1
|
Ioannou A. Evolution of Disease-modifying Therapy for Transthyretin Cardiac Amyloidosis. Heart Int 2024; 18:30-37. [PMID: 39006464 PMCID: PMC11239131 DOI: 10.17925/hi.2024.18.1.5] [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: 03/08/2024] [Accepted: 05/28/2024] [Indexed: 07/16/2024] Open
Abstract
Transthyretin cardiac amyloidosis (ATTR-CA) represents an inexorably progressive and fatal cardiomyopathy. Increased understanding of the underlying pathogenesis responsible for the misfolding of transthyretin and the subsequent accumulation of amyloid fibrils within the myocardium has led to the development of several disease-modifying therapies that act on different stages of the disease pathway. Tafamidis is the first, and to date remains the only, therapy approved for the treatment of ATTR-CA, which, alongside acoramidis, stabilizes the transthyretin tetramer, preventing disaggregation, misfolding and formation of amyloid fibrils. Gene-silencing agents, such as patisiran, vutrisian and eplontersen, and novel gene-editing therapies, such as NTLA-2001, act to reduce the hepatic synthesis of transthyretin. Anti-amyloid therapies represent another strategy in the treatment of ATTR-CA and are designed to bind amyloid fibril epitopes and stimulate macrophage-mediated removal of amyloid fibrils from the myocardium. Many of these treatments are at an early investigational stage but represent an important area of unmet clinical need and could potentially reverse disease and restore cardiac functions even in patients with advanced disease.
Collapse
Affiliation(s)
- Adam Ioannou
- National Amyloidosis Centre, University College London, Royal Free Campus, London, UK
| |
Collapse
|
2
|
Dave P, Anand P, Kothawala A, Srikaram P, Shastri D, Uddin A, Bhavsar J, Winer A. RNA Interference Therapeutics for Hereditary Amyloidosis: A Narrative Review of Clinical Trial Outcomes and Future Directions. Cureus 2024; 16:e62981. [PMID: 39044869 PMCID: PMC11265807 DOI: 10.7759/cureus.62981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2024] [Indexed: 07/25/2024] Open
Abstract
Hereditary transthyretin amyloidosis (ATTR) is an autosomal dominant, life-threatening genetic disorder caused by a single-nucleotide variant in the transthyretin gene. This mutation leads to the misfolding and deposition of amyloid in various body organs. Both mutant and wild-type transthyretin contribute to the resulting polyneuropathy and cardiomyopathy, leading to significant sensorimotor disturbances and severe cardiac conditions such as heart failure and arrhythmias, thereby impacting quality of life. Despite several treatments, including orthotopic liver transplantation and transthyretin tetramer stabilizers, their limitations persisted until the introduction of RNA interference (RNAi). RNAi, a means to regulate mRNA stability and translation of targeted genes, has brought about significant changes in treatment strategies for ATTR with the introduction of patisiran in 2018. This study reviews patisiran, vutrisiran, inotersen, and eplontersen, developed for the treatment of ATTR. It provides an overview of the clinical trial outcomes, focusing mainly on quality of life, adverse reactions, and the future of RNAi-based therapies.
Collapse
Affiliation(s)
- Prashil Dave
- Internal Medicine, State University of New York Downstate Health Sciences University, New York, USA
| | - Puneet Anand
- Pediatrics, Icahn School of Medicine at Mount Sinai/Elmhurst Hospital Center, New York, USA
| | - Azra Kothawala
- Medicine, Jawaharlal Nehru Medical College, Ahmedabad, IND
| | | | - Dipsa Shastri
- Internal Medicine, East Tennessee State University (ETSU), Johnson City, USA
| | - Anwar Uddin
- Internal Medicine, State University of New York Downstate Health Sciences University, New York, USA
| | - Jill Bhavsar
- Internal Medicine, Medical College Baroda, Baroda, IND
| | - Andrew Winer
- Urology, State University of New York Downstate Health Sciences University, New York, USA
| |
Collapse
|
3
|
Liu Y, Li H, Hu C, Tan L, Yin P, Li Z, Zhou S, Su L. A real-world pharmacovigilance analysis for transthyretin inhibitors: findings from the FDA adverse event reporting database. Front Pharmacol 2024; 15:1368244. [PMID: 38873427 PMCID: PMC11169801 DOI: 10.3389/fphar.2024.1368244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 05/13/2024] [Indexed: 06/15/2024] Open
Abstract
Objective The purpose of this study is to investigate the drug safety of three Transthyretin (TTR) inhibitors in the real world using the United States Food and Drug Administration Adverse Event Reporting System (FAERS) database. Methods This study extracted reports received by the FAERS database from the first quarter of 2018 to the third quarter of 2023 for descriptive analysis and disproportionality analysis. Safety signal mining was conducted at the Preferred Term (PT) level and the System Organ Class (SOC) level using reporting odds ratio (ROR). The characteristics of the time-to-onset curves were analyzed using the Weibull Shape Parameter (WSP). The cumulative incidence of TTR inhibitors was evaluated using the Kaplan-Meier method. Subgroup analyses were conducted based on whether the reporter was a medical professional. Results A total of 3,459 reports of adverse events (AEs) caused by TTR inhibitors as the primary suspect (PS) drug were extracted. The top three reported AEs for patisiran were fatigue, asthenia, and fall, with the most unexpectedly strong association being nonspecific reaction. The top three reported AEs for vutrisiran were fall, pain in extremity and malaise, with the most unexpectedly strong association being subdural haematoma. The top three reported AEs for inotersen were platelet count decreased, blood creatinine increased, and fatigue, with the most unexpectedly strong association being blood albumin decreased. Vitamin A decreased, arthralgia, and dyspnea were the same AEs mentioned in the drug labels of all three drugs, while malaise and asthenia were the same unexpected significant signals. This study offers evidence of the variability in the onset time characteristics of AEs associated with TTR inhibitors, as well as evidence of differences in adverse event reporting between medical professionals and non-medical professionals. Conclusion In summary, we compared the similarities and differences in drug safety of three TTR inhibitors in the real world using the FAERS database. The results indicate that not only do these three drugs share common AEs, but they also exhibit differences in drug safety profiles. This study contributes to enhancing the understanding of medical professionals regarding the safety of TTR inhibitors.
Collapse
Affiliation(s)
- Yuan Liu
- Department of Cardiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Hao Li
- Department of Cardiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Cheng Hu
- Department of Cardiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Li Tan
- Department of Cardiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Ping Yin
- Department of Cardiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Zhihao Li
- Second Clinical College, Chongqing Medical University, Chongqing, China
| | - Shuangshan Zhou
- Department of Cardiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Li Su
- Department of Cardiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| |
Collapse
|
4
|
Vogel J, Carpinteiro A, Luedike P, Buehning F, Wernhart S, Rassaf T, Michel L. Current Therapies and Future Horizons in Cardiac Amyloidosis Treatment. Curr Heart Fail Rep 2024:10.1007/s11897-024-00669-7. [PMID: 38809394 DOI: 10.1007/s11897-024-00669-7] [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] [Accepted: 05/20/2024] [Indexed: 05/30/2024]
Abstract
PURPOSE OF REVIEW Cardiac amyloidosis (CA) is a condition characterized by misfolding and extracellular deposition of proteins, leading to organ dysfunction. While numerous forms of CA exist, two subtypes dominate clinical prevalence: Transthyretin amyloid (ATTR) and immunoglobulin light chain amyloid. RECENT FINDINGS The current scientific landscape reflects the urgency to advance therapeutic interventions with over 100 ongoing clinical trials. Heart failure treatment is affected by CA phenotype with poor tolerance of otherwise frequently used medications. Treating comorbidities including atrial fibrillation and valvular disease remains a challenge in CA, driven by technical difficulties and uncertain outcomes. Tafamidis is the first ATTR-stabilizer approved with a rapidly growing rate of clinical use. In parallel, various new therapeutic classes are in late-stage clinical trials including silencers, antibodies and genetic therapy. Managing CA is a critical challenge for future heart failure care. This review delineates the current standard-of-care and scientific landscape of CA therapy.
Collapse
Affiliation(s)
- Julia Vogel
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Alexander Carpinteiro
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Peter Luedike
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Florian Buehning
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Simon Wernhart
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Lars Michel
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany.
| |
Collapse
|
5
|
Bart NK, Fatkin D, Gunton J, Hare JL, Korczyk D, Kwok F, Lam K, Russell D, Sidiqi H, Sutton T, Gibbs SDJ, Mollee P, Thomas L. 2024 Australia-New Zealand Expert Consensus Statement on Cardiac Amyloidosis. Heart Lung Circ 2024; 33:420-442. [PMID: 38570258 DOI: 10.1016/j.hlc.2023.11.027] [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: 11/09/2023] [Accepted: 11/17/2023] [Indexed: 04/05/2024]
Abstract
Over the past 5 years, early diagnosis of and new treatments for cardiac amyloidosis (CA) have emerged that hold promise for early intervention. These include non-invasive diagnostic tests and disease modifying therapies. Recently, CA has been one of the first types of cardiomyopathy to be treated with gene editing techniques. Although these therapies are not yet widely available to patients in Australia and New Zealand, this may change in the near future. Given the rapid pace with which this field is evolving, it is important to view these advances within the Australian and New Zealand context. This Consensus Statement aims to update the Australian and New Zealand general physician and cardiologist with regards to the diagnosis, investigations, and management of CA.
Collapse
Affiliation(s)
- Nicole K Bart
- Department of Cardiology, St Vincent's Hospital, Sydney; School of Clinical Medicine, Faculty of Health and Medicine, The University of New South Wales, Sydney, and The Victor Chang Cardiac Research Institute, Sydney, NSW, Australia. http://www.twitter.com/drnikkibart
| | - Diane Fatkin
- Department of Cardiology, St Vincent's Hospital, Sydney; School of Clinical Medicine, Faculty of Health and Medicine, The University of New South Wales, Sydney, and The Victor Chang Cardiac Research Institute, Sydney, NSW, Australia
| | - James Gunton
- Department of Cardiology, Flinders Medical Centre, Adelaide, SA, Australia
| | - James L Hare
- Department of Cardiology, Alfred Health, Melbourne, and Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Vic, Australia
| | - Dariusz Korczyk
- Department of Cardiology, The Princess Alexandra Hospital, Brisbane, Qld, Australia
| | - Fiona Kwok
- Department of Haematology, Westmead Hospital, Sydney, NSW, Australia
| | - Kaitlyn Lam
- Department of Cardiology, Western Australia Advanced Heart Failure and Cardiac Transplant Service, Perth, WA, Australia
| | - David Russell
- Department of Cardiology, Royal Hobart Hospital, Hobart, Tas, Australia
| | - Hasib Sidiqi
- Department of Haematology, Fiona Stanley Hospital, Perth, WA, Australia
| | - Tim Sutton
- Te Whatu Ora Counties Manukau, Auckland; and Department of Cardiology, Auckland, Aotearoa, New Zealand
| | - Simon D J Gibbs
- Department of Haematology, Eastern Health; Epworth Freemasons; and Monash University, Melbourne, Vic, Australia
| | - Peter Mollee
- Queensland Amyloidosis Centre, The Princess Alexandra Hospital, Brisbane; and, School of Medicine, University of Queensland, Brisbane, Qld, Australia
| | - Liza Thomas
- Department of Cardiology, Westmead Hospital, Sydney; Westmead Clinical School, University of Sydney, Sydney; and, South West Clinical School, University of New South Wales, Sydney, NSW, Australia.
| |
Collapse
|
6
|
Huang P, Li X, Tan Z, Wang Y, Yan J. Characterization of the G-quadruplexes in the transthyretin gene and its role in silencing transthyretin mRNA transcription. Bioorg Med Chem Lett 2024; 97:129568. [PMID: 38008337 DOI: 10.1016/j.bmcl.2023.129568] [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: 08/02/2023] [Revised: 11/21/2023] [Accepted: 11/23/2023] [Indexed: 11/28/2023]
Abstract
Transthyretin Amyloidosis arises from the misfolding of monomers or oligomers of the normal transthyretin protein. Our investigation revealed that certain guanine-rich regions within the 5' UTR sequence of the transthyretin gene possess the ability to form G2-quadruplex structures, as determined through analysis with QGRS mapper. We demonstrated that small molecule ligands, including TMPyP4, Braco-19, NMM, and TO, have a significant impact on the stabilization of transthyretin G-quadruplexes. The objective of this study was to confirm the effect of ligands on transthyretin gene transcription through the stabilization of G-quadruplexes. To comprehend the interaction between ligands and transthyretin G-quadruplexes, a range of analytical techniques were employed, includingUV titration, fluorescence titration assays, circular dichroism, quantitative RT-PCR and cytotoxicity tests. The results revealed the presence of four putative G2-quadruplex sequences, which formed stable anti-parallel, parallel, and hybrid G2-quadruplex structures. Notably, Ttrg 3 (5'-GGAAGGAAGGGAGGGAGGG-3') exhibited the highest stability to form G-quadruplex. Furthermore, TmPyP4, Braco-19, NMM and TO were found to stabilize the parallel topology of Ttrg 3. After 48 h of incubation, the RT-PCR experiments revealed a significant reduction in transthyretin mRNA transcription in HepG2 cells when treated with 20 μM TmPyP4 and Braco-19, without inducing apoptosis. Our findings suggested that ligand-mediated stabilization of G-quadruplexes within the 5'-UTR can effectively silence transthyretin expression, highlighting the potential of G-quadruplex as a novel therapeutic target for Transthyretin Amyloidosis. This study might shed valuable lights for the development of innovative therapeutic approach against Transthyretin Amyloidosis.
Collapse
Affiliation(s)
- Peimin Huang
- MOE International Joint Research Laboratory on Synthetic Biology and Medicines, School of Biology and Biological Engineering, South China University of Technology, Guangzhou 510006, China
| | - Xu Li
- Guangzhou Municipal and Guangdong Provincial Key Laboratory of Molecular Target & Clinical Pharmacology, The NMPA and State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences and the Fifth Affiliated Hospital, Guangzhou Medical University, Guangzhou 511436, China
| | - Zhonghan Tan
- Guangzhou Municipal and Guangdong Provincial Key Laboratory of Molecular Target & Clinical Pharmacology, The NMPA and State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences and the Fifth Affiliated Hospital, Guangzhou Medical University, Guangzhou 511436, China
| | - Yuqing Wang
- Guangzhou Municipal and Guangdong Provincial Key Laboratory of Molecular Target & Clinical Pharmacology, The NMPA and State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences and the Fifth Affiliated Hospital, Guangzhou Medical University, Guangzhou 511436, China.
| | - Jinwu Yan
- MOE International Joint Research Laboratory on Synthetic Biology and Medicines, School of Biology and Biological Engineering, South China University of Technology, Guangzhou 510006, China.
| |
Collapse
|
7
|
Patil MB, Ghode P, Joshi P. A Comprehensive Review on Chemistry and Biology of Tafamidis in Transthyretin Amyloidosis. Mini Rev Med Chem 2024; 24:571-587. [PMID: 37828667 DOI: 10.2174/0113895575241556231003055323] [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: 12/21/2022] [Revised: 07/30/2023] [Accepted: 07/31/2023] [Indexed: 10/14/2023]
Abstract
Transthyretin amyloid cardiomyopathy and Transthyretin amyloid peripheral neuropathy are progressive disease conditions caused by Transthyretin amyloidosis (ATTR) fibril infiltration in the tissue. Transthyretin (TTR) protein misfolding and amyloid fibril deposits are pathological biomarkers of ATTR-related disorders. There are various treatment strategies targeting different stages in pathophysiology. One such strategy is TTR tetramer stabilization. Recently, a new TTR tetramer stabilizer, tafamidis, has been introduced that reduces the protein misfolding and amyloidosis and, consequently, disease progression in ATTR cardiomyopathy and peripheral neuropathy. This review will provide a comprehensive overview of the literature on tafamidis discovery, development, synthetic methods, pharmacokinetics, analytical methods and clinical trials. Overall, 7 synthetic methods, 5 analytical methods and 23 clinical trials have been summarized from the literature.
