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Briasoulis A, Bampatsias D, Papamichail A, Kuno T, Skoularigis J, Xanthopoulos A, Triposkiadis F. Invasive and Non-Invasive Diagnostic Pathways in the Diagnosis of Cardiac Amyloidosis. J Cardiovasc Dev Dis 2023; 10:256. [PMID: 37367421 DOI: 10.3390/jcdd10060256] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/07/2023] [Accepted: 06/08/2023] [Indexed: 06/28/2023] Open
Abstract
The appropriate diagnosis and subtyping of cardiac amyloidosis (CA) is frequently missed or delayed due to its vague presentation, clinical overlapping, and diagnostic pitfalls. Recent developments in both invasive and non-invasive diagnostic techniques have significantly changed the diagnostic approach of CA. With the present review, we aim to summarize the current diagnostic approach of CA and to underline the indications of tissue biopsy, either surrogate site or myocardial. The most important factor for timely diagnosis is increased clinical suspicion, especially in certain clinical scenarios. Appropriate imaging with echocardiography or cardiac magnetic resonance (CMR) can provide significant evidence for the diagnosis of CA. Importantly, all patients should undergo monoclonal proteins assessment, with these results significantly determining the steps to follow. A negative monoclonal protein assessment will lead to a non-invasive algorithm which, in combination with positive cardiac scintigraphy, can establish the diagnosis of ATTR-CA. The latter is the only clinical scenario in which the diagnosis can be established without the need of biopsy. However, if the imaging results are negative but the clinical suspicion remains high, a myocardial biopsy should be performed. In the case of the presence of monoclonal protein, an invasive algorithm follows, first by surrogate site sampling and then by myocardial biopsy if the results are inconclusive or prompt diagnosis is needed. The role of endomyocardial biopsy, even though limited by current advances in other techniques, is highly valuable in selected patients and is the only method to reliably establish a diagnosis in challenging cases.
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Affiliation(s)
- Alexandros Briasoulis
- Amyloidosis Center, Department of Clinical Therapeutics, Faculty of Medicine, Alexandra Hospital, National and Kapodistrian University of Athens, 80 Vasilissis Sophias Avenue, 11528 Athens, Greece
| | - Dimitrios Bampatsias
- Amyloidosis Center, Department of Clinical Therapeutics, Faculty of Medicine, Alexandra Hospital, National and Kapodistrian University of Athens, 80 Vasilissis Sophias Avenue, 11528 Athens, Greece
| | - Adamantia Papamichail
- Amyloidosis Center, Department of Clinical Therapeutics, Faculty of Medicine, Alexandra Hospital, National and Kapodistrian University of Athens, 80 Vasilissis Sophias Avenue, 11528 Athens, Greece
| | | | - John Skoularigis
- Department of Cardiology, University Hospital of Larissa, 41110 Larissa, Greece
| | - Andrew Xanthopoulos
- Department of Cardiology, University Hospital of Larissa, 41110 Larissa, Greece
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2
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Bay K, Gustafsson F, Maiborg M, Bagger‐Bahnsen A, Strand AM, Pilgaard T, Poulsen SH. Suspicion, screening, and diagnosis of wild-type transthyretin amyloid cardiomyopathy: a systematic literature review. ESC Heart Fail 2022; 9:1524-1541. [PMID: 35343098 PMCID: PMC9065854 DOI: 10.1002/ehf2.13884] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 02/11/2022] [Accepted: 02/25/2022] [Indexed: 01/15/2023] Open
Abstract
Wild-type transthyretin amyloid cardiomyopathy (ATTRwt CM) is a more common disease than previously thought. Awareness of ATTRwt CM and its diagnosis has been challenged by its unspecific and widely distributed clinical manifestations and traditionally invasive diagnostic tools. Recent advances in echocardiography and cardiac magnetic resonance (CMR), non-invasive diagnosis by bone scintigraphy, and the development of disease-modifying treatments have resulted in an increased interest, reflected in multiple publications especially during the last decade. To get an overview of the scientific knowledge and gaps related to patient entry, suspicion, diagnosis, and systematic screening of ATTRwt CM, we developed a framework to systematically map the available evidence of (i) when to suspect ATTRwt CM in a patient, (ii) how to diagnose the disease, and (iii) which at-risk populations to screen for ATTRwt CM. Articles published between 2010 and August 2021 containing part of or a full diagnostic pathway for ATTRwt CM were included. From these articles, data for patient entry, suspicion, diagnosis, and screening were extracted, as were key study design and results from the original studies referred to. A total of 50 articles met the inclusion criteria. Of these, five were position statements from academic societies, while one was a clinical guideline. Three articles discussed the importance of primary care providers in terms of patient entry, while the remaining articles had the cardiovascular setting as point of departure. The most frequently mentioned suspicion criteria were ventricular wall thickening (44/50), carpal tunnel syndrome (42/50), and late gadolinium enhancement on CMR (43/50). Diagnostic pathways varied slightly, but most included bone scintigraphy, exclusion of light-chain amyloidosis, and the possibility of doing a biopsy. Systematic screening was mentioned in 16 articles, 10 of which suggested specific at-risk populations for screening. The European Society of Cardiology recommends to screen patients with a wall thickness ≥12 mm and heart failure, aortic stenosis, or red flag symptoms, especially if they are >65 years. The underlying evidence was generally good for diagnosis, while significant gaps were identified for the relevance and mutual ranking of the different suspicion criteria and for systematic screening. Conclusively, patient entry was neglected in the reviewed literature. While multiple red flags were described, high-quality prospective studies designed to evaluate their suitability as suspicion criteria were lacking. An upcoming task lies in defining and evaluating at-risk populations for screening. All are steps needed to promote early detection and diagnosis of ATTRwt CM, a prerequisite for timely treatment.
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Affiliation(s)
- Katrine Bay
- Bay WritingCopenhagenDenmark
- Pfizer DenmarkBallerupDenmark
| | - Finn Gustafsson
- The Heart CenterCopenhagen University Hospital, RigshospitaletCopenhagenDenmark
| | - Michael Maiborg
- Odense Amyloidosis Center & Department of CardiologyOdense University HospitalOdenseDenmark
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3
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Santarelli MF, Genovesi D, Positano V, Di Sarlo R, Scipioni M, Giorgetti A, Landini L, Marzullo P. Cardiac amyloidosis detection by early bisphosphonate (99mTc-HMDP) scintigraphy. J Nucl Cardiol 2022; 29:307-318. [PMID: 32596791 DOI: 10.1007/s12350-020-02239-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 06/09/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To determine one or more indexes able to detect the presence of cardiac amyloidosis (CA) from planar scintigraphy images after injection of 99mTc-HMDP tracer and to identify the earliest acquisition time able to ensure an accurate diagnosis of amyloid transthyretin CA. METHODS AND RESULTS A total of 38 patients were included: 18 subjects with a final diagnosis of ATTR-CA and 20 controls. Dynamic planar images of the anterior thorax were acquired, starting at intravenous injection of ≈ 700 MBq of 99mTc-HMDP. From time/activity curves (TAC) of regions of interest such as heart, vascular region, right ribcage, and soft tissues, several indices were considered. From the analysis, it resulted that both TACHeart/Bone(t) and RIheart-bone(t), for t > 6 minutes, well distinguish ATTR-CA patients from controls subjects. This is confirmed by the area under curves (AUC) analysis giving AUC values =.9 at t ≅ 6 minutes and AUC ≅ 1 for t > 10 minutes. CONCLUSIONS The method proposed allows determining the presence of ATTR-CA, in an inexpensive manner both in terms of examination costs and time spent.
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Affiliation(s)
- M F Santarelli
- CNR Institute of Clinical Physiology, CNR Research Area, Via Moruzzi 1, 56124, Pisa, Italy.
