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Bampatsias D, Wardhere A, Maurer MS. Treatment of transthyretin cardiac amyloidosis. Curr Opin Cardiol 2024; 39:407-416. [PMID: 38652263 PMCID: PMC11305969 DOI: 10.1097/hco.0000000000001156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
PURPOSE OF REVIEW Tafamidis is currently the only approved disease-modifying treatment for ATTR-CM. However, there have been important developments in the treatment of ATTR-CM, as the results of two phase 3 trials were published and several other trials are in their final stages. In this review, we summarize current and future therapies for ATTR-CM. RECENT FINDINGS Recently, acoramidis, a TTR stabilizer has been proven to be effective in reducing mortality and morbidity compared to placebo in the ATTRibute-CM trial. Additionally, patisiran, an RNA silencer, preserved functional capacity and quality of life compared to placebo in the APOLLO-B trial. However, the FDA declined to approve patisiran for ATTR-CM. The results of phase 1 trial of ALXN2220, an antiamyloid antibody raise hope for reversal of myocardial damage by amyloid depletion. Phase 3 trials evaluating the efficacy of different RNA silencers, gene editing with CRISPR-Cas9, and other anti-amyloid antibodies are ongoing. SUMMARY Therapies targeting different mechanism in the pathophysiology of ATTR-CM provide new alternatives for treating patients with ATTR-CM. Future research should focus on comparing their effectiveness, the potential of combined treatment with agents from different classes and on identifying the patients who will benefit most from each class of medication.
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Affiliation(s)
- Dimitrios Bampatsias
- Cardiac Amyloidosis Program, Department of Cardiology, Columbia University Irving Medical Center, New York, USA
| | - Abdirahman Wardhere
- Cardiac Amyloidosis Program, Department of Cardiology, Columbia University Irving Medical Center, New York, USA
| | - Mathew S. Maurer
- Cardiac Amyloidosis Program, Department of Cardiology, Columbia University Irving Medical Center, New York, USA
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2
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Westermark P, Merlini G. Successes in translation. Amyloid 2024; 31:159-167. [PMID: 39101820 DOI: 10.1080/13506129.2024.2387163] [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: 06/24/2024] [Revised: 07/11/2024] [Accepted: 07/27/2024] [Indexed: 08/06/2024]
Abstract
Translational research is key in advancing the diagnosis and therapy of systemic amyloidoses. This paper summarises our presentations at the ISA Workshop on Translation in Systemic Amyloidoses held in Athens on September 25-26, 2023. The critical advances made by the pioneers in the field are reviewed, with particular attention to the discoveries and developments of utmost importance to our understanding of what amyloid is and how the substance affects functions. Examples of translational research regarding the mechanisms of cardiac damage in light chain amyloidosis, the role of biomarkers in improving our understanding of the biology of the disease and patients' management, and the molecular mechanisms involved in the cytotoxicity are described. Advances in basic research continue to open new therapeutic avenues.
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Affiliation(s)
- Per Westermark
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Giampaolo Merlini
- Department of Molecular Medicine, Amyloidosis Research and Treatment Center, IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
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3
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Bellofatto IA, Nikolaou PE, Andreadou I, Canepa M, Carbone F, Ghigo A, Heusch G, Kleinbongard P, Maack C, Podesser BK, Stamatelopoulos K, Stellos K, Vilahur G, Montecucco F, Liberale L. Mechanisms of damage and therapies for cardiac amyloidosis: a role for inflammation? Clin Res Cardiol 2024:10.1007/s00392-024-02522-2. [PMID: 39167195 DOI: 10.1007/s00392-024-02522-2] [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: 06/03/2024] [Accepted: 08/12/2024] [Indexed: 08/23/2024]
Abstract
The term cardiac amyloidosis (CA) refers to the accumulation of extracellular amyloid deposits in the heart because of different conditions often affecting multiple organs including brain, kidney and liver. Notably, cardiac involvement significantly impacts prognosis of amyloidosis, with cardiac biomarkers playing a pivotal role in prognostic stratification. Therapeutic management poses a challenge due to limited response to conventional heart failure therapies, necessitating targeted approaches aimed at preventing, halting or reversing amyloid deposition. Mechanisms underlying organ damage in CA are multifactorial, involving proteotoxicity, oxidative stress, and mechanical interference. While the role of inflammation in CA remains incompletely understood, emerging evidence suggests its potential contribution to disease progression as well as its utility as a therapeutic target. This review reports on the cardiac involvement in systemic amyloidosis, its prognostic role and how to assess it. Current and emerging therapies will be critically discussed underscoring the need for further efforts aiming at elucidating CA pathophysiology. The emerging evidence suggesting the contribution of inflammation to disease progression and its prognostic role will also be reviewed possibly offering insights into novel therapeutic avenues for CA.
