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Patel RK, Bandera F, Venneri L, Porcari A, Razvi Y, Ioannou A, Chacko L, Martinez-Naharro A, Rauf MU, Knight D, Brown J, Petrie A, Wechalekar A, Whelan C, Lachmann H, Muthurangu V, Guazzi M, Hawkins PN, Gillmore JD, Fontana M. Cardiopulmonary Exercise Testing in Evaluating Transthyretin Amyloidosis. JAMA Cardiol 2024; 9:367-376. [PMID: 38446436 PMCID: PMC10918582 DOI: 10.1001/jamacardio.2024.0022] [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: 09/01/2023] [Accepted: 12/26/2023] [Indexed: 03/07/2024]
Abstract
Importance Cardiopulmonary exercise testing (CPET) has an established role in the assessment of patients with heart failure. However, data are lacking in patients with transthyretin (ATTR) amyloidosis. Objective To use CPET to characterize the spectrum of functional phenotypes in patients with ATTR amyloidosis and assess their association with the cardiac amyloid burden as well as the association between CPET parameters and prognosis. Design, Setting and Participants This single-center study evaluated patients diagnosed with ATTR amyloidosis from May 2019 to September 2022 who underwent CPET at the National Amyloidosis Centre. Of 1045 patients approached, 506 were included and completed the study. Patients were excluded if they had an absolute contraindication to CPET or declined participation. The mean (SD) follow-up period was 22.4 (11.6) months. Main Outcomes and Measures Comparison of CPET parameters across disease phenotypes (ATTR with cardiomyopathy [ATTR-CM], polyneuropathy, or both [ATTR-mixed]), differences in CPET parameters based on degree of amyloid infiltration (as measured by cardiovascular magnetic resonance [CMR] with extracellular volume mapping), and association between CPET parameters and prognosis. Results Among the 506 patients with ATTR amyloidosis included in this study, the mean (SD) age was 73.5 (10.2) years, and 457 participants (90.3%) were male. Impairment in functional capacity was highly prevalent. Functional impairment in ATTR-CM and ATTR-mixed phenotypes (peak mean [SD] oxygen consumption [VO2], 14.5 [4.3] mL/kg/min and 15.7 [6.2] mL/kg/min, respectively) was observed alongside impairment in the oxygen pulse, with ventilatory efficiency highest in ATTR-CM (mean [SD] ventilatory efficiency/volume of carbon dioxide expired slope, 38.1 [8.6]). Chronotropic incompetence and exercise oscillatory ventilation (EOV) were highly prevalent across all phenotypes, with both the prevalence and severity being higher than in heart failure from different etiologies. Worsening of amyloid burden on CMR was associated with decline in multiple CPET parameters, although chronotropic response and EOV remained abnormal irrespective of amyloid burden. On multivariable Cox regression analysis, peak VO2 and peak systolic blood pressure (SBP) were independently associated with prognosis (peak VO2: hazard ratio, 0.89 [95% CI, 0.81-0.99; P = .03]; peak SBP: hazard ratio, 0.98 [95% CI, 0.97-0.99; P < .001]). Conclusions and Relevance In this study, ATTR amyloidosis was characterized by distinct patterns of functional impairment between all disease phenotypes. A high prevalence of chronotropic incompetence, EOV, and ventilatory inefficiency were characteristic of this population. CPET parameters were associated with amyloid burden by CMR and with peak VO2, and SBP, which have been shown to be independent predictors of mortality. These findings suggest that CPET may be useful in characterizing distinct patterns of functional impairment across the spectrum of amyloid infiltration and predicting outcomes, and potentially offers a more comprehensive method of evaluating functional capacity for future prospective studies.
