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Kanaya H, Shiraishi S, Ogasawara K, Iwashita K, Sakamoto F, Takashio S, Mikami Y, Tsujita K, Hirai T. Inverse correlation between age of onset and myocardial amyloid deposition quantified by 99mTc-PYP scintigraphy in patients with wild-type transthyretin amyloid cardiomyopathy. Ann Nucl Med 2024; 38:744-753. [PMID: 38874878 DOI: 10.1007/s12149-024-01943-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 05/12/2024] [Indexed: 06/15/2024]
Abstract
OBJECTIVE Wild-type transthyretin amyloidosis cardiomyopathy (ATTRwt-CM) is increasingly recognized as a contributing factor to cardiac insufficiency in the elderly population. We aimed to identify the factors affecting age of onset of ATTRwt-CM, encompassing the assessment of amyloid deposition in myocardial tissue through the use of 99mTc-pyrophosphate (PYP) and clinical parameters. METHODS A retrospective investigation involving a consecutive cohort of 107 cases, each having been diagnosed with ATTRwt-CM confirmed through histopathological and genetic analysis, was performed. All patients underwent PYP scintigraphy, and the heart-to-contralateral (H/CL) ratio was calculated to measure amyloid deposition in the myocardium. Univariate and multivariate analyses were performed to identify independent predictors of the age of onset of ATTRwt-CM, considering the H/CL ratio and various clinical risk factors for heart failure. RESULTS Gender (p = 0.03), Creatinine (Cr) (r = 0.32, p < 0.01), hemoglobin (Hb) (r = - 0.44, p < 0.01), albumin (Alb) (r = - 0.32, p < 0.01), brain natriuretic peptide (BNP) (r = 0.21, p = 0.03), low-density lipoprotein-cholesterol (LDL-C) (r = - 0.27, p < 0.01), and H/CL ratio (r = - 0.44, p < 0.01) were all significantly associated with the onset age. In multiple regression analysis, the independent predictive factors for the onset age of ATTRwt-CM were identified as the H/CL ratio (p < 0.01), Hb (p < 0.01), and Cr (p < 0.01). CONCLUSION The H/CL ratio, Hb, and Cr independently affect age of onset in patients with ATTRwt-CM. The H/CL ratio is inversely correlated with age of onset, and may be the sole factor in the development of heart failure in early onset patients, while it may have a synergistic effect on heart failure with anemia and renal dysfunction in late-onset patients.
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Affiliation(s)
- Hiroshi Kanaya
- Department of Diagnostic Radiology, Graduate School of Life Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-Ku, Kumamoto, 860-8556, Japan
| | - Shinya Shiraishi
- Department of Diagnostic Radiology, Graduate School of Life Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-Ku, Kumamoto, 860-8556, Japan.
| | - Kouji Ogasawara
- Department of Diagnostic Radiology, Graduate School of Life Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-Ku, Kumamoto, 860-8556, Japan
| | - Koya Iwashita
- Department of Diagnostic Radiology, Graduate School of Life Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-Ku, Kumamoto, 860-8556, Japan
| | - Fumi Sakamoto
- Department of Diagnostic Medical Imaging, School of Health Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-Ku, Kumamoto, 860-8556, Japan
| | - Seiji Takashio
- Department of Cardiovascular Medicine, Graduate School of Life Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-Ku, Kumamoto, 860-8556, Japan
| | - Yoshiki Mikami
- Department of Diagnostic Pathology, Kumamoto University Hospital, 1-1-1 Honjo, Chuo-Ku, Kumamoto, 860-8556, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Life Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-Ku, Kumamoto, 860-8556, Japan
| | - Toshinori Hirai
- Department of Diagnostic Radiology, Graduate School of Life Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-Ku, Kumamoto, 860-8556, Japan
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Izumiya Y, Kubo T, Endo J, Takashio S, Minamisawa M, Hamada J, Ishii T, Abe H, Konishi H, Tsujita K. Transthyretin amyloid cardiomyopathy: Literature review and red-flag symptom clusters for each cardiology specialty. ESC Heart Fail 2024. [PMID: 39168835 DOI: 10.1002/ehf2.15016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 06/19/2024] [Accepted: 07/22/2024] [Indexed: 08/23/2024] Open
Abstract
