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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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Hendren NS, De Lemos JA, Berry JD, Kozlitina J, Saelices L, Ji AX, Shao Z, Liu CF, Garg S, Farr MA, Drazner MH, Tang WW, Grodin JL. Circulating transthyretin and retinol binding protein 4 levels among middle-age V122I TTR carriers in the general population. Amyloid 2024; 31:124-131. [PMID: 38445629 PMCID: PMC11127723 DOI: 10.1080/13506129.2024.2322479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 02/19/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND Hereditary transthyretin cardiac amyloidosis (ATTRv-CA) has a long latency phase before clinical onset, creating a need to identify subclinical disease. We hypothesized circulating transthyretin (TTR) and retinol binding protein 4 (RBP4) levels would be associated with TTR carrier status and correlated with possible evidence of subclinical ATTRv-CA. METHODS TTR and RBP4 were measured in blood samples from V122I TTR carriers and age-, sex- and race-matched non-carrier controls (1:2 matching) among Dallas Heart Study participants (phases 1 (DHS-1) and 2 (DHS-2)). Multivariable linear regression models determined factors associated with TTR and RBP4. RESULTS There were 40 V122I TTR carriers in DHS-1 and 54 V122I TTR carriers in DHS-2. In DHS-1 and DHS-2, TTR was lower in V122I TTR carriers (p < .001 for both), and RBP4 in DHS-2 was lower in V122I TTR carriers than non-carriers (p = .002). Among V122I TTR carriers, TTR was negatively correlated with markers of kidney function, and limb lead voltage (p < .05 for both) and TTR and RBP4 were correlated with atrial volume in DHS-2 (p < .05). CONCLUSIONS V122I TTR carrier status is independently associated with lower TTR and RBP4 in comparison with non-carriers. These findings support the hypothesis that TTR and RBP4 may correlate with evidence of subclinical ATTRv-CA.
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Affiliation(s)
- Nicholas S. Hendren
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
- Parkland Health System, Dallas, TX
| | - James A. De Lemos
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
- Parkland Health System, Dallas, TX
| | - Jarett D. Berry
- Department of Internal Medicine, University of Texas Tyler, Tyler, TX
| | - Julia Kozlitina
- Eugene McDermott Center for Human Growth and Development, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Lorena Saelices
- Center for Alzheimer’s and Neurodegenerative Diseases, Department of Biophysics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Alan X. Ji
- Eidos Therapeutics, a BridgeBio Company, Palo Alto, CA
| | - Zhili Shao
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland OH
| | - Chia-Feng Liu
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland OH
| | - Sonia Garg
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
- Parkland Health System, Dallas, TX
| | - Maryjane A. Farr
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
- Parkland Health System, Dallas, TX
| | - Mark H. Drazner
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
- Parkland Health System, Dallas, TX
| | - W.H. Wilson Tang
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland OH
| | - Justin L. Grodin
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
- Parkland Health System, Dallas, TX
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Dixon S, Kang X, Quan D. Practical Guidance for the Use of Patisiran in the Management of Polyneuropathy in Hereditary Transthyretin-Mediated Amyloidosis. Ther Clin Risk Manag 2023; 19:973-981. [PMID: 38047038 PMCID: PMC10691373 DOI: 10.2147/tcrm.s361706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 11/13/2023] [Indexed: 12/05/2023] Open
Abstract
Variant transthyretin amyloidosis (ATTRv) is an autosomal dominant inherited genetic disorder that affects 5000-10,000 people worldwide. It is caused by mutations in the transthyretin (TTR) gene and results in amyloid deposition in a variety of organs due to abnormal accumulation of TTR protein fibrils. Although this is a multisystem disorder, the heart and peripheral nerves are the preferentially affected organs. Over 150 TTR gene mutations have been associated with this disease and the clinical phenotype can vary significantly. Severe forms of the disorder can be fatal. Fortunately, the oligonucleotide-based therapy era has resulted in the development of several novel treatment options. Patisiran is a small interfering RNA (siRNA) encapsulated in a lipid nanoparticle that targets both mutant and wild-type TTR and results in significant reductions of the TTR protein in the serum and in tissue deposits. Patisiran has been approved for treatment of adults with polyneuropathy due to hereditary TTR-mediated amyloidosis in both the United States (US) and European Union (EU). In this review, we will discuss the development of patisiran, the clinical trials that lead to treatment approval, and provide guideline parameters for use in clinical practice. .
