, Kaikita K, Izumiya Y, Yamashita Y, Ando Y, Tsujita K. Combination of Commonly Examined Parameters Is a Useful Predictor of Positive 99 mTc-Labeled Pyrophosphate Scintigraphy Findings in Elderly Patients With Suspected Transthyretin Cardiac Amyloidosis. Circ J 2019; 83:1698-1708. [PMID: 31189791 DOI: 10.1253/circj.cj-19-0255] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND A recent study revealed a high prevalence of transthyretin (TTR) cardiac amyloidosis (CA) in elderly patients. 99 mTc-labeled pyrophosphate (99 mTc-PYP) scintigraphy is a remarkably sensitive and specific modality for TTR-CA, but is only available in specialist centres; thus, it is important to raise the pretest probability. The aim of this study was to evaluate the characteristics of patients with 99 mTc-PYP positivity and make recommendations about patient selection for 99 mTc-PYP scintigraphy.Methods and Results:We examined 181 consecutive patients aged ≥70 years who underwent 99 mTc-PYP scintigraphy at Kumamoto University Hospital between January 2012 and December 2018. Logistic regression analyses showed that high-sensitivity cardiac troponin T (hs-cTnT) ≥0.0308 ng/mL, left ventricular posterior wall thickness ≥13.6 mm, and wide QRS (QRS ≥120 ms) were strongly associated with 99 mTc-PYP positivity. We developed a new index for predicting 99 mTc-PYP positivity by adding 1 point for each of the 3 factors. The 99 mTc-PYP positive rate increased by a factor of 4.57 for each 1-point increase (P<0.001). Zero points corresponded to a negative predictive value of 87% and 3 points corresponded to a positive predictive value of 96% for 99 mTc-PYP positivity. CONCLUSIONS The combination of biochemical (hs-cTnT), physiological (wide QRS), and structural (left ventricular posterior wall thickness) findings can raise the pretest probability for 99 mTc-PYP scintigraphy. It can assist clinicians in determining management strategies for elderly patients with suspected CA.
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Affiliation(s)
- Kyohei Marume
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kumamoto University
| | - Seiji Takashio
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kumamoto University
| | - Masato Nishi
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kumamoto University
| | - Kyoko Hirakawa
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kumamoto University
| | - Masahiro Yamamoto
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kumamoto University
| | - Shinsuke Hanatani
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kumamoto University
| | - Seitaro Oda
- Department of Diagnostic Radiology, Graduate School of Medical Science, Kumamoto University
| | - Daisuke Utsunomiya
- Department of Diagnostic Radiology, Graduate School of Medical Science, Kumamoto University
| | - Shinya Shiraishi
- Department of Diagnostic Radiology, Graduate School of Medical Science, Kumamoto University
| | - Mitsuharu Ueda
- Department of Neurology, Graduate School of Medical Science, Kumamoto University
| | - Taro Yamashita
- Department of Neurology, Graduate School of Medical Science, Kumamoto University
| | - Kenji Sakamoto
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kumamoto University
| | - Eiichiro Yamamoto
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kumamoto University
| | - Koichi Kaikita
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kumamoto University
| | - Yasuhiro Izumiya
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine
| | - Yasuyuki Yamashita
- Department of Diagnostic Radiology, Graduate School of Medical Science, Kumamoto University
| | - Yukio Ando
- Department of Neurology, Graduate School of Medical Science, Kumamoto University
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kumamoto University
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157
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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: 560] [Impact Index Per Article: 112.0] [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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158
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Affiliation(s)
- Jan M Griffin
- Cardiac Amyloidosis Program, Center for Advanced Cardiac Care, Department of Medicine, Columbia University Irving Medical Center, New York Presbyterian Hospital
| | - Mathew S Maurer
- Cardiac Amyloidosis Program, Center for Advanced Cardiac Care, Department of Medicine, Columbia University Irving Medical Center, New York Presbyterian Hospital
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159
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Wisniowski B, McLeod DSA, Adams R, Harvey Y, Brown I, McGuire L, Armes J, Mollee P. The epidemiology of amyloidosis in Queensland, Australia. Br J Haematol 2019; 186:829-836. [PMID: 31148162 DOI: 10.1111/bjh.16000] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 04/11/2019] [Indexed: 11/30/2022]
Abstract
Published studies on the epidemiology of amyloidosis have relied on death certificate data for case ascertainment. We estimated the incidence and mortality burden of amyloidosis among residents of the Australian state, Queensland, aged ≥20 years for the years 1999-2013 based on case ascertainment from histopathology reports. Information systems for participating laboratories were scrutinised to identify histopathology reports that documented a diagnosis of amyloidosis. Case mortality status was determined via linkage to the National Death Index. A total of 447 cases of amyloidosis were identified, with a median age at diagnosis of 66 years. A plasma cell dyscrasia was identified in 72% of patients who had paraprotein studies performed. The estimated incidence for Queenslanders aged ≥20 years was 12·1 cases per million person years. The median survival was 2·45 years. Age at diagnosis, presence of a paraprotein, earlier year of diagnosis, and inner regional location of residence (compared with residence in a major city) were independently associated with reduced survival. Our data confirms previously reported incidence data for amyloidosis of approximately 10 cases per million patient years and indicates that survival for Queensland patients with amyloidosis is improving, though it remains poor for the elderly and patients with AL amyloidosis.
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Affiliation(s)
- Brendan Wisniowski
- Pathology Queensland, Woolloongabba, Queensland, Australia.,School of Medicine, University of Queensland, Saint Lucia, Queensland, Australia
| | - Donald S A McLeod
- QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
| | - Rebecca Adams
- Pathology Queensland, Woolloongabba, Queensland, Australia.,QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia.,QML Pathology, Mansfield, Queensland, Australia
| | - Yasmin Harvey
- Sullivan Nicolaides Pathology, Bowen Hills, Queensland, Australia
| | - Ian Brown
- Envoi Pathology, Kelvin Grove, Queensland, Australia
| | | | - Jane Armes
- Mater Health Services, South Brisbane, Queensland, Australia
| | - Peter Mollee
- Pathology Queensland, Woolloongabba, Queensland, Australia.,School of Medicine, University of Queensland, Saint Lucia, Queensland, Australia
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160
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Gargiulo P, Perrone-Filardi P. Dangerous relationships: aortic stenosis and transthyretin cardiac amyloidosis. Eur Heart J 2019; 38:2888-2889. [PMID: 29019616 DOI: 10.1093/eurheartj/ehx513] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Paola Gargiulo
- IRCCS SDN spa, Institute of Diagnostic and Nuclear Development, Naples, Italy
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161
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Affiliation(s)
- Omar K Siddiqi
- Section of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA, USA.,Amyloidosis Center, Boston University School of Medicine, Boston Medical Center, Boston, MA, USA
| | - Frederick L Ruberg
- Section of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA, USA.,Amyloidosis Center, Boston University School of Medicine, Boston Medical Center, Boston, MA, USA.,Department of Radiology, Boston University School of Medicine, Boston Medical Center, Boston, MA, USA
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162
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Hanson JLS, Arvanitis M, Koch CM, Berk JL, Ruberg FL, Prokaeva T, Connors LH. Use of Serum Transthyretin as a Prognostic Indicator and Predictor of Outcome in Cardiac Amyloid Disease Associated With Wild-Type Transthyretin. Circ Heart Fail 2019; 11:e004000. [PMID: 29449366 DOI: 10.1161/circheartfailure.117.004000] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 12/11/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Wild-type transthyretin amyloidosis (ATTRwt), an underappreciated cause of heart failure in older adults, is challenging to diagnose and monitor in the absence of validated, disease-specific biomarkers. We examined the prognostic use and survival association of serum TTR (transthyretin) concentration in ATTRwt. METHODS AND RESULTS Patients with biopsy-proven ATTRwt were retrospectively identified. Serum TTR, cardiac biomarkers, and echocardiographic parameters were assessed at baseline and follow-up evaluations. Statistical analyses included Kaplan-Meier method, Cox proportional hazard survival models, and receiver-operating characteristic curve analysis. Median serum TTR concentration at presentation was 23 mg/dL (n=116). Multivariate predictors of shorter overall survival were decreased TTR, left ventricular ejection fraction and elevated cTn-I (cardiac troponin I); an inclusive model demonstrated superior accuracy in 4-year survival prediction by receiver-operating characteristic curve analysis (area under the curve, 0.77). TTR values lower than the normal limit, <18 mg/dL, were associated with shorter survival (2.8 versus 4.1 years; P=0.03). Further, TTR values at 1- and 2-year follow-ups were significantly lower (P<0.001) in untreated patients (n=23) compared with those treated with TTR stabilizer, diflunisal (n=12), after baseline evaluation. During 2-year follow-up, unchanged TTR corresponded to increased cTn-I (P=0.006) in untreated patients; conversely, the diflunisal-treated group showed increased TTR (P=0.001) and stabilized cTn-I and left ventricular ejection fraction at 1 year. CONCLUSIONS In this series of biopsy-proven ATTRwt, lower baseline serum TTR concentration was associated with shorter survival as an independent predictor of outcome. Longitudinal analysis demonstrated that decreasing TTR corresponded to worsening cardiac function. These data suggest that TTR may be a useful prognostic marker and predictor of outcome in ATTRwt.
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Affiliation(s)
- Jacquelyn L S Hanson
- From the Amyloidosis Center (J.L.S.H., C.M.K., J.L.B., F.L.R., T.P., L.H.C.), Department of Pathology and Laboratory Medicine (J.L.S.H., C.M.K., L.H.C.), Department of Medicine (M.A., J.L.B., F.L.R.), and Section of Cardiovascular Medicine, Department of Medicine (F.L.R.), Boston University School of Medicine, MA. The current affiliation for C.M.H. is the Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University, Chicago, IL
| | - Marios Arvanitis
- From the Amyloidosis Center (J.L.S.H., C.M.K., J.L.B., F.L.R., T.P., L.H.C.), Department of Pathology and Laboratory Medicine (J.L.S.H., C.M.K., L.H.C.), Department of Medicine (M.A., J.L.B., F.L.R.), and Section of Cardiovascular Medicine, Department of Medicine (F.L.R.), Boston University School of Medicine, MA. The current affiliation for C.M.H. is the Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University, Chicago, IL
| | - Clarissa M Koch
- From the Amyloidosis Center (J.L.S.H., C.M.K., J.L.B., F.L.R., T.P., L.H.C.), Department of Pathology and Laboratory Medicine (J.L.S.H., C.M.K., L.H.C.), Department of Medicine (M.A., J.L.B., F.L.R.), and Section of Cardiovascular Medicine, Department of Medicine (F.L.R.), Boston University School of Medicine, MA. The current affiliation for C.M.H. is the Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University, Chicago, IL
| | - John L Berk
- From the Amyloidosis Center (J.L.S.H., C.M.K., J.L.B., F.L.R., T.P., L.H.C.), Department of Pathology and Laboratory Medicine (J.L.S.H., C.M.K., L.H.C.), Department of Medicine (M.A., J.L.B., F.L.R.), and Section of Cardiovascular Medicine, Department of Medicine (F.L.R.), Boston University School of Medicine, MA. The current affiliation for C.M.H. is the Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University, Chicago, IL
| | - Frederick L Ruberg
- From the Amyloidosis Center (J.L.S.H., C.M.K., J.L.B., F.L.R., T.P., L.H.C.), Department of Pathology and Laboratory Medicine (J.L.S.H., C.M.K., L.H.C.), Department of Medicine (M.A., J.L.B., F.L.R.), and Section of Cardiovascular Medicine, Department of Medicine (F.L.R.), Boston University School of Medicine, MA. The current affiliation for C.M.H. is the Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University, Chicago, IL
| | - Tatiana Prokaeva
- From the Amyloidosis Center (J.L.S.H., C.M.K., J.L.B., F.L.R., T.P., L.H.C.), Department of Pathology and Laboratory Medicine (J.L.S.H., C.M.K., L.H.C.), Department of Medicine (M.A., J.L.B., F.L.R.), and Section of Cardiovascular Medicine, Department of Medicine (F.L.R.), Boston University School of Medicine, MA. The current affiliation for C.M.H. is the Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University, Chicago, IL
| | - Lawreen H Connors
- From the Amyloidosis Center (J.L.S.H., C.M.K., J.L.B., F.L.R., T.P., L.H.C.), Department of Pathology and Laboratory Medicine (J.L.S.H., C.M.K., L.H.C.), Department of Medicine (M.A., J.L.B., F.L.R.), and Section of Cardiovascular Medicine, Department of Medicine (F.L.R.), Boston University School of Medicine, MA. The current affiliation for C.M.H. is the Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University, Chicago, IL.
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163
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Almarzooq Z, Pareek M, Sinnenberg L, Vaduganathan M, Mehra MR. Nine contemporary therapeutic directions in heart failure. HEART ASIA 2019; 11:e011150. [PMID: 31031834 DOI: 10.1136/heartasia-2018-011150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 02/08/2019] [Accepted: 02/11/2019] [Indexed: 12/11/2022]
Abstract
The global burden of heart failure has continued to increase dramatically with 26 million people affected and an estimated health expenditure of $31 billion worldwide. Several practice-influencing studies were reported recently, bringing advances along many frontiers in heart failure, particularly heart failure with reduced ejection fraction. In this article, we discuss nine distinct therapeutic areas that were significantly influenced by this scientific progress. These distinct areas include the emergence of sodium-glucose cotransporter-2 inhibitors, broadening the application of angiotensin-neprilysin inhibition, clinical considerations in therapy withdrawal in those patients with heart failure that 'recover' myocardial function, benefits of low-dose direct oral anticoagulants in sinus rhythm, targeted therapy for treating cardiac amyloidosis, usefulness of mitral valve repair in heart failure, the advent of newer left ventricular assist devices for advanced heart failure, the role of ablation in atrial fibrillation in heart failure, and finally the use of wearable defibrillators to address sudden death.