Collapse
Affiliation(s)
- Monali B Patil
- SVKM's NMIMS School of Pharmacy & Technology Management, Shirpur, and Maharashtra, India
| | - Piyush Ghode
- SVKM's NMIMS School of Pharmacy & Technology Management, Shirpur, and Maharashtra, India
| | - Prashant Joshi
- SVKM's NMIMS School of Pharmacy & Technology Management, Shirpur, and Maharashtra, India
- Department of Pharmaceutical Sciences, School of Health Sciences and Technology, Dr. Vishwanath Karad MIT World Peace University, Pune, Maharashtra, India
| |
Collapse
|
8
|
Shah SJ, Fine N, Garcia-Pavia P, Klein AL, Fernandes F, Weissman NJ, Maurer MS, Boman K, Gundapaneni B, Sultan MB, Elliott P. Effect of Tafamidis on Cardiac Function in Patients With Transthyretin Amyloid Cardiomyopathy: A Post Hoc Analysis of the ATTR-ACT Randomized Clinical Trial. JAMA Cardiol 2024; 9:25-34. [PMID: 37966817 PMCID: PMC10652219 DOI: 10.1001/jamacardio.2023.4147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 09/11/2023] [Indexed: 11/16/2023]
Abstract
Importance Tafamidis has been shown to improve survival in patients with transthyretin amyloid cardiomyopathy (ATTR-CM) compared with placebo. However, its effect on cardiac function has not been fully characterized. Objective To examine the effect of tafamidis on cardiac function in patients with ATTR-CM. Design, Setting, and Participants This was an exploratory, post hoc analysis of the Tafamidis in Transthyretin Cardiomyopathy Clinical Trial (ATTR-ACT), a multicenter, international, double-blind, placebo-controlled phase 3 randomized clinical trial conducted from December 2013 to February 2018. The ATTR-ACT included 48 sites in 13 counties and enrolled patients aged 18 to 90 years with ATTR-CM. Data were analyzed from July 2018 to September 2023. Intervention Patients were randomized to tafamidis meglumine, 80 mg or 20 mg, or placebo for 30 months. Main Outcomes and Measures Patients were categorized based on left ventricular (LV) ejection fraction at enrollment as having heart failure with preserved ejection fraction (≥50%), mildly reduced ejection fraction (41% to 49%), or reduced ejection fraction (≤40%). Changes from baseline to month 30 in LV ejection fraction, LV stroke volume, LV global longitudinal strain, and the ratio of early mitral inflow velocity to septal and lateral early diastolic mitral annular velocity (E/e') were compared in patients receiving tafamidis, 80 mg, vs placebo. Results A total of 441 patients were randomized in ATTR-ACT, and 436 patients had available echocardiographic data. Of 436 included patients, 393 (90.1%) were male, and the mean (SD) age was 74 (7) years. A total of 220 (50.5%), 119 (27.3%), and 97 (22.2%) had heart failure with preserved, mildly reduced, and reduced LV ejection fraction, respectively. Over 30 months, there was less pronounced worsening in 4 of the echocardiographic measures in patients receiving tafamidis, 80 mg (n = 176), vs placebo (n = 177) (least squares mean difference: LV stroke volume, 7.02 mL; 95% CI, 2.55-11.49; P = .002; LV global longitudinal strain, -1.02%; 95% CI, -1.73 to -0.31; P = .005; septal E/e', -3.11; 95% CI, -5.50 to -0.72; P = .01; lateral E/e', -2.35; 95% CI, -4.01 to -0.69; P = .006). Conclusions and Relevance Compared with placebo, tafamidis, 80 mg, attenuated the decline of LV systolic and diastolic function over 30 months in patients with ATTR-CM. Approximately half of patients had mildly reduced or reduced LV ejection fraction at enrollment, suggesting that ATTR-CM should be considered as a possible diagnosis in patients with heart failure regardless of underlying LV ejection fraction. Trial Registration ClinicalTrials.gov Identifier: NCT01994889.
Collapse
Affiliation(s)
- Sanjiv J. Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Nowell Fine
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Pablo Garcia-Pavia
- Hospital Universitario Puerta de Hierro Majadahonda, CIBERCV and Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | | | | | - Neil J. Weissman
- Medstar Health Research Institute, Georgetown University, Washington, DC
| | - Mathew S. Maurer
- Columbia University College of Physicians and Surgeons, New York City, New York
| | - Kurt Boman
- Research Unit, Skellefteå County Hospital, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | | | | | | |
Collapse
|
9
|
Tsang C, Huda A, Norman M, Dickerson C, Leo V, Brownrigg J, Mamas M, Elliott P. Detecting transthyretin amyloid cardiomyopathy (ATTR-CM) using machine learning: an evaluation of the performance of an algorithm in a UK setting. BMJ Open 2023; 13:e070028. [PMID: 37899155 PMCID: PMC10619059 DOI: 10.1136/bmjopen-2022-070028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 10/11/2023] [Indexed: 10/31/2023] Open
Abstract
OBJECTIVE The aim of this study was to evaluate the potential real-world application of a machine learning (ML) algorithm, developed and trained on heart failure (HF) cohorts in the USA, to detect patients with undiagnosed wild type cardiac amyloidosis (ATTRwt) in the UK. DESIGN In this retrospective observational study, anonymised, linked primary and secondary care data (Clinical Practice Research Datalink GOLD and Hospital Episode Statistics, respectively, were used to identify patients diagnosed with HF between 2009 and 2018 in the UK. International Classification of Diseases (ICD)-10 clinical modification codes were matched to equivalent Read (primary care) and ICD-10 WHO (secondary care) diagnosis codes used in the UK. In the absence of specific Read or ICD-10 WHO codes for ATTRwt, two proxy case definitions (definitive and possible cases) based on the degree of confidence that the contributing codes defined true ATTRwt cases were created using ML. PRIMARY OUTCOME MEASURE Algorithm performance was evaluated primarily using the area under the receiver operating curve (AUROC) by comparing the actual versus algorithm predicted case definitions at varying sensitivities and specificities. RESULTS The algorithm demonstrated strongest predictive ability when a combination of primary care and secondary care data were used (AUROC: 0.84 in definitive cohort and 0.86 in possible cohort). For primary care or secondary care data alone, performance ranged from 0.68 to 0.78. CONCLUSION The ML algorithm, despite being developed in a US population, was effective at identifying patients that may have ATTRwt in a UK setting. Its potential use in research and clinical care to aid identification of patients with undiagnosed ATTRwt, possibly enabling earlier diagnosis in the disease pathway, should be investigated.
Collapse
Affiliation(s)
| | | | - Max Norman
- Health Economics and Outcomes Research Ltd, Cardiff, UK
| | | | | | | | | | | |
Collapse
|
10
|
Obici L, Ajroud-Driss S, Lin KP, Berk JL, Gillmore JD, Kale P, Koike H, Danese D, Aldinc E, Chen C, Vest J, Adams D. Impact of Vutrisiran on Quality of Life and Physical Function in Patients with Hereditary Transthyretin-Mediated Amyloidosis with Polyneuropathy. Neurol Ther 2023; 12:1759-1775. [PMID: 37523143 PMCID: PMC10444729 DOI: 10.1007/s40120-023-00522-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 06/26/2023] [Indexed: 08/01/2023] Open
Abstract
INTRODUCTION Hereditary transthyretin (ATTRv; v for variant) amyloidosis, also known as hATTR amyloidosis, is a progressive and fatal disease associated with rapid deterioration of physical function and patients' quality of life (QOL). Vutrisiran, a subcutaneously administered RNA interference (RNAi) therapeutic that reduces hepatic production of transthyretin, was assessed in patients with ATTRv amyloidosis with polyneuropathy in the pivotal HELIOS-A study. METHODS The phase 3 open-label HELIOS-A study investigated the efficacy and safety of vutrisiran in patients with ATTRv amyloidosis with polyneuropathy, compared with an external placebo group from the APOLLO study of the RNAi therapeutic patisiran. Measures of QOL and physical function were assessed. RESULTS At month 18, vutrisiran improved Norfolk Quality of Life-Diabetic Neuropathy (Norfolk QOL-DN) total score (least squares mean difference [LSMD] in change from baseline [CFB]: -21.0; p = 1.84 × 10-10) and Norfolk QOL-DN domain scores, compared with external placebo. This benefit relative to external placebo was evident across all baseline polyneuropathy disability (PND) scores and most pronounced in patients with baseline PND scores I-II. Compared with external placebo, vutrisiran also demonstrated benefit in EuroQoL-Visual Analog Scale (EQ-VAS) score (LSMD in CFB: 13.7; nominal p = 2.21 × 10-7), 10-m walk test (LSMD in CFB: 0.239 m/s; p = 1.21 × 10-7), Rasch-built Overall Disability Score (LSMD in CFB: 8.4; p = 3.54 × 10-15), and modified body mass index (mBMI) (LSMD in CFB: 140.7; p = 4.16 × 10-15) at month 18. Overall, Norfolk QOL-DN, EQ-VAS, and mBMI improved from pretreatment baseline with vutrisiran, whereas all measures worsened from baseline in the external placebo group. At month 18, Karnofsky Performance Status was stable/improved from baseline in 58.2/13.1% with vutrisiran versus 34.7/8.1% with external placebo. CONCLUSION Vutrisiran treatment provided significant clinical benefits in multiple measures of QOL and physical function in patients with ATTRv amyloidosis with polyneuropathy. Benefits were most pronounced in patients with earlier-stage disease, highlighting the importance of early diagnosis and treatment. TRIAL REGISTRATION NUMBER ClinicalTrials.gov: NCT03759379.
Collapse
Affiliation(s)
- Laura Obici
- Amyloidosis Research and Treatment Centre, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy.
| | - Senda Ajroud-Driss
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Kon-Ping Lin
- Department of Neurology, Taipei Veterans General Hospital, Taipei, Taiwan
| | | | - Julian D Gillmore
- National Amyloidosis Centre, Royal Free Hospital, University College London, London, UK
| | - Parag Kale
- Baylor University Medical Center, Dallas, TX, USA
| | - Haruki Koike
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | | | | | | | - John Vest
- Alnylam Pharmaceuticals, Cambridge, MA, USA
| | - David Adams
- Neurology Department, Université Paris-Saclay, U1195, INSERM, AP-HP, CHU Bicêtre, Le Kremlin Bicêtre, France
| |
Collapse
|
11
|
Wang M, Yang H, Lin Z, Li X, Liu L, Huang S, Zhao H, Zhu X, Xiao Q, Duan R, Wang J, Zuchner S, Tang B, Zhang R. The genetic and clinical spectrum in a cohort of 39 families with complex inherited peripheral neuropathies. J Neurol 2023; 270:4959-4967. [PMID: 37365282 DOI: 10.1007/s00415-023-11821-z] [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: 05/06/2023] [Revised: 06/07/2023] [Accepted: 06/11/2023] [Indexed: 06/28/2023]
Abstract
With complicated conditions and a large number of potentially causative genes, the diagnosis of a patient with complex inherited peripheral neuropathies (IPNs) is challenging. To provide an overview of the genetic and clinical features of 39 families with complex IPNs from central south China and to optimize the molecular diagnosis approach to this group of heterogeneous diseases, a total of 39 index patients from unrelated families were enrolled, and detailed clinical data were collected. TTR Sanger sequencing, hereditary spastic paraplegia (HSP) gene panel, and dynamic mutation detection in spinocerebellar ataxia (SCAs) were performed according to the respective additional clinical features. Whole-exome sequencing (WES) was used in patients with negative or unclear results. Dynamic mutation detection in NOTCH2NLC and RCF1 was applied as a supplement to WES. As a result, an overall molecular diagnosis rate of 89.7% was achieved. All 21 patients with predominant autonomic dysfunction and multiple organ system involvement carried pathogenic variants in TTR, among which nine had c.349G > T (p.A97S) hotspot variants. Five out of 7 patients (71.4%) with muscle involvement harbored biallelic pathogenic variants in GNE. Five out of 6 patients (83.3%) with spasticity reached definite genetic causes in SACS, KIF5A, BSCL2, and KIAA0196, respectively. NOTCH2NLC GGC repeat expansions were identified in all three cases accompanied by chronic coughing and in one patient accompanied by cognitive impairment. The pathogenic variants, p.F284S and p.G111R in GNE, and p.K4326E in SACS, were first reported. In conclusion, transthyretin amyloidosis with polyneuropathy (ATTR-PN), GNE myopathy, and neuronal intranuclear inclusion disease (NIID) were the most common genotypes in this cohort of complex IPNs. NOTCH2NLC dynamic mutation testing should be added to the molecular diagnostic workflow. We expanded the genetic and related clinical spectrum of GNE myopathy and ARSACS by reporting novel variants.
Collapse
Affiliation(s)
- Mengli Wang
- Department of Neurology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Honglan Yang
- Department of Neurology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Zhiqiang Lin
- Department of Neurology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Xiaobo Li
- Department of Neurology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Lei Liu
- Department of Neurology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Shunxiang Huang
- Department of Neurology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Huadong Zhao
- Department of Neurology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Xiying Zhu
- Department of Neurology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Qiao Xiao
- Center for Medical Genetics, School of Life Sciences, Central South University, Changsha, China
| | - Ranhui Duan
- Center for Medical Genetics, School of Life Sciences, Central South University, Changsha, China
| | - Junling Wang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Stephan Zuchner
- Dr John T. Macdonald Foundation Department of Human Genetics and John P. Hussman Institute for Human Genomics, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Beisha Tang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Ruxu Zhang
- Department of Neurology, The Third Xiangya Hospital, Central South University, Changsha, China.
| |
Collapse
|
12
|
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.
Collapse
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
| |
Collapse
|
13
|
Tamargo J, Agewall S, Borghi C, Ceconi C, Cerbai E, Dan GA, Ferdinandy P, Grove EL, Rocca B, Sulzgruber P, Semb AG, Sossalla S, Niessner A, Kaski JC, Dobrev D. New pharmacological agents and novel cardiovascular pharmacotherapy strategies in 2022. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2023; 9:pvad034. [PMID: 37169875 PMCID: PMC10236523 DOI: 10.1093/ehjcvp/pvad034] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/10/2023] [Accepted: 05/10/2023] [Indexed: 05/13/2023]
Abstract
Cardiovascular diseases (CVD) remain the leading cause of death worldwide and pharmacotherapy of most of them is suboptimal. Thus, there is a clear unmet clinical need to develop new pharmacological strategies with greater efficacy and better safety profiles. In this review, we summarize the most relevant advances in cardiovascular pharmacology in 2022 including the approval of first-in-class drugs that open new avenues for the treatment of obstructive hypertrophic cardiomyopathy (mavacamten), type 2 diabetes mellitus (tirzepatide), and heart failure (HF) independent of left ventricular ejection fraction (sodium-glucose cotransporter 2 inhibitors). We also dealt with fixed dose combination therapies repurposing different formulations of "old" drugs with well-known efficacy and safety for the treatment of patients with acute decompensated HF (acetazolamide plus loop diuretics), atherosclerotic cardiovascular disease (moderate-dose statin plus ezetimibe), Marfan syndrome (angiotensin receptor blockers plus β-blockers), and secondary cardiovascular prevention (i.e. low-dose aspirin, ramipril and atorvastatin), thereby filling existing gaps in knowledge, and opening new avenues for the treatment of CVD. Clinical trials confirming the role of dapagliflozin in patients with HF and mildly reduced or preserved ejection fraction, long-term evolocumab to reduce the risk of cardiovascular events, vitamin K antagonists for stroke prevention in patients with rheumatic heart disease-associated atrial fibrillation, antibiotic prophylaxis in patients at high risk for infective endocarditis before invasive dental procedures, and vutrisiran for the treatment of hereditary transthyretin-related amyloidosis with polyneuropathy were also reviewed. Finally, we briefly discuss recent clinical trials suggesting that FXIa inhibitors may have the potential to uncouple thrombosis from hemostasis and attenuate/prevent thromboembolic events with minimal disruption of hemostasis.
Collapse
Affiliation(s)
- Juan Tamargo
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense, Instituto de Investigación Sanitaria Gregorio Marañón, Plaza de Ramón y Cajal s/n, Madrid 28040, Spain
| | - Stefan Agewall
- Department of Cardiology, Oslo University Hospital and Institute of Clinical Medicine, Oslo University, Oslo, Norvay
| | - Claudio Borghi
- Department of Cardiovascular Medicine, University of Bologna-IRCCS AOU S. Orsola, Bologna, Italy
| | - Claudio Ceconi
- Unit of Cardiologia, ASST Garda, Desenzano del Garda, Italy
| | - Elisabetta Cerbai
- Department Neurofarba, Section of Pharmacology and Toxicology, University of Florence, Florence, Italy
| | - Gheorghe A Dan
- “Carol Davila” University of Medicine, Colentina University Hospital, Bucharest, Romania
| | - Péter Ferdinandy
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
- Pharmahungary Group, Szeged, Hungary
| | - Erik Lerkevang Grove
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Bianca Rocca
- Section of Pharmacology, Catholic University School of Medicine, Rome, Italy
| | - Patrick Sulzgruber
- Department of Medicine, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Anne Grete Semb
- Preventive Cario-Rheuma Clinic, Division of Research and Innovation, REMEDY Centre, Diakonhjemmet Hospital, Oslo, Norway
| | - Samuel Sossalla
- Department of Internal Medicine II, University Regensburg, Regensburg, Germany
| | - Alexander Niessner
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Juan Carlos Kaski
- Molecular and Clinical Sciences Research Institute, St. George's, University of London, Cranmer Terrace, London SW17 0RE, UK
| | - Dobromir Dobrev
- Institute of Pharmacology, West-German Heart and Vascular Centre, University Duisburg-Essen, Essen, Germany
- Department of Medicine, Montreal Heart Institute and Université de Montréal, Montréal, Canada
- Department of Molecular Physiology & Biophysics, Baylor College of Medicine, Houston, TX, USA
| |
Collapse
|
14
|
Bruno M, Sheer R, Reed C, Schepart A, Nair R, Simmons JD. Clinical characteristics and health care resource use of patients at risk for wild-type transthyretin amyloid cardiomyopathy identified by machine learning model. J Manag Care Spec Pharm 2023; 29:530-540. [PMID: 37121249 PMCID: PMC10387948 DOI: 10.18553/jmcp.2023.29.5.530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
BACKGROUND: Transthyretin amyloid cardiomyopathy (ATTR-CM) is a progressive, life-threatening systemic disorder that is an underrecognized cause of heart failure (HF). When the diagnosis of wild-type ATTR-CM (ATTRwt-CM) is delayed, patients often undergo additional assessments, deferring appropriate management as symptoms potentially worsen. Prompt recognition of patients at risk for ATTRwt-CM is essential to facilitate earlier diagnosis and disease-modifying treatment. A previously developed machine learning model performed well in identifying ATTRwt-CM in patients with HF vs controls with nonamyloid HF using medical claims/electronic health records, providing a systematic framework to raise disease suspicion. OBJECTIVE: To further evaluate this model's performance in identifying ATTRwt-CM using a large claims database of older adults with HF and confirmed ATTRwt-CM or nonamyloid HF; and to explore the characteristics and health care resource utilization (HCRU) of patients with confirmed and suspected ATTRwt-CM. METHODS: In this retrospective study, the prior model was applied using Humana administrative claims for patients diagnosed with ATTRwt-CM (cases) and nonamyloid HF (controls [1:1]). Patients were aged 65-89 years, had at least 2 claims for HF diagnosis (2015-2020), and were continuously enrolled in a Medicare Advantage prescription drug plan for at least 12 months before and at least 6 months after HF diagnosis. For the assessment of characteristics and HCRU, the suspected risk level was categorized based on the predicted probability (PP) from model output (high, moderate, and low risk: PP≥0.70; ≥0.50 and < 0.70; and < 0.50, respectively). RESULTS: Of 267,025 eligible patients, 119 (0.04%) had confirmed ATTRwt-CM; of 266,906 patients with nonamyloid HF, 10,997 (4.1%), 68,174 (25.5%), and 187,735 (70.3%) were categorized as high, moderate, and low risk for ATTRwt-CM, respectively. The model demonstrated sensitivity/specificity/accuracy/receiver operating characteristic area under the concentration-time curve of 88%/65%/77%/0.89, respectively, in differentiating ATTRwt-CM from nonamyloid HF. In patients with confirmed ATTRwt-CM, the mean (SD) time between HF and ATTRwt-CM diagnoses was 751 (528) days; 65% and 48% were hospitalized before and after ATTRwt-CM diagnosis, respectively. Atrial fibrillation was more common in patients with confirmed ATTRwt-CM and high risk (39% and 55%) vs low risk (27%). Hospitalization and emergency department visits after HF diagnosis were reported in 57% and 46% of patients with high ATTRwt-CM risk, respectively. CONCLUSIONS: The ATTRwt-CM predictive model performed well in identifying disease risk in the Humana Research Database. Patients at high risk for ATTRwt-CM had high HCRU and may benefit from the earlier suspicion of ATTRwt-CM. The model may be used as a tool to identify patients with a suspected high risk for the disease to facilitate earlier detection and treatment. DISCLOSURES: This study was sponsored by Pfizer. Medical writing support was provided by Donna McGuire of Engage Scientific Solutions and funded by Pfizer. Drs Bruno and Schepart and Mr Casey are currently employees of Pfizer and equity holders in this publicly traded company. Dr Reed was an employee of Pfizer at the time that this analysis was planned and conducted. Mr Sheer and Dr Simmons are currently employees of Humana, which received research funding from Pfizer. Dr Nair was an employee of Humana at the time that this analysis was planned and conducted.