- Fondazione Toscana "G. Monasterio", CNR Research Area, Via Moruzzi 1, Pisa, Italy.
| | - D Genovesi
- Fondazione Toscana "G. Monasterio", CNR Research Area, Via Moruzzi 1, Pisa, Italy
| | - V Positano
- Fondazione Toscana "G. Monasterio", CNR Research Area, Via Moruzzi 1, Pisa, Italy
| | - R Di Sarlo
- Dipartimento di Ingegneria dell'Informazione: DII, Pisa University, Via Caruso 16, Pisa, Italy
| | - M Scipioni
- CNR Institute of Clinical Physiology, CNR Research Area, Via Moruzzi 1, 56124, Pisa, Italy
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - A Giorgetti
- Fondazione Toscana "G. Monasterio", CNR Research Area, Via Moruzzi 1, Pisa, Italy
| | - L Landini
- Fondazione Toscana "G. Monasterio", CNR Research Area, Via Moruzzi 1, Pisa, Italy
- Dipartimento di Ingegneria dell'Informazione: DII, Pisa University, Via Caruso 16, Pisa, Italy
| | - P Marzullo
- Fondazione Toscana "G. Monasterio", CNR Research Area, Via Moruzzi 1, Pisa, Italy
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4
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Palmiero G, Rubino M, Monda E, Caiazza M, D'Urso L, Carlomagno G, Verrillo F, Ascione R, Manganelli F, Cerciello G, De Rimini ML, Bossone E, Pacileo G, Calabrò P, Golino P, Ascione L, Caso P, Limongelli G. Global Left Ventricular Myocardial Work Efficiency in Heart Failure Patients with Cardiac Amyloidosis: Pathophysiological Implications and Role in Differential Diagnosis. J Cardiovasc Echogr 2021; 31:157-164. [PMID: 34900551 PMCID: PMC8603776 DOI: 10.4103/jcecho.jcecho_16_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 04/19/2021] [Accepted: 07/10/2021] [Indexed: 01/15/2023] Open
Abstract
Introduction Cardiac amyloidosis (CA) is an infiltrative cardiomyopathy and a common cause of heart failure with preserved and mid-range ejection fraction (HFpEF and HFmrEF). Left ventricular (LV) systolic assessment is pivotal in differential diagnostic and prognostic stratification in CA. However, nondeformation and deformation-based parameters classically implied had many limitations. Myocardial work (MW) has been recently introduced for the evaluation of myocardial performance, in a load-independent fashion, in patients with cardiomyopathies. Aims This study aimed to evaluate MW parameters in LV performance assessment in CA and their possible role in differential diagnosis between AL and ATTR forms, compared with other echocardiographic parameters, also exploring the possible association between MW parameters and blood biomarkers. Materials and Methods The study population consisted of 25 patients with CA (10 with AL amyloidosis and 15 with wild-type ATTR [ATTRwt] form) and HFpEF or HFmrHF, enrolled between March 2018 and December 2019, undergoing a comprehensive clinical, biochemical, and imaging evaluation. Ten healthy individuals were studied as controls. ATTR patients had a noninvasive diagnosis of wtATTR-CA (positive 99mTc-hydroxy methylene-diphosphonate scintigraphy with a negative hematological screening), while AL patients underwent endomyocardial biopsy. All patients underwent standard transthoracic echocardiography. MW and related indices were estimated using a vendor-specific module. Results Compared to the ATTRwt group, patients in the AL group showed a more pronounced myocardial performance impairment assessed by Global Word Efficiency (GWE: 83.5% ± 6.3% vs. 88.2% ± 3.6%; P = 0.026). In multiple linear regression analysis, cardiac troponin I (Β = -0.55; P < 0.0001), global longitudinal strain (Β =0.35; P < 0.008), and regional relative strain ratio (Β = -0.30; P < 0.016) were significant predictors of GWE reduction in CA patients. At receiver operating characteristics curve analysis, among all other deformation-based and nondeformation-based echocardiographic parameters, GWE showed the highest area under the curve (AUC) (AUC 0.74; 95% CI: 0.55-0.96; P < 0.04). The optimal cutoff was determined by sensitivity/specificity analysis: a GWE < 86.5% identified patients with AL amyloidosis with a sensitivity and specificity, respectively, of 80.0% and 66.7%. Conclusions The results of our pivotal study seem to highlight the importance of new deformation parameters to study myocardial performance in patients with CA, and to differentiate between AL CA and ATTR CA.
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Affiliation(s)
- Giuseppe Palmiero
- Division of Cardiology, Department of Cardiology, AORN Ospedali dei Colli - Monaldi Hospital, Naples, Italy.,Inherited and Rare Cardiovascular Diseases Unit, Department of Translational Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Marta Rubino
- Inherited and Rare Cardiovascular Diseases Unit, Department of Translational Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Emanuele Monda
- Inherited and Rare Cardiovascular Diseases Unit, Department of Translational Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Martina Caiazza
- Inherited and Rare Cardiovascular Diseases Unit, Department of Translational Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Lucia D'Urso
- Department of Cardiac Surgery and Transplantation, Heart Transplantation Unit in Adults, AORN Ospedali dei Colli - Monaldi Hospital, Naples, Italy
| | - Guido Carlomagno
- Echocardiography Laboratory, Mediterranea Cardiocentro, Antonio Cardarelli Hospital, Naples, Italy
| | - Federica Verrillo
- Inherited and Rare Cardiovascular Diseases Unit, Department of Translational Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Raffaele Ascione
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy
| | - Fiore Manganelli
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples "Federico II", Naples, Italy
| | - Giuseppe Cerciello
- Haematology Unit, Department of Clinical Medicine and Surgery, University of Naples "Federico II", Naples, Italy
| | - Maria Luisa De Rimini
- Department of Nuclear Medicine, AORN Ospedali dei Colli - Monaldi Hospital, Naples, Italy
| | - Eduardo Bossone
- Unit of Cardiac Rehabilitation, Antonio Cardarelli Hospital, Naples, Italy
| | - Giuseppe Pacileo
- Heart Failure Unit, Department of Cardiology, AORN Ospedali dei Colli - Monaldi Hospital, Naples, Italy
| | - Paolo Calabrò
- Division of Cardiology, Department of Cardiothoracic and Respiratory Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Paolo Golino
- Department of Cardiology, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Luigi Ascione
- Division of Cardiology, Department of Cardiology, AORN Ospedali dei Colli - Monaldi Hospital, Naples, Italy
| | - Pio Caso
- Division of Cardiology, Department of Cardiology, AORN Ospedali dei Colli - Monaldi Hospital, Naples, Italy
| | - Giuseppe Limongelli
- Inherited and Rare Cardiovascular Diseases Unit, Department of Translational Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy.,Institute of Cardiovascular Sciences, University College of London, St. Bartholomew's Hospital, London, United Kingdom
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5
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Camilli M, La Vecchia G, Lillo R, Iannaccone G, Lamendola P, Montone RA, Hohaus S, Aspromonte N, Massetti M, Lanza GA, Crea F, Graziani F, Lombardo A. Cardiovascular involvement in patients affected by multiple myeloma: a comprehensive review of recent advances. Expert Rev Hematol 2021; 14:1115-1128. [PMID: 34739762 DOI: 10.1080/17474086.2021.2003704] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Multiple Myeloma (MM) is hematological neoplasia originating from plasma cells, which accounts for almost 1% of all oncologic malignancies. The median age of patients at diagnosis is about 65 years old and over. In this age group, cardiovascular (CV) diseases often co-exist, increasing the risk of adverse events related to MM treatment. A comprehensive search on the main educational platforms was performed and high-quality original articles and reviews were included. AREAS COVERED Patients affected by MM are at risk for heart failure, uncontrolled systemic hypertension, accelerated ischemic heart disease, arterial/venous thromboembolism, and arrhythmias. These complications may be due to the effects of chemotherapy on the CV system, which may play on preexisting risk factors, and amyloid deposition at cardiac level. EXPERT OPINION This review provides an updated overview of the spectrum of CV diseases that may affect MM patients, highlighting possible treatment strategies according to the latest recommendations. Cooperation between onco-hematologist and cardiologist is crucial in managing this population, in particular for adequate risk assessment, early diagnosis of CV complications, and proper treatment.
