1
|
Ioannou A, Fumagalli C, Razvi Y, Porcari A, Rauf MU, Martinez-Naharro A, Venneri L, Moody W, Steeds RP, Petrie A, Whelan C, Wechalekar A, Lachmann H, Hawkins PN, Solomon SD, Gillmore JD, Fontana M. Prognostic Value of a 6-Minute Walk Test in Patients With Transthyretin Cardiac Amyloidosis. J Am Coll Cardiol 2024; 84:43-58. [PMID: 38739065 PMCID: PMC11218050 DOI: 10.1016/j.jacc.2024.04.011] [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: 03/13/2024] [Revised: 04/03/2024] [Accepted: 04/10/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND The 6-minute walk test (6MWT) represents a comprehensive functional assessment that is commonly used in patients with heart failure; however, data are lacking in patients with transthyretin cardiac amyloidosis (ATTR-CA). OBJECTIVES This study aimed to assess the prognostic importance of the 6MWT in patients with ATTR-CA. METHODS A retrospective analysis of patients diagnosed with ATTR-CA at the National Amyloidosis Centre who underwent a baseline 6MWT between 2011 and 2023 identified 2,141 patients, of whom 1,118 had follow-up at 1 year. RESULTS The median baseline 6MWT distance was 347 m (Q1-Q3: 250-428 m) and analysis by quartiles demonstrated an increased death rate with each distance reduction (deaths per 100 person-years: 6.3 vs 9.2 vs 13.6 vs 19.0; log-rank P < 0.001). A 6MWT distance of <350 m was associated with a 2.2-fold higher risk of mortality (HR: 2.15; 95% CI: 1.85-2.50; P < 0.001), with a similar increased risk across National Amyloidosis Centre disease stages (P for interaction = 0.761) and genotypes (P for interaction = 0.172). An absolute (reduction of >35 m) and relative worsening (reduction of >5%) of 6MWT at 1 year was associated with an increased risk of mortality (HR: 1.80; 95% CI: 1.51-2.15; P < 0.001 and HR: 1.89; 95% CI: 1.59-2.24; P < 0.001, respectively), which was similar across the aforementioned subgroups. When combined with established measures of disease progression (N-terminal pro-B-type natriuretic peptide progression and outpatient diuretic intensification), each incremental increase in progression markers was associated with an increased death rate (deaths per 100 person-years: 7.6 vs 13.9 vs 22.4 vs 32.9; log-rank P < 0.001). CONCLUSIONS The baseline 6MWT distance can refine risk stratification beyond traditional prognosticators. A worsening 6MWT distance can stratify disease progression and, when combined with established markers, identifies patients at the highest risk of mortality.
Collapse
Affiliation(s)
- Adam Ioannou
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Carlo Fumagalli
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom; Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Yousuf Razvi
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Aldostefano Porcari
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom; Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina, University of Trieste, Trieste, Italy
| | - Muhammad U Rauf
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Ana Martinez-Naharro
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Lucia Venneri
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - William Moody
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom; Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham, United Kingdom
| | - Richard P Steeds
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom; Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham, United Kingdom
| | - Aviva Petrie
- University College London, London, United Kingdom
| | - Carol Whelan
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Ashutosh Wechalekar
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Helen Lachmann
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Philip N Hawkins
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Julian D Gillmore
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Marianna Fontana
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom.
