Efficacy and Safety of Acoramidis in Transthyretin Amyloid Cardiomyopathy

Emerging, novel gene-modulating therapies for transthyretin amyloid cardiomyopathy

Transthyretin amyloid cardiomyopathy (ATTR-CM) is a progressive, life-threatening disease caused by the pathological deposition of misfolded transthyretin (TTR) protein in the myocardium, leading to restrictive cardiomyopathy and heart failure. While TTR stabilizers such as tafamidis and acoramidis are the only FDA-approved treatments, novel gene-modulating therapies are emerging as transformative approaches. Small interfering RNA (siRNA) and antisense oligonucleotide (ASO) therapies effectively reduce TTR production and have demonstrated promising clinical outcomes, though their use in cardiac amyloidosis remains investigational. CRISPR-Cas9 therapies represent a paradigm shift, offering a potential one-time treatment by permanently silencing the TTR gene. Recent clinical trials have shown significant TTR reduction and stabilization of disease biomarkers, although long-term safety and efficacy require further evaluation. Despite the lack of direct comparisons among these modalities, their emergence highlights a promising future for ATTR-CM management. This review discusses the pathogenesis of ATTR-CM, mechanisms of novel gene-modulating therapies, clinical evidence, challenges, and the future outlook for advancing treatment options.

Mangiferin as a potential inhibitor of transthyretin fibrillogenesis

By using in silico molecular docking, we predicted a high potential of mangiferin to inhibit transthyretin amyloidogenesis. Subsequently, we tested this prediction in an in vitro system. The study involved testing effect of mangiferrin in a system that included isolated and purified recombinant transthyretin under fibrillogenesis conditions and a detection assay based on the fluorescent dye thioflavin T, characteristic of amyloid fibrils. The conditions for fibrillogenesis of this protein at neutral pH values were established. Using the developed test system, it was shown that mangiferin is able to inhibit abnormal transthyretin fibrillogenesis.

Sodium-glucose cotransporter 2 inhibitors and outcomes in transthyretin amyloid cardiomyopathy: Systematic review and meta-analysis

BACKGROUND

Transthyretin amyloid cardiomyopathy (ATTR-CM) commonly leads to heart failure but has traditionally been an exclusion criterion in randomized clinical trials (RCTs) of sodium-glucose cotransporter 2 inhibitors (SGLT2i); therefore, the effects of these drugs in this population remain undocumented. In light of recent studies, this meta-analysis aimed to investigate the effect of SGLT2i on the prognosis of patients with ATTR-CM.

METHODS

A comprehensive search of Medline, Scopus, and the Cochrane Library was conducted up to November 17, 2024. Study selection, data extraction and quality assessment were carried out independently by two investigators. Associations of SGLT2i with outcomes were pooled using random-effects meta-analyses.

RESULTS

A total of five studies (9766 participants, 4 propensity score-matched) were included. The use of SGLT2i was associated with significant reductions in all-cause mortality [hazard ratio (HR) .54, 95% confidence interval (CI) .44-.66], cardiovascular mortality (HR .39, 95% CI .23-.65), major adverse cardiovascular events (HR .71, 95% CI .61-.83), and heart failure hospitalizations (HFHs) (HR .63, 95% CI .52-.77) compared to non-use. The odds of cardiac arrhythmias were significantly lower among SGLT2i users compared to non-users [odds ratio (OR) .73, 95% CI .65-.83]. Specifically, SGLT2i use was associated with significant reductions in the odds of atrial fibrillation (AF) (OR .75, 95% CI .62-.91), ventricular tachycardia (OR .72, 95% CI .59-.88), and sudden cardiac arrest (OR .71, 95% CI .50-.99).

CONCLUSIONS

The use of SGLT2is may be associated with a more favourable prognosis in patients with ATTR-CM. Adequately powered, long-term RCTs are required to validate the available observational evidence.

