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Ruiz Hueso R, Salamanca Bautista P, Quesada Simón MA, Yun S, Conde Martel A, Morales Rull JL, Fiteni Mera I, Abad Pérez D, Páez Rubio I, Aramburu Bodas Ó. Cardiac amyloidosis worsens prognosis in patients with heart failure: findings from the PREVAMIC study. Rev Clin Esp 2024:S2254-8874(24)00100-0. [PMID: 39032915 DOI: 10.1016/j.rceng.2024.07.006] [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: 05/04/2024] [Accepted: 06/18/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND AND OBJECTIVES Cardiac amyloidosis (CA) is a common pathology in elderly patients that usually presents as heart failure (HF). However, it is not clear whether CA associated with HF has a worse prognosis compared with HF due to other etiologies. MATERIAL AND METHODS Prospective, observational cohort study that recruited patients ≥65 years of age with HF in 30 Spanish centers. The cohort was divided according to whether the patients had AC or not. Patients were followed for 1 year. RESULTS A total of 484 patients were included in the analysis. The population was elderly (median 86 years) and 49% were women CA was present in 23.8 % of the included patients. In the CA group, there was a lower prevalence of diabetes mellitus and valvular disease. At one year of follow-up, mortality was significantly more frequent in patients with CA compared to those without (33.0 vs.14.9%, p < 0.001). However, there were no differences between both groups in visits to the emergency room or readmissions. In the multivariate analysis, the variables that were shown to predict all-cause mortality at one year of follow-up were chronic kidney disease (HR 1.75 (1.01-3.05) p 0.045), NT-proBNP levels (HR 2.51 (1.46-4.30) p < 0.001), confusion (HR 2.05 (1.01-4.17), p 0.048), and the presence of CA (HR 1.77 (1.11-2.84), p 0.017). CONCLUSION The presence of CA in elderly patients with HF is related to a worse prognosis at one year of follow-up. Early diagnosis of the pathology and multidisciplinary management can help improve patient outcomes.
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Affiliation(s)
- R Ruiz Hueso
- Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - P Salamanca Bautista
- Hospital Universitario Virgen Macarena, Sevilla, Spain; Departamento de Medicina, Universidad de Sevilla, Sevilla, Spain.
| | | | - S Yun
- Unidad de Insuficiencia Cardiaca Comunitaria, Servicios de Cardiología y Medicina Interna, Hospital Universitario de Bellvitge. Instituto de Investigación Biomédica de Bellvitge (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain
| | - A Conde Martel
- Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | | | | | - D Abad Pérez
- Hospital Universitario de Getafe, Getafe, Madrid, Spain
| | | | - Ó Aramburu Bodas
- Hospital Universitario Virgen Macarena, Sevilla, Spain; Departamento de Medicina, Universidad de Sevilla, Sevilla, Spain
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2
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Ahammed MR, Ananya FN. Cardiac Amyloidosis: A Comprehensive Review of Pathophysiology, Diagnostic Approach, Applications of Artificial Intelligence, and Management Strategies. Cureus 2024; 16:e63673. [PMID: 39092395 PMCID: PMC11293487 DOI: 10.7759/cureus.63673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2024] [Indexed: 08/04/2024] Open
Abstract
Cardiac amyloidosis (CA) is a serious and often fatal condition caused by the accumulation of amyloid fibrils in the heart, leading to progressive heart failure. It involves the misfolding of normally soluble proteins into insoluble amyloid fibrils, with transthyretin and light-chain amyloidosis being the most common forms affecting the heart. Advances in diagnostics, especially cardiac magnetic resonance imaging and non-invasive techniques, have improved early detection and disease management. Artificial intelligence has emerged as a diagnostic tool for cardiac amyloidosis, improving accuracy and enabling earlier intervention through advanced imaging analysis and pattern recognition. Management strategies include volume control, specific pharmacotherapies like tafamidis, and addressing arrhythmias and advanced heart failure. However, further research is needed for novel therapeutic approaches, the long-term effectiveness of emerging treatments, and the optimization of artificial intelligence applications in clinical practice for better patient outcomes. The article aims to provide an overview of CA, outlining its pathophysiology, diagnostic advancements, the role of artificial intelligence, management strategies, and the need for further research.
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Affiliation(s)
- Md Ripon Ahammed
- Internal Medicine, Icahn School of Medicine at Mount Sinai/New York City Health and Hospitals Queens, New York City, USA
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3
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Bart NK, Fatkin D, Gunton J, Hare JL, Korczyk D, Kwok F, Lam K, Russell D, Sidiqi H, Sutton T, Gibbs SDJ, Mollee P, Thomas L. 2024 Australia-New Zealand Expert Consensus Statement on Cardiac Amyloidosis. Heart Lung Circ 2024; 33:420-442. [PMID: 38570258 DOI: 10.1016/j.hlc.2023.11.027] [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: 11/09/2023] [Accepted: 11/17/2023] [Indexed: 04/05/2024]
Abstract
Over the past 5 years, early diagnosis of and new treatments for cardiac amyloidosis (CA) have emerged that hold promise for early intervention. These include non-invasive diagnostic tests and disease modifying therapies. Recently, CA has been one of the first types of cardiomyopathy to be treated with gene editing techniques. Although these therapies are not yet widely available to patients in Australia and New Zealand, this may change in the near future. Given the rapid pace with which this field is evolving, it is important to view these advances within the Australian and New Zealand context. This Consensus Statement aims to update the Australian and New Zealand general physician and cardiologist with regards to the diagnosis, investigations, and management of CA.