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Affiliation(s)
- Zaid Almarzooq
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Manan Pareek
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts, USA.,Department of Cardiology, North Zealand Hospital, Hillerød, Denmark
| | - Lauren Sinnenberg
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Mandeep R Mehra
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts, USA
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164
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Duca F, Aschauer S, Zotter-Tufaro C, Binder C, Kammerlander AA, Börries B, Agis H, Kain R, Hengstenberg C, Mascherbauer J, Bonderman D. EXPRESS: Riociguat for the treatment of transthyretin cardiac amyloidosis - Data from a named patient use program in Austria. Pulm Circ 2019; 9:2045894019849394. [PMID: 31007127 PMCID: PMC6886277 DOI: 10.1177/2045894019849394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Accepted: 04/17/2019] [Indexed: 01/14/2023] Open
Abstract
Patients with transthyretin cardiac amyloidosis (TTR CA) suffer from impaired exercise capacity, have a poor quality of life (QoL), and approved treatments are lacking. Stimulators of the soluble guanylate cyclase are promising new pharmaceuticals in the treatment armamentarium of heart failure patients. The aim of the present study was to report on the safety and efficacy of riociguat administration in patients with TTR CA. TTR CA patients received riociguat for 4–6 months within the frames of a national named patient use (NPU) program. Parameters of interest included changes in submaximal exercise capacity, invasive hemodynamic parameters, and QoL. Between March 2012 and June 2017, 86 CA patients were screened for the NPU program, of whom 13 TTR CA patients were eligible for participation. In our study cohort, riociguat had an acceptable tolerability profile. At follow-up, we could detect slight improvements in median 6-min walk distance (396 m [interquartile range (IQR) = 340–518] vs. 400 m [IQR = 350–570], P = 0.045), New York Heart Association class ≥ III (n = 7 [53.9%] vs. n = 0 [0.0%], P = 0.031), cardiac output (4.3 L/min [IQR = 3.9–5.1] vs. 4.5 L/min [IQR = 4.2–5.1], P = 0.022), diastolic pressure gradient (1.0 mmHg [IQR = −1.5–3.0) vs. −1.0 mmHg [IQR = −3.0–1.0], P = 0.049), and QoL (50.0% [IQR = 40.0–58.0] vs. 60.0% [IQR = 50.0–75.0], P = 0.021). Pulmonary arterial pressures were not altered. The present case series of TTR CA patients indicates that riociguat administration was safe and associated with minor clinical as well as hemodynamic improvements.
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Affiliation(s)
- Franz Duca
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Stefan Aschauer
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Caroline Zotter-Tufaro
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Christina Binder
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Andreas A. Kammerlander
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Benedikt Börries
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Hermine Agis
- Division of Oncology, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Renate Kain
- Clinical Institute of Pathology, Medical University of Vienna, Vienna, Austria
| | - Christian Hengstenberg
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Julia Mascherbauer
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Diana Bonderman
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
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165
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van den Berg MP, Mulder BA, Klaassen SHC, Maass AH, van Veldhuisen DJ, van der Meer P, Nienhuis HLA, Hazenberg BPC, Rienstra M. Heart failure with preserved ejection fraction, atrial fibrillation, and the role of senile amyloidosis. Eur Heart J 2019; 40:1287-1293. [PMID: 30753432 PMCID: PMC6553504 DOI: 10.1093/eurheartj/ehz057] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 12/21/2018] [Accepted: 01/22/2019] [Indexed: 12/15/2022] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) and atrial fibrillation (AF) are very common conditions, particularly in the elderly. However, the mechanisms underlying the two disorders, including their intricate interaction have not been fully resolved. Here, our aim is to review the evidence on the role of the two types of senile amyloidosis in this connection. Two types of senile amyloidosis can be identified: wild-type transthyretin (TTR)-derived amyloidosis (ATTRwt) and isolated atrial amyloidosis (IAA). ATTRwt is an underlying condition that is being increasingly recognized in patients with HFpEF and often accompanied by AF. IAA is an established cause of AF, adding to the mechanism problem. New diagnostic and therapeutic possibilities have emerged that may facilitate clinical management of (senile) amyloidosis, which in turn may have implications for the management of HFpEF and AF.
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Affiliation(s)
- Maarten P van den Berg
- Department of Cardiology, Thorax Centre, University of Groningen, University Medical Centre Groningen, 9700 RB Groningen, The Netherlands
| | - Bart A Mulder
- Department of Cardiology, Thorax Centre, University of Groningen, University Medical Centre Groningen, 9700 RB Groningen, The Netherlands
| | - Sebastiaan H C Klaassen
- Department of Cardiology, Thorax Centre, University of Groningen, University Medical Centre Groningen, 9700 RB Groningen, The Netherlands
| | - Alexander H Maass
- Department of Cardiology, Thorax Centre, University of Groningen, University Medical Centre Groningen, 9700 RB Groningen, The Netherlands
| | - Dirk J van Veldhuisen
- Department of Cardiology, Thorax Centre, University of Groningen, University Medical Centre Groningen, 9700 RB Groningen, The Netherlands
| | - Peter van der Meer
- Department of Cardiology, Thorax Centre, University of Groningen, University Medical Centre Groningen, 9700 RB Groningen, The Netherlands
| | - Hans L A Nienhuis
- Department of Internal Medicine, University of Groningen, University Medical Centre Groningen, 9700 RB Groningen, The Netherlands
| | - Bouke P C Hazenberg
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Centre Groningen, 9700 RB Groningen, The Netherlands
| | - Michiel Rienstra
- Department of Cardiology, Thorax Centre, University of Groningen, University Medical Centre Groningen, 9700 RB Groningen, The Netherlands
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166
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Carpal tunnel syndrome and spinal canal stenosis: harbingers of transthyretin amyloid cardiomyopathy? Clin Res Cardiol 2019; 108:1324-1330. [PMID: 30953182 DOI: 10.1007/s00392-019-01467-1] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 01/19/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Carpal tunnel syndrome (CTS) and spinal canal stenosis can be frequently observed in the medical history of patients with transthyretin amyloidosis (ATTR), both in the hereditary (mt-ATTR) and wild-type (wt-ATTR) form. The aim of this retrospective single-center analysis was to determine the prevalence of these findings, delay to diagnosis of systemic amyloidosis and the prognostic value in a large cohort of patients with wt-ATTR and mt-ATTR amyloidosis. METHODS Medical records of 253 patients diagnosed with wt-ATTR, 136 patients with mt-ATTR and 77 asymptomatic gene carriers were screened for history of CTS and spinal canal stenosis and laboratory analysis, electrocardiography and echocardiographic results, respectively. Clinical follow-up was performed by phone assessment. RESULTS History of CTS was present in 77 patients (56%) with mt-ATTR, in 152 patients (60%) with wt-ATTR and even in 10 of the asymptomatic gene carriers (13%). Latency between carpal tunnel surgery and first diagnosis of systemic amyloidosis was significantly longer in wt-ATTR compared to mt-ATTR (117 ± 179 months vs. 66 ± 73 months; p = 0.02). In total, 36 patients (14%) with wt-ATTR and 7 patients (5%) with mt-ATTR had a history of clinically significant spinal canal stenosis. In the subgroup of mt-ATTR, patients with CTS had thicker IVS (19 ± 5 mm vs. 16 ± 5 mm, p < 0.05), higher LV mass index (225 ± 78 g vs. 193 ± 98 g, p < 0.05), lower Karnofsky index (78 ± 15% vs. 83 ± 17%, p < 0.05), and lower mitral annular plane systolic excursion (MAPSE; 9 ± 4 mm vs. 11 ± 5 mm, p < 0.05) compared to patients without CTS, whereas in wt-ATTR no significant differences could be observed. No significant difference in survival was observed between patients with and without CTS (wt-ATTR: 67 vs. 63 months, p = 0.45; mt-ATTR: 74 vs. 63 months, p = 0.60). A combination of CTS and spinal stenosis was present in 32 wt-ATTR patients (12%) and 3 mt-ATTR patients (2.2%). CONCLUSIONS The prevalence of CTS is high and the latency between CTS surgery and diagnosis of amyloidosis is long among patients with wt-ATTR and mt-ATTR. CTS might be predictive for future occurrence of systemic (predominantly cardiac) ATTR amyloidosis.
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167
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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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168
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Role of echocardiography in assessing cardiac amyloidoses: a systematic review. J Echocardiogr 2019; 17:64-75. [PMID: 30741395 DOI: 10.1007/s12574-019-00420-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 01/29/2019] [Accepted: 01/30/2019] [Indexed: 12/21/2022]
Abstract
Cardiac amyloidosis is a manifestation of one of several systemic amyloidoses, and is characterized by increased left-ventricular (LV) wall thickness and normal or decreased LV cavity size. Congestive heart failure in cardiac amyloidosis is characterized by a predominant diastolic LV dysfunction, and systolic dysfunction occurs only in late-stage disease. Echocardiography is a noninvasive, reproducible method for assessing cardiac morphology and function in cardiac amyloidosis, and some echocardiographic indices are prognostic for amyloidoses. This review describes the advances in echocardiography and its role in the diagnosis and management of cardiac amyloidoses. Our review suggests that LV longitudinal function and the cyclic variation of myocardial integrated backscatter may be the best predictors of adverse outcomes. In the future, new echocardiographic techniques, such as fully automated echocardiogram interpretation, should provide further useful information for assessing cardiac function and prognosis in cardiac amyloidosis patients.
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169
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Saelices L, Nguyen BA, Chung K, Wang Y, Ortega A, Lee JH, Coelho T, Bijzet J, Benson MD, Eisenberg DS. A pair of peptides inhibits seeding of the hormone transporter transthyretin into amyloid fibrils. J Biol Chem 2019; 294:6130-6141. [PMID: 30733338 DOI: 10.1074/jbc.ra118.005257] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 01/22/2019] [Indexed: 11/06/2022] Open
Abstract
The tetrameric protein transthyretin is a transporter of retinol and thyroxine in blood, cerebrospinal fluid, and the eye, and is secreted by the liver, choroid plexus, and retinal epithelium, respectively. Systemic amyloid deposition of aggregated transthyretin causes hereditary and sporadic amyloidoses. A common treatment of patients with hereditary transthyretin amyloidosis is liver transplantation. However, this procedure, which replaces the patient's variant transthyretin with the WT protein, can fail to stop subsequent cardiac deposition, ultimately requiring heart transplantation. We recently showed that preformed amyloid fibrils present in the heart at the time of surgery can template or seed further amyloid aggregation of native transthyretin. Here we assess possible interventions to halt this seeding, using biochemical and EM assays. We found that chemical or mutational stabilization of the transthyretin tetramer does not hinder amyloid seeding. In contrast, binding of the peptide inhibitor TabFH2 to ex vivo fibrils efficiently inhibits amyloid seeding by impeding self-association of the amyloid-driving strands F and H in a tissue-independent manner. Our findings point to inhibition of amyloid seeding by peptide inhibitors as a potential therapeutic approach.
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Affiliation(s)
- Lorena Saelices
- From the Departments of Biological Chemistry and Chemistry and Biochemistry, Howard Hughes Medical Institute, UCLA-DOE Institute, Molecular Biology Institute, UCLA, Los Angeles, California 90095-1570
| | - Binh A Nguyen
- From the Departments of Biological Chemistry and Chemistry and Biochemistry, Howard Hughes Medical Institute, UCLA-DOE Institute, Molecular Biology Institute, UCLA, Los Angeles, California 90095-1570
| | - Kevin Chung
- From the Departments of Biological Chemistry and Chemistry and Biochemistry, Howard Hughes Medical Institute, UCLA-DOE Institute, Molecular Biology Institute, UCLA, Los Angeles, California 90095-1570
| | - Yifei Wang
- From the Departments of Biological Chemistry and Chemistry and Biochemistry, Howard Hughes Medical Institute, UCLA-DOE Institute, Molecular Biology Institute, UCLA, Los Angeles, California 90095-1570
| | - Alfredo Ortega
- From the Departments of Biological Chemistry and Chemistry and Biochemistry, Howard Hughes Medical Institute, UCLA-DOE Institute, Molecular Biology Institute, UCLA, Los Angeles, California 90095-1570
| | - Ji H Lee
- From the Departments of Biological Chemistry and Chemistry and Biochemistry, Howard Hughes Medical Institute, UCLA-DOE Institute, Molecular Biology Institute, UCLA, Los Angeles, California 90095-1570
| | - Teresa Coelho
- the Neurophysiology Department and Corino de Andrade Unit, Hospital Santo António, Centro Hospitalar do Porto, Porto 4099-001, Portugal
| | - Johan Bijzet
- the Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, Groningen, 9713 GZ, The Netherlands
| | - Merrill D Benson
- the Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, Indiana 46202
| | - David S Eisenberg
- From the Departments of Biological Chemistry and Chemistry and Biochemistry, Howard Hughes Medical Institute, UCLA-DOE Institute, Molecular Biology Institute, UCLA, Los Angeles, California 90095-1570.