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Affiliation(s)
- Massimiliano Camilli
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Giulia La Vecchia
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Rosa Lillo
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giulia Iannaccone
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Priscilla Lamendola
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Rocco Antonio Montone
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Stefan Hohaus
- Institute of Hematology, Catholic University of Sacred Heart, Rome, Italy.,Dipartimento Diagnostica per Immagini, Radioterapia Oncologica Ed Ematologia, Fondazione Policlinico A. Gemelli IRCCS, Roma, Italia
| | - Nadia Aspromonte
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy.,Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Massimo Massetti
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy.,Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Gaetano Antonio Lanza
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy.,Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Filippo Crea
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy.,Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesca Graziani
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Antonella Lombardo
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy.,Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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Ruan D, Sun L. Diagnostic efficacy of bone scintigraphy in transthyretin cardiac amyloidosis: an updated systematic review and Bayesian bivariate meta-analysis. Clin Transl Imaging 2021. [DOI: 10.1007/s40336-021-00471-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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7
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Castiglione V, Franzini M, Aimo A, Carecci A, Lombardi CM, Passino C, Rapezzi C, Emdin M, Vergaro G. Use of biomarkers to diagnose and manage cardiac amyloidosis. Eur J Heart Fail 2021; 23:217-230. [PMID: 33527656 DOI: 10.1002/ejhf.2113] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 11/28/2020] [Accepted: 01/25/2021] [Indexed: 12/22/2022] Open
Abstract
Amyloidoses are characterized by the tissue accumulation of misfolded proteins into insoluble fibrils. The two most common types of systemic amyloidosis result from the deposition of immunoglobulin light chains (AL) and wild-type or variant transthyretin (ATTRwt/ATTRv). Cardiac involvement is the main determinant of outcome in both AL and ATTR, and cardiac amyloidosis (CA) is increasingly recognized as a cause of heart failure. In CA, circulating biomarkers are important diagnostic tools, allow to refine risk stratification at baseline and during follow-up, help to tailor the therapeutic strategy and monitor the response to treatment. Among amyloid precursors, free light chains are established biomarkers in AL amyloidosis, while the plasma transthyretin assay is currently being investigated as a tool for supporting the diagnosis of ATTRv amyloidosis, predicting outcome and monitor response to novel tetramer stabilizers or small interfering RNA drugs in ATTR CA. Natriuretic peptides (NPs) and troponins are consistently elevated in patients with AL and ATTR CA. Plasma NPs, troponins and free light chains hold prognostic significance in AL amyloidosis, and are evaluated for therapy decision-making and follow-up, while the value of NPs and troponins in ATTR is less well established. Biomarkers can be usefully integrated with clinical and imaging variables at all levels of the clinical algorithm of systemic amyloidosis, from screening to diagnosis and prognosis, and treatment tailoring.
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Affiliation(s)
| | - Maria Franzini
- Department of Translational Research and of New Surgical and Medical Technologies, University of Pisa, Pisa, Italy
| | - Alberto Aimo
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.,Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | | | - Carlo Mario Lombardi
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health University and Civil Hospital, Brescia, Italy
| | - Claudio Passino
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.,Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Claudio Rapezzi
- Centro Cardiologico Universitario di Ferrara, University of Ferrara, Ferrara, Italy.,Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Michele Emdin
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.,Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Giuseppe Vergaro
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.,Fondazione Toscana Gabriele Monasterio, Pisa, Italy
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8
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Vervaat FE, Bouwmeester S, Vlaar PJ. Case report regarding the evolution of electrocardiographic and echocardiographic features in cardiac amyloidosis. Eur Heart J Case Rep 2021; 5:ytaa426. [PMID: 33644637 PMCID: PMC7898588 DOI: 10.1093/ehjcr/ytaa426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 04/27/2020] [Accepted: 09/09/2020] [Indexed: 11/15/2022]
Abstract
Background Cardiac amyloidosis is an important cause for heart failure with preserved ejection fraction. It is often under diagnosed due to the fact that clinicians do not always recognize the specific diagnostic findings associated with this disease, also leading to the wrong diagnosis. When left untreated further irreversible organ dysfunction occurs, with high morbidity and mortality rates. Case summary A 71-year-old patient presented with progressive exertional dyspnoea and angina pectoris at the outpatient clinic. Medical history noted a percutaneous coronary intervention of the right coronary artery due to stable angina pectoris. The electrocardiogram showed low voltage in the limb leads and pseudo-infarct pattern in the precordial leads. Echocardiographic findings included left and right ventricular hypertrophy, decreased left ventricular systolic function, restrictive diastolic function, and ‘relative’ apical sparing of the left ventricle. This led to the suspicion of cardiac amyloidosis, which was confirmed with a positive bone scintigraphy using 99mTechnecium-DPD and the absence of monoclonal proteins. Treatment with Tafamidis was initiated. Discussion Electrocardiographic findings suggestive of cardiac amyloidosis are low voltage in the limb leads and/or a pseudo-infarct pattern in the precordial leads. Important echocardiographic findings are left and right ventricular hypertrophy, restrictive diastolic function, ‘relative’ apical sparing of the left ventricle and impaired left atrial strain. The next step in confirming the diagnosis is 99mTechnecium PYP/DPD/HMDP bone scintigraphy and testing for monoclonal proteins. The diagnosis ATTR amyloidosis is confirmed by the combination of positive bone scintigraphy (Perugini Grade 2 or 3) and the absence of monoclonal proteins, without the necessity of performing an endomyocardial biopsy.
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Affiliation(s)
- Fabienne E Vervaat
- Department of Cardiology, Catharina Hospital, Michelangelolaan 2, 5623 EJ Eindhoven, the Netherlands
| | - Sjoerd Bouwmeester
- Department of Cardiology, Catharina Hospital, Michelangelolaan 2, 5623 EJ Eindhoven, the Netherlands
| | - Pieter-Jan Vlaar
- Department of Cardiology, Catharina Hospital, Michelangelolaan 2, 5623 EJ Eindhoven, the Netherlands
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9
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Vergaro G, Aimo A, Barison A, Genovesi D, Buda G, Passino C, Emdin M. Keys to early diagnosis of cardiac amyloidosis: red flags from clinical, laboratory and imaging findings. Eur J Prev Cardiol 2020; 27:1806-1815. [DOI: 10.1177/2047487319877708] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Abstract
Cardiac involvement in systemic amyloidosis, due either to immunoglobulin light-chain or transthyretin amyloidosis, influences clinical presentation and is a strong predictor of unfavourable outcome. Until recently considered as a rare, incurable disease, cardiac amyloidosis, is still mis/underdiagnosed, although treatments effective in improving patient survival are now available for both subtypes, including chemotherapy regimens for immunoglobulin light-chain amyloidosis and tetramer stabiliser for transthyretin amyloidosis. Achieving a timely diagnosis allows initiating life-saving therapies and requires the early recognition of clinical, laboratory and imaging signs of cardiac involvement, some of them may be apparent well before the disease becomes clinically manifest. Given the systemic nature of amyloidosis, a close interaction among experts in multiple specialties is also required, including cardiologists, nephrologists, haematologists, neurologists, radiologists, nuclear medicine specialists and internists. As an increased awareness about disease presentation is required to ameliorate diagnostic performance, we aim to provide the clinician with a guide to the screening and early diagnosis of cardiac amyloidosis, and to review the clinical, biohumoral and instrumental ‘red flags’ that should raise the suspicion of cardiac amyloidosis.
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Affiliation(s)
- Giuseppe Vergaro
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Italy
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Alberto Aimo
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Italy
| | - Andrea Barison
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Italy
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | | | - Gabriele Buda
- Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Claudio Passino
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Italy
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Michele Emdin
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Italy
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy
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10
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Cicco S, Solimando AG, Buono R, Susca N, Inglese G, Melaccio A, Prete M, Ria R, Racanelli V, Vacca A. Right Heart Changes Impact on Clinical Phenotype of Amyloid Cardiac Involvement: A Single Centre Study. Life (Basel) 2020; 10:life10100247. [PMID: 33081052 PMCID: PMC7603245 DOI: 10.3390/life10100247] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 10/12/2020] [Accepted: 10/16/2020] [Indexed: 12/18/2022] Open
Abstract
Amyloidosis is due to deposition of an excessive amount of protein in many parenchymal tissues, including myocardium. The onset of cardiac Amyloidosis (CA) is an inauspicious prognostic factor, which can lead to sudden death. We retrospectively analyzed 135 patients with systemic amyloidosis, admitted to our ward between 1981 and 2019. Among them, 54 patients (46.30% F/53.70% M, aged 63.95 ± 12.82) presented CA at baseline. In 53 patients, it was associated with a multiorgan involvement, while in one there was a primary myocardial deposition. As a control group, we enrolled 81 patients (49.30% F/50.70% M, aged 58.33 ± 15.65) who did not meet the criteria for CA. In 44/54 of patients CA was associated with AL, 5/54 with AA and 3/54 of patients with ATTR, and in 1/54 AL was related to hemodialysis and in 1/54 to Gel-Amyloidosis. The most common AL type was IgG (28/44); less frequent forms were either IgA (7/44) or IgD (2/44), while seven patients had a λ free light chain form. The 32 AL with complete Ig were 31 λ-chain and just one k-chain. CA patients presented normal BP (SBP 118.0 ± 8.4 mmHg; DBP 73.8 ± 4.9 mmHg), while those with nCA had an increased proteinuria (p = 0.02). TnI and NT-proBNP were significantly increased compared to nCA (p = 0.031 and p = 0.047, respectively). In CA patients we found an increased LDH compared to nCA (p = 0.0011). CA patients were also found to have an increased interventricular septum thickness compared to nCA (p = 0.002), a decreased Ejection Fraction % (p = 0.0018) and Doppler velocity E/e’ ratio (p = 0.0095). Moreover, CA patients had an enhanced right atrium area (p = 0.0179), right ventricle basal diameter (p = 0.0112) and wall thickness (p = 0.0471) compared to nCA, and an increased inferior cava vein diameter (p = 0.0495) as well. TAPSE was the method chosen to evaluate systolic function of the right heart. In CA subjects very poor TAPSE levels were found compared to nCA patients (p = 0.0495). Additionally, we found a significant positive correlation between TAPSE and lymphocyte count (r = 0.47; p = 0.031) as well as Gamma globulins (r = 0.43, p = 0.033), Monoclonal components (r = 0.72; p = 0.047) and IgG values (r = 0.62, p = 0.018). Conversely, a significant negative correlation with LDH (r = −0.57, p = 0.005), IVS (r = −0.51, p = 0.008) and diastolic function evaluated as E/e’ (r = −0.60, p = 0.003) were verified. CA patients had very poor survival rates compared to controls (30 vs. 66 months in CA vs. nCA, respectively, p = 0.15). Mean survival of CA individuals was worse also when stratified according to NT-proBNP levels, using 2500 pg/mL as class boundary (174 vs. 5.5 months, for patients with lower vs. higher values than the median, respectively p = 0.013). In much the same way, a decreased right heart systolic function was correlated with a worse prognosis (18.0 months median survival, not reached in subjects with lower values than 18 mm, p = 0.0186). Finally, our data highlight the potential prognostic and predictive value of right heart alterations characterizing amyloidosis, as a novel clinical parameter correlated to increased LDH and immunoglobulins levels. Overall, we confirm the clinical relevance of cardiac involvement suggests that right heart evaluation may be considered as a new marker for clinical risk stratification in patients with amyloidosis.