Wild-type transthyretin amyloid cardiomyopathy (ATTRwt-CM) is a progressive and infiltrative cardiac disorder that may cause fatal consequences if left untreated. The estimated survival time from diagnosis is approximately 3-6 years. Because of the non-specificity of initial symptom manifestation and insufficient awareness among treating physicians, approximately one-third of patients with ATTRwt-CM are initially misdiagnosed with other cardiac diseases. Although heart failure (HF) is the most common initial manifestation of ATTRwt-CM, observed in nearly 70% of affected patients, patients may also present with other cardiologic symptoms, such as atrial fibrillation (AF) and aortic stenosis (AS). This non-specific and diverse nature of the initial ATTRwt-CM presentation indicates that various cardiology subspecialties are involved in patient diagnosis and management. Standard guideline-directed pharmacological treatment for HF is not recommended for patients with ATTRwt-CM because of its limited effectiveness. However, no established algorithms are available regarding HF management in this patient population. This literature review provides an overview of the red flags for ATTRwt-CM and research findings regarding HF management in this patient population. In addition to commonly recognized red flags for ATTRwt-CM (e.g., HF, AF and severe AS), published literature identified potential red flags such as coronary microvascular dysfunction. For HF management in patients with ATTRwt-CM, the use of mineralocorticoid receptor antagonists (MRAs) was reported as a well-tolerated option associated with a low discontinuation rate and reduced mortality. Although there is no concrete evidence for recommendations against sodium-glucose cotransporter 2 inhibitor (SGLT2i) administration, research supporting its use is limited to small-scale studies. Robust evidence is lacking for AF ablation, implantable cardioverter-defibrillators and cardiac resynchronization therapy. Based on the published findings and our clinical experience as Japanese ATTRwt-CM experts, red-flag symptom clusters for each cardiology specialty (HF, arrhythmia and ischaemia/structural heart disease) and a treatment scheme for HF management are presented. As this research area remains at an exploratory stage, our observations would require further discussion among experts worldwide.
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Affiliation(s)
- Yasuhiro Izumiya
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Toru Kubo
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University, Kochi, Japan
| | - Jin Endo
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Seiji Takashio
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Masatoshi Minamisawa
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | | | | | | | | | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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Brette JB, Colombat M, Fournier P, Moninhas M, Marcheix B, Lairez O, Cariou E. Descriptive study of the clinical and myocardial status of a population with anatomopathological aortic valve amyloidosis. Cardiovasc Pathol 2024; 73:107674. [PMID: 39025343 DOI: 10.1016/j.carpath.2024.107674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 07/06/2024] [Accepted: 07/07/2024] [Indexed: 07/20/2024] Open
Abstract
BACKGROUND Aortic stenosis (AS) and transthyretin (ATTR) cardiac amyloidosis (CA) share the same clinical profiles and cardiac phenotype. Amyloid deposits have been frequently reported in aortic valves of patients with severe AS referred for surgical aortic valve replacement (SAVR). The aim of this study was to determine the clinical and myocardial status of patients with aortic valve amyloidosis after aortic valve surgery. METHODS AND RESULTS We performed a retrospective descriptive study of 46 patients who underwent SAVR for severe AS with amyloid deposits upon histological analysis. All patients were screened for cardiac involvement. Amyloid deposits typing was successful in 35 (76%) patients and 28 (80%) were ATTR. Two (4%) had positive bone scintigraphy and among the 5 myocardial biopsies performed during surgery, 80% were positive for ATTR deposits. CONCLUSION ATTR is the predominant type in the presence of amyloid deposits on the aortic valve after surgery for severe AS but is only rarely accompanied by cardiac uptake on bone scintigraphy. Early stages of myocardial involvement are frequent and myocardial biopsy is more sensitive for detection of mild amyloid deposits than bone scintigraphy.