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170
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Slart RHJA, Glaudemans AWJM, Hazenberg BPC, Noordzij W. Imaging cardiac innervation in amyloidosis. J Nucl Cardiol 2019; 26:174-187. [PMID: 28887775 PMCID: PMC6394628 DOI: 10.1007/s12350-017-1059-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 08/25/2017] [Indexed: 12/28/2022]
Abstract
Cardiac amyloidosis is a form of restrictive cardiomyopathy resulting in heart failure and potential risk on arrhythmia, due to amyloid infiltration of the nerve conduction system and the myocardial tissue. The prognosis in this progressive disease is poor, probably due the development of cardiac arrhythmias. Early detection of cardiac sympathetic innervation disturbances has become of major clinical interest, because its occurrence and severity limits the choice of treatment. The use of iodine-123 labelled metaiodobenzylguanidine ([I-123]MIBG), a chemical modified analogue of norepinephrine, is well established in patients with heart failure and plays an important role in evaluation of sympathetic innervation in cardiac amyloidosis. [I-123]MIBG is stored in vesicles in the sympathetic nerve terminals and is not catabolized like norepinephrine. Decreased heart-to-mediastinum ratios on late planar images and increased wash-out rates indicate cardiac sympathetic denervation and are associated with poor prognosis. Single photon emission computed tomography provides additional information and has advantages for evaluating abnormalities in regional distribution in the myocardium. [I-123]MIBG is mainly useful in patients with hereditary and wild-type ATTR cardiac amyloidosis, not in AA and AL amyloidosis. The potential role of positron emission tomography for cardiac sympathetic innervation in amyloidosis has not yet been identified.
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Affiliation(s)
- Riemer H J A Slart
- Department of Nuclear Medicine and Molecular Imaging (EB50), Medical Imaging Center, University Medical Center Groningen, University of Groningen, Hanzeplein 1, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands.
- Department of Biomedical Photonic Imaging, University of Twente, Enschde, The Netherlands.
| | - Andor W J M Glaudemans
- Department of Nuclear Medicine and Molecular Imaging (EB50), Medical Imaging Center, University Medical Center Groningen, University of Groningen, Hanzeplein 1, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Bouke P C Hazenberg
- Department of Rheumatology & Clinical Immunology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Walter Noordzij
- Department of Nuclear Medicine and Molecular Imaging (EB50), Medical Imaging Center, University Medical Center Groningen, University of Groningen, Hanzeplein 1, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
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Nuvolone M, Milani P, Palladini G, Merlini G. Management of the elderly patient with AL amyloidosis. Eur J Intern Med 2018; 58:48-56. [PMID: 29801808 DOI: 10.1016/j.ejim.2018.05.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 05/04/2018] [Indexed: 12/25/2022]
Abstract
Systemic immunoglobulin light chain (AL) amyloidosis is an aging-associated protein misfolding and deposition disease. This condition is caused by a small and otherwise indolent plasma cell (or B cell) clone secreting an unstable circulating light chain, which misfolds and deposits as amyloid fibrils possibly leading to progressive dysfunction of affected organs. AL amyloidosis can occur in the typical setting of other, rarer forms of systemic amyloidosis and can mimic other more prevalent conditions of the elderly. Therefore, its diagnosis requires a high degree of clinical suspicion and reliable diagnostic tools for accurate amyloid typing, available at specialized referral centers. In AL amyloidosis, frailty is dictated by the type and severity of organ involvement, with heart involvement being the main determinant of morbidity and mortality. Still, given a similar disease stage, elderly patients with AL amyloidosis are often an even frailer group, due to significant comorbidities, associated disability and polypharmacotherapy, socioeconomic restrictions, and limited access to clinical trials. Recent improvements in the use of biomarkers for early diagnosis, risk stratification and response monitoring, the flourishing of novel, effective anti-plasma cell therapies developed against multiple myeloma and adapted to treat AL amyloidosis, and possibly the introduction of anti-amyloid therapies are rapidly changing the clinical management of this disease and are reflected by improved outcomes. Of note, hematologic and organ responses in elderly patients with AL amyloidosis do translate in better outcome, advocating the importance of treating these patients and striving for a rapid response to therapy also in this challenging clinical setting.
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Affiliation(s)
- Mario Nuvolone
- Amyloidosis Research and Treatment Center, Foundation IRCCS Policlinico San Matteo, Department of Molecular Medicine, University of Pavia, Italy
| | - Paolo Milani
- Amyloidosis Research and Treatment Center, Foundation IRCCS Policlinico San Matteo, Department of Molecular Medicine, University of Pavia, Italy
| | - Giovanni Palladini
- Amyloidosis Research and Treatment Center, Foundation IRCCS Policlinico San Matteo, Department of Molecular Medicine, University of Pavia, Italy
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Center, Foundation IRCCS Policlinico San Matteo, Department of Molecular Medicine, University of Pavia, Italy.
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173
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Diagnosis of Cardiac Amyloidosis: Clinical and Echocardiographic Features. CURRENT CARDIOVASCULAR IMAGING REPORTS 2018. [DOI: 10.1007/s12410-018-9472-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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174
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Hutt DF, Fontana M, Burniston M, Quigley AM, Petrie A, Ross JC, Page J, Martinez-Naharro A, Wechalekar AD, Lachmann HJ, Quarta CC, Rezk T, Mahmood S, Sachchithanantham S, Youngstein T, Whelan CJ, Lane T, Gilbertson JA, Rowczenio D, Hawkins PN, Gillmore JD. Prognostic utility of the Perugini grading of 99mTc-DPD scintigraphy in transthyretin (ATTR) amyloidosis and its relationship with skeletal muscle and soft tissue amyloid. Eur Heart J Cardiovasc Imaging 2018; 18:1344-1350. [PMID: 28159995 DOI: 10.1093/ehjci/jew325] [Citation(s) in RCA: 115] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 12/20/2016] [Indexed: 01/08/2023] Open
Abstract
Aims High-grade (Perugini grade 2 or 3) cardiac uptake on bone scintigraphy with 99mTechnetium labelled 3,3-diphosphono-1,2-propanodicarboxylic acid (99mTc-DPD) has lately been confirmed to have high diagnostic sensitivity and specificity for cardiac transthyretin (ATTR) amyloidosis. We sought to determine whether patient stratification by Perugini grade on 99mTc-DPD scintigraphy has prognostic significance in ATTR amyloidosis. Methods and results Patient survival from time of 99mTc-DPD scintigraphy was determined in 602 patients with ATTR amyloidosis, including 377 with wild-type ATTR (ATTRwt) and 225 with mutant ATTR (ATTRm) amyloidosis. Patients were stratified according to Perugini grade (0-3) on 99mTc-DPD scan. The prognostic significance of additional patient and disease-related factors at baseline were determined. In the whole cohort, the finding of a Perugini grade 0 99mTc-DPD scan (n = 28) was invariably associated with absence of cardiac amyloid according to consensus criteria as well as significantly better patient survival compared to a Perugini grade 1 (n = 28), 2 (n = 436) or 3 (n = 110) 99mTc-DPD scan (P < 0.005). There were no differences in survival between patients with a grade 1, grade 2 or grade 3 99mTc-DPD scan in ATTRwt (n = 369), V122I-associated ATTRm (n = 92) or T60A-associated ATTRm (n = 59) amyloidosis. Cardiac amyloid burden, determined by equilibrium contrast cardiac magnetic resonance imaging, was similar between patients with Perugini grade 2 and Perugini grade 3 99mTc-DPD scans but skeletal muscle/soft tissue to femur ratio was substantially higher in the latter group (P < 0.001). Conclusion 99mTc-DPD scintigraphy is exquisitely sensitive for identification of cardiac ATTR amyloid, but stratification by Perugini grade of positivity at diagnosis has no prognostic significance.
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Affiliation(s)
- David F Hutt
- National Amyloidosis Centre, Division of Medicine, University College London, Rowland Hill Street, London, NW3 2PF, UK
| | - Marianna Fontana
- National Amyloidosis Centre, Division of Medicine, University College London, Rowland Hill Street, London, NW3 2PF, UK
| | - Maria Burniston
- Department of Nuclear Medicine, Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK
| | - Ann-Marie Quigley
- Department of Nuclear Medicine, Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK
| | - Aviva Petrie
- Eastman Dental Institute, University College London, 256 Grays Inn Road, London, WC1X 8LD, UK
| | - James C Ross
- National Amyloidosis Centre, Division of Medicine, University College London, Rowland Hill Street, London, NW3 2PF, UK
| | - Joanne Page
- National Amyloidosis Centre, Division of Medicine, University College London, Rowland Hill Street, London, NW3 2PF, UK
| | - Ana Martinez-Naharro
- National Amyloidosis Centre, Division of Medicine, University College London, Rowland Hill Street, London, NW3 2PF, UK
| | - Ashutosh D Wechalekar
- National Amyloidosis Centre, Division of Medicine, University College London, Rowland Hill Street, London, NW3 2PF, UK
| | - Helen J Lachmann
- National Amyloidosis Centre, Division of Medicine, University College London, Rowland Hill Street, London, NW3 2PF, UK
| | - Candida C Quarta
- National Amyloidosis Centre, Division of Medicine, University College London, Rowland Hill Street, London, NW3 2PF, UK
| | - Tamer Rezk
- National Amyloidosis Centre, Division of Medicine, University College London, Rowland Hill Street, London, NW3 2PF, UK
| | - Shameem Mahmood
- National Amyloidosis Centre, Division of Medicine, University College London, Rowland Hill Street, London, NW3 2PF, UK
| | - Sajitha Sachchithanantham
- National Amyloidosis Centre, Division of Medicine, University College London, Rowland Hill Street, London, NW3 2PF, UK
| | - Taryn Youngstein
- National Amyloidosis Centre, Division of Medicine, University College London, Rowland Hill Street, London, NW3 2PF, UK
| | - Carol J Whelan
- National Amyloidosis Centre, Division of Medicine, University College London, Rowland Hill Street, London, NW3 2PF, UK
| | - Thirusha Lane
- National Amyloidosis Centre, Division of Medicine, University College London, Rowland Hill Street, London, NW3 2PF, UK
| | - Janet A Gilbertson
- National Amyloidosis Centre, Division of Medicine, University College London, Rowland Hill Street, London, NW3 2PF, UK
| | - Dorota Rowczenio
- National Amyloidosis Centre, Division of Medicine, University College London, Rowland Hill Street, London, NW3 2PF, UK
| | - Philip N Hawkins
- National Amyloidosis Centre, Division of Medicine, University College London, Rowland Hill Street, London, NW3 2PF, UK
| | - Julian D Gillmore
- National Amyloidosis Centre, Division of Medicine, University College London, Rowland Hill Street, London, NW3 2PF, UK
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175
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Effects of dietary salt on gene and protein expression in brain tissue of a model of sporadic small vessel disease. Clin Sci (Lond) 2018; 132:1315-1328. [PMID: 29632138 PMCID: PMC6365623 DOI: 10.1042/cs20171572] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 03/13/2018] [Accepted: 03/14/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND The effect of salt on cerebral small vessel disease (SVD) is poorly understood. We assessed the effect of dietary salt on cerebral tissue of the stroke-prone spontaneously hypertensive rat (SHRSP) - a relevant model of sporadic SVD - at both the gene and protein level. Methods: Brains from 21-week-old SHRSP and Wistar-Kyoto rats, half additionally salt-loaded (via a 3-week regime of 1% NaCl in drinking water), were split into two hemispheres and sectioned coronally - one hemisphere for mRNA microarray and qRT-PCR, the other for immunohistochemistry using a panel of antibodies targeting components of the neurovascular unit. Results: We observed differences in gene and protein expression affecting the acute phase pathway and oxidative stress (ALB, AMBP, APOH, AHSG and LOC100129193, up-regulated in salt-loaded WKY versus WKY, >2-fold), active microglia (increased Iba-1 protein expression in salt-loaded SHRSP versus salt-loaded WKY, p<0.05), vascular structure (ACTB and CTNNB, up-regulated in salt-loaded SHRSP versus SHRSP, >3-fold; CLDN-11, VEGF and VGF down-regulated >2-fold in salt-loaded SHRSP versus SHRSP) and myelin integrity (MBP down-regulated in salt loaded WKY rats versus WKY, >2.5-fold). Changes of salt-loading were more pronounced in SHRSP and occurred without an increase in blood pressure in WKY rats. CONCLUSION Salt exposure induced changes in gene and protein expression in an experimental model of SVD and its parent rat strain in multiple pathways involving components of the glio-vascular unit. Further studies in pertinent experimental models at different ages would help clarify the short- and long-term effect of dietary salt in SVD.
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176
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González-López E, Gagliardi C, Dominguez F, Quarta CC, de Haro-Del Moral FJ, Milandri A, Salas C, Cinelli M, Cobo-Marcos M, Lorenzini M, Lara-Pezzi E, Foffi S, Alonso-Pulpon L, Rapezzi C, Garcia-Pavia P. Clinical characteristics of wild-type transthyretin cardiac amyloidosis: disproving myths. Eur Heart J 2018; 38:1895-1904. [PMID: 28329248 DOI: 10.1093/eurheartj/ehx043] [Citation(s) in RCA: 226] [Impact Index Per Article: 37.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 01/24/2017] [Indexed: 12/17/2022] Open
Abstract
Aims Wild-type transthyretin amyloidosis (ATTRwt) is mostly considered a disease predominantly of elderly male, characterized by concentric LV hypertrophy, preserved LVEF, and low QRS voltages. We sought to describe the characteristics of a large cohort of ATTRwt patients to better define the disease. Methods and results Clinical findings of consecutive ATTRwt patients diagnosed at 2 centres were reviewed. ATTRwt was diagnosed histologically or non-invasively (LV hypertrophy ≥12 mm, intense cardiac uptake at 99mTc-DPD scintigraphy and AL exclusion). Mutations in TTR were excluded in all cases. The study cohort comprised 108 patients (78.6 ± 8 years); 67 (62%) diagnosed invasively and 41 (38%) non-invasively. Twenty patients (19%) were females. An asymmetric hypertrophy pattern was observed in 25 (23%) patients. Mean LVEF was 52 ± 14%, with 39 patients (37%) showing a LVEF < 50%. Atrial fibrillation (56%) and a pseudo-infarct pattern (63%) were the commonest ECG findings. Only 22 patients fulfilled QRS low-voltage criteria while 10 showed LV hypertrophy on ECG. Although heart failure was the most frequent profile leading to diagnosis (68%), 7% of individuals presented with atrioventricular block and 11% were diagnosed incidentally. Almost one third (35; 32%) were previously misdiagnosed. Conclusion The clinical spectrum of ATTRwt is heterogeneous and differs from the classic phenotype: women are affected in a significant proportion; asymmetric LV hypertrophy and impaired LVEF are not rare and only a minority have low QRS voltages. Clinicians should be aware of the broad clinical spectrum of ATTRwt to correctly identify an entity for which a number of disease-modifying treatments are under investigation.
