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Selvaraj S, Claggett B, Shah SH, Mentz RJ, Khouri MG, Manichaikul AW, Khan SS, Rich SS, Mosley TH, Levitan EB, Arora P, Goyal P, Haring B, Eaton CB, Cheng RK, Wells GL, Manson JE, Fontana M, Solomon SD. Cardiovascular Burden of the V142I Transthyretin Variant. JAMA 2024; 331:1824-1833. [PMID: 38734952 PMCID: PMC11089467 DOI: 10.1001/jama.2024.4467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 02/20/2024] [Indexed: 05/13/2024]
Abstract
Importance Individual cohort studies concur that the amyloidogenic V142I variant of the transthyretin (TTR) gene, present in 3% to 4% of US Black individuals, increases heart failure (HF) and mortality risk. Precisely defining carrier risk across relevant clinical outcomes and estimating population burden of disease are important given established and emerging targeted treatments. Objectives To better define the natural history of disease in carriers across mid to late life, assess variant modifiers, and estimate cardiovascular burden to the US population. Design, Setting, and Participants A total of 23 338 self-reported Black participants initially free from HF were included in 4 large observational studies across the US (mean [SD], 15.5 [8.2] years of follow-up). Data analysis was performed between May 2023 and February 2024. Exposure V142I carrier status (n = 754, 3.2%). Main Outcomes and Measures Hospitalizations for HF (including subtypes of reduced and preserved ejection fraction) and all-cause mortality. Outcomes were analyzed by generating 10-year hazard ratios for each age between 50 and 90 years. Using actuarial methods, mean survival by carrier status was estimated and applied to the 2022 US population using US Census data. Results Among the 23 338 participants, the mean (SD) age at baseline was 62 (9) years and 76.7% were women. Ten-year carrier risk increased for HF hospitalization by age 63 years, predominantly driven by HF with reduced ejection fraction, and 10-year all-cause mortality risk increased by age 72 years. Only age (but not sex or other select variables) modified risk with the variant, with estimated reductions in longevity ranging from 1.9 years (95% CI, 0.6-3.1) at age 50 to 2.8 years (95% CI, 2.0-3.6) at age 81. Based on these data, 435 851 estimated US Black carriers between ages 50 and 95 years are projected to cumulatively lose 957 505 years of life (95% CI, 534 475-1 380 535) due to the variant. Conclusions and Relevance Among self-reported Black individuals, male and female V142I carriers faced similar and substantial risk for HF hospitalization, predominantly with reduced ejection fraction, and death, with steep age-dependent penetrance. Delineating the individual contributions of, and complex interplay among, the V142I variant, ancestry, the social construct of race, and biological or social determinants of health to cardiovascular disease merits further investigation.
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Affiliation(s)
- Senthil Selvaraj
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
- Duke Molecular Physiology Institute, Durham, North Carolina
| | - Brian Claggett
- Division of Cardiology, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Svati H. Shah
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
- Duke Molecular Physiology Institute, Durham, North Carolina
| | - Robert J. Mentz
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Michel G. Khouri
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Ani W. Manichaikul
- Center for Public Health Genomics, University of Virginia, Charlottesville
| | - Sadiya S. Khan
- Division of Cardiology, Department of Medicine and Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Stephen S. Rich
- Center for Public Health Genomics, University of Virginia, Charlottesville
| | - Thomas H. Mosley
- The MIND Center, University of Mississippi Medical Center, Jackson
| | | | - Pankaj Arora
- Division of Cardiovascular Disease, University of Alabama at Birmingham
| | - Parag Goyal
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Bernhard Haring
- Department of Medicine III, Saarland University, Homburg, Saarland, Germany
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
| | - Charles B. Eaton
- Center for Primary Care and Prevention, Department of Family Medicine, Department of Epidemiology, Warren Alpert Medical Scholl of Brown University, Brown University School of Public Health, Providence, Rhode Island
| | | | - Gretchen L. Wells
- Division of Cardiovascular Disease, University of Alabama at Birmingham
| | - JoAnn E. Manson
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Scott D. Solomon
- Division of Cardiology, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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2
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Aimo A, Morfino P, Arzilli C, Vergaro G, Spini V, Fabiani I, Castiglione V, Rapezzi C, Emdin M. Disease features and management of cardiomyopathies in women. Heart Fail Rev 2024; 29:663-674. [PMID: 38308002 PMCID: PMC11035404 DOI: 10.1007/s10741-024-10386-x] [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] [Accepted: 01/24/2024] [Indexed: 02/04/2024]
Abstract
Over the last years, there has been a growing interest in the clinical manifestations and outcomes of cardiomyopathies in women. Peripartum cardiomyopathy is the only women-specific cardiomyopathy. In cardiomyopathies with X-linked transmission, women are not simply healthy carriers of the disorder, but can show a wide spectrum of clinical manifestations ranging from mild to severe manifestations because of heterogeneous patterns of X-chromosome inactivation. In mitochondrial disorders with a matrilinear transmission, cardiomyopathy is part of a systemic disorder affecting both men and women. Even some inherited cardiomyopathies with autosomal transmission display phenotypic and prognostic differences between men and women. Notably, female hormones seem to exert a protective role in hypertrophic cardiomyopathy (HCM) and variant transthyretin amyloidosis until the menopausal period. Women with cardiomyopathies holding high-risk features should be referred to a third-level center and evaluated on an individual basis. Cardiomyopathies can have a detrimental impact on pregnancy and childbirth because of the associated hemodynamic derangements. Genetic counselling and a tailored cardiological evaluation are essential to evaluate the likelihood of transmitting the disease to the children and the possibility of a prenatal or early post-natal diagnosis, as well as to estimate the risk associated with pregnancy and delivery, and the optimal management strategies.
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Affiliation(s)
- Alberto Aimo
- Scuola Superiore Sant'Anna, Pisa, Italy.
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy.
| | | | - Chiara Arzilli
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Giuseppe Vergaro
- Scuola Superiore Sant'Anna, Pisa, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Valentina Spini
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Iacopo Fabiani
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | | | - Claudio Rapezzi
- Cardiologic Centre, University of Ferrara, Ferrara, Italy
- Maria Cecilia Hospital, GVM Care & Research, Cotignola (Ravenna), Ravenna, Italy
| | - Michele Emdin
- Scuola Superiore Sant'Anna, Pisa, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
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3
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Fragner M, Elsaygh J, Srivats SS, Pink K. Gender Differences in the Evaluation and Management of New Acute CHF Due to ATTRwt Cardiac Amyloidosis. Cureus 2024; 16:e59058. [PMID: 38800288 PMCID: PMC11128148 DOI: 10.7759/cureus.59058] [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] [Accepted: 04/26/2024] [Indexed: 05/29/2024] Open
Abstract
Cardiac amyloidosis can be grouped into two main categories: immunoglobulin light chain (AL) and transthyretin (hATTR or hereditary and ATTRwt or wild type). Cardiac infiltration of misfolded proteins can lead to significant infiltrative processes and subsequent heart failure. Diagnosis of ATTRwt heavily relies on clinical suspicion, as it typically appears later in life and is limited to the heart. It is routinely reported that ATTRwt significantly affects males more than females; however, older patients diagnosed with ATTRwt and those diagnosed at autopsy are significantly more likely to be female. Earlier, a more precise diagnosis in females could detect disease at an earlier stage and expedite treatment.
