1
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Slivnick JA, Singulane C, Sun D, Eshun D, Narang A, Mazzone S, Addetia K, Patel AR, Zareba KM, Smart S, Kwon JW, Husain A, Cody B, Scheetz S, Asch FM, Goyal A, Sarswat N, Mor-Avi V, Lang RM. Preservation of Circumferential and Radial Left Ventricular Function as a Mitigating Mechanism for Impaired Longitudinal Strain in Early Cardiac Amyloidosis. J Am Soc Echocardiogr 2023; 36:1290-1301. [PMID: 37574149 DOI: 10.1016/j.echo.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 07/05/2023] [Accepted: 08/01/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND In patients with cardiac amyloidosis (CA), left ventricular ejection fraction (LVEF) is frequently preserved, despite commonly reduced global longitudinal strain (GLS). We hypothesized that nonlongitudinal contraction may initially serve as a mitigating mechanism to maintain cardiac output and studied the relationship between global circumferential (GCS) and radial (GRS) strain with LVEF and extracellular volume (ECV), a marker of amyloid burden. METHODS Patients with CA who underwent cardiac magnetic resonance (CMR; n = 140, 70.7 ± 11.5 years, 66% male) or echocardiography (n = 67, 71 ± 13 years, 66% male) and normal controls (CMR, n = 20; echocardiography, n = 45) were retrospectively identified, and GCS, GLS, and GRS were quantified using feature-tracking CMR or speckle-tracking echocardiography and compared between CA patients with preserved and reduced LVEF (CAHFpEF, CAHFrEF) and controls. The prevalence of impaired strain (magnitudes <2.5th percentile of the controls) was compared between CAHFpEF and CAHFrEF and between ECV quartiles. RESULTS While echocardiography-derived GLS was impaired in both CAHFpEF (-13.4% ± 3.1%, P < .003) and CAHFrEF (-9.1% ± 3.2%, P < .003), compared with controls (-20.8% ± 2.4%), GCS was more impaired in CAHFrEF compared with both controls (-15.6% ± 5.0% vs -32.3% ± 3.3%, P < .003) and CAHFpEF (-30.4% ± 5.7%, P < .003) and did not differ between CAHFpEF and controls (P = .24). The prevalence of abnormal CMR-derived GCS (P < .0001) and GRS (P < .0001) but not GLS (P = .054) varied significantly across ECV quartiles. CONCLUSIONS Among CA patients with preserved LVEF, preserved GCS and GRS, despite near-universally impaired GLS, may be explained by an initial predominantly subendocardial involvement, where mostly longitudinal fibers are located. If confirmed in future studies, these findings may facilitate identification of patients with early stages of CA, when treatments may be most effective.
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Affiliation(s)
- Jeremy A Slivnick
- Division of Cardiology, University of Chicago Medical Center, Chicago, Illinois
| | - Cristiane Singulane
- Division of Cardiology, University of Chicago Medical Center, Chicago, Illinois
| | - Deyu Sun
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Derek Eshun
- Division of Cardiology, Northwestern Medicine, Chicago, Illinois
| | - Akhil Narang
- Division of Cardiology, Northwestern Medicine, Chicago, Illinois
| | - Steven Mazzone
- Division of Cardiology, University of Chicago Medical Center, Chicago, Illinois
| | - Karima Addetia
- Division of Cardiology, University of Chicago Medical Center, Chicago, Illinois
| | - Amit R Patel
- Division of Cardiology, University of Virginia, Charlottesville, Virginia
| | - Karolina M Zareba
- Division of Cardiology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Suzanne Smart
- Division of Cardiology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Jung Woo Kwon
- Division of Cardiology, University of Chicago Medical Center, Chicago, Illinois
| | - Aliya Husain
- Division of Cardiology, University of Chicago Medical Center, Chicago, Illinois
| | - Brittany Cody
- Division of Cardiology, University of Chicago Medical Center, Chicago, Illinois
| | - Seth Scheetz
- Division of Cardiology, University of Chicago Medical Center, Chicago, Illinois
| | - Federico M Asch
- Division of Cardiology, Medstar Health, Washington, District of Columbia
| | - Akash Goyal
- Division of Cardiology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Nitasha Sarswat
- Division of Cardiology, University of Chicago Medical Center, Chicago, Illinois
| | - Victor Mor-Avi
- Division of Cardiology, University of Chicago Medical Center, Chicago, Illinois
| | - Roberto M Lang
- Division of Cardiology, University of Chicago Medical Center, Chicago, Illinois.
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2
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Jaiswal V, Agrawal V, Khulbe Y, Hanif M, Huang H, Hameed M, Shrestha AB, Perone F, Parikh C, Gomez SI, Paudel K, Zacks J, Grubb KJ, De Rosa S, Gimelli A. Cardiac amyloidosis and aortic stenosis: a state-of-the-art review. EUROPEAN HEART JOURNAL OPEN 2023; 3:oead106. [PMID: 37941729 PMCID: PMC10630099 DOI: 10.1093/ehjopen/oead106] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 10/03/2023] [Accepted: 10/04/2023] [Indexed: 11/10/2023]
Abstract
Cardiac amyloidosis is caused by the extracellular deposition of amyloid fibrils in the heart, involving not only the myocardium but also any cardiovascular structure. Indeed, this progressive infiltrative disease also involves the cardiac valves and, specifically, shows a high prevalence with aortic stenosis. Misfolded protein infiltration in the aortic valve leads to tissue damage resulting in the onset or worsening of valve stenosis. Transthyretin cardiac amyloidosis and aortic stenosis coexist in patients > 65 years in about 4-16% of cases, especially in those undergoing transcatheter aortic valve replacement. Diagnostic workup for cardiac amyloidosis in patients with aortic stenosis is based on a multi-parametric approach considering clinical assessment, electrocardiogram, haematologic tests, basic and advanced echocardiography, cardiac magnetic resonance, and technetium labelled cardiac scintigraphy like technetium-99 m (99mTc)-pyrophosphate, 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid, and 99mTc-hydroxymethylene diphosphonate. However, a biopsy is the traditional gold standard for diagnosis. The prognosis of patients with coexisting cardiac amyloidosis and aortic stenosis is still under evaluation. The combination of these two pathologies worsens the prognosis. Regarding treatment, mortality is reduced in patients with cardiac amyloidosis and severe aortic stenosis after undergoing transcatheter aortic valve replacement. Further studies are needed to confirm these findings and to understand whether the diagnosis of cardiac amyloidosis could affect therapeutic strategies. The aim of this review is to critically expose the current state-of-art regarding the association of cardiac amyloidosis with aortic stenosis, from pathophysiology to treatment.