Collapse
|
15
|
Rosenblum HR, Griffin JM, Minamisawa M, Prasad N, Vest J, White MT, Solomon SD, Burkhoff D, Maurer MS. Effect of patisiran on stroke volume in hereditary transthyretin-mediated amyloidosis: insights from pressure-volume analysis of the APOLLO study. Eur J Heart Fail 2023; 25:727-736. [PMID: 36693807 PMCID: PMC10277223 DOI: 10.1002/ejhf.2783] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 12/11/2022] [Accepted: 01/22/2023] [Indexed: 01/26/2023] Open
Abstract
AIMS Transthyretin-mediated (ATTR) amyloidosis is caused by deposition of transthyretin protein fibrils in the heart, nerves, and other organs. Patisiran, an RNA interference therapeutic that inhibits hepatic synthesis of transthyretin, was approved for the treatment of hereditary ATTR amyloidosis with polyneuropathy based on the phase 3 APOLLO study. We use left ventricular (LV) stroke volume (SV) to quantify LV function overtime and non-invasive pressure-volume techniques to delineate the effects of patisiran on LV mechanics in the pre-specified cardiac subpopulation of the APOLLO study. METHODS AND RESULTS Left ventricular SV was assessed by transthoracic echocardiography at baseline, and after 9 and 18 months of therapy. To determine the mechanisms underlying changes in LV SV, non-invasive pressure-volume parameters, including the end-systolic and end-diastolic pressure-volume relationship, were derived using single beat techniques. At baseline, the mean SV was 51 ± 14 ml. At 9 months, the least-squares mean change in SV was -0.3 ± 1.2 ml for patisiran and -5.4 ± 1.9 ml for placebo (p = 0.021). At 18 months, the least-squares mean change in SV was -1.7 ± 1.3 ml for patisiran and - 8.1 ± 2.3 ml for placebo (p = 0.016). Decline in LV SV was driven by diminished LV capacitance in placebo relative to patisiran. CONCLUSIONS Patisiran may delay progression of LV chamber dysfunction starting at 9 months of therapy. These data elucidate the mechanisms by which transthyretin-reducing therapies modulate progression of cardiac disease and need to be confirmed in ongoing phase 3 trials.
Collapse
Affiliation(s)
- Hannah R. Rosenblum
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center-NYP Hospital, New York, NY
| | - Jan M. Griffin
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center-NYP Hospital, New York, NY
| | | | - Narayana Prasad
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - John Vest
- Alnylam Pharmaceuticals, Cambridge, MA
| | | | - Scott D. Solomon
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | | | - Mathew S. Maurer
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center-NYP Hospital, New York, NY
| |
Collapse
|
16
|
Thimm A, Carpinteiro A, Oubari S, Papathanasiou M, Kessler L, Rischpler C, Malik RA, Herrmann K, Reinhardt HC, Rassaf T, Kleinschnitz C, Hagenacker T, Stettner M. Corneal confocal microscopy identifies corneal nerve loss and increased Langerhans cells in presymptomatic carriers and patients with hereditary transthyretin amyloidosis. J Neurol 2023:10.1007/s00415-023-11689-z. [PMID: 37014422 DOI: 10.1007/s00415-023-11689-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/21/2023] [Accepted: 03/25/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND Hereditary transthyretin amyloidosis (ATTRv amyloidosis) is a rare, but life-threatening protein misfolding disorder due to TTR gene mutations. Cardiomyopathy (ATTRv-CM) and polyneuropathy (ATTRv-PN) with early small nerve fibre involvement are the most common manifestations. Timely diagnosis and treatment initiation are key to limiting progression of disease. Corneal confocal microscopy (CCM) is a non-invasive method to quantify corneal small nerve fibres and immune cell infiltrates in vivo. METHODS This cross-sectional study investigated the utility of CCM in 20 patients with ATTRv amyloidosis (ATTRv-CM, n = 6; ATTRv-PN, n = 14) and presymptomatic carriers (n = 5) compared to 20 age- and sex-matched healthy controls. Corneal nerve fibre density, corneal nerve fibre length, corneal nerve branch density, and cell infiltrates were assessed. RESULTS Corneal nerve fibre density and nerve fibre length were significantly lower in patients with ATTRv amyloidosis compared to healthy controls regardless of the clinical phenotype (ATTRv-CM, ATTRv-PN) and corneal nerve fibre density was significantly lower in presymptomatic carriers. Immune cell infiltrates were only evident in patients with ATTRv amyloidosis, which correlated with reduced corneal nerve fibre density. CONCLUSIONS CCM identifies small nerve fibre damage in presymptomatic carriers and symptomatic patients with ATTRv amyloidosis and may serve as a predictive surrogate marker to identify individuals at risk of developing symptomatic amyloidosis. Furthermore, increased corneal cell infiltration suggests an immune-mediated mechanism in the pathogenesis of amyloid neuropathy.
Collapse
Affiliation(s)
- Andreas Thimm
- Department of Neurology, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany.
- Center for Translational Neuro- and Behavioral Scienes (C-TNBS), University Hospital Essen, Essen, Germany.
| | - Alexander Carpinteiro
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, Essen, Germany
- Institute of Molecular Biology, University of Duisburg-Essen, Essen, Germany
| | - Sara Oubari
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - Maria Papathanasiou
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Essen, Germany
| | - Lukas Kessler
- Department of Nuclear Medicine, University Hospital Essen, Essen, Germany
| | | | - Rayaz Ahmed Malik
- Institute of Cardiovascular Science, Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK
- Weill Cornell Medicine-Qatar, Education City, Doha, Qatar
| | - Ken Herrmann
- Department of Nuclear Medicine, University Hospital Essen, Essen, Germany
| | - Hans Christian Reinhardt
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Essen, Germany
| | - Christoph Kleinschnitz
- Department of Neurology, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
- Center for Translational Neuro- and Behavioral Scienes (C-TNBS), University Hospital Essen, Essen, Germany
| | - Tim Hagenacker
- Department of Neurology, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
- Center for Translational Neuro- and Behavioral Scienes (C-TNBS), University Hospital Essen, Essen, Germany
| | - Mark Stettner
- Department of Neurology, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
- Center for Translational Neuro- and Behavioral Scienes (C-TNBS), University Hospital Essen, Essen, Germany
| |
Collapse
|
17
|
Morfino P, Aimo A, Vergaro G, Sanguinetti C, Castiglione V, Franzini M, Perrone MA, Emdin M. Transthyretin Stabilizers and Seeding Inhibitors as Therapies for Amyloid Transthyretin Cardiomyopathy. Pharmaceutics 2023; 15:pharmaceutics15041129. [PMID: 37111614 PMCID: PMC10143494 DOI: 10.3390/pharmaceutics15041129] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 03/15/2023] [Accepted: 03/30/2023] [Indexed: 04/07/2023] Open
Abstract
Transthyretin (TTR) amyloid cardiomyopathy (ATTR-CM) is a progressive and increasingly recognized cause of heart failure which is associated with high mortality and morbidity. ATTR-CM is characterized by the misfolding of TTR monomers and their deposition within the myocardium as amyloid fibrils. The standard of care for ATTR-CM consists of TTR-stabilizing ligands, such as tafamidis, which aim at maintaining the native structure of TTR tetramers, thus preventing amyloid aggregation. However, their efficacy in advanced-staged disease and after long-term treatment is still a source of concern, suggesting the existence of other pathogenetic factors. Indeed, pre-formed fibrils present in the tissue can further accelerate amyloid aggregation in a self-propagating process known as “amyloid seeding”. The inhibition of amyloidogenesis through TTR stabilizers combined with anti-seeding peptides may represent a novel strategy with additional benefits over current therapies. Finally, the role of stabilizing ligands needs to be reassessed in view of the promising results derived from trials which have evaluated alternative strategies, such as TTR silencers and immunological amyloid disruptors.
Collapse
Affiliation(s)
- Paolo Morfino
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant’Anna, 56127 Pisa, Italy
| | - Alberto Aimo
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant’Anna, 56127 Pisa, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, 56124 Pisa, Italy
| | - Giuseppe Vergaro
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant’Anna, 56127 Pisa, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, 56124 Pisa, Italy
| | - Chiara Sanguinetti
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy
| | - Vincenzo Castiglione
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant’Anna, 56127 Pisa, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, 56124 Pisa, Italy
| | - Maria Franzini
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy
| | - Marco Alfonso Perrone
- Division of Cardiology and CardioLab, Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Michele Emdin
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant’Anna, 56127 Pisa, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, 56124 Pisa, Italy
| |
Collapse
|
18
|
Adams D, Tournev IL, Taylor MS, Coelho T, Planté-Bordeneuve V, Berk JL, González-Duarte A, Gillmore JD, Low SC, Sekijima Y, Obici L, Chen C, Badri P, Arum SM, Vest J, Polydefkis M. Efficacy and safety of vutrisiran for patients with hereditary transthyretin-mediated amyloidosis with polyneuropathy: a randomized clinical trial. Amyloid 2023; 30:1-9. [PMID: 35875890 DOI: 10.1080/13506129.2022.2091985] [Citation(s) in RCA: 99] [Impact Index Per Article: 99.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND The study objective was to assess the effect of vutrisiran, an RNA interference therapeutic that reduces transthyretin (TTR) production, in patients with hereditary transthyretin (ATTRv) amyloidosis with polyneuropathy. METHODS HELIOS-A was a phase 3, global, open-label study comparing the efficacy and safety of vutrisiran with an external placebo group (APOLLO study). Patients were randomized 3:1 to subcutaneous vutrisiran 25 mg every 3 months (Q3M) or intravenous patisiran 0.3 mg/kg every 3 weeks (Q3W) for 18 months. RESULTS HELIOS-A enrolled 164 patients (vutrisiran, n = 122; patisiran reference group, n = 42); external placebo, n = 77. Vutrisiran met the primary endpoint of change from baseline in modified Neuropathy Impairment Score +7 (mNIS+7) at 9 months (p = 3.54 × 10-12), and all secondary efficacy endpoints; significant improvements versus external placebo were observed in Norfolk Quality of Life-Diabetic Neuropathy, 10-meter walk test (both at 9 and 18 months), mNIS+7, modified body-mass index, and Rasch-built Overall Disability Scale (all at 18 months). TTR reduction with vutrisiran Q3M was non-inferior to within-study patisiran Q3W. Most adverse events were mild or moderate in severity, and consistent with ATTRv amyloidosis natural history. There were no drug-related discontinuations or deaths. CONCLUSIONS Vutrisiran significantly improved multiple disease-relevant outcomes for ATTRv amyloidosis versus external placebo, with an acceptable safety profile. CLINICALTRIALS.GOV NCT03759379.
Collapse
Affiliation(s)
- David Adams
- Neurology Department, CHU Bicêtre, APHP, Université Paris-Saclay, Le Kremlin Bicêtre Cedex, France
| | - Ivailo L Tournev
- Department of Neurology, Clinic of Nervous Diseases, University Hospital Aleksandrovska, Medical University, Sofia, Bulgaria.,Department of Cognitive Sciences, New Bulgarian University, Sofia, Bulgaria
| | - Mark S Taylor
- Department of Clinical Immunology and Allergy, Westmead Hospital and Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Teresa Coelho
- Hospital de Santo António, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | | | - John L Berk
- Boston Medical Center, Boston University, Boston, Massachusetts, USA
| | | | - Julian D Gillmore
- National Amyloidosis Centre, University College London, Royal Free Hospital, London, UK
| | - Soon-Chai Low
- Department of Medicine, Division of Neurology, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Yoshiki Sekijima
- Department of Medicine (Neurology & Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Laura Obici
- Amyloidosis Research and Treatment Centre, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
| | - Chongshu Chen
- Alnylam Pharmaceuticals, Cambridge, Massachusetts, USA
| | | | - Seth M Arum
- Alnylam Pharmaceuticals, Cambridge, Massachusetts, USA
| | - John Vest
- Alnylam Pharmaceuticals, Cambridge, Massachusetts, USA
| | - Michael Polydefkis
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | |
Collapse
|
19
|
A retrospective survey of patients with hereditary transthyretin-mediated (hATTR) amyloidosis treated with patisiran in real-world clinical practice in Belgium. Acta Neurol Belg 2023:10.1007/s13760-023-02188-z. [PMID: 36829087 DOI: 10.1007/s13760-023-02188-z] [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: 03/15/2022] [Accepted: 01/16/2023] [Indexed: 02/26/2023]
Abstract
INTRODUCTION Hereditary transthyretin-mediated (hATTR) amyloidosis, a genetic disease caused by mutations in the transthyretin gene, leads to progressive sensory and autonomic neuropathy and/or cardiomyopathy and is associated with renal and ophthalmologic manifestations and a poor prognosis. METHODS This is a retrospective study based on data collected from the medical records of patients with hATTR amyloidosis treated with patisiran between 01 July 2018 and 01 February 2021. Six Belgian neuromuscular reference centers participated, covering all patisiran-treated hATTR amyloidosis patients at the study time. This study was conducted to collect data requested in the context of the reimbursement of patisiran in Belgium. RESULTS Thirty-one patients were diagnosed with hATTR amyloidosis with polyneuropathy, Coutinho stage 1 or 2, and eligible for active treatment during the data collection period. Of the hATTR amyloidosis patients treated with patisiran (n = 12), seven and five had polyneuropathy stages 1 and 2, respectively. Six patients had cardiac symptoms (New York Heart Association class 2 or above). Follow-up information was available for nine patients. Following patisiran treatment, eight patients showed stable or improved assessments for most neurological or cardiological parameters. Only one patient presented with worsening statuses at the end of the data collection period. CONCLUSIONS The patients with hATTR amyloidosis in Belgium have similar baseline demographics and disease characteristics to those studied in the patisiran APOLLO study and show a similar therapeutic response in the real-world, altering the expected disease progression in most patients.
Collapse
|
20
|
Imdad U. Amyloidosis of the Heart: A Comprehensive Review. Cureus 2023; 15:e35264. [PMID: 36968873 PMCID: PMC10035605 DOI: 10.7759/cureus.35264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2023] [Indexed: 02/25/2023] Open
Abstract
Cardiac amyloidosis is a progressive, infiltrative cardiomyopathy, whose types are based on various infiltrating amyloids, namely, light chains in primary amyloidosis, mutated transthyretin proteins in hereditary amyloidosis, and wild-type transthyretin proteins in senile amyloidosis. While cardiac amyloidosis has a non-specific presentation, the type-specific presentations may provide some clues to the diagnosis. While tissue biopsy remains the gold standard, other newer non-invasive methods can aid in the diagnostic approach for suspected cardiac amyloidosis. Various medications used to treat heart failure may lead to adverse outcomes in patients with cardiac amyloidosis. More research is needed to understand the adequate management and treatment of cardiac amyloidosis.