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Affiliation(s)
- Michael Fragner
- Internal Medicine, New York-Presbyterian Brooklyn Methodist, Brooklyn, USA
| | - Jude Elsaygh
- Internal Medicine, New York-Presbyterian Brooklyn Methodist, Brooklyn, USA
| | | | - Kevin Pink
- Internal Medicine, New York-Presbyterian Brooklyn Methodist, Brooklyn, USA
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4
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Aimo A, Panichella G, Garofalo M, Gasparini S, Arzilli C, Castiglione V, Vergaro G, Emdin M, Maffei S. Sex differences in transthyretin cardiac amyloidosis. Heart Fail Rev 2024; 29:321-330. [PMID: 37566193 PMCID: PMC10942898 DOI: 10.1007/s10741-023-10339-w] [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] [Accepted: 08/03/2023] [Indexed: 08/12/2023]
Abstract
Transthyretin cardiac amyloidosis (ATTR-CA) is a progressive disease characterized by the deposition of abnormal transthyretin protein fibrils in the heart, leading to cardiac dysfunction. Recent evidence suggests that sex differences may play a significant role in various steps of ATTR-CA, including clinical presentation, diagnostic challenges, disease progression, and treatment outcomes. ATTR-CA predominantly affects men, whereas women are older at presentation. Women generally present with a history of heart failure with preserved ejection fraction and/or carpal tunnel syndrome. When indexed, left ventricular (LV) wall thickness is equal, or even increased, than men. Women also have smaller LV cavities, more preserved ejection fractions, and apparently a slightly worse right ventricular and diastolic function. Given the under-representation on women in clinical trials, no data regarding sex influence on the treatment response are currently available. Finally, it seems there are no differences in overall prognosis, even if premenopausal women may have a certain level of myocardial protection. Genetic variations, environmental factors, and hormonal changes are considered as potential contributors to observed disparities. Understanding sex differences in ATTR-CA is vital for accurate diagnosis and management. By considering these differences, clinicians can improve diagnostic accuracy, tailor treatments, and optimize outcomes for both sexes with ATTR-CA.
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Affiliation(s)
- Alberto Aimo
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy.
| | - Giorgia Panichella
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Manuel Garofalo
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Simone Gasparini
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
- Paediatric Neurology Unit and Laboratories, Neuroscience Department, Meyer Children's Hospital IRCCS, Florence, Italy
| | | | - Vincenzo Castiglione
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Giuseppe Vergaro
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Michele Emdin
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy
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5
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Massalha S, Kennedy J, Hussein E, Mahida B, Keidar Z. Cardiovascular Imaging in Women. Semin Nucl Med 2024; 54:191-205. [PMID: 38395672 DOI: 10.1053/j.semnuclmed.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 01/28/2024] [Indexed: 02/25/2024]
Abstract
Multimodality cardiovascular imaging is a cornerstone diagnostic tool in the diagnosis, risk stratification, and management of cardiovascular diseases, whether those involving the coronary tree, myocardial, or pericardial diseases in general and particularly in women. This manuscript aims to shed some light and summarize the very features of cardiovascular disease in women, explore their unique characteristics and discuss the role of cardiovascular imaging in ischemic heart disease and cardiomyopathies. The role of four imaging modalities will be discussed including nuclear medicine, echocardiography, noninvasive coronary angiography, and cardiac magnetic resonance.
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Affiliation(s)
- Samia Massalha
- Department of Cardiology, Rambam Health Care Campus, Haifa. Israel; Department of Nuclear Medicine, Rambam Health Care Campus, Haifa. Israel.
| | - John Kennedy
- Department of Cardiology, Rambam Health Care Campus, Haifa. Israel; Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Essam Hussein
- Department of Nuclear Medicine, Rambam Health Care Campus, Haifa. Israel
| | - Besma Mahida
- Nuclear Medicine BICHAT Hospital Assistance Publique Hôpitaux de Paris, Paris. France; LVTS, Inserm U1148, Équipe 4 (Imagerie Cardio-Vasculaire), Paris, France
| | - Zohar Keidar
- Department of Cardiology, Rambam Health Care Campus, Haifa. Israel; Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
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6
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Sarkar A, Sanchez-Nadales A, Kunutsor SK, Hanna MA, Asher CR, Wolinsky DG. Outcomes of Octogenarian Patients Treated with Tafamidis for Transthyretin Amyloid Cardiomyopathy. Am J Cardiol 2024; 214:144-148. [PMID: 38306809 DOI: 10.1016/j.amjcard.2023.08.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 07/28/2023] [Accepted: 08/01/2023] [Indexed: 02/04/2024]
Abstract
Patients with transthyretin amyloid cardiomyopathy (ATTR-CM) benefit from disease-modifying agents such as tafamidis. However, the survival benefit of tafamidis in elderly patients (age ≥80 years) is not reported. This study aimed to assess the survival of patients with ATTR-CM aged 80 years and older who were treated with tafamidis compared with patients aged <80 years. We conducted a retrospective analysis of patients with ATTR-CM who underwent tafamidis treatment, aged 45 to 97 years at the time of diagnosis between January 1, 2008, and May 31, 2021. A total of 484 patients were included, with 208 in the ≥80 years group and 276 in the <80 years group. The cohort was followed up for mortality outcomes, and hazard ratios with 95% confidence intervals were calculated. After a median follow-up of 18.5 months, 72 deaths were recorded in the entire cohort. Kaplan-Meier curves showed no differences in survival probability between the 2 groups at 30 months (p for log-rank test = 0.76). The survival rates for patients aged ≥80 years who underwent treatment at 1, 2, 3, 4, and 5 years were 94.7%, 86.0%, 77.0%, 77.0%, and 38.5%, respectively. The corresponding rates for patients aged <80 years who underwent treatment were 93.2, 84.8, 74.4, 68.2, and 64.6%, respectively. In the multivariable analysis, the hazard ratio (95% confidence interval) of the mortality comparing treatment patients aged ≥80 years with those aged <80 years was 0.81 (0.41 to 1.61). In conclusion, tafamidis treatment is associated with similar reductions in mortality in older and younger patients with ATTR-CM.
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Affiliation(s)
- Abdullah Sarkar
- Robert and Suzanne Tomsich Department of Cardiovascular Disease, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic Florida, Weston, Florida
| | - Alejandro Sanchez-Nadales
- Robert and Suzanne Tomsich Department of Cardiovascular Disease, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic Florida, Weston, Florida
| | - Setor K Kunutsor
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester, United Kingdom
| | - Mazen A Hanna
- Section of Heart Failure and Cardiac Transplantation Medicine, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Craig R Asher
- Robert and Suzanne Tomsich Department of Cardiovascular Disease, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic Florida, Weston, Florida
| | - David G Wolinsky
- Robert and Suzanne Tomsich Department of Cardiovascular Disease, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic Florida, Weston, Florida.
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7
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Ruiz-Hueso R, Salamanca-Bautista P, Quesada-Simón MA, Yun S, Conde-Martel A, Morales-Rull JL, Suárez-Gil R, García-García JÁ, Llàcer P, Fonseca-Aizpuru EM, Amores-Arriaga B, Martínez-González Á, Armengou-Arxe A, Peña-Somovilla JL, López-Reboiro ML, Aramburu-Bodas Ó. Estimating the Prevalence of Cardiac Amyloidosis in Old Patients with Heart Failure—Barriers and Opportunities for Improvement: The PREVAMIC Study. J Clin Med 2023; 12:jcm12062273. [PMID: 36983274 PMCID: PMC10057876 DOI: 10.3390/jcm12062273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 03/09/2023] [Accepted: 03/11/2023] [Indexed: 03/17/2023] Open
Abstract
Background: Cardiac amyloidosis (CA) could be a common cause of heart failure (HF). The objective of the study was to estimate the prevalence of CA in patients with HF. Methods: Observational, prospective, and multicenter study involving 30 Spanish hospitals. A total of 453 patients ≥ 65 years with HF and an interventricular septum or posterior wall thickness > 12 mm were included. All patients underwent a 99mTc-DPD/PYP/HMDP scintigraphy and monoclonal bands were studied, following the current criteria for non-invasive diagnosis. In inconclusive cases, biopsies were performed. Results: The vast majority of CA were diagnosed non-invasively. The prevalence was 20.1%. Most of the CA were transthyretin (ATTR-CM, 84.6%), with a minority of cardiac light-chain amyloidosis (AL-CM, 2.2%). The remaining (13.2%) was untyped. The prevalence was significantly higher in men (60.1% vs 39.9%, p = 0.019). Of the patients with CA, 26.5% had a left ventricular ejection fraction less than 50%. Conclusions: CA was the cause of HF in one out of five patients and should be screened in the elderly with HF and myocardial thickening, regardless of sex and LVEF. Few transthyretin-gene-sequencing studies were performed in older patients. In many patients, it was not possible to determine the amyloid subtype.
