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Nebhwani M, Chaibekava K, Achten A, Oerlemans MIFJ, Michels M, van der Meer P, Nienhuis HLA, Weerts J, van Empel V, Rocca HPBL, Wijk SSV, van der Pol J, Knackstedt C. Detection of cardiac amyloidosis on routine bone scintigraphy: an important gatekeeper role for the nuclear medicine physician. Int J Cardiovasc Imaging 2024; 40:1183-1192. [PMID: 38520623 PMCID: PMC11213735 DOI: 10.1007/s10554-024-03085-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 03/11/2024] [Indexed: 03/25/2024]
Abstract
Cardiac amyloidosis (CA)-mostly transthyretin-related (ATTR-CA)-has recently gained interest in cardiology. Bone scintigraphy (BS) is one of the main screening tools for ATTR-CA but also used for various other reasons. The objective was to evaluate whether all CA cases are detected and what happens during follow-up. All routine BS performed at the Maastricht University Medical Center (May 2012-August 2020) were screened for the presence of CA. Scans performed for suspected CA were excluded. A Perugini stage ≥1 was classified as positive necessitating further examination. The electronic medical record system was evaluated for any contact with cardiology or other specialists until 2021. Of the 2738 BS evaluated, 40 scans (1.46%; median age 73.5 [IQR: 65.8-79.5], 82.5% male) were positive (Perugini grade 1: 31/77.5%, grade 2: 6/15%, grade 3: 3/7.5%); the potential diagnosis ATTR-CA was not seen in 38 patients (95%) by the nuclear medicine specialist. During follow-up, 19 out of those 40 patients (47.5%) underwent cardiac evaluation without diagnosing CA. Available echocardiograms of patients with a positive BS showed left ventricular hypertrophy, a preserved ejection fraction, and diastolic dysfunction ≥2 in 9/47%, 10/53%, and 4/21% of patients, respectively. Additionally, 20 (50%) patients presented to at least one specialty with symptoms indicative of cardiac amyloidosis. The prevalence of a positive BS indicating potential CA in an unselected population is low but substantial. The majority was not detected which asks for better awareness for CA of all involved specialists to ensure appropriate treatment and follow-up.
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Affiliation(s)
- Mohit Nebhwani
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Karina Chaibekava
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Anouk Achten
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
| | | | - Michelle Michels
- Department of Cardiology, Erasmus MC, Cardiovascular Institute, Thoraxcenter, Rotterdam, The Netherlands
| | - Peter van der Meer
- Department of Cardiology, University Medical Center, Groningen, The Netherlands
| | - Hans L A Nienhuis
- Department of Rheumatology & Clinical Immunology, University Medical Center Groningen, Groningen, The Netherlands
| | - Jerremy Weerts
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Vanessa van Empel
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Hans-Peter Brunner-La Rocca
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
| | | | - Jochem van der Pol
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Christian Knackstedt
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, PO Box 5800, 6202 AZ, Maastricht, The Netherlands.
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Tingen HSA, Tubben A, Bijzet J, van den Berg MP, van der Meer P, Houwerzijl EJ, Muntinghe FLH, van der Zwaag PA, Glaudemans AWJM, Oerlemans MIFJ, Knackstedt C, Michels M, Hirsch A, Hazenberg BPC, Slart RHJA, Nienhuis HLA. Cardiac [ 99mTc]Tc-hydroxydiphosphonate uptake on bone scintigraphy in patients with hereditary transthyretin amyloidosis: an early follow-up marker? Eur J Nucl Med Mol Imaging 2024; 51:681-690. [PMID: 37843599 PMCID: PMC10796605 DOI: 10.1007/s00259-023-06459-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 09/23/2023] [Indexed: 10/17/2023]
Abstract
PURPOSE There is a need for early quantitative markers of potential treatment response in patients with hereditary transthyretin (ATTRv) amyloidosis to guide therapy. This study aims to evaluate changes in cardiac tracer uptake on bone scintigraphy in ATTRv amyloidosis patients on different treatments. METHODS In this retrospective cohort study, outcomes of 20 patients treated with the transthyretin (TTR) gene silencer patisiran were compared to 12 patients treated with a TTR-stabilizer. Changes in NYHA class, cardiac biomarkers in serum, wall thickness, and diastolic parameters on echocardiography and NYHA class during treatment were evaluated. RESULTS Median heart/whole-body (H/WB) ratio on bone scintigraphy decreased from 4.84 [4.00 to 5.31] to 4.16 [3.66 to 4.81] (p < .001) in patients treated with patisiran for 29 [15-34] months. No changes in the other follow-up parameters were observed. In patients treated with a TTR-stabilizer for 24 [20 to 30] months, H/WB ratio increased from 4.46 [3.24 to 5.13] to 4.96 [ 3.39 to 5.80] (p = .010), and troponin T increased from 19.5 [9.3 to 34.0] ng/L to 20.0 [11.8 to 47.8] ng/L (p = .025). All other parameters did not change during treatment with a TTR-stabilizer. CONCLUSION A change in cardiac tracer uptake on bone scintigraphy may be an early marker of treatment-specific response or disease progression in ATTRv amyloidosis patients.
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Affiliation(s)
- H S A Tingen
- Department of Nuclear Medicine and Molecular Imaging, University Medical Centre Groningen and Amyloidosis Centre of Expertise, Groningen, The Netherlands.
