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Holcman K, Ząbek A, Boczar K, Podolec P, Kostkiewicz M. Management of Arrhythmias and Conduction Disorders in Amyloid Cardiomyopathy. J Clin Med 2024; 13:3088. [PMID: 38892799 PMCID: PMC11172576 DOI: 10.3390/jcm13113088] [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: 04/26/2024] [Revised: 05/19/2024] [Accepted: 05/22/2024] [Indexed: 06/21/2024] Open
Abstract
Cardiac amyloidosis, a condition characterized by abnormal protein deposition in the heart, leads to restrictive cardiomyopathy and is notably associated with an increased risk of arrhythmias and conduction disorders. This article reviews the current understanding and management strategies for these cardiac complications, with a focus on recent advancements and clinical challenges. The prevalence and impact of atrial arrhythmias, particularly atrial fibrillation, are examined, along with considerations for stroke risk and anticoagulation therapy. The article also addresses the complexities of managing rate and rhythm control, outlining the utility and limitations of pharmacological agents and interventions such as catheter ablation. Furthermore, it reviews the challenges in the treatment of ventricular arrhythmias, including the contentious use of implantable cardioverter-defibrillators for primary and secondary prevention. Individualized approaches, considering the unique characteristics of cardiac amyloidosis, are paramount. Continuous research and clinical exploration are essential to refine treatment strategies and improve outcomes in this challenging patient population.
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Affiliation(s)
- Katarzyna Holcman
- Department of Nuclear Medicine, John Paul II Hospital, 31-202 Krakow, Poland;
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital, 31-202 Krakow, Poland;
| | - Andrzej Ząbek
- Department of Electrocardiology, Jagiellonian University Medical College, John Paul II Hospital, 31-202 Krakow, Poland; (A.Z.); (K.B.)
| | - Krzysztof Boczar
- Department of Electrocardiology, Jagiellonian University Medical College, John Paul II Hospital, 31-202 Krakow, Poland; (A.Z.); (K.B.)
| | - Piotr Podolec
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital, 31-202 Krakow, Poland;
| | - Magdalena Kostkiewicz
- Department of Nuclear Medicine, John Paul II Hospital, 31-202 Krakow, Poland;
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital, 31-202 Krakow, Poland;
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2
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Assaf A, Mekhael M, Noujaim C, Chouman N, Younes H, Kreidieh O, Marrouche N, Donnellan E. Conduction system disease in cardiac amyloidosis. Trends Cardiovasc Med 2024; 34:250-253. [PMID: 36804858 DOI: 10.1016/j.tcm.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 02/06/2023] [Accepted: 02/07/2023] [Indexed: 02/18/2023]
Abstract
Cardiac amyloidosis (CA) has diverse and deleterious effects on the conductive system. Atrial fibrillation is by far the most common electrophysiological manifestation of CA and is associated with more mortality, morbidity, and hospitalizations. While AF increases the risk of thrombosis regardless of the CHA2DS2-VASc score, the risk of thromboembolism seems to be high even in CA patients without AF. AV Nodal disease is prevalent and may precede the diagnosis of CA. The incidence of ventricular arrhythmias remains disputed, and the role of implantable cardioverter defibrillator devices in CA patients is controversial. Newer therapies targeted against specific types of CA have been developed, but their effects on conductive system disease are not well studied.
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Affiliation(s)
- Ala' Assaf
- Tulane Research Innovation for Arrhythmia Discovery (TRIAD), Tulane University School of Medicine, New Orleans, LA, USA
| | - Mario Mekhael
- Tulane Research Innovation for Arrhythmia Discovery (TRIAD), Tulane University School of Medicine, New Orleans, LA, USA
| | - Charbel Noujaim
- Tulane Research Innovation for Arrhythmia Discovery (TRIAD), Tulane University School of Medicine, New Orleans, LA, USA
| | - Nour Chouman
- Tulane Research Innovation for Arrhythmia Discovery (TRIAD), Tulane University School of Medicine, New Orleans, LA, USA
| | - Hadi Younes
- Tulane Research Innovation for Arrhythmia Discovery (TRIAD), Tulane University School of Medicine, New Orleans, LA, USA
| | - Omar Kreidieh
- Tulane Research Innovation for Arrhythmia Discovery (TRIAD), Tulane University School of Medicine, New Orleans, LA, USA
| | - Nassir Marrouche
- Tulane Research Innovation for Arrhythmia Discovery (TRIAD), Tulane University School of Medicine, New Orleans, LA, USA
| | - Eoin Donnellan
- Tulane Research Innovation for Arrhythmia Discovery (TRIAD), Tulane University School of Medicine, New Orleans, LA, USA.
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3
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Tan L, Byard RW. Cardiac amyloid deposition and the forensic autopsy - A review and analysis. J Forensic Leg Med 2024; 103:102663. [PMID: 38447343 DOI: 10.1016/j.jflm.2024.102663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 02/27/2024] [Accepted: 02/29/2024] [Indexed: 03/08/2024]
Abstract
Although amyloid material in the heart is not infrequently encountered at autopsy it may on occasion be difficult to determine the significance in terms of possible contributions to the terminal mechanisms of death. A review was undertaken of the literature and of autopsy cases at Forensic Science SA over a 20-year-period (2003-2022) for all cases where significant amyloid material had been encountered on microscopy of the heart. Sixteen cases were found consisting of 11 cases where cardiac amyloid was involved in the lethal episode, and five where it was considered an incidental feature. Of the 11 lethal cases, there were three where cardiac amyloidosis was the cause of death, and eight where it was a contributing factor, along with ischaemic heart disease (N = 7) and bronchopneumonia (N = 1). The age range was 47-92 years, average 78.6 years, with a male to female ratio of 10:1. The weights of the hearts ranged from 496 to 1059 g - average 648 g. Of the five cases where it was considered an incidental finding, the causes of death were blunt head trauma (N = 2), small intestinal ischaemia (N = 2) and small intestinal obstruction (N = 1). The weights of the hearts ranged from 299 to 487 g, average 369 g. The most relevant types of amyloidosis in forensic cases tend to be light chain amyloidosis, senile cardiac amyloidosis and familial amyloid cardiomyopathy. Other forms of amyloidosis that affect the heart, which include reactive amyloidosis, haemodialysis-related amyloidosis and isolated atrial amyloidosis, either have minimal or no clinical significance, or are of uncertain significance. While it may be difficult to determine the prognostic significance of amyloid material at autopsy clinicopathological correlation may provide useful supportive information.
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Affiliation(s)
- Luzern Tan
- Adelaide Medical School, The University of Adelaide, Frome Road, Australia
| | - Roger W Byard
- Adelaide Medical School, The University of Adelaide, Frome Road, Australia; Forensic Science South Australia, 21 Divett Place, Adelaide, South Australia, 5005, Australia.
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4
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Block M, Klein HU. [History of the implantable cardioverter-defibrillator in Germany]. Herzschrittmacherther Elektrophysiol 2024; 35:55-67. [PMID: 38421401 PMCID: PMC10923992 DOI: 10.1007/s00399-024-01001-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2024] [Indexed: 03/02/2024]
Abstract
The implantable cardioverter-defibrillator (ICD) was a breakthrough in the prevention of sudden cardiac death. After years of technical development in the USA, Michel Mirowski succeeded in proving reliable automatic defibrillation of ventricular tachyarrhythmias through initial human implantations in 1980, despite many obstacles. Nearly 4 years later, the first patients received ICDs at multiple centers in Germany. Subsequently, outside the USA, Germany became the country with highest implantation rates. The absolute number of implantations remained small as long as implantations required epicardial defibrillation electrodes and therefore thoracotomy by cardiac surgeons. Pacemaker-like implantation using a transvenous defibrillation electrode with a pectoral ICD became feasible in the early 1990s pushing implantation rates to the next level. Technical advancements were accompanied by clinical research in Germany, and often, the first-in-human studies were conducted in Germany. In 1991, the first guidelines for indications were established in the USA and Germany. Several randomized studies on indications were published between 1996 and 2009, mostly led by American teams with German participation, but also under German leadership (CASH, CAT, DINAMIT, IRIS). The DANISH study in 2016 questioned the results of these long-standing studies. Instead of providing ICDs to patients using a broad indication, future efforts aim to identify patients who, despite optimal medical therapy, cardiac resynchronization therapy (CRT), and/or catheter ablation, need protection against sudden cardiac death. Risk scores incorporating myocardial scars in magnetic resonance imaging (MRI) and genetic information are expected to contribute to more individualized and effective indications.
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Bukhari S, Khan SZ, Ghoweba M, Khan B, Bashir Z. Arrhythmias and Device Therapies in Cardiac Amyloidosis. J Clin Med 2024; 13:1300. [PMID: 38592132 PMCID: PMC10932014 DOI: 10.3390/jcm13051300] [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: 01/13/2024] [Revised: 02/20/2024] [Accepted: 02/22/2024] [Indexed: 04/10/2024] Open
Abstract
Cardiac amyloidosis is caused by amyloid fibrils that deposit in the myocardial interstitium, causing restrictive cardiomyopathy and eventually death. The electromechanical, inflammatory, and autonomic changes due to amyloid deposition result in arrhythmias. Atrial fibrillation is by far the most common arrhythmia. The rate control strategy is generally poorly tolerated due to restrictive filling physiology and heart rate dependance, favoring adoption of the rhythm control strategy. Anticoagulation for stroke prophylaxis is warranted, irrespective of CHA2DS2-VASc score in patients with a favorable bleeding profile; data on left appendage closure devices are still insufficient. Ventricular arrhythmias are also not uncommon, and the role of implantable cardioverter-defibrillator in cardiac amyloidosis is controversial. There is no evidence of improvement in outcomes when used for primary prevention in these patients. Bradyarrhythmia is most commonly associated with sudden cardiac death in cardiac amyloidosis. Pacemaker implantation can help provide symptomatic relief but does not confer mortality benefit.
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Affiliation(s)
- Syed Bukhari
- Department of Cardiovascular Medicine, Section of Vascular Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, USA; (S.Z.K.); (M.G.)
| | - Syed Zamrak Khan
- Department of Cardiovascular Medicine, Section of Vascular Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, USA; (S.Z.K.); (M.G.)
| | - Mohamed Ghoweba
- Department of Cardiovascular Medicine, Section of Vascular Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, USA; (S.Z.K.); (M.G.)
| | - Bilal Khan
- Department of Hospital Medicine, Temple University-Jeanes Campus, Philadelphia, PA 19111, USA;
| | - Zubair Bashir
- Department of Hospital Medicine, Alpert Medical School of Brown University, Providence, RI 02903, USA;
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Acharya I, Liang JJ, Haas CJ. Coronary artery bypass grafting for triple vessel disease in cardiac amyloidosis. BMJ Case Rep 2023; 16:e254668. [PMID: 37699742 PMCID: PMC10503383 DOI: 10.1136/bcr-2023-254668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023] Open
Abstract
Cardiac amyloidosis is a rare condition with an estimated incidence of 18-55 per 100 000 person-years. It is associated with either immunoglobulin light chain (AL) or transthyretin amyloid (ATTR), both of which result in a restrictive cardiomyopathy complicated initially by diastolic dysfunction and subsequently followed by biventricular systolic heart failure. Untreated cardiac amyloidosis carries an extremely poor prognosis with an estimated median survival time of less than 1 year in AL and 4 years in ATTR amyloidosis. This is the sixth described report of coronary artery bypass grafting in patients with underlying cardiac amyloidosis.
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Affiliation(s)
- Indira Acharya
- Department of Internal Medicine, MedStar Union Memorial Hospital, Baltimore, Maryland, USA
| | - John J Liang
- Pathology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Christopher J Haas
- Internal Medicine, MedStar Harbor Hospital, Baltimore, Maryland, USA
- Department of Internal Medicine, MedStar Franklin Square Medical Center, Baltimore, Maryland, USA
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Briasoulis A, Kourek C, Papamichail A, Loritis K, Bampatsias D, Repasos E, Xanthopoulos A, Tsougos E, Paraskevaidis I. Arrhythmias in Patients with Cardiac Amyloidosis: A Comprehensive Review on Clinical Management and Devices. J Cardiovasc Dev Dis 2023; 10:337. [PMID: 37623350 PMCID: PMC10455774 DOI: 10.3390/jcdd10080337] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/01/2023] [Accepted: 08/03/2023] [Indexed: 08/26/2023] Open
Abstract
Cardiac amyloidosis (CA) is a rare but potentially life-threatening disease in which misfolded proteins accumulate in the cardiac wall tissue. Heart rhythm disorders in CA, including supraventricular arrhythmias, conduction system disturbances, or ventricular arrhythmias, play a major role in CA morbidity and mortality, and thus require supplementary management. Among them, AF is the most frequent arrhythmia during CA hospitalizations and is associated with significantly higher mortality, while ventricular arrhythmias are also common and are usually associated with poor prognosis. Early diagnosis of potential arrythmias could be performed through ECG, Holter monitoring, and/or electrophysiology study. Clinical management of these patients is quite significant, and it usually includes initiation of amiodarone and/or digoxin in patients with AF, potential electrical cardioversion, or ablation in specific patients with indication, as well as initiation of anticoagulants in all patients, independent of AF and CHADS-VASc score, for potential intracardiac thrombus. Moreover, identification of patients with conduction disorders that could benefit from prophylactic pacemaker implantation and/or CRT as well as identification of patients with life-threatening ventricular arrythmias that could benefit from ICD could both increase the survival rates of these patients and improve their quality of life.