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Affiliation(s)
- Ilaria Anna Bellofatto
- Department of Internal Medicine, University of Genoa, 6 Viale Benedetto XV, 16132, Genoa, Italy
| | - Panagiota Efstathia Nikolaou
- Laboratory of Pharmacology, Faculty of Pharmacy, National and Kapodistrian University of Athens, Panepistimiopolis, Zografou, 15771, Athens, Greece
| | - Ioanna Andreadou
- Laboratory of Pharmacology, Faculty of Pharmacy, National and Kapodistrian University of Athens, Panepistimiopolis, Zografou, 15771, Athens, Greece
| | - Marco Canepa
- Department of Internal Medicine, University of Genoa, 6 Viale Benedetto XV, 16132, Genoa, Italy
- Cardiology Unit, Ospedale Policlinico San Martino IRCCS, Genoa, Italy
| | - Federico Carbone
- Department of Internal Medicine, University of Genoa, 6 Viale Benedetto XV, 16132, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino Genoa-Italian Cardiovascular Network, L.Go R. Benzi 10, 16132, Genoa, Italy
| | - Alessandra Ghigo
- Department of Molecular Biotechnology and Health Sciences, Molecular Biotechnology Center "Guido Tarone", University of Torino, Turin, Italy
| | - Gerd Heusch
- Institute for Pathophysiology, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany
| | - Petra Kleinbongard
- Institute for Pathophysiology, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany
| | - Christoph Maack
- Department of Translational Research, Comprehensive Heart Failure Center (CHFC), and Medical Clinic I, University Clinic Würzburg, Würzburg, Germany
| | - Bruno K Podesser
- Ludwig Boltzmann Institute for Cardiovascular Research at the Center for Biomedical Research and Translational Surgery, Medical University of Vienna, Vienna, Austria
| | - Kimon Stamatelopoulos
- Angiology and Endothelial Pathophysiology Unit, Department of Clinical Therapeutics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Stellos
- Department of Cardiovascular Research, European Center for Angioscience, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Gemma Vilahur
- Research Institute, Hospital de La Santa Creu I Sant Pau, IIB-Sant Pau, C/Sant Antoni Mª Claret 167, 08025, Barcelona, Spain
- CiberCV, Institute Carlos III, Madrid, Spain
| | - Fabrizio Montecucco
- Department of Internal Medicine, University of Genoa, 6 Viale Benedetto XV, 16132, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino Genoa-Italian Cardiovascular Network, L.Go R. Benzi 10, 16132, Genoa, Italy
| | - Luca Liberale
- Department of Internal Medicine, University of Genoa, 6 Viale Benedetto XV, 16132, Genoa, Italy.
- IRCCS Ospedale Policlinico San Martino Genoa-Italian Cardiovascular Network, L.Go R. Benzi 10, 16132, Genoa, Italy.