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Affiliation(s)
- Vikash Jaiswal
- Department of Cardiovascular Research, Larkin Community Hospital, South Miami, FL, USA
| | - Vibhor Agrawal
- Department of Medicine, King George’s Medical University, Lucknow, India
| | - Yashita Khulbe
- Department of Medicine, King George’s Medical University, Lucknow, India
| | - Muhammad Hanif
- Department of Internal Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Helen Huang
- University of Medicine and Health Science, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Maha Hameed
- Department of Internal Medicine, Florida State University, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Abhigan Babu Shrestha
- Department of Internal Medicine, M Abdur Rahim Medical College, Dinajpur, Bangladesh
| | - Francesco Perone
- Cardiac Rehabilitation Unit, Rehabilitation Clinic ‘Villa delle Magnolie’,81020 Castel Morrone, Caserta, Italy
| | | | - Sabas Ivan Gomez
- Department of Cardiovascular Research, Larkin Community Hospital, South Miami, FL, USA
| | - Kusum Paudel
- Department of Medicine, Kathmandu University School of Medical Science, Dhulikhel, Kathmandu 45209, Nepal
| | - Jerome Zacks
- Department of Cardiology, The Icahn Medical School at Mount Sinai, NewYork 10128, USA
| | - Kendra J Grubb
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Salvatore De Rosa
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Alessia Gimelli
- Department of Imaging, Fondazione Toscana/CNR Gabriele Monasterio, Pisa 56124, Italy
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3
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Mellqvist UH, Cai Q, Hester LL, Grövdal M, Börsum J, Rahman I, Ammann EM, Hansson M. Epidemiology and clinical outcomes of light-chain amyloidosis in Sweden: A nationwide population-based study. Eur J Haematol 2023; 111:697-705. [PMID: 37533343 DOI: 10.1111/ejh.14063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 07/13/2023] [Accepted: 07/14/2023] [Indexed: 08/04/2023]
Abstract
OBJECTIVES This study evaluated data from six Swedish national registries to fill current evidence gaps on the epidemiology, clinical burden, and overall survival (OS) associated with light-chain (AL) amyloidosis. METHODS Patients newly diagnosed with AL amyloidosis were identified using six linked Swedish nationwide population-based registers. For each case, individuals from the general population were selected and matched with a maximum ratio of 1:5 based on age, sex, calendar year, and county. RESULTS 846 patients newly diagnosed with AL amyloidosis and 4227 demographically matched individuals were identified. From 2011 to 2019, annual AL amyloidosis incidence increased from 10.5 to 15.1 cases per million. At baseline, patients with AL amyloidosis had a significantly higher disease burden including higher rates of cardiac and renal failure relative to the comparison group. Among patients with AL amyloidosis, 21.5% had incident heart failure and 17.1% had incident renal failure after initial diagnosis. Median OS for patients with AL amyloidosis was 56 months versus not reached in the matched general population comparison group. CONCLUSION The incidence of newly diagnosed AL amyloidosis in Sweden increased over time with AL amyloidosis being associated with a higher risk of cardiac/renal failure and all-cause mortality compared with the general population.
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Affiliation(s)
- Ulf-Henrik Mellqvist
- Section of Hematology and Coagulation, Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Qian Cai
- Janssen Global Services, Titusville, New Jersey, USA
| | - Laura L Hester
- Janssen Research & Development, Horsham, Pennsylvania, USA
| | | | | | | | | | - Markus Hansson
- Department of Hematology, Sahlgrenska Academy, Göteborg University and Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Hematology, Skåne University Hospital, Lund, Sweden
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4
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Jackson JW, Foster JS, Martin EB, Macy S, Wooliver C, Balachandran M, Richey T, Heidel RE, Williams AD, Kennel SJ, Wall JS. Collagen inhibits phagocytosis of amyloid in vitro and in vivo and may act as a 'don't eat me' signal. Amyloid 2023; 30:249-260. [PMID: 36541892 DOI: 10.1080/13506129.2022.2155133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/04/2022] [Accepted: 11/29/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Systemic amyloidosis refers to a group of protein misfolding disorders characterized by the extracellular deposition of amyloid fibrils in organs and tissues. For reasons heretofore unknown, amyloid deposits are not recognized by the immune system, and progressive deposition leads to organ dysfunction. METHODS In vitro and in vivo phagocytosis assays were performed to elucidate the impact of collagen and other amyloid associated proteins (eg serum amyloid p component and apolipoprotein E) had on amyloid phagocytosis. Immunohistochemical and histopathological staining regimens were employed to analyze collagen-amyloid interactions and immune responses. RESULTS Histological analysis of amyloid-laden tissue indicated that collagen is intimately associated with amyloid deposits. We report that collagen inhibits phagocytosis of amyloid fibrils by macrophages. Treatment of 15 patient-derived amyloid extracts with collagenase significantly enhanced amyloid phagocytosis. Preclinical mouse studies indicated that collagenase treatment of amyloid extracts significantly enhanced clearance as compared to controls, coincident with increased immune cell infiltration of the subcutaneous amyloid lesion. CONCLUSIONS These data suggest that amyloid-associated collagen serves as a 'don't eat me' signal, thereby hindering clearance of amyloid. Targeted degradation of amyloid-associated collagen could result in innate immune cell recognition and clearance of pathologic amyloid deposits.
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Affiliation(s)
- Joseph W Jackson
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - James S Foster
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - Emily B Martin
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - Sallie Macy
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - Craig Wooliver
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - Manasi Balachandran
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - Tina Richey
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - R Eric Heidel
- Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - Angela D Williams
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - Stephen J Kennel
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - Jonathan S Wall
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
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5
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Quock TP, D'Souza A, Broder MS, Bognar K, Chang E, Tarbox MH. In-hospital mortality in amyloid light chain amyloidosis: analysis of the Premier Healthcare Database. J Comp Eff Res 2023; 12:e220185. [PMID: 36476016 PMCID: PMC10288963 DOI: 10.2217/cer-2022-0185] [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: 10/25/2022] [Accepted: 11/22/2022] [Indexed: 12/13/2022] Open
Abstract
Aim: Describe the clinical and economic burden of hospitalizations for amyloid light chain (AL) amyloidosis. Materials & methods: This retrospective analysis used nationally representative hospital discharge data (2017-2020) to report discharge status, resource use and costs for hospitalizations among patients with AL amyloidosis. Results: Of 1341 patients identified, 92% were discharged alive and 8% experienced in-hospital death. Compared with the average US hospital stay during 2017-2019 (4.7 days, mean costs of $13,046 and mean charges of $54,496), hospital stays for AL amyloidosis were longer and costlier (9.7 days, $27,098.61, $111,233.91), especially in patients with in-hospital death (12.2 days, $44,966, $182,338.18). Conclusion: AL amyloidosis is associated with significant clinical and economic burden.
