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Singulane C, Sun D, Hu Z, Lee L, Sarswat N, Emami Neyestanak M, Patel AR, Lang RM, Addetia K. Defining echocardiographic predictors of outcome in cardiac amyloidosis by subtype. Curr Probl Cardiol 2024; 49:102729. [PMID: 38945183 DOI: 10.1016/j.cpcardiol.2024.102729] [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: 06/23/2024] [Accepted: 06/26/2024] [Indexed: 07/02/2024]
Abstract
BACKGROUND Current echocardiographic risk factors for prognosis in cardiac amyloidosis (CA) do not distinguish between the two main subtypes: transthyretin cardiomyopathy (TTR) and immunoglobulin light chain cardiomyopathy (AL), each of which require distinct diagnostic and therapeutic approaches. Additionally, only traditional parameters have been studied with little data on advanced techniques. Accordingly, we sought to determine whether differences exist in 2D transthoracic echocardiography (2DE) predictors of survival between the CA subtypes using a comprehensive approach. METHODS 220 patients (72±12 years) with confirmed CA (AL=89, TTR=131) who underwent 2DE at the time of CA diagnosis were enrolled. Left ventricular (LV) dimensions, indexed mass (LVMi), global longitudinal strain (LVGLS), apical-sparing ratio (LVASR), diastology, right ventricular (RV) size and function indices including tricuspid annular systolic excursion (TAPSE), RV free-wall (RVFWS) and global (RVGLS) strain, indexed left (LA) and right atrial volumes (LAVi and RAVi), LA strain (reservoir and booster) and RV systolic pressure (RVSP) were measured. A propensity-score weighted stepwise variable selection Cox proportional hazards model derived from NYHA class and renal impairment status at diagnosis was used to determine the associations between 2DE parameters and mortality specific to CA subtype over a median follow-up of 36-months. RESULTS After adjusting for age, atrial fibrillation and treatment, parameters associated with survival were RVFWS (p=0.003, HR 1.15, 95% CI[1.053,1.245]) and RVSP (p=0.03, HR 1.03, 95% CI[1.004,1.063]) in AL and LVASR (p=0.007, HR 6.68, 95% CI[1.75,25.492]) and RAVi (p=0.049, HR 1.03, 95% CI[1.000,1.052]) in TTR. CONCLUSIONS Echocardiographic prognosticators for survival are specific to cardiac amyloid subtype. These results potentially provide information critical for clinical decision-making and follow-up in these patients.
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Affiliation(s)
- Cristiane Singulane
- University of Chicago, Department of Medicine, Section of Cardiology, Chicago, IL, USA
| | - Deyu Sun
- University of Chicago, Department of Medicine, Section of Cardiology, Chicago, IL, USA
| | - Zhen Hu
- University of Chicago, Department of Medicine, Section of Cardiology, Chicago, IL, USA
| | - Linda Lee
- University of Chicago, Department of Medicine, Section of Cardiology, Chicago, IL, USA
| | - Nitasha Sarswat
- University of Chicago, Department of Medicine, Section of Cardiology, Chicago, IL, USA
| | | | - Amit R Patel
- University of Chicago, Department of Medicine, Section of Cardiology, Chicago, IL, USA
| | - Roberto M Lang
- University of Chicago, Department of Medicine, Section of Cardiology, Chicago, IL, USA
| | - Karima Addetia
- University of Chicago, Department of Medicine, Section of Cardiology, Chicago, IL, USA.
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Nemes A. Myocardial Mechanics and Valvular and Vascular Abnormalities in Cardiac Amyloidosis. J Clin Med 2024; 13:4330. [PMID: 39124597 PMCID: PMC11313348 DOI: 10.3390/jcm13154330] [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: 05/08/2024] [Revised: 07/16/2024] [Accepted: 07/19/2024] [Indexed: 08/12/2024] Open
Abstract
Cardiac amyloidosis is an infiltrative disease primarily caused by extracellular tissue deposition of amyloid fibrils in the myocardial interstitium. The aim of the present review was to summarize findings regarding changes in myocardial mechanics, valvular abnormalities, and vascular remodeling detected in patients with cardiac amyloidosis.