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Affiliation(s)
- Alexandros Briasoulis
- Medical School of Athens, National and Kapodistrian University of Athens, 15772 Athens, Greece; (C.K.); (A.P.); (K.L.); (D.B.); (E.R.); (I.P.)
| | - Christos Kourek
- Medical School of Athens, National and Kapodistrian University of Athens, 15772 Athens, Greece; (C.K.); (A.P.); (K.L.); (D.B.); (E.R.); (I.P.)
| | - Adamantia Papamichail
- Medical School of Athens, National and Kapodistrian University of Athens, 15772 Athens, Greece; (C.K.); (A.P.); (K.L.); (D.B.); (E.R.); (I.P.)
| | - Konstantinos Loritis
- Medical School of Athens, National and Kapodistrian University of Athens, 15772 Athens, Greece; (C.K.); (A.P.); (K.L.); (D.B.); (E.R.); (I.P.)
| | - Dimitrios Bampatsias
- Medical School of Athens, National and Kapodistrian University of Athens, 15772 Athens, Greece; (C.K.); (A.P.); (K.L.); (D.B.); (E.R.); (I.P.)
| | - Evangelos Repasos
- Medical School of Athens, National and Kapodistrian University of Athens, 15772 Athens, Greece; (C.K.); (A.P.); (K.L.); (D.B.); (E.R.); (I.P.)
| | - Andrew Xanthopoulos
- Department of Cardiology, University Hospital of Larissa, 41110 Larissa, Greece;
| | - Elias Tsougos
- Department of Cardiology, Hygeia Hospital, 15123 Athens, Greece;
| | - Ioannis Paraskevaidis
- Medical School of Athens, National and Kapodistrian University of Athens, 15772 Athens, Greece; (C.K.); (A.P.); (K.L.); (D.B.); (E.R.); (I.P.)
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8
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Miyamoto M, Nakamura K, Nakagawa K, Nishii N, Kawada S, Ueoka A, Asada S, Watanabe A, Morita H, Ito H. Prevalence and Treatment of Arrhythmias in Patients With Transthyretin and Light-Chain Cardiac Amyloidosis. Circ Rep 2023; 5:298-305. [PMID: 37431518 PMCID: PMC10329899 DOI: 10.1253/circrep.cr-23-0022] [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: 03/02/2023] [Revised: 05/22/2023] [Accepted: 05/29/2023] [Indexed: 07/12/2023] Open
Abstract
Background: Various types of arrhythmia are observed in patients with cardiac amyloidosis, but the prevalence of arrhythmia has not been fully investigated. This study investigated the prevalence and treatment of arrhythmias in patients with cardiac amyloidosis before the introduction of new agents for amyloidosis, such as tafamidis. Methods and Results: Of 53 patients who were histologically diagnosed with cardiac amyloidosis at 10 centers in western Japan between 2009 and 2021, 43 who were diagnosed on the basis of immunohistochemical staining were evaluated in this study. Of these 43 patients, 13 had immunoglobulin light-chain (AL) amyloidosis and 30 had transthyretin (ATTR) amyloidosis; further, 27 had atrial tachyarrhythmia, 13 had ventricular tachyarrhythmia, and 17 had bradyarrhythmia. Atrial fibrillation (AF) was the most common arrhythmia in patients with cardiac amyloidosis (n=24; 55.8%), especially among those with ATTR amyloidosis (70.0% of ATTR vs. 23.1% of AL). Eleven (25.6%) patients were treated with a cardiac implantable device. All 3 patients with pacemakers were alive at the last follow-up (median 76.7 months; interquartile range [IQR] 4.8-146.4 months). Of the 8 patients who underwent AF ablation, there was no recurrence in 6 (75%) after a median of 39.3 months (IQR 19.8-59.3 months). Conclusions: The prevalence of various arrhythmias was high in patients with cardiac amyloidosis. AF occurred most frequently in patients with cardiac amyloidosis, especially among patients with ATTR.
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Affiliation(s)
- Masakazu Miyamoto
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Okayama Japan
| | - Kazufumi Nakamura
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Okayama Japan
| | - Koji Nakagawa
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Okayama Japan
| | - Nobuhiro Nishii
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Okayama Japan
- Department of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Okayama Japan
| | - Satoshi Kawada
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Okayama Japan
| | - Akira Ueoka
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Okayama Japan
| | - Saori Asada
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Okayama Japan
| | - Atsuyuki Watanabe
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Okayama Japan
- Department of Cardiology, National Hospital Organization Okayama Medical Center Okayama Japan
| | - Hiroshi Morita
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Okayama Japan
- Department of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Okayama Japan
| | - Hiroshi Ito
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Okayama Japan
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Tomasoni D, Bonfioli GB, Aimo A, Adamo M, Canepa M, Inciardi RM, Lombardi CM, Nardi M, Pagnesi M, Riccardi M, Vergaro G, Vizzardi E, Emdin M, Metra M. Treating amyloid transthyretin cardiomyopathy: lessons learned from clinical trials. Front Cardiovasc Med 2023; 10:1154594. [PMID: 37288260 PMCID: PMC10242061 DOI: 10.3389/fcvm.2023.1154594] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 05/05/2023] [Indexed: 06/09/2023] Open
Abstract
An increasing awareness of the disease, new diagnostic tools and novel therapeutic opportunities have dramatically changed the management of patients with amyloid transthyretin cardiomyopathy (ATTR-CM). Supportive therapies have shown limited benefits, mostly related to diuretics for the relief from signs and symptoms of congestion in patients presenting heart failure (HF). On the other hand, huge advances in specific (disease-modifying) treatments occurred in the last years. Therapies targeting the amyloidogenic cascade include several pharmacological agents that inhibit hepatic synthesis of TTR, stabilize the tetramer, or disrupt fibrils. Tafamidis, a TTR stabilizer that demonstrated to prolong survival and improve quality of life in the ATTR-ACT trial, is currently the only approved drug for patients with ATTR-CM. The small interfering RNA (siRNA) patisiran and the antisense oligonucleotide (ASO) inotersen have been approved for the treatment of patients with hereditary ATTR polyneuropathy regardless of the presence of cardiac involvement, with patisiran also showing preliminary benefits on the cardiac phenotype. Ongoing phase III clinical trials are investigating another siRNA, vutrisiran, and a novel ASO formulation, eplontersen, in patients with ATTR-CM. CRISPR-Cas9 represents a promising strategy of genome editing to obtain a highly effective blockade of TTR gene expression.
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Affiliation(s)
- Daniela Tomasoni
- Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, Public Health, University of Brescia, Brescia, Italy
| | - Giovanni Battista Bonfioli
- Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, Public Health, University of Brescia, Brescia, Italy
| | - Alberto Aimo
- Health Science Interdisciplinary Center, Scuola Superiore Sant’Anna, Pisa, Italy
- Cardiology and Cardiovascular Medicine Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Marianna Adamo
- Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, Public Health, University of Brescia, Brescia, Italy
| | - Marco Canepa
- Cardiology Unit, IRCCS OSpedale Policlinico San Martino, Genova, Italy
- Department of Internal Medicine, University of Genova, Genoa, Italy
| | - Riccardo M. Inciardi
- Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, Public Health, University of Brescia, Brescia, Italy
| | - Carlo Mario Lombardi
- Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, Public Health, University of Brescia, Brescia, Italy
| | - Matilde Nardi
- Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, Public Health, University of Brescia, Brescia, Italy
| | - Matteo Pagnesi
- Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, Public Health, University of Brescia, Brescia, Italy
| | - Mauro Riccardi
- Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, Public Health, University of Brescia, Brescia, Italy
| | - Giuseppe Vergaro
- Health Science Interdisciplinary Center, Scuola Superiore Sant’Anna, Pisa, Italy
- Cardiology and Cardiovascular Medicine Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Enrico Vizzardi
- Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, Public Health, University of Brescia, Brescia, Italy
| | - Michele Emdin
- Health Science Interdisciplinary Center, Scuola Superiore Sant’Anna, Pisa, Italy
- Cardiology and Cardiovascular Medicine Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Marco Metra
- Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, Public Health, University of Brescia, Brescia, Italy
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10
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Laptseva N, Rossi VA, Sudano I, Schwotzer R, Ruschitzka F, Flammer AJ, Duru F. Arrhythmic Manifestations of Cardiac Amyloidosis: Challenges in Risk Stratification and Clinical Management. J Clin Med 2023; 12:jcm12072581. [PMID: 37048664 PMCID: PMC10095126 DOI: 10.3390/jcm12072581] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/23/2023] [Accepted: 03/27/2023] [Indexed: 03/31/2023] Open
Abstract
Amylodiosis is a systemic disease characterized by extracellular deposits of insoluble amyloid in various tissues and organs. Cardiac amyloidosis is a frequent feature of the disease, causing a progressive, restrictive type of cardiomyopathy, and is associated with adverse clinical outcomes and increased mortality. The typical clinical presentation in patients with cardiac amyloidosis is heart failure (HF) with preserved ejection fraction. Most patients present with typical symptoms and signs of HF, such as exertional dyspnea, pretibial edema, pleural effusions and angina pectoris due to microcirculatory dysfunction. However, patients may also frequently encounter various arrhythmias, such as atrioventricular nodal block, atrial fibrillation and ventricular tachyarrhythmias. The management of arrhythmias in cardiac amyloidosis patients with drugs and devices is often a clinical challenge. Moreover, predictors of life-threatening arrhythmic events are not well defined. This review intends to give a deepened insight into the arrhythmic features of cardiac amyloidosis by discussing the pathogenesis of these arrhythmias, addressing the challenges in risk stratification and strategies for management in these patients.
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11
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Bukhari S, Khan B. Prevalence of ventricular arrhythmias and role of implantable cardioverter-defibrillator in cardiac amyloidosis. J Cardiol 2023; 81:429-433. [PMID: 36894119 DOI: 10.1016/j.jjcc.2023.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 02/27/2023] [Accepted: 02/28/2023] [Indexed: 03/09/2023]
Abstract
Cardiac amyloidosis is an underdiagnosed disease that is caused by myocardial deposition of misfolded light chain (AL) or transthyretin (ATTR) amyloid fibrils, leading to restrictive cardiomyopathy and eventually death if untreated. Ventricular arrhythmias are common in cardiac amyloidosis, and the prevalence is higher in AL than ATTR. There are multiple suspected pathogenic mechanisms for ventricular arrhythmia including activation of inflammatory cascade from direct amyloid deposition, and electro-mechanical as well as autonomic dysfunction due to systemic amyloid deposition. Cardiac amyloidosis is associated with an increased risk of sudden cardiac death, and the risk is higher in AL than ATTR. Finally, the role of implantable cardioverter-defibrillators in cardiac amyloidosis is controversial, and while successful termination of life-threatening ventricular arrhythmias has been reported in few studies, there has been no evidence of improvement in outcomes when used for primary prevention in patients with cardiac amyloidosis.
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Affiliation(s)
- Syed Bukhari
- Department of Medicine, Temple University Hospital-Jeanes Campus, Philadelphia, PA, USA.
| | - Bilal Khan
- Department of Medicine, Temple University Hospital-Jeanes Campus, Philadelphia, PA, USA
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12
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Zanwar S, Gertz MA, Muchtar E. Immunoglobulin Light Chain Amyloidosis: Diagnosis and Risk Assessment. J Natl Compr Canc Netw 2023; 21:83-90. [PMID: 36630897 PMCID: PMC10164359 DOI: 10.6004/jnccn.2022.7077] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 09/22/2022] [Indexed: 01/13/2023]
Abstract
Immunoglobulin light chain (AL) amyloidosis is a clonal plasma cell disorder with multiple clinical presentations. The diagnosis of AL amyloidosis requires a high index of suspicion, making a delay in diagnosis common, which contributes to the high early mortality seen in this disease. Establishing the diagnosis of AL amyloidosis requires the demonstration of tissue deposition of amyloid fibrils. A bone marrow biopsy and fat pad aspirate performed concurrently have a high sensitivity for the diagnosis of AL amyloidosis and negate the need for organ biopsies in most patients. An accurate diagnosis requires amyloid typing via additional testing, including tissue mass spectrometry. Prognostication for AL amyloidosis is largely driven by the organs impacted. Cardiac involvement represents the single most important prognostic marker, and the existing staging systems are driven by cardiac biomarkers. Apart from organ involvement, plasma cell percentage on the bone marrow biopsy, specific fluorescence in situ hybridization findings, age at diagnosis, and performance status are important prognostic markers. This review elaborates on the diagnostic testing and prognostication for patients with newly diagnosed AL amyloidosis.
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Affiliation(s)
- Saurabh Zanwar
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | - Morie A Gertz
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | - Eli Muchtar
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
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13
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Argirò A, Del Franco A, Mazzoni C, Allinovi M, Tomberli A, Tarquini R, Di Mario C, Perfetto F, Cappelli F, Zampieri M. Arrhythmic Burden in Cardiac Amyloidosis: What We Know and What We Do Not. Biomedicines 2022; 10:2888. [PMID: 36359408 PMCID: PMC9687719 DOI: 10.3390/biomedicines10112888] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 10/31/2022] [Accepted: 11/08/2022] [Indexed: 08/26/2023] Open
Abstract
Cardiac amyloidosis (CA), caused by the deposition of insoluble amyloid fibrils, impairs different cardiac structures, altering not only left ventricle (LV) systo-diastolic function but also atrial function and the conduction system. The consequences of the involvement of the cardiac electrical system deserve more attention, as well as the study of the underlying molecular mechanisms. This is an issue of considerable interest, given the conflicting data on the effectiveness of conventional antiarrhythmic strategies. Therefore, this review aims at summarizing the arrhythmic burden related to CA and the available evidence on antiarrhythmic treatment in this population.