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4
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Schilling JD, Nuvolone M, Merlini G. The Pathophysiological and Therapeutic Implications of Cardiac Light-Chain Amyloidosis Compared With Transthyretin Amyloidosis. JACC. HEART FAILURE 2024:S2213-1779(24)00519-5. [PMID: 39177569 DOI: 10.1016/j.jchf.2024.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Revised: 07/02/2024] [Accepted: 07/02/2024] [Indexed: 08/24/2024]
Affiliation(s)
- Joel D Schilling
- Center for Cardiovascular Research, Washington University School of Medicine, St. Louis, Missouri, USA; Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA; Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri, USA.
| | - Mario Nuvolone
- Department of Molecular Medicine, University of Pavia, Pavia, Italy; Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Giampaolo Merlini
- Department of Molecular Medicine, University of Pavia, Pavia, Italy; Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
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Ichimata S, Hata Y, Yoshida K, Hirono K, Nishida N. Distinctive Deposition Patterns of Sporadic Transthyretin-Derived Amyloidosis in the Atria: A Forensic Autopsy-Based Study. Int J Mol Sci 2024; 25:8176. [PMID: 39125745 PMCID: PMC11311325 DOI: 10.3390/ijms25158176] [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: 07/05/2024] [Revised: 07/24/2024] [Accepted: 07/24/2024] [Indexed: 08/12/2024] Open
Abstract
Left-to-right differences in the histopathologic patterns of transthyretin-derived amyloid (ATTR) deposition in the atria of older adults have not yet been investigated. Hence, this study evaluated heart specimens from 325 serial autopsy subjects. The amount of ATTR deposits in the seven cardiac regions, including both sides of atria and atrial appendages, was evaluated semiquantitatively. Using digital pathology, we quantitatively evaluated the immunohistochemical deposition burden of ATTR in the myocardium. We identified 20 sporadic ATTR cardiac amyloidosis cases (nine males). All patients had ATTR deposition in the left atrial regions of the myocardium. In the semiquantitative analysis, 14 of the 20 cases showed more severe ATTR deposition on the left atrial regions than on the right side, with statistically significant differences in the pathology grading (p < 0.01 for both the atrium and atrial appendage). Quantitative analysis further supported the difference. Moreover, six had ATTR deposition in the epineurium and/or neural fibers of the atria. Cluster analysis revealed that ATTR deposition in the myocardium was significantly more severe in males than in females. The heterogeneous distribution of amyloid deposits between atria revealed in this study may impair the orderly transmission of the cardiac conduction system and induce arrhythmias, which may be further aggravated by additional neuropathy in the advanced phase. This impairment could be more severe among males. These findings emphasize that atrial evaluation is important for individuals with sporadic ATTR cardiac amyloidosis, particularly for early detection.
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Affiliation(s)
- Shojiro Ichimata
- Department of Legal Medicine, Faculty of Medicine, University of Toyama, Toyama 930-0194, Japan (N.N.)
| | - Yukiko Hata
- Department of Legal Medicine, Faculty of Medicine, University of Toyama, Toyama 930-0194, Japan (N.N.)
| | - Koji Yoshida
- Department of Legal Medicine, Faculty of Medicine, University of Toyama, Toyama 930-0194, Japan (N.N.)
| | - Keiichi Hirono
- Department of Pediatrics, Faculty of Medicine, University of Toyama, Toyama 930-0194, Japan;
| | - Naoki Nishida
- Department of Legal Medicine, Faculty of Medicine, University of Toyama, Toyama 930-0194, Japan (N.N.)
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Fontana M, Porcari A. Imaging in Amyloidosis: 20 Years of Sustained Innovation. JACC Cardiovasc Imaging 2024:S1936-878X(24)00237-7. [PMID: 39093255 DOI: 10.1016/j.jcmg.2024.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Accepted: 06/06/2024] [Indexed: 08/04/2024]
Affiliation(s)
- Marianna Fontana
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, United Kingdom.