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Affiliation(s)
- Esther González-López
- Heart Failure and Inherited Cardiac Diseases Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro, Madrid, Spain.,Myocardial Biology Programme, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV)
| | - Christian Gagliardi
- Institute of Cardiology, University of Bologna and S Orsola-Malpighi Hospital, Bologna, Italy
| | - Fernando Dominguez
- Heart Failure and Inherited Cardiac Diseases Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro, Madrid, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV)
| | - Cristina Candida Quarta
- Institute of Cardiology, University of Bologna and S Orsola-Malpighi Hospital, Bologna, Italy
| | | | - Agnese Milandri
- Institute of Cardiology, University of Bologna and S Orsola-Malpighi Hospital, Bologna, Italy
| | - Clara Salas
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV).,Department of Pathology, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Mario Cinelli
- Institute of Cardiology, University of Bologna and S Orsola-Malpighi Hospital, Bologna, Italy
| | - Marta Cobo-Marcos
- Heart Failure and Inherited Cardiac Diseases Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro, Madrid, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV)
| | - Massimiliano Lorenzini
- Institute of Cardiology, University of Bologna and S Orsola-Malpighi Hospital, Bologna, Italy
| | - Enrique Lara-Pezzi
- Myocardial Biology Programme, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV)
| | - Serena Foffi
- Institute of Cardiology, University of Bologna and S Orsola-Malpighi Hospital, Bologna, Italy
| | - Luis Alonso-Pulpon
- Heart Failure and Inherited Cardiac Diseases Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro, Madrid, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV)
| | - Claudio Rapezzi
- Institute of Cardiology, University of Bologna and S Orsola-Malpighi Hospital, Bologna, Italy
| | - Pablo Garcia-Pavia
- Heart Failure and Inherited Cardiac Diseases Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro, Madrid, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV).,Medical School, Francisco de Vitoria University, Madrid, Spain
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177
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Quarta CC, Gonzalez-Lopez E, Gilbertson JA, Botcher N, Rowczenio D, Petrie A, Rezk T, Youngstein T, Mahmood S, Sachchithanantham S, Lachmann HJ, Fontana M, Whelan CJ, Wechalekar AD, Hawkins PN, Gillmore JD. Diagnostic sensitivity of abdominal fat aspiration in cardiac amyloidosis. Eur Heart J 2018; 38:1905-1908. [PMID: 28605421 PMCID: PMC5837229 DOI: 10.1093/eurheartj/ehx047] [Citation(s) in RCA: 129] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 01/24/2017] [Indexed: 01/15/2023] Open
Abstract
Aims Congo red staining of an endomyocardial biopsy is the diagnostic gold-standard in suspected cardiac amyloidosis (CA), but the procedure is associated with the risk, albeit small, of serious complications, and delay in diagnosis due to the requirement for technical expertise. In contrast, abdominal fat pad fine needle aspiration (FPFNA) is a simple, safe and well-established procedure in systemic amyloidosis, but its diagnostic sensitivity in patients with suspected CA remains unclear. Methods and results We assessed the diagnostic sensitivity of FPFNA in 600 consecutive patients diagnosed with CA [216 AL amyloidosis, 113 hereditary transthyretin (ATTRm), and 271 wild-type transthyretin (ATTRwt) amyloidosis] at our Centre. Amyloid was detected on Congo red staining of FPFNAs in 181/216 (84%) patients with cardiac AL amyloidosis, including 100, 97, and 78% of those with a large, moderate, and small whole-body amyloid burden, respectively, as assessed by serum amyloid P (SAP) component scintigraphy (P < 0.001); the deposits were successfully typed as AL by immunohistochemistry in 102/216 (47%) cases. Amyloid was detected in FPFNAs of 51/113 (45%) patients with ATTRm CA, and only 42/271 (15%) cases with ATTRwt CA. Conclusions FPFNA has reasonable diagnostic sensitivity in cardiac AL amyloidosis, particularly in patients with a large whole-body amyloid burden. Although the diagnostic sensitivity of FPFNA is substantially lower in transthyretin CA, particularly ATTRwt, it may nevertheless sometimes obviate the need for endomyocardial biopsy.
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Affiliation(s)
- Candida Cristina Quarta
- National Amyloidosis Centre, Division of Medicine, UCL, Royal Free Hospital, Rowland Hill Street, NW3 2PF, London, UK.,Istituto di Cardiologia, Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Alma Mater Studiorum Università di Bologna, Via Massarenti 9, 40100, Bologna, Italy
| | - Esther Gonzalez-Lopez
- Heart Failure and Inherited Cardiac Diseases Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro Majadahonda, Manuel de Falla 1, 28222, Madrid, Spain
| | - Janet A Gilbertson
- National Amyloidosis Centre, Division of Medicine, UCL, Royal Free Hospital, Rowland Hill Street, NW3 2PF, London, UK
| | - Nichola Botcher
- National Amyloidosis Centre, Division of Medicine, UCL, Royal Free Hospital, Rowland Hill Street, NW3 2PF, London, UK
| | - Dorota Rowczenio
- National Amyloidosis Centre, Division of Medicine, UCL, Royal Free Hospital, Rowland Hill Street, NW3 2PF, London, UK
| | - Aviva Petrie
- Eastman Dental Institute, University College London, 256 Grays Inn Rd, WC1X 8LD, London, UK
| | - Tamer Rezk
- National Amyloidosis Centre, Division of Medicine, UCL, Royal Free Hospital, Rowland Hill Street, NW3 2PF, London, UK
| | - Taryn Youngstein
- National Amyloidosis Centre, Division of Medicine, UCL, Royal Free Hospital, Rowland Hill Street, NW3 2PF, London, UK
| | - Shameem Mahmood
- National Amyloidosis Centre, Division of Medicine, UCL, Royal Free Hospital, Rowland Hill Street, NW3 2PF, London, UK
| | - Sajitha Sachchithanantham
- National Amyloidosis Centre, Division of Medicine, UCL, Royal Free Hospital, Rowland Hill Street, NW3 2PF, London, UK
| | - Helen J Lachmann
- National Amyloidosis Centre, Division of Medicine, UCL, Royal Free Hospital, Rowland Hill Street, NW3 2PF, London, UK
| | - Marianna Fontana
- National Amyloidosis Centre, Division of Medicine, UCL, Royal Free Hospital, Rowland Hill Street, NW3 2PF, London, UK
| | - Carol J Whelan
- National Amyloidosis Centre, Division of Medicine, UCL, Royal Free Hospital, Rowland Hill Street, NW3 2PF, London, UK
| | - Ashutosh D Wechalekar
- National Amyloidosis Centre, Division of Medicine, UCL, Royal Free Hospital, Rowland Hill Street, NW3 2PF, London, UK
| | - Philip N Hawkins
- National Amyloidosis Centre, Division of Medicine, UCL, Royal Free Hospital, Rowland Hill Street, NW3 2PF, London, UK
| | - Julian D Gillmore
- National Amyloidosis Centre, Division of Medicine, UCL, Royal Free Hospital, Rowland Hill Street, NW3 2PF, London, UK
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Abstract
Systemic amyloidosis comprises an uncommon group of disorders caused by the extracellular deposition of misfolded proteins in various organs. Cardiac amyloid deposition, causing an infiltrative/restrictive cardiomyopathy, is a frequent feature of amyloidosis and a major determinant of survival. It may be the presenting feature of the disease or may be identified while investigating a patient presenting with other organ involvement. The need for a high index of suspicion and the critical importance of precise biochemical typing of the amyloid deposits is paramount in light of recent therapeutic advances that can significantly improve prognosis. Most cases of cardiac amyloidosis are of either transthyretin type, which may be acquired in older individuals or inherited in younger patients, or acquired monoclonal immunoglobulin light chain (AL) type. This article aims to review recent developments in diagnosis and management of cardiac amyloidosis.
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Affiliation(s)
- Ana Martinez-Naharro
- ANational Amyloidosis Centre, University College London, Royal Free Hospital, London, UK
| | - Philip N Hawkins
- BNational Amyloidosis Centre, University College London, Royal Free Hospital, London, UK
| | - Marianna Fontana
- CNational Amyloidosis Centre, University College London, Royal Free Hospital, London, UK,Address for correspondence: Dr Marianna Fontana, National Amyloidosis Centre, University College London, Royal Free Hospital, Rowland Hill Street, London NW3 2PF, UK.
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179
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Abstract
Systemic amyloidosis comprises an uncommon group of disorders caused by the extracellular deposition of misfolded proteins in various organs. Cardiac amyloid deposition, causing an infiltrative/restrictive cardiomyopathy, is a frequent feature of amyloidosis and a major determinant of survival. It may be the presenting feature of the disease or may be identified while investigating a patient presenting with other organ involvement. The need for a high index of suspicion and the critical importance of precise biochemical typing of the amyloid deposits is paramount in light of recent therapeutic advances that can significantly improve prognosis. Most cases of cardiac amyloidosis are of either transthyretin type, which may be acquired in older individuals or inherited in younger patients, or acquired monoclonal immunoglobulin light chain (AL) type. This article aims to review recent developments in diagnosis and management of cardiac amyloidosis.
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Affiliation(s)
- Ana Martinez-Naharro
- National Amyloidosis Centre, University College London, Royal Free Hospital, London, UK
| | - Philip N Hawkins
- National Amyloidosis Centre, University College London, Royal Free Hospital, London, UK
| | - Marianna Fontana
- National Amyloidosis Centre, University College London, Royal Free Hospital, London, UK
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180
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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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181
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Halatchev IG, Zheng J, Ou J. Wild-type transthyretin cardiac amyloidosis (ATTRwt-CA), previously known as senile cardiac amyloidosis: clinical presentation, diagnosis, management and emerging therapies. J Thorac Dis 2018; 10:2034-2045. [PMID: 29707360 DOI: 10.21037/jtd.2018.03.134] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Cardiac amyloidosis is thought to be a rare group of diseases caused by extracellular deposition of misfolded proteins in the extracellular cardiac matrix resulting in heart failure with preserved ejection fraction (HFpEF). This review focuses on the similarities and differences between the pathophysiology, clinical presentation and diagnostic tests of wild-type transthyretin cardiac amyloidosis (ATTRwt-CA) compared to immunoglobulin light chain amyloidosis and hereditary cardiac amyloidosis. We address some obstacles to timely diagnosis and opportunities for management of the clinical symptoms as well as possibility of future novel disease modifying therapies.
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Affiliation(s)
- Ilia G Halatchev
- Division of Cardiology, John Cochran Veterans Affairs Medical Center, St. Louis, USA.,Division of Cardiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Jingsheng Zheng
- Department of Cardiology, AtlantiCare Regional Medical Center, Pomona, NJ, USA
| | - Jiafu Ou
- Division of Cardiology, John Cochran Veterans Affairs Medical Center, St. Louis, USA.,Division of Cardiology, Washington University School of Medicine, St. Louis, MO, USA
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182
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Geller HI, Singh A, Mirto TM, Padera R, Mitchell R, Laubach JP, Falk RH. Prevalence of Monoclonal Gammopathy in Wild-Type Transthyretin Amyloidosis. Mayo Clin Proc 2017; 92:1800-1805. [PMID: 29202938 DOI: 10.1016/j.mayocp.2017.09.016] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 09/03/2017] [Accepted: 09/11/2017] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate the prevalence of monoclonal gammopathy (MG) in patients with wild-type transthyretin amyloidosis (ATTRwt) (formerly known as senile amyloidosis). PATIENTS AND METHODS We retrospectively analyzed the serum protein electrophoresis and serum immunofixation results, free light chain (FLC) levels, and renal function of 113 consecutive patients with ATTRwt seen at the Brigham and Women's Hospital's Cardiac Amyloidosis Program between February 21, 2006, and November 9, 2016. Monoclonal gammopathy was defined as a monoclonal protein present in the serum. Light chain MG was defined as an abnormal serum FLC κ/λ ratio with an elevated FLC level in the absence of a monoclonal protein. In patients with renal dysfunction, the renal FLC reference range was used. RESULTS The mean age of the population was 75 years, 3 of the 113 patients (3%) were female, and 110 (97%) were white. Monoclonal gammopathy was present in 26 patients (23%), 24 of whom had monoclonal protein present and 2 others who met criteria for light chain MG. Most clones (12 of 20 [60%]) were λ restricted. Another 7 patients had an abnormal FLC κ/λ ratio in the setting of renal dysfunction. CONCLUSION In this study, MG was present in 23% of patients with ATTRwt. The finding of MG or an abnormal FLC κ/λ ratio in an elderly man may cause diagnostic confusion during subtyping of amyloidosis. A high degree of clinical suspicion for ATTRwt and precise tissue typing using mass spectrometry may overcome such diagnostic challenges.