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Affiliation(s)
- Attila Nemes
- Department of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Semmelweis Street 8, P.O. Box 427, 6725 Szeged, Hungary
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3
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Yang H, Li R, Ma F, Liu Y, He X, Yang Q, Wang DW, Zeng H, Wang H. Echocardiographic phenotype for refined risk stratification and treatment selection in light chain amyloidosis with heart failure. J Cancer Res Clin Oncol 2023:10.1007/s00432-023-04783-2. [PMID: 37084113 DOI: 10.1007/s00432-023-04783-2] [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: 02/09/2023] [Accepted: 04/15/2023] [Indexed: 04/22/2023]
Abstract
AIMS Light chain amyloidosis (AL) patients with heart failure (HF) are usually with revised Mayo (rMayo) stage III/IV disease and have a poor prognosis. We sought to investigate whether and what echocardiographic phenotype provides value for further risk stratification and guiding optimal risk-adapted treatment in this subgroup of AL patients. METHODS AND RESULTS 95 AL patients who presented with HF and were on rMayo stage III/IV were retrospectively included. Of them, 51 patients (53.7%) were with stage III, 44 (46.3%) were with stage IV, and 44 (46.3%) underwent chemotherapy. Laboratory and echocardiographic measurements were acquired before the initiation of chemotherapy. The relevance of different variables with survival was assessed in the entire cohort, chemotherapy, and non-chemotherapy group. By Multivariate Cox regression analysis, right ventricular wall thickness (RVT) [HR 1.145, 95% confidence interval (CI) 1.026-1.279, P = 0.016], relative wall thickness (RWT) (HR 6.709, 95% CI 1.101-40.877, P = 0.039), and left ventricular ejection fraction (LVEF) < 50% (HR 1.939, 95% CI 1.048-3.590, P = 0.035) were found to be independently associated with survival in the entire cohort, RWT (HR 15.488, 95% CI 2.045-117.292, P = 0.008) in the non-chemotherapy group, and RVT (HR 1.331, 95% CI 1.054-1.681, P = 0.016) in the chemotherapy group, respectively. Kaplan-Meier survival analysis revealed that survival was significantly reduced in the presence of RVT ≥ 6.5 mm or LVEF < 50% in the entire cohort, and the significance of RVT ≥ 6.5 mm was irrespective of rMayo stages. In the chemotherapy group, survival was decreased if RVT ≥ 6.5 mm alone or together with RWT ≥ 0.67 were present, particularly in patients on rMayo stage IV. CONCLUSIONS Echocardiographic phenotype provides incremental value beyond rMayo staging for predicting survival and could further guide treatment in advanced AL with HF. Those with high-risk echocardiographic phenotypes as higher RVT and RWT and lower LVEF had a worse prognosis.
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Affiliation(s)
- Hong Yang
- Division of Cardiology and Department of Internal Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, #1095 Jiefang Ave., Wuhan, 430030, People's Republic of China
| | - Rui Li
- Division of Cardiology and Department of Internal Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, #1095 Jiefang Ave., Wuhan, 430030, People's Republic of China
| | - Fei Ma
- Division of Cardiology and Department of Internal Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, #1095 Jiefang Ave., Wuhan, 430030, People's Republic of China
| | - Yujian Liu
- Division of Cardiology and Department of Internal Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, #1095 Jiefang Ave., Wuhan, 430030, People's Republic of China
| | - Xingwei He
- Division of Cardiology and Department of Internal Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, #1095 Jiefang Ave., Wuhan, 430030, People's Republic of China
| | - Qiao Yang
- Division of Cardiology and Department of Internal Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, #1095 Jiefang Ave., Wuhan, 430030, People's Republic of China
| | - Dao Wen Wang
- Division of Cardiology and Department of Internal Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, #1095 Jiefang Ave., Wuhan, 430030, People's Republic of China
| | - Hesong Zeng
- Division of Cardiology and Department of Internal Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, #1095 Jiefang Ave., Wuhan, 430030, People's Republic of China.
| | - Hong Wang
- Division of Cardiology and Department of Internal Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, #1095 Jiefang Ave., Wuhan, 430030, People's Republic of China.