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Affiliation(s)
- Tiffany P Quock
- Health Economics and Outcomes Research, Prothena Biosciences Inc, South San Francisco, CA 94080, USA
| | - Anita D'Souza
- Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Michael S Broder
- Real World Evidence, PHAR (Partnership for Health Analytic Research), Beverly Hills, CA 90212, USA
| | - Katalin Bognar
- Real World Evidence, PHAR (Partnership for Health Analytic Research), Beverly Hills, CA 90212, USA
| | - Eunice Chang
- Real World Evidence, PHAR (Partnership for Health Analytic Research), Beverly Hills, CA 90212, USA
| | - Marian H Tarbox
- Real World Evidence, PHAR (Partnership for Health Analytic Research), Beverly Hills, CA 90212, USA
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6
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Punnoose LR, Siddiqi H, Rosenthal J, Kittleson M, Witteles R, Alexander K. Implications of Extra-cardiac Disease in Patient Selection for Heart Transplantation: Considerations in Cardiac Amyloidosis. Card Fail Rev 2023; 9:e01. [PMID: 36891177 PMCID: PMC9987512 DOI: 10.15420/cfr.2022.24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 10/26/2022] [Indexed: 02/01/2023] Open
Abstract
Disease-modifying therapies in both light chain and transthyretin amyloidosis have improved patient functional status and survival. Conceivably, as heart failure may progress despite amyloid therapies, more patients may be considered for heart transplantation. In earlier eras, extra-cardiac amyloid deposits significantly reduced post-heart transplant patient survival and functional status compared to the non-amyloid population. In the modern era, transplant centres have reported improved outcomes in amyloidosis as patient selection has grown more stringent. Importantly, systematic candidate evaluation should assess the degree of extra-cardiac involvement, the effectiveness of disease-modifying therapies and downstream effects on patients' nutrition and frailty. This review outlines such an overall approach while also considering that organ-specific selection criteria may vary between individual transplant centres. A methodical approach to patient evaluation will promote better understanding of the prevalence and severity of extra-cardiac disease in amyloidosis patients referred for heart transplantation and of any disparities in decision outcomes in this population.
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Affiliation(s)
- Lynn Raju Punnoose
- Division of Cardiovascular Medicine, Vanderbilt University School of Medicine Nashville, TN, US
| | - Hasan Siddiqi
- Division of Cardiovascular Medicine, Vanderbilt University School of Medicine Nashville, TN, US
| | - Julie Rosenthal
- Department of Cardiovascular Medicine, Mayo Clinic Phoenix, AZ, US
| | - Michelle Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center Los Angeles, CA, US
| | - Ronald Witteles
- Division of Cardiovascular Medicine, Stanford University School of Medicine Palo Alto, CA, US
| | - Kevin Alexander
- Division of Cardiovascular Medicine, Stanford University School of Medicine Palo Alto, CA, US
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7
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Slivnick JA, Alvi N, Singulane CC, Scheetz S, Goyal A, Patel H, Sarswat N, Addetia K, Fernandes F, Vieira MLC, Cafezeiro CRF, Carvalhal SF, Simonetti OP, Singh J, Lang RM, Zareba KM, Patel AR. Non-invasive diagnosis of transthyretin cardiac amyloidosis utilizing typical late gadolinium enhancement pattern on cardiac magnetic resonance and light chains. Eur Heart J Cardiovasc Imaging 2023; 24:829-837. [PMID: 36624559 DOI: 10.1093/ehjci/jeac249] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 11/19/2022] [Indexed: 01/11/2023] Open
Abstract
AIMS While cardiac magnetic resonance (CMR) is often obtained early in the evaluation of suspected cardiac amyloidosis (CA), it currently cannot be utilized to differentiate immunoglobulin (AL) and transthyretin (ATTR) CA. We aimed to determine whether a novel CMR and light-chain biomarker-based algorithm could accurately diagnose ATTR-CA. METHODS AND RESULTS Patients with confirmed AL or ATTR-CA with typical late gadolinium enhancement (LGE) and Look-Locker pattern for CA on CMR were retrospectively identified at three academic medical centres. Comprehensive light-chain analysis including free light chains, serum, and urine electrophoresis/immunofixation was performed. The diagnostic accuracy of the typical CMR pattern for CA in combination with negative light chains for the diagnosis of ATTR-CA was determined both in the entire cohort and in the subset of patients with invasive tissue biopsy as the gold standard. A total of 147 patients (age 70 ± 11, 76% male, 51% black) were identified: 89 ATTR-CA and 58 AL-CA. Light-chain biomarkers were abnormal in 81 (55%) patients. Within the entire cohort, the sensitivity and specificity of a typical LGE and Look-Locker CMR pattern and negative light chains for ATTR-CA was 73 and 98%, respectively. Within the subset with biopsy-confirmed subtype, the CMR and light-chain algorithm were 69% sensitive and 98% specific. CONCLUSION The combination of a typical LGE and Look-Locker pattern on CMR with negative light chains is highly specific for ATTR-CA. The successful non-invasive diagnosis of ATTR-CA using CMR has the potential to reduce diagnostic and therapeutic delays and healthcare costs for many patients.
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Affiliation(s)
- Jeremy A Slivnick
- Division of Cardiovascular Medicine, The University of Chicago Medicine, Chicago, IL, USA
| | - Nazia Alvi
- Division of Cardiology, AMITA Health Adventist Medical Center, Hinsdale, IL, USA
| | - Cristiane C Singulane
- Division of Cardiovascular Medicine, The University of Chicago Medicine, Chicago, IL, USA
| | - Seth Scheetz
- Division of Cardiovascular Medicine, The University of Chicago Medicine, Chicago, IL, USA
| | - Akash Goyal
- Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Hena Patel
- Division of Cardiovascular Medicine, The University of Chicago Medicine, Chicago, IL, USA
| | - Nitasha Sarswat
- Division of Cardiovascular Medicine, The University of Chicago Medicine, Chicago, IL, USA
| | - Karima Addetia
- Division of Cardiovascular Medicine, The University of Chicago Medicine, Chicago, IL, USA
| | - Fabio Fernandes
- Division of Cardiology, Heart Institute (InCor), São Paulo University Medical School, São Paulo, Brazil
| | | | | | - Suênia Freitas Carvalhal
- Division of Cardiology, Heart Institute (InCor), São Paulo University Medical School, São Paulo, Brazil
| | - Orlando P Simonetti
- Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jai Singh
- Division of Cardiovascular Medicine, Atrium Health, Charlotte, NC, USA
| | - Roberto M Lang
- Division of Cardiovascular Medicine, The University of Chicago Medicine, Chicago, IL, USA
| | - Karolina M Zareba
- Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Amit R Patel
- Division of Cardiovascular Medicine, The University of Virginia Health System, Charlottesville, VA, USA
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8
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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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9
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Li A, Chen FX, Li Y. Unusual case of abdominal tenderness. Frontline Gastroenterol 2022; 14:350-351. [PMID: 37409335 PMCID: PMC11138177 DOI: 10.1136/flgastro-2022-102236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- Ai Li
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Center for IBD Research, Shanghai Tenth People's Hospital, Shanghai, China
| | - Fei-Xue Chen
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Yanqing Li
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, Shandong, China
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10
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Current Understanding of Systemic Amyloidosis and Underlying Disease Mechanisms. Am J Cardiol 2022; 185 Suppl 1:S2-S10. [PMID: 36549788 DOI: 10.1016/j.amjcard.2022.10.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 10/17/2022] [Accepted: 10/27/2022] [Indexed: 12/24/2022]
Abstract
Amyloidosis is a group of diverse disorders caused by misfolded proteins that aggregate into insoluble fibrils and ultimately cause organ damage. In medical practice, amyloidosis classification is based on the amyloid precursor protein type, of which amyloid immunoglobulin light chain, amyloid transthyretin, amyloid leukocyte chemotactic factor 2, and amyloid derived from serum amyloid A protein are the most common. Distinct mechanisms appear to be predominantly operational in the pathogenesis of particular types of amyloidosis, including increased protein precursor synthesis, somatic or germ line mutations, and inherent instability in the precursor protein in its wild form. An increased supply of misfolded proteins and/or a decreased capacity of the protein quality control systems can result in an imbalance that leads to increased circulation of misfolded proteins. Although the detection of mature fibrils is the basis for diagnosis of amyloidosis, a growing body of evidence has implicated the prefibrillar species as proteotoxic and key contributors to the development of the disease.