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Affiliation(s)
- Jean-Baptiste Brette
- Department of Cardiology, Toulouse University Hospital, France; Cardiac Imaging Center, Toulouse University Hospital, France
| | - Magali Colombat
- Medical School, Toulouse III Paul Sabatier University, Toulouse, France; Department of Pathology, IUCT Oncopôle, Toulouse France
| | - Pauline Fournier
- Department of Cardiology, Toulouse University Hospital, France; Cardiac Imaging Center, Toulouse University Hospital, France
| | - Maxime Moninhas
- Department of Cardiology, Toulouse University Hospital, France; Cardiac Imaging Center, Toulouse University Hospital, France
| | - Bertrand Marcheix
- Medical School, Toulouse III Paul Sabatier University, Toulouse, France; Department of Cardiac Surgery, Toulouse University Hospital, France
| | - Olivier Lairez
- Department of Cardiology, Toulouse University Hospital, France; Cardiac Imaging Center, Toulouse University Hospital, France; Department of Nuclear Medicine, Toulouse University Hospital, France; Medical School, Toulouse III Paul Sabatier University, Toulouse, France.
| | - Eve Cariou
- Department of Cardiology, Toulouse University Hospital, France; Cardiac Imaging Center, Toulouse University Hospital, France
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Yamasaki H, Kondo H, Shiroo T, Iwata N, Masuda T, Makita T, Iwabuchi Y, Tanazawa K, Takahashi M, Ono Y, Ogawa N, Harada T, Mitarai K, Yamauchi S, Takano M, Kodama N, Hirota K, Miyoshi M, Yonezu K, Tawara K, Abe I, Saito S, Fukui A, Fukuda T, Akioka H, Shinohara T, Akiyoshi K, Teshima Y, Yufu K, Daa T, Matsubara E, Asayama Y, Ueda M, Takahashi N. Efficacy of Computed Tomography-Based Evaluation of Myocardial Extracellular Volume Combined With Red Flags for Early Screening of Concealed Cardiac Amyloidosis in Patients With Atrial Fibrillation. Circ J 2024; 88:1167-1175. [PMID: 38522901 DOI: 10.1253/circj.cj-23-0948] [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] [Indexed: 03/26/2024]
Abstract
BACKGROUND The prevalence of transthyretin amyloid cardiomyopathy (ATTR-CM) in atrial fibrillation (AF) patients remains unclear. We explored the efficacy of computed tomography-based myocardial extracellular volume (CT-ECV) combined with red flags for the early screening of concealed ATTR-CM in AF patients undergoing catheter ablation. METHODS AND RESULTS Patients referred for AF ablation at Oita University Hospital were prescreened using the red-flag signs defined by echocardiographic or electrocardiographic findings, medical history, symptoms, and blood biochemical findings. Myocardial CT-ECV was quantified in red flag-positive patients using routine pre-AF ablation planning cardiac CT with the addition of delayed-phase cardiac CT scans. Patients with high (>35%) ECV were evaluated using technetium pyrophosphate (99 mTc-PYP) scintigraphy. A cardiac biopsy was performed during the planned AF ablation procedure if 99 mTc-PYP scintigraphy was positive. Between June 2022 and June 2023, 342 patients were referred for AF ablation. Sixty-seven (19.6%) patients had at least one of the red-flag signs. Myocardial CT-ECV was evaluated in 57 patients because of contraindications to contrast media, revealing that 16 patients had high CT-ECV. Of these, 6 patients showed a positive 99 mTc-PYP study, and 6 patients were subsequently diagnosed with wild-type ATTR-CM via cardiac biopsy and genetic testing. CONCLUSIONS CT-ECV combined with red flags could contribute to the systematic early screening of concealed ATTR-CM in AF patients undergoing catheter ablation.