| | - A Tubben
- Department of Cardiology, University Medical Centre Groningen and Amyloidosis Centre of Expertise, Groningen, The Netherlands
| | - J Bijzet
- Department of Rheumatology & Clinical Immunology, University Medical Centre Groningen and Amyloidosis Centre of Expertise, Groningen, The Netherlands
| | - M P van den Berg
- Department of Cardiology, University Medical Centre Groningen and Amyloidosis Centre of Expertise, Groningen, The Netherlands
| | - P van der Meer
- Department of Cardiology, University Medical Centre Groningen and Amyloidosis Centre of Expertise, Groningen, The Netherlands
| | - E J Houwerzijl
- Department of Internal Medicine, University Medical Centre Groningen and Amyloidosis Centre of Expertise, Groningen, The Netherlands
| | - F L H Muntinghe
- Department of Internal Medicine, University Medical Centre Groningen and Amyloidosis Centre of Expertise, Groningen, The Netherlands
| | - P A van der Zwaag
- Department of Clinical Genetics, University Medical Centre Groningen and Amyloidosis Centre of Expertise, Groningen, The Netherlands
| | - A W J M Glaudemans
- Department of Nuclear Medicine and Molecular Imaging, University Medical Centre Groningen and Amyloidosis Centre of Expertise, Groningen, The Netherlands
| | - M I F J Oerlemans
- Department of Cardiology and Member of the European Reference Network for rare, low prevalence and complex diseases of the heart: ERN GUARD-Heart , University Medical Centre Utrecht, Utrecht, The Netherlands
| | - C Knackstedt
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre +, Maastricht, The Netherlands
| | - M Michels
- Department of Cardiology, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - A Hirsch
- Department of Radiology and Nuclear Medicine, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - B P C Hazenberg
- Department of Rheumatology & Clinical Immunology, University Medical Centre Groningen and Amyloidosis Centre of Expertise, Groningen, The Netherlands
| | - R H J A Slart
- Department of Nuclear Medicine and Molecular Imaging, University Medical Centre Groningen and Amyloidosis Centre of Expertise, Groningen, The Netherlands
- Biomedical Photonic Imaging Group, Faculty of Science and Technology, University of Twente, Enschede, The Netherlands
| | - H L A Nienhuis
- Department of Internal Medicine, University Medical Centre Groningen and Amyloidosis Centre of Expertise, Groningen, The Netherlands
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3
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Tingen HSA, Berends M, Tubben A, Bijzet J, Houwerzijl EJ, Muntinghe FLH, Kroesen BJ, van der Zwaag PA, van der Meer P, Slart RHJA, Hazenberg BPC, Nienhuis HLA. High-Sensitivity Cardiac Troponin T to Exclude Cardiac Involvement in TTR Variant Carriers and ATTRv Amyloidosis Patients. J Clin Med 2024; 13:810. [PMID: 38337504 PMCID: PMC10856062 DOI: 10.3390/jcm13030810] [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: 12/22/2023] [Revised: 01/17/2024] [Accepted: 01/19/2024] [Indexed: 02/12/2024] Open
Abstract
(1) Background: Individuals carrying a pathogenic transthyretin gene variant (TTRv) are at high risk for developing hereditary transthyretin (ATTRv) amyloidosis and are routinely screened for the development of cardiomyopathy (ATTRv-CM). This study aims to evaluate whether the cardiac biomarkers N-terminal pro B-type natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin T (hs-cTnT) can be used to rule out ATTRv-CM. (2) Methods: In this retrospective case-control study, data from 46 ATTRv-CM patients and 101 TTRv carriers and ATTRv amyloidosis patients without cardiomyopathy were included. Binary logistic regression models were used to assess the ability of NT-proBNP and hs-cTnT to predict the diagnosis of ATTRv-CM. An optimal cutoff for the relevant biomarker(s) was determined based on a sensitivity of ≥99% and the highest possible percentage of additional tests avoided (%ATA) in the index dataset. (3) Results: Hs-cTnT demonstrated the highest predictive capabilities for ATTRv-CM. The addition of NT-proBNP did not improve the predictive model. A hs-cTnT cutoff of <6 ng/L resulted in a 97% sensitivity and a negative predictive value of 95% with a %ATA of 30% in the validation dataset. (4) Conclusion: In conclusion, hs-cTnT is a useful biomarker for excluding cardiac involvement in TTRv carriers and ATTRv amyloidosis patients and it has the potential to prevent unnecessary diagnostic procedures.
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Affiliation(s)
- Hendrea S. A. Tingen
- Department of Nuclear Medicine and Molecular Imaging, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Milou Berends
- Department of Internal Medicine, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands (H.L.A.N.)
| | - Alwin Tubben
- Department of Cardiology, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Johan Bijzet
- Department of Laboratory Medicine, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Ewout J. Houwerzijl
- Department of Internal Medicine, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands (H.L.A.N.)
| | - Friso L. H. Muntinghe
- Department of Internal Medicine, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands (H.L.A.N.)
| | - Bart-Jan Kroesen
- Department of Laboratory Medicine, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Paul A. van der Zwaag
- Department of Genetics, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Peter van der Meer
- Department of Cardiology, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Riemer H. J. A. Slart
- Department of Nuclear Medicine and Molecular Imaging, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
- Biomedical Photonic Imaging Group, Faculty of Science and Technology, University of Twente, Drienerlolaan 5, 7522 NB Enschede, The Netherlands
| | - Bouke P. C. Hazenberg
- Department of Rheumatology & Clinical Immunology, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Hans L. A. Nienhuis
- Department of Internal Medicine, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands (H.L.A.N.)
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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.
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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
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Zhang Y, Chaolu H. Diagnostic Role of NT-proBNP in Patients with Cardiac Amyloidosis Involvement: A Meta-Analysis. Arq Bras Cardiol 2022; 119:212-222. [PMID: 35544851 PMCID: PMC9363055 DOI: 10.36660/abc.20210486] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 12/08/2021] [Indexed: 11/23/2022] Open
Abstract
Fundamento A amiloidose é definida como um distúrbio caracterizado pela deposição de material proteico amiloide extracelular nos tecidos. Objetivos O N-terminal pró-peptídeo natriurético tipo-B (NT-proBNP) é usado para prever a amiloidose cardíaca (AC), mas seu efeito diagnóstico no comprometimento por AC ainda não é claro, especialmente em termos de especificidade e sensibilidade. Métodos Foi feita uma busca de literatura nos bancos de dados Pubmed, Embase e a biblioteca Cochrane, e o QUADAS 2 foi utilizado para avaliação da qualidade. O comando Midas no Stata 12.0 foi usado para analisar os indicadores dos sujeitos. O teste Q de Cochran e o I2 foram usados como testes de heterogeneidade, e a heterogeneidade significativa foi definida como p <0,05 e/ou I2 >50%. A análise de correlação de Spearman foi usada para avaliar o efeito de limiar, e o viés da publicação foi avaliado pelo teste de assimetria. A significância estatística foi definida em p <0,05. Resultados Como resultados, 10 conjuntos de dados de 7 estudos foram incluídos para análise, apresentando alta qualidade metodológica e pequenos vieses de confusão. A sensibilidade e a especificidade do NT-proBNP no diagnóstico do comprometimento cardíaco para pacientes com amiloidose foram 0,93 e 0,84, respectivamente. As curvas ROC também sugeriram uma validade diagnóstica alta do NT-proBNP com AUC de 0,95. Um nomograma de Fagan demonstrou que as probabilidades de NT-proBNP positivo e negativo no avanço do comprometimento por AC eram de 90% e 8%, respectivamente. O gráfico de funil de Deek não sugeriu viés significativo de publicação entre os estudos incluídos, e os resultados foram estáveis e confiáveis. Conclusões O NT-proBNP desempenha um papel positivo no diagnóstico precoce do comprometimento por AC, com alta sensibilidade e especificidade.