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Affiliation(s)
- Alessia Argirò
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, 50134 Florence, Italy
| | - Annamaria Del Franco
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, 50134 Florence, Italy
| | - Carlotta Mazzoni
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, 50134 Florence, Italy
| | - Marco Allinovi
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, 50134 Florence, Italy
| | - Alessia Tomberli
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, 50134 Florence, Italy
| | - Roberto Tarquini
- Department of Internal Medicine I, San Giuseppe Hospital, 50053 Empoli, Italy
| | - Carlo Di Mario
- Structural Interventional Cardiology Department, Careggi University Hospital, 50134 Florence, Italy
| | - Federico Perfetto
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, 50134 Florence, Italy
| | - Francesco Cappelli
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, 50134 Florence, Italy
| | - Mattia Zampieri
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, 50134 Florence, Italy
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14
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Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M. 2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Eur Heart J 2022; 43:3997-4126. [PMID: 36017572 DOI: 10.1093/eurheartj/ehac262] [Citation(s) in RCA: 749] [Impact Index Per Article: 374.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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15
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Adrogue HE. Amyloidosis of the Heart and Kidney. Methodist Debakey Cardiovasc J 2022; 18:27-33. [PMID: 36132587 PMCID: PMC9461691 DOI: 10.14797/mdcvj.1150] [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: 06/27/2022] [Accepted: 08/01/2022] [Indexed: 11/17/2022] Open
Abstract
Amyloidosis encompasses a collection of disorders of pathological protein folding. The extracellular location where these “amyloid fibril” proteins are deposited determines the clinical presentation of the disease. The abnormal architecture of these fibrils makes them insoluble and not easily removed, leading to disruption of normal tissue structure and interference with normal physiology. Amyloidosis of the heart and kidney can be inherited, secondary to unrelated diseases, or due to a plasma cell disorder. This review will focus on immunoglobulin light chain amyloidosis, which is life-threatening and must be diagnosed as early as possible by employing precise and accurate typing to ensure timely and frequently curative therapy.
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Affiliation(s)
- Horacio E Adrogue
- Division of Nephrology, Transplantation, and Hypertension, Department of Medicine, Houston Methodist Hospital, Houston, Texas, US.,Texas A&M Medical School, Houston, Texas, US
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16
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Management of Cardiac Symptoms in Amyloidosis. Am J Med 2022; 135 Suppl 1:S9-S12. [PMID: 35235819 DOI: 10.1016/j.amjmed.2022.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/09/2022] [Accepted: 02/10/2022] [Indexed: 11/22/2022]
Abstract
Cardiac amyloidosis (CA) results in symptoms of heart failure, atrial and ventricular arrhythmias, conduction disturbances, and profound autonomic dysfunction. These symptoms present unique management challenges as compared with patients without CA, and can be very debilitating. Thus, management of the cardiovascular symptoms of these patients plays a central role in their care. This review presents an overview of the typical cardiovascular manifestations encountered in patients with CA and highlights the key management considerations for each.
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17
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Salinas-Arce J, Alca-Clares R, Gonzales-Luna AC, Cabrera-Saldaña M, Mendoza-Novoa P, Solórzano-Altamirano P, Guevara-Valdivia M. [Cardiac arrhythmias and amyloidosis]. ARCHIVOS PERUANOS DE CARDIOLOGIA Y CIRUGIA CARDIOVASCULAR 2022; 3:82-97. [PMID: 37351307 PMCID: PMC10284580 DOI: 10.47487/apcyccv.v3i2.217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 06/27/2022] [Indexed: 06/24/2023]
Abstract
Cardiac amyloidosis (CA) is a form of cardiomyopathy characterized by the extracellular deposit of protein fibers in the myocardium, leading to the development of heart failure, arrhythmias, and electrical conduction system alterations. It is known that most cardiomyopathies have a close relationship with heart rhythm abnormalities, however, CA is specially related to different kinds of arrhythmias even in pre-diagnosis stages. Arrhythmias like atrial fibrillation are present in up to 70% of patients with CA associated with a high risk of cardioembolic complications independent of the risk stratification. Ventricular arrhythmias are frequent, but the use of implantable cardioverter defibrillator has not been demonstrated to improve survival. The Atrial-Ventricular node disease is also common, and is frequently associated with the implantation of a pacemaker, even in asymptomatic patients. In this review, we clarify the recommendations of the most current guidelines, summarize historical and contemporaneous data and describe evidence-based strategies for the management of arrhythmias and their complications in CA.
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Affiliation(s)
- Jorge Salinas-Arce
- Unidad de Arritmias, Clínica Delgado. Lima, Perú.Unidad de ArritmiasClínica DelgadoLimaPerú
| | - Raúl Alca-Clares
- Unidad de Arritmias, Clínica Delgado. Lima, Perú.Unidad de ArritmiasClínica DelgadoLimaPerú
- . Servicio de Cardiología, Hospital Cayetano Heredia. Lima, Perú.Servicio de CardiologíaHospital Cayetano HerediaLimaPerú
| | - Ana Cecilia Gonzales-Luna
- Unidad de Arritmias, Clínica Delgado. Lima, Perú.Unidad de ArritmiasClínica DelgadoLimaPerú
- . Unidad de Arritmias, Hospital Edgardo Rebagliati. Lima, Perú.Unidad de ArritmiasHospital Edgardo RebagliatiLimaPerú
| | - Mario Cabrera-Saldaña
- Unidad de Arritmias, Clínica Delgado. Lima, Perú.Unidad de ArritmiasClínica DelgadoLimaPerú
- . Unidad de Arritmias, Servicio de Cardiología Invasiva, Instituto Nacional Cardiovascular - INCOR EsSalud. Lima, Perú.Unidad de ArritmiasServicio de Cardiología InvasivaInstituto Nacional Cardiovascular - INCOR EsSaludLimaPerú
| | - Pablo Mendoza-Novoa
- Unidad de Arritmias, Clínica Delgado. Lima, Perú.Unidad de ArritmiasClínica DelgadoLimaPerú
- . Unidad de Arritmias, Hospital del Niño. Lima, Perú.Unidad de ArritmiasHospital del NiñoLimaPerú
| | - Paula Solórzano-Altamirano
- . Unidad de Docencia en Arritmias, APSA-QRS VITAL. Lima, Perú.Unidad de Docencia en ArritmiasAPSA-QRS VITALLimaPerú
| | - Milton Guevara-Valdivia
- . Departamento de Electrofisiología Cardiaca, Unidad Médica de Alta Especialidad del Hospital de Especialidades Dr. Antonio Fraga Mouret, Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social. Ciudad de México, México.Instituto Mexicano del Seguro SocialDepartamento de Electrofisiología Cardiaca, Unidad Médica de Alta Especialidad del Hospital de Especialidades Dr. Antonio Fraga MouretCentro Médico Nacional La RazaInstituto Mexicano del Seguro SocialCiudad de MéxicoMexico
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18
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Brown MT, Yalamanchili S, Evans ST, Ram P, Blank EA, Lyle MA, Merchant FM, Bhatt KN. Ventricular arrhythmia burden and implantable Cardioverter-defibrillator outcomes in transthyretin cardiac amyloidosis. Pacing Clin Electrophysiol 2022; 45:443-451. [PMID: 35257420 DOI: 10.1111/pace.14458] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 01/09/2022] [Accepted: 01/30/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND As targeted treatments for amyloid transthyretin cardiomyopathy (ATTR-CM) are becoming available, we aim to characterize the rates of ventricular arrhythmias (VAs), implantable cardioverter-defibrillator (ICD) utilization, and their impact on survival. METHODS This is a retrospective cohort study of 130 patients with ATTR-CM diagnosed at Emory University's Cardiac Amyloidosis Center between April 2012 and September 2020. VAs were defined as non-sustained or sustained ventricular tachycardia and ventricular fibrillation. RESULTS Of 130 patients, 42 had wild-type disease (wtATTR) and 88 had hereditary variants (hATTR), most commonly Val122Ile (89%). At ATTR-CM diagnosis, 80 (62%) patients had EF ≤ 40% consistent with systolic heart failure. Of the 69 (53%) patients with documented VAs significantly higher rates occurred among those with EF ≤ 40% compared with EF > 40% (67% vs 28%, p = 0.001). Thirty-two patients (25 hATTR, 7 wtATTR) had primary prevention ICDs implanted. Eight (25%) of these patients received appropriate ICD therapy while two (6%) experienced inappropriate therapy. Comparing patients with EF ≤ 35% with and without ICDs did not reveal any survival difference (3.3 ± 0.5 vs. 2.8 ± 0.4 years, p = 0.699). CONCLUSIONS High rates of VAs and appropriate ICD therapy were found amongst a unique cohort of largely hereditary ATTR-CM patients with a high rate of systolic heart failure. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Matthew T Brown
- Division of Cardiology, Department of Medicine, Emory University, Atlanta, GA
| | | | - Sean T Evans
- Department of Medicine, Emory University, Atlanta, GA
| | - Pradhum Ram
- Division of Cardiology, Department of Medicine, Emory University, Atlanta, GA
| | - Evan A Blank
- Division of Cardiology, Department of Medicine, Emory University, Atlanta, GA
| | - Melissa A Lyle
- Division of Cardiology, Department of Medicine, Mayo Clinic, Jacksonville, FL
| | - Faisal M Merchant
- Division of Cardiology, Department of Medicine, Emory University, Atlanta, GA
| | - Kunal N Bhatt
- Division of Cardiology, Department of Medicine, Emory University, Atlanta, GA
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19
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Stelmach-Gołdyś A, Zaborek-Łyczba M, Łyczba J, Garus B, Pasiarski M, Mertowska P, Małkowska P, Hrynkiewicz R, Niedźwiedzka-Rystwej P, Grywalska E. Physiology, Diagnosis and Treatment of Cardiac Light Chain Amyloidosis. J Clin Med 2022; 11:jcm11040911. [PMID: 35207184 PMCID: PMC8880759 DOI: 10.3390/jcm11040911] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/27/2022] [Accepted: 02/02/2022] [Indexed: 02/04/2023] Open
Abstract
AL (light-chain) amyloidosis is a systemic disease in which amyloid fibers are formed from kappa or lambda immunoglobulin light chains, or fragments thereof, produced by a neoplastic clone of plasmocytes. The produced protein is deposited in tissues and organs in the form of extracellular deposits, which leads to impairment of their functions and, consequently, to death. Despite the development of research on pathogenesis and therapy, the mortality rate of patients with late diagnosed amyloidosis is 30%. The diagnosis is delayed due to the complex clinical picture and the slow progression of the disease. This is the type of amyloidosis that most often contributes to cardiac lesions and causes cardiac amyloidosis (CA). Early diagnosis and correct identification of the type of amyloid plays a crucial role in the planning and effectiveness of therapy. In addition to standard histological studies based on Congo red staining, diagnostics are enriched by tests to determine the degree of cardiac involvement. In this paper, we discuss current diagnostic methods used in cardiac light chain amyloidosis and the latest therapies that contribute to an improved patient prognosis.
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Affiliation(s)
- Agnieszka Stelmach-Gołdyś
- Department of Immunology, Faculty of Health Sciences, Jan Kochanowski University, 25-317 Kielce, Poland; (A.S.-G.); (B.G.); (M.P.)
- Department of Hematology, Holy Cross Cancer Centre, 25-734 Kielce, Poland
| | - Monika Zaborek-Łyczba
- Department of Experimental Immunology, Medical University of Lublin, 20-093 Lublin, Poland; (M.Z.-Ł.); (J.Ł.); (P.M.); (E.G.)
| | - Jakub Łyczba
- Department of Experimental Immunology, Medical University of Lublin, 20-093 Lublin, Poland; (M.Z.-Ł.); (J.Ł.); (P.M.); (E.G.)
| | - Bartosz Garus
- Department of Immunology, Faculty of Health Sciences, Jan Kochanowski University, 25-317 Kielce, Poland; (A.S.-G.); (B.G.); (M.P.)
- Department of Hematology, Holy Cross Cancer Centre, 25-734 Kielce, Poland
| | - Marcin Pasiarski
- Department of Immunology, Faculty of Health Sciences, Jan Kochanowski University, 25-317 Kielce, Poland; (A.S.-G.); (B.G.); (M.P.)
- Department of Hematology, Holy Cross Cancer Centre, 25-734 Kielce, Poland
| | - Paulina Mertowska
- Department of Experimental Immunology, Medical University of Lublin, 20-093 Lublin, Poland; (M.Z.-Ł.); (J.Ł.); (P.M.); (E.G.)
| | - Paulina Małkowska
- Institute of Biology, University of Szczecin, 71-412 Szczecin, Poland; (P.M.); (R.H.)
| | - Rafał Hrynkiewicz
- Institute of Biology, University of Szczecin, 71-412 Szczecin, Poland; (P.M.); (R.H.)
| | | | - Ewelina Grywalska
- Department of Experimental Immunology, Medical University of Lublin, 20-093 Lublin, Poland; (M.Z.-Ł.); (J.Ł.); (P.M.); (E.G.)