| | - Aldostefano Porcari
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, United Kingdom; 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
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Maurer MS, Soman P, Hernandez A, Garcia-Pavia P, Signorovitch J, Wei LJ, Hanna M, Ruberg FL, Kittleson M, Kazi D, Dorbala S, Hsu K, Lousada I, Adigun R, Dunnmon P, Kelly J, Gillmore J. Advancing Transthyretin Amyloidosis Drug Development in an Evolving Treatment Landscape: Amyloidosis Forum Meeting Proceedings. Adv Ther 2024; 41:2723-2742. [PMID: 38833142 PMCID: PMC11334214 DOI: 10.1007/s12325-024-02891-0] [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: 02/29/2024] [Accepted: 04/29/2024] [Indexed: 06/06/2024]
Abstract
INTRODUCTION Hereditary transthyretin amyloidosis (ATTRv, also referred to as hATTR; ORPHA 271861) and wild-type ATTR amyloidosis (ATTRwt; ORPHA 330001) are rare, progressive, systemic protein misfolding disorders with heterogeneous clinical presentations. ATTRv and ATTRwt amyloidosis are characterized by the deposition of amyloid fibrils in multiple organs including the heart, nerves, eyes, and soft tissues. The management of ATTR amyloidosis is complex because of its multisystemic nature and progression despite available treatment options. Morbidity is high and there are many unmet medical needs for patients. While contemporary ATTR amyloidosis cohorts are diagnosed earlier, have lower risk disease and lower mortality compared with the previous era, these advances coupled with the emergence of effective disease-modifying therapies have confounded the design of future prospective clinical trials and interpretation of historical control data. MAIN BODY The Amyloidosis Forum is a public-private partnership between the US Food and Drug Administration Center for Drug Evaluation and Research and the nonprofit Amyloidosis Research Consortium ( www.arci.org ). This article summarizes proceedings from the 21 June 2023 Amyloidosis Forum on advancing drug development in ATTR amyloidosis in an evolving treatment landscape. The Forum focused on elements of clinical trial design to address these challenges and discussed their strengths and weaknesses from multiple stakeholder perspectives (i.e., patient, sponsor, statistician, clinician, and regulatory authorities). CONCLUSION Given rapid evolution of natural history in ATTR amyloidosis, the utility of historical control data is limited. Leveraging contemporary real-world data is essential for clinical trial design. Evidence generation from clinical trials should address clinically relevant questions. Key factors in successful trial design must be informed by up-to-date data on natural history, prognostic factors, clinically meaningful thresholds, and sharing available clinical trial data. The Amyloidosis Forum includes the community of patients with ATTR amyloidosis, the physicians who treat them, and the sponsors and regulators who collectively stand ready to support further studies in order to develop novel effective therapies.
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Affiliation(s)
- Mathew S Maurer
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Prem Soman
- University of Pittsburgh Medical Center, UPMC Heart and Vascular Institute, Cardiac Amyloidosis Center, Pittsburg, PA, USA
| | - Adrian Hernandez
- Duke University School of Medicine, Duke Clinical Research Center, Durham, NC, USA
| | - Pablo Garcia-Pavia
- Hospital Universitario Puerta de Hierro Majadahonda, IDIPHISA, CIBERCV, Madrid, Spain
- Spanish National Cardiovascular Research Institute (CNIC), Madrid, Spain
| | | | - L J Wei
- T.H. Chan School of Public Health, Biostatistics, Harvard University, Boston, MA, USA
| | - Mazen Hanna
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Frederick L Ruberg
- Chobanian and Avedisian School of Medicine, Department of Medicine, Boston University, Boston, MA, USA
| | | | - Dhruv Kazi
- Beth Israel Deaconess Medical Center, Cardiac Critical Care Unit; Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Health Economics, Boston, MA, USA
| | - Sharmila Dorbala
- Brigham and Women's Hospital, Cardiovascular Medicine, Nuclear Radiology, Boston, MA, USA
| | - Kristen Hsu
- Amyloidosis Research Consortium, 320 Nevada Street, Suite 210, Newton, MA, 02460, USA
| | - Isabelle Lousada
- Amyloidosis Research Consortium, 320 Nevada Street, Suite 210, Newton, MA, 02460, USA.