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Affiliation(s)
- Rocío Ruiz-Hueso
- Internal Medicine Department, Hospital Universitario Virgen Macarena, Avda. Dr. Fedriani, 3, 41009 Sevilla, Spain
| | - Prado Salamanca-Bautista
- Internal Medicine Department, Hospital Universitario Virgen Macarena, Avda. Dr. Fedriani, 3, 41009 Sevilla, Spain
- Department of Medicine, Universidad de Sevilla, San Fernando, 4, 41004 Sevilla, Spain
- Correspondence:
| | | | - Sergi Yun
- Community Heart Failure Program, Cardiology Department, Bellvitge University Hospital, L’Hospitalet de Llobregat, Carrer de la Feixa Llarga, s/n., 08907 Barcelona, Spain
- Department of Internal Medicine, Bellvitge University Hospital, L’Hospitalet de Llobregat, 08907 Barcelona, Spain
- Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), L’Hospitalet de Llobregat, 08907 Barcelona, Spain
| | - Alicia Conde-Martel
- Internal Medicine Department, Hospital Universitario Dr. Negrín, Pl. Barranco de la Ballena s/n. 35010 Las Palmas de Gran Canaria, Spain
| | - José Luis Morales-Rull
- Internal Medicine Deparment, Hospital Universitario Arnau de Vilanova, IRBLleida, Avda. Alcalde Rovira Roure, 80, 25198 Lérida, Spain
| | - Roi Suárez-Gil
- Internal Medicine Department, Hospital Universitario Lucus Augusti, Rua Dr. Ulises Romero, 1, 27003 Lugo, Spain
| | - José Ángel García-García
- Internal Medicine Department, Hospital Universitario Virgen del Valme, Ctra. Cádiz, km 548,9, 41014 Sevilla, Spain
| | - Pau Llàcer
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, IRYCIS, M-607, 9, 100, 28034 Madrid, Spain
| | | | - Beatriz Amores-Arriaga
- Internal Medicine Deparment, Hospital Universitario Lozano Blesa, C/San Juan Bosco, 15, 50009 Zaragoza, Spain
| | | | - Arola Armengou-Arxe
- Internal Medicine Department, Leon University Hospital Complex, Hospital Universitario Josep Trueta, Avinguda de Franca s/n., 17007 Gerona, Spain
| | | | - Manuel Lorenzo López-Reboiro
- Internal Medicine Department, Hospital Comarcal Monforte de Lemos., Rua Corredoira s/n., 27400 Monforte de Lemos, Spain
| | - Óscar Aramburu-Bodas
- Internal Medicine Department, Hospital Universitario Virgen Macarena, Avda. Dr. Fedriani, 3, 41009 Sevilla, Spain
- Department of Medicine, Universidad de Sevilla, San Fernando, 4, 41004 Sevilla, Spain
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8
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Sperry BW, Vadalia A. Primer on the Differential Diagnosis and Workup for Transthyretin Cardiac Amyloidosis. Am J Cardiol 2022; 185 Suppl 1:S11-S16. [PMID: 36549787 DOI: 10.1016/j.amjcard.2022.10.052] [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: 09/06/2022] [Revised: 10/24/2022] [Accepted: 10/27/2022] [Indexed: 12/24/2022]
Abstract
Amyloidosis has often been referred to as a "great masquerader," mimicking other systemic and cardiac diseases. As diagnostic techniques such as echocardiography with longitudinal strain, cardiac magnetic resonance imaging, and nuclear scintigraphy have advanced, identification of cardiac amyloidosis has become less daunting. This review covers the differential diagnosis and workup of patients with transthyretin cardiac amyloidosis, with a specific focus on developing a clinical suspicion through demographic, clinical, and echocardiographic features of the disease. The most common mimics of cardiac amyloidosis, i.e., conditions that likewise cause heart failure with preserved or mildly reduced ejection fraction, are also explored with respect to differential diagnosis, both for patients with normal and increased ventricular wall thickness. Ultimately, this review aims to demystify the diagnostic process by offering an algorithmic approach to the identification of transthyretin cardiac amyloidosis.
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Affiliation(s)
- Brett W Sperry
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri.
| | - Anuj Vadalia
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri
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9
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Patel RK, Ioannou A, Razvi Y, Chacko L, Venneri L, Bandera F, Knight D, Kotecha T, Martinez‐Naharro A, Masi A, Porcari A, Brown J, Patel K, Manisty C, Moon J, Rowczenio D, Gilbertson JA, Sinagra G, Lachmann H, Wechalekar A, Petrie A, Whelan C, Hawkins PN, Gillmore JD, Fontana M. Sex differences among patients with transthyretin amyloid cardiomyopathy - from diagnosis to prognosis. Eur J Heart Fail 2022; 24:2355-2363. [PMID: 36575133 PMCID: PMC10087683 DOI: 10.1002/ejhf.2646] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 07/29/2022] [Accepted: 07/29/2022] [Indexed: 01/18/2023] Open
Abstract
AIMS Transthyretin amyloid cardiomyopathy (ATTR-CM) is predominantly diagnosed in men. The few available studies suggest affected women have a more favourable cardiac phenotype. We aimed to characterize sex differences among consecutive patients with non-hereditary and two prevalent forms of hereditary (h)ATTR-CM diagnosed over a 20-year period. METHODS AND RESULTS Analysis of deep phenotyping at presentation, changes on serial echocardiography and overall prognosis were evaluated. In total, 1732 consecutive patients were studied, comprising: 1095 with wild-type (wt)ATTR-CM; 206 with T60A-hATTR-CM; and 431 with V122I-hATTR-CM. Female prevalence was greater in T60A-hATTR-CM (29.6%) and V122I-hATTR-CM (27.8%) compared to wtATTR-CM (6%). At presentation, females were 3.3 years older than males (wtATTR-CM: 81.9 vs. 77.8 years; T60A-hATTR-CM: 68.7 vs. 65.1 years; V122I-hATTR-CM: 77.1 vs. 74.9 years). Body size significantly influenced measures of disease severity; when indexed, overall structural and functional phenotype was similar between sexes, the few significant differences suggested a mildly worse phenotype in females. No significant differences were observed in both disease progression on serial echocardiography and mortality across the overall population (p = 0.459) and when divided by genotype (wtATTR-CM: p = 0.730; T60A-hATTR-CM: p = 0.161; V122I-hATTR-CM: p = 0.056). CONCLUSION This study of a well-characterized large cohort of ATTR-CM patients did not demonstrate overall differences between sexes in either clinical phenotype, when indexed, or with respect to disease progression and prognosis. Non-indexed wall thickness measurements may have contributed to both under-representation and delays in diagnosis for affected females and highlights the potential role of utilizing indexed echocardiographic parameters for a more accurate assessment of patients at diagnosis and for disease prognostication.