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Affiliation(s)
- Stacy Dixon
- Department of Neurology, University of Colorado, Aurora, CO, USA
| | - Xuan Kang
- Department of Neurology, University of Colorado, Aurora, CO, USA
| | - Dianna Quan
- Department of Neurology, University of Colorado, Aurora, CO, USA
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Abstract
Amyloidosis is a pathologic and clinical condition resulting from the accumulation of insoluble aggregates of misfolded proteins in tissues. Extracellular deposition of amyloid fibrils in the myocardium leads to cardiac amyloidosis, which is often overlooked as a cause of diastolic heart failure. Although cardiac amyloidosis was previously believed to have a poor prognosis, recent advances in diagnosis and treatment have emphasized the importance of early recognition and changed management of this condition. This article provides an overview of cardiac amyloidosis and summarizes current screening, diagnosis, evaluation, and treatment options.
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Affiliation(s)
- Michelle Weisfelner Bloom
- Division of Cardiology, Renaissance School of Medicine, State University of New York at Stony Brook, Stony Brook, New York (M.W.B.)
| | - Peter D Gorevic
- Division of Rheumatology, Renaissance School of Medicine, State University of New York at Stony Brook, Stony Brook, New York (P.D.G.)
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Shah S, Segar MW, Kondamudi N, Ayers C, Chandra A, Matulevicius S, Agusala K, Peshock R, Abbara S, Michos ED, Drazner MH, Lima JAC, Longstreth WT, Pandey A. Supranormal Left Ventricular Ejection Fraction, Stroke Volume, and Cardiovascular Risk: Findings From Population-Based Cohort Studies. JACC. HEART FAILURE 2022; 10:583-594. [PMID: 35902163 DOI: 10.1016/j.jchf.2022.05.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 04/18/2022] [Accepted: 05/04/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Supranormal ejection fraction by echocardiography in clinically referred patient populations has been associated with an increased risk of cardiovascular disease (CVD). The prognostic implication of supranormal left ventricular ejection fraction (LVEF)-assessed by cardiac magnetic resonance (CMR)-in healthy, community-dwelling individuals is unknown. OBJECTIVES The purpose of this study is to investigate the prognostic implication of supranormal LVEF as assessed by CMR and its inter-relationship with stroke volume among community-dwelling adults without CVD. METHODS Participants from the MESA (Multi-Ethnic Study of Atherosclerosis) and DHS (Dallas Heart Study) cohorts free of CVD who underwent CMR with LVEF above the normal CMR cutoff (≥57%) were included. The association between cohort-specific LVEF categories and risk of clinically adjudicated major adverse cardiovascular events (MACE) was assessed using adjusted Cox models. Subgroup analysis was also performed to evaluate the association of LVEF and risk of MACE among individuals stratified by left ventricular stroke volume index. RESULTS The study included 4,703 participants from MESA and 2,287 from DHS with 727 and 151 MACE events, respectively. In adjusted Cox models, the risk of MACE was highest among individuals in LVEF Q4 (vs Q1) in both cohorts after accounting for potential confounders (MESA: HR = 1.27 [95% CI: 1.01-1.60], P = 0.04; DHS: HR = 1.72 [95% CI: 1.05-2.79], P = 0.03). A significant interaction was found between the continuous measures of LVEF and left ventricular stroke volume index (P interaction = 0.02) such that higher LVEF was significantly associated with an increased risk of MACE among individuals with low but not high stroke volume. CONCLUSIONS Among community-dwelling adults without CVD, LVEF in the supranormal range is associated with a higher risk of adverse cardiovascular outcomes, particularly in those with lower stroke volume.
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Affiliation(s)
- Sonia Shah
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Matthew W Segar
- Department of Cardiology, Texas Heart Institute, Houston, Texas, USA
| | - Nitin Kondamudi
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Colby Ayers
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Alvin Chandra
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Susan Matulevicius
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Kartik Agusala
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Ron Peshock
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Suhny Abbara
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Erin D Michos
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Mark H Drazner
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Joao A C Lima
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - W T Longstreth
- Departments of Neurology and Epidemiology, University of Washington, Seattle, Washington, USA
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA.
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