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20
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Merlo M, Grilli G, Cappelletto C, Masé M, Porcari A, Ferro MD, Gigli M, Stolfo D, Zecchin M, De Luca A, Mestroni L, Sinagra G. The Arrhythmic Phenotype in Cardiomyopathy. Heart Fail Clin 2022; 18:101-113. [PMID: 34776072 DOI: 10.1016/j.hfc.2021.07.011] [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] [Indexed: 11/23/2022]
Abstract
In the wide phenotypic spectrum of cardiomyopathies, sudden cardiac death (SCD) has always been the most visible and devastating disease complication. The introduction of implantable cardioverter-defibrillators for SCD prevention by the late 1980s has moved the question from how to whom we should protect from SCD, leaving clinicians with a measure of uncertainty regarding the most reliable option to guide identification of the highest-risk patients. In this review, we will go through all the available evidence in the field of arrhythmic expression and arrhythmic risk stratification in the different phenotypes of cardiomyopathies to provide practical suggestions in daily clinical management.
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Affiliation(s)
- Marco Merlo
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Italy.
| | - Giulia Grilli
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Italy
| | - Chiara Cappelletto
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Italy
| | - Marco Masé
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Italy
| | - Aldostefano Porcari
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Italy
| | - Matteo Dal Ferro
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Italy
| | - Marta Gigli
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Italy
| | - Davide Stolfo
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Italy
| | - Massimo Zecchin
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Italy
| | - Antonio De Luca
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Italy
| | - Luisa Mestroni
- Cardiovascular Institute and Adult Medical Genetics Program, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Gianfranco Sinagra
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Italy
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21
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Guo X, Chen Z, Wan K, Song R, Yang T, Xu Y, Zhang Q, Alexander KM, Han Y, Chen Y. Electrocardiogram Characteristics and Prognostic Value in Light-Chain Amyloidosis: A Comparison With Cardiac Magnetic Resonance Imaging. Front Cardiovasc Med 2021; 8:751422. [PMID: 34938781 PMCID: PMC8685267 DOI: 10.3389/fcvm.2021.751422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 11/10/2021] [Indexed: 02/05/2023] Open
Abstract
Background: An electrocardiogram (ECG) is a simple and cheap non-invasive tool that shows various abnormalities and has prognostic value for patients with light-chain amyloidosis (AL). The present study aimed to explore the association between ECG characteristics and cardiac magnetic resonance (CMR)-detected amyloid burden and to investigate the prognostic value of ECG in AL amyloidosis. Methods: We prospectively enrolled 99 patients with AL amyloidosis (56 male patients; median age, 58 y). Detailed clinical information, 12-lead ECG, and CMR data were collected. All patients were followed up longitudinally, and the endpoint was all-cause mortality. ECG characteristics were analyzed and correlated with the degree of late gadolinium enhancement (LGE) and extracellular volume (ECV) by T1 mapping on CMR. The prognostic value of ECG characteristics was analyzed using Kaplan–Meier survival analysis and multivariate Cox regression. Results: During a median follow-up period of 33 months, 69 of the 99 patients died. Fragmented Q wave-R wave-S wave (QRS), pathological Q waves, the Sokolow index, QRS duration, and voltages were significantly associated with the extent of LGE, native T1, and ECV by CMR (p < 0.05). Fragmented QRS and Sokolow index showed independent prognostic value in AL amyloidosis (p = 0.001; p = 0.026, respectively). Fragmented QRS remained independent after adjusting for clinical values (hazard ratio: 2.034; 95% confidence interval: 1.148–3.603; p = 0.015). However, no ECG characteristics were independent predictors for prognosis in AL amyloidosis when LGE and ECV were included in the multivariate analysis. Conclusion: ECG abnormalities showed significant association with CMR indicators of amyloid burden. Fragmented QRS has an independent prognostic value in AL amyloidosis and could be used as an alternative marker when CMR is not available.
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Affiliation(s)
- Xinli Guo
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Zhian Chen
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Ke Wan
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China.,Department of Geriatrics and National Clinical Research Centre for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Rizhen Song
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Tingjie Yang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Yuanwei Xu
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Qing Zhang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Kevin Michael Alexander
- Stanford Amyloid Center, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, United States.,Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, United States
| | - Yuchi Han
- Department of Medicine (Cardiovascular Division), University of Pennsylvania, Philadelphia, PA, United States
| | - Yucheng Chen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China.,Center of Rare Diseases, West China Hospital, Sichuan University, Chengdu, China
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22
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Electrophysiological Manifestations of Cardiac Amyloidosis: JACC: CardioOncology State-of-the-Art Review. JACC: CARDIOONCOLOGY 2021; 3:506-515. [PMID: 34729522 PMCID: PMC8543134 DOI: 10.1016/j.jaccao.2021.07.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 07/27/2021] [Accepted: 07/30/2021] [Indexed: 01/15/2023]
Abstract
Cardiac amyloidosis (CA) is an infiltrative cardiomyopathy caused by the extracellular deposition of amyloid fibrils in the myocardium. Although cardiac amyloidosis patients primarily present with heart failure symptoms, arrhythmias and conduction system disease are frequently encountered. Atrial fibrillation (AF) is observed in up to 70% of patients at the time of diagnosis, and patients typically have controlled ventricular rates caused by concomitant conduction system disease. Thromboembolic risk is particularly high in patients with CA and AF, and left atrial thrombi have been observed even in the absence of clinically diagnosed AF. Atrioventricular nodal and infra-Hisian disease are common, and permanent pacemakers are frequently required. The use of implantable cardioverter-defibrillators in this population is controversial. This review summarizes the published data and therapeutic strategies surrounding arrhythmias and conduction system disease with the goal of aiding clinicians managing the clinical complexities of CA.
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23
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Kim MM, Kolseth CM, Carlson D, Masri A. Clinical management of amyloid cardiomyopathy. Heart Fail Rev 2021; 27:1549-1557. [PMID: 34471997 DOI: 10.1007/s10741-021-10159-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/16/2021] [Indexed: 01/04/2023]
Abstract
Clinical heart failure, restrictive cardiomyopathy, and arrhythmias are hallmark features of amyloid cardiomyopathy. In contrast to the advancements in targeted therapies, there is a general lack of evidence-based practice guidelines for clinical management of amyloid cardiomyopathy. In this review, we review the role of routine medical therapy in amyloid cardiomyopathy, from heart failure management to orthostatic hypotension, atrial arrhythmias, thromboembolic complications, and prevention of sudden death. We conclude by discussing approaches to patients with end-stage disease.
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Affiliation(s)
- Morris M Kim
- Center for Amyloidosis, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Clinton M Kolseth
- Center for Amyloidosis, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Dayna Carlson
- Center for Amyloidosis, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Ahmad Masri
- Center for Amyloidosis, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA.
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24
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Abstract
Diagnoses of amyloidosis are increasing annually, and advances in bone scintigraphy and cardiac MRI accompanied by development of nonbiopsy diagnostic criteria have specifically led to a huge increase in transthyretin amyloidosis cardiomyopathy (ATTR-CM) diagnoses worldwide. Tafamidis use is increasing, and there are several ongoing phase III clinical trials of novel agents that promise to transform the treatment landscape for patients with ATTR-CM. In systemic light chain (AL) amyloidosis, more effective chemotherapeutic agents continue to improve patient outcomes. Accelerating the removal of amyloid deposits to accompany these therapies remains the holy grail. However, in the meantime, early diagnosis is undoubtedly key in improving patient outcomes.
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Affiliation(s)
- Steven Law
- Division of Medicine (Royal Free Campus), National Amyloidosis Centre, Centre for Amyloidosis and Acute Phase Proteins, University College London, Rowland Hill Street, London NW3 2PF, UK
| | - Marianna Fontana
- Division of Medicine (Royal Free Campus), National Amyloidosis Centre, Centre for Amyloidosis and Acute Phase Proteins, University College London, Rowland Hill Street, London NW3 2PF, UK
| | - Julian D Gillmore
- Division of Medicine (Royal Free Campus), National Amyloidosis Centre, Centre for Amyloidosis and Acute Phase Proteins, University College London, Rowland Hill Street, London NW3 2PF, UK.
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25
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Adam RD, Coriu D, Jercan A, Bădeliţă S, Popescu BA, Damy T, Jurcuţ R. Progress and challenges in the treatment of cardiac amyloidosis: a review of the literature. ESC Heart Fail 2021; 8:2380-2396. [PMID: 34089308 PMCID: PMC8318516 DOI: 10.1002/ehf2.13443] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 05/04/2021] [Accepted: 05/12/2021] [Indexed: 12/19/2022] Open
Abstract
Cardiac amyloidosis is a restrictive cardiomyopathy determined by the accumulation of amyloid, which is represented by misfolded protein fragments in the cardiac extracellular space. The main classification of systemic amyloidosis is determined by the amyloid precursor proteins causing a very heterogeneous disease spectrum, but the main types of amyloidosis involving the heart are light chain (AL) and transthyretin amyloidosis (ATTR). AL, in which the amyloid precursor is represented by misfolded immunoglobulin light chains, can involve almost any system carrying the worst prognosis among amyloidosis patients. This has however dramatically improved in the last few years with the increased usage of the novel therapies such as proteasome inhibitors and haematopoietic cell transplantation, in the case of timely diagnosis and initiation of treatment. The treatment for AL is directed by the haematologist working closely with the cardiologist when there is a significant cardiac involvement. Transthyretin (TTR) is a protein that is produced by the liver and is involved in the transportation of thyroid hormones, especially thyroxine and retinol binding protein. ATTR results from the accumulation of transthyretin amyloid in the extracellular space of different organs and systems, especially the heart and the nervous system. Specific therapies for ATTR act at various levels of TTR, from synthesis to deposition: TTR tetramer stabilization, oligomer aggregation inhibition, genetic therapy, amyloid fibre degradation, antiserum amyloid P antibodies, and antiserum TTR antibodies. Treatment of systemic amyloidosis has dramatically evolved over the last few years in both AL and ATTR, improving disease prognosis. Moreover, recent studies revealed that timely treatment can lead to an improvement in clinical status and in a regression of amyloid myocardial infiltration showed by imaging, especially by cardiac magnetic resonance, in both AL and ATTR. However, treating cardiac amyloidosis is a complex task due to the frequent association between systemic congestion and low blood pressure, thrombo-embolic and haemorrhagic risk balance, patient frailty, and generally poor prognosis. The aim of this review is to describe the current state of knowledge regarding cardiac amyloidosis therapy in this constantly evolving field, classified as treatment of the cardiac complications of amyloidosis (heart failure, rhythm and conduction disturbances, and thrombo-embolic risk) and the disease-modifying therapy.
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Affiliation(s)
- Robert Daniel Adam
- Department of CardiologyEmergency Institute for Cardiovascular Diseases ‘Prof. Dr. C. C. Iliescu’3rd Cardiology Department, 258 Fundeni StreetBucharest022328Romania
- University of Medicine and Pharmacy ‘Carol Davila’BucharestRomania
| | - Daniel Coriu
- University of Medicine and Pharmacy ‘Carol Davila’BucharestRomania
- Department of HematologyFundeni Clinical InstituteBucharestRomania
| | - Andreea Jercan
- University of Medicine and Pharmacy ‘Carol Davila’BucharestRomania
| | - Sorina Bădeliţă
- Department of HematologyFundeni Clinical InstituteBucharestRomania
| | - Bogdan A. Popescu
- Department of CardiologyEmergency Institute for Cardiovascular Diseases ‘Prof. Dr. C. C. Iliescu’3rd Cardiology Department, 258 Fundeni StreetBucharest022328Romania
- University of Medicine and Pharmacy ‘Carol Davila’BucharestRomania
| | - Thibaud Damy
- French Referral Center for Cardiac AmyloidosisAmyloidosis Mondor NetworkCréteilFrance
- Department of CardiologyHenri Mondor Hospital/AP‐HPCréteilFrance
| | - Ruxandra Jurcuţ
- Department of CardiologyEmergency Institute for Cardiovascular Diseases ‘Prof. Dr. C. C. Iliescu’3rd Cardiology Department, 258 Fundeni StreetBucharest022328Romania
- University of Medicine and Pharmacy ‘Carol Davila’BucharestRomania
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26
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Kim EJ, Holmes BB, Huang S, Lugo R, Al Aboud A, Goodman S, Hung RR, Slosky D, Stevenson WG, Michaud GF, John RM. Outcomes in patients with cardiac amyloidosis and implantable cardioverter-defibrillator. Europace 2021; 22:1216-1223. [PMID: 32514579 DOI: 10.1093/europace/euaa094] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 11/26/2019] [Accepted: 04/03/2020] [Indexed: 12/21/2022] Open
Abstract
AIMS Cardiac amyloidosis (CA) is associated with increased mortality due to arrhythmias, heart failure, and electromechanical dissociation. However, the role of an implantable cardioverter-defibrillator (ICD) remains unclear. We conducted case-control study to assess survival in CA patients with and without a primary prevention ICD and compared outcomes to an age, sex, and device implant year-matched non-CA group with primary prevention ICD. METHODS AND RESULTS There were 91 subjects with CA [mean age= 71.2 ± 10.2, female 22.0%, 49 AL with Mayo Stage 2.9 ± 1.0, 41 transthyretin amyloidosis (ATTR), 1 other] followed by Vanderbilt Amyloidosis centre. Patients with ICD (n = 23) were compared with those without (n = 68) and a non-amyloid group with ICD (n = 46). All subjects with ICD had implantation for primary prevention. Mean left ventricular ejection fraction was 36.2% ± 14.4% in CA with ICD, 41.0% ± 10.6% in CA without ICD, and 33.5% ± 14.4% in non-CA patients. Over 3.5 ± 3.1 years, 6 (26.1%) CA, and 12 (26.1%) non-CA subjects received ICD therapies (P = 0.71). Patients with CA had a significantly higher mortality (43.9% vs. 17.4%, P = 0.002) compared with the non-CA group. Mean time from device implantation to death was 21.8 months in AL and 22.8 months in ATTR patients. There was no significant difference in mortality between CA patients who did and did not receive an ICD (39.0% vs. 46.0%, P = 0.59). CONCLUSIONS Despite comparable event rates patients with CA had a significantly higher mortality and ICDs were not associated with longer survival. With the emergence of effective therapy for AL amyloidosis, further study of ICD is needed in this group.