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Affiliation(s)
- Rishi K. Patel
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, London, United Kingdom
| | - Francesco Bandera
- Cardiac Rehabilitation and Heart Failure Unit, Cardiology University Department, Scientific Institute for Research, Hospitalization and Healthcare MultiMedica, Sesto San Giovanni, Milan, Italy
- Department of Biomedical Sciences for Health, University of Milano, Milan, Italy
| | - Lucia Venneri
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, London, United Kingdom
| | - Aldostefano Porcari
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, London, United Kingdom
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina, University of Trieste, Italy, Trieste, Italy
| | - Yousuf Razvi
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, London, United Kingdom
| | - Adam Ioannou
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, London, United Kingdom
| | - Liza Chacko
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, London, United Kingdom
| | - Ana Martinez-Naharro
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, London, United Kingdom
| | - Muhammad U. Rauf
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, London, United Kingdom
| | - Daniel Knight
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, London, United Kingdom
| | - James Brown
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, London, United Kingdom
| | - Aviva Petrie
- Eastman Dental Institute, University College London, University Street, London, United Kingdom
| | - Ashutosh Wechalekar
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, London, United Kingdom
| | - Carol Whelan
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, London, United Kingdom
| | - Helen Lachmann
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, London, United Kingdom
| | - Vivek Muthurangu
- Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Marco Guazzi
- Cardiac Rehabilitation and Heart Failure Unit, Cardiology University Department, Scientific Institute for Research, Hospitalization and Healthcare MultiMedica, Sesto San Giovanni, Milan, Italy
- Department of Biomedical Sciences for Health, University of Milano, Milan, Italy
| | - Philip N. Hawkins
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, London, United Kingdom
| | - Julian D. Gillmore
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, London, United Kingdom
| | - Marianna Fontana
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, London, United Kingdom
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Monfort A, Thevenet E, Lacavalerie MR, Banydeen R, Inamo J, Neviere R. Determinants of ventilatory inefficiency in transthyretin cardiac amyloidosis: The role of excessive ventilatory drive. Front Physiol 2022; 13:1002238. [DOI: 10.3389/fphys.2022.1002238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 10/11/2022] [Indexed: 11/13/2022] Open
Abstract
Background and objective: Along with impaired aerobic capacity, increased slope of the relationship between ventilation (VE) and pulmonary CO2 output (VCO2), i.e., VE-VCO2 slope is a common finding in patients with cardiac amyloidosis (CA), which suggests ventilatory inefficiency. Little is known about mechanisms leading to ventilatory inefficiency in CA patients. The purpose of this investigation was to examine the factors that underlie the abnormal ventilatory efficiency in transthyretin hereditary CA patients, such as excessive ventilatory drive, inability of pulmonary blood flow to increase adequately during exercise and excessive sympathetic stimulation, which are known mechanisms of VE-VCO2 slope increase.Methods: In this single-center retrospective observational study, consecutive patients (n = 41) with known familial transthyretin amyloidosis p.Val142Ile mutation carriers with confirmed cardiac phenotype were included.Results: Compared with CA patients without ventilatory inefficiency (VE-VCO2 slope < 36), patients with ventilatory inefficiency (VE-VCO2 slope ≥ 36) had increased inter-ventricular septum thickness, lower VO2 peak along with hyperventilation, and prolonged post-exercise heart rate recovery. By multivariate analysis, only excess of minute-ventilation at anaerobic threshold (β = 0.127; p = 0.011) remained an independent predictor of ventilatory inefficiency.Conclusion: Our data suggest that high ventilatory stimulation during exercise leading to hyperventilation is the main determinant of ventilatory inefficiency in hereditary transthyretin cardiac amyloidosis patients. This novel finding helps to better understand the mechanism of exercise intolerance in these patients where physiological limitation may be related to both heart dysfunction and abnormal pulmonary response.