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Affiliation(s)
- Sebastiano Cicco
- Unit of Internal Medicine “Guido Baccelli”, Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro Medical School, Piazza Giulio Cesare 11, I-70124 Bari, Italy; (S.C.); (A.G.S.); (R.B.); (N.S.); (G.I.); (A.M.); (M.P.); (R.R.); (V.R.)
- Internal Medicine Department, AUO Policlinico Ospedali Riuniti, Viale L. Pinto, I-71122 Foggia, Italy
| | - Antonio Giovanni Solimando
- Unit of Internal Medicine “Guido Baccelli”, Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro Medical School, Piazza Giulio Cesare 11, I-70124 Bari, Italy; (S.C.); (A.G.S.); (R.B.); (N.S.); (G.I.); (A.M.); (M.P.); (R.R.); (V.R.)
- IRCCS Istituto Tumori “Giovanni Paolo II” of Bari, Viale Orazio Flacco 65, I-70124 Bari, Italy
| | - Roberta Buono
- Unit of Internal Medicine “Guido Baccelli”, Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro Medical School, Piazza Giulio Cesare 11, I-70124 Bari, Italy; (S.C.); (A.G.S.); (R.B.); (N.S.); (G.I.); (A.M.); (M.P.); (R.R.); (V.R.)
| | - Nicola Susca
- Unit of Internal Medicine “Guido Baccelli”, Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro Medical School, Piazza Giulio Cesare 11, I-70124 Bari, Italy; (S.C.); (A.G.S.); (R.B.); (N.S.); (G.I.); (A.M.); (M.P.); (R.R.); (V.R.)
| | - Gianfranco Inglese
- Unit of Internal Medicine “Guido Baccelli”, Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro Medical School, Piazza Giulio Cesare 11, I-70124 Bari, Italy; (S.C.); (A.G.S.); (R.B.); (N.S.); (G.I.); (A.M.); (M.P.); (R.R.); (V.R.)
| | - Assunta Melaccio
- Unit of Internal Medicine “Guido Baccelli”, Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro Medical School, Piazza Giulio Cesare 11, I-70124 Bari, Italy; (S.C.); (A.G.S.); (R.B.); (N.S.); (G.I.); (A.M.); (M.P.); (R.R.); (V.R.)
| | - Marcella Prete
- Unit of Internal Medicine “Guido Baccelli”, Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro Medical School, Piazza Giulio Cesare 11, I-70124 Bari, Italy; (S.C.); (A.G.S.); (R.B.); (N.S.); (G.I.); (A.M.); (M.P.); (R.R.); (V.R.)
| | - Roberto Ria
- Unit of Internal Medicine “Guido Baccelli”, Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro Medical School, Piazza Giulio Cesare 11, I-70124 Bari, Italy; (S.C.); (A.G.S.); (R.B.); (N.S.); (G.I.); (A.M.); (M.P.); (R.R.); (V.R.)
| | - Vito Racanelli
- Unit of Internal Medicine “Guido Baccelli”, Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro Medical School, Piazza Giulio Cesare 11, I-70124 Bari, Italy; (S.C.); (A.G.S.); (R.B.); (N.S.); (G.I.); (A.M.); (M.P.); (R.R.); (V.R.)
| | - Angelo Vacca
- Unit of Internal Medicine “Guido Baccelli”, Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro Medical School, Piazza Giulio Cesare 11, I-70124 Bari, Italy; (S.C.); (A.G.S.); (R.B.); (N.S.); (G.I.); (A.M.); (M.P.); (R.R.); (V.R.)
- Correspondence:
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11
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Cavigli L, Focardi M, Cameli M, Mandoli GE, Mondillo S, D'Ascenzi F. The right ventricle in “Left-sided” cardiomyopathies: The dark side of the moon. Trends Cardiovasc Med 2020; 31:476-484. [DOI: 10.1016/j.tcm.2020.10.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 09/26/2020] [Accepted: 10/09/2020] [Indexed: 02/07/2023]
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12
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Transthyretin Cardiac Amyloidosis as Diagnosed by 99mTc-PYP Scanning in Patients with Acute Heart Failure and Preserved Ejection Fraction. Crit Pathw Cardiol 2020; 18:195-199. [PMID: 31725511 DOI: 10.1097/hpc.0000000000000183] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Transthyretin amyloid deposition is present in 17% of autopsies of patients with heart failure and a preserved ejection fraction (HFpEF). Technetium-pyrophosphate scintigraphy (Tc-PYP) is sensitive and specific to diagnose cardiac transthyretin amyloid deposition (ATTR). The prevalence of ATTR by Tc-PYP was evaluated along with echocardiographic parameters in patients with HFpEF. One-hundred consecutive patients with HFpEF, who had Tc-PYP, were retrospectively evaluated. Echocardiographic variables were analyzed to compare patients with positive versus negative ATTR infiltration. Myocardial ATTR was present in 19% of patients. Individuals with ATTR were older with a mean age of 82 ± 7 versus 75 ± 13 years (P = 0.03), had increased left ventricular hypertrophy with the interventricular septum measuring 1.6 (IQR, 1.4-2.0) versus 1.4 (IQR, 1.3-1.6) cm (P = 0.002), had a greater mean left ventricular mass index of 160 ± 50 g/m versus 131 ± 44 g/m (P = 0.01), and a reduced global longitudinal strain measuring -11% (IQR, -9 to -12) versus -12% (IQR, -10 to -16), P = 0.04. The prevalence of ATTR myocardial deposition demonstrated by Tc-PYP in patients with HFpEF is comparable to that of autopsy studies. It is more common in older patients, with increased left ventricular hypertrophy and reduced global longitudinal strain.
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Adamczak DM, Oduah MT, Kiebalo T, Nartowicz S, Bęben M, Pochylski M, Ciepłucha A, Gwizdała A, Lesiak M, Straburzyńska-Migaj E. Heart Failure with Preserved Ejection Fraction-a Concise Review. Curr Cardiol Rep 2020; 22:82. [PMID: 32648130 PMCID: PMC7347676 DOI: 10.1007/s11886-020-01349-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Purpose of Review Heart failure with preserved ejection fraction (HFpEF) is a relatively new disease entity used in medical terminology; however, both the number of patients and its clinical significance are growing. HFpEF used to be seen as a mild condition; however, the symptoms and quality of life of the patients are comparable to those with reduced ejection fraction. The disease is much more complex than previously thought. In this article, information surrounding the etiology, diagnosis, prognosis, and possible therapeutic options of HFpEF are reviewed and summarized. Recent Findings It has recently been proposed that heart failure (HF) is rather a heterogeneous syndrome with a spectrum of overlapping and distinct characteristics. HFpEF itself can be distilled into different phenotypes based on the underlying biology. The etiological factors of HFpEF are unclear; however, systemic low-grade inflammation and microvascular damage as a consequence of comorbidities associated with endothelial dysfunction, oxidative stress, myocardial remodeling, and fibrosis are considered to play a crucial role in the pathogenesis of a disease. The H2FPEF score and the HFpEF nomogram are recently validated highly sensitive tools employed for risk assessment of subclinical heart failure. Summary Despite numerous studies, there is still no evidence-based pharmacotherapy for HFpEF and the mortality and morbidity associated with HFpEF remain high. A better understanding of the etiological factors, the impact of comorbidities, the phenotypes of the disease, and implementation of machine learning algorithms may play a key role in the development of future therapeutic strategies.