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Affiliation(s)
- Yingwei Zhang
- First Hospital of Shanxi Medical University, Yingze District, Taiyuan - China
| | - Hasi Chaolu
- First Hospital of Shanxi Medical University, Yingze District, Taiyuan - China
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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: 27] [Impact Index Per Article: 9.0] [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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Izumiya Y, Hayashi H, Ishikawa H, Shibata A, Yoshiyama M. How to Identify Transthyretin Cardiac Amyloidosis at an Early Stage. Intern Med 2021; 60:1-7. [PMID: 32713926 PMCID: PMC7835474 DOI: 10.2169/internalmedicine.5505-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Cardiac involvement of systemic amyloidosis is preferentially observed in patients with amyloid light chain amyloidosis or transthyretin amyloidosis (ATTR). Owing to the development of diagnostic modalities and changes in recognition by physicians, transthyretin cardiac amyloidosis (ATTR-CA) is now understood to be a more common cause of heart failure than previously thought. Recent progress in disease-modifying therapeutic interventions, such as transthyretin stabilizers, has resulted in ATTR-CA changing from an incurable disease to a curable disease. These interventions are particularly effective in patients with mild symptoms of heart failure, thus indicating that early detection and a precise diagnosis are important for improving the prognosis. In this review article, we summarize the recent reports of early screening of ATTR-CA and describe some important points regarding the making of a precise diagnosis, especially focusing on histological evaluations.
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Affiliation(s)
- Yasuhiro Izumiya
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine, Japan
| | - Hiroya Hayashi
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine, Japan
| | - Hirotoshi Ishikawa
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine, Japan
| | - Atsushi Shibata
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine, Japan
| | - Minoru Yoshiyama
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine, Japan
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Okada M, Misumi Y, Masuda T, Takashio S, Tasaki M, Matsushita H, Ueda A, Inoue Y, Nomura T, Nakajima M, Yamashita T, Shinriki S, Matsui H, Tsujita K, Ando Y, Ueda M. Plasma growth differentiation factor 15: a novel tool to detect early changes of hereditary transthyretin amyloidosis. ESC Heart Fail 2020; 8:1178-1185. [PMID: 33381924 PMCID: PMC8006664 DOI: 10.1002/ehf2.13176] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 10/27/2020] [Accepted: 11/29/2020] [Indexed: 01/04/2023] Open
Abstract
AIMS Hereditary transthyretin (ATTRv) amyloidosis is the most frequent and representative form of autosomal dominant hereditary systemic amyloidosis. Disease-modifying treatments of the disease are more effective during the early stages, and we require biomarkers to detect early pathological changes for prompt diagnosis. This study aimed to investigate whether plasma growth differentiation factor 15 (GDF-15) levels could aid detection of early pathological changes in ATTRv amyloidosis. METHODS AND RESULTS We retrospectively studied 32 patients with ATTRv amyloidosis, eight asymptomatic TTR mutation carriers, and eight healthy volunteers. We evaluated plasma GDF-15 levels in these subjects as related to levels of brain natriuretic peptide and high-sensitivity troponin T, echocardiographic features, 99m Tc-pyrophosphate (PYP) scans, and cardiac magnetic resonance imaging findings. Plasma GDF-15 levels significantly increased even in asymptomatic TTR mutation carriers compared with healthy volunteers (P < 0.01). Plasma GDF-15 levels were significantly correlated with plasma brain natriuretic peptide values (P < 0.01), serum high-sensitivity troponin T values (P < 0.05), and interventricular septal thickness at end-diastole (P < 0.01) in patients with ATTRv amyloidosis. Plasma GDF-15 levels in patients with PYP-positive ATTRv amyloidosis were significantly higher than those in patients with PYP-negative ATTRv amyloidosis (P < 0.01). Plasma GDF-15 levels in patients with late gadolinium enhancement-positive ATTRv amyloidosis were significantly higher than those in patients with late gadolinium enhancement-negative ATTRv amyloidosis (P < 0.01). Groups of patients with different TTR genotypes manifested different plasma GDF-15 levels. CONCLUSIONS Growth differentiation factor 15 may reflect early pathological changes of ATTRv amyloidosis.
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Affiliation(s)
- Masamitsu Okada
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-0811, Japan
| | - Yohei Misumi
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-0811, Japan
| | - Teruaki Masuda
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-0811, Japan
| | - Seiji Takashio
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Masayoshi Tasaki
- Department of Morphological and Physiological Sciences, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hiroaki Matsushita
- Department of Amyloidosis Research, Nagasaki International University, Nagasaki, Japan
| | - Akihiko Ueda
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-0811, Japan
| | - Yasuteru Inoue
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-0811, Japan
| | - Toshiya Nomura
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-0811, Japan
| | - Makoto Nakajima
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-0811, Japan
| | - Taro Yamashita
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-0811, Japan
| | - Satoru Shinriki
- Department of Molecular Laboratory Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hirotaka Matsui
- Department of Molecular Laboratory Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yukio Ando
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-0811, Japan.,Department of Amyloidosis Research, Nagasaki International University, Nagasaki, Japan
| | - Mitsuharu Ueda
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-0811, Japan
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9
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Adams D, Polydefkis M, González-Duarte A, Wixner J, Kristen AV, Schmidt HH, Berk JL, Losada López IA, Dispenzieri A, Quan D, Conceição IM, Slama MS, Gillmore JD, Kyriakides T, Ajroud-Driss S, Waddington-Cruz M, Mezei MM, Planté-Bordeneuve V, Attarian S, Mauricio E, Brannagan TH, Ueda M, Aldinc E, Wang JJ, White MT, Vest J, Berber E, Sweetser MT, Coelho T. Long-term safety and efficacy of patisiran for hereditary transthyretin-mediated amyloidosis with polyneuropathy: 12-month results of an open-label extension study. Lancet Neurol 2020; 20:49-59. [PMID: 33212063 DOI: 10.1016/s1474-4422(20)30368-9] [Citation(s) in RCA: 89] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 09/09/2020] [Accepted: 09/21/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Hereditary transthyretin-mediated amyloidosis is a rare, inherited, progressive disease caused by mutations in the transthyretin (TTR) gene. We assessed the safety and efficacy of long-term treatment with patisiran, an RNA interference therapeutic that inhibits TTR production, in patients with hereditary transthyretin-mediated amyloidosis with polyneuropathy. METHODS This