Pathogenesis, manifestations, diagnosis, and management of CNS complications in hereditary ATTR amyloidosis

The clinical efficacy of transthyretin (TTR) tetramer stabilisers and TTR gene silencers in addition to liver transplantation has been established for hereditary ATTR (ATTRv) amyloidosis. Accordingly, non-central nervous system (CNS) systemic amyloidosis manifestations, such as peripheral neuropathy and cardiomyopathy, are now being overcome. However, emerging disease-modifying therapeutics have limited effects on CNS amyloidosis since they target the blood-circulating TTR produced in the liver, and not the cerebral spinal fluid (CSF) TTR synthesised in the choroid plexus. CNS involvement is therefore becoming the most common and severe complication in patients with ATTRv amyloidosis, including transient focal neurologic episodes, haemorrhagic and ischaemic stroke, cognitive decline, and cranial nerve dysfunction. Pathologically, extensive amyloid depositions are observable in the leptomeninges and leptomeningeal vessels, which are in direct contact with the CSF. Amyloid positron emission tomography is a useful biomarker for the early detection and treatment evaluation of early-onset ATTRv amyloidosis with the V30M (p.V50M) variant. Treatment-wise, blood-brain barrier-permeable stabilisers, intrathecal injection of silencers, and monoclonal antibodies against misfolded TTR and/or ATTR amyloid may potentially ameliorate CNS ATTR amyloidosis. The development of novel imaging/CSF biomarkers and disease-modifying therapies are the greatest unmet medical need in ATTRv amyloidosis and require further clinical trials.

Supportive care for systemic amyloidosis: International Society of Amyloidosis (ISA) expert panel guidelines

Systemic amyloidosis refers to a group of protein misfolding disorders resulting in organ deposition with amyloid, leading to organ dysfunction, ultimately resulting in organ failure and death if not successfully treated. Treatment is type-specific and aimed at the underlying source of the misfolded protein. In the past decades, treatments have become increasingly available across the various amyloidosis types with improved response rates and longer survival. Supportive care measures are an integral part of care for patients with systemic amyloidosis to improve symptom burden and quality of life, reduce healthcare costs, and potentially prolong survival while type-directed therapy takes effect. In these guidelines, we provide supportive care recommendations across eight areas of interest in systemic amyloidosis: cardiology, nephrology, peripheral neuropathy, central nervous system involvement, autonomic neuropathy, gastroenterology, coagulopathy and bleeding, nutrition and hematology. These guidelines were developed on behalf of the International Society of Amyloidosis (ISA) by experts in the above fields and provide the best available evidence and expertise for supportive care in these rare disorders.

Acoramidis: First Approval

Disassociation of transthyretin (TTR) has been identified as a key step in the pathology of TTR amyloid cardiomyopathy, which is characterised by the presence of amyloid fibrils in cardiac tissue. Acoramidis (ATTRUBY™) is a small molecule TTR stabiliser being developed by BridgeBio Pharma, Inc. and is the first drug to demonstrate near-complete (> 90%) stabilisation of TTR. This article summarizes the milestones in the development of acoramidis leading to its first approval in the USA for the treatment of the cardiomyopathy of wild-type or variant TTR-mediated amyloidosis in adults to reduce cardiovascular death and cardiovascular-related hospitalization. In the EU, a positive opinion has been adopted for the treatment of wild-type or variant transthyretin amyloidosis in adult patients with cardiomyopathy.

Right ventricular to pulmonary artery uncoupling is an early predictor of poor outcome in wild-type transthyretin amyloid cardiomyopathy

Non-invasive right ventricular to pulmonary artery (RV-PA) uncoupling assessment has prognostic value in patients with heart failure (HF). Little is known about its application in patients with wild-type transthyretin amyloid cardiomyopathy (wtATTR-CM). This single-centre retrospective study included consecutive patients with wtATTR-CM diagnosis undergoing 2D echocardiogram. RV-PA uncoupling was evaluated with the ratios between tricuspid annular plane systolic excursion (TAPSE), RV free wall longitudinal strain (RVFWLS) or RV four-chamber longitudinal strain (RV4CLS) and pulmonary artery systolic pressure (sPAP). Primary endpoint was the composite of all-cause mortality and HF hospitalisation. Overall, 100 patients (91% males, median age 81 years, 85% in National Amyloid Centre (NAC) stage ≤ 2, 18% in NAC stage Ia and 82% in New York Heart Association class ≤ II) were enrolled. Over a 16-months follow up (Q1-Q3:12-24), the primary endpoint occurred in 37 patients (37%). TAPSE/sPAP (HR 0.04, 95% CI 0.01-0.24, p < 0.001), RVFWLS/sPAP (HR 0.07, 95% CI 0.01-0.41, p = 0.003) and RV4CLS/sPAP (HR 0.06, 95% CI 0.01-0.53, p = 0.011) emerged as independent predictors of the primary endpoint and showed incremental risk prediction compared with TAPSE, RVFWLS and RV4CLS, considered as separate parameters. No differences in outcome risk prediction were observed among TAPSE/sPAP, RVFWLS/sPAP and RV4CLS/sPAP (p > 0.05). RV-PA uncoupling, as assessed by different echocardiography modalities, is an early predictor of poor outcome in patients with wtATTR-CM.