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Affiliation(s)
- Rishi K. Patel
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Adam Ioannou
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Yousuf Razvi
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Liza Chacko
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Lucia Venneri
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Francesco Bandera
- Heart Failure Unit, Cardiology University DepartmentIRCCS Policlinico San DonatoMilanItaly
- Department for Biomedical Sciences for HealthUniversity of MilanoMilanItaly
| | - Daniel Knight
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Tushar Kotecha
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Ana Martinez‐Naharro
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Ambra Masi
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Aldostefano Porcari
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular DepartmentAzienda Sanitaria Universitaria Giuliano‐Isontina (ASUGI), University of TriesteTriesteItaly
| | - James Brown
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Kiara Patel
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Charlotte Manisty
- Barts Heart Centre, The Cardiovascular Magnetic Resonance Imaging Unit, and the Inherited Cardiovascular Diseases UnitSt Bartholomew's HospitalLondonUK
| | - James Moon
- Barts Heart Centre, The Cardiovascular Magnetic Resonance Imaging Unit, and the Inherited Cardiovascular Diseases UnitSt Bartholomew's HospitalLondonUK
| | - Dorota Rowczenio
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Janet A. Gilbertson
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Gianfranco Sinagra
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular DepartmentAzienda Sanitaria Universitaria Giuliano‐Isontina (ASUGI), University of TriesteTriesteItaly
| | - Helen Lachmann
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Ashutosh Wechalekar
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Aviva Petrie
- Eastman Dental Institute, University College LondonLondonUK
| | - Carol Whelan
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Philip N. Hawkins
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Julian D. Gillmore
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Marianna Fontana
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
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10
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Maestro-Benedicto A, Vela P, de Frutos F, Mora N, Pomares A, Gonzalez-Vioque E, Briceño A, Cabrera E, Cobo-Marcos M, Dominguez F, Gonzalez-Lopez E, Segovia J, Lara-Pezzi E, Garcia-Pavia P. Frequency of hereditary transthyretin amyloidosis among elderly patients with transthyretin cardiomyopathy. Eur J Heart Fail 2022; 24:2367-2373. [PMID: 35999650 PMCID: PMC10087903 DOI: 10.1002/ejhf.2658] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 08/04/2022] [Accepted: 08/13/2022] [Indexed: 01/18/2023] Open
Abstract
AIMS Transthyretin amyloid cardiomyopathy (ATTR-CM) is increasingly recognized as a cause of heart failure in the elderly. Although wild-type transthyretin amyloidosis is the most frequent form of ATTR-CM found in the elderly, hereditary transthyretin amyloidosis (ATTRv) can also occur. We sought to determine the prevalence of ATTRv among elderly ATTR-CM patients, identify predictors of ATTRv and evaluate the clinical consequences of positive genetic testing in this population. METHODS AND RESULTS Prevalence of ATTRv in elderly ATTR-CM patients (≥70 years) was assessed in a cohort of 300 consecutive ATTR-CM patients (median age 78 years at diagnosis, 82% ≥70 years, 16% female, 99% Caucasian). ATTRv was diagnosed in 35 (12%; 95% confidence interval [CI] 3.1-8.8) and 13 (5.3%; 95% CI 5.6-26.7) patients in the overall cohort and in those ≥70 years, respectively. Prevalence of ATTRv among elderly female patients with ATTR-CM was 13% (95% CI 2.1-23.5). Univariate analysis identified female sex (odds ratio [OR] 3.66; 95% CI 1.13-11.85; p = 0.03), black ancestry (OR 46.31; 95% CI 3.52-Inf; p = 0.005), eye symptoms (OR 6.64; 95% CI 1.20-36.73; p = 0.03) and polyneuropathy (OR 10.05; 95% CI 3.09-32.64; p < 0.001) as the only factors associated with ATTRv in this population. Diagnosis of ATTRv in elderly ATTR-CM patients allowed initiation of transthyretin-specific drug treatment in 5 individuals, genetic screening in 33 relatives from 13 families, and identification of 9 ATTRv asymptomatic carriers. CONCLUSIONS Hereditary transthyretin amyloidosis is present in a substantial number of ATTR-CM patients aged ≥70 years. Identification of ATTRv in elderly patients with ATTR-CM has clinical meaningful therapeutic and diagnostic implications. These results support routine genetic testing in patients with ATTR-CM regardless of age.
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Affiliation(s)
- Alba Maestro-Benedicto
- Heart Failure and Inherited Cardiac Diseases Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro, IDIPHISA, CIBERCV, Madrid, Spain.,IIB Sant Pau, Barcelona, Spain.,Heart Failure and Transplant Unit, Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Paula Vela
- Heart Failure and Inherited Cardiac Diseases Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro, IDIPHISA, CIBERCV, Madrid, Spain
| | - Fernando de Frutos
- Heart Failure and Inherited Cardiac Diseases Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro, IDIPHISA, CIBERCV, Madrid, Spain
| | - Nerea Mora
- Heart Failure and Inherited Cardiac Diseases Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro, IDIPHISA, CIBERCV, Madrid, Spain
| | - Antonia Pomares
- Heart Failure and Inherited Cardiac Diseases Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro, IDIPHISA, CIBERCV, Madrid, Spain
| | - Emiliano Gonzalez-Vioque
- Heart Failure and Inherited Cardiac Diseases Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro, IDIPHISA, CIBERCV, Madrid, Spain
| | - Ana Briceño
- Heart Failure and Inherited Cardiac Diseases Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro, IDIPHISA, CIBERCV, Madrid, Spain
| | - Eva Cabrera
- Heart Failure and Inherited Cardiac Diseases Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro, IDIPHISA, CIBERCV, Madrid, Spain
| | - Marta Cobo-Marcos
- Heart Failure and Inherited Cardiac Diseases Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro, IDIPHISA, CIBERCV, Madrid, Spain
| | - Fernando Dominguez
- Heart Failure and Inherited Cardiac Diseases Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro, IDIPHISA, CIBERCV, Madrid, Spain.,Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Esther Gonzalez-Lopez
- Heart Failure and Inherited Cardiac Diseases Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro, IDIPHISA, CIBERCV, Madrid, Spain
| | - Javier Segovia
- Heart Failure and Inherited Cardiac Diseases Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro, IDIPHISA, CIBERCV, Madrid, Spain
| | - Enrique Lara-Pezzi
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Pablo Garcia-Pavia
- Heart Failure and Inherited Cardiac Diseases Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro, IDIPHISA, CIBERCV, Madrid, Spain.,Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.,Universidad Francisco de Vitoria (UFV), Pozuelo de Alarcón, Spain.,Universidad Autónoma de Madrid, Madrid, Spain
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11
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Wang S, Peng W, Pang M, Mao L, Peng D, Yu B, Wu S, Hu D, Yang Y, He J, Ouyang M. Clinical Profile and Prognosis of Hereditary Transthyretin Amyloid Cardiomyopathy: A Single-Center Study in South China. Front Cardiovasc Med 2022; 9:900313. [PMID: 35833187 PMCID: PMC9271707 DOI: 10.3389/fcvm.2022.900313] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 06/07/2022] [Indexed: 01/15/2023] Open
Abstract
Background Hereditary transthyretin amyloid cardiomyopathy (ATTR-CM) is a genotypically heterogeneous disorder with a poor prognosis. There is limited literature describing the variants responsible for ATTRv in areas outside the United State, the United Kingdom and Europe. This study was performed to describe the clinical characteristics and genotypic profiles of this disease in South China. Methods This was a single-center retrospective study that evaluated 29 patients with a confirmed diagnosis of hereditary transthyretin amyloid cardiomyopathy enrolled from January 2016 to November 2021. Results 93.1% patients were male and the median age of symptom onset was 53 (46, 62.5) years old. The initial manifestations of ATTR-CM were cardiovascular symptoms (55.2%), neuropathy (41.4%) and vitreous opacity (3.4%). Phenotypes at diagnosis were mixed (82.8%), predominant cardiac (6.9%), neurological (6.9%) and ophthalmic (3.4%). Poor R-wave progression (41%), pseudo-infarct (31%) and low-voltage (31%) patterns were common findings on electrocardiogram. Unexplained increased wall thickness was observed in all 29 patients, with mean septal and posterior wall thicknesses of 14.25 ± 6.26 mm and 15.34 ± 2.84 mm, respectively. Diastolic dysfunction was also seen in all 29 patients, and 17 (58%) had a restrictive fill pattern at diagnosis. Nine different missense mutations of the TTR gene were found in 29 patients from 23 families, with c.349G>T (p.Ala117Ser) the most common mutation. The median survival time after diagnosis was 47.6 (95% CI 37.9-57.4) months, with 1, 3 and 5-year survival rates of 91.2%, 74% and 38% respectively. Patients with advanced heart failure (National Amyloidosis Staging stage II/III) had worse survival than stage I [Breslow (Generalized Wilcoxon), χ2 = 4.693, P = 0.03)]. Conclusions ATTR amyloidosis genotypes and phenotypes are highly heterogeneous. Advanced heart failure predicts a poor prognosis. Understanding the different clinical profiles of ATTR cardiac amyloidosis with different genotype is important to its early recognition.