| | - Rosalyn Adigun
- Center for Drug Evaluation and Research, Division of Cardiology and Nephrology, US Food and Drug Administration, Silver Spring, MD, USA
| | - Preston Dunnmon
- Janssen Research and Development Data Sciences, Cardiovascular/Metabolic and Pulmonary Hypertension, Raritan, NJ, USA
| | - Jeffery Kelly
- Department of Chemistry, Scripps Research Institute, San Diego, CA, USA
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Saro R, Allegro V, Merlo M, Dore F, Sinagra G, Porcari A. Specific Therapy in Transthyretin Amyloid Cardiomyopathy: Future Perspectives Beyond Tafamidis. Heart Fail Clin 2024; 20:343-352. [PMID: 38844305 DOI: 10.1016/j.hfc.2024.03.005] [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] [Indexed: 06/09/2024]
Abstract
Transthyretin amyloid cardiomyopathy (ATTR-CM) is a relatively prevalent cause of morbidity and mortality. Over the recent years, development of disease-modifying treatments has enabled stabilization of the circulating transthyretin tetramer and suppression of its hepatic production, resulting in a remarkable improvement in survival of patients with ATTR-CM. Second-generation drugs for silencing are currently under investigation in randomized clinical trials. In vivo gene editing of transthyretin has been achieving unanticipated suppression of hepatic production in ATTR-CM. Trials of antibodies inducing the active removal of transthyretin amyloid deposits in the heart are ongoing, and evidence has gathered for exceptional spontaneous regression of ATTR-CM.
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Affiliation(s)
- Riccardo Saro
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Via P. Valdoni 7, 34100, Trieste, Italy; European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Via P. Valdoni 7, 34100, Trieste, Italy
| | - Valentina Allegro
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Via P. Valdoni 7, 34100, Trieste, Italy; European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Via P. Valdoni 7, 34100, Trieste, Italy
| | - Marco Merlo
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Via P. Valdoni 7, 34100, Trieste, Italy; European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Via P. Valdoni 7, 34100, Trieste, Italy
| | - Franca Dore
- Head of Nuclear Medicine Division, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Trieste, Italy
| | - Gianfranco Sinagra
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Via P. Valdoni 7, 34100, Trieste, Italy; European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Via P. Valdoni 7, 34100, Trieste, Italy
| | - Aldostefano Porcari
- Department of Nuclear Medicine, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Via P. Valdoni 7, 34100, Trieste, Italy; National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK.
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9
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Nitsche C, Ioannou A, Patel RK, Razvi Y, Porcari A, Rauf MU, Bandera F, Aimo A, Emdin M, Martinez-Naharro A, Venneri L, Petrie A, Wechalekar A, Lachmann H, Hawkins PN, Gillmore JD, Fontana M. Expansion of the National Amyloidosis Centre staging system to detect early mortality in transthyretin cardiac amyloidosis. Eur J Heart Fail 2024. [PMID: 38922779 DOI: 10.1002/ejhf.3354] [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: 02/02/2024] [Revised: 05/28/2024] [Accepted: 06/10/2024] [Indexed: 06/28/2024] Open
Abstract
AIMS Transthyretin cardiac amyloidosis (ATTR-CA) is stratified into prognostic categories using the National Amyloidosis Centre (NAC) staging system. The aims of this study were to further expand the existing NAC staging system to incorporate an additional disease stage that would identify patients at high risk of early mortality. METHODS AND RESULTS The traditional NAC staging system (stage 1: N-terminal pro-B-type natriuretic peptide [NT-proBNP] ≤3000 ng/L and estimated glomerular filtration rate [eGFR] ≥45 ml/min; stage 3: NT-proBNP >3000 ng/L and eGFR <45 ml/min; stage 2: remainder) was expanded by the introduction of a new stage 4 (defined as NT-proBNP ≥10 000 ng/L irrespective of eGFR) and studied in 2042 patients. The optimal NT-proBNP cut-point was established using time-dependent receiver operating characteristic curves in the subgroup of patients with NAC stage 3 disease. Mortality at 1 year according to NAC stage was 2.3% (n = 20/886) for stage 1, 8.8% (n = 62/706) for stage 2, 10.4% (n = 28/270) for stage 3, and 30.6% (n = 55/180) for stage 4 (log-rank p < 0.001). After adjustment for age, mortality hazard for stage 4 was >15-fold higher than that of stage 1 (hazard ratio [HR] 15.5; 95% confidence interval [CI] 9.3-26.1) and >3-fold higher than that of stage 3 (HR 3.4; 95% CI 2.2-5.4). The increased risk of early mortality was consistent across the different genotypes and subclasses of patients based on the severity of heart failure symptoms and echocardiographic parameters. CONCLUSIONS The proposed modification of the NAC staging system identifies patients with ATTR-CA at a high risk of early mortality, who may benefit from a more intensive treatment strategy, and who are most likely to experience an event early in the course of a clinical trial.