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Affiliation(s)
- Nicole K Bart
- Department of Cardiology, St Vincent's Hospital, Sydney; School of Clinical Medicine, Faculty of Health and Medicine, The University of New South Wales, Sydney, and The Victor Chang Cardiac Research Institute, Sydney, NSW, Australia. http://www.twitter.com/drnikkibart
| | - Diane Fatkin
- Department of Cardiology, St Vincent's Hospital, Sydney; School of Clinical Medicine, Faculty of Health and Medicine, The University of New South Wales, Sydney, and The Victor Chang Cardiac Research Institute, Sydney, NSW, Australia
| | - James Gunton
- Department of Cardiology, Flinders Medical Centre, Adelaide, SA, Australia
| | - James L Hare
- Department of Cardiology, Alfred Health, Melbourne, and Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Vic, Australia
| | - Dariusz Korczyk
- Department of Cardiology, The Princess Alexandra Hospital, Brisbane, Qld, Australia
| | - Fiona Kwok
- Department of Haematology, Westmead Hospital, Sydney, NSW, Australia
| | - Kaitlyn Lam
- Department of Cardiology, Western Australia Advanced Heart Failure and Cardiac Transplant Service, Perth, WA, Australia
| | - David Russell
- Department of Cardiology, Royal Hobart Hospital, Hobart, Tas, Australia
| | - Hasib Sidiqi
- Department of Haematology, Fiona Stanley Hospital, Perth, WA, Australia
| | - Tim Sutton
- Te Whatu Ora Counties Manukau, Auckland; and Department of Cardiology, Auckland, Aotearoa, New Zealand
| | - Simon D J Gibbs
- Department of Haematology, Eastern Health; Epworth Freemasons; and Monash University, Melbourne, Vic, Australia
| | - Peter Mollee
- Queensland Amyloidosis Centre, The Princess Alexandra Hospital, Brisbane; and, School of Medicine, University of Queensland, Brisbane, Qld, Australia
| | - Liza Thomas
- Department of Cardiology, Westmead Hospital, Sydney; Westmead Clinical School, University of Sydney, Sydney; and, South West Clinical School, University of New South Wales, Sydney, NSW, Australia.
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4
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Porcari A, Fontana M. The changing landscape of heart failure treatment in transthyretin amyloid cardiomyopathy: Is the time ripe for clinical use of sodium-glucose cotransporter 2 inhibitors? Eur J Heart Fail 2024; 26:948-951. [PMID: 38623722 DOI: 10.1002/ejhf.3245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 04/03/2024] [Indexed: 04/17/2024] Open
Affiliation(s)
- Aldostefano Porcari
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, UK
- Centre for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Trieste, Italy
| | - Marianna Fontana
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, UK
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5
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Fragner M, Elsaygh J, Srivats SS, Pink K. Gender Differences in the Evaluation and Management of New Acute CHF Due to ATTRwt Cardiac Amyloidosis. Cureus 2024; 16:e59058. [PMID: 38800288 PMCID: PMC11128148 DOI: 10.7759/cureus.59058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2024] [Indexed: 05/29/2024] Open
Abstract
Cardiac amyloidosis can be grouped into two main categories: immunoglobulin light chain (AL) and transthyretin (hATTR or hereditary and ATTRwt or wild type). Cardiac infiltration of misfolded proteins can lead to significant infiltrative processes and subsequent heart failure. Diagnosis of ATTRwt heavily relies on clinical suspicion, as it typically appears later in life and is limited to the heart. It is routinely reported that ATTRwt significantly affects males more than females; however, older patients diagnosed with ATTRwt and those diagnosed at autopsy are significantly more likely to be female. Earlier, a more precise diagnosis in females could detect disease at an earlier stage and expedite treatment.
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Affiliation(s)
- Michael Fragner
- Internal Medicine, New York-Presbyterian Brooklyn Methodist, Brooklyn, USA
| | - Jude Elsaygh
- Internal Medicine, New York-Presbyterian Brooklyn Methodist, Brooklyn, USA
| | | | - Kevin Pink
- Internal Medicine, New York-Presbyterian Brooklyn Methodist, Brooklyn, USA
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6
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Vaishnav J, Brown E, Sharma K. Advances in the diagnosis and treatment of transthyretin amyloid cardiomyopathy. Prog Cardiovasc Dis 2024; 82:113-124. [PMID: 38246305 DOI: 10.1016/j.pcad.2024.01.013] [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: 01/14/2024] [Accepted: 01/14/2024] [Indexed: 01/23/2024]
Abstract
Transthyretin amyloid cardiomyopathy (ATTR-CM) is an underrecognized cause of heart failure (HF). ATTR-CM can lead to a number of cardiovascular manifestations including HF, rhythm disturbances, and valvular disease that ultimately limit quality of life and prognosis. Due to advances in diagnostic modalities and therapeutic options, the prevalence of ATTR-CM is rising. There are several classes of medications under active investigation, though most therapies are most efficacious if instituted early on in the disease course. As such, early clinical recognition and prompt diagnosis are crucial to improving disease related outcomes. In this review, we highlight clinical manifestations of ATTR-CM as well as contemporary diagnostic and treatment approaches to the disease.