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Affiliation(s)
- Hallie I Geller
- Cardiac Amyloidosis Program, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Avinainder Singh
- Cardiac Amyloidosis Program, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Tara M Mirto
- Cardiac Amyloidosis Program, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Robert Padera
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Richard Mitchell
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Jacob P Laubach
- Cardiac Amyloidosis Program, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Rodney H Falk
- Cardiac Amyloidosis Program, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
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183
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Benson MD, Dasgupta NR, Rissing SM, Smith J, Feigenbaum H. Safety and efficacy of a TTR specific antisense oligonucleotide in patients with transthyretin amyloid cardiomyopathy. Amyloid 2017; 24:219-225. [PMID: 28906150 DOI: 10.1080/13506129.2017.1374946] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Cardiomyopathy is a major cause of death in both the hereditary form of transthyretin (TTR) amyloidosis and the sporadic late-age-onset transthyretin amyloidosis (ATTR wild-type (ATTRwt)). Clinically disease progression from time of diagnosis to death is usually quoted as 5- to 15-years. In prior studies, significant progression of cardiac parameters in patients with moderate to severe cardiomyopathy has been noted within a 12-month time span. METHODS The present study was designed to prospectively monitor changes in cardiac parameters, both structural and functional, in patients with ATTR cardiomyopathy while treated with a TTR specific antisense oligonucleotide (ASO; IONIS-TTR℞) designed to lower blood levels of the amyloid fibril precursor protein. To date 22 patients have been admitted to the study, 15 have completed 12 months on the drug and are the subject of this report. RESULTS Eight patients with hereditary ATTR amyloidosis and 7 patients with wild-type ATTR amyloidosis with moderate to severely advanced restrictive cardiomyopathy showed stabilization of disease as measured by left ventricular wall thickness, left ventricular mass (LVM), 6-min walk test (6MWT), and echocardiographic global systolic strain. IONIS-TTR℞ was well tolerated by all 15 subjects and showed a good safety profile. CONCLUSIONS ASO treatment of patients with moderate to advanced ATTR cardiomyopathy shows indication of stabilization of disease progression and may therefore contribute to enhanced life expectancy.
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Affiliation(s)
- Merrill D Benson
- a Department of Pathology and Laboratory Medicine , Indiana University School of Medicine , Indianapolis , IN , USA.,b RLR Veterans Affairs Medical Center , Indianapolis , IN , USA
| | - Noel R Dasgupta
- c Department of Cardiology , Indiana University School of Medicine , Indianapolis , IN , USA
| | - Stacy M Rissing
- d Department of Radiology , Indiana University School of Medicine , Indianapolis , IN , USA
| | - Jessica Smith
- d Department of Radiology , Indiana University School of Medicine , Indianapolis , IN , USA
| | - Harvey Feigenbaum
- c Department of Cardiology , Indiana University School of Medicine , Indianapolis , IN , USA
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184
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González-López E, López-Sainz Á, Garcia-Pavia P. Diagnóstico y tratamiento de la amiloidosis cardiaca por transtiretina. Progreso y esperanza. Rev Esp Cardiol 2017. [DOI: 10.1016/j.recesp.2017.05.018] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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185
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Sultan MB, Gundapaneni B, Schumacher J, Schwartz JH. Treatment With Tafamidis Slows Disease Progression in Early-Stage Transthyretin Cardiomyopathy. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2017; 11:1179546817730322. [PMID: 28951660 PMCID: PMC5606341 DOI: 10.1177/1179546817730322] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 08/15/2017] [Indexed: 01/15/2023]
Abstract
Background: Transthyretin cardiomyopathy (TTR-CM) is a progressive, fatal disease caused by the accumulation of misfolded transthyretin (TTR) amyloid fibrils in the heart. Tafamidis is a kinetic stabilizer of TTR that inhibits misfolding and amyloid formation. Methods: In this post hoc analysis, data from an observational study (Transthyretin Amyloidosis Cardiac Study; n = 29) were compared with an open-label study of tafamidis in patients with TTR-CM (Fx1B-201; n = 35). To ensure comparable baseline disease severity, patients with New York Heart Association (NYHA) functional classification ≥III were excluded in this time-to-mortality analysis. Results: Patients with either wild-type or Val122Ile genotypes treated with tafamidis have a significantly longer time to death compared with untreated patients (P = .0004). Similar results were obtained when limiting the analysis to wild-type patients only, without restricting NYHA functional classification (P = .0262). Conclusions: These results support earlier conclusions suggesting that tafamidis slows disease progression compared with no treatment outside of standard of care and warrant further investigation. Trial Registration: ClinicalTrials.gov, NCT00694161.
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Affiliation(s)
- Marla B Sultan
- Global Product Development, Pfizer Inc, New York, NY, USA
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186
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Takashio S, Yamamuro M, Izumiya Y, Hirakawa K, Marume K, Yamamoto M, Ueda M, Yamashita T, Ishibashi-Ueda H, Yasuda S, Ogawa H, Ando Y, Anzai T, Tsujita K. Diagnostic utility of cardiac troponin T level in patients with cardiac amyloidosis. ESC Heart Fail 2017; 5:27-35. [PMID: 28869340 PMCID: PMC5793964 DOI: 10.1002/ehf2.12203] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 06/23/2017] [Accepted: 07/14/2017] [Indexed: 01/15/2023] Open
Abstract
AIM The aim of this study was to evaluate the diagnostic utility of high-sensitivity cardiac troponin T (hs-cTnT) levels in discriminating cardiac amyloidosis from patients with cardiac hypertrophy caused by aetiologies other than cardiac amyloidosis. METHODS AND RESULTS Serum hs-cTnT levels were measured in 96 patients with cardiac amyloidosis (light chain: 23, wild-type transthyretin amyloidosis: 40, and mutated transthyretin amyloidosis: 33), and 91 patients with other causes of cardiac hypertrophy who were confirmed to have no cardiac amyloidosis by endomyocardial biopsy (control group). The diagnostic utility and cut-off value of hs-cTnT were evaluated by receiver operating characteristic analysis. The median hs-cTnT levels were higher in cardiac amyloidosis than the control group [0.048 (0.029-0.073) vs. 0.016 (0.010-0.031) ng/mL; P < 0.001]. High levels of hs-cTnT were suggestive of cardiac amyloidosis (cut-off value: 0.0312 ng/mL, sensitivity: 0.74, specificity: 0.76, area under the curve: 0.788; 95% confidence interval: 0.723-0.854, P < 0.001), compared with brain natriuretic peptide and E/e' ratio. The hs-cTnT levels were also useful in differentiating each type of amyloidosis from the control group. Multivariate analysis identified log hs-cTnT as an independent diagnostic factor for cardiac amyloidosis (odds ratio: 2.22; 95% confidence interval: 1.30-3.80; P = 0.004). CONCLUSIONS High serum levels of hs-cTnT are highly suggestive of cardiac amyloidosis, allowing its differentiation from cardiac hypertrophy of other aetiologies. Further refined diagnostic approaches that include imaging modalities and histopathological examination are needed for these patients to avoid underdiagnosis of cardiac amyloidosis.
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Affiliation(s)
- Seiji Takashio
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.,Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Megumi Yamamuro
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yasuhiro Izumiya
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Kyoko Hirakawa
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Kyohei Marume
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Masahiro Yamamoto
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Mitsuharu Ueda
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Taro Yamashita
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | | | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Hisao Ogawa
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yukio Ando
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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187
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González-López E, López-Sainz Á, Garcia-Pavia P. Diagnosis and Treatment of Transthyretin Cardiac Amyloidosis. Progress and Hope. ACTA ACUST UNITED AC 2017; 70:991-1004. [PMID: 28870641 DOI: 10.1016/j.rec.2017.05.036] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 05/19/2017] [Indexed: 12/15/2022]
Abstract
Cardiac amyloidosis is an infiltrative disorder caused by extracellular protein deposition. Transthyretin is a proamyloidotic protein that produces one of the most frequent forms of cardiac amyloidosis, either through mutations or a wild-type form (previously known as senile amyloidosis). Until very recently, diagnosis of transthyretin amyloidosis (ATTR) was very uncommon and histological confirmation was mandatory, making diagnosis of ATTR a real challenge in daily clinical practice. Moreover, the specific therapeutic options to alter the clinical course of the disease were very limited. However, advances in cardiac imaging and diagnostic strategies have improved recognition of ATTR. In addition, several compounds able to modify the natural history of the disease are in the final phases of research, with promising results. Given that effective therapies are on the horizon, cardiologists should be well-versed in this disease and be familiar with its diagnosis and treatment. This review describes the broad clinical spectrum of ATTR in detail, as well as recent advances in the diagnosis and treatment of this condition.
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Affiliation(s)
- Esther González-López
- Unidad de Insuficiencia Cardiaca y Cardiopatías Familiares, Servicio de Cardiología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Ángela López-Sainz
- Unidad de Insuficiencia Cardiaca y Cardiopatías Familiares, Servicio de Cardiología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Pablo Garcia-Pavia
- Unidad de Insuficiencia Cardiaca y Cardiopatías Familiares, Servicio de Cardiología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain; Facultad de Medicina, Universidad Francisco de Vitoria, Madrid, Spain.
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188
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Martinez-Naharro A, Treibel TA, Abdel-Gadir A, Bulluck H, Zumbo G, Knight DS, Kotecha T, Francis R, Hutt DF, Rezk T, Rosmini S, Quarta CC, Whelan CJ, Kellman P, Gillmore JD, Moon JC, Hawkins PN, Fontana M. Magnetic Resonance in Transthyretin Cardiac Amyloidosis. J Am Coll Cardiol 2017; 70:466-477. [PMID: 28728692 DOI: 10.1016/j.jacc.2017.05.053] [Citation(s) in RCA: 260] [Impact Index Per Article: 37.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 05/21/2017] [Accepted: 05/24/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Cardiac transthyretin amyloidosis (ATTR) is an increasingly recognized cause of heart failure. Cardiac magnetic resonance (CMR), with late gadolinium enhancement (LGE) and T1 mapping, is emerging as a reference standard for diagnosis and characterization of cardiac amyloidosis. OBJECTIVES The authors used CMR with extracellular volume fraction (ECV) measurement to characterize cardiac involvement in relation to outcome in ATTR. METHODS Subjects comprised 263 patients with cardiac ATTR corroborated by grade 2 to 3 99mTc-DPD (99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid) cardiac uptake, 17 with suspected cardiac ATTR (grade 1 99mTc-DPD), and 12 asymptomatic individuals with amyloidogenic transthyretin (TTR) mutations. Fifty patients with cardiac light-chain (AL) amyloidosis acted as disease comparators. RESULTS Unlike cardiac AL amyloidosis, asymmetrical septal left ventricular hypertrophy (LVH) was present in 79% of patients with ATTR (70% sigmoid septum and 30% reverse septal contour), whereas symmetrical LVH was present in 18%, and 3% had no LVH. In patients with cardiac amyloidosis, the pattern of LGE was always typical for amyloidosis (29% subendocardial, 71% transmural), including right ventricular LGE (96%). During follow-up (19 ± 14 months), 65 patients died. ECV independently correlated with mortality and remained independent after adjustment for age, N-terminal pro-B-type natriuretic peptide, ejection fraction, E/E', and left ventricular mass (hazard ratio: 1.164; 95% confidence interval: 1.066 to 1.271; p < 0.01). CONCLUSIONS Asymmetrical hypertrophy, traditionally associated with hypertrophic cardiomyopathy, was the commonest pattern of ventricular remodeling in ATTR. LGE imaging was typical in all patients with cardiac ATTR. ECV correlated with amyloid burden and was an independent prognostic factor for survival in this cohort of patients.
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Affiliation(s)
- Ana Martinez-Naharro
- National Amyloidosis Centre, University College London, Royal Free Hospital, London, United Kingdom; Division of Medicine, University College London, London, United Kingdom
| | - Thomas A Treibel
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Barts Heart Centre, West Smithfield, London, United Kingdom
| | - Amna Abdel-Gadir
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Barts Heart Centre, West Smithfield, London, United Kingdom
| | - Heerajnarain Bulluck
- The Hatter Cardiovascular Institute, Institute of Cardiovascular Science, University College London, United Kingdom
| | - Giulia Zumbo
- National Amyloidosis Centre, University College London, Royal Free Hospital, London, United Kingdom
| | - Daniel S Knight
- National Amyloidosis Centre, University College London, Royal Free Hospital, London, United Kingdom
| | - Tushar Kotecha
- National Amyloidosis Centre, University College London, Royal Free Hospital, London, United Kingdom; Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Rohin Francis
- National Amyloidosis Centre, University College London, Royal Free Hospital, London, United Kingdom; The Hatter Cardiovascular Institute, Institute of Cardiovascular Science, University College London, United Kingdom
| | - David F Hutt
- National Amyloidosis Centre, University College London, Royal Free Hospital, London, United Kingdom
| | - Tamer Rezk
- National Amyloidosis Centre, University College London, Royal Free Hospital, London, United Kingdom
| | | | - Candida C Quarta
- National Amyloidosis Centre, University College London, Royal Free Hospital, London, United Kingdom
| | - Carol J Whelan
- National Amyloidosis Centre, University College London, Royal Free Hospital, London, United Kingdom
| | - Peter Kellman
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Julian D Gillmore
- National Amyloidosis Centre, University College London, Royal Free Hospital, London, United Kingdom; Division of Medicine, University College London, London, United Kingdom
| | - James C Moon
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Barts Heart Centre, West Smithfield, London, United Kingdom
| | - Philip N Hawkins
- National Amyloidosis Centre, University College London, Royal Free Hospital, London, United Kingdom; Division of Medicine, University College London, London, United Kingdom
| | - Marianna Fontana
- National Amyloidosis Centre, University College London, Royal Free Hospital, London, United Kingdom; Division of Medicine, University College London, London, United Kingdom; Institute of Cardiovascular Science, University College London, London, United Kingdom.