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Fujita Y, Yano T, Kanamori H, Nagahara D, Muranaka A, Kouzu H, Mochizuki A, Koyama M, Nagano N, Fujito T, Nishikawa R, Kamiyama N, Tanaka M, Kuno A, Tanno M, Miura T. Enhanced nuclear localization of phosphorylated MLKL predicts adverse events in patients with dilated cardiomyopathy. ESC Heart Fail 2022; 9:3435-3451. [PMID: 35851586 PMCID: PMC9715765 DOI: 10.1002/ehf2.14059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 04/28/2022] [Accepted: 06/27/2022] [Indexed: 11/09/2022] Open
Abstract
AIMS The role of necroptosis in dilated cardiomyopathy (DCM) remains unclear. Here, we examined whether phosphorylation of mixed lineage kinase domain-like protein (MLKL), an indispensable event for execution of necroptosis, is associated with the progression of DCM. METHODS AND RESULTS Patients with DCM (n = 56, 56 ± 15 years of age; 68% male) were enrolled for immunohistochemical analyses of biopsies. Adverse events were defined as a composite of death or admission for heart failure or ventricular arrhythmia. Compared with the normal myocardium, increased signals of MLKL phosphorylation were detected in the nuclei, cytoplasm, and intercalated discs of cardiomyocytes in biopsy samples from DCM patients. The phosphorylated MLKL (p-MLKL) signal was increased in enlarged nuclei or nuclei with bizarre shapes in hypertrophied cardiomyocytes. Nuclear p-MLKL level was correlated negatively with septal peak myocardial velocity during early diastole (r = -0.327, P = 0.019) and was correlated positively with tricuspid regurgitation pressure gradient (r = 0.339, P = 0.023), while p-MLKL level in intercalated discs was negatively correlated with mean left ventricular wall thickness (r = -0.360, P = 0.014). During a median follow-up period of 3.5 years, 10 patients (18%) had adverse events. To examine the difference in event rates according to p-MLKL expression levels, patients were divided into two groups by using the median value of nuclear p-MLKL or intercalated disc p-MLKL. A group with high nuclear p-MLKL level (H-nucMLKL group) had a higher adverse event rate than did a group with low nuclear p-MLKL level (L-nucMLKL group) (32% vs. 4%, P = 0.012), and Kaplan-Meier survival curves showed that the adverse event-free survival rate was lower in the H-nucMLKL group than in the L-nucMLKL group (P = 0.019 by the log-rank test). Such differences were not detected between groups divided by a median value of intercalated disc p-MLKL. In δ-sarcoglycan-deficient (Sgcd-/- ) mice, a model of DCM, total p-MLKL and nuclear p-MLKL levels were higher than in wild-type mice. CONCLUSION The results suggest that increased localization of nuclear p-MLKL in cardiomyocytes is associated with left ventricular diastolic dysfunction and future adverse events in DCM.
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Affiliation(s)
- Yugo Fujita
- Department of Cardiovascular, Renal and Metabolic MedicineSapporo Medical University School of MedicineSapporo060‐8543Japan
| | - Toshiyuki Yano
- Department of Cardiovascular, Renal and Metabolic MedicineSapporo Medical University School of MedicineSapporo060‐8543Japan
| | - Hiromitsu Kanamori
- Department of CardiologyGifu University Graduate School of MedicineGifuJapan
| | - Daigo Nagahara
- Department of Cardiovascular, Renal and Metabolic MedicineSapporo Medical University School of MedicineSapporo060‐8543Japan
| | - Atsuko Muranaka
- Department of Cardiovascular, Renal and Metabolic MedicineSapporo Medical University School of MedicineSapporo060‐8543Japan
| | - Hidemichi Kouzu
- Department of Cardiovascular, Renal and Metabolic MedicineSapporo Medical University School of MedicineSapporo060‐8543Japan
| | - Atsushi Mochizuki
- Department of Cardiovascular, Renal and Metabolic MedicineSapporo Medical University School of MedicineSapporo060‐8543Japan
| | - Masayuki Koyama
- Department of Cardiovascular, Renal and Metabolic MedicineSapporo Medical University School of MedicineSapporo060‐8543Japan
- Department of Public HealthSapporo Medical University School of MedicineSapporoJapan
| | - Nobutaka Nagano
- Department of Cardiovascular, Renal and Metabolic MedicineSapporo Medical University School of MedicineSapporo060‐8543Japan