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Affiliation(s)
- Joban Vaishnav
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, United States of America
| | - Emily Brown
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, United States of America
| | - Kavita Sharma
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, United States of America.
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7
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Khan MS, Sperry BW, Butler J. Kidney involvement in transthyretin cardiac amyloidosis - Role of urinary albumin to creatinine ratio and need for further evidence generation. Eur J Heart Fail 2024; 26:74-76. [PMID: 38191996 DOI: 10.1002/ejhf.3127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 12/20/2023] [Indexed: 01/10/2024] Open
Affiliation(s)
| | - Brett W Sperry
- Saint Luke's Mid America Heart Institute; University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX, USA
- Department of Medicine, University of Mississippi, Jackson, MS, USA
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8
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Herzog E, Leibowitz D, Gatt ME, Koren T, Pollak A. Pathway for the Diagnosis and Management of Cardiac Amyloidosis. Crit Pathw Cardiol 2023; 22:114-119. [PMID: 37625191 DOI: 10.1097/hpc.0000000000000331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/27/2023]
Abstract
The systemic amyloidoses are a broad spectrum of diseases that result from misfolding of proteins that aggregate into amyloid fibrils. In cardiac amyloidosis, amyloid fibrils accumulate in the interstitial space between cardiac myocytes causing cellular injury and impairing compliance. Current data suggest that cardiac amyloidosis is more common than previously thought. Advances in cardiac imaging, diagnostic strategies, and therapies have improved the recognition and treatment of cardiac amyloidosis. A position statement for the diagnosis and treatment of cardiac amyloidosis has been published in 2021 by the European Society of Cardiology and an expert consensus decision pathway was published in 2023 by the American College of Cardiology. These are excellent documents but quite lengthy and complex. For this reason, our team developed a novel and simple pathway to help health care providers diagnose and treat patients with cardiac amyloidosis. Our pathway starts with a section titled "suspicion" in which we provide simple clues or "red flags" that are associated with the cardiac amyloidosis phenotype. It is followed by a section titled "diagnosis," where we present in a simplified 2 × 2 format the laboratory and imaging tests that must be performed for an accurate diagnosis. In the section titled "treatment," we describe the 4 pillars in the management of patients with cardiac amyloidosis, which includes the following: heart failure treatments, management of arrhythmias, treatment of significant aortic stenosis, and appropriate selection of disease modifying therapies. Our algorithm ends with our simplified recommendation for follow-up.
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Affiliation(s)
- Eyal Herzog
- From the Department of Cardiology, Hadassah Medical Center, Hebrew University of Jerusalem, Israel
| | - David Leibowitz
- From the Department of Cardiology, Hadassah Medical Center, Hebrew University of Jerusalem, Israel
| | - Moshe E Gatt
- Department of Hematology, Hadassah Medical Center, Hebrew University of Jerusalem, Israel
| | - Tali Koren
- From the Department of Cardiology, Hadassah Medical Center, Hebrew University of Jerusalem, Israel
| | - Arthur Pollak
- From the Department of Cardiology, Hadassah Medical Center, Hebrew University of Jerusalem, Israel
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9
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Ye M, Liu X, Gu Z, Sun J, Dong Y, Chen Y, Liu C, Wu Z, Zhu W. A simple ATTR-CM score to identify transthyretin amyloid cardiomyopathy burden in HFpEF patients. Eur J Clin Invest 2023; 53:e14045. [PMID: 37357789 DOI: 10.1111/eci.14045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 06/06/2023] [Accepted: 06/15/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Transthyretin amyloid cardiomyopathy (ATTR-CM) is often found in patients with heart failure with preserved ejection fraction (HFpEF). However, the evidence regarding ATTR-CM and prognosis in HFpEF remains scarce. This study sought to determine whether the ATTR-CM burden was associated with clinical outcomes in HFpEF patients. METHODS We evaluated the associations of baseline ATTR-CM score with adverse outcomes in HFpEF patients from the TOPCAT trial using the Cox proportional hazards model or the competing risk regression model. The discriminatory ability of the ATTR-CM score was assessed using the area under the time-dependent receiver operating characteristic curve (AUC). RESULTS We included 870 HFpEF patients, 18.9% of which had an ATTR-CM score ≥6. Per 1 increment in the ATTR-CM score was significantly associated with an increased risk of the primary outcome (adjusted hazard ratio [HR] 1.19, 95% confidence interval [CI] 1.12-1.27) with an AUC of 0.652 (0.594-0.711), whereas patients with ATTR-CM score ≥6 presented higher risks of the primary outcome (adjusted HR 2.20, 95% CI 1.65-2.95). Similar results were observed toward the secondary outcomes. CONCLUSIONS The simple ATTR-CM score identified an 18.9% ATTR-CM burden in HFpEF patients, and a higher ATTR-CM burden might predict adverse outcomes with moderate discriminatory abilities in HFpEF.