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189
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Youngstein T, Gilbertson JA, Hutt DF, Coyne MRE, Rezk T, Manwani R, Quarta CC, Lachmann HJ, Gillmore JD, Beynon H, Goddard N, Hawkins PN. Carpal Tunnel Biopsy Identifying Transthyretin Amyloidosis. Arthritis Rheumatol 2017; 69:2051. [PMID: 28556554 DOI: 10.1002/art.40162] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 05/23/2017] [Indexed: 11/06/2022]
Affiliation(s)
| | | | - David F Hutt
- National Amyloidosis Centre, University College of London
| | - Mark R E Coyne
- National Amyloidosis Centre, University College of London
| | - Tamer Rezk
- National Amyloidosis Centre, University College of London
| | - Richa Manwani
- National Amyloidosis Centre, University College of London
| | | | | | | | | | | | - Philip N Hawkins
- National Amyloidosis Centre, University College of London, London, UK
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190
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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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191
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Maurer MS, Elliott P, Merlini G, Shah SJ, Cruz MW, Flynn A, Gundapaneni B, Hahn C, Riley S, Schwartz J, Sultan MB, Rapezzi C. Design and Rationale of the Phase 3 ATTR-ACT Clinical Trial (Tafamidis in Transthyretin Cardiomyopathy Clinical Trial). Circ Heart Fail 2017; 10:CIRCHEARTFAILURE.116.003815. [PMID: 28611125 DOI: 10.1161/circheartfailure.116.003815] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 05/04/2017] [Indexed: 12/17/2022]
Abstract
Transthyretin amyloidosis is a rare, life-threatening disease resulting from aggregation and deposition of transthyretin amyloid fibrils in various tissues. There are 2 predominate phenotypic presentations of the disease: transthyretin familial amyloid polyneuropathy, which primarily affects the peripheral nerves, and transthyretin cardiomyopathy (TTR-CM), which primarily affects the heart. However, there is a wide overlap with symptoms at presentation and disease course being highly variable and influenced by the underlying transthyretin mutation, age of the affected individual, sex, and geographic location. Treatment of transthyretin amyloidosis is typically focused on symptom management. Although tafamidis has been shown to delay neurologic progression of transthyretin familial amyloid polyneuropathy, there are no approved pharmacologic therapies shown to improve survival in TTR-CM. The natural history of TTR-CM is poorly characterized, which presents difficulties for the design of large-scale trials for new treatments. This review provides a brief overview of TTR-CM and the challenges of identifying clinically meaningful end points and study parameters to determine the efficacy of treatments for rare diseases. The design and rationale behind the ongoing phase 3 ATTR-ACT study (Tafamidis in Transthyretin Cardiomyopathy Clinical Trial), an international, multicenter, double-blind, placebo-controlled, randomized clinical trial, is also outlined. The ATTR-ACT study will provide important insight into the efficacy and safety of tafamidis for the treatment of TTR-CM. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01994889.
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Affiliation(s)
- Mathew S Maurer
- From the Center for Advanced Cardiac Care, Columbia University College of Physicians and Surgeons, NY (M.S.M); Cardiovascular Medicine, University College London, United Kingdom (P.E.); IRCCS Policlinico San Matteo, University of Pavia, Italy (G.M.); Division of Cardiology, Northwestern University, Chicago, IL (S.J.S.); National Amyloidosis Referral Center, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello, Federal University of Rio de Janeiro, Brazil (M.W.C.); Pfizer, Inc, Collegeville, PA (A.F., C.H.); inVentiv Health, Burlington, MA (B.G.); Pfizer, Inc, Groton, CT (S.R., J.S.); Pfizer, Inc, NY (M.B.S.); and Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy (C.R.).
| | - Perry Elliott
- From the Center for Advanced Cardiac Care, Columbia University College of Physicians and Surgeons, NY (M.S.M); Cardiovascular Medicine, University College London, United Kingdom (P.E.); IRCCS Policlinico San Matteo, University of Pavia, Italy (G.M.); Division of Cardiology, Northwestern University, Chicago, IL (S.J.S.); National Amyloidosis Referral Center, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello, Federal University of Rio de Janeiro, Brazil (M.W.C.); Pfizer, Inc, Collegeville, PA (A.F., C.H.); inVentiv Health, Burlington, MA (B.G.); Pfizer, Inc, Groton, CT (S.R., J.S.); Pfizer, Inc, NY (M.B.S.); and Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy (C.R.)
| | - Giampaolo Merlini
- From the Center for Advanced Cardiac Care, Columbia University College of Physicians and Surgeons, NY (M.S.M); Cardiovascular Medicine, University College London, United Kingdom (P.E.); IRCCS Policlinico San Matteo, University of Pavia, Italy (G.M.); Division of Cardiology, Northwestern University, Chicago, IL (S.J.S.); National Amyloidosis Referral Center, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello, Federal University of Rio de Janeiro, Brazil (M.W.C.); Pfizer, Inc, Collegeville, PA (A.F., C.H.); inVentiv Health, Burlington, MA (B.G.); Pfizer, Inc, Groton, CT (S.R., J.S.); Pfizer, Inc, NY (M.B.S.); and Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy (C.R.)
| | - Sanjiv J Shah
- From the Center for Advanced Cardiac Care, Columbia University College of Physicians and Surgeons, NY (M.S.M); Cardiovascular Medicine, University College London, United Kingdom (P.E.); IRCCS Policlinico San Matteo, University of Pavia, Italy (G.M.); Division of Cardiology, Northwestern University, Chicago, IL (S.J.S.); National Amyloidosis Referral Center, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello, Federal University of Rio de Janeiro, Brazil (M.W.C.); Pfizer, Inc, Collegeville, PA (A.F., C.H.); inVentiv Health, Burlington, MA (B.G.); Pfizer, Inc, Groton, CT (S.R., J.S.); Pfizer, Inc, NY (M.B.S.); and Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy (C.R.)
| | - Márcia Waddington Cruz
- From the Center for Advanced Cardiac Care, Columbia University College of Physicians and Surgeons, NY (M.S.M); Cardiovascular Medicine, University College London, United Kingdom (P.E.); IRCCS Policlinico San Matteo, University of Pavia, Italy (G.M.); Division of Cardiology, Northwestern University, Chicago, IL (S.J.S.); National Amyloidosis Referral Center, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello, Federal University of Rio de Janeiro, Brazil (M.W.C.); Pfizer, Inc, Collegeville, PA (A.F., C.H.); inVentiv Health, Burlington, MA (B.G.); Pfizer, Inc, Groton, CT (S.R., J.S.); Pfizer, Inc, NY (M.B.S.); and Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy (C.R.)
| | - Alison Flynn
- From the Center for Advanced Cardiac Care, Columbia University College of Physicians and Surgeons, NY (M.S.M); Cardiovascular Medicine, University College London, United Kingdom (P.E.); IRCCS Policlinico San Matteo, University of Pavia, Italy (G.M.); Division of Cardiology, Northwestern University, Chicago, IL (S.J.S.); National Amyloidosis Referral Center, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello, Federal University of Rio de Janeiro, Brazil (M.W.C.); Pfizer, Inc, Collegeville, PA (A.F., C.H.); inVentiv Health, Burlington, MA (B.G.); Pfizer, Inc, Groton, CT (S.R., J.S.); Pfizer, Inc, NY (M.B.S.); and Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy (C.R.)
| | - Balarama Gundapaneni
- From the Center for Advanced Cardiac Care, Columbia University College of Physicians and Surgeons, NY (M.S.M); Cardiovascular Medicine, University College London, United Kingdom (P.E.); IRCCS Policlinico San Matteo, University of Pavia, Italy (G.M.); Division of Cardiology, Northwestern University, Chicago, IL (S.J.S.); National Amyloidosis Referral Center, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello, Federal University of Rio de Janeiro, Brazil (M.W.C.); Pfizer, Inc, Collegeville, PA (A.F., C.H.); inVentiv Health, Burlington, MA (B.G.); Pfizer, Inc, Groton, CT (S.R., J.S.); Pfizer, Inc, NY (M.B.S.); and Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy (C.R.)
| | - Carolyn Hahn
- From the Center for Advanced Cardiac Care, Columbia University College of Physicians and Surgeons, NY (M.S.M); Cardiovascular Medicine, University College London, United Kingdom (P.E.); IRCCS Policlinico San Matteo, University of Pavia, Italy (G.M.); Division of Cardiology, Northwestern University, Chicago, IL (S.J.S.); National Amyloidosis Referral Center, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello, Federal University of Rio de Janeiro, Brazil (M.W.C.); Pfizer, Inc, Collegeville, PA (A.F., C.H.); inVentiv Health, Burlington, MA (B.G.); Pfizer, Inc, Groton, CT (S.R., J.S.); Pfizer, Inc, NY (M.B.S.); and Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy (C.R.)
| | - Steven Riley
- From the Center for Advanced Cardiac Care, Columbia University College of Physicians and Surgeons, NY (M.S.M); Cardiovascular Medicine, University College London, United Kingdom (P.E.); IRCCS Policlinico San Matteo, University of Pavia, Italy (G.M.); Division of Cardiology, Northwestern University, Chicago, IL (S.J.S.); National Amyloidosis Referral Center, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello, Federal University of Rio de Janeiro, Brazil (M.W.C.); Pfizer, Inc, Collegeville, PA (A.F., C.H.); inVentiv Health, Burlington, MA (B.G.); Pfizer, Inc, Groton, CT (S.R., J.S.); Pfizer, Inc, NY (M.B.S.); and Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy (C.R.)
| | - Jeffrey Schwartz
- From the Center for Advanced Cardiac Care, Columbia University College of Physicians and Surgeons, NY (M.S.M); Cardiovascular Medicine, University College London, United Kingdom (P.E.); IRCCS Policlinico San Matteo, University of Pavia, Italy (G.M.); Division of Cardiology, Northwestern University, Chicago, IL (S.J.S.); National Amyloidosis Referral Center, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello, Federal University of Rio de Janeiro, Brazil (M.W.C.); Pfizer, Inc, Collegeville, PA (A.F., C.H.); inVentiv Health, Burlington, MA (B.G.); Pfizer, Inc, Groton, CT (S.R., J.S.); Pfizer, Inc, NY (M.B.S.); and Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy (C.R.)
| | - Marla B Sultan
- From the Center for Advanced Cardiac Care, Columbia University College of Physicians and Surgeons, NY (M.S.M); Cardiovascular Medicine, University College London, United Kingdom (P.E.); IRCCS Policlinico San Matteo, University of Pavia, Italy (G.M.); Division of Cardiology, Northwestern University, Chicago, IL (S.J.S.); National Amyloidosis Referral Center, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello, Federal University of Rio de Janeiro, Brazil (M.W.C.); Pfizer, Inc, Collegeville, PA (A.F., C.H.); inVentiv Health, Burlington, MA (B.G.); Pfizer, Inc, Groton, CT (S.R., J.S.); Pfizer, Inc, NY (M.B.S.); and Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy (C.R.)
| | - Claudio Rapezzi
- From the Center for Advanced Cardiac Care, Columbia University College of Physicians and Surgeons, NY (M.S.M); Cardiovascular Medicine, University College London, United Kingdom (P.E.); IRCCS Policlinico San Matteo, University of Pavia, Italy (G.M.); Division of Cardiology, Northwestern University, Chicago, IL (S.J.S.); National Amyloidosis Referral Center, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello, Federal University of Rio de Janeiro, Brazil (M.W.C.); Pfizer, Inc, Collegeville, PA (A.F., C.H.); inVentiv Health, Burlington, MA (B.G.); Pfizer, Inc, Groton, CT (S.R., J.S.); Pfizer, Inc, NY (M.B.S.); and Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy (C.R.)
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192
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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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193
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Shah KB, Mankad AK, Castano A, Akinboboye OO, Duncan PB, Fergus IV, Maurer MS. Transthyretin Cardiac Amyloidosis in Black Americans. Circ Heart Fail 2017; 9:e002558. [PMID: 27188913 DOI: 10.1161/circheartfailure.115.002558] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2015] [Accepted: 02/10/2016] [Indexed: 12/20/2022]
Abstract
Transthyretin-related cardiac amyloidosis is a progressive infiltrative cardiomyopathy that mimics hypertensive and hypertrophic heart disease and often goes undiagnosed. In the United States, the hereditary form disproportionately afflicts black Americans, who when compared with whites with wild-type transthyretin amyloidosis, a phenotypically similar condition, present with more advanced disease despite having a noninvasive method for early identification (genetic testing). Although reasons for this are unclear, this begs to consider the inadequate access to care, societal factors, or a biological basis. In an effort to improve awareness and explore unique characteristics, we review the pathophysiology, epidemiology, and therapeutic strategies for transthyretin amyloidosis and highlight diagnostic pitfalls and clinical pearls for identifying patients with amyloid heart disease.