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Affiliation(s)
- Shuai Wang
- Department of Cardiovascular Medicine, Second Xiangya Hospital, Central South University, Changsha, China
| | - Wenke Peng
- Department of Cardiovascular Medicine, Second Xiangya Hospital, Central South University, Changsha, China
| | - Min Pang
- Department of Cardiovascular Medicine, Second Xiangya Hospital, Central South University, Changsha, China
| | - Ling Mao
- Department of Cardiovascular Medicine, Second Xiangya Hospital, Central South University, Changsha, China
| | - Daoquan Peng
- Department of Cardiovascular Medicine, Second Xiangya Hospital, Central South University, Changsha, China
| | - Bilian Yu
- Department of Cardiovascular Medicine, Second Xiangya Hospital, Central South University, Changsha, China
| | - Sha Wu
- Department of Cardiovascular Medicine, Second Xiangya Hospital, Central South University, Changsha, China
| | - Die Hu
- Department of Cardiovascular Medicine, Second Xiangya Hospital, Central South University, Changsha, China
| | - Yang Yang
- Department of Cardiovascular Medicine, Second Xiangya Hospital, Central South University, Changsha, China
| | - Jia He
- Department of Cardiovascular Medicine, Second Xiangya Hospital, Central South University, Changsha, China
| | - Mingqi Ouyang
- Department of Cardiovascular Medicine, Second Xiangya Hospital, Central South University, Changsha, China
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12
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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.
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Affiliation(s)
| | - Andrew Peterson
- Department of Pharmacy Practice and Pharmacy Administration, Philadelphia College of Pharmacy, University of the Sciences, Philadelphia, PA
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13
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Campbell CM, LoRusso S, Dispenzieri A, Kristen AV, Maurer MS, Rapezzi C, Lairez O, Drachman B, Garcia-Pavia P, Grogan M, Chapman D, Amass L. Sex Differences in Wild-Type Transthyretin Amyloidosis: An Analysis from the Transthyretin Amyloidosis Outcomes Survey (THAOS). Cardiol Ther 2022; 11:393-405. [PMID: 35583798 PMCID: PMC9381661 DOI: 10.1007/s40119-022-00265-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 04/30/2022] [Indexed: 12/24/2022] Open
Abstract
Introduction Wild-type transthyretin amyloidosis (ATTRwt amyloidosis) is a progressive disease resulting from the accumulation of wild-type transthyretin (TTR) amyloid fibrils, and is diagnosed primarily in males. This analysis examined sex differences in patients with ATTRwt amyloidosis from the Transthyretin Amyloidosis Outcomes Survey (THAOS). Methods THAOS is an ongoing, global, longitudinal, observational survey of patients with transthyretin amyloidosis, including both inherited and wild-type disease, and asymptomatic carriers of TTR mutations. THAOS data were analyzed to identify potential differences in demographic and clinical characteristics between males and females with ATTRwt amyloidosis (data cutoff: August 1, 2021). Results Of 1386 patients with ATTRwt amyloidosis, 84 (6%) were female and 1302 (94%) were male. Females had a higher median age at enrollment (80 vs. 78 years; p = 0.002) and symptom onset (75 vs. 73 years; p = 0.045) than males. Mean left ventricular (LV) ejection fraction was higher (53% vs. 48%; p = 0.001) and mean LV diastolic diameter lower (42 vs. 46 mm; p < 0.001) in females versus males, but sex was not identified as a predictor of LV mean wall thickness adjusted for height (beta coefficient − 0.22; p = 0.460) or a predominantly cardiac phenotype (odds ratio 1.60; p = 0.191). Modified polyneuropathy disability scores differed between groups (p < 0.001), with a larger proportion of scores ≥ IIIa among females (23% vs. 7%). Conclusions Females with ATTRwt amyloidosis in THAOS tended to present at a later age and showed signs of less severe cardiac impairment and more severe walking impairment. Trial Registration ClinicalTrials.gov: NCT00628745.
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Affiliation(s)
- Courtney M Campbell
- The Ohio State University, Columbus, OH, USA. .,Cardio-Oncology Center of Excellence, Washington University, 660 S Euclid Ave, St. Louis, MO, 63110, USA.
| | | | | | - Arnt V Kristen
- Department of Cardiology, Angiology, Respiratory Medicine, Medical University of Heidelberg, Heidelberg, Germany
| | - Mathew S Maurer
- Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Claudio Rapezzi
- Cardiological Centre, University of Ferrara, Ferrara, Italy.,Maria Cecilia Hospital, GVM Care and Research, Cotignola, RA, Italy
| | - Olivier Lairez
- Department of Cardiology and Nuclear Medicine, Toulouse University Hospital, Toulouse, France
| | - Brian Drachman
- Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Pablo Garcia-Pavia
- Hospital Universitario Puerta de Hierro Majadahonda, IDIPHISA, CIBERCV, Madrid, Spain.,Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Martha Grogan
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
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14
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Naegeli AN, Balkaran BL, Shan M, Hunter TM, Lee LK, Jairath V. The impact of symptom severity on the humanistic and economic burden of inflammatory bowel disease: a real-world data linkage study. Curr Med Res Opin 2022; 38:541-551. [PMID: 35175166 DOI: 10.1080/03007995.2022.2043655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Few studies have examined the association between inflammatory bowel disease (IBD) severity, and humanistic, and economic burden. We addressed this gap using a unique real-world data source that links self-reported patient data from the US National Health and Wellness Survey (NHWS) to claims data. METHODS This cross-sectional study linked the 2015-2018 US NHWS data with medical, and pharmacy claims. Patients (≥18 years) who self-reported a physician diagnosis of IBD (ulcerative colitis [UC], or Crohn's disease [CD]) in the NHWS, and had a medical or pharmacy claim indicating a possible diagnosis of IBD were included. Disease symptom severity was defined by a weighted symptom score and main outcomes include health-related quality of life (HRQoL), work productivity (WPAI), healthcare resource use (HRU), and associated costs. RESULTS Overall, 687 patients with IBD were included, of which 347 were identified with UC and 340 with CD. Validation analysis showed that 94.7% of UC and 88.7% of patients with CD who self-reported diagnosis of CD or UC in NHWS had evidence of diagnosis and/or treatment patterns in claims. Patients with both UC and CD with moderate or severe symptoms had significantly lower HRQoL, increased work productivity loss, greater HRU, and associated costs compared with patients with mild symptoms. CONCLUSIONS Patients with moderate/severe UC or CD experience substantial humanistic, and economic burden compared with patients with mild UC or CD. These factors should be considered within treatment goals for patients in order to provide holistic care beyond the treatment of objective markers or disease severity and symptoms alone.