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Affiliation(s)
- Christian Nitsche
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
- Institute of Cardiovascular Science, University College London, London, UK
- Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - Adam Ioannou
- National Amyloidosis Centre, University College London, Royal Free Hospital, London, UK
| | - Rishi K Patel
- National Amyloidosis Centre, University College London, Royal Free Hospital, London, UK
| | - Yousuf Razvi
- National Amyloidosis Centre, University College London, Royal Free Hospital, London, UK
| | - Aldostefano Porcari
- National Amyloidosis Centre, University College London, Royal Free Hospital, London, UK
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Muhammad U Rauf
- National Amyloidosis Centre, University College London, Royal Free Hospital, London, UK
| | - Francesco Bandera
- Cardiology University Department, IRCCS Policlinico San Donato, Milan, Italy
| | - Alberto Aimo
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Michele Emdin
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Ana Martinez-Naharro
- National Amyloidosis Centre, University College London, Royal Free Hospital, London, UK
| | - Lucia Venneri
- National Amyloidosis Centre, University College London, Royal Free Hospital, London, UK
| | - Aviva Petrie
- Biostatistics Unit, UCL Eastman Dental Institute, University College London, London, UK
| | - Ashutosh Wechalekar
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Helen Lachmann
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Philip N Hawkins
- National Amyloidosis Centre, University College London, Royal Free Hospital, London, UK
| | - Julian D Gillmore
- National Amyloidosis Centre, University College London, Royal Free Hospital, London, UK
| | - Marianna Fontana
- National Amyloidosis Centre, University College London, Royal Free Hospital, London, UK
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10
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Porcari A, Sinagra G, Gillmore JD, Fontana M, Hawkins PN. Breakthrough advances enhancing care in ATTR amyloid cardiomyopathy. Eur J Intern Med 2024; 123:29-36. [PMID: 38184468 DOI: 10.1016/j.ejim.2024.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 01/02/2024] [Indexed: 01/08/2024]
Abstract
Transthyretin amyloid cardiomyopathy (ATTR-CM) has been traditionally considered a rare and inexorably fatal condition. ATTR-CM now is an increasingly recognized cause of heart failure (HF) and mortality worldwide with effective pharmacological treatments. Advances in non-invasive diagnosis, coupled with the development of effective treatments, have transformed the diagnosis of ATTR-CM, which is now possible without recourse to endomyocardial biopsy in ≈70 % of cases. Many patients are now diagnosed at an earlier stage. Echocardiography and cardiac magnetic resonance have enabled identification of patients with possible ATTR-CM and more accurate prognostic stratification. Although radionuclide scintigraphy with 'bone' tracers has an established diagnostic value, the diagnostic performance of the bone tracers validated for non-invasive confirmation of ATTR-CM may not be equal. Characterising the wider clinical phenotype of patients with ATTR-CM has enabled identification of features with potential for earlier diagnosis such as carpal tunnel syndrome. Therapies able to slow or halt ATTR-CM progression and increase survival are now available and there is also evidence that patients may benefit from specific conventional HF medications. Cutting-edge research in the field of antibody-mediated removal of ATTR deposits compellingly suggest that ATTR-CM is a truly reversible disorder, bringing hope for patients even with advanced disease. A wide horizon of possibilities is unfolding and awaits discovery.