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Affiliation(s)
- Hirochika Yamasaki
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Hidekazu Kondo
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Tomoaki Shiroo
- Department of Medical Technology, Oita University Hospital
| | - Naohiro Iwata
- Department of Medical Technology, Oita University Hospital
| | - Teruaki Masuda
- Department of Neurology, Faculty of Medicine, Oita University
| | - Taiki Makita
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Yuki Iwabuchi
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Kota Tanazawa
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Masaki Takahashi
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Yuma Ono
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Naoko Ogawa
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Taisuke Harada
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Kazuki Mitarai
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Shuichiro Yamauchi
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Masayuki Takano
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Nozomi Kodama
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Kei Hirota
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Miho Miyoshi
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Keisuke Yonezu
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Katsunori Tawara
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Ichitaro Abe
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Shotaro Saito
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Akira Fukui
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Tomoko Fukuda
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Hidefumi Akioka
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Tetsuji Shinohara
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Kumiko Akiyoshi
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Yasushi Teshima
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Kunio Yufu
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Tsutomu Daa
- Department of Diagnostic Pathology, Faculty of Medicine, Oita University
| | | | - Yoshiki Asayama
- Department of Radiology, Faculty of Medicine, Oita University
| | - Mitsuharu Ueda
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University
| | - Naohiko Takahashi
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
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Kurisu S, Fujiwara H. Deep vein thrombosis in a patient with wild-type transthyretin cardiac amyloidosis. J Cardiol Cases 2024; 29:218-221. [PMID: 39100518 PMCID: PMC11295011 DOI: 10.1016/j.jccase.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/22/2023] [Accepted: 01/09/2024] [Indexed: 08/06/2024] Open
Abstract
Wild-type transthyretin cardiac amyloidosis (ATTRwt-CA) is a progressive myocardial disease characterized by an increased ventricular wall thickness. ATTRwt-CA is often accompanied by monoclonal gammopathy of undetermined significance (MGUS), as indicated by an abnormal serum-free light chain ratio or detection of monoclonal protein (M-protein) on serum immunofixation electrophoresis. Increasing evidence has emerged regarding the risk of venous thromboembolic disease in patients with MGUS. Herein, we report a case of ATTRwt-CA with M-protein, where the patient developed deep vein thrombosis (DVT). A 72-year-old man presented with gradual progressive swelling of the right lower extremity. He had undergone surgical treatment for bilateral carpal syndrome and lumbar spinal canal stenosis. He was diagnosed with DVT and severe left ventricular (LV) hypertrophy, and was treated with a direct factor Xa inhibitor. Given severe LV hypertrophy, the patient underwent further cardiac examinations. 99mTc-labelled pyrophosphate scintigraphy revealed grade 3 myocardial uptake. Serum immunofixation electrophoresis detected IgA-κ M-protein. An endomyocardial biopsy revealed amyloid deposits. Based on immunohistochemical staining and genetic testing, the patient was diagnosed as having ATTRwt-CA with IgA-κ M-protein. Therefore, clinicians should be aware that ATTRwt-CA is often associated with M-protein. Under these conditions, attention should be paid to both pathological issues. Learning objective Wild-type transthyretin cardiac amyloidosis (ATTRwt-CA) is often accompanied by monoclonal gammopathy of undetermined significance (MGUS), as indicated by an abnormal serum-free light chain ratio or detection of monoclonal protein (M-protein). Meanwhile, increasing evidence has emerged about the risk of deep vein thrombosis (DVT) in patients with MGUS. We report a case of ATTRwt-CA with M-protein, in which DVT developed. Under these conditions, paying attention to both pathological aspects is warranted.