| |
Collapse
|
2
|
Porcari A, Fontana M, Canepa M, Biagini E, Cappelli F, Gagliardi C, Longhi S, Pagura L, Tini G, Dore F, Bonfiglioli R, Bauckneht M, Miceli A, Girardi F, Martini AL, Barbati G, Costanzo EN, Caponetti AG, Paccagnella A, Sguazzotti M, La Malfa G, Zampieri M, Sciagrà R, Perfetto F, Rowczenio D, Gilbertson J, Hutt DF, Hawkins PN, Rapezzi C, Merlo M, Sinagra G, Gillmore JD. Clinical and Prognostic Implications of Right Ventricular Uptake on Bone Scintigraphy in Transthyretin Amyloid Cardiomyopathy. Circulation 2024; 149:1157-1168. [PMID: 38328945 PMCID: PMC11000629 DOI: 10.1161/circulationaha.123.066524] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 01/16/2024] [Indexed: 02/09/2024]
Abstract
BACKGROUND The extent of myocardial bone tracer uptake with technetium pyrophosphate, hydroxymethylene diphosphonate, and 3,3-diphosphono-1,2-propanodicarboxylate in transthyretin amyloid cardiomyopathy (ATTR-CM) might reflect cardiac amyloid burden and be associated with outcome. METHODS Consecutive patients with ATTR-CM who underwent diagnostic bone tracer scintigraphy with acquisition of whole-body planar and cardiac single-photon emission computed tomography (SPECT) images from the National Amyloidosis Centre and 4 Italian centers were included. Cardiac uptake was defined according to the Perugini classification: 0=absent cardiac uptake; 1=mild uptake less than bone; 2=moderate uptake equal to bone; and 3=high uptake greater than bone. Extent of right ventricular (RV) uptake was defined as focal (basal segment of the RV free wall only) or diffuse (extending beyond basal segment) on the basis of SPECT imaging. The primary outcome was all-cause mortality. RESULTS Among 1422 patients with ATTR-CM, RV uptake accompanying left ventricular uptake was identified by SPECT imaging in 100% of cases at diagnosis. Median follow-up in the whole cohort was 34 months (interquartile range, 21 to 50 months), and 494 patients died. By Kaplan-Meier analysis, diffuse RV uptake on SPECT imaging (n=936) was associated with higher all-cause mortality compared with focal (n=486) RV uptake (77.9% versus 22.1%; P<0.001), whereas Perugini grade was not associated with survival (P=0.27 in grade 2 versus grade 3). On multivariable analysis, after adjustment for age at diagnosis (hazard ratio [HR], 1.03 [95% CI, 1.02-1.04]; P<0.001), presence of the p.(V142I) TTR variant (HR, 1.42 [95% CI, 1.20-1.81]; P=0.004), National Amyloidosis Centre stage (each category, P<0.001), stroke volume index (HR, 0.99 [95% CI, 0.97-0.99]; P=0.043), E/e' (HR, 1.02 [95% CI, 1.007-1.03]; P=0.004), right atrial area index (HR, 1.05 [95% CI, 1.02-1.08]; P=0.001), and left ventricular global longitudinal strain (HR, 1.06 [95% CI, 1.03-1.09]; P<0.001), diffuse RV uptake on SPECT imaging (HR, 1.60 [95% CI, 1.26-2.04]; P<0.001) remained an independent predictor of all-cause mortality. The prognostic value of diffuse RV uptake was maintained across each National Amyloidosis Centre stage and in both wild-type and hereditary ATTR-CM (P<0.001 and P=0.02, respectively). CONCLUSIONS Diffuse RV uptake of bone tracer on SPECT imaging is associated with poor outcomes in patients with ATTR-CM and is an independent prognostic marker at diagnosis.
Collapse
Affiliation(s)
- Aldostefano Porcari
- National Amyloidosis Centre, Division of Medicine, University College London, UK (A.P., M.F., D.R., J.G., D.F.H., P.N.H., J.D.G.)
- Centre for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina and University of Trieste, Italy (A.P., L.P., M.M., G.S.)
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart (A.P., E.B., C.G., S.L., L.P., A.G.C., M.S., M.M., G.S.)
| | - Marianna Fontana
- National Amyloidosis Centre, Division of Medicine, University College London, UK (A.P., M.F., D.R., J.G., D.F.H., P.N.H., J.D.G.)
- Centre for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina and University of Trieste, Italy (A.P., L.P., M.M., G.S.)
| | - Marco Canepa
- Cardiovascular Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy (M.C., G.L.M.)
- Department of Internal Medicine, University of Genova, Italy (M.C.)
| | - Elena Biagini
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart (A.P., E.B., C.G., S.L., L.P., A.G.C., M.S., M.M., G.S.)
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy (E.B., C.G., S.L.)
| | - Francesco Cappelli
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy (F.C., F.P.)
- Cardiomyopathy Unit, Careggi University Hospital, University of Florence, Italy (F.C., M.Z.)
- Department of Nuclear Medicine, Azienda Sanitaria Universitaria Giuliano-Isontina and University of Trieste, Italy (F.D., F.G.)
| | - Christian Gagliardi
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart (A.P., E.B., C.G., S.L., L.P., A.G.C., M.S., M.M., G.S.)
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy (E.B., C.G., S.L.)
| | - Simone Longhi
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart (A.P., E.B., C.G., S.L., L.P., A.G.C., M.S., M.M., G.S.)
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy (E.B., C.G., S.L.)
| | - Linda Pagura
- Centre for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina and University of Trieste, Italy (A.P., L.P., M.M., G.S.)
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart (A.P., E.B., C.G., S.L., L.P., A.G.C., M.S., M.M., G.S.)
| | - Giacomo Tini
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Azienda Ospedaliera Universitaria Sant’Andrea, Italy (G.T.)
| | - Franca Dore
- Department of Nuclear Medicine, Azienda Sanitaria Universitaria Giuliano-Isontina and University of Trieste, Italy (F.D., F.G.)
| | - Rachele Bonfiglioli
- Department of Nuclear Medicine, IRCCS, University Sant’Orsola Hospital, University of Bologna, Italy (R.B., A.P.)
| | - Matteo Bauckneht
- Nuclear Medicine, IRCCS Ospedale Policlinico San Martino, Genova, Italy (M.B.)