multicentre, open-label extension (OLE) trial enrolled patients at 43 hospitals or clinical centres in 19 countries as of Sept 24, 2018. Patients were eligible if they had completed the phase 3 APOLLO or phase 2 OLE parent studies and tolerated the study drug. Eligible patients from APOLLO (patisiran and placebo groups) and the phase 2 OLE (patisiran group) studies enrolled in this global OLE trial and received patisiran 0·3 mg/kg by intravenous infusion every 3 weeks with plans to continue to do so for up to 5 years. Efficacy assessments included measures of polyneuropathy (modified Neuropathy Impairment Score +7 [mNIS+7]), quality of life, autonomic symptoms, nutritional status, disability, ambulation status, motor function, and cardiac stress, with analysis by study groups (APOLLO-placebo, APOLLO-patisiran, phase 2 OLE patisiran) based on allocation in the parent trial. The global OLE is ongoing with no new enrolment, and current findings are based on the interim analysis of the patients who had completed 12-month efficacy assessments as of the data cutoff. Safety analyses included all patients who received one or more dose of patisiran up to the data cutoff. This study is registered with ClinicalTrials.gov, NCT02510261. FINDINGS Between July 13, 2015, and Aug 21, 2017, of 212 eligible patients, 211 were enrolled: 137 patients from the APOLLO-patisiran group, 49 from the APOLLO-placebo group, and 25 from the phase 2 OLE patisiran group. At the data cutoff on Sept 24, 2018, 126 (92%) of 137 patients from the APOLLO-patisiran group, 38 (78%) of 49 from the APOLLO-placebo group, and 25 (100%) of 25 from the phase 2 OLE patisiran group had completed 12-month assessments. At 12 months, improvements in mNIS+7 with patisiran were sustained from parent study baseline with treatment in the global OLE (APOLLO-patisiran mean change -4·0, 95 % CI -7·7 to -0·3; phase 2 OLE patisiran -4·7, -11·9 to 2·4). Mean mNIS+7 score improved from global OLE enrolment in the APOLLO-placebo group (mean change from global OLE enrolment -1·4, 95% CI -6·2 to 3·5). Overall, 204 (97%) of 211 patients reported adverse events, 82 (39%) reported serious adverse events, and there were 23 (11%) deaths. Serious adverse events were more frequent in the APOLLO-placebo group (28 [57%] of 49) than in the APOLLO-patisiran (48 [35%] of 137) or phase 2 OLE patisiran (six [24%] of 25) groups. The most common treatment-related adverse event was mild or moderate infusion-related reactions. The frequency of deaths in the global OLE was higher in the APOLLO-placebo group (13 [27%] of 49), who had a higher disease burden than the APOLLO-patisiran (ten [7%] of 137) and phase 2 OLE patisiran (0 of 25) groups. INTERPRETATION In this interim 12-month analysis of the ongoing global OLE study, patisiran appeared to maintain efficacy with an acceptable safety profile in patients with hereditary transthyretin-mediated amyloidosis with polyneuropathy. Continued long-term follow-up will be important for the overall assessment of safety and efficacy with patisiran. FUNDING Alnylam Pharmaceuticals.
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Affiliation(s)
- David Adams
- Université Paris-Saclay, U1195, INSERM, Le Kremlin Bicêtre, France; Neurology Department, AP-HP, Centre Hospitalier Universitaire Bicêtre, Le Kremlin Bicêtre, France.
| | - Michael Polydefkis
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Jonas Wixner
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Arnt V Kristen
- Department of Cardiology, University of Heidelberg, Heidelberg, Germany
| | | | | | | | | | | | - Isabel M Conceição
- Centro Hospitalar Universitário Lisboa Norte, Hospital de Santa Maria and Faculdade de Medicina, Lisbon, Portugal
| | - Michel S Slama
- Cardiology Department, Centre de Compétence Amylose Cardiaque, Centre Hospitalier Universitaire Xavier Bichat Assistance Publique Hôpitaux de Paris, Université Paris-Saclay, Paris, France
| | - Julian D Gillmore
- National Amyloidosis Centre, University College London, Royal Free Hospital, London, UK
| | - Theodoros Kyriakides
- The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus; Medical School, University of Nicosia, Nicosia, Cyprus
| | - Senda Ajroud-Driss
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Márcia Waddington-Cruz
- Hospital Universitario Clementino Fraga Filho-Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Michelle M Mezei
- Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Violaine Planté-Bordeneuve
- Centre Hospitalier Universitaire, Henri Mondor-Assistance Publique Hopitaux de Paris, Univ Paris Est Creteil, INSERM, IMRB, Creteil, France
| | - Shahram Attarian
- Neuromuscular disorders and ALS Department, Centre Hospitalier Universitaire La Timone, Marseille, France
| | | | - Thomas H Brannagan
- Columbia University, College of Physicians and Surgeons, Neurology Department, New York, NY, USA
| | - Mitsuharu Ueda
- Kumamoto University Hospital, Department of Neurology, Kumamoto, Japan
| | | | | | | | - John Vest
- Alnylam Pharmaceuticals, Cambridge, MA, USA
| | - Erhan Berber
- Alnylam Pharmaceuticals, Cambridge, MA, USA; Myokardia, Brisbane, CA, USA
| | | | - Teresa Coelho
- Centro Hospitalar Universitário do Porto, Porto, Portugal
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10
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Jonker DL, Hazenberg BPC, Nienhuis HLA, Slart RHJA, Glaudemans AWJM, Noordzij W. Imaging cardiac innervation in hereditary transthyretin (ATTRm) amyloidosis: A marker for neuropathy or cardiomyopathy in case of heart failure? J Nucl Cardiol 2020; 27:1774-1784. [PMID: 30374850 PMCID: PMC7599160 DOI: 10.1007/s12350-018-01477-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 10/01/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Nuclear imaging modalities using 123Iodine-metaiodobenzylguanidine (123I-MIBG) and bone seeking tracers identify early cardiac involvement in ATTRm amyloidosis patients. However, little is known whether results from 123I-MIBG scintigraphy actually correlate to markers for either cardiac autonomic neuropathy or cardiomyopathy. METHODS All TTR mutation carriers and ATTRm patients who underwent both 123I-MIBG and 99mTechnetium-hydroxymethylene diphosphonate (99mTc-HDP) scintigraphy were included. Cardiomyopathy was defined as NT-proBNP > 365 ng/L, and cardiac autonomic neuropathy as abnormal cardiovascular reflexes at autonomic function tests. Late 123I-MIBG heart-to-mediastinum ratio (HMR) < 2.0 or wash-out > 20%, and any cardiac 99mTc-HDP uptake were considered as abnormal. RESULTS 39 patients (13 carriers and 26 ATTRm patients) were included in this study. Patients with cardiomyopathy, with or without cardiac autonomic neuropathy, had lower late HMR than similar patients without cardiomyopathy [median 1.1 (range 1.0-1.5) and 1.5(1.2-2.6) vs 2.4 (1.4-3.8) and 2.5 (1.5-3.7), respectively, P < 0.001]. Late HMR and wash-out (inversely) correlated with NT-proBNP r = - 0.652 (P < 0.001) and r = 0.756 (P < 0.001), respectively. Furthermore, late HMR and wash-out (inversely) correlated with cardiac 99mTc-HDP uptake r = - 0.663 (P < 0.001) and r = 0.617 (P < 0.001), respectively. CONCLUSION In case of heart failure, 123I-MIBG scintigraphy reflects cardiomyopathy rather than cardiac autonomic neuropathy in ATTRm patients and TTR mutation carriers. 123I-MIBG scintigraphy may already be abnormal before any cardiac bone tracer uptake is visible.