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Affiliation(s)
- Keyur B Shah
- From the Pauley Heart Center, Division of Cardiology, Virginia Commonwealth University, Richmond (K.B.S., A.K.M., P.B.D.); Division of Cardiology, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA (A.K.M.); Division of Cardiology, Columbia University Medical Center, New York, NY (A.C., M.S.M.); Queens Heart Institute, Rosedale, NY (O.O.A.); Cardiac Health Management Network, Chester, VA (P.B.D.); and Division of Cardiology, Mount Sinai Medical Center, New York, NY (I.V.F.).
| | - Anit K Mankad
- From the Pauley Heart Center, Division of Cardiology, Virginia Commonwealth University, Richmond (K.B.S., A.K.M., P.B.D.); Division of Cardiology, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA (A.K.M.); Division of Cardiology, Columbia University Medical Center, New York, NY (A.C., M.S.M.); Queens Heart Institute, Rosedale, NY (O.O.A.); Cardiac Health Management Network, Chester, VA (P.B.D.); and Division of Cardiology, Mount Sinai Medical Center, New York, NY (I.V.F.)
| | - Adam Castano
- From the Pauley Heart Center, Division of Cardiology, Virginia Commonwealth University, Richmond (K.B.S., A.K.M., P.B.D.); Division of Cardiology, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA (A.K.M.); Division of Cardiology, Columbia University Medical Center, New York, NY (A.C., M.S.M.); Queens Heart Institute, Rosedale, NY (O.O.A.); Cardiac Health Management Network, Chester, VA (P.B.D.); and Division of Cardiology, Mount Sinai Medical Center, New York, NY (I.V.F.)
| | - Olakunle O Akinboboye
- From the Pauley Heart Center, Division of Cardiology, Virginia Commonwealth University, Richmond (K.B.S., A.K.M., P.B.D.); Division of Cardiology, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA (A.K.M.); Division of Cardiology, Columbia University Medical Center, New York, NY (A.C., M.S.M.); Queens Heart Institute, Rosedale, NY (O.O.A.); Cardiac Health Management Network, Chester, VA (P.B.D.); and Division of Cardiology, Mount Sinai Medical Center, New York, NY (I.V.F.)
| | - Phillip B Duncan
- From the Pauley Heart Center, Division of Cardiology, Virginia Commonwealth University, Richmond (K.B.S., A.K.M., P.B.D.); Division of Cardiology, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA (A.K.M.); Division of Cardiology, Columbia University Medical Center, New York, NY (A.C., M.S.M.); Queens Heart Institute, Rosedale, NY (O.O.A.); Cardiac Health Management Network, Chester, VA (P.B.D.); and Division of Cardiology, Mount Sinai Medical Center, New York, NY (I.V.F.)
| | - Icilma V Fergus
- From the Pauley Heart Center, Division of Cardiology, Virginia Commonwealth University, Richmond (K.B.S., A.K.M., P.B.D.); Division of Cardiology, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA (A.K.M.); Division of Cardiology, Columbia University Medical Center, New York, NY (A.C., M.S.M.); Queens Heart Institute, Rosedale, NY (O.O.A.); Cardiac Health Management Network, Chester, VA (P.B.D.); and Division of Cardiology, Mount Sinai Medical Center, New York, NY (I.V.F.)
| | - Mathew S Maurer
- From the Pauley Heart Center, Division of Cardiology, Virginia Commonwealth University, Richmond (K.B.S., A.K.M., P.B.D.); Division of Cardiology, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA (A.K.M.); Division of Cardiology, Columbia University Medical Center, New York, NY (A.C., M.S.M.); Queens Heart Institute, Rosedale, NY (O.O.A.); Cardiac Health Management Network, Chester, VA (P.B.D.); and Division of Cardiology, Mount Sinai Medical Center, New York, NY (I.V.F.)
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Falk RH, Alexander KM, Liao R, Dorbala S. AL (Light-Chain) Cardiac Amyloidosis: A Review of Diagnosis and Therapy. J Am Coll Cardiol 2017; 68:1323-41. [PMID: 27634125 DOI: 10.1016/j.jacc.2016.06.053] [Citation(s) in RCA: 381] [Impact Index Per Article: 54.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 06/14/2016] [Indexed: 12/20/2022]
Abstract
The amyloidoses are a group of protein-folding disorders in which ≥1 organ is infiltrated by proteinaceous deposits known as amyloid. The deposits are derived from 1 of several amyloidogenic precursor proteins, and the prognosis of the disease is determined both by the organ(s) involved and the type of amyloid. Amyloid involvement of the heart (cardiac amyloidosis) carries the worst prognosis of any involved organ, and light-chain (AL) amyloidosis is the most serious form of the disease. The last decade has seen considerable progress in understanding the amyloidoses. In this review, current and novel approaches to the diagnosis and treatment of cardiac amyloidosis are discussed, with particular reference to AL amyloidosis in the heart.
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Affiliation(s)
- Rodney H Falk
- Brigham and Women's Hospital Cardiac Amyloidosis Program, Harvard Medical School and Department of Medicine, Section of Cardiology, Brigham and Women's Hospital, Boston, Massachusetts.
| | - Kevin M Alexander
- Brigham and Women's Hospital Cardiac Amyloidosis Program, Harvard Medical School and Department of Medicine, Section of Cardiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ronglih Liao
- Brigham and Women's Hospital Cardiac Amyloidosis Program, Harvard Medical School and Department of Medicine, Section of Cardiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sharmila Dorbala
- Brigham and Women's Hospital Cardiac Amyloidosis Program, Harvard Medical School and Department of Medicine, Section of Cardiology, Brigham and Women's Hospital, Boston, Massachusetts; Department of Radiology, Division of Nuclear Medicine and Molecular Imaging, Harvard Medical School, Boston, Massachusetts
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195
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Mesquita ET, Jorge AJL, Souza CV, Andrade TRD. Cardiac Amyloidosis and its New Clinical Phenotype: Heart Failure with Preserved Ejection Fraction. Arq Bras Cardiol 2017; 109:71-80. [PMID: 28678923 PMCID: PMC5524478 DOI: 10.5935/abc.20170079] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 03/09/2017] [Indexed: 12/24/2022] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is now an emerging
cardiovascular epidemic, being identified as the main phenotype observed in
clinical practice. It is more associated with female gender, advanced age and
comorbidities such as hypertension, diabetes, obesity and chronic kidney
disease. Amyloidosis is a clinical disorder characterized by the deposition of
aggregates of insoluble fibrils originating from proteins that exhibit anomalous
folding. Recently, pictures of senile amyloidosis have been described in
patients with HFpEF, demonstrating the need for clinical cardiologists to
investigate this etiology in suspect cases. The clinical suspicion of
amyloidosis should be increased in cases of HFPS where the cardio imaging
methods are compatible with infiltrative cardiomyopathy. Advances in cardio
imaging methods combined with the possibility of performing genetic tests and
identification of the type of amyloid material allow the diagnosis to be made.
The management of the diagnosed patients can be done in partnership with centers
specialized in the study of amyloidosis, which, together with the new
technologies, investigate the possibility of organ or bone marrow
transplantation and also the involvement of patients in clinical studies that
evaluate the action of the new emerging drugs.
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196
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Castaño A, Manson DK, Maurer MS, Bokhari S. Transthyretin Cardiac Amyloidosis in Older Adults: Optimizing Cardiac Imaging to the Corresponding Diagnostic and Management Goal. CURRENT CARDIOVASCULAR RISK REPORTS 2017; 11:17. [PMID: 29057029 PMCID: PMC5648026 DOI: 10.1007/s12170-017-0541-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW Transthyretin cardiac amyloidosis is increasingly recognized as an important cause of heart failure in older adults. Many cardiac imaging modalities have evolved to evaluate transthyretin cardiac amyloidosis and include 2D echocardiography with tissue Doppler and speckle-strain imaging, nuclear scintigraphy, cardiac magnetic resonance imaging, and positron emission tomography. The purpose of this review is to highlight the optimal selection of advanced cardiac imaging techniques with corresponding diagnostic goals including raising suspicion, making an early diagnosis, and subtyping transthyretin cardiac amyloid, as well as management goals including assessment of ventricular impairment, prognosticating, and monitoring disease progression. Potential benefits of optimizing cardiac imaging in the elderly patient with transthyretin cardiac amyloidosis may include enhanced and earlier diagnosis and refined long-term management. RECENT FINDINGS Advances in cardiac imaging techniques are changing diagnostic and management algorithms for transthyretin cardiac amyloidosis. SUMMARY With a new era of novel therapeutics, enhanced recognition, and earlier diagnosis approaching, selecting the appropriate non-invasive cardiac imaging modality will be essential for optimal care in the elderly patient with transthyretin cardiac amyloidosis.
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Affiliation(s)
- Adam Castaño
- Columbia University College of Physicians & Surgeons, Division of Cardiology, Center for Advanced Cardiac Care, Laboratory of Nuclear Cardiology, New York, NY 10032-3784, USA,
| | - Daniel K Manson
- Columbia University College of Physicians & Surgeons, Division of Cardiology, Center for Advanced Cardiac Care, New York, NY 10032-3784, USA
| | - Mathew S Maurer
- Columbia University College of Physicians & Surgeons, Division of Cardiology, Center for Advanced Cardiac Care, New York, NY 10032-3784, USA
| | - Sabahat Bokhari
- Columbia University College of Physicians & Surgeons, Division of Cardiology, Laboratory of Nuclear Cardiology, New York, NY 10032-3784, USA
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197
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Treibel TA, Fontana M, Gilbertson JA, Castelletti S, White SK, Scully PR, Roberts N, Hutt DF, Rowczenio DM, Whelan CJ, Ashworth MA, Gillmore JD, Hawkins PN, Moon JC. Occult Transthyretin Cardiac Amyloid in Severe Calcific Aortic Stenosis: Prevalence and Prognosis in Patients Undergoing Surgical Aortic Valve Replacement. Circ Cardiovasc Imaging 2017; 9:CIRCIMAGING.116.005066. [PMID: 27511979 DOI: 10.1161/circimaging.116.005066] [Citation(s) in RCA: 197] [Impact Index Per Article: 28.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 06/23/2016] [Indexed: 12/24/2022]
Abstract
BACKGROUND Calcific aortic stenosis (cAS) affects 3% of individuals aged >75 years, leading to heart failure and death unless the valve is replaced. Wild-type transthyretin cardiac amyloid is also a disorder of ageing individuals. Prevalence and clinical significance of dual pathology are unknown. This study explored the prevalence of wild-type transthyretin amyloid in cAS by myocardial biopsy, its imaging phenotype and prognostic significance. METHODS AND RESULTS A total of 146 patients with severe AS requiring surgical valve replacement underwent cardiovascular magnetic resonance and intraoperative biopsies; 112 had cAS (75±6 years; 57% men). Amyloid was sought histologically using Congo red staining and then typed using immunohistochemistry and mass spectrometry; patients with amyloid underwent clinical evaluation including genotyping and (99m)TC-3,3-diphosphono-1,2-propanodicarboxylic-acid (DPD) bone scintigraphy. Amyloid was identified in 6 of 146 patients, all with cAS and >65 years (prevalence 5.6% in cAS >65). All 6 patients had wild-type transthyretin amyloid (mean age 75 years; range, 69-85; 4 men), not suspected on echocardiography. Cardiovascular magnetic resonance findings were of definite cardiac amyloidosis in 2, but could be explained solely by AS in the other 4. Postoperative DPD scans demonstrated cardiac localization in all 4 patients who had this investigation (2 died prior). At follow-up (median, 2.3 years), 50% with amyloid had died (versus 7.5% in cAS; 6.9% in age >65 years). In univariable analyses, the presence of transthyretin amyloidosis amyloid had the highest hazard ratio for death (9.5 [95% confidence interval, 2.5-35.8]; P=0.001). CONCLUSIONS Occult wild-type transthyretin cardiac amyloid had a prevalence of 6% among patients with AS aged >65 years undergoing surgical aortic valve replacement and was associated with a poor outcome.
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Affiliation(s)
- Thomas A Treibel
- From the Cardiovascular Magnetic Resonance Imaging Unit, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom (T.A.T., M.F., S.C., S.K.W., P.R.S., N.R., J.C.M.); Institute of Cardiovascular Science (T.A.T., M.F., S.K.W., J.C.M.) and National Amyloidosis Centre, Royal Free Campus (M.F., J.A.G., D.F.H., D.M.R., C.W., J.D.G., P.N.H.), University College London, United Kingdom; and Histopathology Department, Great Ormond Street Hospital for Children, London, United Kingdom (M.A.A.).
| | - Marianna Fontana
- From the Cardiovascular Magnetic Resonance Imaging Unit, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom (T.A.T., M.F., S.C., S.K.W., P.R.S., N.R., J.C.M.); Institute of Cardiovascular Science (T.A.T., M.F., S.K.W., J.C.M.) and National Amyloidosis Centre, Royal Free Campus (M.F., J.A.G., D.F.H., D.M.R., C.W., J.D.G., P.N.H.), University College London, United Kingdom; and Histopathology Department, Great Ormond Street Hospital for Children, London, United Kingdom (M.A.A.)
| | - Janet A Gilbertson
- From the Cardiovascular Magnetic Resonance Imaging Unit, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom (T.A.T., M.F., S.C., S.K.W., P.R.S., N.R., J.C.M.); Institute of Cardiovascular Science (T.A.T., M.F., S.K.W., J.C.M.) and National Amyloidosis Centre, Royal Free Campus (M.F., J.A.G., D.F.H., D.M.R., C.W., J.D.G., P.N.H.), University College London, United Kingdom; and Histopathology Department, Great Ormond Street Hospital for Children, London, United Kingdom (M.A.A.)
| | - Silvia Castelletti
- From the Cardiovascular Magnetic Resonance Imaging Unit, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom (T.A.T., M.F., S.C., S.K.W., P.R.S., N.R., J.C.M.); Institute of Cardiovascular Science (T.A.T., M.F., S.K.W., J.C.M.) and National Amyloidosis Centre, Royal Free Campus (M.F., J.A.G., D.F.H., D.M.R., C.W., J.D.G., P.N.H.), University College London, United Kingdom; and Histopathology Department, Great Ormond Street Hospital for Children, London, United Kingdom (M.A.A.)