Collapse
|
21
|
Robinson C, Pham C, Zamarripa AM, Dugay CS, Lee CA, Berger AA, Landman A, Cornett EM, Kassem H, Kaye AD, Urits I, Viswanath O, Ganti L. Inotersen to Treat Polyneuropathy Associated with Hereditary Transthyretin (hATTR) Amyloidosis. Health Psychol Res 2023; 10:67910. [PMID: 36726478 PMCID: PMC9886172 DOI: 10.52965/001c.67910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Background Amyloidosis is a group of diseases with the common pathophysiology of protein misfolding and aberrant deposition in tissue. There are both acquired and hereditary forms of this disease, and this review focuses on the latter hereditary transthyretin-mediated (hATTR). hATTR affects about 50,000 individuals globally and mostly appears as one of three syndromes - cardiac, polyneuropathy, and oculoleptomeningeal. Polyneuropathy is the most common form, and there is usually some overlap in individual patients. Results Recently, novel therapeutic options emerged in the form of groundbreaking drugs, Patisiran and Inotersen, small interfering RNA molecules that target TTR and reduce the production of this protein. By targeting TTR mRNA transcripts, Inotersen decreases protein translation and production, reducing the deposition of misfolded proteins. It was shown to be both effective and safe for use and specifically formulated to concentrate in the liver - where protein production takes place. Conclusion hATTR is a rare, progressive, and debilitating disease. Its most common presentation is that of polyneuropathy, and it carries a very poor prognosis and a natural history conveying a median survival of < 12 years. Novel therapeutic options are groundbreaking by providing disease-modifying specific, targeted therapies against TTR production and deposition. The use of RNA interference (RNAi) opens the door to the treatment of hereditary diseases by targeting them at the genetic level.
Collapse
Affiliation(s)
- Christopher Robinson
- Anesthesia, Critical Care, and Pain MedicineBeth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Cynthia Pham
- Georgetown University School of Medicine, MedStar Georgetown University Hospital, Washington, DC
| | | | - Chase S. Dugay
- Department of AnesthesiologyCreighton University School of Medicine, Omaha, NE
| | - Christopher A. Lee
- Department of AnesthesiologyCreighton University School of Medicine, Omaha, NE
| | - Amnon A. Berger
- Anesthesia, Critical Care, and Pain MedicineBeth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Avi Landman
- University of Central Florida College of Medicine, Orlando, FL and HCA Osceola Hospital, Kissimmee, FL
| | | | - Hisham Kassem
- Department of AnesthesiologyMount Sinai Medical Center, Miami Beach, FL
| | - Alan D. Kaye
- Department of AnesthesiologyLouisiana State University Health Sciences, New Orleans, LA
| | - Ivan Urits
- Department of AnesthesiologyLouisiana State University Health Sciences, New Orleans, LA
| | - Omar Viswanath
- University of Arizona College of Medicine-Phoenix, Phoenix, AZ,Department of AnesthesiologyCreighton University School of Medicine, Omaha, NE,Department of AnesthesiologyLSU Health, Shreveport, LA
| | - Latha Ganti
- University of Central Florida College of Medicine, Orlando, FL and HCA Osceola Hospital, Kissimmee, FL
| |
Collapse
|
22
|
Duran JM, Borges-Neto S. Bone scintigraphy imaging and transthyretin-related (ATTR) cardiac amyloidosis: New tricks from an old tool? J Nucl Cardiol 2023; 30:368-370. [PMID: 35869405 PMCID: PMC9984317 DOI: 10.1007/s12350-022-03032-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 05/31/2022] [Indexed: 10/17/2022]
Affiliation(s)
- Jessica M Duran
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Salvador Borges-Neto
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
- Division of Nuclear Medicine, Department of Radiology, Duke University School of Medicine, Durham, NC, USA.
| |
Collapse
|
23
|
Ribeiro ASF, Zerolo BE, López-Espuela F, Sánchez R, Fernandes VS. Cardiac System during the Aging Process. Aging Dis 2023:AD.2023.0115. [PMID: 37163425 PMCID: PMC10389818 DOI: 10.14336/ad.2023.0115] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 01/15/2023] [Indexed: 05/12/2023] Open
Abstract
The aging process is accompanied by a continuous decline of the cardiac system, disrupting the homeostatic regulation of cells, organs, and systems. Aging increases the prevalence of cardiovascular diseases, thus heart failure and mortality. Understanding the cardiac aging process is of pivotal importance once it allows us to design strategies to prevent age-related cardiac events and increasing the quality of live in the elderly. In this review we provide an overview of the cardiac aging process focus on the following topics: cardiac structural and functional modifications; cellular mechanisms of cardiac dysfunction in the aging; genetics and epigenetics in the development of cardiac diseases; and aging heart and response to the exercise.
Collapse
Affiliation(s)
| | - Blanca Egea Zerolo
- Escuela de Enfermería y Fisioterapia San Juan de Dios. Universidad Pontificia Comillas, Madrid, Spain
| | - Fidel López-Espuela
- Metabolic Bone Diseases Research Group, Nursing and Occupational Therapy College, University of Extremadura, Caceres, Spain
| | - Raúl Sánchez
- Unidad de Cardiopatías Congénitas, Hospital Universitario La Paz, Madrid, Spain
| | - Vítor S Fernandes
- Departamento de Fisiología, Facultad de Farmacia, Universidad Complutense de Madrid, Madrid, Spain
| |
Collapse
|
24
|
Kitchlu A, Chan CT, Jhaveri KD, Delgado D, Tam P. Amyloidoses in Onco-Nephrology Practice: A Multidisciplinary Case-Based Conference Report. Can J Kidney Health Dis 2023; 10:20543581231165711. [PMID: 37101848 PMCID: PMC10123889 DOI: 10.1177/20543581231165711] [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: 12/08/2022] [Accepted: 02/09/2023] [Indexed: 04/28/2023] Open
Abstract
Introduction and Objective Amyloidoses are a heterogeneous group of disorders resulting from deposition of amyloid fibrils into extracellular tissues. While the kidneys are one of the most frequent sites of amyloid deposition, amyloid deposits can also affect a wide range of organ systems, including the heart, liver, gastrointestinal tract, and peripheral nerves. The prognosis of amyloidosis, especially with cardiac involvement, remains poor; however, a collaborative approach applying new tools for diagnosis and management may improve outcomes. In September 2021, the Canadian Onco-Nephrology Interest Group hosted a symposium to discuss diagnostic challenges and recent advances in the management of amyloidosis from the perspectives of the nephrologist, cardiologist, and onco-hematologist. Methods and Sources of Information Through structured presentations, the group discussed a series of cases highlighting the varied clinical presentations of amyloidoses affecting the kidney and heart. Expert opinions, clinical trial findings, and publication summaries were used to illustrate patient-related and treatment-related considerations in the diagnosis and management of amyloidoses. Key findings (1) Overview of the clinical presentation of amyloidoses and the role of specialists in performing timely and accurate diagnostic workup; (2) review of best practices for multidisciplinary management of amyloidosis, including prognostic variables and determinants of treatment response; and (3) update on new and emerging treatments in the management of light chain and amyloid transthyretin amyloidoses. Limitations This conference featured multidisciplinary discussion of cases, and learning points reflect the assessments by the involved experts/authors. Implications Identification and management of amyloidoses can be facilitated with a multidisciplinary approach and higher index of suspicion from cardiologists, nephrologists, and hemato-oncologists. Increased awareness of clinical presentations and diagnostic algorithms for amyloidosis subtyping will lead to more timely interventions and improved clinical outcomes.
Collapse
Affiliation(s)
- Abhijat Kitchlu
- Department of Medicine, Division of Nephrology, University Health Network, University of Toronto, ON, Canada
- Abhijat Kitchlu, Department of Medicine, Division of Nephrology, University Health Network, University of Toronto, 200 Elizabeth St, 8N-842, Toronto, ON M5G 2C4, Canada.
| | - Christopher T. Chan
- Department of Medicine, Division of Nephrology, University Health Network, University of Toronto, ON, Canada
| | - Kenar D. Jhaveri
- The Glomerular Disease Center at Northwell Health, Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY, USA
| | - Diego Delgado
- Division of Cardiology, Heart Failure and Transplant Program, University Health Network, Toronto General Hospital, ON, Canada
| | - Paul Tam
- Division of Nephrology, The Scarborough Hospital, Toronto, ON, Canada
| |
Collapse
|
25
|
Gawor M, Holcman K, Franaszczyk M, Lipowska M, Michałek P, Teresińska A, Bilińska ZT, Rubiś P, Kostkiewicz M, Szot W, Podolec P, Grzybowski J. Spectrum of transthyretin gene mutations and clinical characteristics of Polish patients with cardiac transthyretin amyloidosis. Cardiol J 2022; 29:985-993. [PMID: 32789836 PMCID: PMC9788745 DOI: 10.5603/cj.a2020.0104] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 06/29/2020] [Accepted: 07/13/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Transthyretin amyloidosis (ATTR) is a rare, life-threatening systemic disorder. We present first findings on the cardiac hereditary ATTR in Poland. METHODS Sixty-eight consecutive patients with suspected or known cardiac amyloidosis were evaluated, including blood tests, standard 12-lead electrocardiography (ECG) and transthoracic echocardiography. ATTR was confirmed histologically or non-invasively using 99mTc-DPD scintigraphy. Transthyretin (TTR) gene sequencing was performed. RESULTS In 2017-2019, 10 unrelated male patients were diagnosed with hereditary ATTR. All patients had very uncommon TTR gene mutations: 7 patients had p.Phe53Leu mutation, 2 patients had p.Glu109Lys mutation and 1 patient had p.Ala101Val mutation. The age of onset ranged from 49 to 67 years (mean [SD] age, 58.7 [6.4] years). On ECG, most patients (70%) had pseudoinfarct pattern and/or low QRS voltage. The maximal wall thickness (MWT) on echocardiography varied considerably among the patients from moderate (16 mm) to massively increased (30 mm). Most patients (90%) had decreased left ventricular ejection fraction (mean [SD], 43 [11] %). On follow-up, we observed progressive heart failure in almost all cases. The first patient with p.Phe53Leu mutation died of heart failure, the second died suddenly, the third successfully underwent combined heart and liver transplant with 15 months survival from the surgery. The patient with p.Ala101Val mutation died of stroke. CONCLUSIONS According to available data, this is the first time that the types of TTR mutations and the clinical characteristics of Polish patients with cardiac hereditary ATTR have been described. Previous literature data about Polish background in families with p.Phe53Leu mutation and the present results, suggest that this TTR mutation might be endemic in the Polish population.
Collapse
Affiliation(s)
- Monika Gawor
- Department of Cardiomyopathy, Institute of Cardiology, Warsaw, Poland
| | - Katarzyna Holcman
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, Jagiellonian University Medical College, Krakow, Poland
| | - Maria Franaszczyk
- Department of Medical Biology, Institute of Cardiology, Warsaw, Poland
| | - Marta Lipowska
- Department of Neurology, Medical University of Warsaw, Poland
| | - Piotr Michałek
- Rapid Diagnosis Department, Emergency Room, Institute of Cardiology, Warsaw, Poland
| | - Anna Teresińska
- Department of Nuclear Medicine, Institute of Cardiology, Warsaw, Poland
| | - Zofia T. Bilińska
- Unit for Screening Studies in Inherited Cardiovascular Diseases, The Cardinal Stefan Wyszynski Institute of Cardiology, Warsaw, Poland
| | - Paweł Rubiś
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, Jagiellonian University Medical College, Krakow, Poland
| | - Magdalena Kostkiewicz
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, Jagiellonian University Medical College, Krakow, Poland,Department of Nuclear Medicine, John Paul II Hospital, Jagiellonian University Medical College, Krakow, Poland
| | - Wojciech Szot
- Department of Nuclear Medicine, John Paul II Hospital, Jagiellonian University Medical College, Krakow, Poland
| | - Piotr Podolec
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, Jagiellonian University Medical College, Krakow, Poland
| | - Jacek Grzybowski
- Department of Cardiomyopathy, Institute of Cardiology, Warsaw, Poland
| |
Collapse
|
26
|
Dasgupta NR. Care of Patients With Transthyretin Amyloidosis: the Roles of Nutrition, Supplements, Exercise, and Mental Health. Am J Cardiol 2022; 185 Suppl 1:S35-S42. [PMID: 36549789 DOI: 10.1016/j.amjcard.2022.10.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 10/24/2022] [Accepted: 10/27/2022] [Indexed: 12/24/2022]
Abstract
Transthyretin (ATTR) amyloidosis is a debilitating disease that results in organ failure and eventual death. As the disease progresses, patients experience neurologic, gastrointestinal, and cardiovascular symptoms that increasingly compromise their nutritional status and exercise capacity. These symptoms cause considerable emotional stress and mental health challenges for patients and caregivers. This review summarizes common symptoms and mechanisms associated with malnutrition and exercise intolerance, and sources of emotional stress, and offers therapeutic strategies to address these issues. Although earlier diagnosis and disease-specific treatment are central to caring for patients with ATTR amyloidosis, additional attention to symptom-focused treatments to improve nutritional status, maintain exercise tolerance and capacity, and improve and maintain mental health are also important. In conclusion, a team-based approach involving multiple clinicians and providers can offer more comprehensive and coordinated care, support, and education for patients and caregivers.
Collapse
Affiliation(s)
- Noel R Dasgupta
- Department of Cardiology, Indiana University School of Medicine, Indianapolis, Indiana.
| |
Collapse
|
27
|
Brannagan TH, Berk JL, Gillmore JD, Maurer MS, Waddington‐Cruz M, Fontana M, Masri A, Obici L, Brambatti M, Baker BF, Hannan LA, Buchele G, Viney NJ, Coelho T, Nativi‐Nicolau J. Liver-directed drugs for transthyretin-mediated amyloidosis. J Peripher Nerv Syst 2022; 27:228-237. [PMID: 36345805 PMCID: PMC10100204 DOI: 10.1111/jns.12519] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/28/2022] [Accepted: 10/30/2022] [Indexed: 11/11/2022]
Abstract
Transthyretin-mediated amyloidosis (ATTR) is a rare, under-recognized, progressively debilitating, fatal disease caused by the aggregation and extracellular deposition of amyloid transthyretin (TTR) fibrils in multiple organs and tissues throughout the body. TTR is predominantly synthesized by the liver and normally circulates as a homotetramer, while misfolded monomers aggregate to form amyloid fibrils. One strategy to treat ATTR amyloidosis is to reduce the amount of TTR produced by the liver using drugs that directly target the TTR mRNA or gene. This narrative review focuses on how TTR gene silencing tools act to reduce TTR production, describing strategies for improved targeted delivery of these agents to hepatocytes where TTR is preferentially expressed. Antisense oligonucleotides (ASOs) and small interfering RNAs (siRNAs), termed RNA silencers, cause selective degradation of TTR mRNA, while a TTR gene editing tool reduces TTR expression by introducing nonsense mutations into the TTR gene. Two strategies to facilitate tissue-specific delivery of these nucleic acid-based drugs employ endogenous receptors expressed by hepatocytes. Lipid nanoparticles (LNPs) that recruit apolipoprotein E support low-density lipoprotein receptor-mediated uptake of unconjugated siRNA and are now used for CRISPR gene editing tools. Additionally, conjugating N-acetylgalactosamine (GalNAc) moieties to ASOs or siRNAs facilitates receptor-mediated uptake by the asialoglycoprotein receptor. In summary, ATTR is a progressive disease with various clinical manifestations due to TTR aggregation, deposition, and amyloid formation. Receptor-targeted ligands (eg, GalNAc) and nanoparticle encapsulation (eg, LNPs) are technologies to deliver ASOs, siRNAs, and gene editing tools to hepatocytes, the primary location of TTR synthesis.
Collapse
Affiliation(s)
- Thomas H. Brannagan
- Peripheral Neuropathy CenterColumbia University, Vagelos College of Physicians and SurgeonsNew YorkNew YorkUSA
| | - John L. Berk
- Amyloidosis CenterBoston University School of MedicineBostonMassachusettsUSA
| | - Julian D. Gillmore
- National Amyloidosis CentreUniversity College London, Royal Free HospitalLondonUK
| | - Mathew S. Maurer
- Cardiac Amyloidosis Program, Division of CardiologyColumbia College of Physicians and SurgeonsNew YorkNew YorkUSA
| | - Márcia Waddington‐Cruz
- National Amyloidosis Referral Center‐CEPARMUniversity HospitalFederal University of Rio de JaneiroRio de JaneiroBrazil
| | - Marianna Fontana
- National Amyloidosis CentreUniversity College London, Royal Free HospitalLondonUK
| | - Ahmad Masri
- Cardiac Amyloidosis Program, Knight Cardiovascular InstituteOregon Health & Science UniversityPortlandOregonUSA
| | - Laura Obici
- Amyloidosis Research and Treatment CenterIRCCS Fondazione Policlinico San MatteoPaviaItaly
| | | | | | | | | | | | - Teresa Coelho
- Department of NeurosciencesCentro Hospitalar Universitário do PortoPortoPortugal
| | | |
Collapse
|
28
|
Khella SL. Noncardiac Manifestations of Hereditary Amyloidosis. Am J Cardiol 2022; 185 Suppl 1:S17-S22. [PMID: 36369035 DOI: 10.1016/j.amjcard.2022.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 09/19/2022] [Accepted: 10/03/2022] [Indexed: 11/11/2022]
Abstract
The most common forms of cardiac amyloidosis are progressive, life threatening, and underrecognized. Symptoms affect a variety of organs and overlap with those of more common conditions, complicating and postponing diagnosis. Cardiac disease generally determines mortality, but noncardiac manifestations typically surface before cardiac symptoms, often several years before diagnosis. Familiarity with noncardiac manifestations may lead to early diagnosis, enabling treatment and improving prognosis.