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Affiliation(s)
- Daphne L. Jonker
- Department of Nuclear Medicine and Molecular Imaging, Medical Imaging Center, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Bouke P. C. Hazenberg
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Hans L. A. Nienhuis
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Riemer H. J. A. Slart
- Department of Nuclear Medicine and Molecular Imaging, Medical Imaging Center, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Biomedical Photonic Imaging, University of Twente, Enschede, The Netherlands
| | - Andor W. J. M. Glaudemans
- Department of Nuclear Medicine and Molecular Imaging, Medical Imaging Center, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Walter Noordzij
- Department of Nuclear Medicine and Molecular Imaging, Medical Imaging Center, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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11
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Solomon SD, Adams D, Kristen A, Grogan M, González-Duarte A, Maurer MS, Merlini G, Damy T, Slama MS, Brannagan TH, Dispenzieri A, Berk JL, Shah AM, Garg P, Vaishnaw A, Karsten V, Chen J, Gollob J, Vest J, Suhr O. Effects of Patisiran, an RNA Interference Therapeutic, on Cardiac Parameters in Patients With Hereditary Transthyretin-Mediated Amyloidosis. Circulation 2019; 139:431-443. [PMID: 30586695 DOI: 10.1161/circulationaha.118.035831] [Citation(s) in RCA: 304] [Impact Index Per Article: 60.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Hereditary transthyretin-mediated (hATTR) amyloidosis is a rapidly progressive, multisystem disease that presents with cardiomyopathy or polyneuropathy. The APOLLO study assessed the efficacy and tolerability of patisiran in patients with hATTR amyloidosis. The effects of patisiran on cardiac structure and function in a prespecified subpopulation of patients with evidence of cardiac amyloid involvement at baseline were assessed. METHODS APOLLO was an international, randomized, double-blind, placebo-controlled phase 3 trial in patients with hATTR amyloidosis. Patients were randomized 2:1 to receive 0.3 mg/kg patisiran or placebo via intravenous infusion once every 3 weeks for 18 months. The prespecified cardiac subpopulation comprised patients with a baseline left ventricular wall thickness ≥13 mm and no history of hypertension or aortic valve disease. Prespecified exploratory cardiac end points included mean left ventricular wall thickness, global longitudinal strain, and N-terminal prohormone of brain natriuretic peptide. Cardiac parameters in the overall APOLLO patient population were also evaluated. A composite end point of cardiac hospitalizations and all-cause mortality was assessed in a post hoc analysis. RESULTS In the cardiac subpopulation (n=126; 56% of total population), patisiran reduced mean left ventricular wall thickness (least-squares mean difference ± SEM: -0.9±0.4 mm, P=0.017), interventricular septal wall thickness, posterior wall thickness, and relative wall thickness at month 18 compared with placebo. Patisiran also led to increased end-diastolic volume (8.3±3.9 mL, P=0.036), decreased global longitudinal strain (-1.4±0.6%, P=0.015), and increased cardiac output (0.38±0.19 L/min, P=0.044) compared with placebo at month 18. Patisiran lowered N-terminal prohormone of brain natriuretic peptide at 9 and 18 months (at 18 months, ratio of fold-change patisiran/placebo 0.45, P<0.001). A consistent effect on N-terminal prohormone of brain natriuretic peptide at 18 months was observed in the overall APOLLO patient population (n=225). Median follow-up duration was 18.7 months. The exposure-adjusted rates of cardiac hospitalizations and all-cause death were 18.7 and 10.1 per 100 patient-years in the placebo and patisiran groups, respectively (Andersen-Gill hazard ratio, 0.54; 95% CI, 0.28-1.01). CONCLUSIONS Patisiran decreased mean left ventricular wall thickness, global longitudinal strain, N-terminal prohormone of brain natriuretic peptide, and adverse cardiac outcomes compared with placebo at month 18, suggesting that patisiran may halt or reverse the progression of the cardiac manifestations of hATTR amyloidosis. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov . Unique identifier: NCT01960348.
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Affiliation(s)
- Scott D Solomon
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S.D.S., A.M.S.)
| | - David Adams
- Assistance Publique - Hôpitaux de Paris, National Reference Center for FAP, CHU Bicêtre, INSERM U1195, Université Paris Sud, Le Kremlin-Bicêtre, France (D.A.)
| | - Arnt Kristen
- Department of Cardiology, University of Heidelberg, Germany (A.K.)
| | | | | | - Mathew S Maurer
- Department of Medicine/Cardiology, Columbia University Medical Center, New York, NY (M.S.M.)
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Center, Foundation IRCCS Policlinico San Matteo and University of Pavia, Italy (G.M.)
| | - Thibaud Damy
- French Referral Center for Cardiac Amyloidosis, Amyloidosis Mondor Network, GRC Amyloid Research Institute, Department of Cardiology, Assistance Publique - Hôpitaux de Paris, CHU Henri Mondor, and INSERM U955, Clinical Investigation Center, and DHU ATVB, Creteil, France (T.D.)
| | - Michel S Slama
- Hôpital Bichat, Cardiology Department, Université Paris Sud, Paris, France (M.S.S.)
| | - Thomas H Brannagan
- Neurology Department, Columbia University, College of Physicians and Surgeons, New York, NY (T.H.B.)
| | | | - John L Berk
- Amyloidosis Center, Boston Medical Center, MA (J.L.B.)
| | - Amil M Shah
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S.D.S., A.M.S.)
| | - Pushkal Garg
- Alnylam Pharmaceuticals, Cambridge, MA (P.G., A.V., V.K., J.C., J.G., J.V.)
| | - Akshay Vaishnaw
- Alnylam Pharmaceuticals, Cambridge, MA (P.G., A.V., V.K., J.C., J.G., J.V.)
| | - Verena Karsten
- Alnylam Pharmaceuticals, Cambridge, MA (P.G., A.V., V.K., J.C., J.G., J.V.)
| | - Jihong Chen
- Alnylam Pharmaceuticals, Cambridge, MA (P.G., A.V., V.K., J.C., J.G., J.V.)
| | - Jared Gollob
- Alnylam Pharmaceuticals, Cambridge, MA (P.G., A.V., V.K., J.C., J.G., J.V.)
| | - John Vest
- Alnylam Pharmaceuticals, Cambridge, MA (P.G., A.V., V.K., J.C., J.G., J.V.)
| | - Ole Suhr
- Department of Public Health and Clinical Medicine, Umeå University, Sweden (O.S.)