- Nuclear Medicine, Department of Health Sciences (DISSAL), University of Genova, Italy (M.B.)
| | - Alberto Miceli
- Nuclear Medicine Unit, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy (A.M.)
| | - Francesca Girardi
- Department of Nuclear Medicine, Azienda Sanitaria Universitaria Giuliano-Isontina and University of Trieste, Italy (F.D., F.G.)
| | - Anna Lisa Martini
- Nuclear Medicine Unit, Department of Experimental and Clinical Biomedical Sciences “Mario Serio,” University of Florence, Careggi University Hospital, Italy (A.L.M., E.N.C., R.S.)
| | - Giulia Barbati
- Department of Medical Sciences, Biostatistics Unit, University of Trieste, Italy (G.B.)
| | - Egidio Natalino Costanzo
- Nuclear Medicine Unit, Department of Experimental and Clinical Biomedical Sciences “Mario Serio,” University of Florence, Careggi University Hospital, Italy (A.L.M., E.N.C., R.S.)
| | - Angelo Giuseppe Caponetti
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy (A.G.C., M.S.)
| | - Andrea Paccagnella
- Department of Nuclear Medicine, IRCCS, University Sant’Orsola Hospital, University of Bologna, Italy (R.B., A.P.)
| | - Maurizio Sguazzotti
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart (A.P., E.B., C.G., S.L., L.P., A.G.C., M.S., M.M., G.S.)
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy (A.G.C., M.S.)
| | - Giovanni La Malfa
- Cardiovascular Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy (M.C., G.L.M.)
| | - Mattia Zampieri
- Cardiomyopathy Unit, Careggi University Hospital, University of Florence, Italy (F.C., M.Z.)
| | - Roberto Sciagrà
- Nuclear Medicine Unit, Department of Experimental and Clinical Biomedical Sciences “Mario Serio,” University of Florence, Careggi University Hospital, Italy (A.L.M., E.N.C., R.S.)
| | - Federico Perfetto
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy (F.C., F.P.)
| | - Dorota Rowczenio
- National Amyloidosis Centre, Division of Medicine, University College London, UK (A.P., M.F., D.R., J.G., D.F.H., P.N.H., J.D.G.)
| | - Janet Gilbertson
- National Amyloidosis Centre, Division of Medicine, University College London, UK (A.P., M.F., D.R., J.G., D.F.H., P.N.H., J.D.G.)
| | - David F. Hutt
- National Amyloidosis Centre, Division of Medicine, University College London, UK (A.P., M.F., D.R., J.G., D.F.H., P.N.H., J.D.G.)
| | - Philip N. Hawkins
- National Amyloidosis Centre, Division of Medicine, University College London, UK (A.P., M.F., D.R., J.G., D.F.H., P.N.H., J.D.G.)
| | - Claudio Rapezzi
- Cardiothoracic Department, University of Ferrara, Italy (C.R.)
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, Ravenna, Italy (C.R.)
| | - Marco Merlo
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart (A.P., E.B., C.G., S.L., L.P., A.G.C., M.S., M.M., G.S.)
| | - Gianfranco Sinagra
- Centre for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina and University of Trieste, Italy (A.P., L.P., M.M., G.S.)
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart (A.P., E.B., C.G., S.L., L.P., A.G.C., M.S., M.M., G.S.)
| | - Julian D. Gillmore
- National Amyloidosis Centre, Division of Medicine, University College London, UK (A.P., M.F., D.R., J.G., D.F.H., P.N.H., J.D.G.)