Collapse
Affiliation(s)
- Sami L Khella
- Department of Neurology, Penn Presbyterian Medical Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| |
Collapse
|
29
|
Martyn T, Saef J, Hussain M, Ives L, Kiang A, Estep JD, Collier P, Starling RC, Cremer PC, Tang WHW, Hanna M, Jaber WA. The Association of Cardiac Biomarkers, the Intensity of Tc99 Pyrophosphate Uptake, and Survival in Patients Evaluated for Transthyretin Cardiac Amyloidosis in the Early Therapeutics Era. J Card Fail 2022; 28:1509-1518. [PMID: 35843490 DOI: 10.1016/j.cardfail.2022.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 06/06/2022] [Accepted: 06/23/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Transthyretin amyloid cardiomyopathy (ATTR-CM) is an increasingly recognized cause of heart failure. Given the expansion of noninvasive diagnosis with 99mTc-pyrophosphate (99mTc-PYP) scanning, and clinical use of the transthyretin stabilizer, tafamidis, we sought to examine the interplay of planar imaging heart-to-contralateral lung (H/CL) ratio, cardiac biomarkers, and survival probability in a contemporary cohort of patients referred for noninvasive evaluation of ATTR-CM. METHODS This single-center retrospective cohort study included 351 consecutive patients who underwent a standardized imaging protocol with 99mTc-PYP scanning for the evaluation of ATTR-CM from January 1, 2018, to January 1, 2020. After the exclusion of light chain amyloidosis, patients were characterized as scan consistent with ATTR (+ATTR-CM) or scan not consistent with ATTR (-ATTR-CM) using current guidelines. Linear regression was used to examine the relationship between biomarkers and H/CL and univariate Cox proportional hazards models were used to assess the probability of transplant-free survival. RESULTS We included 318 patients in the analysis (n = 86 patients +ATTR-CM; n = 232 patients -ATTR-CM). The median follow-up time was 20.1 months. During the study period, 67% of +ATTR-CM patients received tafamidis (median treatment duration, 17 months). The median H/CL ratio was 1.58 (interquartile range, 1.40-1.75). An H/CL ratio of more than 1.6 or less than 1.6 did not seem to have an impact on survival probability in +ATTR-CM patients (P = .30; hazard ratio, 0.65; 95% confidence interval, 0.31-1.41). Cardiac biomarkers were poorly correlated with H/CL (troponin T, R2 = 0.024; N-terminal pro-B-type natriuretic peptide, R2 =0.023). The Gillmore staging system predicted survival probability in +ATTR-CM as well as in the entire cohort referred for scanning. There was a trend toward longer survival among those who were -ATTR-CM compared with +ATTR-CM (P = .051; hazard ratio, 0.64; 95% confidence interval, 0.40-1.00). CONCLUSIONS At a large referral center, the intensity of 99mTc-PYP uptake (H/CL ratio) has neither correlation with cardiac biomarker concentrations nor prognostic usefulness in an analysis of intermediate term outcomes in the early therapeutics era. The H/CL ratio has diagnostic value, but offers little prognostic value in patients with ATTR-CM. Established staging schema were predictive of survival in this contemporary cohort, re-emphasizing the importance of cardiac biomarkers and renal function in assessing disease severity and prognosis.
Collapse
Affiliation(s)
- Trejeeve Martyn
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio; The George M. and Linda H. Kaufman Center for Heart Failure and Recovery, Cleveland Clinic, Cleveland, Ohio
| | - Joshua Saef
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Muzna Hussain
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Lauren Ives
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio; The George M. and Linda H. Kaufman Center for Heart Failure and Recovery, Cleveland Clinic, Cleveland, Ohio
| | - Alan Kiang
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Jerry D Estep
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio; The George M. and Linda H. Kaufman Center for Heart Failure and Recovery, Cleveland Clinic, Cleveland, Ohio
| | - Patrick Collier
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Randall C Starling
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio; The George M. and Linda H. Kaufman Center for Heart Failure and Recovery, Cleveland Clinic, Cleveland, Ohio
| | - Paul C Cremer
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio; The George M. and Linda H. Kaufman Center for Heart Failure and Recovery, Cleveland Clinic, Cleveland, Ohio
| | - W H Wilson Tang
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio; The George M. and Linda H. Kaufman Center for Heart Failure and Recovery, Cleveland Clinic, Cleveland, Ohio
| | - Mazen Hanna
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio; The George M. and Linda H. Kaufman Center for Heart Failure and Recovery, Cleveland Clinic, Cleveland, Ohio
| | - Wael A Jaber
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio.
| |
Collapse
|
30
|
Oghina S, Delbarre MA, Poullot E, Belhadj K, Fanen P, Damy T. [Cardiac amyloidosis: State of art in 2022]. Rev Med Interne 2022; 43:537-544. [PMID: 35870985 DOI: 10.1016/j.revmed.2022.04.036] [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: 01/19/2022] [Revised: 04/17/2022] [Accepted: 04/30/2022] [Indexed: 10/17/2022]
Abstract
The 3 main types of cardiac amyloidosis are linked to two protein precursors: AL amyloidosis secondary to free light chain deposits in the context of monoclonal gammopathy (mainly of undetermined significance or myeloma) and transthyretin amyloidosis (ATTR), comprising wild-type transthyretin amyloidosis (ATTRwt for wild type) and hereditary transthyretin amyloidosis (ATTRv for variant). These diseases are underdiagnosed and highly prevalent in common cardiac phenotypes in recent studies (heart failure with preserved ejection fraction, severe aortic stenosis, hypertrophic cardiomyopathy). Myocardial amyloid infiltration affects all cardiac structures and clinically promotes predominantly heart failure, conductive disorders and cardioembolic events. The search for extracardiac signs makes it possible to arouse diagnostic suspicion. Electrocardiogram, echocardiography and cardiac MRI can suspect cardiac amyloidosis. The diagnostic confirmation follows a simple algorithm including a systematic search for monoclonal gammapathy and a disphosphonate scintigraphy. Histological proof is necessary in case of AL or ATTR amyloidosis with concomitant monoclonal gammopathy in order to initiate specific treatment. Due to the late disease onset in ATTRv, genetic testing must be routine in all cases of ATTR. These diseases are no longer perceived as incurable since recent therapeutic innovations. A better knowledge of the disease is more than ever necessary.
Collapse
Affiliation(s)
- S Oghina
- Service de cardiologie, Centre Hospitalier Universitaire Henri-Mondor, AP-HP (Assistance Publique-Hôpitaux de Paris), 1, rue Gustave-Eiffel, 94010 Créteil, France; Centre de référence national des amyloses cardiaques et réseau amylose Mondor, Filière Cardiogen, Centre Hospitalier Universitaire Henri-Mondor, AP-HP (Assistance Publique-Hôpitaux de Paris), 1, rue Gustave-Eiffel, 94010 Créteil, France.
| | - M A Delbarre
- Service de cardiologie, Centre Hospitalier Universitaire Henri-Mondor, AP-HP (Assistance Publique-Hôpitaux de Paris), 1, rue Gustave-Eiffel, 94010 Créteil, France; Centre de référence national des amyloses cardiaques et réseau amylose Mondor, Filière Cardiogen, Centre Hospitalier Universitaire Henri-Mondor, AP-HP (Assistance Publique-Hôpitaux de Paris), 1, rue Gustave-Eiffel, 94010 Créteil, France
| | - E Poullot
- Centre de référence national des amyloses cardiaques et réseau amylose Mondor, Filière Cardiogen, Centre Hospitalier Universitaire Henri-Mondor, AP-HP (Assistance Publique-Hôpitaux de Paris), 1, rue Gustave-Eiffel, 94010 Créteil, France; Service d'anatomo-pathologie, Centre Hospitalier Universitaire Henri-Mondor, AP-HP (Assistance Publique-Hôpitaux de Paris), 1, rue Gustave-Eiffel, 94010 Créteil, France
| | - K Belhadj
- Centre de référence national des amyloses cardiaques et réseau amylose Mondor, Filière Cardiogen, Centre Hospitalier Universitaire Henri-Mondor, AP-HP (Assistance Publique-Hôpitaux de Paris), 1, rue Gustave-Eiffel, 94010 Créteil, France; Service d'hématologie lymphoïde, Centre Hospitalier Universitaire Henri-Mondor, AP-HP (Assistance Publique-Hôpitaux de Paris), 1, rue Gustave-Eiffel, 94010 Créteil, France
| | - P Fanen
- Centre de référence national des amyloses cardiaques et réseau amylose Mondor, Filière Cardiogen, Centre Hospitalier Universitaire Henri-Mondor, AP-HP (Assistance Publique-Hôpitaux de Paris), 1, rue Gustave-Eiffel, 94010 Créteil, France; Service de génétique, Centre Hospitalier Universitaire Henri-Mondor, AP-HP (Assistance Publique-Hôpitaux de Paris), 1, rue Gustave-Eiffel, 94010 Créteil, France; Centre Hospitalier Universitaire Henri-Mondor, AP-HP (Assistance Publique-Hôpitaux de Paris), FHU SENEC, 1, rue Gustave-Eiffel, 94010 Créteil, France
| | - T Damy
- Service de cardiologie, Centre Hospitalier Universitaire Henri-Mondor, AP-HP (Assistance Publique-Hôpitaux de Paris), 1, rue Gustave-Eiffel, 94010 Créteil, France; Centre de référence national des amyloses cardiaques et réseau amylose Mondor, Filière Cardiogen, Centre Hospitalier Universitaire Henri-Mondor, AP-HP (Assistance Publique-Hôpitaux de Paris), 1, rue Gustave-Eiffel, 94010 Créteil, France; Centre Hospitalier Universitaire Henri-Mondor, AP-HP (Assistance Publique-Hôpitaux de Paris), FHU SENEC, 1, rue Gustave-Eiffel, 94010 Créteil, France
| |
Collapse
|
31
|
Richards D, Millns H, Cookson L, Lukas MA. An observational, non-interventional study for the follow-up of patients with amyloidosis who received miridesap followed by dezamizumab in a phase 1 study. Orphanet J Rare Dis 2022; 17:259. [PMID: 35810311 PMCID: PMC9271258 DOI: 10.1186/s13023-022-02405-7] [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: 12/08/2021] [Accepted: 06/26/2022] [Indexed: 11/10/2022] Open
Abstract
Background Miridesap depletes circulating serum amyloid P (SAP) and dezamizumab (anti-SAP monoclonal antibody) targets SAP on amyloid deposits, triggering amyloid removal. In a phase 1, first-in-human study (FIHS), progressive amyloid removal was observed in some patients after ≤ 3 cycles of miridesap/dezamizumab. Methods This observational, non-interventional study in patients who received miridesap/dezamizumab during the FIHS (planned follow-up: 5 years) evaluated response to treatment based on routine assessments of disease status and key organ function. In a post hoc analysis, patients responding to treatment in the FIHS during follow-up were identified as responders and further categorized as sustained or declining responders.
Results In the FIHS, 17/23 patients were treatment responders. Of these patients, seven (immunoglobulin light chain [AL], n = 6; serum amyloid A, n = 1) were considered sustained responders and ten (fibrinogen-a alpha chain [AFib], n = 5; AL, n = 4; apolipoprotein A-I, n = 1) were considered declining responders. We primarily present responder patient-level data for functional, cardiac, laboratory and imaging assessments conducted during the follow-up period, with non-responder data presented as supplementary. Conclusion No further development of miridesap/dezamizumab is planned in amyloidosis. However, long-term follow-up of these patients may provide insight into whether active removal of amyloid deposits has an impact on disease progression. Trial registration ClinicalTrials.gov, NCT01777243. Registered 28 January 2013, https://clinicaltrials.gov/ct2/show/study/NCT01777243. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-022-02405-7.
Collapse
|
32
|
Pané Foix M, Fernandez Calvo D, Condom I Mundó E, Suarez Novo JF, Merino Serra E, Garcia Benett JR, Gomà Gàllego M, Yun Viladomat S, Vigués Julià F, Vidal I Bel A. Clinical relevance of amyloid in prostate samples: a report on 40 patients. Histopathology 2022; 81:363-370. [PMID: 35788982 DOI: 10.1111/his.14717] [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: 04/07/2022] [Revised: 06/15/2022] [Accepted: 07/02/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To describe the clinical findings in patients with incidental prostatic amyloidosis. PATIENTS AND METHODS Retrospective search in the database of the Department of Pathology, Hospital de Bellvitge, for prostate specimens with amyloid. Congo red and immunohistochemical staining of the sections. Review of the patients' clinical charts for symptoms attributable to systemic amyloidosis. RESULTS Amyloid deposition in the prostate was identified and reported in 40 patients between 2001 and 2022. Median age was 76.5 years (range 62-90). Prostate cancer was diagnosed in 25 patients. Only 4 patients had a previous diagnosis of amyloidosis. In the remaining 36 the prostate sample (31 needle biopsies, two transurethral resections (TUR), two simple prostatectomies, one radical cystectomy for bladder cancer) provided the initial diagnosis. Amyloid deposits were mainly located in the wall of small vessels and rarely in the prostatic stroma. Immunohistochemistry was available in 32 cases, 26 of which were positive for TTR. All patients showed at least one symptom indicative of systemic amyloidosis, the most frequent being hearing loss (55%), carpal tunnel syndrome (42,5%) or other osteoarticular symptoms (tendinopathies, osteoarthritis), cataracts (37.5%), and cardiac symptoms (32.5%), among others. CONCLUSION The prostate is a target tissue for amyloid deposition. The incidental finding of amyloid in prostate corresponds, in the majority of cases, to previously undiagnosed systemic TTR amyloidosis in patients lacking signs of heart involvement but having mainly osteoarticular symptoms, hearing and visual impairment.
Collapse
Affiliation(s)
- Maria Pané Foix
- Department of Pathology, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona
| | - Davinia Fernandez Calvo
- Department of Pathology, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona
| | - Enric Condom I Mundó
- Department of Pathology, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona
| | - José Francisco Suarez Novo
- Department of Urology, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona
| | - Eva Merino Serra
- Department of Radiology, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona
| | - Josep Ronald Garcia Benett
- Department of Radiology, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona
| | - Montserrat Gomà Gàllego
- Department of Pathology, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona
| | - Sergi Yun Viladomat
- Community Heart Failure Program, Department of Internal Medicine, Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona
| | - Francesc Vigués Julià
- Department of Urology, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona
| | - August Vidal I Bel
- Department of Pathology, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona
| |
Collapse
|
33
|
Roy A, Peterson A, Marchant N, Alvir J, Bhambri R, Bredl Z, Benjumea D, Kemner J, Parasuraman B. Baseline characteristics and secondary medication adherence among Medicare patients diagnosed with transthyretin amyloid cardiomyopathy and/or receiving tafamidis prescriptions: A retrospective analysis of a Medicare cohort. J Manag Care Spec Pharm 2022; 28:766-777. [PMID: 35737856 PMCID: PMC10372989 DOI: 10.18553/jmcp.2022.28.7.766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND: Transthyretin amyloid cardiomyopathy (ATTR-CM) is an underdiagnosed, life-threatening condition that mostly affects older persons. In May 2019, regulatory approval of tafamidis provided the first pharmacologic treatment of ATTR-CM. In the pivotal phase 3 Transthyretin Amyloidosis Cardiomyopathy Clinical Trial (ATTR-ACT), 97.2% of patients were classified as adherent (defined as taking ≥ 80% of scheduled doses). Given its recent approval, there is limited real-world evidence examining patient adherence to tafamidis. OBJECTIVE: To evaluate adherence patterns, demographics, and clinical characteristics of patients in the United States receiving tafamidis prescriptions through Medicare. Secondarily, we aimed to evaluate concomitant medications filled by this patient population. METHODS: We conducted a retrospective cohort study of US Medicare claims data, limited by the Health Insurance Portability and Accountability Act of 1996, in adult patients with an adjudicated pharmacy claim for tafamidis (tafamidis free acid 61-mg capsule once daily or tafamidis meglumine four 20-mg capsules once daily) between May 1, 2019, and June 30, 2021. Gaps in therapy were measured using day gaps between prescription refills and continuous measure of medication gaps. Implementation adherence was assessed through modified medication possession ratio (MPRm), medication refill adherence (MRA), and proportion of days covered (PDC). Patients were grouped based on Medicare coverage. Patients were analyzed by subgroups based on age and at the zip code level, via distressed communities index quartiles and rural-urban tiers. RESULTS: A total of 3,558 patients who received a prescription fill of a tafamidis formulation were identified using Medicare Fee-for-Service (FFS) and Medicare Advantage (MA) claims data from May 1, 2019, to June 30, 2021. The characteristics of this patient population were consistent with published literature, as 98.6% were older than 65 years, 53.4% were between 75 years and 84 years, and 81.5% were male. In the patient population receiving tafamidis refills, adherence was high across all 3 measures, with mean MPRm greater than 90% and mean MRA greater than 80%, across all age groups. Mean PDC adherence rates were 79% or more across all age groups. Concomitant medications were generally indicated for heart failure and thrombosis. Among monotherapy groups with similar demographic makeup, adherence was significantly higher among users of tafamidis free acid vs tafamidis meglumine (P < 0.0001 across all mean adherence measures). CONCLUSIONS: Our results demonstrate that real-world adherence to tafamidis in the Medicare population is high, regardless of age, zip code-level socioeconomic quartile, or geography. Adherence was higher among patients receiving tafamidis free acid, suggesting that the enhanced convenience of a single capsule once daily may positively contribute to adherence among patients with ATTR-CM. DISCLOSURES: Darrin Benjumea is an employee of Genesis Research who has been contracted by Pfizer, Inc., for involvement in this study. Andrew Peterson is an employee of University of the Sciences who has been contracted by Pfizer, Inc., for involvement in this study. Zach Bredl is an employee of Care Journey who has been contracted by Pfizer, Inc., for involvement in this study. Anuja Roy, Nick Marchant, Jose Alvir, Rahul Bhambri, Jason Kemner, and Bhash Parasuraman are employees of Pfizer, Inc., and own stock and/or stock options. This study was supported by Pfizer, Inc.