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Affiliation(s)
- April N Naegeli
- Global Patient Outcomes and Real-World Evidence, Eli Lilly and Company, Indianapolis, IN, USA
| | | | - Mingyang Shan
- Global Patient Outcomes and Real-World Evidence, Eli Lilly and Company, Indianapolis, IN, USA
| | - Theresa Marie Hunter
- Global Patient Outcomes and Real-World Evidence, Eli Lilly and Company, Indianapolis, IN, USA
| | - Lulu K Lee
- Real-World Evidence, Cerner Enviza, Malvern, PA, USA
| | - Vipul Jairath
- Department of Gastroenterology, Western University & London Health Sciences Centre, London, Ontario, Canada
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15
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DeFilippis EM, Beale A, Martin T, Agarwal A, Elkayam U, Lam CSP, Hsich E. Heart Failure Subtypes and Cardiomyopathies in Women. Circ Res 2022; 130:436-454. [PMID: 35175847 PMCID: PMC10361647 DOI: 10.1161/circresaha.121.319900] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Heart failure affects over 2.6 million women and 3.4 million men in the United States with known sex differences in epidemiology, management, response to treatment, and outcomes across a wide spectrum of cardiomyopathies that include peripartum cardiomyopathy, hypertrophic cardiomyopathy, stress cardiomyopathy, cardiac amyloidosis, and sarcoidosis. Some of these sex-specific considerations are driven by the cellular effects of sex hormones on the renin-angiotensin-aldosterone system, endothelial response to injury, vascular aging, and left ventricular remodeling. Other sex differences are perpetuated by implicit bias leading to undertreatment and underrepresentation in clinical trials. The goal of this narrative review is to comprehensively examine the existing literature over the last decade regarding sex differences in various heart failure syndromes from pathophysiological insights to clinical practice.
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Affiliation(s)
| | - Anna Beale
- Department of Cardiology, Alfred Hospital, Melbourne, Australia (A.B.)
| | - Trejeeve Martin
- Department of Cardiology, Cleveland Clinic, Ohio (T.M., E.H.)
| | - Anubha Agarwal
- Northwestern University Feinberg School of Medicine (A.A.)
| | - Uri Elkayam
- Division of Cardiovascular Medicine, Keck School of Medicine, University of Southern California (U.E.)
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore (C.S.P.L.)
| | - Eileen Hsich
- Department of Cardiology, Cleveland Clinic, Ohio (T.M., E.H.)
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16
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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.
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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
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17
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Sex-related differences in the clinical characteristics of wild-type transthyretin amyloidosis cardiomyopathy. J Cardiol 2021; 79:50-57. [PMID: 34756766 DOI: 10.1016/j.jjcc.2021.10.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 09/28/2021] [Accepted: 10/01/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND A significant male predominance has been reported in wild-type transthyretin amyloid cardiomyopathy (ATTRwt-CM). Hence, female cases of ATTRwt-CM are overlooked, and sex-related differences in ATTRwt-CM remain unclear. This study aimed to examine sex-related differences in clinical characteristics and diagnostic approaches in ATTRwt-CM. METHODS We retrospectively analyzed 199 consecutive patients who were diagnosed with ATTRwt-CM and evaluated sex-related differences in clinical characteristics, imaging parameters, biomarkers, and diagnostic approaches. RESULTS Twenty-nine patients (15%) were female. These female patients were significantly older at diagnosis (77.1 ± 6.5 years vs. 82.9 ± 4.8 years; p<0.001) and had a more advanced New York Health Association functional class (2.2 ± 0.7 vs. 2.6 ± 0.8; p = 0.006) than their male counterparts. The median B-type natriuretic peptide levels were significantly higher (236 pg/mL vs. 394 pg/mL; p = 0.017) in female patients. Echocardiography revealed that the mean interventricular septum diameter was thinner (15.7 ± 2.6 mm vs. 14.1 ± 2.5 mm; p = 0.004) and left ventricular ejection fraction (LVEF) was preserved (51.2 ± 10.2% vs. 57.2 ± 9.1%; p = 0.003) in female patients. The mean heart-to-contralateral ratio obtained using 99mTc-labeled pyrophosphate (99mTc-PYP) was significantly lower (1.89 ± 0.33 vs. 1.63 ± 0.20; p < 0.001), moderate to severe aortic stenosis was more frequently observed (5% vs. 45%; p < 0.001), and the frequency of histological diagnosis was significantly lower (77% vs. 59%; p = 0.036) in female patients. CONCLUSIONS Female patients with ATTRwt-CM were predominantly octogenarians and less hypertrophic and had preserved LVEF and weaker cardiac uptake of the 99mTc-PYP tracer compared with male patients. These characteristics contribute to the underdiagnosis of ATTRwt-CM in female patients.
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18
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Lauppe RE, Liseth Hansen J, Gerdesköld C, Rozenbaum MH, Strand AM, Vakevainen M, Kuusisto J, Gude E, Gustafsson F, Smith JG. Nationwide prevalence and characteristics of transthyretin amyloid cardiomyopathy in Sweden. Open Heart 2021; 8:openhrt-2021-001755. [PMID: 34645699 PMCID: PMC8515473 DOI: 10.1136/openhrt-2021-001755] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 09/23/2021] [Indexed: 01/15/2023] Open
Abstract
Objective Transthyretin amyloid cardiomyopathy (ATTR-CM) is a rare, progressive and fatal condition caused by deposition of transthyretin amyloid fibrils in the heart. This study aims to identify all patients diagnosed with ATTR-CM in Sweden, estimate the prevalence of ATTR-CM, describe patient characteristics and mortality, assess the importance of early symptoms (red flags) for identification of ATTR-CM, and compare with patients with heart failure (HF). Methods This retrospective study combined multiple national health registers covering all specialist visits and prescriptions for the entire population of Sweden. Between January 2008 and December 2018, patients with ATTR-CM were identified retrospectively based on a combination of diagnosis codes and compared with matched, all-cause non-ATTR HF patients. Results Overall, a total of 994 patients diagnosed with ATTR-CM were identified, with an average age at diagnosis of 73 years, and 30% of whom were female. The prevalence of diagnosed ATTR-CM cases in 2018 was 5.0 per 100 000. The median survival from diagnosis was 37.6 months (CI 33.8 to 43.8), with a lower median survival in women (27.9 months, CI 23.3 to 33.8) compared with men (43.5 months, CI 37.6 to 49.6). Patients with ATTR-CM demonstrated reduced survival compared with patients with HF (p<0.001). Compared with patients with HF, clinical identification of carpal tunnel syndrome, spinal stenosis, and atrioventricular and left bundle branch block can facilitate earlier diagnosis of ATTR-CM. Conclusions This study provides the first nationwide estimates of ATTR-CM prevalence and risk factors. The results reinforce the severity of the disease and the importance of earlier diagnosis, especially for female patients, in order to allow effective treatment and prevention of disease progression.