| | - Steven K White
- From the Cardiovascular Magnetic Resonance Imaging Unit, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom (T.A.T., M.F., S.C., S.K.W., P.R.S., N.R., J.C.M.); Institute of Cardiovascular Science (T.A.T., M.F., S.K.W., J.C.M.) and National Amyloidosis Centre, Royal Free Campus (M.F., J.A.G., D.F.H., D.M.R., C.W., J.D.G., P.N.H.), University College London, United Kingdom; and Histopathology Department, Great Ormond Street Hospital for Children, London, United Kingdom (M.A.A.)
| | - Paul R Scully
- From the Cardiovascular Magnetic Resonance Imaging Unit, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom (T.A.T., M.F., S.C., S.K.W., P.R.S., N.R., J.C.M.); Institute of Cardiovascular Science (T.A.T., M.F., S.K.W., J.C.M.) and National Amyloidosis Centre, Royal Free Campus (M.F., J.A.G., D.F.H., D.M.R., C.W., J.D.G., P.N.H.), University College London, United Kingdom; and Histopathology Department, Great Ormond Street Hospital for Children, London, United Kingdom (M.A.A.)
| | - Neil Roberts
- From the Cardiovascular Magnetic Resonance Imaging Unit, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom (T.A.T., M.F., S.C., S.K.W., P.R.S., N.R., J.C.M.); Institute of Cardiovascular Science (T.A.T., M.F., S.K.W., J.C.M.) and National Amyloidosis Centre, Royal Free Campus (M.F., J.A.G., D.F.H., D.M.R., C.W., J.D.G., P.N.H.), University College London, United Kingdom; and Histopathology Department, Great Ormond Street Hospital for Children, London, United Kingdom (M.A.A.)
| | - David F Hutt
- From the Cardiovascular Magnetic Resonance Imaging Unit, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom (T.A.T., M.F., S.C., S.K.W., P.R.S., N.R., J.C.M.); Institute of Cardiovascular Science (T.A.T., M.F., S.K.W., J.C.M.) and National Amyloidosis Centre, Royal Free Campus (M.F., J.A.G., D.F.H., D.M.R., C.W., J.D.G., P.N.H.), University College London, United Kingdom; and Histopathology Department, Great Ormond Street Hospital for Children, London, United Kingdom (M.A.A.)
| | - Dorota M Rowczenio
- From the Cardiovascular Magnetic Resonance Imaging Unit, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom (T.A.T., M.F., S.C., S.K.W., P.R.S., N.R., J.C.M.); Institute of Cardiovascular Science (T.A.T., M.F., S.K.W., J.C.M.) and National Amyloidosis Centre, Royal Free Campus (M.F., J.A.G., D.F.H., D.M.R., C.W., J.D.G., P.N.H.), University College London, United Kingdom; and Histopathology Department, Great Ormond Street Hospital for Children, London, United Kingdom (M.A.A.)
| | - Carol J Whelan
- From the Cardiovascular Magnetic Resonance Imaging Unit, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom (T.A.T., M.F., S.C., S.K.W., P.R.S., N.R., J.C.M.); Institute of Cardiovascular Science (T.A.T., M.F., S.K.W., J.C.M.) and National Amyloidosis Centre, Royal Free Campus (M.F., J.A.G., D.F.H., D.M.R., C.W., J.D.G., P.N.H.), University College London, United Kingdom; and Histopathology Department, Great Ormond Street Hospital for Children, London, United Kingdom (M.A.A.)
| | - Michael A Ashworth
- From the Cardiovascular Magnetic Resonance Imaging Unit, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom (T.A.T., M.F., S.C., S.K.W., P.R.S., N.R., J.C.M.); Institute of Cardiovascular Science (T.A.T., M.F., S.K.W., J.C.M.) and National Amyloidosis Centre, Royal Free Campus (M.F., J.A.G., D.F.H., D.M.R., C.W., J.D.G., P.N.H.), University College London, United Kingdom; and Histopathology Department, Great Ormond Street Hospital for Children, London, United Kingdom (M.A.A.)
| | - Julian D Gillmore
- From the Cardiovascular Magnetic Resonance Imaging Unit, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom (T.A.T., M.F., S.C., S.K.W., P.R.S., N.R., J.C.M.); Institute of Cardiovascular Science (T.A.T., M.F., S.K.W., J.C.M.) and National Amyloidosis Centre, Royal Free Campus (M.F., J.A.G., D.F.H., D.M.R., C.W., J.D.G., P.N.H.), University College London, United Kingdom; and Histopathology Department, Great Ormond Street Hospital for Children, London, United Kingdom (M.A.A.)
| | - Philip N Hawkins
- From the Cardiovascular Magnetic Resonance Imaging Unit, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom (T.A.T., M.F., S.C., S.K.W., P.R.S., N.R., J.C.M.); Institute of Cardiovascular Science (T.A.T., M.F., S.K.W., J.C.M.) and National Amyloidosis Centre, Royal Free Campus (M.F., J.A.G., D.F.H., D.M.R., C.W., J.D.G., P.N.H.), University College London, United Kingdom; and Histopathology Department, Great Ormond Street Hospital for Children, London, United Kingdom (M.A.A.)
| | - James C Moon
- From the Cardiovascular Magnetic Resonance Imaging Unit, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom (T.A.T., M.F., S.C., S.K.W., P.R.S., N.R., J.C.M.); Institute of Cardiovascular Science (T.A.T., M.F., S.K.W., J.C.M.) and National Amyloidosis Centre, Royal Free Campus (M.F., J.A.G., D.F.H., D.M.R., C.W., J.D.G., P.N.H.), University College London, United Kingdom; and Histopathology Department, Great Ormond Street Hospital for Children, London, United Kingdom (M.A.A.)
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Davies T, Saleh A, Coghlan G, Whelan C, Agarwal B. A case study of likely wild-type cardiac transthyretin amyloidosis causing rapid deterioration. J Intensive Care Soc 2017; 18:138-142. [PMID: 28979560 PMCID: PMC5606417 DOI: 10.1177/1751143716682263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We present the case of an 88-year-old gentleman who presented to hospital septic with bilateral leg cellulitis, pulmonary oedema and hypotension. He had no history of heart disease but had had bilateral carpal tunnel releases. His condition deteriorated with refractory hypotension in spite of fluid filling, inotropic and vasopressor support. His echocardiogram showed an infiltrative cardiomyopathy with a speckled myocardium, severe concentric left and right ventricular increased wall thickness, diastolic dysfunction, biatrial dilatation and restrictive physiology in keeping with cardiac amyloidosis. He developed atrial fibrillation and worsening respiratory failure due to fluid overload and was intubated and ventilated but continued to decline and passed away. The degree of heart failure in the absence of ischaemia, the patient's advanced age, echocardiographic findings and past history of carpal tunnel syndrome in a male are strongly indicative of a diagnosis of wild-type cardiac transthyretin amyloidosis. We discuss the key features and intensive care management of this disease.
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Affiliation(s)
- Thomas Davies
- Intensive Care Department, Royal Free Hospital, London, UK
| | - Aarash Saleh
- Intensive Care Department, Royal Free Hospital, London, UK
| | | | - Carol Whelan
- Cardiology, Royal Free Hospital, London, UK
- National Amyloidosis Centre, Royal Free Hospital, London, UK
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199
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Maurer MS, Elliott P, Comenzo R, Semigran M, Rapezzi C. Addressing Common Questions Encountered in the Diagnosis and Management of Cardiac Amyloidosis. Circulation 2017; 135:1357-1377. [PMID: 28373528 PMCID: PMC5392416 DOI: 10.1161/circulationaha.116.024438] [Citation(s) in RCA: 278] [Impact Index Per Article: 39.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Advances in cardiac imaging have resulted in greater recognition of cardiac amyloidosis in everyday clinical practice, but the diagnosis continues to be made in patients with late-stage disease, suggesting that more needs to be done to improve awareness of its clinical manifestations and the potential of therapeutic intervention to improve prognosis. Light chain cardiac amyloidosis, in particular, if recognized early and treated with targeted plasma cell therapy, can be managed very effectively. For patients with transthyretin amyloidosis, there are numerous therapies that are currently in late-phase clinical trials. In this review, we address common questions encountered in clinical practice regarding etiology, clinical presentation, diagnosis, and management of cardiac amyloidosis, focusing on recent important developments in cardiac imaging and biochemical diagnosis. The aim is to show how a systematic approach to the evaluation of suspected cardiac amyloidosis can impact the prognosis of patients in the modern era.
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Affiliation(s)
- Mathew S Maurer
- From Columbia University Medical Center, New York, NY (M.S.M.); University College London and St. Bartholomew's Hospital, UK (P.E.); Tufts Medical Center, Boston, MA (R.C.); Massachusetts General Hospital, Harvard University, Boston (M.S.); and Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum University of Bologna, Italy (C.R.).
| | - Perry Elliott
- From Columbia University Medical Center, New York, NY (M.S.M.); University College London and St. Bartholomew's Hospital, UK (P.E.); Tufts Medical Center, Boston, MA (R.C.); Massachusetts General Hospital, Harvard University, Boston (M.S.); and Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum University of Bologna, Italy (C.R.)
| | - Raymond Comenzo
- From Columbia University Medical Center, New York, NY (M.S.M.); University College London and St. Bartholomew's Hospital, UK (P.E.); Tufts Medical Center, Boston, MA (R.C.); Massachusetts General Hospital, Harvard University, Boston (M.S.); and Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum University of Bologna, Italy (C.R.)
| | - Marc Semigran
- From Columbia University Medical Center, New York, NY (M.S.M.); University College London and St. Bartholomew's Hospital, UK (P.E.); Tufts Medical Center, Boston, MA (R.C.); Massachusetts General Hospital, Harvard University, Boston (M.S.); and Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum University of Bologna, Italy (C.R.)
| | - Claudio Rapezzi
- From Columbia University Medical Center, New York, NY (M.S.M.); University College London and St. Bartholomew's Hospital, UK (P.E.); Tufts Medical Center, Boston, MA (R.C.); Massachusetts General Hospital, Harvard University, Boston (M.S.); and Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum University of Bologna, Italy (C.R.)
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200
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Oda S, Utsunomiya D, Nakaura T, Yuki H, Kidoh M, Morita K, Takashio S, Yamamuro M, Izumiya Y, Hirakawa K, Ishida T, Tsujita K, Ueda M, Yamashita T, Ando Y, Hata H, Yamashita Y. Identification and Assessment of Cardiac Amyloidosis by Myocardial Strain Analysis of Cardiac Magnetic Resonance Imaging. Circ J 2017; 81:1014-1021. [PMID: 28367859 DOI: 10.1253/circj.cj-16-1259] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND We explored the usefulness of myocardial strain analysis on cardiac magnetic resonance imaging (CMR) scans for the identification of cardiac amyloidosis.Methods and Results:The 61 patients with systemic amyloidosis underwent 3.0-T CMR, including CMR tagging and late-gadolinium enhanced (LGE) imaging. The circumferential strain (CS) of LGE-positive and LGE-negative patients was measured on midventricular short-axis images and compared. Logistic regression modeling of CMR parameters was performed to detect patients with LGE-positive cardiac amyloidosis. Of the 61 patients with systemic amyloidosis 48 were LGE-positive and 13 were LGE-negative. The peak CS was significantly lower in the LGE-positive than in the LGE-negative patients (-9.5±2.3 vs. -13.3±1.4%, P<0.01). The variability in the peak CS time was significantly greater in the LGE-positive than in the LGE-negative patients (46.1±24.5 vs. 21.2±20.1 ms, P<0.01). The peak CS significantly correlated with clinical biomarkers. The sensitivity, specificity, and accuracy of the diagnostic model using CS parameters for the identification of LGE-positive amyloidosis were 93.8%, 76.9%, and 90.2%, respectively. CONCLUSIONS Myocardial strain analysis by CMR helped detect LGE-positive amyloidosis without the need for contrast medium. The peak CS and variability in the peak CS time may correlate with the severity of cardiac amyloid deposition and may be more sensitive than LGE imaging for the detection of early cardiac disease in patients with amyloidosis.
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Affiliation(s)
- Seitaro Oda
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University
| | - Daisuke Utsunomiya
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University
| | - Takeshi Nakaura
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University
| | - Hideaki Yuki
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University
| | - Masafumi Kidoh
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University
| | - Kosuke Morita
- Department of Central Radiology, Kumamoto University Hospital
| | - Seiji Takashio
- Department of Cardiology, Faculty of Life Sciences, Kumamoto University
| | - Megumi Yamamuro
- Department of Cardiology, Faculty of Life Sciences, Kumamoto University
| | - Yasuhiro Izumiya
- Department of Cardiology, Faculty of Life Sciences, Kumamoto University
| | - Kyoko Hirakawa
- Department of Cardiology, Faculty of Life Sciences, Kumamoto University
| | - Toshifumi Ishida
- Department of Cardiology, Faculty of Life Sciences, Kumamoto University
| | - Kenichi Tsujita
- Department of Cardiology, Faculty of Life Sciences, Kumamoto University
| | - Mitsuharu Ueda
- Department of Neurology, Faculty of Life Sciences, Kumamoto University
| | - Taro Yamashita
- Department of Neurology, Faculty of Life Sciences, Kumamoto University
| | - Yukio Ando
- Department of Neurology, Faculty of Life Sciences, Kumamoto University
| | - Hiroyuki Hata
- Department of Informative Clinical Sciences, Faculty of Life Sciences, Kumamoto University
| | - Yasuyuki Yamashita
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University
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