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Affiliation(s)
- Satoshi Kurisu
- Department of Cardiology, NHO Hiroshimanishi Medical Center, Otake, Japan
| | - Hitoshi Fujiwara
- Department of Cardiology, NHO Hiroshimanishi Medical Center, Otake, Japan
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Miyamoto M, Nakamura K, Nakagawa K, Nishii N, Kawada S, Ueoka A, Asada S, Watanabe A, Morita H, Ito H. Prevalence and Treatment of Arrhythmias in Patients With Transthyretin and Light-Chain Cardiac Amyloidosis. Circ Rep 2023; 5:298-305. [PMID: 37431518 PMCID: PMC10329899 DOI: 10.1253/circrep.cr-23-0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 05/22/2023] [Accepted: 05/29/2023] [Indexed: 07/12/2023] Open
Abstract
Background: Various types of arrhythmia are observed in patients with cardiac amyloidosis, but the prevalence of arrhythmia has not been fully investigated. This study investigated the prevalence and treatment of arrhythmias in patients with cardiac amyloidosis before the introduction of new agents for amyloidosis, such as tafamidis. Methods and Results: Of 53 patients who were histologically diagnosed with cardiac amyloidosis at 10 centers in western Japan between 2009 and 2021, 43 who were diagnosed on the basis of immunohistochemical staining were evaluated in this study. Of these 43 patients, 13 had immunoglobulin light-chain (AL) amyloidosis and 30 had transthyretin (ATTR) amyloidosis; further, 27 had atrial tachyarrhythmia, 13 had ventricular tachyarrhythmia, and 17 had bradyarrhythmia. Atrial fibrillation (AF) was the most common arrhythmia in patients with cardiac amyloidosis (n=24; 55.8%), especially among those with ATTR amyloidosis (70.0% of ATTR vs. 23.1% of AL). Eleven (25.6%) patients were treated with a cardiac implantable device. All 3 patients with pacemakers were alive at the last follow-up (median 76.7 months; interquartile range [IQR] 4.8-146.4 months). Of the 8 patients who underwent AF ablation, there was no recurrence in 6 (75%) after a median of 39.3 months (IQR 19.8-59.3 months). Conclusions: The prevalence of various arrhythmias was high in patients with cardiac amyloidosis. AF occurred most frequently in patients with cardiac amyloidosis, especially among patients with ATTR.
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Affiliation(s)
- Masakazu Miyamoto
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Okayama Japan
| | - Kazufumi Nakamura
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Okayama Japan
| | - Koji Nakagawa
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Okayama Japan
| | - Nobuhiro Nishii
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Okayama Japan
- Department of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Okayama Japan
| | - Satoshi Kawada
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Okayama Japan
| | - Akira Ueoka
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Okayama Japan
| | - Saori Asada
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Okayama Japan
| | - Atsuyuki Watanabe
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Okayama Japan
- Department of Cardiology, National Hospital Organization Okayama Medical Center Okayama Japan
| | - Hiroshi Morita
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Okayama Japan
- Department of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Okayama Japan
| | - Hiroshi Ito
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Okayama Japan
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Nagai T, Horinouchi H, Hashimoto K, Ichiji T, Yoshioka K, Hashimoto J, Ikari Y. Echocardiographic score for the screening of cardiac amyloidosis with positive 99m technetium pyrophosphate scintigraphy result. Echocardiography 2023. [PMID: 37243310 DOI: 10.1111/echo.15626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 04/06/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023] Open
Abstract
INTRODUCTION Speckle-tracking-derived strains in cardiac chambers may provide better solutions for transthyretin amyloid cardiomyopathy (ATTR-CM) screening. This study aimed to evaluate the efficacy of biventricular strain measurements using speckle tracking for screening 99m Tc-pyrophosphate (99m Tc-PYP) scintigraphy-positive cardiomyopathy, which is nearly equivalent to ATTR-CM. METHODS We performed a retrospective analysis of transthoracic echocardiographic studies using vendor-independent speckle tracking analysis in older patients (≥65 years) who underwent 99m Tc-PYP scintigraphy to evaluate the etiology of suspected ATTR-CM in our institute between January 2019 and December 2022. RESULTS The entire cohort (n = 89) was divided into two subgroups positive 99m Tc-PYP scan results (n = 34) and negative 99m Tc-PYP scan results (n = 55). In the multivariate analysis, posterior wall thickness (p = .003, odds ratio [OR]:1.48, 95% confidence interval [CI]:1.14 -1.92), left ventricular longitudinal strain apical/basal ratio (LVLSapi/bas) (p = .015, OR: 2.78, 95% CI: 1.23-6.32, and right ventricular longitudinal strain (RVLS) (p = .003, OR: 1.15, 95% CI: 1.05 -1.26) were selected to be the most representative echocardiographic findings in 99m Tc-PYP positive cardiomyopathy. The receiver operating characteristic analysis indicated that posterior wall thickness (p < .0001, area under the curve [AUC]: .821, cut-off value: 14.0 mm), LVLSapi/bas (p < .001, AUC: .802, cut-off value: 2,16), and RVLS (p < .001, AUC: .791, cut-off value: -18.7%) could significantly detect 99m Tc-PYP positive results with an excellent credibility. Echocardiographic score points calculated using the summary of these three parameters in each patient revealed that a 2-point score had a fair sensitivity (85%) and an excellent specificity (93%), while a 1-point score had an excellent sensitivity (91%) and a modest specificity (53%). CONCLUSION Our proposed echocardiographic screening tool for 99m Tc-PYP scintigraphy-positive cardiomyopathy may help clinicians manage patients with suspected ATTR-CM.