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Affiliation(s)
- Eun-Jeong Kim
- Division of Cardiovascular Medicine, Department of Medicine, University of California San Francisco Medical Center, San Francisco, CA 94143, USA
| | - Benjamin B Holmes
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Shi Huang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Ricardo Lugo
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Asad Al Aboud
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Stacey Goodman
- Division of Hematology and Oncology, Department of MedicineVanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Rebecca R Hung
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - David Slosky
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - William G Stevenson
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Gregory F Michaud
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Roy M John
- Cardiac Arrhythmia Service, Northshore University Medical Center, Cohen 1, 300 Community Drive, Manhasset, NY 11030, USA
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27
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Muchtar E, Dispenzieri A, Gertz MA, Kumar SK, Buadi FK, Leung N, Lacy MQ, Dingli D, Ailawadhi S, Bergsagel PL, Fonseca R, Hayman SR, Kapoor P, Grogan M, Abou Ezzeddine OF, Rosenthal JL, Mauermann M, Siddiqui M, Gonsalves WI, Kourelis TV, Larsen JT, Reeder CB, Warsame R, Go RS, Murray DL, McPhail ED, Dasari S, Jevremovic D, Kyle RA, Lin Y, Lust JA, Russell SJ, Hwa YL, Fonder AL, Hobbs MA, Rajkumar SV, Roy V, Sher T. Treatment of AL Amyloidosis: Mayo Stratification of Myeloma and Risk-Adapted Therapy (mSMART) Consensus Statement 2020 Update. Mayo Clin Proc 2021; 96:1546-1577. [PMID: 34088417 DOI: 10.1016/j.mayocp.2021.03.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 01/31/2021] [Accepted: 03/03/2021] [Indexed: 12/17/2022]
Abstract
Immunoglobulin light chain (AL) amyloidosis is a clonal plasma cell disorder leading to progressive and life-threatening organ failure. The heart and the kidneys are the most commonly involved organs, but almost any organ can be involved. Because of the nonspecific presentation, diagnosis delay is common, and many patients are diagnosed with advanced organ failure. In the era of effective therapies and improved outcomes for patients with AL amyloidosis, the importance of early recognition is further enhanced as the ability to reverse organ dysfunction is limited in those with a profound organ failure. As AL amyloidosis is an uncommon disorder and given patients' frailty and high early death rate, management of this complex condition is challenging. The treatment of AL amyloidosis is based on various anti-plasma cell therapies. These therapies are borrowed and customized from the treatment of multiple myeloma, a more common disorder. However, a growing number of phase 2/3 studies dedicated to the AL amyloidosis population are being performed, making treatment decisions more evidence-based. Supportive care is an integral part of management of AL amyloidosis because of the inherent organ dysfunction, limiting the delivery of effective therapy. This extensive review brings an updated summary on the management of AL amyloidosis, sectioned into the 3 pillars for survival improvement: early disease recognition, anti-plasma cell therapy, and supportive care.
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Affiliation(s)
- Eli Muchtar
- Division of Hematology, Mayo Clinic, Rochester, MN.
| | | | | | | | | | - Nelson Leung
- Division of Hematology, Mayo Clinic, Rochester, MN; Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | | | - David Dingli
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | | | - Rafael Fonseca
- Division of Hematology/Oncology, Mayo Clinic, Scottsdale, AZ
| | | | | | - Martha Grogan
- Division of Hematology, Mayo Clinic, Rochester, MN; Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | | | | | | | | | | | | | - Jeremy T Larsen
- Division of Hematology/Oncology, Mayo Clinic, Scottsdale, AZ
| | - Craig B Reeder
- Division of Hematology/Oncology, Mayo Clinic, Scottsdale, AZ
| | | | - Ronald S Go
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - David L Murray
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Ellen D McPhail
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Surendra Dasari
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Dragan Jevremovic
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | - Yi Lin
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - John A Lust
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | - Yi Lisa Hwa
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | | | - S Vincent Rajkumar
- Division of Hematology, Mayo Clinic, Rochester, MN; Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Vivek Roy
- Division of Hematology/Oncology, Mayo Clinic, Jacksonville, FL
| | - Taimur Sher
- Division of Hematology/Oncology, Mayo Clinic, Jacksonville, FL
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28
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Liżewska-Springer A, Sławiński G, Lewicka E. Arrhythmic Sudden Cardiac Death and the Role of Implantable Cardioverter-Defibrillator in Patients with Cardiac Amyloidosis-A Narrative Literature Review. J Clin Med 2021; 10:1858. [PMID: 33922892 PMCID: PMC8123220 DOI: 10.3390/jcm10091858] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/07/2021] [Accepted: 04/20/2021] [Indexed: 11/16/2022] Open
Abstract
Cardiac amyloidosis (CA) is considered to be associated with an increased risk of sudden cardiac death (SCD) due to ventricular tachyarrhythmias and electromechanical dissociation. However, current arrhythmic risk stratification and the role of an implantable cardioverter-defibrillator (ICD) for primary prevention of SCD remains unclear. This article provides a narrative review of the literature on electrophysiological abnormalities in the context of ventricular arrhythmias in patients with CA and the role of ICD in terms of survival benefit in this group of patients.
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Affiliation(s)
- Aleksandra Liżewska-Springer
- Department of Cardiology and Electrotherapy, Medical University of Gdańsk, 80-210 Gdańsk, Poland; (G.S.); (E.L.)
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29
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Zampieri M, Allinovi M, Olivotto I, Antonioli E, Gabriele M, Argirò A, Fumagalli C, Nardi G, Di Mario C, Vannucchi AM, Perfetto F, Cappelli F. Ventricular tachyarrhythmias and sudden cardiac death in light-chain amyloidosis: a clash of cardio-toxicities? Br J Haematol 2021; 193:e27-e31. [PMID: 33840100 DOI: 10.1111/bjh.17399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Mattia Zampieri
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy.,Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Marco Allinovi
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Iacopo Olivotto
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | | | - Martina Gabriele
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Alessia Argirò
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Carlo Fumagalli
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy.,Geriatric Cardiology - Intensive Care Unit, Azienda ospedaliera Careggi, Florence, Italy
| | - Giulia Nardi
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Carlo Di Mario
- Division of Interventional Structural Cardiology, Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
| | - Alessandro M Vannucchi
- Center Research Innovation of Myeloproliferative Neoplasms (CRIMN), SOD Hematology, University of Florence and AOU Careggi, Florence, Italy
| | - Federico Perfetto
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy.,IV Internal Medicine Division, Careggi University Hospital, Florence, Italy
| | - Francesco Cappelli
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy.,Division of Interventional Structural Cardiology, Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
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30
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De Bruijn S, Galloo X, De Keulenaer G, Prihadi EA, Brands C, Helbert M. A special case of hypertrophic cardiomyopathy with a differential diagnosis of isolated cardiac amyloidosis or junctophilin type 2 associated cardiomyopathy. Acta Clin Belg 2021; 76:136-143. [PMID: 31478477 DOI: 10.1080/17843286.2019.1662572] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Differential diagnosis between hypertrophic cardiomyopathy (HCM) and cardiac amyloidosis (CA) is mandatory since the prognosis is very different, but not always possible as both diseases present with increased myocardial thickness and mass. Despite better knowledge of the pathophysiology of both HCM and CA, and new developments in diagnosis, many patients with cardiac involvement in systemic amyloidosis are still only diagnosed in an advanced stage. Improvements in non-invasive diagnostic methods such as ultrasound techniques and cardiac magnetic resonance imaging will eventually obviate the need for invasive studies in order to prove amyloid cardiomyopathy. Nevertheless, today, an endomyocardial biopsy still remains the golden standard. We present an 86-year-old man, diagnosed with hypertrophic cardiomyopathy, in whom echocardiography and cardiac magnetic resonance imaging strongly suggested amyloidosis to be the underlying cause. Interestingly, a new variant of the junctophilin 2 (JPH2) gene, related to hypertrophic cardiomyopathies, was found in our patient.
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Affiliation(s)
- Sévérine De Bruijn
- Cardiology Department, ZNA Hartcentrum - ZNA Middelheim, Antwerpen, Belgium
| | - Xavier Galloo
- Cardiology Department, ZNA Hartcentrum - ZNA Middelheim, Antwerpen, Belgium
| | | | - Edgard A. Prihadi
- Cardiology Department, ZNA Hartcentrum - ZNA Middelheim, Antwerpen, Belgium
| | | | - Mark Helbert
- Nephrology Department, ZNA Middelheim, Antwerpen, Belgium
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31
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Cruz Rodriguez JB, Tallaj JA. Narrative review of pharmacotherapy for transthyretin cardiac amyloid. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:519. [PMID: 33850916 PMCID: PMC8039703 DOI: 10.21037/atm-20-4636] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Treatment of cardiac amyloidosis is determined by the amyloid type and degree of involvement. Two types of amyloid commonly infiltrate the heart: immunoglobulin light-chain amyloid (AL), and transthyretin amyloid (ATTR), that encompasses other two forms, a hereditary form (hATTR), and a sporadic, age-related wild-type (wtATTR). The prevalence is expected to increase with aging population. The natural history of ATTR cardiomyopathy includes progressive heart failure (HF), complicated by arrhythmias and conduction system disease. New therapies options have been approved or are under investigation. We performed a narrative literature review, manually-searched the reference lists of included articles and relevant reviews. Treatment for cardiac ATTR should be directed towards alleviation of HF symptoms and to slow or stop progressive amyloid deposition. Conventional HF medications are poorly tolerated and may not alter the disease progression or symptoms, except perhaps with the administration of diuretics. There are three approaches of therapy for ATTR cardiomyopathy: tetramer stabilizers, inhibition of ATTR protein synthesis and clearance of deposited fibrils. Tafamidis diminishes the progression of cardiomyopathy, functional parameters, improves overall outcome in patients with early disease stages, irrespective of ATTR status and is well tolerated. Diflunisal has shown promising results in early studies, but at the expense of significant side effects. Two new agents, antisense oligonucleotides, patisiran and inotersen are under investigation in cardiac amyloidosis. Patisiran appears to be the most effective treatment for hATTR, although evidence is limited, with a relatively small cardiac subpopulation. Therapies considering clearance of amyloid fibrils from tissue remain experimental. In conclusion, tafamidis is the only approved agent for the treatment of ATTR cardiomyopathy although multiple other agents have shown promising early results and are undergoing clinical trials. Careful consideration of the type of ATTR, comorbidities and disease stage will be key in deciding the optimal therapy for ATTR patients.
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Affiliation(s)
- Jose B Cruz Rodriguez
- Division of Cardiovascular Diseases, Texas Tech University Health Science Center El Paso, El Paso, TX, USA
| | - Jose A Tallaj
- Division of Cardiovascular Diseases, University of Alabama at Birmingham, Birmingham, AL, USA.,Department of Medicine, Birmingham VA Medical Center, Birmingham, AL, USA
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32
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Cardiac Amyloidosis Therapy: A Systematic Review. CARDIOGENETICS 2021. [DOI: 10.3390/cardiogenetics11010002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Heart involvement in Cardiac Amyloidosis (CA) results in a worsening of the prognosis in almost all patients with both light-chain (AL) and transthyretin amyloidosis (ATTR). The mainstream CA is a restrictive cardiomyopathy with hypertrophic phenotype at cardiac imaging that clinically leads to heart failure with preserved ejection fraction (HFpEF). An early diagnosis is essential to reduce cardiac damage and to improve the prognosis. Many therapies are available, but most of them have late benefits to cardiac function; for this reason, novel therapies are going to come soon.