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11
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Khella SL. Noncardiac Manifestations of Hereditary Amyloidosis. Am J Cardiol 2022; 185 Suppl 1:S17-S22. [PMID: 36369035 DOI: 10.1016/j.amjcard.2022.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 09/19/2022] [Accepted: 10/03/2022] [Indexed: 11/11/2022]
Abstract
The most common forms of cardiac amyloidosis are progressive, life threatening, and underrecognized. Symptoms affect a variety of organs and overlap with those of more common conditions, complicating and postponing diagnosis. Cardiac disease generally determines mortality, but noncardiac manifestations typically surface before cardiac symptoms, often several years before diagnosis. Familiarity with noncardiac manifestations may lead to early diagnosis, enabling treatment and improving prognosis.
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Affiliation(s)
- Sami L Khella
- Department of Neurology, Penn Presbyterian Medical Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
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12
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Lyon AR, López-Fernández T, Couch LS, Asteggiano R, Aznar MC, Bergler-Klein J, Boriani G, Cardinale D, Cordoba R, Cosyns B, Cutter DJ, de Azambuja E, de Boer RA, Dent SF, Farmakis D, Gevaert SA, Gorog DA, Herrmann J, Lenihan D, Moslehi J, Moura B, Salinger SS, Stephens R, Suter TM, Szmit S, Tamargo J, Thavendiranathan P, Tocchetti CG, van der Meer P, van der Pal HJH. 2022 ESC Guidelines on cardio-oncology developed in collaboration with the European Hematology Association (EHA), the European Society for Therapeutic Radiology and Oncology (ESTRO) and the International Cardio-Oncology Society (IC-OS). Eur Heart J 2022; 43:4229-4361. [PMID: 36017568 DOI: 10.1093/eurheartj/ehac244] [Citation(s) in RCA: 734] [Impact Index Per Article: 367.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
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13
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Posadas-Martinez ML, Aguirre MA, Brulc E, Saez MS, Sorroche P, Machnicki G, Fernandez M, Nucifora EM. Treatment patterns and outcomes in light chain amyloidosis: An institutional registry of amyloidosis report in Argentina. PLoS One 2022; 17:e0274578. [PMID: 36301970 PMCID: PMC9612475 DOI: 10.1371/journal.pone.0274578] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 08/30/2022] [Indexed: 11/06/2022] Open
Abstract
Light chain (AL) amyloidosis is a form of systemic amyloidosis, causing organ dysfunction, mainly affecting the heart and kidney. Patient-tailored and risk-adapted decision making is critical in AL amyloidosis management. There is limited real-world evidence data from Argentina and Latin America regarding the treatment approaches for AL amyloidosis. This retrospective cohort study aimed to describe the treatment patterns and outcomes in adult patients (>18 years) diagnosed with AL amyloidosis at the Hospital Italiano in Buenos Aires, Argentina, using a 10-yearfollow-up data (June 1, 2010 to May 31, 2019) from the institutional registry of amyloidosis (IRA). The study population had a mean age of 63 years and 54.4% weremale. Heart and kidney were the most frequently affected organs. Of the 90 eligible patients included in the study, 70underwent treatment. Bortezomib-based regimen was the preferred first-line treatment (75.7% patients). Overall,54.4% of the patients presented a deep response (complete or very good partial response). Median overall survival (OS) was 5years, the 1-year OS and progression free survival rates were 80% (95% confidence interval [CI]: 68–87) and 80% (95%CI 68–87)), respectively. This study provides vital real-world evidence for the long-term treatment patterns and survival in a large cohort of AL amyloidosis patients in Argentina.
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Affiliation(s)
- Maria Lourdes Posadas-Martinez
- Internal Medicine Department, Internal Medicine Research Unit, CONICET, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
- * E-mail:
| | - María Adela Aguirre
- Internal Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Erika Brulc
- Internal Medicine Department, Hematology Service, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Maria Soledad Saez
- Internal Medicine Department, Biochemestry Service, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Patricia Sorroche
- Internal Medicine Department, Biochemestry Service, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | | | - Elsa Mercedes Nucifora
- Hematology Service, Internal Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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14
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Dispenzieri A, Zonder J, Hoffman J, Wong SW, Liedtke M, Abonour R, D'Souza A, Lee C, Cote S, Potluri R, Ammann E, Tran N, Lam A, Nair S. Real-world treatment patterns, costs, and outcomes in patients with AL amyloidosis: analysis of the Optum EHR and commercial claims databases. Amyloid 2022:1-8. [PMID: 36282014 DOI: 10.1080/13506129.2022.2137400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND This study characterised real-world treatment patterns, clinical outcomes, and cost-of-illness in patients with light-chain (AL) amyloidosis. METHODS Data were extracted from the US-based Optum® EHR and Clinformatics® Data Mart (claims) databases (2008-2019) for patients newly diagnosed with AL amyloidosis and who initiated anti-plasma cell therapies. Healthcare resource utilisation (HCRU) and related costs were compared across lines of therapy (LOT). Incidences of cardiac and renal failure were evaluated using the Kaplan-Meier method. RESULTS About 1347 patients (EHR, n = 776; claims, n = 571) were included. Median age was 68 years; 56.8% were male. At initial diagnosis, 33.1% and 15.1% of patients had cardiac and renal failure, respectively. Most patients received bortezomib-containing treatment in LOT1 (69%); bortezomib-cyclophosphamide-dexamethasone was most common (26%). HCRU was similar across LOTs. Mean per-patient-per-month and per-patient-per-LOT costs were $19,343 and $105,944 for LOT1, $19,183 and $95,793 for LOT2, and $16,611 and $128,446 for LOT3, respectively. Costs were primarily driven by anti-plasma cell therapies, outpatient visits, and hospitalisations. The 5-year cardiac and renal failure rates following initial diagnosis were 64.5% and 39.0%, respectively. CONCLUSION AL amyloidosis is associated with substantial costs and suboptimal outcomes, highlighting the need for new therapeutic approaches to prevent organ deterioration, and reduce disease burden.