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Affiliation(s)
- Tomoo Nagai
- Division of Cardiology, Department of Internal Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Hitomi Horinouchi
- Division of Cardiology, Department of Internal Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Kaho Hashimoto
- Division of Cardiology, Department of Internal Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Takeshi Ichiji
- Division of Cardiology, Department of Internal Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Koichiro Yoshioka
- Division of Cardiology, Department of Internal Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Jun Hashimoto
- Department of Diagnostic Radiology, Tokai University School of Medicine, Kanagawa, Japan
| | - Yuji Ikari
- Division of Cardiology, Department of Internal Medicine, Tokai University School of Medicine, Kanagawa, Japan
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Naito T, Nakamura K, Abe Y, Watanabe H, Sakuragi S, Katayama Y, Kihara H, Okizaki A, Kawai Y, Yoshikawa M, Takaishi A, Fujio H, Otsuka H, Ogura S, Ito H, Nomura N, Matsumura Y, Nakashima M, Nikaido K, Ono T, Kawamura K, Arai J, Tobita S, Takahashi S, Tanimoto M. Prevalence of transthyretin amyloidosis among heart failure patients with preserved ejection fraction in Japan. ESC Heart Fail 2023. [DOI: 10.1002/ehf2.14364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
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9
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Obokata M, Sorimachi H, Harada T, Kagami K, Saito Y, Ishii H. Epidemiology, Pathophysiology, Diagnosis, and Therapy of Heart Failure With Preserved Ejection Fraction in Japan. J Card Fail 2023; 29:375-388. [PMID: 37162126 DOI: 10.1016/j.cardfail.2022.09.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 09/13/2022] [Accepted: 09/13/2022] [Indexed: 03/17/2023]
Abstract
Heart failure (HF) with preserved ejection fraction (HFpEF) is a global health care problem, with diagnostic difficulty, limited treatment options and high morbidity and mortality rates. The prevalence of HFpEF is increasing because of the aging population and the increasing burden of cardiac and metabolic comorbidities, such as systemic hypertension, diabetes, chronic kidney disease, and obesity. The knowledge base is derived primarily from the United States and Europe, and data from Asian countries, including Japan, remain limited. Given that phenotypic differences may exist between Japanese and Western patients with HFpEF, careful characterization may hold promise to deliver new therapy specific to the Japanese population. In this review, we summarize the current knowledge regarding the epidemiology, pathophysiology and diagnosis of and the potential therapies for HFpEF in Japan.