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Affiliation(s)
- Aldostefano Porcari
- National Amyloidosis Centre, Division of Medicine, Royal Free Campus, University College London, Rowland Hill Street, London NW3 2PF, UK; Centre for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste 34149, Italy; European Reference Network for rare, low prevalence and complex diseases of the heart (ERN GUARD-Heart), Italy.
| | - Gianfranco Sinagra
- Centre for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste 34149, Italy; European Reference Network for rare, low prevalence and complex diseases of the heart (ERN GUARD-Heart), Italy
| | - Julian D Gillmore
- National Amyloidosis Centre, Division of Medicine, Royal Free Campus, University College London, Rowland Hill Street, London NW3 2PF, UK
| | - Marianna Fontana
- National Amyloidosis Centre, Division of Medicine, Royal Free Campus, University College London, Rowland Hill Street, London NW3 2PF, UK
| | - Philip N Hawkins
- National Amyloidosis Centre, Division of Medicine, Royal Free Campus, University College London, Rowland Hill Street, London NW3 2PF, UK
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Slaven S, Raymer DS, Mestroni L. The electrocardiographic signature of variant transthyretin amyloidosis. Int J Cardiol 2024; 398:131442. [PMID: 37852541 PMCID: PMC10843784 DOI: 10.1016/j.ijcard.2023.131442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 10/11/2023] [Indexed: 10/20/2023]
Affiliation(s)
- Sarah Slaven
- Department of Medicine, Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - David S Raymer
- Department of Medicine, Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Luisa Mestroni
- Department of Medicine, Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
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Fontana M, Porcari A, Hawkins PN. Standardising Care and Treatment of Transthyretin Amyloid Cardiomyopathy. Glob Heart 2023; 18:63. [PMID: 38028963 PMCID: PMC10668877 DOI: 10.5334/gh.1275] [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: 09/20/2023] [Accepted: 10/20/2023] [Indexed: 12/01/2023] Open
Abstract
Transthyretin cardiac amyloidosis (ATTR-CA) has been traditionally considered a rare and inexorably fatal condition. ATTR-CA now is an increasingly recognised cause of heart failure and mortality worldwide with effective pharmacological treatments. Advances in non-invasive diagnosis, coupled with the development of effective treatments, have transformed the diagnosis of ATTR-CA, which is now possible without recourse to endomyocardial biopsy in around 70% of cases. Many patients are now diagnosed at an earlier stage. Echocardiography and cardiac magnetic resonance have enabled identification of patients with possible ATTR-CA and more accurate prognostic stratification. Therapies able to slow or halt ATTR-CA progression and increase survival are now available and there is also evidence that patients may benefit from specific conventional heart failure medications. A wide horizon of possibilities is unfolding and awaits discovery.
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Affiliation(s)
- Marianna Fontana
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Aldostefano Porcari
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
- Centre for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste 34149, IT
- European Reference Network for rare, low prevalence and complex diseases of the heart (ERN GUARD-Heart), Europe
| | - Philip N. Hawkins
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
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Affiliation(s)
- Giampaolo Merlini
- From the Amyloidosis Research Center, Foundation IRCCS Policlinico San Matteo, Department of Molecular Medicine, University of Pavia, Pavia, Italy
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Foster JS, Balachandran M, Hancock TJ, Martin EB, Macy S, Wooliver C, Richey T, Stuckey A, Williams AD, Jackson JW, Kennel SJ, Wall JS. Development and characterization of a prototypic pan-amyloid clearing agent - a novel murine peptide-immunoglobulin fusion. Front Immunol 2023; 14:1275372. [PMID: 37854603 PMCID: PMC10580800 DOI: 10.3389/fimmu.2023.1275372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 09/13/2023] [Indexed: 10/20/2023] Open
Abstract