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Affiliation(s)
- Min Ye
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
- NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, People's Republic of China
- National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, People's Republic of China
| | - Xiao Liu
- Department of Cardiology, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Zhenbang Gu
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Junyi Sun
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Yugang Dong
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
- NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, People's Republic of China
- National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, People's Republic of China
| | - Yili Chen
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
- NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, People's Republic of China
- National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, People's Republic of China
| | - Chen Liu
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
- NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, People's Republic of China
- National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, People's Republic of China
| | - Zexuan Wu
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
- NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, People's Republic of China
- National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, People's Republic of China
| | - Wengen Zhu
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
- NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, People's Republic of China
- National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, People's Republic of China
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10
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Cheng RK, Cuddy SAM. Neurohormonal blockade in transthyretin amyloidosis: perhaps one size does not fit all? Eur Heart J 2023; 44:2908-2910. [PMID: 37224517 DOI: 10.1093/eurheartj/ehad357] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 05/19/2023] [Indexed: 05/26/2023] Open
Affiliation(s)
- Richard K Cheng
- Division of Cardiology, University of Washington, Seattle, WA, USA
| | - Sarah A M Cuddy
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02116, USA
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11
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Ioannou A, Massa P, Patel RK, Razvi Y, Porcari A, Rauf MU, Jiang A, Cabras G, Filisetti S, Bolhuis RE, Bandera F, Venneri L, Martinez-Naharro A, Law S, Kotecha T, Virsinskaite R, Knight DS, Emdin M, Petrie A, Lachmann H, Wechelakar A, Petrie M, Hughes A, Freemantle N, Hawkins PN, Whelan C, McMurray JJV, Gillmore JD, Fontana M. Conventional heart failure therapy in cardiac ATTR amyloidosis. Eur Heart J 2023; 44:2893-2907. [PMID: 37216684 PMCID: PMC10424879 DOI: 10.1093/eurheartj/ehad347] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 05/09/2023] [Accepted: 05/19/2023] [Indexed: 05/24/2023] Open
Abstract
AIMS The aims of this study were to assess prescription patterns, dosages, discontinuation rates, and association with prognosis of conventional heart failure medications in patients with transthyretin cardiac amyloidosis (ATTR-CA). METHODS AND RESULTS A retrospective analysis of all consecutive patients diagnosed with ATTR-CA at the National Amyloidosis Centre between 2000 and 2022 identified 2371 patients with ATTR-CA. Prescription of heart failure medications was greater among patients with a more severe cardiac phenotype, comprising beta-blockers in 55.4%, angiotensin-converting enzyme inhibitors (ACEis)/angiotensin II receptor blockers (ARBs) in 57.4%, and mineralocorticoid receptor antagonists (MRAs) in 39.0% of cases. During a median follow-up of 27.8 months (interquartile range 10.6-51.3), 21.7% had beta-blockers discontinued, and 32.9% had ACEi/ARBs discontinued. In contrast, only 7.5% had MRAs discontinued. A propensity score-matched analysis demonstrated that treatment with MRAs was independently associated with a reduced risk of mortality in the overall population [hazard ratio (HR) 0.77 (95% confidence interval (CI) 0.66-0.89), P < .001] and in a pre-specified subgroup of patients with a left ventricular ejection fraction (LVEF) >40% [HR 0.75 (95% CI 0.63-0.90), P = .002]; and treatment with low-dose beta-blockers was independently associated with a reduced risk of mortality in a pre-specified subgroup of patients with a LVEF ≤40% [HR 0.61 (95% CI 0.45-0.83), P = .002]. No convincing differences were found for treatment with ACEi/ARBs. CONCLUSION Conventional heart failure medications are currently not widely prescribed in ATTR-CA, and those that received medication had more severe cardiac disease. Beta-blockers and ACEi/ARBs were often discontinued, but low-dose beta-blockers were associated with reduced risk of mortality in patients with a LVEF ≤40%. In contrast, MRAs were rarely discontinued and were associated with reduced risk of mortality in the overall population; but these findings require confirmation in prospective randomized controlled trials.