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33
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Angsubhakorn N, Agdamag A, Sumransub N, Velangi P, Freund R, Martin CM, Alexy T. A case of AL amyloidosis presenting with refractory ventricular fibrillation. Respir Med Case Rep 2021; 32:101349. [PMID: 33552893 PMCID: PMC7851180 DOI: 10.1016/j.rmcr.2021.101349] [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: 09/03/2020] [Revised: 11/28/2020] [Accepted: 01/13/2021] [Indexed: 11/25/2022] Open
Abstract
A 66-year-old male with recent diagnosis of heart failure with reduced ejection fraction was referred to our institution for management of cardiogenic/vasodilatory shock. During his evaluation, he suffered a sudden cardiac arrest from refractory ventricular tachycardia/fibrillation (VT/VF) despite normal electrolytes and no evidence of prior ventricular arrhythmias. He was placed on rescue peripheral veno-arterial extracorporeal membrane oxygenation support (VA-ECMO) for 4 days and was decannulated without end-organ damage. Continued workup revealed Mayo stage IV immunoglobulin light chain (AL) amyloidosis. Unfortunately, he developed acute cerebellar hemorrhage several days later. Autopsy findings were consistent with AL amyloidosis, with extensive cardiac fibrosis and amyloid deposition in the myocardium and vasculature. While the most common cause of cardiac death in patients with amyloidosis is severe bradycardia and pulseless electrical activity, sustained ventricular arrhythmias have been reported. The use of implantable cardioverter defibrillators (ICD) is highly debated in this population given the lack of survival benefit. Our patient also developed refractory VT/VF arrest, and ICD shocks would not have rescued him while causing significant distress. Emergent VA-ECMO cannulation allowed us to make a diagnosis, yet this intervention cannot be routinely recommended given the limited survival of patients with AL amyloidosis.
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Affiliation(s)
| | - Arianne Agdamag
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | | | - Pratik Velangi
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Robert Freund
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Cindy M Martin
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Tamas Alexy
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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34
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Yilmaz A, Bauersachs J, Bengel F, Büchel R, Kindermann I, Klingel K, Knebel F, Meder B, Morbach C, Nagel E, Schulze-Bahr E, Aus dem Siepen F, Frey N. Diagnosis and treatment of cardiac amyloidosis: position statement of the German Cardiac Society (DGK). Clin Res Cardiol 2021; 110:479-506. [PMID: 33459839 PMCID: PMC8055575 DOI: 10.1007/s00392-020-01799-3] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 12/21/2020] [Indexed: 12/15/2022]
Abstract
Systemic forms of amyloidosis affecting the heart are mostly light-chain (AL) and transthyretin (ATTR) amyloidoses. The latter is caused by deposition of misfolded transthyretin, either in wild-type (ATTRwt) or mutant (ATTRv) conformation. For diagnostics, specific serum biomarkers and modern non-invasive imaging techniques, such as cardiovascular magnetic resonance imaging (CMR) and scintigraphic methods, are available today. These imaging techniques do not only complement conventional echocardiography, but also allow for accurate assessment of the extent of cardiac involvement, in addition to diagnosing cardiac amyloidosis. Endomyocardial biopsy still plays a major role in the histopathological diagnosis and subtyping of cardiac amyloidosis. The main objective of the diagnostic algorithm outlined in this position statement is to detect cardiac amyloidosis as reliably and early as possible, to accurately determine its extent, and to reliably identify the underlying subtype of amyloidosis, thereby enabling subsequent targeted treatment.
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Affiliation(s)
- A Yilmaz
- Sektion für Herzbildgebung, Klinik für Kardiologie, Universitätsklinikum Münster, Von-Esmarch-Str. 48, 48149, Münster, Germany.
| | - J Bauersachs
- Klinik für Kardiologie und Angiologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - F Bengel
- Klinik für Nuklearmedizin, Medizinische Hochschule Hannover, Hannover, Germany
| | - R Büchel
- Klinik für Nuklearmedizin, Universitätsspital Zürich, Zurich, Switzerland
| | - I Kindermann
- Klinik für Innere Medizin III (Kardiologie, Angiologie und Internistische Intensivmedizin), Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Homburg, Germany
| | - K Klingel
- Institut für Pathologie und Neuropathologie, Universität Tübingen, Tübingen, Germany
| | - F Knebel
- Medizinische Klinik m.S. Kardiologie und Angiologie, Charite Universitätsmedizin Berlin Campus Mitte, Berlin, Germany
| | - B Meder
- Klinik für Innere Medizin III, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - C Morbach
- Klinik für Innere Medizin III, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - E Nagel
- Interdisziplinäres Amyloidosezentrum Nordbayern, Deutsches Zentrum für Herzinsuffizienz, Medizinische Klinik I der Universität Würzburg, Würzburg, Germany
| | - E Schulze-Bahr
- Institut für Experimentelle und translationale kardiovaskuläre Bildgebung, Universitätsklinikum Frankfurt, Frankfurt, Germany
| | - F Aus dem Siepen
- Institut für Genetik von Herzerkrankungen (IfGH), Universitätsklinikum Münster, Münster, Germany
| | - N Frey
- Klinik für Innere Medizin III, Schwerpunkt Kardiologie und Angiologie, Universitätsklinikum Schleswig-Holstein, Kiel, Germany.,Kommission für Klinische Kardiovaskuläre Medizin, Deutsche Gesellschaft für Kardiologie, Düsseldorf, Germany
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35
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Porcari A, Merlo M, Rapezzi C, Sinagra G. Transthyretin amyloid cardiomyopathy: An uncharted territory awaiting discovery. Eur J Intern Med 2020; 82:7-15. [PMID: 33032855 PMCID: PMC7534738 DOI: 10.1016/j.ejim.2020.09.025] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 09/21/2020] [Accepted: 09/26/2020] [Indexed: 01/14/2023]
Abstract
Transthyretin amyloid cardiomyopathy (ATTR-AC) is an under-recognized and underdiagnosed disease. Although traditionally considered a rare condition, the epidemiology of the disease is rapidly changing due to the possibility of non-invasive diagnosis through cardiac scintigraphy with bone tracers and novel disease-modifying treatments providing survival advantages. Nevertheless, many questions and grey areas have to be addressed, such as the natural history of ATTR-AC, the role and implications of genotype-phenotype interactions, the best clinical management, prognostic stratification and the most appropriate treatments, including those already recommended for patients with heart failure. Clinicians have to cope with old beliefs and evolving concepts in ATTR-AC. A wide horizon of possibilities for physicians of many specialties is unfolding and awaits discovery.
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Affiliation(s)
- Aldostefano Porcari
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Italy
| | - Marco Merlo
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Italy
| | - Claudio Rapezzi
- Cardiovascular Center, University of Ferrara, Italy; GVM Care & Research, Cotignola, Italy
| | - Gianfranco Sinagra
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Italy.
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36
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Nazir T, Nuffati M. Cardiac amyloidosis-an underdiagnosed cause of heart failure in the elderly. J Saudi Heart Assoc 2020; 32:98-102. [PMID: 33154899 PMCID: PMC7640612 DOI: 10.37616/2212-5043.1016] [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: 07/17/2019] [Revised: 09/12/2019] [Accepted: 09/27/2019] [Indexed: 11/20/2022] Open
Abstract
Amyloidosis is a rare, generally multisystem disease that can also involve the heart. Infiltration of the myocardium with amyloid proteins is an important and underappreciated cause of heart failure with preserved ejection fraction in the elderly. We present the case of an 84-year-old man with chest tightness, dyspnoea, and ascites. He had a history of dyslipidaemia and ischaemic heart disease. Initial investigations showed severe diastolic dysfunction and elevated pulmonary artery systolic pressure on echocardiogram along with elevated serum natriuretic peptides. Further evaluation by a magnetic resonance imaging scan of the heart and endomyocardial biopsy confirmed the diagnosis of senile systemic amyloidosis. He made good progress after treatment with conventional heart failure drugs and is currently under consideration to start on specific medications to slow down the progression of amyloidosis. This case aims to increase clinicians' awareness of senile amyloidosis as a cause of heart failure in the elderly.
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Affiliation(s)
- Tahir Nazir
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | - Mahmud Nuffati
- Cardiothoracic Centre, Royal Liverpool Hospital, Liverpool, UK
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Wong SW, Fogaren T. Supportive Care for Patients with Systemic Light Chain Amyloidosis. Hematol Oncol Clin North Am 2020; 34:1177-1191. [PMID: 33099432 DOI: 10.1016/j.hoc.2020.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Light chain amyloidosis is a disease in which clonal plasma cells produce toxic immunoglobulin light chains that form amyloid fibrils with deposition in organs, most commonly the heart and kidneys, but also the nervous system, gastrointestinal tract, and soft tissues. Treatment directed at the clonal cells eliminates light chain production and further deposition and may enable organ improvement and decrease the risk of organ failure. Supportive care manages the symptoms of organ involvement and the side effects of treatment. Supportive care also addresses the psychological and social issues that may arise in patients with light chain amyloidosis.
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Affiliation(s)
- Sandy W Wong
- Hematology/Blood and Marrow Transplantation, Comprehensive Amyloid Program, University of California, 400 Parnassus Avenue, San Francisco, CA 94143, USA.
| | - Teresa Fogaren
- Division of Hematology/Oncology, Tufts Medical Center, 800 Washington Street, Boston, MA 02111, USA
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Emdin M, Aimo A, Rapezzi C, Fontana M, Perfetto F, Seferović PM, Barison A, Castiglione V, Vergaro G, Giannoni A, Passino C, Merlini G. Treatment of cardiac transthyretin amyloidosis: an update. Eur Heart J 2020; 40:3699-3706. [PMID: 31111153 DOI: 10.1093/eurheartj/ehz298] [Citation(s) in RCA: 114] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 02/11/2019] [Accepted: 04/23/2019] [Indexed: 12/21/2022] Open
Abstract
Transthyretin (TTR) is a tetrameric protein synthesized mostly by the liver. As a result of gene mutations or as an ageing-related phenomenon, TTR molecules may misfold and deposit in the heart and in other organs as amyloid fibrils. Cardiac involvement in TTR-related amyloidosis (ATTR) manifests typically as left ventricular pseudohypertrophy and/or heart failure with preserved ejection fraction. ATTR is an underdiagnosed disorder as well as a crucial determinant of morbidity and mortality, thus justifying the current quest for a safe and effective treatment. Therapies targeting cardiac damage and its direct consequences may yield limited benefit, mostly related to dyspnoea relief through diuretics. For many years, liver or combined heart and liver transplantation have been the only available treatments for patients with mutations causing ATTR, including those with cardiac involvement. The therapeutic options now include several pharmacological agents that inhibit hepatic synthesis of TTR, stabilize the tetramer, or disrupt fibrils. Following the positive results of a phase 3 trial on tafamidis, and preliminary findings on patisiran and inotersen in patients with ATTR-related neuropathy and cardiac involvement, we provide an update on this rapidly evolving field, together with practical recommendations on the management of cardiac involvement.
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Affiliation(s)
- Michele Emdin
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà 33, Pisa, Italy.,Cardiology Department, Fondazione Toscana Gabriele Monasterio, Via G. Moruzzi 1, Pisa, Italy
| | - Alberto Aimo
- Cardiology Division, University Hospital of Pisa, via Paradisa 2, Pisa, Italy
| | - Claudio Rapezzi
- Cardiology Division, University Hospital of Bologna, via Massarenti 9, Bologna, Italy
| | - Marianna Fontana
- Institute of Cardiovascular Science, University College London, 62 Huntley St, Fitzrovia, London, UK.,National Amyloidosis Centre, University College London, Royal Free Hospital, Gower Street, London, UK
| | - Federico Perfetto
- Regional Amyloid Centre, Azienda Ospedaliero Universitaria Careggi, Largo Piero Palagi 1, Florence, Italy.,Department of Internal and Experimental Medicine, University of Florence, Largo Piero Palagi 1, Florence, Italy
| | - Petar M Seferović
- Department of Internal Medicine, Belgrade University School of Medicine, Dr Subotica 8, Belgrade, Serbia.,Cardiology Department, University Institute for Cardiovascular Diseases, Heroja Milana Tepića 1, Belgrade, Serbia
| | - Andrea Barison
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà 33, Pisa, Italy.,Cardiology Department, Fondazione Toscana Gabriele Monasterio, Via G. Moruzzi 1, Pisa, Italy
| | - Vincenzo Castiglione
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà 33, Pisa, Italy.,Cardiology Division, University Hospital of Pisa, via Paradisa 2, Pisa, Italy
| | - Giuseppe Vergaro
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà 33, Pisa, Italy.,Cardiology Department, Fondazione Toscana Gabriele Monasterio, Via G. Moruzzi 1, Pisa, Italy
| | - Alberto Giannoni
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà 33, Pisa, Italy.,Cardiology Department, Fondazione Toscana Gabriele Monasterio, Via G. Moruzzi 1, Pisa, Italy
| | - Claudio Passino
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà 33, Pisa, Italy.,Cardiology Department, Fondazione Toscana Gabriele Monasterio, Via G. Moruzzi 1, Pisa, Italy
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Centre, Fondazione IRCCS Policlinico San Matteo, Viale Camillo Golgi 19, Pavia, Italy.,Department of Molecular Medicine, University of Pavia, Via C Forlanini 6, Pavia, Italy
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Khanna S, Lo P, Cho K, Subbiah R. Ventricular Arrhythmias in Cardiac Amyloidosis: A Review of Current Literature. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2020; 14:1179546820963055. [PMID: 33088185 PMCID: PMC7545745 DOI: 10.1177/1179546820963055] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 09/06/2020] [Indexed: 01/29/2023]
Abstract
Cardiac Amyloidosis is an infiltrative cardiomyopathy which occurs secondary to deposition of mis-folded protein in the myocardium, with the two most common subtypes being AL amyloidosis and TTR amyloidosis. The pathogenesis of the disease is multifaceted and involves a variety of mechanisms including an inflammatory response cascade, oxidative stress and subsequent separation of myocyte fibrils. Cardiac Amyloidosis frequently results in congestive cardiac failure and arrhythmias, from a disruption in cardiac substrate with subsequent electro-mechanical remodelling. Disease progression is usually demonstrated by development of progressive pump failure, which may be seen with a high arrhythmic burden, usually portending a poor prognosis. There is a paucity of literature on the clinical implications of ventricular arrhythmias in the context of cardiac amyloidosis. The important diagnostic investigations for these patients include transthoracic echocardiography, cardiac magnetic resonance imaging and an electrophysiology study. Whilst there are no robust management guidelines, studies have indicated benefits from contemporary pharmacological therapy and case-by-case catheter ablation. There are novel directed therapies available for TTR amyloidosis that have shown to improve overall survival. The role of ICD therapy in cardiac amyloidosis is controversial, with benefits seen predominantly in early phases of the disease process. The only definitive surgical therapy includes heart transplantation, but is largely indicated for progressive decompensated heart failure (Figure 1). Further large-scale studies are required to better outline management paradigms for treating ventricular arrhythmias in cardiac amyloidosis.