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Cardiopulmonary Exercise Physiology in AL Amyloidosis Patients with Cardiac Involvement and Its Association with Cardiac Imaging Parameters. J Clin Med 2022; 11:jcm11185437. [PMID: 36143084 PMCID: PMC9505621 DOI: 10.3390/jcm11185437] [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: 09/02/2022] [Revised: 09/11/2022] [Accepted: 09/14/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Cardiopulmonary exercise testing (CPET) has been widely used for the functional evaluation of patients with heart failure. Patients with amyloidosis and cardiac involvement typically present with heart failure with preserved or mildly reduced ejection fraction. We sought to evaluate the use of CPET parameters in patients with AL amyloidosis for the assessment of disease severity and prognosis and their association with cardiac imaging findings. Methods: A single-center prospective analysis was conducted, which included 23 consecutive ambulatory patients with AL amyloidosis with cardiac involvement, not requiring hospitalization or intravenous diuretics. Patient evaluation included CPET, laboratory testing, echocardiography and cardiac MRI. The cohort was divided according to the presence of high-risk CPET characteristics (below median peak VO2 and above median VE/VCO2). Results: Patients with AL amyloidosis and cardiac involvement (median age was 60 years (56.5% males) had median peak relative VO2 (VO2/kg) of 17.8 mL/kg/min, VE/VCO2 slope of 39.4 and circulatory power of 2362.5 mmHg⋅mL/kg/min. Peak relative VO2 gradually declined across Mayo stages (p = 0.046) and exhibited a significant inverse correlation with NT-proBNP levels (r = −0.52, p = 0.01). Among imaging parameters, peak VO2 positively correlated with global work efficiency (r = 0.61, p < 0.001), and global work index (r = 0.45, p = 0.04). The group of patients with high-risk CPET findings showed evidence of more advanced disease, such as higher NT-proBNP levels (p = 0.007), increased septal and posterior left ventricular wall thickness (p = 0.043 and p = 0.033 respectively) and decreased global work efficiency (p = 0.027) without substantial differences in cardiac MRI parameters. In this group of patients, peak VO2 and VE/VCO2 were not associated significantly with overall survival and cardiac response at one year. Conclusion: In patients with AL amyloidosis, evaluation of exercise capacity with CPET identified a group of patients with more advanced cardiac involvement. The potential of CPET as a risk stratification tool in AL amyloidosis with cardiac involvement warrants further research.
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Banydeen R, Monfort A, Inamo J, Neviere R. Diagnostic and Prognostic Values of Cardiopulmonary Exercise Testing in Cardiac Amyloidosis. Front Cardiovasc Med 2022; 9:898033. [PMID: 35734274 PMCID: PMC9207317 DOI: 10.3389/fcvm.2022.898033] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 05/09/2022] [Indexed: 12/30/2022] Open
Abstract
Cardiac amyloidosis (CA) is a myocardial disease characterized by extracellular amyloid infiltration throughout the heart, resulting in increased myocardial stiffness, and restrictive heart wall chamber behavior. Its diagnosis among patients hospitalized for cardiovascular diseases is becoming increasingly frequent, suggesting improved disease awareness, and higher diagnostic capacities. One predominant functional manifestation of patients with CA is exercise intolerance, objectified by reduced peak oxygen uptake (VO2 peak), and assessed by metabolic cart during cardiopulmonary exercise testing (CPET). Hemodynamic adaptation to exercise in patients with CA is characterized by low myocardial contractile reserve and impaired myocardial efficiency. Rapid shallow breathing and hyperventilation, in the absence of ventilatory limitation, are also typically observed in response to exercise. Ventilatory inefficiency is further suggested by an increased VE-VCO2 slope, which has been attributed to excessive sympathoexcitation and a high physiological dead space (VD/VT) ratio during exercise. Growing evidence now suggests that, in addition to well-established biomarker risk models, a reduced VO2 peak is potentially a strong and independent predictive factor of adverse patient outcomes, both for monoclonal immunoglobulin light chain (AL) or transthyretin (ATTR) CA. Besides generating prognostic information, CPET can be used for the evaluation of the impact of therapeutic interventions in patients with CA.
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Affiliation(s)
- Rishika Banydeen
- Clinical Research Department, CHU Martinique (University Hospital of Martinique), Fort de France, France
- Cardiovascular Research Team EA7525, Université des Antilles (University of the French West Indies), Fort de France, France
| | - Astrid Monfort
- Cardiovascular Research Team EA7525, Université des Antilles (University of the French West Indies), Fort de France, France
- Cardiology Department, CHU Martinique (University Hospital of Martinique), Fort de France, France
| | - Jocelyn Inamo
- Cardiovascular Research Team EA7525, Université des Antilles (University of the French West Indies), Fort de France, France
- Cardiology Department, CHU Martinique (University Hospital of Martinique), Fort de France, France
| | - Remi Neviere
- Cardiovascular Research Team EA7525, Université des Antilles (University of the French West Indies), Fort de France, France
- Cardiopulmonary Physiology Unit, CHU Martinique (University Hospital of Martinique), Fort de France, France
- *Correspondence: Remi Neviere,
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