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Affiliation(s)
| | | | - James Hoffman
- Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Sandra W Wong
- Division of Hematology/Oncology, University of California, San Francisco, CA, USA
| | | | | | - Anita D'Souza
- Froedtert & Medical College of Wisconsin Cancer Center, Milwaukee, WI, USA
| | | | - Sarah Cote
- Janssen Global Services, Raritan, NJ, USA
| | | | | | - NamPhuong Tran
- Janssen Research & Development, LLC, Los Angeles, CA, USA
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15
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Lyon AR, López-Fernández T, Couch LS, Asteggiano R, Aznar MC, Bergler-Klein J, Boriani G, Cardinale D, Cordoba R, Cosyns B, Cutter DJ, de Azambuja E, de Boer RA, Dent SF, Farmakis D, Gevaert SA, Gorog DA, Herrmann J, Lenihan D, Moslehi J, Moura B, Salinger SS, Stephens R, Suter TM, Szmit S, Tamargo J, Thavendiranathan P, Tocchetti CG, van der Meer P, van der Pal HJH. 2022 ESC Guidelines on cardio-oncology developed in collaboration with the European Hematology Association (EHA), the European Society for Therapeutic Radiology and Oncology (ESTRO) and the International Cardio-Oncology Society (IC-OS). Eur Heart J Cardiovasc Imaging 2022; 23:e333-e465. [PMID: 36017575 DOI: 10.1093/ehjci/jeac106] [Citation(s) in RCA: 96] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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16
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Kumar N, Zhang NJ, Cherepanov D, Romanus D, Hughes M, Faller DV. Global epidemiology of amyloid light-chain amyloidosis. Orphanet J Rare Dis 2022; 17:278. [PMID: 35854312 PMCID: PMC9295439 DOI: 10.1186/s13023-022-02414-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 06/26/2022] [Indexed: 12/19/2022] Open
Abstract
Background Amyloid light-chain (AL) amyloidosis is an ultra-rare disease associated with significant morbidity and mortality. Few studies have examined the global epidemiology of this condition. Methods This study estimated the diagnosed incidence and 1-year, 5-year, 10-year, and 20-year period prevalence of AL amyloidosis in 2018 for countries in and near Europe, and in the United States (US), Canada, Brazil, Japan, South Korea, Taiwan, and Russia. A systematic literature review (SLR) was conducted to identify country-specific, age- and gender-specific diagnosed incidence of AL amyloidosis and observed survival data-point inputs for an incidence-to-prevalence model. Extrapolations were used to estimate incidence and prevalence for countries without registry or published epidemiological data. Results Of 171 publications identified in the SLR, 10 records met the criteria for data extraction, and two records were included in the final incidence-to-prevalence model. In 2018, an estimated 74,000 AL amyloidosis cases worldwide were diagnosed during the preceding 20 years. The estimated incidence and 20-year prevalence rates were 10 and 51 cases per million population, respectively. Conclusions Orphan medicinal product designation criteria of the European Medicines Agency or Electronic Code of Federal Regulations indicate that a disease must not affect > 5 in 10,000 people across the European Union or affect < 200,000 people in the US. This study provides up-to-date epidemiological patterns of AL amyloidosis, which is vital for understanding the burden of the disease, increasing awareness, and to further research and treatment options.
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Affiliation(s)
- Nishant Kumar
- RwHealth, Level 39, One Canada Square, Canary Wharf, London, E14 5AB, GB, UK
| | - Nicole J Zhang
- RwHealth, Level 39, One Canada Square, Canary Wharf, London, E14 5AB, GB, UK
| | - Dasha Cherepanov
- Takeda Development Center Americas, Inc., 95 Hayden Ave., Lexington, MA, 02421, USA.
| | - Dorothy Romanus
- Takeda Development Center Americas, Inc., 95 Hayden Ave., Lexington, MA, 02421, USA
| | - Michael Hughes
- RwHealth, Level 39, One Canada Square, Canary Wharf, London, E14 5AB, GB, UK
| | - Douglas V Faller
- Takeda Development Center Americas, Inc., 95 Hayden Ave., Lexington, MA, 02421, USA
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17
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Lee Chuy K, Gomez J, Malhotra S. Coexistent transthyretin amyloid cardiomyopathy and monoclonal gammopathy: Diagnostic challenges and prognostic implications. J Nucl Cardiol 2022; 29:519-527. [PMID: 32720059 DOI: 10.1007/s12350-020-02281-3] [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: 07/05/2020] [Accepted: 07/06/2020] [Indexed: 10/23/2022]
Abstract
Establishing an accurate diagnosis of amyloid subtype in patients with coexistent cardiac amyloidosis and monoclonal gammopathy is crucial due to treatment and prognostic implications. Here, we discuss a case of coexistent diagnoses of transthyretin amyloid cardiomyopathy and smoldering multiple myeloma, highlighting the challenges associated with the possibility of several disease combinations and the limitations of diagnostic testing. In addition, the importance of clinical clues such as disease course and progression, patient preference, and multidisciplinary collaboration should not be discounted in the diagnostic and management approach of these patients.
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Affiliation(s)
| | - Javier Gomez
- Division of Cardiology, Cook County Health, Chicago, IL, USA
- Division of Cardiology, Rush Medical College, Chicago, IL, USA
| | - Saurabh Malhotra
- Division of Cardiology, Cook County Health, Chicago, IL, USA.
- Division of Cardiology, Rush Medical College, Chicago, IL, USA.
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18
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Westin O, Butt JH, Gustafsson F, Schou M, Salomo M, Køber L, Maurer M, Fosbøl EL. Two Decades of Cardiac Amyloidosis: A Danish Nationwide Study. JACC: CARDIOONCOLOGY 2021; 3:522-533. [PMID: 34729524 PMCID: PMC8543084 DOI: 10.1016/j.jaccao.2021.05.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 05/26/2021] [Indexed: 12/17/2022]
Abstract
Background Cardiac amyloidosis (CA) has been associated with poor outcomes. Screening studies suggest that CA is overlooked-especially in the elderly. Recent advances in treatment have brought attention to the disease, but data on temporal changes in CA epidemiology are sparse. Objectives The aim of this work was to describe all patients with CA in Denmark, examining changes in patient characteristics from 1998 to 2017. Methods All patients with any form of amyloidosis diagnosed from 1998 to 2017, as well as their comorbidities and pharmacotherapy, were identified in Danish nationwide registries. CA was defined as any diagnosis code for amyloidosis combined with a diagnosis code for heart failure, cardiomyopathy, or atrial fibrillation or a procedural code for pacemaker implantation, regardless of the order. The index date was defined as the date of meeting those criteria. Patients were divided into 5-year periods by index date. For comparison, we also included control subjects (1:4 ratio) from the general population. Results CA criteria were met by 619 patients. Comparing 1998-2002 vs 2013-2017, the median age at baseline increased from 67.4 years (interquartile range [IQR]: 53.9-75.2 years) to 72.3 years (IQR: 66.0-79.3 years). The frequency of male patients increased from 62.1% to 66.2%. The incidence of CA rose from 0.88 to 3.56 per 100,000 person-years in the Danish population aged ≥65 years, and the 2-year mortality decreased from 82.6% (IQR: 69.9%-90.5%) to 50.2% (IQR: 43.1%-56.9%). Compared with control subjects, the mortality among CA patients was significantly higher (log-rank test: P < 0.0001). Conclusions CA, as defined in this study, was increasingly diagnosed on a national scale. The increasing frequency of male patients and median age suggest that wild-type transthyretin amyloidosis is driving this increase. Greater recognition of earlier, less advanced cases might explain decreasing mortality.