| |
Collapse
|
3
|
Ioannou A, Nitsche C, Porcari A, Patel RK, Razvi Y, Rauf MU, Martinez‐Naharro A, Venneri L, Accietto A, Netti L, Bandera F, Virsinskaite R, Kotecha T, Knight D, Petrie A, Whelan C, Wechalekar A, Lachmann H, Hawkins PN, Gillmore JD, Fontana M. Multiorgan Dysfunction and Associated Prognosis in Transthyretin Cardiac Amyloidosis. J Am Heart Assoc 2024; 13:e033094. [PMID: 38314569 PMCID: PMC11010096 DOI: 10.1161/jaha.123.033094] [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: 10/16/2023] [Accepted: 01/08/2024] [Indexed: 02/06/2024]
Abstract
BACKGROUND Transthyretin cardiac amyloidosis (ATTR-CA) is a progressive and ultimately fatal cardiomyopathy. Biomarkers reflecting multiorgan dysfunction are of increasing importance in patients with heart failure; however, their significance in ATTR-CA remains largely unknown. The aims of this study were to characterize the multifaceted nature of ATTR-CA using blood biomarkers and assess the association between blood biomarkers and prognosis. METHODS AND RESULTS This is a retrospective cohort study of 2566 consecutive patients diagnosed with ATTR-CA between 2007 and 2023. Anemia (39%), high urea (52%), hyperbilirubinemia (18%), increased alkaline phosphatase (16%), increased CRP (C-reactive protein; 27%), and increased troponin (98.2%) were common findings in the overall population, whereas hyponatremia (6%) and hypoalbuminemia (2%) were less common. These abnormalities were most common in patients with p.(V142I) hereditary ATTR-CA, and became more prevalent as the severity of cardiac disease increased. Multivariable Cox regression analysis demonstrated that anemia (hazard ratio [HR], 1.19 [95% CI, 1.04-1.37]; P=0.01), high urea (HR, 1.23 [95% CI, 1.04-1.45]; P=0.01), hyperbilirubinemia (HR, 1.32 [95% CI, 1.13-1.57; P=0.001), increased alkaline phosphatase (HR, 1.20 [95% CI, 1.01-1.42; P=0.04), hyponatremia (HR, 1.65 [95% CI, 1.28-2.11]; P<0.001), and troponin-T >56 ng/L (HR, 1.72 [95% CI, 1.46-2.03]; P<0.001) were all independently associated with mortality in the overall population. The association between biomarkers and mortality varied across the spectrum of genotypes and left ventricular ejection fraction, with anemia remining independently associated with mortality in p.(V142I) hereditary ATTR-CA (HR, 1.58 [95% CI, 1.17-2.12]; P=0.003) and in a subgroup of the overall population with a left ventricular ejection fraction ≤40% (HR, 1.39 [95% CI, 1.08-1.81]; P=0.01). CONCLUSIONS Cardiac and noncardiac biomarker abnormalities were common and reflect the complex and multifaceted nature of ATTR-CA, with a wide range of biomarkers remaining independently associated with mortality. Clinical trials are needed to investigate whether biomarker abnormalities represent modifiable risk factors that if specifically targeted could improve outcomes.
Collapse
Affiliation(s)
- Adam Ioannou
- National Amyloidosis CentreUniversity College LondonLondonUnited Kingdom
| | - Christian Nitsche
- National Amyloidosis CentreUniversity College LondonLondonUnited Kingdom
| | - Aldostefano Porcari
- National Amyloidosis CentreUniversity College LondonLondonUnited Kingdom
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular DepartmentAzienda Sanitaria Universitaria Giuliano‐Isontina, University of TriesteTriesteItaly
| | - Rishi K. Patel
- National Amyloidosis CentreUniversity College LondonLondonUnited Kingdom
| | - Yousuf Razvi
- National Amyloidosis CentreUniversity College LondonLondonUnited Kingdom
| | - Muhammad U. Rauf
- National Amyloidosis CentreUniversity College LondonLondonUnited Kingdom
| | | | - Lucia Venneri
- National Amyloidosis CentreUniversity College LondonLondonUnited Kingdom
| | - Antonella Accietto
- Cardiology Unit, Department of Cardiac Thoracic and VascularIstituto di Ricovero e Cura a Carattere Scientifico Azienda Ospedaliero–Universitaria di BolognaBolognaItaly
| | - Lucrezia Netti
- Department of Clinical, Internal, Anesthesiological and Cardiovascular SciencesSapienza University of RomeRomeItaly
| | - Francesco Bandera
- Heart Failure and Rehabilitation Unit, IRCCS MultiMedica, Sesto San GiovanniMilanItaly
- Department for Biomedical Sciences for HealthUniversity of MilanoMilanItaly
| | - Ruta Virsinskaite
- National Amyloidosis CentreUniversity College LondonLondonUnited Kingdom
| | - Tushar Kotecha
- National Amyloidosis CentreUniversity College LondonLondonUnited Kingdom
| | - Dan Knight
- National Amyloidosis CentreUniversity College LondonLondonUnited Kingdom
| | | | - Carol Whelan
- National Amyloidosis CentreUniversity College LondonLondonUnited Kingdom
| | | | - Helen Lachmann
- National Amyloidosis CentreUniversity College LondonLondonUnited Kingdom
| | - Philip N. Hawkins
- National Amyloidosis CentreUniversity College LondonLondonUnited Kingdom
| | - Julian D. Gillmore
- National Amyloidosis CentreUniversity College LondonLondonUnited Kingdom
| | - Marianna Fontana
- National Amyloidosis CentreUniversity College LondonLondonUnited Kingdom
| |
Collapse
|