Collapse
Affiliation(s)
| | - Andrew Peterson
- Department of Pharmacy Practice and Pharmacy Administration, Philadelphia College of Pharmacy, University of the Sciences, Philadelphia, PA
| | | | | | | | | | | | | | | |
Collapse
|
34
|
Siddiqi OK, Mints YY, Berk JL, Connors L, Doros G, Gopal DM, Kataria S, Lohrmann G, Pipilas AR, Ruberg FL. Diflunisal treatment is associated with improved survival for patients with early stage wild-type transthyretin (ATTR) amyloid cardiomyopathy: the Boston University Amyloidosis Center experience. Amyloid 2022; 29:71-78. [PMID: 35083944 PMCID: PMC9258521 DOI: 10.1080/13506129.2021.2000388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Diflunisal is a non-steroidal anti-inflammatory drug that stabilises transthyretin (TTR) and reduces neurologic deterioration in patients with polyneuropathy caused by hereditary transthyretin amyloidosis (ATTRv). METHODS We conducted a retrospective cohort study of patients with wild-type transthyretin cardiac amyloidosis (ATTRwt-CM) treated with diflunisal for at least one year between 2009 and 2016 at the Boston University Amyloidosis Centre. Baseline and one year follow up characteristics were measured, including plasma chemistries and echocardiography. Cox proportional hazards analysis assessed the primary outcome of all-cause mortality. RESULTS A total of 104 ATTRwt-CM patients were evaluated with 35 patients receiving diflunisal. Patients in the diflunisal group were younger (73.8 vs 76.8 years, p = 0.034), with lower B-type natriuretic peptide (BNP, 335 +/- 67 vs. 520 +/- 296 pg/mL, p = 0.006), similar troponin I (0.1 +/- 0.1 vs 0.2 +/- 0.3 ng/mL, p = 0.09), and better renal function (eGFR 67 +/- 17 vs 53 +/- 18 mL/min/1.73m2, p = 0.0002) at baseline. Over a median follow-up of 3.2 years, 52 deaths occurred. Diflunisal administration was associated with improved survival in unadjusted analysis (HR 0.13, 95% CI 0.05 - 0.36, p < 0.001) that persisted after adjustment for age, baseline BNP, eGFR, troponin I, interventricular septal thickness, and left ventricular ejection fraction (HR 0.18, 95% CI 0.06 - 0.51, p = 0.0006). Over the observation period, no significant changes in BNP, troponin I, interventricular septal thickness or left ventricular ejection fraction were observed with diflunisal treatment. A total of 14 patients (40%) discontinued diflunisal in this study, but only 3 within the first year. Mean eGFR in treated patients was 59 ml/min/1.73m2 at 1 year (change from baseline p = 0.03). CONCLUSION Diflunisal administration in ATTRwt-CM was associated with improved survival and overall stability in clinical and echocardiographic markers of disease with decrement renal function.
Collapse
Affiliation(s)
- Omar K Siddiqi
- Amyloidosis Center, Boston University School of Medicine, Boston, MA, USA.,Department of Medicine, Section of Cardiovascular Medicine, Boston Medical Center, Boston, MA, USA
| | - Yuliya Y Mints
- Department of Medicine, Section of Cardiovascular Medicine, Boston Medical Center, Boston, MA, USA
| | - John L Berk
- Amyloidosis Center, Boston University School of Medicine, Boston, MA, USA.,Department of Medicine, Boston Medical Center, Boston, MA, USA
| | - Lawreen Connors
- Amyloidosis Center, Boston University School of Medicine, Boston, MA, USA.,Department of Pathology and Laboratory Medicine, Boston Medical Center, Boston, MA, USA
| | - Gheorghe Doros
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Deepa M Gopal
- Amyloidosis Center, Boston University School of Medicine, Boston, MA, USA.,Department of Medicine, Section of Cardiovascular Medicine, Boston Medical Center, Boston, MA, USA
| | - Shivangi Kataria
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Graham Lohrmann
- Department of Medicine, Boston Medical Center, Boston, MA, USA
| | - Alexandra R Pipilas
- Department of Medicine, Section of Cardiovascular Medicine, Boston Medical Center, Boston, MA, USA
| | - Frederick L Ruberg
- Amyloidosis Center, Boston University School of Medicine, Boston, MA, USA.,Department of Medicine, Section of Cardiovascular Medicine, Boston Medical Center, Boston, MA, USA.,Department of Radiology, Boston Medical Center, Boston, MA, USA
| |
Collapse
|
35
|
Carroll A, Dyck PJ, de Carvalho M, Kennerson M, Reilly MM, Kiernan MC, Vucic S. Novel approaches to diagnosis and management of hereditary transthyretin amyloidosis. J Neurol Neurosurg Psychiatry 2022; 93:668-678. [PMID: 35256455 PMCID: PMC9148983 DOI: 10.1136/jnnp-2021-327909] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 02/12/2022] [Indexed: 12/27/2022]
Abstract
Hereditary transthyretin amyloidosis (ATTRv) is a severe, adult-onset autosomal dominant inherited systemic disease predominantly affecting the peripheral and autonomic nervous system, heart, kidney and the eyes. ATTRv is caused by mutations of the transthyretin (TTR) gene, leading to extracellular deposition of amyloid fibrils in multiple organs including the peripheral nervous system. Typically, the neuropathy associated with ATTRv is characterised by a rapidly progressive and disabling sensorimotor axonal neuropathy with early small-fibre involvement. Carpal tunnel syndrome and cardiac dysfunction frequently coexist as part of the ATTRv phenotype. Although awareness of ATTRv polyneuropathy among neurologists has increased, the rate of misdiagnosis remains high, resulting in significant diagnostic delays and accrued disability. A timely and definitive diagnosis is important, given the emergence of effective therapies which have revolutionised the management of transthyretin amyloidosis. TTR protein stabilisers diflunisal and tafamidis can delay the progression of the disease, if treated early in the course. Additionally, TTR gene silencing medications, patisiran and inotersen, have resulted in up to 80% reduction in TTR production, leading to stabilisation or slight improvement of peripheral neuropathy and cardiac dysfunction, as well as improvement in quality of life and functional outcomes. The considerable therapeutic advances have raised additional challenges, including optimisation of diagnostic techniques and management approaches in ATTRv neuropathy. This review highlights the key advances in the diagnostic techniques, current and emerging management strategies, and biomarker development for disease progression in ATTRv.
Collapse
Affiliation(s)
- Antonia Carroll
- Brain and Mind Centre, Faculty of Medicine and Health, Translational Research Collective, University of Sydney and Department of Neurology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - P James Dyck
- Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mamede de Carvalho
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal.,Department of Neurosciences and Mental Health, Hospital de Santa Maria, Lisboa, Portugal
| | - Marina Kennerson
- Northcott Neuroscience Laboratory, ANZAC Research Institute, Molecular Medicine Laboratory Concord Repatriation General Hospital, and Concord Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Mary M Reilly
- MRC Centre for Neuromuscular Diseases, UCL Institute of Neurology and National Hospital for Neurology and Neurosurgery, London, UK
| | - Matthew C Kiernan
- Bushell Chair of Neurology, Brain and Mind Centre, University of Sydney, Sydney, New South Wales, Australia.,Neurology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Steve Vucic
- Brain and Nerve Research Center, Concord Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
36
|
Irabor B, McMillan JM, Fine NM. Assessment and Management of Older Patients With Transthyretin Amyloidosis Cardiomyopathy: Geriatric Cardiology, Frailty Assessment and Beyond. Front Cardiovasc Med 2022; 9:863179. [PMID: 35656395 PMCID: PMC9152087 DOI: 10.3389/fcvm.2022.863179] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 03/23/2022] [Indexed: 11/29/2022] Open
Abstract
Transthyretin amyloidosis cardiomyopathy (ATTR-CM) is commonly diagnosed in older adults, in particular the wild-type (ATTRwt), which is regarded as an age-related disease. With an aging population and improved diagnostic techniques, the prevalence and incidence of ATTR-CM will continue to increase. With increased availability of mortality reducing ATTR-CM therapies, patients are living longer. The predominant clinical manifestation of ATTR-CM is heart failure, while other cardiovascular manifestations include arrhythmia and aortic stenosis. Given their older age at diagnosis, patients often present with multiple age-related comorbidities, some of which can be exacerbated by ATTR, including neurologic, musculoskeletal, and gastrointestinal problems. Considerations related to older patient care, such as frailty, cognitive decline, polypharmacy, falls/mobility, functional capacity, caregiver support, living environment, quality of life and establishing goals of care are particularly important for many patients with ATTR-CM. Furthermore, the high cost ATTR treatments has increased interest in establishing improved predictors of response to therapy, with assessment of frailty emerging as a potentially important determinant. Multidisciplinary care inclusive of collaboration with geriatric and elder care medicine specialists, and others such as neurology, orthopedic surgery, electrophysiology and transcatheter aortic valve replacement clinics, is now an important component of ATTR-CM management. This review will examine current aspects of the management of older ATTR-CM patients, including shared care with multiple medical specialists, the emerging importance of frailty assessment and other considerations for using ATTR therapies.
Collapse
Affiliation(s)
| | - Jacqueline M. McMillan
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Division of Geriatrics, Departments of Medicine and Community Health Sciences, Calgary, AB, Canada
| | - Nowell M. Fine
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Division of Cardiology, Departments of Cardiac Sciences, Medicine and Community Health Sciences, Libin Cardiovascular Institute, Calgary, AB, Canada
- *Correspondence: Nowell M. Fine
| |
Collapse
|
37
|
New Advanced Imaging Parameters and Biomarkers—A Step Forward in the Diagnosis and Prognosis of TTR Cardiomyopathy. J Clin Med 2022; 11:jcm11092360. [PMID: 35566485 PMCID: PMC9101617 DOI: 10.3390/jcm11092360] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 04/13/2022] [Accepted: 04/19/2022] [Indexed: 11/17/2022] Open
Abstract
Transthyretin amyloid cardiomyopathy (ATTR-CM) is an infiltrative disorder characterized by extracellular myocardial deposits of amyloid fibrils, with poor outcome, leading to heart failure and death, with significant treatment expenditure. In the era of a novel therapeutic arsenal of disease-modifying agents that target a myriad of pathophysiological mechanisms, timely and accurate diagnosis of ATTR-CM is crucial. Recent advances in therapeutic strategies shown to be most beneficial in the early stages of the disease have determined a paradigm shift in the screening, diagnostic algorithm, and risk classification of patients with ATTR-CM. The aim of this review is to explore the utility of novel specific non-invasive imaging parameters and biomarkers from screening to diagnosis, prognosis, risk stratification, and monitoring of the response to therapy. We will summarize the knowledge of the most recent advances in diagnostic, prognostic, and treatment tailoring parameters for early recognition, prediction of outcome, and better selection of therapeutic candidates in ATTR-CM. Moreover, we will provide input from different potential pathways involved in the pathophysiology of ATTR-CM, on top of the amyloid deposition, such as inflammation, endothelial dysfunction, reduced nitric oxide bioavailability, oxidative stress, and myocardial fibrosis, and their diagnostic, prognostic, and therapeutic implications.
Collapse
|
38
|
Treatment of Transthyretin Amyloid Cardiomyopathy: The Current Options, the Future, and the Challenges. J Clin Med 2022; 11:jcm11082148. [PMID: 35456241 PMCID: PMC9031576 DOI: 10.3390/jcm11082148] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/07/2022] [Accepted: 04/08/2022] [Indexed: 12/13/2022] Open
Abstract
Transthyretin amyloid cardiomyopathy (ATTR-CM) is a progressively debilitating, rare disease associated with high mortality. ATTR-CM occurs when TTR amyloid protein builds up in the myocardium along with different organs, most commonly the peripheral and the autonomic nervous systems. Managing the cardiac complications with standard heart failure medications is difficult due to the challenge to maintain a balance between the high filling pressure associated with restricted ventricular volume and the low cardiac output. To date, tafamidis is the only agent approved for ATTR-CM treatment. Besides, several agents, including green tea, tolcapone, and diflunisal, are used off-label in ATTR-CM patients. Novel therapies using RNA interference also offer clinical promise. Patisiran and inotersen are currently approved for ATTR-polyneuropathy of hereditary origin and are under investigation for ATTR-CM. Monoclonal antibodies in the early development phases carry hope for amyloid deposit clearance. Despite several drug candidates in the clinical development pipeline, the small ATTR-CM patient population raises several challenges. This review describes current and future therapies for ATTR-CM and sheds light on the clinical development hurdles facing them.
Collapse
|
39
|
Ibrahim M, Saint Croix GR, Lacy S, Fattouh M, Barillas-Lara MI, Behrooz L, Mechanic O. The use of diflunisal for transthyretin cardiac amyloidosis: a review. Heart Fail Rev 2022; 27:517-524. [PMID: 34272629 DOI: 10.1007/s10741-021-10143-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/07/2021] [Indexed: 11/28/2022]
Abstract
Transthyretin cardiac amyloidosis (ATTR-CM) is caused by the accumulation of misfolded transthyretin (TTR) protein in the myocardium. Diflunisal, an agent that stabilizes TTR, has been used as an off-label therapeutic for ATTR-CM. Given limited data surrounding the use of diflunisal, a systematic review of the literature is warranted. We searched the PubMed, MEDLINE, and Embase databases for studies that reported on the use of diflunisal therapy for patients with ATTR-CM. We included English language studies which assessed the effect of diflunisal in adult patients with ATTR-CM who received diflunisal as primary treatment and reported clinical outcomes with emphasis on studies that noted the safety and efficacy of diflunisal in cardiac manifestations of ATTR amyloidosis. We excluded studies which did not use diflunisal therapy or used diflunisal therapy for non-cardiac manifestations of TTR amyloidosis. We also excluded case reports, abstracts, oral presentations, and studies with fewer than 10 subjects. Our search yielded 316 records, and we included 6 studies reporting on 400 patients. Non-comparative single-arm small non-randomized trials for diflunisal comprised 4 of the included studies. The 2 studies that compared diflunisal versus no treatment found improvements in TTR concentration, left atrial volume index, cardiac troponin I, and global longitudinal strain. Overall, diflunisal use was associated with decreased mortality and number of orthotopic heart transplant in ATTR-CM patients. Although a smaller number of patients had to stop treatment due to gastrointestinal side effects and transient renal dysfunction, there were no severe reactions reported in the studies included in our review. This systematic review supports the use of diflunisal for ATTR-CM. Additional long-term analyses and randomized clinical trials are needed to confirm these results.
Collapse
Affiliation(s)
- Michel Ibrahim
- Department Medicine, Division of Cardiovascular Medicine, Boston University Hospital, 801 Massachusetts Avenue Suite 400, Boston, MA, 02118, USA
| | - Garly Rushler Saint Croix
- Division of Cardiology At Mount Sinai Medical Center, Columbia University, 4300 Alton Rd, Miami Beach, FL, 33140, USA
| | - Spencer Lacy
- Department of Medicine, University of Miami Miller School of Medicine, 1120 NW 14th Street, Clinical Research Building, Miami, 33136, FL, USA
| | - Michael Fattouh
- Department of Internal Medicine Boston Medical Center, Boston University School of Medicine, 72 East Concord St, Boston, MA, 02118, USA
| | - Maria Irene Barillas-Lara
- Department of Internal Medicine Boston Medical Center, Boston University School of Medicine, 72 East Concord St, Boston, MA, 02118, USA
| | - Leili Behrooz
- Department Medicine, Division of Cardiovascular Medicine, Boston University Hospital, 801 Massachusetts Avenue Suite 400, Boston, MA, 02118, USA.
| | - Olivia Mechanic
- Division of Cardiology At Mount Sinai Medical Center, Columbia University, 4300 Alton Rd, Miami Beach, FL, 33140, USA
| |
Collapse
|
40
|
Usuku H, Takashio S, Yamamoto E, Yamada T, Egashira K, Morioka M, Nishi M, Komorita T, Oike F, Tabata N, Ishii M, Yamanaga K, Fujisue K, Sueta D, Arima Y, Araki S, Oda S, Misumi Y, Kawano H, Matsushita K, Ueda M, Matsui H, Tsujita K. Prognostic value of right ventricular global longitudinal strain in transthyretin amyloid cardiomyopathy. J Cardiol 2022; 80:56-63. [DOI: 10.1016/j.jjcc.2022.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 12/21/2021] [Accepted: 02/13/2022] [Indexed: 10/18/2022]
|
41
|
Damy T, Kristen AV, Suhr OB, Maurer MS, Planté-Bordeneuve V, Yu CR, Ong ML, Coelho T, Rapezzi C. Transthyretin cardiac amyloidosis in continental Western Europe: an insight through the Transthyretin Amyloidosis Outcomes Survey (THAOS). Eur Heart J 2022; 43:391-400. [PMID: 30938420 PMCID: PMC8825236 DOI: 10.1093/eurheartj/ehz173] [Citation(s) in RCA: 99] [Impact Index Per Article: 49.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 06/03/2018] [Accepted: 03/11/2019] [Indexed: 11/15/2022] Open
Abstract
AIMS Transthyretin amyloidosis (ATTR amyloidosis) is a heterogeneous disorder with cardiac, neurologic, and mixed phenotypes. We describe the phenotypic and genotypic profiles of this disease in continental Western Europe as it appears from the Transthyretin Amyloidosis Survey (THAOS). METHODS AND RESULTS THAOS is an ongoing, worldwide, longitudinal, observational survey established to study differences in presentation, diagnosis, and natural history in ATTR amyloidosis subjects. At data cut-off, 1411 symptomatic subjects from nine continental Western European countries were enrolled in THAOS [1286 hereditary (ATTRm) amyloidosis; 125 wild-type ATTR (ATTRwt) amyloidosis]. Genotypes and phenotypes varied notably by country. Four mutations (Val122Ile, Leu111Met, Thr60Ala, and Ile68Leu), and ATTRwt, were associated with a mainly cardiac phenotype showing symmetric left ventricular (LV) hypertrophy, normal diastolic LV dimensions and volume, and mildly depressed LV ejection fraction (LVEF). Morphologic and functional abnormalities on echocardiogram were significantly more severe in subjects with cardiac (n'= 210), compared with a mixed (n = 298), phenotype: higher median (Q1-Q3) interventricular septal thickness [18 (16-21) vs. 16 (13-20) mm; P = 0.0006]; and more frequent incidence of LVEF <50% (38.1 vs. 17.5%; P = 0.0008). Subjects with cardiac mutations or ATTRwt (or cardiac or mixed phenotype) had a lower survival rate than subjects in other genotype (or the neurologic phenotype) categories (P < 0.0001, for both). CONCLUSION ATTR amyloidosis genotypes and phenotypes are highly heterogeneous in continental Western Europe. A geographic map of the different disease profiles and awareness that a subset of subjects have a dominant cardiac phenotype, mimicking hypertrophic cardiomyopathy, at presentation can facilitate the clinical recognition of this underdiagnosed disease. TRIAL REGISTRATION ClinicalTrials.gov: NCT00628745.