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Affiliation(s)
- Masaru Obokata
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan.
| | - Hidemi Sorimachi
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Tomonari Harada
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Kazuki Kagami
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan; Division of Cardiovascular Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Yuki Saito
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan; Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Hideki Ishii
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
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10
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Watanabe Y, Murata H, Takano H, Kiriyama T, Kunugi S, Hachisuka M, Uchiyama S, Matsuda J, Nakano H, Imori Y, Yodogawa K, Iwasaki YK, Kodani E, Shimizu A, Shimizu W. External Validation of the Kumamoto Criteria in Transthyretin Amyloid Cardiomyopathy Screening ― A Retrospective Cohort Study ―. Circ Rep 2022; 4:579-587. [DOI: 10.1253/circrep.cr-22-0110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 11/02/2022] [Indexed: 11/27/2022] Open
Affiliation(s)
| | | | - Hitoshi Takano
- Department of Cardiovascular Medicine, Nippon Medical School
| | | | - Shinobu Kunugi
- Department of Analytic Human Pathology, Graduate School of Medicine, Nippon Medical School
| | | | - Saori Uchiyama
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Junya Matsuda
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Hiroyuki Nakano
- Department of Cardiovascular Medicine, Nippon Medical School Tama-Nagayama Hospital
| | - Yoichi Imori
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Kenji Yodogawa
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Yu-ki Iwasaki
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Eitaro Kodani
- Department of Cardiovascular Medicine, Nippon Medical School Tama-Nagayama Hospital
| | - Akira Shimizu
- Department of Analytic Human Pathology, Graduate School of Medicine, Nippon Medical School
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School
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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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Inomata T, Tahara N, Nakamura K, Endo J, Ueda M, Ishii T, Kitano Y, Koyama J. Diagnosis of wild-type transthyretin amyloid cardiomyopathy in Japan: red-flag symptom clusters and diagnostic algorithm. ESC Heart Fail 2021; 8:2647-2659. [PMID: 34137515 PMCID: PMC8318452 DOI: 10.1002/ehf2.13473] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 04/09/2021] [Accepted: 05/31/2021] [Indexed: 01/04/2023] Open
Abstract
Wild‐type transthyretin amyloid cardiomyopathy (ATTRwt‐CM) is caused by the deposition of wild‐type transthyretin (TTR) amyloid fibrils in the heart. The age at diagnosis of ATTRwt‐CM is reported to be approximately 70–80 years, and patients commonly present with non‐disease‐specific cardiac abnormalities, such as heart failure with preserved ejection fraction and diastolic dysfunction. The disease can be fatal if left untreated, with an approximate survival of 3–5 years from diagnosis. An oral TTR stabilizer, tafamidis, has enabled early intervention for the treatment of ATTRwt‐CM. However, awareness of ATTRwt‐CM remains low, and misdiagnosis and a delay in diagnosis are common. This review discusses the epidemiology, characteristics, treatment strategy, and red‐flag symptoms and signs of ATTRwt‐CM based on the published literature, as well as recent advances in diagnostic modalities that enable early and accurate diagnosis of the disease. We also discuss an algorithm for early and accurate diagnosis of ATTRwt‐CM in daily clinical practice. In our diagnostic algorithm, a suspected diagnosis of ATTRwt‐CM should be triggered by unexplained left ventricular hypertrophy (LVH), which is LVH that cannot be explained by an increased afterload due to hypertension or valvular disease. In addition, heart failure symptoms, laboratory test results (N‐terminal pro‐B‐type natriuretic peptide, high‐sensitivity troponin T, or high‐sensitivity troponin I), electrocardiogram and imaging (echocardiogram or cardiac magnetic resonance) data, age (≥60 years), and medical history suggestive of ATTRwt‐CM (e.g. carpal tunnel syndrome) should be examined. Detailed examinations using bone scintigraphy and monoclonal protein detection tests followed by tissue biopsy, amyloid typing, and TTR genetic testing are warranted for a definite diagnosis of ATTRwt‐CM.
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Affiliation(s)
- Takayuki Inomata
- Department of Cardiovascular Medicine, Kitasato University Kitasato Institute Hospital, 5-9-1, Shirokane, Minato-ku, Tokyo, 108-8642, Japan
| | - Nobuhiro Tahara
- Division of Cardiovascular Medicine, Department of Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Kazufumi Nakamura
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Jin Endo
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Mitsuharu Ueda
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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