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Affiliation(s)
- Daria M Adamczak
- Ist Department of Cardiology, Poznan University of Medical Sciences, Dluga Street ½, 61-848, Poznan, Poland.
| | - Mary-Tiffany Oduah
- Center for Medical Education in English, Poznan University of Medical Sciences, Poznan, Poland
| | - Thomas Kiebalo
- Center for Medical Education in English, Poznan University of Medical Sciences, Poznan, Poland
| | - Sonia Nartowicz
- Faculty of Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Marcin Bęben
- Faculty of Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Mateusz Pochylski
- Faculty of Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Aleksandra Ciepłucha
- Ist Department of Cardiology, Poznan University of Medical Sciences, Dluga Street ½, 61-848, Poznan, Poland
| | - Adrian Gwizdała
- Ist Department of Cardiology, Poznan University of Medical Sciences, Dluga Street ½, 61-848, Poznan, Poland
| | - Maciej Lesiak
- Ist Department of Cardiology, Poznan University of Medical Sciences, Dluga Street ½, 61-848, Poznan, Poland
| | - Ewa Straburzyńska-Migaj
- Ist Department of Cardiology, Poznan University of Medical Sciences, Dluga Street ½, 61-848, Poznan, Poland
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Abstract
IMPORTANCE Many patients with systemic amyloidosis are underdiagnosed. Overall, 25% of patients with immunoglobulin light chain (AL) amyloidosis die within 6 months of diagnosis and 25% of patients with amyloid transthyretin (ATTR) amyloidosis die within 24 months of diagnosis. Effective therapy exists but is ineffective if end-organ damage is severe. OBJECTIVE To provide evidence-based recommendations that could allow clinicians to diagnose this rare set of diseases earlier and enable accurate staging and counseling about prognosis. EVIDENCE REVIEW A comprehensive literature search was conducted by a reference librarian with publication dates from January 1, 2000, to December 31, 2019. Key search terms included amyloid, amyloidosis, nephrotic syndrome, heart failure preserved ejection fraction, and peripheral neuropathy. Exclusion criteria included case reports, non-English-language text, and case series of fewer than 10 patients. The authors independently selected and appraised relevant literature. FINDINGS There was a total of 1769 studies in the final data set. Eighty-one articles were included in this review, of which 12 were randomized clinical trials of therapy that included 3074 patients, 9 were case series, and 3 were cohort studies. The incidence of AL amyloidosis is approximately 12 cases per million persons per year and there is an estimated prevalence of 30 000 to 45 000 cases in the US and European Union. The incidence of variant ATTR amyloidosis is estimated to be 0.3 cases per year per million persons with a prevalence estimate of 5.2 cases per million persons. Wild-type ATTR is estimated to have a prevalence of 155 to 191 cases per million persons. Amyloidosis should be considered in the differential diagnosis of adult nondiabetic nephrotic syndrome; heart failure with preserved ejection fraction, particularly if restrictive features are present; unexplained hepatomegaly without imaging abnormalities; peripheral neuropathy with distal sensory symptoms, such as numbness, paresthesia, and dysesthesias (although the autonomic manifestations occasionally may be the presenting feature); and monoclonal gammopathy of undetermined significance with atypical clinical features. Staging can be performed using blood testing only. Therapeutic decision-making for AL amyloidosis involves choosing between high-dose chemotherapy and stem cell transplant or bortezomib-based chemotherapy. There are 3 therapies approved by the US Food and Drug Administration for managing ATTR amyloidosis, depending on clinical phenotype. CONCLUSIONS AND RELEVANCE All forms of amyloidosis are underdiagnosed. All forms now have approved therapies that have been demonstrated to improve either survival or disability and quality of life. The diagnosis should be considered in patients that have a multisystem disorder involving the heart, kidney, liver, or nervous system.
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Affiliation(s)
- Morie A Gertz
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Angela Dispenzieri
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
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15
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Cardiac Amyloidosis in Patients Undergoing TAVR: Why We Need to Think About It. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 22:109-114. [PMID: 32571759 DOI: 10.1016/j.carrev.2020.06.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 04/20/2020] [Accepted: 06/03/2020] [Indexed: 01/15/2023]
Abstract
Systemic amyloidosis encompasses a variety of diseases characterized by extracellular deposition of protein-derived fibrils in different tissues and organs. Immunoglobulin light-chain (AL) and transthyretin (ATTR) amyloid are the two types that more commonly affect the heart and in both subtypes cardiac involvement is the main determinant of prognosis. Recently, several studies have suggested that Cardiac Amyloidosis (CA) and Aortic Stenosis (AS) can coexist more frequently than previously suspected with prevalence ranging from 5,6% to 16% in different cohorts. The unexpected high prevalence of CA in AS and the availability of potentially effective treatment in CA should push us to carefully investigate elderly patients with aortic valve stenosis in order to identify those with coexistent amyloidosis. While the motivation to exclude amyloidosis was in the past their exclusion from active treatment of the valve disease, judged as futile because of their poor unavoidable prognosis, the improved therapeutic options available challenges this conservative approach. Aim of this review is to identify the triggers to investigate AS patients at risk of having concomitant ATTR-CA, to propose a diagnostic path to reach diagnosis and to discuss the changes in the therapeutic strategy caused by this discovery in the era of TAVR and active pharmacological treatments to slow down disease progression.
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16
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Macedo AVS, Schwartzmann PV, de Gusmão BM, Melo MDTD, Coelho-Filho OR. Advances in the Treatment of Cardiac Amyloidosis. Curr Treat Options Oncol 2020; 21:36. [PMID: 32328845 PMCID: PMC7181421 DOI: 10.1007/s11864-020-00738-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OPINION STATEMENT Cardiac amyloidosis is associated with a high mortality rate, a long delay between the first signs and the diagnosis but a short interval between diagnosis and death. This scenario has changed recently due to improved disease awareness among doctors and significant progress in diagnosis thanks to multimodal imaging and a multidisciplinary approach. Therefore, during the last few years, we have had access to specific therapies for those patients. Those therapies are quite different depending on the type of amyloidosis, but there has been real progress. Systemic light chain amyloidosis (AL) with cardiac involvement is the most common form of cardiac amyloidosis. The severity of heart disease dictates the prognosis in AL amyloidosis. Advances in chemotherapy and immunotherapy that suppress light chain production have improved the outcomes. These recent improvements in survival rates have enabled therapies such as implanted cardiac defibrillators and heart transplantation that were usually not indicated for patients with advanced light chain amyloid cardiomyopathy to now be applied in selected patients. For transthyretin amyloidosis (ATTR), the second most common form of amyloidosis with cardiac involvement, there is also significant progress in treatment. Until recently, we had no specific therapy for ATTR cardiomyopathy (ATTR-CM), though now disease-modifying therapies are available. Therapies that stabilize transthyretin, such as tafamidis, have been shown to improve outcomes for patients with ATTR-CM. Modern treatments that stop the synthesis of TTR through gene silencing, such as patisiran and inotersen, have shown positive results for patients with TTR amyloidosis. Significant progress has been made in the treatment of amyloid cardiomyopathy, and hopefully, we will see even more progress with the spread of those treatments. We now can be optimistic about patients with this disease.