Collapse
Affiliation(s)
- Thibaud Damy
- Referral Center for Cardiac Amyloidosis, Department of Cardiology, Mondor Amyloidosis Network, GRC Amyloid Research Institute, Clinical Investigation Center 006, DHU A-TVB INSERM U955 all at CHU Henri Mondor, UPEC, Créteil, France
| | - Arnt V Kristen
- Department of Cardiology, Amyloidosis Center, Heidelberg University, Heidelberg, Germany
| | - Ole B Suhr
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Mathew S Maurer
- Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Violaine Planté-Bordeneuve
- Department of Neurology, Mondor Amyloid Network, Inserm U955-Team10, East Paris University Hospital Henri-Mondor, France
| | | | | | - Teresa Coelho
- Department of Neurosciences, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal
| | - Claudio Rapezzi
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | | |
Collapse
|
42
|
Willis C, Watanabe AH, Hughes J, Nolen K, O'Meara J, Schepart A, Bruno M, Biskupiak J, Kawamoto K, Shara N, Kannampallil T. Applying diagnosis support systems in electronic health records to identify wild-type transthyretin amyloid cardiomyopathy risk. Future Cardiol 2022; 18:367-376. [PMID: 35098741 DOI: 10.2217/fca-2021-0122] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Wild-type transthyretin amyloid cardiomyopathy (ATTRwt-CM) is frequently misdiagnosed, and delayed diagnosis is associated with substantial morbidity and mortality. At three large academic medical centers, combinations of phenotypic features were implemented in electronic health record (EHR) systems to identify patients with heart failure at risk for ATTRwt-CM. Methods: Phenotypes/phenotype combinations were selected based on strength of correlation with ATTRwt-CM versus non-amyloid heart failure; different clinical decision support and reporting approaches and data sources were evaluated on Cerner and Epic EHR platforms. Results: Multiple approaches/sources showed potential usefulness for incorporating predictive analytics into the EHR to identify at-risk patients. Conclusion: These preliminary findings may guide other medical centers in building and implementing similar systems to improve recognition of ATTRwt-CM in patients with heart failure.
Collapse
Affiliation(s)
- Connor Willis
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT 84112, USA
| | - Alexandre H Watanabe
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT 84112, USA
| | - Justin Hughes
- Center for Biostatistics, Informatics & Data Science, MedStar Health Research Institute, Hyattsville, MD 20782, USA
| | | | | | | | | | - Joseph Biskupiak
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT 84112, USA
| | - Kensaku Kawamoto
- Department of Biomedical Informatics, School of Medicine, University of Utah, Salt Lake City, UT 84112, USA
| | - Nawar Shara
- Center for Biostatistics, Informatics & Data Science, MedStar Health Research Institute, Hyattsville, MD 20782, USA
| | - Thomas Kannampallil
- Department of Anesthesiology & The Institute for Informatics, Washington University School of Medicine, St Louis, MO 63130, USA
| |
Collapse
|
43
|
Roy A, Peterson A, Marchant N, Alvir J, Bhambri R, Lynn J, Benjumea D, Prasad S, O’Brien A, Chen Y, Kemner J, Parasuraman B. Baseline Characteristics and Secondary Medication Adherence Patterns Among Patients Receiving Tafamidis Prescriptions: A Retrospective Analysis Using a National Specialty Pharmacy Dispensing Database. Patient Prefer Adherence 2022; 16:1115-1129. [PMID: 35517043 PMCID: PMC9064174 DOI: 10.2147/ppa.s352332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 04/14/2022] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Transthyretin amyloid cardiomyopathy (ATTR-CM) is a serious, underrecognized condition, which leads to heart failure and early mortality if left untreated. Until recently, heart transplantation was the only treatment for ATTR-CM. Regulatory approval of tafamidis transformed treatment for patients. In the phase 3 Transthyretin Amyloidosis Cardiomyopathy Clinical Trial (ATTR-ACT), which established the safety and efficacy of tafamidis, medication adherence was high with 97.2% of patients taking ≥80% of scheduled doses. Evidence of real-world adherence to cardiology drugs demonstrates low adherence and suboptimal outcomes; however, real-world adherence to tafamidis has not been investigated. The main objective of this study was to describe adherence patterns of patients filling tafamidis in the Symphony Health database. METHODS This retrospective analysis of the Symphony Health Solutions claims database used secondary adherence measures, including modified medication possession ratio (MPRm), days between fills adherence rate, and compliance rate, to assess adherence patterns of 2020 patients filling tafamidis free acid 61-mg capsules or tafamidis meglumine 4x20-mg capsules from June 1, 2019 to August 31, 2020. RESULTS Patients receiving a tafamidis formulation had characteristics consistent with the expected patient population; 71.6% were aged 75-84 years, 83.2% were male, and the highest proportion resided in the Northeast region (30.5%) of the United States. Adherence for tafamidis was high, as 75% to 100% of the patients across subgroups met or exceeded the commonly defined adherence threshold of 80%. Median number of refills ordered and received was six refills per patient. Most patients received refills with no gap (n=1633) or a gap <30 days (n=1267/1317 patients). Adherence was high across follow-up time, sex, and age subgroups. Adherence varied by geographic region, with the Northeast being significantly higher than the Midwest (mean MPRm 94.41% vs 88.21%, p=0.0007). CONCLUSION These results provide evidence that real-world adherence to tafamidis in patients with ATTR-CM is high.
Collapse
Affiliation(s)
- Anuja Roy
- Global HEOR, Patient & Health Impact, Rare Diseases BU, Pfizer Inc, New York, NY, USA
- Correspondence: Anuja Roy, Global HEOR, Patient & Health Impact, Rare Diseases BU, Pfizer Inc, New York, NY, USA, Email
| | - Andrew Peterson
- Department of Pharmacy Practice/Pharmacy Administration, University of the Sciences, Philadelphia, PA, USA
| | - Nick Marchant
- Global HEOR, Patient & Health Impact, Rare Diseases BU, Pfizer Inc, New York, NY, USA
| | - Jose Alvir
- Statistical Research and Data Science Center Global Product Development, Pfizer Inc, New York, NY, USA
| | | | - Jason Lynn
- Medical Affairs, Pfizer Inc, New York, NY, USA
| | | | - Sapna Prasad
- Clarify Insights Services, Clarify Health Solutions, New York, NY, USA
| | - Alex O’Brien
- Clarify Insights Services, Clarify Health Solutions, New York, NY, USA
| | - Yong Chen
- Rare Disease, Pfizer Inc, Collegeville, PA, USA
| | - Jason Kemner
- Patient & Health Impact, Pfizer Inc, Collegeville, PA, USA
| | | |
Collapse
|
44
|
Razvi Y, Patel RK, Fontana M, Gillmore JD. Cardiac Amyloidosis: A Review of Current Imaging Techniques. Front Cardiovasc Med 2021; 8:751293. [PMID: 34957240 PMCID: PMC8702802 DOI: 10.3389/fcvm.2021.751293] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 10/11/2021] [Indexed: 12/15/2022] Open
Abstract
Systemic amyloidosis is a rare, heterogenous group of diseases characterized by extracellular infiltration and deposition of amyloid fibrils. Cardiac amyloidosis (CA) occurs when these fibrils deposit within the myocardium. Untreated, this inevitably leads to progressive heart failure and fatality. Historically, treatment has remained supportive, however, there are now targeted disease-modifying therapeutics available to patients with CA. Advances in echocardiography, cardiac magnetic resonance (CMR) and repurposed bone scintigraphy have led to a surge in diagnoses of CA and diagnosis at an earlier stage of the disease natural history. CMR has inherent advantages in tissue characterization which has allowed us to better understand the pathological disease process behind CA. Combined with specialist assessment and repurposed bone scintigraphy, diagnosis of CA can be made without the need for invasive histology in a significant proportion of patients. With existing targeted therapeutics, and novel agents being developed, understanding these imaging modalities is crucial to achieving early diagnosis for patients with CA. This will allow for early treatment intervention, accurate monitoring of disease course over time, and thereby improve the length and quality of life of patients with a disease that historically had an extremely poor prognosis. In this review, we discuss key radiological features of CA, focusing on the two most common types; immunoglobulin light chain (AL) and transthyretin (ATTR) CA. We highlight recent advances in imaging techniques particularly in respect of their clinical application and utility in diagnosis of CA as well as for tracking disease change over time.
Collapse
Affiliation(s)
- Yousuf Razvi
- National Amyloidosis Centre, Division of Medicine, University College London, London, United Kingdom
| | - Rishi K Patel
- National Amyloidosis Centre, Division of Medicine, University College London, London, United Kingdom
| | - Marianna Fontana
- National Amyloidosis Centre, Division of Medicine, University College London, London, United Kingdom
| | - Julian D Gillmore
- National Amyloidosis Centre, Division of Medicine, University College London, London, United Kingdom
| |
Collapse
|
45
|
Korosoglou G, Giusca S, André F, Aus dem Siepen F, Nunninger P, Kristen AV, Frey N. Diagnostic Work-Up of Cardiac Amyloidosis Using Cardiovascular Imaging: Current Standards and Practical Algorithms. Vasc Health Risk Manag 2021; 17:661-673. [PMID: 34720583 PMCID: PMC8550552 DOI: 10.2147/vhrm.s295376] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 10/07/2021] [Indexed: 01/15/2023] Open
Abstract
Among non-ischemic cardiomyopathies, cardiac amyloidosis is one of the most common, being caused by extracellular depositions of amyloid fibrils in the myocardium. Two main forms of cardiac amyloidosis are known so far, including 1) light-chain (AL) amyloidosis caused by monoclonal production of light-chains, and 2) transthyretin (ATTR) amyloidosis, caused by dissociation of the transthyretin tetramer into monomers. Both AL and ATTR amyloidosis are progressive diseases with median survival from diagnosis of less than 6 months and 3 to 5 years, respectively, if untreated. In this regard, death occurs in most patients due to cardiac causes, mainly congestive heart failure, which can be prevented due to the presence of effective, life-saving treatment regimens. Therefore, early diagnosis of cardiac amyloidosis is crucial more than ever. However, diagnosis of cardiac amyloidosis may be challenging due to variable clinical manifestations and the perceived rarity of the disease. In this regard, clinical and laboratory reg flags are available, which may help clinicians to raise suspicion of cardiac amyloidosis. In addition, advances in cardiovascular imaging have already revealed a higher prevalence of cardiac amyloidosis in specific populations, so that the diagnosis especially of ATTR amyloidosis has experienced a >30-fold increase during the past ten years. The goal of our review article is to summarize these findings and provide a practical approach for clinicians on how to use cardiovascular imaging techniques, such as echocardiography, cardiac magnetic resonance, bone scintigraphy and, if required, organ biopsy within predefined diagnostic algorithms for the diagnostic work-up of patients with suspected cardiac amyloidosis. In addition, two clinical cases and practical tips are provided in this context.
Collapse
Affiliation(s)
- Grigorios Korosoglou
- GRN Hospital Weinheim, Department of Cardiology, Vascular Medicine and Pneumology, Weinheim, Germany.,Cardiac Imaging Center Weinheim, Hector Foundation, Weinheim, Germany
| | - Sorin Giusca
- GRN Hospital Weinheim, Department of Cardiology, Vascular Medicine and Pneumology, Weinheim, Germany.,Cardiac Imaging Center Weinheim, Hector Foundation, Weinheim, Germany
| | - Florian André
- Department of Cardiology, Pneumology and Angiology, University Hospital Heidelberg, Heidelberg, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Heidelberg, Heidelberg, Germany
| | - Fabian Aus dem Siepen
- Department of Cardiology, Pneumology and Angiology, University Hospital Heidelberg, Heidelberg, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Heidelberg, Heidelberg, Germany
| | | | - Arnt V Kristen
- Department of Cardiology, Pneumology and Angiology, University Hospital Heidelberg, Heidelberg, Germany.,Cardiovascular Center Darmstadt, Darmstadt, Germany
| | - Norbert Frey
- Department of Cardiology, Pneumology and Angiology, University Hospital Heidelberg, Heidelberg, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Heidelberg, Heidelberg, Germany
| |
Collapse
|
46
|
Harapoz M, Evans S, Geenty P, Kwok F, Stewart G, Taylor MS, Farlow D, Thomas L. Correlation Between Quantitative Uptake of 99mTC-DPD and Echocardiographic Parameters in Cardiac ATTR: A Novel Follow-Up Strategy. Front Cardiovasc Med 2021; 8:663929. [PMID: 34722650 PMCID: PMC8553935 DOI: 10.3389/fcvm.2021.663929] [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: 02/04/2021] [Accepted: 09/13/2021] [Indexed: 11/25/2022] Open
Abstract
Aims: There has been a paradigm shift in diagnosis of cardiac transthyretin amyloidosis (ATTR) with non-invasive techniques including technetium-99m 3,3-diphosphono-1,2-propanodicarboxylic acid (99mTc-DPD) bone scintigraphy. We evaluated structural and functional biventricular alterations by transthoracic echocardiography (TTE) and determined the correlation with 99mTc-DPD tracer uptake in ATTR. Materials and Methods: ATTR patients (wild-type, hereditary or asymptomatic transthyretin [TTR] variant carriers) with 99mTc-DPD and TTE were selected; 99mTc-DPD uptake was analyzed quantitatively. TTE assessment of left ventricle (LV) and right ventricle (RV) parameters was performed. Results: Forty ATTR patients (wild-type n = 17; hereditary ATTR and TTR variant carriers n = 23; median age 68.8 ± 22 years) were included. TTE parameters displaying good correlation with 99mTc-DPD tracer uptake included LV average wall thickness (r = 0.837), LV indexed mass (LVMI; r = 0.802), RV wall thickness (r = 0.610), average e' (r = -0.830), E/e' ratio (r = 0.786), LV global longitudinal strain (GLS; r = 0.714) and RV GLS (r = 0.632; p < 0.001 for all). Hereditary ATTR and TTR variant carriers without cardiac tracer uptake had normal echocardiographic parameters. Receiver operating characteristic curves demonstrated strong diagnostic accuracies for structural (LV wall thickness, LVMI and RV wall thickness; area under the curve (AUC) of 0.96 for all) and functional (LV and RV GLS; AUC of 0.86 and 0.88, respectively) parameters. Conclusion: Good correlations between TTE biventricular structural and functional parameters were demonstrated with quantitative 99mTc-DPD uptake. Echocardiography may potentially assume a significant role in longitudinal follow-up for monitoring disease progression and for evaluating treatment response.
Collapse
Affiliation(s)
- Mehmet Harapoz
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia
- Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Scott Evans
- Department of Nuclear Medicine, Westmead Hospital, Sydney, NSW, Australia
| | - Paul Geenty
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia
- Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Fiona Kwok
- Westmead Amyloidosis Service, Westmead Hospital, Sydney, NSW, Australia
- Department of Haematology, Westmead Hospital, Sydney, NSW, Australia
| | - Graeme Stewart
- Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
- Westmead Amyloidosis Service, Westmead Hospital, Sydney, NSW, Australia
- Department of Clinical Immunology and Allergy, Westmead Hospital, Sydney, NSW, Australia
| | - Mark S. Taylor
- Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
- Westmead Amyloidosis Service, Westmead Hospital, Sydney, NSW, Australia
- Department of Clinical Immunology and Allergy, Westmead Hospital, Sydney, NSW, Australia
| | - David Farlow
- Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
- Department of Nuclear Medicine, Westmead Hospital, Sydney, NSW, Australia
| | - Liza Thomas
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia
- Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
- Westmead Amyloidosis Service, Westmead Hospital, Sydney, NSW, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| |
Collapse
|
47
|
Minutoli F, Di Bella G, Mazzeo A, Laudicella R, Gentile L, Russo M, Vita G, Baldari S. Serial scanning with 99mTc-3, 3-diphosphono-1, 2-propanodicarboxylic acid ( 99mTc-DPD) for early detection of cardiac amyloid deposition and prediction of clinical worsening in subjects carrying a transthyretin gene mutation. J Nucl Cardiol 2021; 28:1949-1957. [PMID: 31741327 DOI: 10.1007/s12350-019-01950-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 10/07/2019] [Indexed: 01/18/2023]
Abstract
BACKGROUND To determine the capability of 99mTc-DPD scintigraphy to detect early cardiac involvement and predict clinical worsening in transthyretin (TTR) gene mutation patients. METHODS Eleven mutated subjects with normal interventricular septum (IVS) thickness, NT-proBNP level and no cardiac symptoms underwent three seriate 99mTc-DPD scans (visually and semiquantitatively analyzed), and was followed-up for 5-8-years. RESULTS Six patients showed no myocardial accumulation in all scans. Increased IVS thickness occurring in one patient 4 years after the last scan was the only abnormal finding in these patients; no cardiac symptoms developed during the follow-up. In three patients, cardiac radiotracer uptake was found at enrollment; other laboratory/instrumental abnormal findings occurred later and cardiac symptoms developed during the follow-up period. Two patients had a negative 99mTc-DPD scan at enrollment and showed cardiac uptake in the following scans. Increased mean left-ventricular (LV) wall thickness was found 3 years after positive scintigraphy; NT-proBNP increased later in one patient. These patients developed cardiac symptoms during the follow-up period. CONCLUSIONS 99mTc-DPD scan detects cardiac involvement in subjects with TTR gene mutation earlier than ECG, echocardiography and biochemical markers, occurring some years before the fulfillment of current diagnostic criteria for cardiac amyloidosis. A positive 99mTc-DPD scan predicts cardiac symptoms onset.