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Affiliation(s)
- Shaun Khanna
- Department of Cardiology, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Phillip Lo
- Department of Cardiology, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Kenneth Cho
- Department of Cardiology, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Rajesh Subbiah
- Department of Cardiology, St Vincent's Hospital, Darlinghurst, NSW, Australia.,University of New South Wales, Kensington, Sydney, NSW, Australia.,Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia
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Rehorn MR, Loungani RS, Black-Maier E, Coniglio AC, Karra R, Pokorney SD, Khouri MG. Cardiac Implantable Electronic Devices: A Window Into the Evolution of Conduction Disease in Cardiac Amyloidosis. JACC Clin Electrophysiol 2020; 6:1144-1154. [PMID: 32972550 DOI: 10.1016/j.jacep.2020.04.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 03/30/2020] [Accepted: 04/17/2020] [Indexed: 12/28/2022]
Abstract
OBJECTIVES This study characterized the relationship between conduction disease and cardiac amyloidosis (CA) through longitudinal analysis of cardiac implantable electronic device (CIED) data. BACKGROUND Bradyarrhythmias and tachyarrhythmias are commonly reported in CA and may precede a CA diagnosis, although the natural history of conduction disease in CA is not well-described. METHODS Patients with CA (transthyretin amyloidosis cardiomyopathy [ATTR-CM] and light-chain amyloidosis [AL-CA]) and a CIED were identified within the Duke University Health System. Patient characteristics at the time of implantation, including demographics and data relevant to CA diagnosis, cardiac imaging, and CIED were recorded. CIED interrogations were analyzed for pacing and atrial fibrillation (AF) burden, activity level, lead parameters, and ventricular arrhythmia incidence and/or therapy. RESULTS Thirty-four patients with CA (7 with AL-CA, 27 with ATTR-CM [78% with wild-type]; 82% men) with median age of 75 years and a mean ejection fraction of 42 ± 13% had a CIED implanted for bradycardia (65%) or prevention of sudden cardiac death (35%). CIED implantation preceded CA diagnosis in 14 patients (41%). Over a mean follow-up of 3.1 ± 4.0 years, right ventricular sensing amplitudes decreased but did not result in device malfunction; lead impedances and capture thresholds remained stable. Between post-implantation years 1 and 5, mean ventricular pacing increased from 56 ± 9% to 96 ± 1% (p = 0.003) and AF burden increased from 2 ± 1.3 to 17 ± 3 h/day (p = 0.0002). Ventricular arrhythmias were common (mean episodes per patient per year: 6.7 ± 2.3 [ATTR-CM] and 5.1 ± 3.2 [AL-CA]) but predominately nonsustained; only 1 patient with AL-CA required implantable cardioverter-defibrillator therapy. CONCLUSIONS Longitudinal analysis of CIED data in patients with CA revealed progressive conduction disease, with high AF burden and eventual dependence on ventricular pacing, although lead parameters remained stable. Ventricular arrhythmias were common but predominantly nonsustained, particularly in ATTR-CM.
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Affiliation(s)
- Michael R Rehorn
- Division of Cardiology, Duke University Hospital, Durham, North Carolina, USA
| | - Rahul S Loungani
- Division of Cardiology, Duke University Hospital, Durham, North Carolina, USA
| | - Eric Black-Maier
- Division of Cardiology, Duke University Hospital, Durham, North Carolina, USA
| | - Amanda C Coniglio
- Division of Cardiology, Duke University Hospital, Durham, North Carolina, USA
| | - Ravi Karra
- Division of Cardiology, Duke University Hospital, Durham, North Carolina, USA
| | - Sean D Pokorney
- Division of Cardiology, Duke University Hospital, Durham, North Carolina, USA
| | - Michel G Khouri
- Division of Cardiology, Duke University Hospital, Durham, North Carolina, USA.
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A Peak into the Pace of Cardiac Amyloidosis. JACC Clin Electrophysiol 2020; 6:1155-1157. [PMID: 32972551 DOI: 10.1016/j.jacep.2020.05.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 05/12/2020] [Indexed: 11/23/2022]
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Higgins AY, Annapureddy AR, Wang Y, Minges KE, Lampert R, Rosenfeld LE, Jacoby DL, Curtis JP, Miller EJ, Freeman JV. Survival Following Implantable Cardioverter-Defibrillator Implantation in Patients With Amyloid Cardiomyopathy. J Am Heart Assoc 2020; 9:e016038. [PMID: 32867553 PMCID: PMC7726970 DOI: 10.1161/jaha.120.016038] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background Outcomes data in patients with cardiac amyloidosis after implantable cardioverter-defibrillator (ICD) implantation are limited. We compared outcomes of patients with ICDs implanted for cardiac amyloidosis versus nonischemic cardiomyopathies (NICMs) and evaluated factors associated with mortality among patients with cardiac amyloidosis. Methods and Results Using National Cardiovascular Data Registry's ICD Registry data between April 1, 2010 and December 31, 2015, we created a 1:5 propensity-matched cohort of patients implanted with ICDs with cardiac amyloidosis and NICM. We compared mortality between those with cardiac amyloidosis and matched patients with NICM using Kaplan-Meier survival curves and Cox proportional hazards models. We also evaluated risk factors associated with 1-year mortality in patients with cardiac amyloidosis using multivariable Cox proportional hazards regression models. Among 472 patients with cardiac amyloidosis and 2360 patients with propensity-matched NICMs, 1-year mortality was significantly higher in patients with cardiac amyloidosis compared with patients with NICMs (26.9% versus 11.3%, P<0.001). After adjustment for covariates, cardiac amyloidosis was associated with a significantly higher risk of all-cause mortality (hazard ratio [HR], 1.80; 95% CI, 1.56-2.08). In a multivariable analysis of patients with cardiac amyloidosis, several factors were significantly associated with mortality: syncope (HR, 1.78; 95% CI, 1.22-2.59), ventricular tachycardia (HR, 1.65; 95% CI, 1.15-2.38), cerebrovascular disease (HR, 2.03; 95% CI, 1.28-3.23), diabetes mellitus (HR, 1.55; 95% CI, 1.05-2.27), creatinine = 1.6 to 2.5 g/dL (HR, 1.99; 95% CI, 1.32-3.02), and creatinine >2.5 (HR, 4.34; 95% CI, 2.72-6.93). Conclusions Mortality after ICD implantation is significantly higher in patients with cardiac amyloidosis than in patients with propensity-matched NICMs. Factors associated with death among patients with cardiac amyloidosis include prior syncope, ventricular tachycardia, cerebrovascular disease, diabetes mellitus, and impaired renal function.
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Affiliation(s)
- Angela Y Higgins
- Section of Cardiovascular Medicine Department of Internal Medicine Yale University School of Medicine New Haven CT
| | - Amarnath R Annapureddy
- Section of Cardiovascular Medicine Department of Internal Medicine Yale University School of Medicine New Haven CT.,Center for Outcomes Research and Evaluation Yale New Haven Health Services Corporation New Haven CT
| | - Yongfei Wang
- Center for Outcomes Research and Evaluation Yale New Haven Health Services Corporation New Haven CT
| | - Karl E Minges
- Center for Outcomes Research and Evaluation Yale New Haven Health Services Corporation New Haven CT
| | - Rachel Lampert
- Section of Cardiovascular Medicine Department of Internal Medicine Yale University School of Medicine New Haven CT
| | - Lynda E Rosenfeld
- Section of Cardiovascular Medicine Department of Internal Medicine Yale University School of Medicine New Haven CT
| | - Daniel L Jacoby
- Section of Cardiovascular Medicine Department of Internal Medicine Yale University School of Medicine New Haven CT
| | - Jeptha P Curtis
- Section of Cardiovascular Medicine Department of Internal Medicine Yale University School of Medicine New Haven CT.,Center for Outcomes Research and Evaluation Yale New Haven Health Services Corporation New Haven CT
| | - Edward J Miller
- Section of Cardiovascular Medicine Department of Internal Medicine Yale University School of Medicine New Haven CT
| | - James V Freeman
- Section of Cardiovascular Medicine Department of Internal Medicine Yale University School of Medicine New Haven CT.,Center for Outcomes Research and Evaluation Yale New Haven Health Services Corporation New Haven CT
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Isath A, Correa A, Siroky GP, Perimbeti S, Mohammed S, Chahal CAA, Padmanabhan D, Mehta D. Trends, burden, and impact of arrhythmia on cardiac amyloid patients: A 16-year nationwide study from 1999 to 2014. J Arrhythm 2020; 36:727-734. [PMID: 32782646 PMCID: PMC7411211 DOI: 10.1002/joa3.12376] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 05/12/2020] [Accepted: 05/15/2020] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Patients with cardiac amyloidosis (CA) have increased mortality, which can be explained in part by an increased risk of arrhythmias. The burden of arrhythmias in CA, their predictors, and impact on in-hospital outcomes remains unclear. The role of implantable cardioverter-defibrillators (ICD) in this population is also uncertain. METHODS We queried the National Inpatient Sample (NIS) using ICD-9-CM codes 277.39 and 425.7 to identify CA. Twelve common arrhythmias were extracted using appropriate, validated ICD-9-CM codes. ICD implantation was identified using procedure ICD-9 codes 37.94 to 37.98, 00.51 and 00.54. RESULTS There were a total of 145,920 CA hospitalizations between 1999 and 2014 in the United States and 56,199 (38.5%) of them were associated with arrhythmias. The prevalence of arrhythmias remained relatively constant from 41.5% in 1999 to 40.2% in 2014. The most common arrhythmia was atrial fibrillation (25.4%). In-patient mortality was significantly higher in CA patients with arrhythmias (10.4% vs 6.5%, P < .001). ICD implantation was performed in 1,381 (0.94%) patients with CA and analysis revealed an incremental trend in implantation over the study period (0.48% in 1999 to 0.65% in 2014). In-hospital mortality was significantly lower in patients who underwent ICD implantation (3.7% vs 8%; P = .0078). CA patients with arrhythmias also had an increased cost of hospitalization and length of stay ($65,046 ± 1,079 vs $53,322 ± 687 and 8.3 ± 0.1 vs 7.4 ± 0.1 days, respectively; P < .0001). CONCLUSION Cardiac arrhythmias are common in patients with CA and are associated with worse in-hospital outcomes, increased length of stay, and cost of hospitalization.
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Affiliation(s)
- Ameesh Isath
- Department of MedicineMount Sinai St. Luke's and Mount Sinai WestNew YorkNYUSA
| | - Ashish Correa
- Department of CardiologyMount Sinai St. Luke'sNew YorkNYUSA
| | | | - Stuthi Perimbeti
- Department of MedicineMount Sinai St. Luke's and Mount Sinai WestNew YorkNYUSA
| | - Selma Mohammed
- Department of Cardiovascular MedicineMedStar Washington Hospital CenterWashingtonDCUSA
| | - C. Anwar A. Chahal
- Department of Cardiovascular MedicineMayo ClinicJacksonvilleFLUSA
- University of PennsylvaniaPhiladelphiaPAUSA
| | - Deepak Padmanabhan
- Department of Cardiovascular MedicineMayo ClinicJacksonvilleFLUSA
- Sri Jayadeva Institute of Cardiovascular Sciences and Research, CardiologyBengaluruKarnatakaIndia
| | - Davendra Mehta
- Department of CardiologyMount Sinai St. Luke'sNew YorkNYUSA
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Abstract
PURPOSE Amyloidosis represents an increasingly recognized but still frequently missed cause of heart failure. In the light of many effective therapies for light chain (AL) amyloidosis and promising new treatment options for transthyretin (ATTR) amyloidosis, awareness among caregivers needs to be raised to screen for amyloidosis as an important and potentially treatable differential diagnosis. This review outlines the diversity of cardiac amyloidosis, its relation to heart failure, the diagnostic algorithm, and therapeutic considerations that should be applied depending on the underlying type of amyloidosis. RECENT FINDINGS Non-biopsy diagnosis is feasible in ATTR amyloidosis in the absence of a monoclonal component resulting in higher detection rates of cardiac ATTR amyloidosis. Biomarker-guided staging systems have been updated to facilitate risk stratification according to currently available biomarkers independent of regional differences, but have not yet prospectively been tested. Novel therapies for hereditary and wild-type ATTR amyloidosis are increasingly available. The complex treatment options for AL amyloidosis are improving continuously, resulting in better survival and quality of life. Mortality in advanced cardiac amyloidosis remains high, underlining the importance of early diagnosis and treatment initiation. Cardiac amyloidosis is characterized by etiologic and clinical heterogeneity resulting in a frequently delayed diagnosis and an inappropriately high mortality risk. New treatment options for this hitherto partially untreatable condition have become and will become available, but raise challenges regarding their implementation. Referral to specialized centers providing access to extensive and targeted diagnostic investigations and treatment initiation may help to face these challenges.