Introduction Systemic amyloidosis is a progressive disorder characterized by the extracellular deposition of amyloid fibrils and accessory proteins in visceral organs and tissues. Amyloid accumulation causes organ dysfunction and is not generally cleared by the immune system. Current treatment focuses on reducing amyloid precursor protein synthesis and slowing amyloid deposition. However, curative interventions will likely also require removal of preexisting amyloid deposits to restore organ function. Here we describe a prototypic pan-amyloid binding peptide-antibody fusion molecule (mIgp5) that enhances macrophage uptake of amyloid. Methods The murine IgG1-IgG2a hybrid immunoglobulin with a pan amyloid-reactive peptide, p5, fused genetically to the N-terminal of the immunoglobulin light chain was synthesized in HEK293T/17 cells. The binding of the p5 peptide moiety was assayed using synthetic amyloid-like fibrils, human amyloid extracts and amyloid-laden tissues as substrates. Binding of radioiodinated mIgp5 with amyloid deposits in vivo was evaluated in a murine model of AA amyloidosis using small animal imaging and microautoradiography. The bioactivity of mIgp5 was assessed in complement fixation and in vitro phagocytosis assays in the presence of patient-derived amyloid extracts and synthetic amyloid fibrils as substrates and in the presence or absence of human serum. Results Murine Igp5 exhibited highly potent binding to AL and ATTR amyloid extracts and diverse types of amyloid in formalin-fixed tissue sections. In the murine model of systemic AA amyloidosis, 125I-mIgp5 bound rapidly and specifically to amyloid deposits in all organs, including the heart, with no evidence of non-specific uptake in healthy tissues. The bioactivity of the immunoglobulin Fc domain was uncompromised in the context of mIgp5 and served as an effective opsonin. Macrophage-mediated uptake of amyloid extract and purified amyloid fibrils was enhanced by the addition of mIgp5. This effect was exaggerated in the presence of human serum coincident with deposition of complement C5b9. Conclusion Immunostimulatory, amyloid-clearing therapeutics can be developed by incorporating pan-amyloid-reactive peptides, such as p5, as a targeting moiety. The immunologic functionality of the IgG remains intact in the context of the fusion protein. These data highlight the potential use of peptide-antibody fusions as therapeutics for all types of systemic amyloidosis.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Jonathan S. Wall
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, United States
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Plantone D, Primiano G, Righi D, Romano A, Luigetti M, De Stefano N. Current Evidence Supporting the Role of Immune Response in ATTRv Amyloidosis. Cells 2023; 12:2383. [PMID: 37830598 PMCID: PMC10572348 DOI: 10.3390/cells12192383] [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: 08/16/2023] [Revised: 09/23/2023] [Accepted: 09/27/2023] [Indexed: 10/14/2023] Open
Abstract
Hereditary transthyretin (ATTRv) amyloidosis with polyneuropathy, also known as familial amyloid polyneuropathy (FAP), represents a progressive, heterogeneous, severe, and multisystemic disease caused by pathogenic variants in the TTR gene. This autosomal-dominant neurogenetic disorder has an adult onset with variable penetrance and an inconstant phenotype, even among subjects carrying the same mutation. Historically, ATTRv amyloidosis has been viewed as a non-inflammatory disease, mainly due to the absence of any mononuclear cell infiltration in ex vivo tissues; nevertheless, a role of inflammation in its pathogenesis has been recently highlighted. The immune response may be involved in the development and progression of the disease. Fibrillary TTR species bind to the receptor for advanced glycation end products (RAGE), probably activating the nuclear factor κB (NF-κB) pathway. Moreover, peripheral blood levels of several cytokines, including interferon (IFN)-gamma, IFN-alpha, IL-6, IL-7, and IL-33, are altered in the course of the disease. This review summarizes the current evidence supporting the role of the immune response in ATTRv amyloidosis, from the pathological mechanisms to the possible therapeutic implications.
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Affiliation(s)
- Domenico Plantone
- Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy; (D.R.); (N.D.S.)
| | - Guido Primiano
- Dipartimento di Neuroscienze, Organi di Senso e Torace, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (G.P.); (A.R.); (M.L.)
- Dipartimento di Neuroscienze, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Delia Righi
- Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy; (D.R.); (N.D.S.)
| | - Angela Romano
- Dipartimento di Neuroscienze, Organi di Senso e Torace, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (G.P.); (A.R.); (M.L.)
- Dipartimento di Neuroscienze, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Marco Luigetti
- Dipartimento di Neuroscienze, Organi di Senso e Torace, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (G.P.); (A.R.); (M.L.)
- Dipartimento di Neuroscienze, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Nicola De Stefano
- Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy; (D.R.); (N.D.S.)
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