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Affiliation(s)
- Oscar Westin
- The Heart Center, University Hospital of Copenhagen, Rigshospitalet, Denmark
| | - Jawad H Butt
- The Heart Center, University Hospital of Copenhagen, Rigshospitalet, Denmark
| | - Finn Gustafsson
- The Heart Center, University Hospital of Copenhagen, Rigshospitalet, Denmark
| | - Morten Schou
- Department of Cardiology, University Hospital of Copenhagen, Herlev and Gentofte Hospital, Denmark
| | - Morten Salomo
- Department of Hematology, University Hospital of Copenhagen, Rigshospitalet, Denmark
| | - Lars Køber
- The Heart Center, University Hospital of Copenhagen, Rigshospitalet, Denmark
| | - Mathew Maurer
- Columbia University Irving Medical Center, New York, New York, USA
| | - Emil L Fosbøl
- The Heart Center, University Hospital of Copenhagen, Rigshospitalet, Denmark
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Abstract
Amyloidosis is a disorder characterized by misfolded precursor proteins that form depositions of fibrillar aggregates with an abnormal cross-beta-sheet conformation, known as amyloid, in the extracellular space of several tissues. Although there are more than 30 known amyloidogenic proteins, both hereditary and non-hereditary, cardiac amyloidosis (CA) typically arises from either misfolded transthyretin (ATTR amyloidosis) or immunoglobulin light-chain aggregation (AL amyloidosis). Its prevalence is more common than previously thought, especially among patients with heart failure and preserved ejection fraction (HFpEF) and aortic stenosis. If there is a clinical suspicion of CA, focused echocardiography, laboratory screening for the presence of a monoclonal protein (serum and urinary electrophoresis with immunofixation and serum free light-chain ratio), and cardiac scintigraphy with 99mtechnetium-labeled bone-tracers are sensitive and specific initial diagnostic tests. In some cases, more advanced/invasive techniques are necessary and, in the last several years, treatment options for both AL CA and ATTR CA have rapidly expanded. It is important to note that the aims of therapy are different. Systemic AL amyloidosis requires treatment targeted against the abnormal plasma cell clone, whereas therapy for ATTR CA must be targeted to the production and stabilization of the TTR molecule. It is likely that a multistep treatment approach will be optimal for both AL CA and ATTR CA. Additionally, treatment of CA includes the management of restrictive cardiomyopathy with preserved or reduced ejection fraction in addition to treating the amyloid deposition. Future studies are necessary to define optimal management strategies for AL CA and ATTR CA and confirm cardiac response to therapy.
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Affiliation(s)
- Petra Nijst
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - WH Wilson Tang
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
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20
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Castiglione V, Franzini M, Aimo A, Carecci A, Lombardi CM, Passino C, Rapezzi C, Emdin M, Vergaro G. Use of biomarkers to diagnose and manage cardiac amyloidosis. Eur J Heart Fail 2021; 23:217-230. [PMID: 33527656 DOI: 10.1002/ejhf.2113] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 11/28/2020] [Accepted: 01/25/2021] [Indexed: 12/22/2022] Open
Abstract
Amyloidoses are characterized by the tissue accumulation of misfolded proteins into insoluble fibrils. The two most common types of systemic amyloidosis result from the deposition of immunoglobulin light chains (AL) and wild-type or variant transthyretin (ATTRwt/ATTRv). Cardiac involvement is the main determinant of outcome in both AL and ATTR, and cardiac amyloidosis (CA) is increasingly recognized as a cause of heart failure. In CA, circulating biomarkers are important diagnostic tools, allow to refine risk stratification at baseline and during follow-up, help to tailor the therapeutic strategy and monitor the response to treatment. Among amyloid precursors, free light chains are established biomarkers in AL amyloidosis, while the plasma transthyretin assay is currently being investigated as a tool for supporting the diagnosis of ATTRv amyloidosis, predicting outcome and monitor response to novel tetramer stabilizers or small interfering RNA drugs in ATTR CA. Natriuretic peptides (NPs) and troponins are consistently elevated in patients with AL and ATTR CA. Plasma NPs, troponins and free light chains hold prognostic significance in AL amyloidosis, and are evaluated for therapy decision-making and follow-up, while the value of NPs and troponins in ATTR is less well established. Biomarkers can be usefully integrated with clinical and imaging variables at all levels of the clinical algorithm of systemic amyloidosis, from screening to diagnosis and prognosis, and treatment tailoring.
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Affiliation(s)
| | - Maria Franzini
- Department of Translational Research and of New Surgical and Medical Technologies, University of Pisa, Pisa, Italy
| | - Alberto Aimo
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.,Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | | | - Carlo Mario Lombardi
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health University and Civil Hospital, Brescia, Italy
| | - Claudio Passino
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.,Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Claudio Rapezzi
- Centro Cardiologico Universitario di Ferrara, University of Ferrara, Ferrara, Italy.,Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Michele Emdin
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.,Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Giuseppe Vergaro
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.,Fondazione Toscana Gabriele Monasterio, Pisa, Italy
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21
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Kocher F, Kaser A, Escher F, Doerler J, Zaruba MM, Messner M, Mussner-Seeber C, Mayr A, Ulmer H, Schneiderbauer-Porod S, Ebner C, Poelzl G. Heart failure from ATTRwt amyloid cardiomyopathy is associated with poor prognosis. ESC Heart Fail 2020; 7:3919-3928. [PMID: 33002335 PMCID: PMC7754911 DOI: 10.1002/ehf2.12986] [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] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 08/03/2020] [Accepted: 08/14/2020] [Indexed: 12/16/2022] Open
Abstract
Aims Amyloid cardiomyopathy is an underappreciated cause of morbidity and mortality. Recent evidence suggests that ATTR wild‐type cardiomyopathy (ATTRwt‐CM) is probably much more common than widely appreciated. So far, no data are available on comparison of mortality from ATTRwt‐CM and other heart failure aetiologies. Methods and results This was a retrospective, observational, cohort study of 2251 patients and their data collected prospectively from May 2000 to June 2018. Long‐term mortality was the main outcome measure. Underlying cardiomyopathies were classified as amyloid CM (6.1%) [ATTRwt 3.0%; light‐chain amyloidosis (AL) 3.1%], dilated CM (dCMP) (46.4%), ischaemic heart disease (IHD) (24.4%), hypertensive heart disease (HHD) (14.6%), hypertrophic CM (HCM) (5.1%), and valvular heart disease (VHD) (3.4%). Median duration of follow‐up was 7.1 years (interquartile range 3.4–11.3). Five‐year overall survival in the whole cohort was 80.1%. In multivariate analysis, individuals with amyloid CM were 3.74 times [95% confidence interval (CI) 2.72–5.14; P < 0.001] more likely to die of any reason than were individuals with dCMP. Mortality was higher in AL‐CM compared with ATTRwt‐CM [hazard ratio (HR) 2.88; 95% CI 1.48–5.58; P = 0.002]. Mortality rates in patients with ATTRwt‐CM were higher than in patients with dCMP (HR 1.96; 95% CI 1.24–3.22; P = 0.007), HCM (HR 2.94; 95% CI 1.28–6.67; P = 0.011), HHD (HR 2.08; 95% CI 1.27–3.45; P = 0.004), VHD (HR 2.38; 95% CI 1.30–4.35; P = 0.005), or left ventricular ejection fraction ≥ 40% (HR 1.99; 95% CI 1.12–3.52; P = 0.018). Conclusions Our study demonstrates that amyloid CM is independently associated with poor survival among patients with various causes of heart failure. ATTRwt‐CM had a better long‐term prognosis than did AL‐CM, but was associated with higher mortality than were dCMP, HCM, HHD, VHD, and heart failure with preserved or mid‐range ejection fraction.