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Aouate D, Menet A, Bellevre D, Damy T, Marechaux S. Deleterious effect of right ventricular pacing in patients with cardiac transthyretin amyloidosis: potential clinical benefit of cardiac resynchronization therapy. EUROPEAN HEART JOURNAL-CASE REPORTS 2020; 4:1-5. [PMID: 32617488 PMCID: PMC7319833 DOI: 10.1093/ehjcr/ytaa088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 01/02/2020] [Accepted: 03/24/2020] [Indexed: 11/14/2022]
Abstract
Background Cardiac amyloidosis involvement is associated with a detrimental outcome including frequent arrhythmias, heart failure, and conduction disturbances which may need permanent pacing. Cases summary We report two cases of patients with transthyretin amyloidosis (ATTR) who developed heart failure and depressed left ventricular ejection fraction (LVEF) following permanent right ventricular (RV) pacing but highly responded to cardiac resynchronization therapy (CRT). Discussion The impact of RV pacing and CRT in cardiac amyloidosis is not known. In our cases, the detrimental effect of permanent RV pacing on left ventricular (LV) systolic function and heart failure symptoms was suggested by both permanent RV pacing mediated functional and LV function decline and LV systolic dysfunction reversal following CRT along with QRS width reduction. Whether cardiac resynchronization should be readily recommended in ATTR patients who need ventricular pacing whatever the LVEF deserves further investigation.
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Affiliation(s)
- David Aouate
- Cardiology Department, GCS-Groupement des Hôpitaux de l'Institut Catholique Lillois/Faculté de médecine et de maïeutique, UCLille, F-59000 Lille, France
| | - Aymeric Menet
- Cardiology Department, GCS-Groupement des Hôpitaux de l'Institut Catholique Lillois/Faculté de médecine et de maïeutique, UCLille, F-59000 Lille, France
| | - Dimitri Bellevre
- Department of Nuclear Medicine, UF 5881, Groupement des Hôpitaux de l'Institut Catholique de Lille, Hôpital Saint Philibert rue du grand but, 59160 Lomme, France
| | - Thibaud Damy
- Department of Cardiology, Referral Center for Cardiac Amyloidosis, Mondor Amyloidosis Network, GRC Amyloid Research Institute, Clinical Investigation Center 006, DHU A-TVB INSERM U955 all at CHU Henri Mondor, UPEC, Créteil, France
| | - Sylvestre Marechaux
- Cardiology Department, GCS-Groupement des Hôpitaux de l'Institut Catholique Lillois/Faculté de médecine et de maïeutique, UCLille, F-59000 Lille, France
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Halawa A, Woldu HG, Kacey KG, Alpert MA. Effect of ICD implantation on cardiovascular outcomes in patients with cardiac amyloidosis: A systematic review and meta-anaylsis. J Cardiovasc Electrophysiol 2020; 31:1749-1758. [PMID: 32391952 DOI: 10.1111/jce.14541] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 03/26/2020] [Accepted: 04/24/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Cardiac amyloidosis is associated with a high rate of sudden cardiac death (SCD). Whether implantable cardioverter-defibrillator (ICD) use in such patients prevents SCD is uncertain. This study assesses outcomes of ICD use in patients with cardiac amyloidosis. METHODS A systematic review and meta-analysis of data were performed after searching multiple databases and scientific sites pertaining to ICD use and cardiac amyloidosis. Of 8260 citations identified, six studies comprising 194 patients met inclusion criteria. RESULTS Mean values and frequencies of patient characteristics were as follows: mean NT-proBNP: 6867.9 pg/mL, mean left ventricular ejection fraction: 48.1%, heart failure: 67%, nonsustained ventricular tachycardia: 51%, syncope: 21%, and secondary prevention: 33%. During the mean follow-up period of 18.21 months, 18% of patients received appropriate ICD treatment and 5% received inappropriate ICD treatment. The mortality rate was 31%. Two studies assessed the difference between patients with appropriate ICD treatment and patients with absence of appropriate ICD treatment. There was no difference between the two groups when stratified on multiple selected third variables except for two subgroups. Male gender was associated with a higher rate of appropriate ICD treatment, whereas New York Heart Association class III or IV heart failure patients was associated with a lower rate of appropriate ICD treatment. CONCLUSION The frequency of appropriate ICD treatment in cardiac amyloidosis is low and is not predicted by nonsustained ventricular tachycardia. Male gender is associated with appropriate ICD treatment. New York Heart Association class III or IV heart failure is associated with lower rate of appropriate ICD treatment.
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Affiliation(s)
- Ahmad Halawa
- Division of Cardiovascular Medicine, University of Missouri School of Medicine, Columbia, Missouri
| | - Henok G Woldu
- Biostatistics Design Unit, University of Missouri School of Medicine, Columbia, Missouri
| | - Kristina Gifft Kacey
- Division of Cardiovascular Medicine, University of Missouri School of Medicine, Columbia, Missouri
| | - Martin A Alpert
- Division of Cardiovascular Medicine, University of Missouri School of Medicine, Columbia, Missouri
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Itzhaki Ben Zadok O, Kornowski R. Cardiac Care of Patients with Cardiac Amyloidosis. Acta Haematol 2020; 143:343-351. [PMID: 32408301 DOI: 10.1159/000506919] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 02/28/2020] [Indexed: 12/20/2022]
Abstract
Cardiac amyloidosis, the majority of cases of which are due to immunoglobulin light chain amyloidosis (AL) and transthyretin amyloidosis (ATTR), affects different aspects of the heart and cardiovascular system. Amyloid-induced cardiomyopathy, clinically manifesting with heart failure and electrophysiological abnormalities, has distinct characteristics compared to non-amyloid cardiomyopathies. Accordingly, specific management strategies are required. This paper will review the cardiovascular manifestations of patients with cardiac amyloidosis and their suggested treatment strategies, emphasizing the importance of multidisciplinary care.
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Affiliation(s)
- Osnat Itzhaki Ben Zadok
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel,
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,
| | - Ran Kornowski
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Macedo AVS, Schwartzmann PV, de Gusmão BM, Melo MDTD, Coelho-Filho OR. Advances in the Treatment of Cardiac Amyloidosis. Curr Treat Options Oncol 2020; 21:36. [PMID: 32328845 PMCID: PMC7181421 DOI: 10.1007/s11864-020-00738-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OPINION STATEMENT Cardiac amyloidosis is associated with a high mortality rate, a long delay between the first signs and the diagnosis but a short interval between diagnosis and death. This scenario has changed recently due to improved disease awareness among doctors and significant progress in diagnosis thanks to multimodal imaging and a multidisciplinary approach. Therefore, during the last few years, we have had access to specific therapies for those patients. Those therapies are quite different depending on the type of amyloidosis, but there has been real progress. Systemic light chain amyloidosis (AL) with cardiac involvement is the most common form of cardiac amyloidosis. The severity of heart disease dictates the prognosis in AL amyloidosis. Advances in chemotherapy and immunotherapy that suppress light chain production have improved the outcomes. These recent improvements in survival rates have enabled therapies such as implanted cardiac defibrillators and heart transplantation that were usually not indicated for patients with advanced light chain amyloid cardiomyopathy to now be applied in selected patients. For transthyretin amyloidosis (ATTR), the second most common form of amyloidosis with cardiac involvement, there is also significant progress in treatment. Until recently, we had no specific therapy for ATTR cardiomyopathy (ATTR-CM), though now disease-modifying therapies are available. Therapies that stabilize transthyretin, such as tafamidis, have been shown to improve outcomes for patients with ATTR-CM. Modern treatments that stop the synthesis of TTR through gene silencing, such as patisiran and inotersen, have shown positive results for patients with TTR amyloidosis. Significant progress has been made in the treatment of amyloid cardiomyopathy, and hopefully, we will see even more progress with the spread of those treatments. We now can be optimistic about patients with this disease.
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Affiliation(s)
| | | | | | | | - Otávio Rizzi Coelho-Filho
- Department of Internal Medicine, Discipline of Cardiology, Faculty of Medical Science, State University of Campinas, Campinas, Brazil
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Quarta CC, Tinuper AL, Milandri A, Gagliardi C, Caponeti G, Rapezzi C. A new therapy for transthyretin amyloidosis, no longer an orphan condition. Eur Heart J Suppl 2020; 22:E125-E131. [PMID: 32523456 PMCID: PMC7270922 DOI: 10.1093/eurheartj/suaa077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Amyloid cardiomyopathy is a condition characterized by intra-myocardial deposit of protein-like material, in fibrillar shape (amyloid), which presence determine a progressive thickening and stiffening of the cardiac walls leading to a cardiac dysfunction. The proteins most often involved with cardiac amyloid are the light chains of the immunoglobulin, typical of amyloidosis AL, and transthyretin, responsible for transthyretin amyloidosis, in both its forms, hereditary and wild type. An accurate estimate of the incidence of cardiac amyloidosis is still difficult due to the variety and complexity of the clinical presentation of the condition. Nonetheless, the condition has stimulated the interest of the scientific community, so that a specific diagnostic path has been developed, beginning from the clinical suspicion and first-line testing, such as electrocardiogram, echocardiogram, and blood work, to progress to the diagnostic confirmation using more sophisticated testing such as magnetic resonance, scintiscan, and eventually cardiac biopsy. To understand and recognize this condition is very important, stemming from the availability of ‘aetiology oriented therapies’ (designed to prevent, control and possibly regress amyloid deposition), which should be added to the ‘supportive therapies’, used for the treatment of the complication of the condition, namely heart failure.
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Affiliation(s)
- Candida Cristina Quarta
- Unità di Cardiologia, Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Alma Mater Studiorum-Università di Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy.,Division of Medicine, National Amyloidosis Centre, UCL, Royal Free Hospital, London, UK
| | - Anna Laura Tinuper
- Unità di Cardiologia, Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Alma Mater Studiorum-Università di Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Agnese Milandri
- Unità di Cardiologia, Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Alma Mater Studiorum-Università di Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Christian Gagliardi
- Unità di Cardiologia, Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Alma Mater Studiorum-Università di Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Giuseppe Caponeti
- Unità di Cardiologia, Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Alma Mater Studiorum-Università di Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Claudio Rapezzi
- Unità di Cardiologia, Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Alma Mater Studiorum-Università di Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy
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Cibeira MT, Ortiz-Pérez JT, Quintana LF, Fernádez de Larrea C, Tovar N, Bladé J. Supportive Care in AL Amyloidosis. Acta Haematol 2020; 143:335-342. [PMID: 32235118 DOI: 10.1159/000506760] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 02/25/2020] [Indexed: 12/17/2022]
Abstract
Immunoglobulin light-chain (AL) amyloidosis is a systemic disease characterized by the production and deposition of light chain-derived amyloid fibrils in different organs. Prompt treatment directed to the underlying plasma cell clone is crucial in order to achieve a rapid, deep and durable hematologic response. The decrease in the production of the amyloidogenic light chains is a required condition to obtain the organ response, which is commonly delayed. Meanwhile, supportive treatment is aimed to maintain quality of life of these patients and preserve their involved organs' function. From simple measures, such as salt restriction or compressive stockings, to very complex interventions, such as heart transplantation in very selected patients with isolated severe cardiac involvement, this supportive care is essential and has to be necessarily included in the multidisciplinary management of this disease.
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Affiliation(s)
- M Teresa Cibeira
- Hematology Department, Amyloidosis and Myeloma Unit, Hospital Clínic of Barcelona, University of Barcelona, IDIBAPS, Barcelona, Spain,
| | - José T Ortiz-Pérez
- Cardiology Department, Amyloidosis and Myeloma Unit, Hospital Clínic of Barcelona, University of Barcelona, IDIBAPS, Barcelona, Spain
| | - Luis F Quintana
- Nephrology Department, Amyloidosis and Myeloma Unit, Complex Glomerular Disease Unit (CSUR), Hospital Clínic of Barcelona, University of Barcelona, IDIBAPS, Barcelona, Spain
| | - Carlos Fernádez de Larrea
- Hematology Department, Amyloidosis and Myeloma Unit, Hospital Clínic of Barcelona, University of Barcelona, IDIBAPS, Barcelona, Spain
| | - Natalia Tovar
- Hematology Department, Amyloidosis and Myeloma Unit, Hospital Clínic of Barcelona, University of Barcelona, IDIBAPS, Barcelona, Spain
| | - Joan Bladé
- Hematology Department, Amyloidosis and Myeloma Unit, Hospital Clínic of Barcelona, University of Barcelona, IDIBAPS, Barcelona, Spain
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