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12
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Connolly MP, Panda S, Patris J, Hazenberg BPC. Estimating the fiscal impact of rare diseases using a public economic framework: a case study applied to hereditary transthyretin-mediated (hATTR) amyloidosis. Orphanet J Rare Dis 2019; 14:220. [PMID: 31533773 PMCID: PMC6751602 DOI: 10.1186/s13023-019-1199-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 09/05/2019] [Indexed: 12/27/2022] Open
Abstract
Background A wide range of rare diseases can have fiscal impacts on government finances that extend beyond expected healthcare costs. Conditions preventing people from achieving national lifetime work averages will influence lifetime taxes paid and increase the likelihood of dependence on public income support. Consequently, interventions that influence projected lifetime work activity, morbidity and mortality can have positive and negative fiscal consequences for government. The aim of this study was to apply a public economic framework to a rare disease that takes into consideration a broad range of costs that are relevant to government in relation to transfers received and taxes paid. As a case study we constructed a simulation model to calculate the fiscal life course of an individual with hereditary transthyretin-mediated (hATTR) amyloidosis in The Netherlands. In this lethal disease different progressive disease scenarios occur, including polyneuropathy and/or cardiomyopathy. Results Due to progressive disability, health care resource use, and early death, hATTR amyloidosis with polyneuropathy receives more transfers from government compared to the general population. In a scenario where a patient is diagnoses with hATTR at age 45, an individual pays €180,812 less in lifetime taxes and receives incrementally €111,695 in transfers from the government, compared to a person without hATTR. Patients suffering from cardiomyopathy die after median 4 years. The health costs of this scenario are therefore lower than that of the other polyneuropathy-based scenarios. Conclusions The fiscal analysis illustrates how health conditions influence not only health costs, but also the cross-sectorial public economic burden attributed to lost tax revenues and public disability allowances. Due to the progressive nature of hATTR amyloidosis used in this study, public costs including disability increase as the disease progresses with reduced lifetime taxes paid. The results indicate that halting disease progression early in the disease course would generate fiscal benefits beyond health benefits for patients. This analysis highlights the fiscal consequences of diseases and the need for broader perspectives applied to evaluate health conditions. Conventional cost-effectiveness framework used by many health technology assessment agencies have well-documented limitations in the field of rare diseases and fiscal modeling should be a complementary approach to consider.
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Affiliation(s)
- Mark P Connolly
- Global Market Access Solutions Sarl, St-Prex, Switzerland. .,Unit of Pharmacoepidemiology & Pharmacoeconomics, Department of Pharmacy, University of Groningen, Groningen, The Netherlands.
| | - Saswat Panda
- Global Market Access Solutions Sarl, St-Prex, Switzerland
| | - Julien Patris
- Alnylam Pharmaceuticals, Strawinskylaan 3051, 1077 ZX, Amsterdam, The Netherlands
| | - Bouke P C Hazenberg
- Department of Rheumatology & Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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13
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Brun S, Cariou E, Fournier P, Ribes D, Faguer S, Huart A, Carrié D, Galinier M, Lairez O. Value of natriuretic peptides and tissue Doppler imaging in the estimation of left ventricular filling pressure in patients with cardiac amyloidosis. Open Heart 2019; 6:e000980. [PMID: 31217996 PMCID: PMC6546193 DOI: 10.1136/openhrt-2018-000980] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 04/01/2019] [Accepted: 04/14/2019] [Indexed: 01/15/2023] Open
Abstract
Background Estimation of left ventricular filling pressures (LVFP) is a determining factor in the follow-up of patients with cardiac amyloidosis (CA). Natriuretic peptides (NPs) and tissue Doppler imaging may be used to monitor LVFP in patients with CA. The aim of this study was to evaluate the value of NPs and Doppler parameters in estimating LVFP in patients with CA. Methods Fifty patients with biopsy-verified light chain (n=31), A protein amyloidosis (AA) (n=1), apoliporotein A2 (n=1) or bone scintigraphy-proven transthyretin (n=17) CA were retrospectively included. All patients underwent right heart catheterisation (RHC). Among them, 48 (96%) and 43 (86%) had assays of NPs (20 brain natriuretic peptide (BNP), 27 N-terminal pro-hormone brain natriuretic peptide (NT-proBNP) and 1 both) and transthoracic echocardiography performed within 24 hours of RHC, respectively. Results The median BNP and NT-proBNP levels were 1000 (243–1477) ng/L and 10 106 (2935–13 348) ng/L, respectively. Echocardiography demonstrated left atrial enlargement with a mean volume of 47±16 mL and low tissue Doppler lateral Ea of 5±2 cm/s. The mean early diastolic mitral inflow velocity on early lateral mitral annular diastolic velocity ratio (E/Ea) ratio was 18±7, and the mean pulmonary capillary wedge pressure (PCWP) by RHC was 18±8 mm Hg. There was no correlation between BNP (r=0.260, p=0.774) or NT-proBNP (r=−0.103, p=0.984) levels and PCWP. There was a slight correlation between E/Ea ratio and PCWP (r=0.337, p=0.029). E/Ea ratio >14 performed poorly in differentiating elevated and low LVFP. Conclusion In patients with CA, NPs do not accurately estimate PCWP. Tissue Doppler-derived mitral E/Ea ratio is correlated with PCWP, but the slight correlation requires to estimate LVFP in a broad clinical and imaging context to avoid diagnostic errors.