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Affiliation(s)
- Adam Ioannou
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Paolo Massa
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Rishi K Patel
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Yousuf Razvi
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Aldostefano Porcari
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Via Giacomo Puccini, Trieste 34100, Italy
| | - Muhammad U Rauf
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Anita Jiang
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Giacomo Cabras
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Stefano Filisetti
- Cardiology University Department, IRCCS Policlinico San Donato, Piazza Edmondo Malan, Milan 20097, Italy
| | - Roos E Bolhuis
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Francesco Bandera
- Cardiology University Department, IRCCS Policlinico San Donato, Piazza Edmondo Malan, Milan 20097, Italy
| | - Lucia Venneri
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Ana Martinez-Naharro
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Steven Law
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Tushar Kotecha
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Ruta Virsinskaite
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Daniel S Knight
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Michele Emdin
- Health Science Interdisciplinary Center, Scuola Superiore Sant’Anna, Via Giuseppe Moruzzi, Pisa 56127, Italy
- Cardiovascular Department, Fondazione Toscana Gabriele Monasterio, Via Giuseppe Moruzzi, Pisa 56124, Italy
| | - Aviva Petrie
- Biostatistics Unit, University College London Eastman Dental Institute, 256 Grays Inn Road, London WC1X 8LD, UK
| | - Helen Lachmann
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Ashutosh Wechelakar
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Mark Petrie
- BHF Cardiovascular Research Centre, University of Glasgow, 126 University Pl, Glasgow G12 8TA, UK
| | - Alun Hughes
- Institute of Cardiovascular Science, University College London, 1–19 Torrington Place, London WC1E 7HB, UK
| | | | - Philip N Hawkins
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Carol Whelan
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, 126 University Pl, Glasgow G12 8TA, UK
| | - Julian D Gillmore
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Marianna Fontana
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
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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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Belfeki N, Ghriss N, Monchi M, Moini C. State of the Art of Cardiac Amyloidosis. Biomedicines 2023; 11:biomedicines11041045. [PMID: 37189662 DOI: 10.3390/biomedicines11041045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 03/20/2023] [Accepted: 03/24/2023] [Indexed: 03/31/2023] Open
Abstract
Cardiac amyloidosis is defined by extracellular deposition of misfolded proteins in the heart. The most frequent cases of cardiac amyloidosis are caused by transthyretin and light chain amyloidosis. This condition is underdiagnosed, and its incidence has been continuously rising in recent studies because of the aging of the population and the development of noninvasive multimodal diagnostic tools. Amyloid infiltration affects all cardiac tunics and causes heart failure with preserved ejection fraction, aortic stenosis, arrythmia, and conductive disorder. Innovative, specific therapeutic approaches have demonstrated an improvement in affected organs and the global survival of patients. This condition is no longer considered rare and incurable. Thus, better knowledge of the disease is mandatory. This review will provide a digest of the clinical signs and symptoms of cardiac amyloidosis, the diagnostic tools used to confirm the diagnosis, and current symptomatic and etiopathogenic management considerations according to guidelines and recommendations.
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Guo Y, Ren M, Wang T, Wang Y, Pu T, Li X, Yu L, Wang L, Liu P, Tang L. Effects of sacubitril/valsartan in ESRD patients undergoing hemodialysis with HFpEF. Front Cardiovasc Med 2022; 9:955780. [PMID: 36440034 PMCID: PMC9681904 DOI: 10.3389/fcvm.2022.955780] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 10/17/2022] [Indexed: 11/11/2022] Open
Abstract
Introduction Heart failure with preserved ejection fraction (HFpEF), which is a common co-morbidity in patients with maintenance hemodialysis (MHD), results in substantial mortality and morbidity. However, there are still no effective therapeutic drugs available for HFpEF currently. Sacubitril/valsartan has been shown to significantly improve clinical outcomes and reverse myocardial remodeling among patients with heart failure with reduced ejection fraction (HFrEF). The effect of sacubitril/valsartan in MHD patients with HFpEF remains unclear. Our study was designed to assess the efficacy and safety of sacubitril/valsartan in MHD patients with HFpEF. Methods A total of 247 MHD patients with HFpEF treated with sacubitril/valsartan were included in this retrospective study. Patients were followed up regularly after medication treatment. The alterations in clinical, biochemical, and echocardiographic parameters before and after taking sacubitril/valsartan were collected. In addition, the safety of the sacubitril/valsartan treatment was also assessed. Among those 247 patients with MHD, 211 patients were already in treatment with angiotensin converting enzyme inhibitors (ACEi)/angiotensin receptor blockers (ARBs) before being treated with sacubitril/valsartan. We also performed an analysis to compare the differences between the 211 patients who had previously received ACEi/ARB treatment and the 36 patients who were sacubitril/valsartan naive. Results Among those 247 patients with MHD, compared with baseline levels, systolic blood pressure (BP) (149.7 ± 23.6 vs. 137.2 ± 21.0 mmHg, P < 0.001), diastolic BP (90.2 ± 16.1 vs. 84.5 ± 14.1 mmHg, P < 0.001), heart rate (83.5 ± 12.5 vs. 80.0 ± 8.7 bpm, P < 0.001), N-terminal