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Affiliation(s)
| | - Johan Liseth Hansen
- Quantify Research AB, Stockholm, Sweden.,Institute of Health and Society, University of Oslo Faculty of Medicine, Oslo, Norway
| | | | | | | | | | - Johanna Kuusisto
- Department of Medicine and Clinical Research, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Einar Gude
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - J Gustav Smith
- Department of Cardiology, Wallenberg Center for Molecular Medicine and Lund University Diabetes Centre, Clinical Sciences, Lund University and Skåne University Hospital, Lund, Sweden .,The Wallenberg Laboratory/Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University and Sahlgrenska University Hospital, Gothenburg, Sweden
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19
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Chandrashekar P, Alhuneafat L, Mannello M, Al-Rashdan L, Kim MM, Dungu J, Alexander K, Masri A. Prevalence and Outcomes of p.Val142Ile TTR Amyloidosis Cardiomyopathy: A Systematic Review. CIRCULATION-GENOMIC AND PRECISION MEDICINE 2021; 14:e003356. [PMID: 34461737 DOI: 10.1161/circgen.121.003356] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The p.Val142Ile variant, predominantly found among people of African descent, is the most common cause of variant transthyretin amyloidosis and carriers predominantly develop a cardiomyopathy (variant transthyretin amyloidosis cardiomyopathy) phenotype. Yet, there are conflicting data on the prevalence and outcomes of p.Val142Ile variant carriers. METHODS We performed a systematic review of the prevalence and outcomes of p.Val142Ile variant transthyretin amyloidosis cardiomyopathy among subjects of African descent. We found 62 relevant articles after searching the MEDLINE databases from 1980 to 2020 that reported data for ≈150 000 subjects. RESULTS The reported worldwide prevalence of the p.Val142Ile variant is 0.3% to 1.6% in the general population. Among people of African descent, the reported prevalence from all studies ranges from 1.1% to 9.8%, but for studies with >1000 subjects, it is 3% to 3.5%. The prevalence of the p.Val142Ile variant in a region is dependent on the reported percentage of subjects who are of African descent in that region. p.Val142Ile variant transthyretin amyloidosis cardiomyopathy typically presents in the seventh to eighth decade of life and the majority of cases reported were male, with 25% to 38% diagnosed with atrial fibrillation. It was associated with a longitudinally worse quality of life and a lower adjusted survival compared with other types of transthyretin amyloidosis cardiomyopathy. CONCLUSIONS The p.Val142Ile variant is the most common variant of the transthyretin gene with most carriers being of African descent. The true penetrance is unknown but the p.Val142Ile variant is associated with increased rates of incident heart failure and portends a lower overall survival. Increased awareness could lead to earlier diagnosis and improved heart failure outcomes among those of African descent, which is of increasing importance given the advent of novel therapeutics for this disease.
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Affiliation(s)
- Pranav Chandrashekar
- Amyloidosis Center, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR (P.C., M.M., L.A.-R., M.M.K., A.M.)
| | - Laith Alhuneafat
- Department of Medicine, Allegheny General Hospital, Pittsburgh, PA (L.A.)
| | - Meghan Mannello
- Amyloidosis Center, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR (P.C., M.M., L.A.-R., M.M.K., A.M.)
| | - Lana Al-Rashdan
- Amyloidosis Center, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR (P.C., M.M., L.A.-R., M.M.K., A.M.).,Department of Medicine, Allegheny General Hospital, Pittsburgh, PA (L.A.)
| | - Morris M Kim
- Amyloidosis Center, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR (P.C., M.M., L.A.-R., M.M.K., A.M.)
| | - Jason Dungu
- Essex Cardiothoracic Center, England, United Kingdom (J.D.)
| | - Kevin Alexander
- School of Medicine, Division of Cardiology, Stanford University, Palo Alto, CA (K.A.)
| | - Ahmad Masri
- Amyloidosis Center, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR (P.C., M.M., L.A.-R., M.M.K., A.M.)
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20
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Ochi Y, Kubo T, Baba Y, Sugiura K, Ueda M, Miyagawa K, Noguchi T, Hirota T, Hamada T, Yamasaki N, Kitaoka H. Wild-Type Transthyretin Amyloidosis in Female Patients - Consideration of Sex Differences. Circ Rep 2021; 3:465-471. [PMID: 34414336 PMCID: PMC8338431 DOI: 10.1253/circrep.cr-21-0067] [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: 05/30/2021] [Accepted: 05/31/2021] [Indexed: 12/12/2022] Open
Abstract
Background:
With recent advances in non-invasive diagnostic tools, some studies indicate that wild-type transthyretin amyloidosis (ATTRwt) may be more common in females than previously reported. However, the clinical characteristics of female ATTRwt patients have not been determined. Methods and Results:
Of the 78 consecutive patients with ATTRwt in our cohort, 14 (17.9 %) were female. Compared with male patients, female ATTRwt patients had smaller left ventricular (LV) wall thicknesses (ventricular septum thickness 12.9 vs. 14.2 mm [P=0.081]; posterior wall thickness 12.7 vs. 13.6 mm [P=0.035]) and a higher LV ejection fraction (EF; mean [±SD] 58.4±8.9% vs. 48.9±11.8%; P=0.006). However, the severity of heart failure (HF), as assessed by HF stage, New York Heart Association functional class and B-type natriuretic peptide concentrations, did not differ between female and male patients. Moreover, LV mass index and relative wall thickness were increased and the stroke volume index was reduced in both female and male patients. In organ biopsies, female patients had a higher sensitivity to transthyretin deposition from abdominal fat than male patients (positive abdominal fat biopsy 80.0 % vs. 26.5%; P=0.016). Conclusions:
This study suggests that a relatively large proportion of elderly females have ATTRwt. Female ATTRwt patients had HF symptoms even at the stage of mild LV hypertrophy and preserved EF. Abdominal fat biopsy may be useful to diagnose ATTRwt, especially in female patients with HF.
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Affiliation(s)
- Yuri Ochi
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Toru Kubo
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Yuichi Baba
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Kenta Sugiura
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Motoko Ueda
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Kazuya Miyagawa
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Tatsuya Noguchi
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Takayoshi Hirota
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Tomoyuki Hamada
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Naohito Yamasaki
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Hiroaki Kitaoka
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
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21
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Caponetti AG, Rapezzi C, Gagliardi C, Milandri A, Dispenzieri A, Kristen AV, Wixner J, Maurer MS, Garcia-Pavia P, Tournev I, Planté-Bordeneuve V, Chapman D, Amass L. Sex-Related Risk of Cardiac Involvement in Hereditary Transthyretin Amyloidosis: Insights From THAOS. JACC-HEART FAILURE 2021; 9:736-746. [PMID: 34391735 DOI: 10.1016/j.jchf.2021.05.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/12/2021] [Accepted: 05/13/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Because patients with ATTRv cardiomyopathy are more likely to be male, this analysis aimed to increase information on associations between sex and genotype, phenotype, and degree of myocardial involvement in ATTRv amyloidosis. BACKGROUND Transthyretin amyloid cardiomyopathy is a progressive, fatal disease that occurs due to accumulation of wild-type or variant (ATTRv) transthyretin amyloid fibrils in the myocardium. METHODS The Transthyretin Amyloidosis Outcomes Survey (THAOS) is an ongoing global longitudinal observational survey of patients with ATTR amyloidosis and asymptomatic carriers with TTR mutations. Data from THAOS (data cutoff: January 6, 2020) were analyzed to determine any sex-based differences in genotype, phenotype, and presence of cardiac and neurological symptoms in patients with ATTRv amyloidosis and in patients with ATTRv amyloidosis and cardiomyopathy. RESULTS There were 2,790 patients with ATTRv amyloidosis enrolled in THAOS, with male patients more likely to have symptoms of cardiac involvement and a cardiac phenotype. Male prevalence was greater in patients with more severe cardiac manifestations of disease, as assessed with N-terminal pro-B-type natriuretic peptide, left-ventricular (LV) ejection fraction, mean LV wall thickness divided by height, and LV mass index divided by height. Sex, age at disease onset, and genotype category were identified by multivariate analyses as risk factors for the development of cardiomyopathy (defined as increased LV septum thickness divided by height). CONCLUSIONS In this analysis, myocardial involvement was more frequent and pronounced in male patients with ATTRv amyloidosis, suggesting that there may be biological characteristics that inhibit myocardial amyloid infiltration in females or facilitate it in males.