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Affiliation(s)
- Stéphanie Brun
- Cardiology, University Hospital of Rangueil, Toulouse, France.,Cardiac Imaging Center, Toulouse University Hospital, Toulouse, France
| | - Eve Cariou
- Cardiology, University Hospital of Rangueil, Toulouse, France.,Cardiac Imaging Center, Toulouse University Hospital, Toulouse, France
| | - Pauline Fournier
- Cardiology, University Hospital of Rangueil, Toulouse, France.,Cardiac Imaging Center, Toulouse University Hospital, Toulouse, France
| | - David Ribes
- Department of Nephrology and Organ Transplantation, University Hospital of Rangueil, Toulouse, France.,Referral Center for Rare Diseases, Toulouse University Hospital, Toulouse, France
| | - Stanislas Faguer
- Department of Nephrology and Organ Transplantation, University Hospital of Rangueil, Toulouse, France.,Referral Center for Rare Diseases, Toulouse University Hospital, Toulouse, France.,Medical School, Universite Toulouse III Paul Sabatier, Toulouse, France
| | - Antoine Huart
- Department of Nephrology and Organ Transplantation, University Hospital of Rangueil, Toulouse, France.,Referral Center for Rare Diseases, Toulouse University Hospital, Toulouse, France
| | - Didier Carrié
- Cardiology, University Hospital of Rangueil, Toulouse, France.,Cardiac Imaging Center, Toulouse University Hospital, Toulouse, France.,Medical School, Universite Toulouse III Paul Sabatier, Toulouse, France
| | - Michel Galinier
- Cardiology, University Hospital of Rangueil, Toulouse, France.,Cardiac Imaging Center, Toulouse University Hospital, Toulouse, France.,Medical School, Universite Toulouse III Paul Sabatier, Toulouse, France
| | - Olivier Lairez
- Cardiology, University Hospital of Rangueil, Toulouse, France.,Cardiac Imaging Center, Toulouse University Hospital, Toulouse, France.,Medical School, Universite Toulouse III Paul Sabatier, Toulouse, France.,Nuclear Medicine, University Hospital of Rangueil, Toulouse, France
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14
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van den Berg MP, Mulder BA, Klaassen SHC, Maass AH, van Veldhuisen DJ, van der Meer P, Nienhuis HLA, Hazenberg BPC, Rienstra M. Heart failure with preserved ejection fraction, atrial fibrillation, and the role of senile amyloidosis. Eur Heart J 2019; 40:1287-1293. [PMID: 30753432 PMCID: PMC6553504 DOI: 10.1093/eurheartj/ehz057] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 12/21/2018] [Accepted: 01/22/2019] [Indexed: 12/15/2022] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) and atrial fibrillation (AF) are very common conditions, particularly in the elderly. However, the mechanisms underlying the two disorders, including their intricate interaction have not been fully resolved. Here, our aim is to review the evidence on the role of the two types of senile amyloidosis in this connection. Two types of senile amyloidosis can be identified: wild-type transthyretin (TTR)-derived amyloidosis (ATTRwt) and isolated atrial amyloidosis (IAA). ATTRwt is an underlying condition that is being increasingly recognized in patients with HFpEF and often accompanied by AF. IAA is an established cause of AF, adding to the mechanism problem. New diagnostic and therapeutic possibilities have emerged that may facilitate clinical management of (senile) amyloidosis, which in turn may have implications for the management of HFpEF and AF.
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Affiliation(s)
- Maarten P van den Berg
- Department of Cardiology, Thorax Centre, University of Groningen, University Medical Centre Groningen, 9700 RB Groningen, The Netherlands
| | - Bart A Mulder
- Department of Cardiology, Thorax Centre, University of Groningen, University Medical Centre Groningen, 9700 RB Groningen, The Netherlands
| | - Sebastiaan H C Klaassen
- Department of Cardiology, Thorax Centre, University of Groningen, University Medical Centre Groningen, 9700 RB Groningen, The Netherlands
| | - Alexander H Maass
- Department of Cardiology, Thorax Centre, University of Groningen, University Medical Centre Groningen, 9700 RB Groningen, The Netherlands
| | - Dirk J van Veldhuisen
- Department of Cardiology, Thorax Centre, University of Groningen, University Medical Centre Groningen, 9700 RB Groningen, The Netherlands
| | - Peter van der Meer
- Department of Cardiology, Thorax Centre, University of Groningen, University Medical Centre Groningen, 9700 RB Groningen, The Netherlands
| | - Hans L A Nienhuis
- Department of Internal Medicine, University of Groningen, University Medical Centre Groningen, 9700 RB Groningen, The Netherlands
| | - Bouke P C Hazenberg
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Centre Groningen, 9700 RB Groningen, The Netherlands
| | - Michiel Rienstra
- Department of Cardiology, Thorax Centre, University of Groningen, University Medical Centre Groningen, 9700 RB Groningen, The Netherlands
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15
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Finsterer J, Iglseder S, Wanschitz J, Topakian R, Löscher WN, Grisold W. Hereditary transthyretin-related amyloidosis. Acta Neurol Scand 2019; 139:92-105. [PMID: 30295933 DOI: 10.1111/ane.13035] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 07/09/2018] [Accepted: 09/04/2018] [Indexed: 12/15/2022]
Abstract
Hereditary transthyretin(TTR)-related amyloidosis (ATTRm amyloidosis) is an endemic/non-endemic, autosomal-dominant, early- and late-onset, rare, progressive disorder, predominantly manifesting as length-dependent, small fiber dominant, axonal polyneuropathy and frequently associated with cardiac disorders and other multisystem diseases. ATTRm amyloidosis is due to variants in the TTR gene, with the substitution Val30Met as the most frequent mutation. TTR mutations lead to destabilization and dissociation of TTR tetramers into variant TTR monomers, and formation of amyloid fibrils, which are consecutively deposited extracellularly in various tissues, such as nerves, heart, brain, eyes, intestines, kidneys, or the skin. Neuropathy may not only include large nerve fibers but also small fibers, and not only sensory and motor fibers but also autonomic fibers. Types of TTR variants, age at onset, penetrance, and clinical presentation vary between geographical areas. Suggestive of a ATTRm amyloidosis are a sensorimotor polyneuropathy, positive family history, autonomic dysfunction, cardiomyopathy, carpal tunnel syndrome, unexplained weight loss, and resistance to immunotherapy. If only sensory A-delta or C fibers are affected, small fiber neuropathy ensues. Diagnostic tests for small fiber neuropathy include determination of intraepidermal nerve fiber density, laser-evoked potentials, heat- and cold-detection thresholds, and measurement of the electrochemical skin conductance. Therapy currently relies on liver transplantation and TTR-stabilizers (tafamidis, diflunisal).