B-type natriuretic peptide precursor (NT-proBNP) [29125.0 (11474.5, 68532.0) vs. 12561.3 (4035.0, 37575.0) pg/ml, P < 0.001], and cardiac troponin I [0.044 (0.025, 0.078) vs. 0.0370 (0.020, 0.064) μg/L, P = 0.009] were markedly decreased after treatment with sacubitril/valsartan. New York Heart Association (NYHA) functional class showed a notable trend of improvement after 3–12 months of follow-up. Echocardiographic parameters including left ventricular posterior wall thickness (LVPWT) (11.8 ± 2.0 vs. 10.8 ± 1.9 mm, P < 0.001), intraventricular septal thickness in diastole (11.8 ± 2.0 vs. 11.2 ± 2.0 mm, P < 0.001), left ventricular end-diastolic diameter (53.8 ± 6.9 vs. 51.2 ± 7.1 mm, P < 0.001), left atrial diameter (LAD) (40.5 ± 6.2 vs. 37.2 ± 7.2 mm, P < 0.001), left ventricular end-diastolic volume (LVEDV) [143.0 (111.5, 174.0) vs. 130.0 (105.0, 163.0) ml, P < 0.001], left ventricular end-systolic volume (LVESV) [57.0 (43.0, 82.5) vs. 48.0 (38.0, 74.0) ml, P < 0.001], and pulmonary arterial systolic pressure [39.0 (30.5, 50.0) vs. 28.0 (21.0, 37.5) mmHg, P < 0.001] were significantly reduced after initiating the treatment of sacubitril/valsartan. The parameters of left ventricular diastolic function including E/A ratio [0.8 (0.7, 1.3) vs. 0.9 (0.8, 1.3), P = 0.008], maximal tricuspid regurgitation velocity [2.7 (2.5, 3.2) vs. 2.4 (2.0, 2.8) m/s, P < 0.001], septal e’wave velocity (8.0 ± 0.6 vs. 8.2 ± 0.5 cm/s, P = 0.001), lateral e’ wave velocity (9.9 ± 0.8 vs. 10.2 ± 0.7 cm/s, P < 0.001), E/e’ [8.3 (6.4, 11.8) vs. 7.2 (6.1, 8.9), P < 0.001], and left atrial volume index (37.9 ± 4.2 vs. 36.4 ± 4.1 ml/m2, P < 0.001) were significantly improved by sacubitril/valsartan. Among 211 patients who were already in treatment with ACEi/ARB and 36 patients who were sacubitril/valsartan naive, the improvement of cardiac function demonstrated by clinical outcomes and echocardiographic parameters were similar to the previous one of the 247 MHD patients with HFpEF. During the follow-up, none of the patients showed severe adverse drug reactions. Conclusion Our study suggested that sacubitril/valsartan treatment in MHD patients with HFpEF was effective and safe.
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Affiliation(s)
- Yanhong Guo
- Department of Nephropathy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Mingjing Ren
- Department of Nephropathy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Tingting Wang
- Department of Gastroenterology, Wenxian People’s Hospital, Jiaozuo, China
| | - Yulin Wang
- Department of Nephropathy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Tian Pu
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiaodan Li
- Department of Nephropathy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lu Yu
- Department of Nephropathy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Liuwei Wang
- Department of Nephropathy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Peipei Liu
- Clinical Systems Biology Laboratories, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- *Correspondence: Peipei Liu,
| | - Lin Tang
- Department of Nephropathy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Lin Tang,
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15
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Cuddy SA, Datar Y, Ovsak G, Saith S, Murphy SP, Bay CP, Haddad M, Lilleness B, Muralidhar V, Pipilas A, Vuong J, Guardino E, Maurer MS, Ruberg FL, Falk RH, Dorbala S. Optimal Echocardiographic Parameters to Improve the Diagnostic Yield of Tc-99m-Bone Avid Tracer Cardiac Scintigraphy for Transthyretin Cardiac Amyloidosis. Circ Cardiovasc Imaging 2022; 15:e014645. [PMID: 36378779 PMCID: PMC9667717 DOI: 10.1161/circimaging.122.014645] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 09/30/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Echocardiographic deformation-based ratios and novel multi-parametric scores have been suggested to discriminate transthyretin cardiac amyloidosis (ATTR-CM) from other causes of increased left ventricular wall thickness among patients referred for ATTR-CM evaluation. Their relative predictive accuracy has not been well studied. We sought to (1) identify echocardiographic parameters predictive of ATTR-CM and (2) compare the diagnostic accuracy of these parameters in patients with suspected ATTR-CM referred for technetium-99m-pyrophosphate scintigraphy. METHODS Echocardiograms from 598 patients referred to 3 major amyloidosis centers for technetium-99m-pyrophosphate to detect ATTR-CM were analyzed, including longitudinal strain (LS) analysis. Deformation ratios (septal apex to base ratio, relative apical sparing, ejection fraction to global LS), a multi-center European increased wall thickness score, and Mayo Clinic derived ATTR score (transthyretin cardiac amyloidosis score) were calculated. A logistic regression model was used to identify the parameters that best associated with a diagnosis of ATTR-CM. Comparison of the diagnostic capacity of the parameters was performed by receiver operating characteristic curves and the area under the curve (AUC). RESULTS Over half of the subjects (54.2%) were diagnosed with ATTR-CM (78% were men, median age of 76 years). Age, inferolateral wall thickness, and basal LS were the strongest predictors of ATTR-CM, AUC of 0.87 (95% CI: 0.83, 0.90), superior to the increased wall thickness score AUC of 0.78 (95% CI: 0.73, 0.83; P=0.004). An inferolateral wall thickness of ≥14 mm (AUC: 0.73) was as accurate as the published cut-offs for transthyretin cardiac amyloidosis score and septal apex to base (AUC: 0.72 and 0.69, P=0.8 and P=0.1, respectively), and was superior to ejection fraction to global LS and relative apical sparing (AUC: 0.64 and 0.53, P<0.001, respectively). A cut-off of ≥-8% for average basal LS (AUC: 0.76, CI: 0.72-0.79) had a similar area under the curve to transthyretin cardiac amyloidosis score (TCAS) (P=0.2); outperforming the other indices (P<0.01). CONCLUSION Inferolateral wall thickness and average basal LS performed as well as or better than more complex echo ratios and multiparametric scores to predict ATTR-CM.