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Affiliation(s)
| | - Claudio Rapezzi
- Cardiological Center, University of Ferrara, Ferrara, Italy; Maria Cecilia Hospital, GVM Care and Research, Cotignola, Emilia-Romagna, Italy.
| | - Christian Gagliardi
- Department of Experimental, Diagnostic, and Specialty Medicine, University of Bologna, Italy
| | - Agnese Milandri
- Department of Cardiology, Bentivoglio Hospital, Bentivoglio, Bologna, Italy
| | | | - Arnt V Kristen
- Department of Cardiology, Angiology, Respiratory Medicine, Medical University of Heidelberg, Heidelberg, Germany
| | - Jonas Wixner
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Mathew S Maurer
- Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Pablo Garcia-Pavia
- Department of Cardiology, Hospital Universitario Puerta de Hierro Majadahonda, Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Madrid, Spain; Universidad Francisco de Vitoria, Pozuelo de Alarcon, Madrid, Spain
| | - Ivailo Tournev
- Clinic of Nervous Diseases, University Hospital Aleksandrovska, Sofia, Bulgaria; Department of Neurology, Medical University, Sofia, Bulgaria; Department of Cognitive Science and Psychology, New Bulgarian University, Sofia, Bulgaria
| | - Violaine Planté-Bordeneuve
- Department of Neurology- Amyloid Network-University Hospital Henri Mondor-Assistance Publique Hopitaux de Paris, IMRB INSERM U955 Team 10 "Biology of the Neuro-Muscular System", Créteil, France
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22
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Wieczorek E, Ożyhar A. Transthyretin: From Structural Stability to Osteoarticular and Cardiovascular Diseases. Cells 2021; 10:1768. [PMID: 34359938 PMCID: PMC8307983 DOI: 10.3390/cells10071768] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 06/29/2021] [Accepted: 07/09/2021] [Indexed: 01/10/2023] Open
Abstract
Transthyretin (TTR) is a tetrameric protein transporting hormones in the plasma and brain, which has many other activities that have not been fully acknowledged. TTR is a positive indicator of nutrition status and is negatively correlated with inflammation. TTR is a neuroprotective and oxidative-stress-suppressing factor. The TTR structure is destabilized by mutations, oxidative modifications, aging, proteolysis, and metal cations, including Ca2+. Destabilized TTR molecules form amyloid deposits, resulting in senile and familial amyloidopathies. This review links structural stability of TTR with the environmental factors, particularly oxidative stress and Ca2+, and the processes involved in the pathogenesis of TTR-related diseases. The roles of TTR in biomineralization, calcification, and osteoarticular and cardiovascular diseases are broadly discussed. The association of TTR-related diseases and vascular and ligament tissue calcification with TTR levels and TTR structure is presented. It is indicated that unaggregated TTR and TTR amyloid are bound by vicious cycles, and that TTR may have an as yet undetermined role(s) at the crossroads of calcification, blood coagulation, and immune response.
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Affiliation(s)
- Elżbieta Wieczorek
- Department of Biochemistry, Molecular Biology and Biotechnology, Faculty of Chemistry, Wroclaw University of Science and Technology, Wybrzeże Wyspiańskiego 27, 50-370 Wroclaw, Poland;
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23
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Burton A, Castaño A, Bruno M, Riley S, Schumacher J, Sultan MB, See Tai S, Judge DP, Patel JK, Kelly JW. Drug Discovery and Development in Rare Diseases: Taking a Closer Look at the Tafamidis Story. Drug Des Devel Ther 2021; 15:1225-1243. [PMID: 33776421 PMCID: PMC7987260 DOI: 10.2147/dddt.s289772] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 01/20/2021] [Indexed: 12/25/2022] Open
Abstract
Rare diseases are increasingly recognized as a global public health priority. Governments worldwide currently provide important incentives to stimulate the discovery and development of orphan drugs for the treatment of these conditions, but substantial scientific, clinical, and regulatory challenges remain. Tafamidis is a first-in-class, disease-modifying transthyretin (TTR) kinetic stabilizer that represents a major breakthrough in the treatment of transthyretin amyloidosis (ATTR amyloidosis). ATTR amyloidosis is a rare, progressive, and fatal systemic disorder caused by aggregation of misfolded TTR and extracellular deposition of amyloid fibrils in various tissues and organs, including the heart and nervous systems. In this review, we present the successful development of tafamidis spanning 3 decades, marked by meticulous laboratory research into disease mechanisms and natural history, and innovative clinical study design and implementation. These efforts established the safety and efficacy profile of tafamidis, leading to its regulatory approval, and enabled post-approval initiatives that further support patients with ATTR amyloidosis.
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Affiliation(s)
| | | | | | - Steve Riley
- Clinical Pharmacology, Pfizer Inc, Groton, CT, USA
| | | | - Marla B Sultan
- Global Product Development, Pfizer Inc, New York, NY, USA
| | - Sandi See Tai
- Global Product Development, Pfizer Inc, Collegeville, PA, USA
| | - Daniel P Judge
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Jignesh K Patel
- Department of Cardiology, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, USA
| | - Jeffery W Kelly
- Department of Chemistry, The Scripps Research Institute, La Jolla, CA, USA
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24
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Kroi F, Fischer N, Gezin A, Hashim M, Rozenbaum MH. Estimating the Gender Distribution of Patients with Wild-Type Transthyretin Amyloid Cardiomyopathy: A Systematic Review and Meta-Analysis. Cardiol Ther 2020; 10:41-55. [PMID: 33315233 PMCID: PMC8126539 DOI: 10.1007/s40119-020-00205-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION This study investigates the gender distribution in patients diagnosed with wild-type transthyretin amyloidosis cardiomyopathy (ATTRwt). METHODS A systematic review and meta-analysis of the male proportion in diagnosed ATTRwt patients were conducted. To avoid overlapping population, pooled estimates in the primary analysis were based on all unique studies. In secondary analyses, we considered predefined subsets of studies based on study sample size, recruitment years, geography, study design, age at diagnosis, and method of diagnosis. Additional meta-regression analyses were tested for potential determinants of gender distribution. RESULTS Twenty-eight unique studies (2542 patients) were included in the meta-analysis. Male proportion in patients with ATTRwt was 86.9% (95% confidence interval 81.5-91.6%). Studies, including patients older than 80 years at diagnosis, had a 29.1% (p value < 0.001) lower male proportion compared to studies, including younger patients. After adjusting for age, studies using autopsy as a method of diagnosis had a 21.1% (p value 0.002) lower male proportion compared to other studies. CONCLUSIONS Studies conducted to date suggest ATTRwt disproportionally affects males. The proportion of males was significantly impacted by the age at diagnosis and method diagnosis, which may suggest important gender-based differences in the clinical manifestation and diagnostic challenges of ATTRwt in females that warrant future research.
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Affiliation(s)
| | | | - Ana Gezin
- Ingress-Health, Rotterdam, The Netherlands
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