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Ioannou A, Patel RK, Razvi Y, Porcari A, Sinagra G, Venneri L, Bandera F, Masi A, Williams GE, O’Beara S, Ganesananthan S, Massa P, Knight D, Martinez-Naharro A, Kotecha T, Chacko L, Brown J, Rauf MU, Manisty C, Moon J, Lachmann H, Wechelakar A, Petrie A, Whelan C, Hawkins PN, Gillmore JD, Fontana M. Impact of Earlier Diagnosis in Cardiac ATTR Amyloidosis Over the Course of 20 Years. Circulation 2022; 146:1657-1670. [PMID: 36325894 PMCID: PMC9698091 DOI: 10.1161/circulationaha.122.060852] [Citation(s) in RCA: 63] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Diagnostic and therapeutic advances have led to much greater awareness of transthyretin cardiac amyloidosis (ATTR-CA). We aimed to characterize changes in the clinical phenotype of patients diagnosed with ATTR-CA over the past 20 years. METHODS This is a retrospective observational cohort study of all patients referred to the National Amyloidosis Centre (2002-2021) in whom ATTR-CA was a differential diagnosis. RESULTS We identified 2995 patients referred with suspected ATTR-CA, of whom 1967 had a diagnosis of ATTR-CA confirmed. Analysis by 5-year periods revealed an incremental increase in referrals, with higher proportions of patients having been referred after bone scintigraphy and cardiac magnetic resonance imaging (2% versus 34% versus 51% versus 55%, chi-square P<0.001). This was accompanied by a greater number of ATTR-CA diagnoses, predominantly of the wild-type nonhereditary form, which is now the most commonly diagnosed form of ATTR-CA (0% versus 54% versus 67% versus 66%, chi-square P<0.001). Over time, the median duration of associated symptoms before diagnosis fell from 36 months between 2002 and 2006 to 12 months between 2017 and 2021 (Mann-Whitney P<0.001), and a greater proportion of patients had early-stage disease at diagnosis across the 5-year periods (National Amyloidosis Centre stage 1: 34% versus 42% versus 44% versus 53%, chi-square P<0.001). This was associated with more favorable echocardiographic parameters of structure and function, including lesser interventricular septal thickness (18.0±3.8 mm versus 17.2±2.6 mm versus 16.9±2.3 mm versus 16.6±2.4 mm, P=0.01) and higher left ventricular ejection fraction (46.0%±8.9% versus 46.8%±11.0% versus 47.8%±11.0% versus 49.5%±11.1%, P<0.001). Mortality decreased progressively during the study period (2007-2011 versus 2012-2016: hazard ratio, 1.57 [95% CI, 1.31-1.89], P<0.001; and 2012-2016 versus 2017-2021: hazard ratio, 1.89 [95% CI, 1.55-2.30], P<0.001). The proportion of patients enrolled into clinical trials and prescribed disease-modifying therapy increased over the 20-year period, but even when censoring at the trial or medication start date, year of diagnosis remained a significant predictor of mortality (2012-2016 versus 2017-2021: hazard ratio, 1.05 [95% CI, 1.03-1.07], P<0.001). CONCLUSIONS There has been a substantial increase in ATTR-CA diagnoses, with more patients being referred after local advanced cardiac imaging. Patients are now more often diagnosed at an earlier stage of the disease, with substantially lower mortality. These changes may have important implications for initiation and outcome of therapy and urgently need to be factored into clinical trial design.
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Affiliation(s)
- Adam Ioannou
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.)
| | - Rishi K. Patel
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.)
| | - Yousuf Razvi
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.)
| | - Aldostefano Porcari
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.).,Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina, University of Trieste, Italy (A. Porcari, G.S.)
| | - Gianfranco Sinagra
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina, University of Trieste, Italy (A. Porcari, G.S.)
| | - Lucia Venneri
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.)
| | - Francesco Bandera
- Cardiology University Department, IRCCS Policlinico San Donato, Milan, Italy (F.B.)
| | - Ambra Masi
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.)
| | - Georgina E. Williams
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.)
| | - Sophie O’Beara
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.)
| | - Sharmananthan Ganesananthan
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.)
| | - Paolo Massa
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.)
| | - Daniel Knight
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.)
| | - Ana Martinez-Naharro
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.)
| | - Tushar Kotecha
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.)
| | - Liza Chacko
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.)
| | - James Brown
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.)
| | - Muhammad U. Rauf
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.)
| | | | - James Moon
- St Bartholomew’s Hospital, London, United Kingdom (C.M., J.M.)
| | - Helen Lachmann
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.)
| | - Ashutosh Wechelakar
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.)
| | - Aviva Petrie
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.)
| | - Carol Whelan
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.)
| | - Philip N. Hawkins
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.)
| | - Julian D. Gillmore
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.)
| | - Marianna Fontana
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.)
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