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Affiliation(s)
- Sarah Am Cuddy
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA (S.A.M.C., Y.D., S.P.M., M.H., R.H.F., S.D.)
- CV imaging program, Cardiovascular Division and Department of Radiology, Brigham and Women's Hospital, Boston, MA (S.A.M.C., Y.D., G.O., S.D.)
| | - Yesh Datar
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA (S.A.M.C., Y.D., S.P.M., M.H., R.H.F., S.D.)
- CV imaging program, Cardiovascular Division and Department of Radiology, Brigham and Women's Hospital, Boston, MA (S.A.M.C., Y.D., G.O., S.D.)
| | - Gavin Ovsak
- CV imaging program, Cardiovascular Division and Department of Radiology, Brigham and Women's Hospital, Boston, MA (S.A.M.C., Y.D., G.O., S.D.)
| | - Sunil Saith
- Division of Cardiology, Columbia University Irving Medical Center, New York, NY (S.S., M.S.M.)
| | - Sean P Murphy
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA (S.A.M.C., Y.D., S.P.M., M.H., R.H.F., S.D.)
| | - Camden P Bay
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, MA (C.P.B., S.D.)
| | - Mia Haddad
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA (S.A.M.C., Y.D., S.P.M., M.H., R.H.F., S.D.)
| | - Brian Lilleness
- Section of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine/Boston Medical Center, Boston, MA (B.L., V.M., A.P., J.V., E.G., F.L.R.)
| | - Varsha Muralidhar
- Section of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine/Boston Medical Center, Boston, MA (B.L., V.M., A.P., J.V., E.G., F.L.R.)
| | - Alexandra Pipilas
- Section of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine/Boston Medical Center, Boston, MA (B.L., V.M., A.P., J.V., E.G., F.L.R.)
| | - Jacqueline Vuong
- Section of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine/Boston Medical Center, Boston, MA (B.L., V.M., A.P., J.V., E.G., F.L.R.)
| | - Eric Guardino
- Section of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine/Boston Medical Center, Boston, MA (B.L., V.M., A.P., J.V., E.G., F.L.R.)
| | - Mathew S Maurer
- Division of Cardiology, Columbia University Irving Medical Center, New York, NY (S.S., M.S.M.)
| | - Frederick L Ruberg
- Section of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine/Boston Medical Center, Boston, MA (B.L., V.M., A.P., J.V., E.G., F.L.R.)
| | - Rodney H Falk
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA (S.A.M.C., Y.D., S.P.M., M.H., R.H.F., S.D.)
| | - Sharmila Dorbala
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA (S.A.M.C., Y.D., S.P.M., M.H., R.H.F., S.D.)
- CV imaging program, Cardiovascular Division and Department of Radiology, Brigham and Women's Hospital, Boston, MA (S.A.M.C., Y.D., G.O., S.D.)
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, MA (C.P.B., S.D.)
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16
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Ando Y, Adams D, Benson MD, Berk JL, Planté-Bordeneuve V, Coelho T, Conceição I, Ericzon BG, Obici L, Rapezzi C, Sekijima Y, Ueda M, Palladini G, Merlini G. Guidelines and new directions in the therapy and monitoring of ATTRv amyloidosis. Amyloid 2022; 29:143-155. [PMID: 35652823 DOI: 10.1080/13506129.2022.2052838] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
The recent approval of three drugs for the treatment of amyloid transthyretin (ATTR) amyloidosis, both hereditary and wild-type, has opened a new era in the care of these diseases. ATTR amyloidosis is embedded in its pathophysiology, and the drugs target critical steps of the amyloid cascade. In addition to liver transplant, which removes the pathogenic variants, the introduction of gene silencers has allowed the suppression of both wild type and mutant transthyretin (TTR), thus extending the potential therapeutic range to wild-type cardiac amyloidosis. The kinetic stabilisation of TTR using small molecules has proved to be clinically effective both for amyloid neuropathy and cardiomyopathy. Gene silencers and kinetic stabilizers were recently approved on the basis of the outcome of phase III trials; however, comparative trials have not been performed, making it difficult to draw recommendations. Indications for liver transplantation have narrowed considerably. Here, guidelines for therapy are proposed based on expert consensus, acknowledging that the several drugs currently undergoing clinical trials will probably change in the near future the therapeutic armamentarium and, consequently, the therapeutic strategy. Indications for monitoring disease progression and drug efficacy are also provided for the management of these complexes, but now very treatable, diseases.