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Affiliation(s)
| | | | | | | | - Otávio Rizzi Coelho-Filho
- Department of Internal Medicine, Discipline of Cardiology, Faculty of Medical Science, State University of Campinas, Campinas, Brazil
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17
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Cappelli F, Martone R, Gabriele M, Taborchi G, Morini S, Vignini E, Allinovi M, Di Gioia M, Bartolini S, Di Mario C, Perfetto F. Biomarkers and Prediction of Prognosis in Transthyretin-Related Cardiac Amyloidosis: Direct Comparison of Two Staging Systems. Can J Cardiol 2020; 36:424-431. [DOI: 10.1016/j.cjca.2019.12.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 12/13/2019] [Accepted: 12/22/2019] [Indexed: 01/17/2023] Open
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18
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Maurer MS, Bokhari S, Damy T, Dorbala S, Drachman BM, Fontana M, Grogan M, Kristen AV, Lousada I, Nativi-Nicolau J, Cristina Quarta C, Rapezzi C, Ruberg FL, Witteles R, Merlini G. Expert Consensus Recommendations for the Suspicion and Diagnosis of Transthyretin Cardiac Amyloidosis. Circ Heart Fail 2019; 12:e006075. [PMID: 31480867 DOI: 10.1161/circheartfailure.119.006075] [Citation(s) in RCA: 278] [Impact Index Per Article: 55.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Cardiomyopathy is a manifestation of transthyretin amyloidosis (ATTR), which is an underrecognized systemic disease whereby the transthyretin protein misfolds to form fibrils that deposit in various tissues and organs. ATTR amyloidosis is debilitating and associated with poor life expectancy, especially in those with cardiac dysfunction, but a variety of treatment options have recently become available. Considered a rare disease, ATTR amyloidosis may be more prevalent than thought, particularly in older persons. Diagnosis is often delayed because of a lack of disease awareness and the heterogeneity of symptoms at presentation. Given the recent availability of effective treatments, early recognition and diagnosis are especially critical because treatment is likely more effective earlier in the disease course. The Amyloidosis Research Consortium recently convened a group of experts in ATTR amyloidosis who, through an iterative process, agreed on best practices for suspicion, diagnosis, and characterization of disease. This review describes these consensus recommendations for ATTR associated with cardiomyopathy as a resource to aid cardiologists and others in the recognition and diagnosis of ATTR associated with cardiomyopathy. Included in this review is an overview of red flag signs and symptoms and a recommended diagnostic approach, including testing for monoclonal protein, scintigraphy, or biopsy and, if ATTR associated with cardiomyopathy is identified, TTR genotyping.
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Affiliation(s)
- Mathew S Maurer
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York (M.S.M., S.B.)
| | - Sabahat Bokhari
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York (M.S.M., S.B.)
| | - Thibaud Damy
- Department of Cardiology, Center for Cardiac Amyloidosis, GRC Amyloid Research Institute, DHU A-TVB, APHP CHU Henri Mondor and Université Paris Est Créteil, France (T.D.)
| | - Sharmila Dorbala
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, MA (S.D.)
| | - Brian M Drachman
- Department of Cardiovascular Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia (B.M.D.)
| | - Marianna Fontana
- National Amyloidosis Centre, Division of Medicine, University College London, United Kingdom (M.F., C.C.Q.)
| | - Martha Grogan
- Cardiovascular Medicine, Mayo Clinic, Rochester, MN (M.G.)
| | - Arnt V Kristen
- Department of Cardiology, Amyloidosis Center, University of Heidelberg, Germany (A.V.K.)
| | | | - Jose Nativi-Nicolau
- Division of Cardiovascular Medicine, University of Utah Health, Salt Lake City (J.N.-N.)
| | - Candida Cristina Quarta
- National Amyloidosis Centre, Division of Medicine, University College London, United Kingdom (M.F., C.C.Q.).,Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum University of Bologna, Italy (C.C.Q., C.R.)
| | - Claudio Rapezzi
- Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum University of Bologna, Italy (C.C.Q., C.R.)
| | - Frederick L Ruberg
- Cardiovascular Center, Boston University School of Medicine, Boston Medical Center, MA (F.L.R.)
| | - Ronald Witteles
- Stanford Amyloid Center, Division of Cardiovascular Medicine, Stanford University School of Medicine, CA (R.W.)
| | - Giampaolo Merlini
- Amyloidosis Center Foundation IRCCS Policlinico San Matteo, Italy (G.M.).,Department of Molecular Medicine, University of Pavia, Italy (G.M.)
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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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Michels da Silva D, Langer H, Graf T. Inflammatory and Molecular Pathways in Heart Failure-Ischemia, HFpEF and Transthyretin Cardiac Amyloidosis. Int J Mol Sci 2019; 20:ijms20092322. [PMID: 31083399 PMCID: PMC6540104 DOI: 10.3390/ijms20092322] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 05/01/2019] [Accepted: 05/07/2019] [Indexed: 02/06/2023] Open
Abstract
Elevated pro-inflammatory biomarkers and cytokines are associated with morbidity and mortality in heart failure (HF). Preclinical and clinical studies have shown multiple inflammatory mechanisms causing cardiac remodeling, dysfunction and chronic failure. Therapeutics in trials targeting the immune response in heart failure and its effects did not result in evident benefits regarding clinical endpoints and mortality. This review elaborates pathways of immune cytokines in pathogenesis and worsening of heart failure in clinical and cellular settings. Besides the well-known mechanisms of immune activation and inflammation in atherosclerosis causing ischemic cardiomyopathy or myocarditis, attention is focused on other mechanisms leading to heart failure such as transthyretin (TTR) amyloidosis or heart failure with preserved ejection fraction. The knowledge of the pathogenesis in heart failure and amyloidosis on a molecular and cellular level might help to highlight new disease defining biomarkers and to lead the way to new therapeutic targets.
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Affiliation(s)
- Diana Michels da Silva
- Department of Cardiology, Angiology and Intensive Care, Medicine Medical Clinic II, University Heart Center Lübeck, 23562 Lübeck, Germany.
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, 23562 Lübeck, Germany.
| | - Harald Langer
- Department of Cardiology, Angiology and Intensive Care, Medicine Medical Clinic II, University Heart Center Lübeck, 23562 Lübeck, Germany.
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, 23562 Lübeck, Germany.
| | - Tobias Graf
- Department of Cardiology, Angiology and Intensive Care, Medicine Medical Clinic II, University Heart Center Lübeck, 23562 Lübeck, Germany.
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, 23562 Lübeck, Germany.
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21
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Cappelli F, Gallini C, Di Mario C, Costanzo EN, Vaggelli L, Tutino F, Ciaccio A, Bartolini S, Angelotti P, Frusconi S, Farsetti S, Vergaro G, Giorgetti A, Marzullo P, Genovesi D, Emdin M, Perfetto F. Accuracy of 99mTc-Hydroxymethylene diphosphonate scintigraphy for diagnosis of transthyretin cardiac amyloidosis. J Nucl Cardiol 2019; 26:497-504. [PMID: 28537040 DOI: 10.1007/s12350-017-0922-z] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 05/04/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND AIM Either 99mTechnetium diphosphonate (Tc-DPD) or pyrophosphate (Tc-PYP) scintigraphy plays a relevant role in diagnosing transthyretin cardiac amyloidosis (CA), and labeled radiotracers have been extensively studied in diagnosing CA. Few studies have analyzed and validated 99mTc-Hydroxymethylene diphosphonate (Tc-HMDP). Our aim was to validate the diagnostic accuracy of Tc-HMDP total-body scintigraphy in a cohort of patients with biopsy-proven transthyretin CA. METHODS AND RESULTS We retrospectively evaluated all patients undergoing 99mTc-HMDP total-body scintigraphy, in adjunct to a comprehensive diagnostic work-up for suspected CA. Sixty-five patients were finally diagnosed with CA, while it was excluded in 20 subjects with left ventricular hypertrophy of various etiologies. Twenty-six patients had AL-CA, 39 had TTR CA (16 TTRm, 23 TTRwt). At Tc-HMDP scintigraphy, 2 AL patients showed a Perugini score grade 1 heart uptake, while 24 showed no uptake. All TTR patients showed Tc-HMDP uptake, with three patients showing a Perugini score grade 1, 16 grade 2, and 20 grade 3, respectively. No uptake was observed in patients with left ventricular hypertrophy. A positive Tc-HMDP scintigraphy showed a 100% sensitivity and a 96% specificity for TTR CA identification. CONCLUSIONS Tc-HMDP scintigraphy is as accurate as Tc-DPD or Tc-PYP, and may therefore de facto be considered a valuable tool for the diagnosis of TTR CA.
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Affiliation(s)
- Francesco Cappelli
- Tuscan Regional Amyloid Center, Azienda Ospedaliero Universitaria Careggi, Florence, Italy.
- Interventional Structural Cardiology Division, Careggi University Hospital, Florence, Italy.