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Affiliation(s)
- Florian Kocher
- Department of Internal Medicine V (Hematology and Oncology), Medical University of Innsbruck, Anichstrasse 35, Innsbruck, 6020, Austria
| | - Alex Kaser
- Department of Internal Medicine III (Cardiology and Angiology), Medical University of Innsbruck, Innsbruck, Austria
| | - Felix Escher
- Department of Radiology, LMU Munich, Munich, Germany
| | - Jacob Doerler
- Department of Internal Medicine III (Cardiology and Angiology), Medical University of Innsbruck, Innsbruck, Austria
| | - Marc-Michael Zaruba
- Department of Internal Medicine III (Cardiology and Angiology), Medical University of Innsbruck, Innsbruck, Austria
| | - Moritz Messner
- Department of Internal Medicine III (Cardiology and Angiology), Medical University of Innsbruck, Innsbruck, Austria
| | - Christine Mussner-Seeber
- Department of Internal Medicine III (Cardiology and Angiology), Medical University of Innsbruck, Innsbruck, Austria
| | - Agnes Mayr
- Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Hanno Ulmer
- Department of Medical Statistics, Informatics and Health Economics, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Christian Ebner
- Department of Cardiology, Ordensklinikum Elisabethinen Linz, Linz, Austria
| | - Gerhard Poelzl
- Department of Internal Medicine V (Hematology and Oncology), Medical University of Innsbruck, Anichstrasse 35, Innsbruck, 6020, Austria
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22
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Hahn VS, Yanek LR, Vaishnav J, Ying W, Vaidya D, Lee YZJ, Riley SJ, Subramanya V, Brown EE, Hopkins CD, Ononogbu S, Perzel Mandell K, Halushka MK, Steenbergen C, Rosenberg AZ, Tedford RJ, Judge DP, Shah SJ, Russell SD, Kass DA, Sharma K. Endomyocardial Biopsy Characterization of Heart Failure With Preserved Ejection Fraction and Prevalence of Cardiac Amyloidosis. JACC-HEART FAILURE 2020; 8:712-724. [PMID: 32653448 DOI: 10.1016/j.jchf.2020.04.007] [Citation(s) in RCA: 136] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 04/03/2020] [Accepted: 04/14/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVES This study prospectively evaluated endomyocardial biopsies in patients with heart failure with preserved ejection fraction (HFpEF) to identify histopathologic phenotypes and their association with clinical characteristics. BACKGROUND Myocardial tissue analysis from a prospectively defined HFpEF cohort reflecting contemporary comorbidities is lacking. METHODS Patients with HFpEF (EF ≥50%) referred to the Johns Hopkins HFpEF Clinic between August 2014 and September 2018 were enrolled for right heart catheterization and endomyocardial biopsy. Clinical features, echocardiography, hemodynamics, and tissue histology were determined and compared with controls (unused donor hearts) and HF with reduced EF (HFrEF). RESULTS Of the 108 patients enrolled, median age was 66 years (25th to 75th percentile: 57 to 74 years), 61% were women, 57% were African American, 62% had a previous HF hospitalization, median systolic blood pressure was 141 mm Hg (25th to 75th percentile: 125 to 162 mm Hg), body mass index (BMI) was 37 kg/m2 (25th to 75th percentile: 32 to 45 kg/m2), and 97% were on a loop diuretic. Myocardial fibrosis and myocyte hypertrophy were often present (93% and 88%, respectively); however, mild in 71% with fibrosis and in 52% with hypertrophy. Monocyte infiltration (CD68+ cells/mm2) was greater in patients with HFpEF versus controls (60.4 cells/mm2 [25th to 75th percentile: 36.8 to 97.8] vs. 32.1 cells/mm2 [25th to 75th percentile: 22.3 to 59.2]; p = 0.02) and correlated with age and renal disease. Cardiac amyloidosis (CA) was diagnosed in 15 (14%) patients (HFpEF-CA: 7 patients with wild-type transthyretin amyloidosis [ATTR], 4 patients with hereditary ATTR, 3 patients with light-chain amyloidosis, and 1 patient with AA (secondary) amyloidosis), of which 7 cases were unsuspected. Patients with HFpEF-CA were older, with lower BMI, higher left ventricular mass index, and higher N-terminal pro-B-type natriuretic peptide and troponin I levels. CONCLUSIONS In this large, prospective myocardial tissue analysis of HFpEF, myocardial fibrosis and hypertrophy were common, CD68+ inflammation was increased, and CA prevalence was 14%. Tissue analysis in HFpEF might improve precision therapies by identifying relevant myocardial mechanisms.
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Affiliation(s)
- Virginia S Hahn
- Division of Cardiology, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Lisa R Yanek
- Division of General Internal Medicine, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Joban Vaishnav
- Division of Cardiology, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Wendy Ying
- Division of Cardiology, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Dhananjay Vaidya
- Division of General Internal Medicine, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Yi Zhen Joan Lee
- Division of Cardiology, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Sarah J Riley
- Division of Cardiology, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Vinita Subramanya
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Emily E Brown
- Division of Cardiology, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - C Danielle Hopkins
- Division of Cardiology, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Sandra Ononogbu
- Division of Cardiology, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Kira Perzel Mandell
- Department of Pathology, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Marc K Halushka
- Department of Pathology, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Charles Steenbergen
- Department of Pathology, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Avi Z Rosenberg
- Department of Pathology, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Ryan J Tedford
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | - Daniel P Judge
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | - Sanjiv J Shah
- Division of Cardiology, Northwestern University, Chicago, Illinois
| | | | - David A Kass
- Division of Cardiology, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Kavita Sharma
- Division of Cardiology, The Johns Hopkins School of Medicine, Baltimore, Maryland.
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23
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Yokoyama H, Shishido K, Ito J, Kamata W, Katoh N, Saito S. Insight from an autopsy in a patient with rapidly worsening heart failure due to amyloid light-chain cardiac amyloidosis: A case report. J Cardiol Cases 2020; 22:48-51. [PMID: 32774518 DOI: 10.1016/j.jccase.2020.04.002] [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: 01/19/2020] [Revised: 03/24/2020] [Accepted: 04/03/2020] [Indexed: 10/24/2022] Open
Abstract
Amyloid light-chain (AL) amyloidosis is a systemic disease characterized by the deposition of misfolded immunoglobulin light chain, causing organ failure, and in particular cardiac involvement is a leading cause of morbidity and mortality. We report the case of a 47-year-old man without prior cardiovascular events who presented with shortness of breath. He was diagnosed with primary AL cardiac amyloidosis (CA) from the laboratory test, the endomyocardial biopsy, the bone marrow examination, and the cardiovascular imaging. Only a week after discharge of the first heart failure (HF) admission, he was readmitted for the exacerbation of HF. Finally, he died 2 weeks after the second admission, that is 3 months after the onset of HF. Autopsy, which was performed to investigate the causes of rapid worsening HF, implied the impairment of ventricular function and coronary microcirculation dysfunction. We could diagnose CA immediately by using diagnostic tools, however, we recognized that there was the fulminant type in CA, and considered the insight from autopsy. 〈Learning objective: This case demonstrates a young patient with cardiac amyloidosis (CA) developed rapid worsening heart failure (RWHF), and then he died 1 month after diagnosis, that is 3 months after the onset of heart failure. This case deems to be a fulminant type in amyloid light-chain CA, and autopsy suggested the mechanisms of RWHF, which are the impairment of ventricular function and coronary microcirculation dysfunction.〉.