| | - Takefumi Fujito
- Department of Cardiovascular, Renal and Metabolic MedicineSapporo Medical University School of MedicineSapporo060‐8543Japan
| | - Ryo Nishikawa
- Department of Cardiovascular, Renal and Metabolic MedicineSapporo Medical University School of MedicineSapporo060‐8543Japan
| | - Naoyuki Kamiyama
- Department of Cardiovascular, Renal and Metabolic MedicineSapporo Medical University School of MedicineSapporo060‐8543Japan
| | - Marenao Tanaka
- Department of Cardiovascular, Renal and Metabolic MedicineSapporo Medical University School of MedicineSapporo060‐8543Japan
| | - Atsushi Kuno
- Department of Cardiovascular, Renal and Metabolic MedicineSapporo Medical University School of MedicineSapporo060‐8543Japan
- Department of PharmacologySapporo Medical University School of MedicineSapporoJapan
| | - Masaya Tanno
- Department of Cardiovascular, Renal and Metabolic MedicineSapporo Medical University School of MedicineSapporo060‐8543Japan
| | - Tetsuji Miura
- Department of Cardiovascular, Renal and Metabolic MedicineSapporo Medical University School of MedicineSapporo060‐8543Japan
- Department of Clinical Pharmacology, Faculty of Pharmaceutical SciencesHokkaido University of ScienceSapporoJapan
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Baker KR. Light Chain Amyloidosis: Epidemiology, Staging, and Prognostication. Methodist Debakey Cardiovasc J 2022; 18:27-35. [PMID: 35414848 PMCID: PMC8932379 DOI: 10.14797/mdcvj.1070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 02/02/2022] [Indexed: 12/19/2022] Open
Abstract
Amyloidosis is a disorder of protein misfolding and metabolism in which insoluble fibrils are deposited in various tissues, causing organ dysfunction and eventually death. Out of the 60-plus heterogeneous amyloidogenic proteins that have been identified, approximately 30 are associated with human disease. The unifying feature of these proteins is their tendency to form beta-pleated sheets aligned in an antiparallel fashion. These sheets then form rigid, nonbranching fibrils that resist proteolysis, causing mechanical disruption and local oxidative stress in affected organs such as the heart, liver, kidneys, nervous system, and gastrointestinal tract. Here we review the epidemiology of light chain amyloidosis, the staging, and the concomitant prognostication that is critical in determining the appropriate treatment.
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Lee C, Lam A, Kangappaden T, Olver P, Kane S, Tran D, Ammann E. Systematic literature review of evidence in amyloid light-chain amyloidosis. J Comp Eff Res 2022; 11:451-472. [DOI: 10.2217/cer-2021-0261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Introduction: Treatment of amyloid light-chain (AL) amyloidosis, a rare disease with a <5-year lifespan, remains challenging. This systematic literature review (SLR) aimed to evaluate the current evidence base in AL amyloidosis. Methods: Literature searches on clinical, health-related quality of life, economic and resource use evidence were conducted using the Embase, MEDLINE and Cochrane databases as well as gray literature. Results: This SLR yielded 84 unique studies from: five randomized controlled trials; 54 observational studies; 12 health-related quality of life studies, none with utility values; no economic evaluation studies; and 16 resource use studies, none with indirect costs. Conclusion: This SLR highlights a paucity of published literature relating to randomized controlled trials, utility values, economic evaluations and indirect costs in AL amyloidosis.
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Affiliation(s)
- Charlene Lee
- Janssen Global Services, LLC, Raritan, NJ 08869, USA
| | - Annette Lam
- Janssen Global Services, LLC, Raritan, NJ 08869, USA
| | | | - Pyper Olver
- EVERSANA Life Science Services, LLC, Burlington, ON, L7N 3H8, Canada
| | - Sarah Kane
- EVERSANA Life Science Services, LLC, Burlington, ON, L7N 3H8, Canada
| | - Diana Tran
- EVERSANA Life Science Services, LLC, Burlington, ON, L7N 3H8, Canada
| | - Eric Ammann
- Janssen Global Services, LLC, Raritan, NJ 08869, USA
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