- Department of Heart, Lung and Vessels, Intensive Cardiac Care Unit, Interventional Structural Cardiology Division, Careggi University Hospital, Largo Brambilla 3, 50134, Florence, Italy.
| | - Chiara Gallini
- Nuclear Medicine Division, Careggi University Hospital, Florence, Italy
| | - Carlo Di Mario
- Interventional Structural Cardiology Division, Careggi University Hospital, Florence, Italy
| | | | - Luca Vaggelli
- Nuclear Medicine Division, Careggi University Hospital, Florence, Italy
| | - Francesca Tutino
- Nuclear Medicine Division, Careggi University Hospital, Florence, Italy
| | - Alfonso Ciaccio
- Nuclear Medicine Division, Careggi University Hospital, Florence, Italy
| | - Simone Bartolini
- Interventional Structural Cardiology Division, Careggi University Hospital, Florence, Italy
| | - Paola Angelotti
- Tuscan Regional Amyloid Center, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Sabrina Frusconi
- Tuscan Regional Amyloid Center, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Silvia Farsetti
- Tuscan Regional Amyloid Center, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | | | | | | | | | - Michele Emdin
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Federico Perfetto
- Tuscan Regional Amyloid Center, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
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22
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Nochioka K, Quarta CC, Claggett B, Roca GQ, Rapezzi C, Falk RH, Solomon SD. Left atrial structure and function in cardiac amyloidosis. Eur Heart J Cardiovasc Imaging 2018. [PMID: 28637305 DOI: 10.1093/ehjci/jex097] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Aims Although cardiac amyloidosis (CA) is characterized by significant left atrial (LA) dilatation, the characteristics of LA function remain to be fully investigated. Methods and results We assessed LA function by speckle-tracking echocardiography in 124 patients with CA and sinus rhythm: 68 with light chain (AL), 29 with mutant (ATTRm), 27 with wild-type (ATTRwt) transthyretin amyloidosis. Conventional and strain-derived parameters, including LA peak longitudinal strain (LS) and strain rate (peak LSR: reservoir function; early LSR: conduit function; late LSR: active function), were assessed compared between CA patients and 20 healthy controls of similar age and gender. All LA function phases, including LA longitudinal strain, peak LSR, early and late LSR were significantly impaired in CA compared to healthy controls after adjusting for LA size, LV ejection fraction and LV filling pressures (E/E') (all P < 0.05). Peak LA LS was moderately correlated with LV global LS (R = -0.60, P < 0.001); late LSR was correlated with A wave at the level of LV inflow (R = -0.69, P < 0.001). Among the different CA subtypes, peak LS and LA active emptying fraction were worse in ATTRwt than AL and ATTRm [P < 0.05 after adjustment for age, sex, body mass index, systolic blood pressure, heart rate, LA volume index, severity of mitral regurgitation, left ejection fraction, and left ventricular end-diastolic pressure (E/E')]. Conclusion In CA, LA function was severely impaired and highly correlated with LV deformation. Differences in LA function between amyloid subtypes suggest that amyloid aetiology plays a role in the pathophysiology of cardiac dysfunction in CA.
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Affiliation(s)
- Kotaro Nochioka
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street Boston, MA 02115, USA.,Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Clinical Research, Innovation and Education Center, Tohoku University Hospital, Seiryo-machi 1-1 Aobaku Sendai, Miyagi 980-8574, Japan
| | - Candida Cristina Quarta
- Division of Medicine, National Amyloidosis Centre UCL, Royal Free Hospital, Rowland Hill Street, London NW3 2PF, UK.,Cardiology, Department of Experimental Diagnostic and Specialty Medicine, Alma Mater Studiorum University of Bolonga, PAD 21,Policlinico S.Orsola-Malpighi, via Massarenti 9, 40138 Bologna, Italy
| | - Brian Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street Boston, MA 02115, USA
| | - Gabriela Querejeta Roca
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street Boston, MA 02115, USA
| | - Claudio Rapezzi
- Cardiology, Department of Experimental Diagnostic and Specialty Medicine, Alma Mater Studiorum University of Bolonga, PAD 21,Policlinico S.Orsola-Malpighi, via Massarenti 9, 40138 Bologna, Italy
| | - Rodney H Falk
- Department of Cardiology, Harvard Vanguard Medical Associates, Brigham and Women's Hospital Cardiac Amyloidosis Program, Harvard Medical School, 75 Francis Street Boston, MA 02115, USA
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street Boston, MA 02115, USA
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23
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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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24
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Cappelli F, Baldasseroni S, Bergesio F, Spini V, Fabbri A, Angelotti P, Grifoni E, Attanà P, Tarantini F, Marchionni N, Moggi Pignone A, Perfetto F. Liver dysfunction as predictor of prognosis in patients with amyloidosis: utility of the Model for End-stage Liver disease (MELD) scoring system. Intern Emerg Med 2017; 12:23-30. [PMID: 27480755 DOI: 10.1007/s11739-016-1500-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 07/01/2016] [Indexed: 11/30/2022]
Abstract
Amyloidosis prognosis is often related to the onset of heart failure and a worsening that is concomitant with kidney-liver dysfunction; thus the Model for End-stage Liver disease (MELD) may be an ideal instrument to summarize renal-liver function. Our aim has been to test the MELD score as a prognostic tool in amyloidosis. We evaluated 128 patients, 46 with TTR-related amyloidosis and 82 with AL amyloidosis. All patients had a complete clinical and echocardiography evaluation; overall biohumoral assessment included troponin I, NT-proBNP, creatinine, total bilirubin and INR ratio. The study population was dichotomized at the 12 cut-off level of MELD scores; those with MELD score >12 had a lower survival compared to controls in the study cohort (40.7 vs 66.3 %; p = 0.006). Either as a continuous and dichotomized variable, MELD shows its independent prognostic value at multivariable analysis (HR = 1.199, 95 % CI 1.082-1.329; HR = 2.707, 95 % CI 1.075-6.817, respectively). MELD shows a lower prognostic sensitivity/specificity ratio than troponin I and NT-proBNP in the whole study population and AL subgroup, while in TTR patients MELD has a higher sensitivity/specificity ratio compared to troponin and NT-proBNP (ROC analysis-AUC: 0.853 vs 0.726 vs 0.659). MELD is able to predict prognosis in amyloidosis. A MELD score >12 selects a subgroup of patients with a higher risk of death. The predictive accuracy seems to be more evident in TTR patients in whom currently no effective scoring systems have been validated.
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Affiliation(s)
- Francesco Cappelli
- Intensive Cardiac Unit, Department of Heart and Vessels, University of Florence and Azienda Ospedaliero-Universitaria Careggi [AOUC], Largo Brambilla 3, 50134, Florence, Italy.
- Regional Amyloid Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - Samuele Baldasseroni
- Intensive Cardiac Unit, Department of Heart and Vessels, University of Florence and Azienda Ospedaliero-Universitaria Careggi [AOUC], Largo Brambilla 3, 50134, Florence, Italy
- Research Unit of Medicine of Aging, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Franco Bergesio
- Regional Amyloid Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Valentina Spini
- Intensive Cardiac Unit, Department of Heart and Vessels, University of Florence and Azienda Ospedaliero-Universitaria Careggi [AOUC], Largo Brambilla 3, 50134, Florence, Italy
| | - Alessia Fabbri
- Department of Heart and Vessels, University of Florence, Florence, Italy
| | - Paola Angelotti
- Department of Heart and Vessels, University of Florence, Florence, Italy
| | - Elisa Grifoni
- Department of Internal Medicine, University of Florence, Florence, Italy
| | - Paola Attanà
- Department of Internal Medicine, University of Florence, Florence, Italy
| | - Francesca Tarantini
- Research Unit of Medicine of Aging, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Niccolò Marchionni
- Research Unit of Medicine of Aging, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | | | - Federico Perfetto
- Regional Amyloid Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
- Department of Internal Medicine, University of Florence, Florence, Italy
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25
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Zhao L, Tian Z, Fang Q. Diagnostic accuracy of cardiovascular magnetic resonance for patients with suspected cardiac amyloidosis: a systematic review and meta-analysis. BMC Cardiovasc Disord 2016; 16:129. [PMID: 27267362 PMCID: PMC4897958 DOI: 10.1186/s12872-016-0311-6] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2015] [Accepted: 05/31/2016] [Indexed: 12/24/2022] Open
Abstract
Background This study is a systematic review and meta-analysis of the diagnostic value of cardiovascular magnetic resonance (CMR) in cardiac amyloidosis (CA). Methods A wide variety of electronic databases were searched for studies of CMR that reported the diagnostic accuracy in patients with suspected CA. Research manuscripts were subjected to further systematic review and meta-analysis. Methodological evaluation was performed under the guidance of the Quality Assessment of Diagnostic Accuracy Studies −2 (QUADAS–2). Heterogeneity was assessed, and a random-effects model was used to assess the diagnostic effects of CMR on pooled sensitivity, pooled specificity, and summary receiver operating characteristics (SROC). Results Seven studies that reported the performance of CMR for CA were included in the present systematic review, among which five studies (257 patients) that evaluated the diagnostic accuracy of late gadolinium enhancement (LGE) CMR were analyzed in the present meta-analysis. Heterogeneity was observed only in specificity. A summary sensitivity and specificity of 85 % (95 % CI: 77–91 %) and 92 % (95 % CI: 83–97 %) indicated a high diagnostic accuracy of LGE for CA. The AUC of SROC curve was 0.9530, suggesting that LGE is an effective way of diagnosing patients with possible cardiac involvement in amyloidosis. Conclusions LGE–CMR seems to have a relatively high diagnostic accuracy for amyloidosis patients with possible cardiac involvement. Combined CMR techniques may provide important information for the selection of suitable therapy. Electronic supplementary material The online version of this article (doi:10.1186/s12872-016-0311-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lei Zhao
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No.1 Shuaifuyuan, Wangfujing, Dongcheng District, Beijing, 100730, China
| | - Zhuang Tian
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No.1 Shuaifuyuan, Wangfujing, Dongcheng District, Beijing, 100730, China
| | - Quan Fang
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No.1 Shuaifuyuan, Wangfujing, Dongcheng District, Beijing, 100730, China.