Collapse
Affiliation(s)
- F Minutoli
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, University Hospital "G. Martino", Via Consolare Valeria 1, 98125, Messina, Italy
| | - G Di Bella
- Department of Clinical and Experimental Medicine, University of Messina, University Hospital "G. Martino", Via Consolare Valeria 1, 98125, Messina, Italy
| | - A Mazzeo
- Department of Clinical and Experimental Medicine, University of Messina, University Hospital "G. Martino", Via Consolare Valeria 1, 98125, Messina, Italy
| | - R Laudicella
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, University Hospital "G. Martino", Via Consolare Valeria 1, 98125, Messina, Italy.
| | - L Gentile
- Department of Clinical and Experimental Medicine, University of Messina, University Hospital "G. Martino", Via Consolare Valeria 1, 98125, Messina, Italy
| | - M Russo
- Nemo Sud Clinical Centre, University Hospital "G. Martino", Messina, Italy
| | - G Vita
- Department of Clinical and Experimental Medicine, University of Messina, University Hospital "G. Martino", Via Consolare Valeria 1, 98125, Messina, Italy
| | - S Baldari
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, University Hospital "G. Martino", Via Consolare Valeria 1, 98125, Messina, Italy
| |
Collapse
|
48
|
Nativi-Nicolau J, Siu A, Dispenzieri A, Maurer MS, Rapezzi C, Kristen AV, Garcia-Pavia P, LoRusso S, Waddington-Cruz M, Lairez O, Witteles R, Chapman D, Amass L, Grogan M. Temporal Trends of Wild-Type Transthyretin Amyloid Cardiomyopathy in the Transthyretin Amyloidosis Outcomes Survey. JACC CardioOncol 2021; 3:537-546. [PMID: 34729526 PMCID: PMC8543133 DOI: 10.1016/j.jaccao.2021.08.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 08/23/2021] [Accepted: 08/25/2021] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Transthyretin amyloid cardiomyopathy results from the accumulation of wild-type (ATTRwt) or variant (ATTRv) transthyretin amyloid fibrils in the myocardium. THAOS (Transthyretin Amyloidosis Outcomes Survey) is a global, longitudinal, observational survey of patients with ATTRv and ATTRwt amyloidosis and asymptomatic patients with transthyretin mutations. OBJECTIVES This study explored temporal trends in ATTRwt amyloidosis diagnoses using data from THAOS. METHODS Using THAOS data from December 2007 to January 2020, the following comparisons were made according to year: ATTRwt amyloidosis diagnoses in the United States versus rest of the world, ATTRwt versus ATTRv amyloidosis with cardiac-associated mutations diagnoses, and ATTRwt amyloidosis diagnoses by tissue biopsy versus bone scintigraphy. RESULTS There were 1,069 patients with ATTRwt amyloidosis and 525 with ATTRv amyloidosis with cardiac mutations enrolled in THAOS. The median time from symptom onset to ATTRwt amyloidosis diagnosis did not change over the past 5 years (>60 months from 2015-2019). ATTRwt amyloidosis diagnoses increased from 2 in 2005 to >100 per year from 2016, with a more pronounced increase in the United States compared with the rest of the world. Diagnoses of ATTRwt amyloidosis by tissue biopsy increased yearly and peaked in 2014 before declining, whereas diagnoses by bone scintigraphy increased markedly since 2011. ATTRv amyloidosis with cardiac mutation diagnoses increased from 3 in 2005 to 37 in 2011, then plateaued. The proportion of patients with ATTRwt amyloidosis diagnosed with New York Heart Association functional class III/IV heart failure decreased from 2012 (46.4%) to 2019 (16.0%). CONCLUSIONS In the past decade, ATTRwt amyloidosis diagnoses increased worldwide. Despite the growing utilization of bone scintigraphy, patients are diagnosed several years after symptom onset. (Transthyretin Amyloidosis Outcomes Survey [THAOS]; NCT00628745).
Collapse
Affiliation(s)
- Jose Nativi-Nicolau
- University of Utah Health & Huntsman Cancer Institute, Salt Lake City, Utah, USA
| | - Alfonso Siu
- University of Utah Health & Huntsman Cancer Institute, Salt Lake City, Utah, USA
| | | | - Mathew S. Maurer
- Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Claudio Rapezzi
- Cardiological Centre, University of Ferrara, Italy
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, Ravenna, Italy
| | - Arnt V. Kristen
- Department of Cardiology, Angiology, Respiratory Medicine, Medical University of Heidelberg, Heidelberg, Germany
| | - Pablo Garcia-Pavia
- Hospital Universitario Puerta de Hierro Majadahonda, CIBERCV, Madrid, Spain
- Universidad Francisco de Vitoria, Pozuelo de Alarcon, Madrid, Spain
| | | | - Márcia Waddington-Cruz
- Federal University of Rio de Janeiro, National Amyloidosis Referral Center, CEPARM, Rio de Janeiro, Brazil
| | - Olivier Lairez
- Department of Cardiology and Nuclear Medicine, Toulouse University Hospital, Toulouse, France
| | - Ronald Witteles
- Stanford University School of Medicine, Stanford, California, USA
| | | | | | - Martha Grogan
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
49
|
Oike F, Usuku H, Yamamoto E, Yamada T, Egashira K, Morioka M, Nishi M, Komorita T, Hirakawa K, Tabata N, Yamanaga K, Fujisue K, Hanatani S, Sueta D, Arima Y, Araki S, Takashio S, Oda S, Misumi Y, Kawano H, Matsushita K, Ueda M, Matsui H, Tsujita K. Prognostic value of left atrial strain in patients with wild-type transthyretin amyloid cardiomyopathy. ESC Heart Fail 2021; 8:5316-5326. [PMID: 34582129 PMCID: PMC8712780 DOI: 10.1002/ehf2.13621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 07/19/2021] [Accepted: 09/04/2021] [Indexed: 01/15/2023] Open
Abstract
Aims This study was performed to investigate whether left atrial (LA) strain by echocardiography provides prognostic information in patients with wild‐type transthyretin amyloid cardiomyopathy (ATTRwt‐CM). Methods and results Among 129 patients who were diagnosed with ATTRwt‐CM at Kumamoto University Hospital from December 2002 to December 2019, 113 patients who had enough information for two‐dimensional speckle tracking echocardiography were enrolled in this study. During a median follow‐up of 668 days, 28 cardiovascular deaths occurred. Compared with patients in the non‐event group, those in the cardiovascular death group were significantly older (81.5 ± 7.4 vs. 78.1 ± 6.1 years, P < 0.01), had a lower incidence of carpal tunnel syndrome (21% vs. 47%, P < 0.05), and had a higher high‐sensitivity cardiac troponin T [0.085 (0.063–0.105) vs. 0.049 (0.036–0.079) ng/mL, P < 0.01] and B‐type natriuretic peptide concentrations [419 (239–541) vs. 271 (155–462) pg/mL, P < 0.01] and lower estimated glomerular filtration rate (41.8 ± 15.4 vs. 53.4 ± 14.6 mL/min/1.73 m2, P < 0.01). Electrocardiography showed higher rate of a V1–V3 QS pattern (52% vs. 24%, P < 0.01) and complete left bundle branch block (27% vs. 6%, P < 0.01), and echocardiography showed a significantly lower peak LA strain rate during the contraction phase (0.16 ± 0.13 vs. 0.28 ± 0.27 S−1, P < 0.05), LA strain during the reservoir phase (LASr) (5.84 ± 2.41 vs. 8.22 ± 4.05%, P < 0.01), and peak LA strain rate during the reservoir phase (0.26 ± 0.09 vs. 0.33 ± 0.15 S−1, P < 0.05) in the cardiovascular death group than in non‐event group. By contrast, conventional echocardiographic findings were not significantly different between these two groups. After adjusting for conventional predictive factors of ATTRwt‐CM (age, high‐sensitivity cardiac troponin T and B‐type natriuretic peptide concentrations, and estimated glomerular filtration rate), multivariable Cox proportional hazard analyses showed that LASr was significantly and independently associated with cardiovascular death in patients with ATTRwt‐CM (odds ratio, 0.84; 95% confidence interval, 0.72–0.98; P < 0.05). After adjusting for age and echocardiographic findings associated with cardiovascular death (LA volume index and peak LA strain rate during the contraction phase), LASr was significantly and independently associated with cardiovascular death in patients with ATTRwt‐CM (odds ratio, 0.83; 95% confidence interval, 0.70–0.98; P < 0.05). Receiver operating characteristic curve analysis showed that the area under the curve of LASr for cardiovascular death was 0.686 and that the best cut‐off value of LASr was 6.69% (sensitivity, 62.4%; specificity, 64.3%). In the Kaplan–Meier analysis, patients with low LASr (<6.69%) had a significantly higher probability of total cardiovascular death (P < 0.05) and heart failure‐related hospitalization (P < 0.05). Conclusions Left atrial strain during the reservoir phase provides significant prognostic value in patients with ATTRwt‐CM even after adjusting for conventional predictive factors.
Collapse
Affiliation(s)
- Fumi Oike
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan.,Center of Metabolic Regulation of Healthy Aging, Kumamoto University Faculty of Life Sciences, Kumamoto, Japan
| | - Hiroki Usuku
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan.,Center of Metabolic Regulation of Healthy Aging, Kumamoto University Faculty of Life Sciences, Kumamoto, Japan.,Department of Laboratory Medicine, Kumamoto University Hospital, Kumamoto, Japan
| | - Eiichiro Yamamoto
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan.,Center of Metabolic Regulation of Healthy Aging, Kumamoto University Faculty of Life Sciences, Kumamoto, Japan
| | - Toshihiro Yamada
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan.,Center of Metabolic Regulation of Healthy Aging, Kumamoto University Faculty of Life Sciences, Kumamoto, Japan
| | - Koichi Egashira
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan.,Center of Metabolic Regulation of Healthy Aging, Kumamoto University Faculty of Life Sciences, Kumamoto, Japan
| | - Mami Morioka
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan.,Center of Metabolic Regulation of Healthy Aging, Kumamoto University Faculty of Life Sciences, Kumamoto, Japan
| | - Masato Nishi
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan.,Center of Metabolic Regulation of Healthy Aging, Kumamoto University Faculty of Life Sciences, Kumamoto, Japan
| | - Takashi Komorita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan.,Center of Metabolic Regulation of Healthy Aging, Kumamoto University Faculty of Life Sciences, Kumamoto, Japan
| | - Kyoko Hirakawa
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan.,Center of Metabolic Regulation of Healthy Aging, Kumamoto University Faculty of Life Sciences, Kumamoto, Japan
| | - Noriaki Tabata
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan.,Center of Metabolic Regulation of Healthy Aging, Kumamoto University Faculty of Life Sciences, Kumamoto, Japan
| | - Kenshi Yamanaga
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan.,Center of Metabolic Regulation of Healthy Aging, Kumamoto University Faculty of Life Sciences, Kumamoto, Japan
| | - Koichiro Fujisue
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan.,Center of Metabolic Regulation of Healthy Aging, Kumamoto University Faculty of Life Sciences, Kumamoto, Japan
| | - Shinsuke Hanatani
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan.,Center of Metabolic Regulation of Healthy Aging, Kumamoto University Faculty of Life Sciences, Kumamoto, Japan
| | - Daisuke Sueta
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan.,Center of Metabolic Regulation of Healthy Aging, Kumamoto University Faculty of Life Sciences, Kumamoto, Japan
| | - Yuichiro Arima
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan.,Center of Metabolic Regulation of Healthy Aging, Kumamoto University Faculty of Life Sciences, Kumamoto, Japan
| | - Satoshi Araki
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan.,Center of Metabolic Regulation of Healthy Aging, Kumamoto University Faculty of Life Sciences, Kumamoto, Japan
| | - Seiji Takashio
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan.,Center of Metabolic Regulation of Healthy Aging, Kumamoto University Faculty of Life Sciences, Kumamoto, Japan
| | - Seitaro Oda
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Yohei Misumi
- Center of Metabolic Regulation of Healthy Aging, Kumamoto University Faculty of Life Sciences, Kumamoto, Japan.,Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hiroaki Kawano
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan.,Center of Metabolic Regulation of Healthy Aging, Kumamoto University Faculty of Life Sciences, Kumamoto, Japan
| | - Kenichi Matsushita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan.,Center of Metabolic Regulation of Healthy Aging, Kumamoto University Faculty of Life Sciences, Kumamoto, Japan.,Division of Advanced Cardiovascular Therapeutics, Kumamoto University Hospital, Kumamoto, Japan
| | - Mitsuharu Ueda
- Center of Metabolic Regulation of Healthy Aging, Kumamoto University Faculty of Life Sciences, Kumamoto, Japan.,Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hirotaka Matsui
- Department of Laboratory Medicine, Kumamoto University Hospital, Kumamoto, Japan.,Department of Molecular Laboratory Medicine, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan.,Center of Metabolic Regulation of Healthy Aging, Kumamoto University Faculty of Life Sciences, Kumamoto, Japan
| |
Collapse
|
50
|
Ben-Haim S, Chicheportiche A, Goshen E, Arad M, Smekhov M, Menezes LJ, Elliott PM, O'Mahoney E, Stern E, Yuzefovich B, Bomanji JB. Quantitative SPECT/CT parameters of myocardial 99mTechnetium-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) uptake in suspected cardiac transthyretin amyloidosis. EJNMMI Res 2021; 11:86. [PMID: 34487268 PMCID: PMC8421473 DOI: 10.1186/s13550-021-00828-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 08/23/2021] [Indexed: 01/15/2023] Open
Abstract
Background 99mTc-labelled bisphosphonates are used for imaging assessment of patients with transthyretin cardiac amyloidosis (ATTR). Present study evaluates whether quantitative SPECT/CT measurement of absolute myocardial 99mTc-labelled 3,3-diphosphono-1,2-propanodicarboxylic acid (Tc-DPD) uptake can diagnose patients with suspected ATTR. Methods Twenty-eight patients (25 male, age 80.03 ± 6.99 years) with suspected ATTR referred for Tc-DPD imaging had planar and SPECT/CT imaging of the chest. Three operators independently obtained Tc-DPD myocardial SUVmax and SUVmean above threshold (SMaT) (20, 40 and 60% of SUVmax), using a semi-automated threshold segmentation method. Results were compared to visual grading (0–3) of cardiac uptake. Results Twenty-two patients (78%) had cardiac uptake (2 grade 1, 15 grade 2, 5 grade 3). SUVmax and SMaT segmentation thresholds enabled separating grades 2/3 from 0/1 with excellent inter- and intra-reader correlation. Cut-off values 6.0, 2.5, 3 and 4 for SUVmax, SMaT20,40,60, respectively, separated between grades 2/3 and 0 /1 with PPV and NPV of 100%. SMaT20,40,60(cardiac)/SUVmean (liver) and SMaT20,40,60(cardiac)/SUVmean(liver/lung) separated grades 2 and 3. Conclusion Quantitative SPECT/CT parameters of cardiac Tc-DPD uptake are robust, enabling separation of patients with grades 2 and 3 cardiac uptake from grades 0 and 1. Larger patient cohorts will determine the incremental value of SPECT/CT quantification for ATTR management.
Collapse
Affiliation(s)
- Simona Ben-Haim
- Hadassah Medical Center, Hebrew University, Jerusalem, Israel. .,NIHR Biomedical Research Centre, UCL Institute of Nuclear Medicine, London, UK.
| | | | - E Goshen
- Wolfson Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - M Arad
- Chaim Sheba Medical Center, Ramat Gan, Israel
| | - M Smekhov
- Chaim Sheba Medical Center, Ramat Gan, Israel
| | - L J Menezes
- NIHR Biomedical Research Centre, UCL Institute of Nuclear Medicine, London, UK
| | - P M Elliott
- NIHR Biomedical Research Centre, UCL Institute of Nuclear Medicine, London, UK
| | - E O'Mahoney
- NIHR Biomedical Research Centre, UCL Institute of Nuclear Medicine, London, UK
| | - E Stern
- GE Healthcare, Haifa, Israel
| | | | - J B Bomanji
- NIHR Biomedical Research Centre, UCL Institute of Nuclear Medicine, London, UK
| |
Collapse
|