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Affiliation(s)
- Yukio Ando
- Department of Amyloidosis Research, Nagasaki International University, Sasebo, Japan
| | - David Adams
- Department of Neurology, French National Reference Centre for Familial Amyloidotic Polyneuropathy, CHU Bicêtre, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Merrill D Benson
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.,RLR Veterans Affairs Medical Center, Indianapolis, IN, USA
| | - John L Berk
- Amyloidosis Center, Boston Medical Center, Boston University, Boston, MA, USA
| | - Violaine Planté-Bordeneuve
- Department of Neurology and Amyloid Network, Hospital Henri Mondor, APHP, East-Paris University, Créteil, France
| | - Teresa Coelho
- Andrade's Center, Centro Hospitalar Univerisitário do Porto - Hospital de Santo António, Porto, Portugal
| | - Isabel Conceição
- Department of Neurosciences and Mental Health, CHULN - Hospital de Santa Maria and Faculdade de Medicina, Instituto de Fisiologia, Universidade de Lisboa, Lisbon, Portugal
| | - Bo-Göran Ericzon
- Division of Transplantation Surgery, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Laura Obici
- Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico San Matteo and University of Pavia, Pavia, Italy
| | - Claudio Rapezzi
- Cardiologic Center, University of Ferrara, and Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Mitsuharu Ueda
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Giovanni Palladini
- Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico San Matteo and University of Pavia, Pavia, Italy
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico San Matteo and University of Pavia, Pavia, Italy
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17
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Transthyretin Cardiac Amyloidosis. Cardiol Clin 2022; 40:541-558. [DOI: 10.1016/j.ccl.2022.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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18
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Lund LH, Pitt B, Metra M. Left ventricular ejection fraction as the primary heart failure phenotyping parameter. Eur J Heart Fail 2022; 24:1158-1161. [PMID: 35703027 DOI: 10.1002/ejhf.2576] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 06/10/2022] [Accepted: 06/13/2022] [Indexed: 11/10/2022] Open
Affiliation(s)
- Lars H Lund
- Karolinska Institutet, Department of Medicine, Unit of Cardiology, Stockholm, Sweden.,Karolinska University Hospital, Heart and Vascular Theme, Stockholm, Sweden
| | - Bertram Pitt
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Marco Metra
- Cardiology, ASST Spedali Civili and University, Brescia, Italy
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19
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Cardiac amyloidosis. Curr Opin Cardiol 2022; 37:272-284. [DOI: 10.1097/hco.0000000000000953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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20
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Martyn T, Rubio AC, Estep JD, Hanna M. Opportunities for Earlier Diagnosis and Treatment of Cardiac Amyloidosis. Methodist Debakey Cardiovasc J 2022; 18:27-39. [PMID: 36561083 PMCID: PMC9733170 DOI: 10.14797/mdcvj.1163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 10/07/2022] [Indexed: 12/12/2022] Open
Abstract
Despite the rapid expansion of noninvasive (nonbiopsy) diagnosis, contemporary patients with cardiac amyloidosis too often present with advanced features of disease, such as diminished quality of life, elevated natriuretic peptides, and advanced heart failure. Therapeutics for transthyretin cardiomyopathy (ATTR-CM) are most effective when administered before significant symptoms of cardiac dysfunction manifest, making early identification of affected individuals of paramount importance. Community engagement and ensuring that a broad range of clinicians have working knowledge of how to screen for ATTR-CM in everyday practice will be an important step in moving disease identification further upstream. However, reliance on the appropriate and timely diagnosis by individual clinicians may continue to underperform. This review highlights how targeted screening of special populations may facilitate earlier diagnosis. Systems of care that operationalize screening of high-risk subpopulations and prospective validation of novel approaches to ATTR-CM identification are needed.
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Affiliation(s)
- Trejeeve Martyn
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, George and Linda Kaufman Center for Heart Failure and Recovery, Cleveland Clinic, Cleveland, Ohio, US,Amyloidosis Center, Cleveland Clinic, Cleveland, Ohio, US
| | - Andres Carmona Rubio
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, George and Linda Kaufman Center for Heart Failure and Recovery, Cleveland Clinic, Cleveland, Ohio, US,Amyloidosis Center, Cleveland Clinic, Cleveland, Ohio, US
| | - Jerry D. Estep
- Amyloidosis Center, Cleveland Clinic, Cleveland, Ohio, US,Department of Cardiovascular Medicine, Cleveland Clinic Florida, Weston, Florida, US
| | - Mazen Hanna
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, George and Linda Kaufman Center for Heart Failure and Recovery, Cleveland Clinic, Cleveland, Ohio, US,Amyloidosis Center, Cleveland Clinic, Cleveland, Ohio, US
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