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Narotsky DL, Castano A, Weinsaft JW, Bokhari S, Maurer MS. Wild-Type Transthyretin Cardiac Amyloidosis: Novel Insights From Advanced Imaging. Can J Cardiol 2016; 32:1166.e1-1166.e10. [PMID: 27568874 DOI: 10.1016/j.cjca.2016.05.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 05/06/2016] [Accepted: 05/07/2016] [Indexed: 12/24/2022] Open
Abstract
Amyloidosis is caused by extracellular deposition of abnormal protein fibrils, resulting in destruction of tissue architecture and impairment of organ function. The most common forms of systemic amyloidosis are light-chain and transthyretin-related (ATTR). ATTR can result from an autosomal dominant hereditary transmission of mutated genes in the transthyretin or from a wild-type form of disease (ATTRwt), previously known as senile cardiac amyloidosis. With the aging of the worldwide population, ATTRwt will emerge as the most common type of cardiac amyloidosis that clinicians encounter. Diagnosis of systemic amyloidosis is often delayed, either because of the false assumption that it is a rare disease, or because of misdiagnosis as a result of mistaking it with other conditions. Clinicians must integrate clinical clues from history, physical examination, and common diagnostic tests to raise suspicion for ATTRwt. The historical gold standard for diagnosis of cardiac amyloid is endomyocardial biopsy analysis with pathological distinction of precursor protein type, but this method often results in delayed diagnosis because of the limited availability of expertise to perform and interpret the endomyocardial biopsy specimen. Emerging noninvasive imaging modalities provide easier, accurate screening for ATTRwt. These modalities include advanced echocardiography, using strain imaging and the myocardial contraction fraction; nuclear scintigraphy, which can differentiate between ATTR and light-chain cardiac amyloid; and cardiac magnetic resonance imaging, using extracellular volume measurement, late gadolinium enhancement, and distinct T1 mapping. These novel approaches reveal insights into the prevalence, clinical course, morphological effects, and prognosis of ATTRwt.
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Affiliation(s)
- David L Narotsky
- Division of Cardiology, Columbia University Medical Center, New York, New York, USA
| | - Adam Castano
- Division of Cardiology, Columbia University Medical Center, New York, New York, USA
| | - Jonathan W Weinsaft
- Division of Cardiology, Weill Cornell Medical Center, New York, New York, USA
| | - Sabahat Bokhari
- Division of Cardiology, Columbia University Medical Center, New York, New York, USA
| | - Mathew S Maurer
- Division of Cardiology, Columbia University Medical Center, New York, New York, USA.
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27
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Mereles D, Aurich M, Greiner S, Riffel J, Buss SJ, Kristen AV, Katus HA. Diagnosis of cardiac involvement in systemic amyloidosis by state-of-the-art echocardiography: where are we now? Expert Opin Orphan Drugs 2016. [DOI: 10.1080/21678707.2016.1179573] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Derliz Mereles
- Department of Internal Medicine III, Cardiology, Angiology and Pneumology, University of Heidelberg, Heidelberg, Germany
| | - Matthias Aurich
- Department of Internal Medicine III, Cardiology, Angiology and Pneumology, University of Heidelberg, Heidelberg, Germany
| | - Sebastian Greiner
- Department of Internal Medicine III, Cardiology, Angiology and Pneumology, University of Heidelberg, Heidelberg, Germany
| | - Johannes Riffel
- Department of Internal Medicine III, Cardiology, Angiology and Pneumology, University of Heidelberg, Heidelberg, Germany
| | - Sebastian J. Buss
- Department of Internal Medicine III, Cardiology, Angiology and Pneumology, University of Heidelberg, Heidelberg, Germany
| | - Arnt V. Kristen
- Department of Internal Medicine III, Cardiology, Angiology and Pneumology, University of Heidelberg, Heidelberg, Germany
| | - Hugo A. Katus
- Department of Internal Medicine III, Cardiology, Angiology and Pneumology, University of Heidelberg, Heidelberg, Germany
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28
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Gertz MA, Benson MD, Dyck PJ, Grogan M, Coelho T, Cruz M, Berk JL, Plante-Bordeneuve V, Schmidt HHJ, Merlini G. Diagnosis, Prognosis, and Therapy of Transthyretin Amyloidosis. J Am Coll Cardiol 2016; 66:2451-2466. [PMID: 26610878 DOI: 10.1016/j.jacc.2015.09.075] [Citation(s) in RCA: 289] [Impact Index Per Article: 36.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 09/24/2015] [Accepted: 09/25/2015] [Indexed: 02/08/2023]
Abstract
Transthyretin amyloidosis is a fatal disorder that is characterized primarily by progressive neuropathy and cardiomyopathy. It occurs in both a mutant form (with autosomal dominant inheritance) and a wild-type form (with predominant cardiac involvement). This article guides clinicians as to when the disease should be suspected, describes the appropriate diagnostic evaluation for those with known or suspected amyloidosis, and reviews the interventions currently available for affected patients.
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Affiliation(s)
- Morie A Gertz
- Division of Hematology, Mayo Clinic, Rochester, Minnesota.
| | | | - Peter J Dyck
- Division of Peripheral Nerve, Mayo Clinic, Rochester, Minnesota
| | - Martha Grogan
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | | | - Marcia Cruz
- Federal University of Rio de Janeiro of Brazil, University Hospital, Rio de Janeiro, Brazil
| | - John L Berk
- Amyloidosis Center, Boston University School of Medicine, Boston, Massachusetts
| | | | | | - Giampaolo Merlini
- Department of Molecular Medicine, University of Pavia, Pavia, Lombardy, Italy
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29
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Senapati A, Sperry BW, Grodin JL, Kusunose K, Thavendiranathan P, Jaber W, Collier P, Hanna M, Popovic ZB, Phelan D. Prognostic implication of relative regional strain ratio in cardiac amyloidosis. Heart 2016; 102:748-54. [PMID: 26830665 DOI: 10.1136/heartjnl-2015-308657] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 01/11/2016] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE Cardiac amyloidosis (CA) is a rapidly progressive disease that portends poor prognosis. Our objective was to evaluate the prognostic impact of relative regional strain ratio (RRSR, a measure of the relative apical sparing of longitudinal strain (LS)) in CA. METHODS This is a retrospective study evaluating 97 patients with CA from 2004 to 2013. Patients were included if they met criteria for CA based on endomyocardial biopsy or advanced imaging criteria coupled with either extracardiac biopsy or genetic analysis. Baseline clinical and imaging data were collected and compared between light-chain amyloidosis (AL) (n=59) and transthyretin amyloidosis (ATTR) (n=38) subtypes. RRSR was defined as the average apical LS divided by the sum of the average mid and basal LS values. A Cox proportional hazards model was used to assess the effects of clinical and echocardiographic characteristics, including RRSR, on the outcome of time to death or heart transplantation. RESULTS Despite younger age, the AL subtype had a statistically significant association with the composite outcome as compared with ATTR (p=0.022). Log-transformed RRSR was independently associated with the composite outcome at 5 years (HR 2.45 (1.36 to 4.40), p=0.003). Patients with low ejection fraction and high RRSR had the worst prognosis. In multivariable analysis, RRSR remained predictive of the primary outcome (p=0.018). Addition of covariates related to systolic function (global LS and ejection fraction) to the model attenuated this effect. CONCLUSIONS High RRSR is adversely prognostic in patients with cardiac amyloid. This novel tool is both diagnostic and prognostic and may have implications in management and suitability for treatment.
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Affiliation(s)
- Alpana Senapati
- Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Brett W Sperry
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Justin L Grodin
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Kenya Kusunose
- Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Paaladinesh Thavendiranathan
- Peter Munk Cardiac Center, Ted Rogers Program in Cardiotoxicity Prevention, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Wael Jaber
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Patrick Collier
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mazen Hanna
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Dermot Phelan
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
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