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Affiliation(s)
| | | | - Julia Wanschitz
- Department of Neurology; Medical University Innsbruck; Innsbruck Austria
| | - Raffi Topakian
- Department of Neurology; Klinikum Wels-Grieskirchen; Wels Austria
| | | | - Wolfgang Grisold
- Ludwig Boltzmann Institute for Experimental und Clinical Traumatology; Vienna Austria
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Wong CW, Ng WY, So KL, Chan YH, Yip SF, Mak CM. A rare variant of transthyretin-related amyloidosis associated with exclusive cardiomyopathy in a Hong Kong Chinese patient. J Cardiol Cases 2019; 18:185-188. [PMID: 30595768 DOI: 10.1016/j.jccase.2018.07.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 06/09/2018] [Accepted: 07/06/2018] [Indexed: 11/29/2022] Open
Abstract
Hereditary transthyretin-related amyloidosis (ATTR, MIM #105210), also previously known as familial amyloidotic polyneuropathy, is one of the most life-threatening types of amyloidosis. ATTR is inherited in autosomal dominant mode with variable penetrance. If untreated, it is a relentless and lethal disease. Patients typically present with polyneuropathy, carpal tunnel syndrome, autonomic insufficiency, cardiomyopathy, and gastrointestinal features, occasionally accompanied by vitreous opacities and renal insufficiency. Frequency of transthyretin (TTR)-related cardiac amyloidosis amongst Chinese populations is unknown. We report here a 63-year-old Chinese man suffering from TTR-related cardiac amyloidosis presented with exclusive cardiomyopathy. He had no other systemic involvement and no significant family history. Echocardiography revealed severe global myocardial impairment and left ventricular ejection fraction of 35%. Serum kappa-to-lambda ratio was normal. Genetic test detected a heterozygous TTR variant, NM_000371.3:c.425T > C p.(Val142Ala). To our knowledge, this is the first case of TTR-related cardiac amyloidosis caused by p.Val142Ala mutation reported in Asian patient. <Learning objective: This case highlights the importance to exclude transthyretin-related cardiac amyloidosis as a cause of extensive cardiomyopathy, despite the late disease onset and lack of systemic amyloidosis. High clinical suspicion and genetic testing is the key for early diagnosis.>.
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Affiliation(s)
- Chi Wing Wong
- Department of Medicine & Geriatric, Pok Oi Hospital, Hong Kong, China
| | - Wai Yan Ng
- Kowloon West Cluster Laboratory Genetic Service, Chemical Pathology Laboratory, Department of Pathology, Princess Margaret Hospital, Hong Kong, China
| | - Ka Li So
- Department of Pathology, Tuen Mun Hospital, Hong Kong, China
| | - Yu Ho Chan
- Department of Medicine & Geriatric, Pok Oi Hospital, Hong Kong, China
| | - Sze Fai Yip
- Department of Pathology, Tuen Mun Hospital, Hong Kong, China
| | - Chloe Miu Mak
- Kowloon West Cluster Laboratory Genetic Service, Chemical Pathology Laboratory, Department of Pathology, Princess Margaret Hospital, Hong Kong, China
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Hirakawa K, Takashio S, Marume K, Yamamoto M, Hanatani S, Yamamoto E, Sakamoto K, Izumiya Y, Kaikita K, Oda S, Utsunomiya D, Shiraishi S, Ueda M, Yamashita T, Yamashita Y, Ando Y, Tsujita K. Non-Val30Met mutation, septal hypertrophy, and cardiac denervation in patients with mutant transthyretin amyloidosis. ESC Heart Fail 2018; 6:122-130. [PMID: 30284755 PMCID: PMC6352919 DOI: 10.1002/ehf2.12361] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 08/30/2018] [Accepted: 09/02/2018] [Indexed: 11/20/2022] Open
Abstract
Aims Mutant transthyretin (ATTRm) amyloidosis is a systemic disease caused by the deposition of amyloid fibrils derived from mutated transthyretin. Although cardiac involvement impacts the prognosis of patients with ATTRm amyloidosis, the incidence of cardiac events, such as bradyarrhythmia, ventricular tachycardia, and heart failure, has not been fully elucidated. The aim of this study was to evaluate the prognosis and predictors of clinical outcomes, including cardiac events, in patients with ATTRm amyloidosis in Japan. Methods and results We evaluated 90 consecutive patients with ATTRm amyloidosis at Kumamoto University. ATTRm amyloidosis was diagnosed by the observation of both amyloid fibril deposition on tissue biopsy and a transthyretin mutation on sequential analysis. Sympathetic nerve activity was evaluated in 59 patients using 123‐iodine metaiodobenzylguanidine (123I‐MIBG) imaging. The endpoint was a composite of all‐cause death, hospitalization for heart failure, and implantation of a pacemaker, implantable cardioverter defibrillator, or cardiac resynchronization therapy defibrillator. Sixty‐seven patients had the Val30Met mutation (74%). The composite endpoint occurred in 23 patients (26%): all‐cause death (n = 6), hospitalization for worsening heart failure (n = 1), and implantation of an implantable cardioverter defibrillator (n = 6), cardiac resynchronization therapy defibrillator (n = 3), or pacemaker (n = 7). The 5‐year incident rate for clinical outcomes was 19%. In a multivariate Cox hazard analysis, age [hazard ratio (HR): 1.07, 95% confidence interval (95% CI): 1.01–1.12, P = 0.015], PQ interval (HR: 1.01, 95% CI: 1.00–1.02, P = 0.042), interventricular septum thickness in diastole (HR: 1.25, 95% CI: 1.09–1.42, P = 0.001), and non‐Val30Met mutation (HR: 4.31, 95% CI: 1.53–12.16, P = 0.006) were independent predictive factors of clinical outcomes. Kaplan–Meier analysis demonstrated a significantly higher probability of the composite endpoint in the non‐Val30Met group than in the Val30Met group (log‐rank test: P = 0.002) and in patients with left ventricular hypertrophy than in patients without left ventricular hypertrophy (log‐rank test: P < 0.001). In patients who underwent 123I‐MIBG imaging, a delayed heart‐to‐mediastinum (HM) ratio <1.6 was a significant predictive factor of the composite endpoint (HR: 4.98, 95% CI: 1.73–14.37, P = 0.003) in the univariate Cox hazard analyses. Kaplan–Meier curve analysis showed that a delayed HM ratio <1.6 was associated with a poor prognosis (log‐rank test: P = 0.001). Conclusions Non‐Val30Met mutation, septal hypertrophy, and a delayed HM ratio are useful predictors of clinical outcomes in patients with ATTRm amyloidosis in Japan. These results suggest that it is important to evaluate cardiac involvement in terms of morphological (left ventricular hypertrophy) and functional (cardiac denervation) perspectives using echocardiography and 123I‐MIBG imaging, respectively.
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Affiliation(s)
- Kyoko Hirakawa
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Seiji Takashio
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Kyohei Marume
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Masahiro Yamamoto
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Shinsuke Hanatani
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Eiichiro Yamamoto
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Kenji Sakamoto
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yasuhiro Izumiya
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Koichi Kaikita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Seitaro Oda
- Department of Diagnostic Radiology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Daisuke Utsunomiya
- Department of Diagnostic Radiology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Shinya Shiraishi
- Department of Diagnostic Radiology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Mitsuharu Ueda
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Taro Yamashita
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yasuyuki Yamashita
- Department of Diagnostic Radiology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yukio Ando
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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