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Affiliation(s)
- Hiroaki Yokoyama
- Department of Cardiology and Catheterization Laboratories, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Koki Shishido
- Department of Cardiology and Catheterization Laboratories, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Junko Ito
- Department of Diagnostic Pathology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Wataru Kamata
- Department of Hematology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Nagaaki Katoh
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Shigeru Saito
- Department of Cardiology and Catheterization Laboratories, Shonan Kamakura General Hospital, Kamakura, Japan
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Duca F, Snidat A, Binder C, Rettl R, Dachs TM, Seirer B, Camuz-Ligios L, Dusik F, Capelle CDJ, Hong Q, Agis H, Kain R, Mascherbauer J, Hengstenberg C, Badr Eslam R, Bonderman D. Hemodynamic Profiles and Their Prognostic Relevance in Cardiac Amyloidosis. J Clin Med 2020; 9:E1093. [PMID: 32290508 PMCID: PMC7230541 DOI: 10.3390/jcm9041093] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/03/2020] [Accepted: 04/07/2020] [Indexed: 12/27/2022] Open
Abstract
This study sought to characterize cardiac amyloidosis (CA) patients with respect to hemodynamic parameters and asses their prognostic impact in different CA cohorts. Intracardiac and pulmonary arterial pressures (PAPs) are among the strongest predictors of outcomes in patients with heart failure (HF). Despite that, the hemodynamic profiles of patients with CA and their relation to prognosis have rarely been investigated. Invasive hemodynamic, clinical, and laboratory assessment, as well as cardiac magnetic resonance imaging were performed in our CA cohort. A total of 61 patients, 35 (57.4%) with wild-type transthyretin amyloidosis (ATTRwt) and 26 (42.6%) with light-chain amyloidosis (AL) were enrolled. ATTRwt patients had lower N-terminal prohormone of brain natriuretic peptide values and were less frequently in New York Heart Association class ≥ III. Intracardiac and PAPs were elevated, but hemodynamic parameters did not differ between CA groups. Whereas in ATTRwt, the median mean PAP (hazard ratio (HR): 1.130, p = 0.040) and pulmonary vascular resistance (HR: 1.010, p = 0.046) were independent predictors of outcome, no hemodynamic parameter was associated with outcome in the AL group. Cardiac ATTRwt and AL patients feature elevated intracardiac and PAPs and show similar hemodynamic profiles. However, hemodynamic parameters are of greater prognostic relevance in ATTRwt, potentially providing a new therapeutic target.
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Affiliation(s)
- Franz Duca
- Department of Internal Medicine II, Department of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (A.S.); (C.B.); (R.R.); (T.-M.D.); (B.S.); (L.C.-L.); (F.D.); (C.D.J.C.); (Q.H.); (J.M.); (C.H.)
| | - Amir Snidat
- Department of Internal Medicine II, Department of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (A.S.); (C.B.); (R.R.); (T.-M.D.); (B.S.); (L.C.-L.); (F.D.); (C.D.J.C.); (Q.H.); (J.M.); (C.H.)
| | - Christina Binder
- Department of Internal Medicine II, Department of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (A.S.); (C.B.); (R.R.); (T.-M.D.); (B.S.); (L.C.-L.); (F.D.); (C.D.J.C.); (Q.H.); (J.M.); (C.H.)
| | - René Rettl
- Department of Internal Medicine II, Department of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (A.S.); (C.B.); (R.R.); (T.-M.D.); (B.S.); (L.C.-L.); (F.D.); (C.D.J.C.); (Q.H.); (J.M.); (C.H.)
| | - Theresa-Marie Dachs
- Department of Internal Medicine II, Department of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (A.S.); (C.B.); (R.R.); (T.-M.D.); (B.S.); (L.C.-L.); (F.D.); (C.D.J.C.); (Q.H.); (J.M.); (C.H.)
| | - Benjamin Seirer
- Department of Internal Medicine II, Department of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (A.S.); (C.B.); (R.R.); (T.-M.D.); (B.S.); (L.C.-L.); (F.D.); (C.D.J.C.); (Q.H.); (J.M.); (C.H.)
| | - Luciana Camuz-Ligios
- Department of Internal Medicine II, Department of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (A.S.); (C.B.); (R.R.); (T.-M.D.); (B.S.); (L.C.-L.); (F.D.); (C.D.J.C.); (Q.H.); (J.M.); (C.H.)
| | - Fabian Dusik
- Department of Internal Medicine II, Department of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (A.S.); (C.B.); (R.R.); (T.-M.D.); (B.S.); (L.C.-L.); (F.D.); (C.D.J.C.); (Q.H.); (J.M.); (C.H.)
| | - Christophe Denis Josef Capelle
- Department of Internal Medicine II, Department of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (A.S.); (C.B.); (R.R.); (T.-M.D.); (B.S.); (L.C.-L.); (F.D.); (C.D.J.C.); (Q.H.); (J.M.); (C.H.)
| | - Qin Hong
- Department of Internal Medicine II, Department of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (A.S.); (C.B.); (R.R.); (T.-M.D.); (B.S.); (L.C.-L.); (F.D.); (C.D.J.C.); (Q.H.); (J.M.); (C.H.)
| | - Hermine Agis
- Department of Internal Medicine I, Department of Oncology, Medical University of Vienna, 1090 Vienna, Austria;
| | - Renate Kain
- Clinical Institute of Pathology, Medical University of Vienna, 1090 Vienna, Austria;
| | - Julia Mascherbauer
- Department of Internal Medicine II, Department of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (A.S.); (C.B.); (R.R.); (T.-M.D.); (B.S.); (L.C.-L.); (F.D.); (C.D.J.C.); (Q.H.); (J.M.); (C.H.)
| | - Christian Hengstenberg
- Department of Internal Medicine II, Department of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (A.S.); (C.B.); (R.R.); (T.-M.D.); (B.S.); (L.C.-L.); (F.D.); (C.D.J.C.); (Q.H.); (J.M.); (C.H.)
| | - Roza Badr Eslam
- Department of Internal Medicine II, Department of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (A.S.); (C.B.); (R.R.); (T.-M.D.); (B.S.); (L.C.-L.); (F.D.); (C.D.J.C.); (Q.H.); (J.M.); (C.H.)
| | - Diana Bonderman
- Department of Internal Medicine II, Department of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (A.S.); (C.B.); (R.R.); (T.-M.D.); (B.S.); (L.C.-L.); (F.D.); (C.D.J.C.); (Q.H.); (J.M.); (C.H.)
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