Impact of Heart Failure Severity on Vutrisiran Efficacy in Transthyretin Amyloidosis With Cardiomyopathy

BACKGROUND

Vutrisiran reduced the risk of all-cause mortality (ACM) and recurrent cardiovascular (CV) events in patients with transthyretin amyloidosis with cardiomyopathy (ATTR-CM) in HELIOS-B (A Study to Evaluate Vutrisiran in Patients With Transthyretin Amyloidosis With Cardiomyopathy; NCT04153149).

OBJECTIVES

This study sought to assess the effect of vutrisiran in HELIOS-B patients with different heart failure severities.

METHODS

HELIOS-B randomized patients with ATTR-CM with NYHA functional class I-III (functional class IV or functional class III with National Amyloidosis Centre [NAC] stage 3 were excluded) 1:1 to vutrisiran 25 mg or placebo every 3 months for up to 36 months. This exploratory subgroup analysis assessed the primary composite endpoint of ACM and recurrent CV events, ACM, and additional functional and biomarker endpoints.

RESULTS

Of 654 patients, 84 (13%), 508 (78%), and 62 (9%) were in NYHA functional class I, II, and III, respectively. Median baseline N-terminal pro-B-type natriuretic peptide (NT-proBNP) level was 1,920 ng/L. Lower risk of ACM and recurrent CV events was observed with vutrisiran vs placebo across baseline severity subgroups: respective HRs were 0.54 (95% CI: 0.27-1.10), 0.77 (95% CI: 0.57-1.03), and 0.68 (95% CI: 0.33-1.41) in NYHA functional classes I, II, and III, respectively; 0.52 (95% CI: 0.30-0.88), 0.61 (95% CI: 0.37-1.00), and 0.93 (95% CI: 0.64-1.35) in NT-proBNP tertiles <1,368 ng/L, ≥1,368 and <2,691 ng/L, and ≥2,691 ng/L; 0.49 (95% CI: 0.34-0.72) and 1.08 (95% CI: 0.74-1.56) in NAC stages 1 and 2/3, respectively; and 0.69 (95% CI: 0.45-1.07) and 0.74 (95% CI: 0.53-1.02) in Columbia early and intermediate/late stages, respectively. Similar effects were observed in the monotherapy population (patients not on tafamidis at baseline) and across the additional endpoints evaluated.

CONCLUSIONS

Vutrisiran demonstrated evidence of benefit across the range of baseline disease severities in HELIOS-B, with the greatest benefit in earlier, less severe disease. (A Study to Evaluate Vutrisiran in Patients With Transthyretin Amyloidosis With Cardiomyopathy [HELIOS-B]; NCT04153149).

Current and emerging treatment options for transthyretin amyloid cardiomyopathy

Transthyretin amyloidosis (ATTR) is a condition caused by TTR protein misfolding and amyloid deposition, particularly in the heart and nervous system, leading to organ dysfunction. Advances in therapeutic strategies have revolutionised the management of ATTR amyloidosis. Treatments available in clinical practice include TTR stabilisers (tafamidis and acoramidis), which prevent the dissociation of TTR tetramer into monomers and oligomers that subsequently form amyloid fibrils, and gene-silencing therapies (patisiran, inotersen and vutrisiran), which suppress the hepatic synthesis of TTR, which is the amyloid precursor protein. Novel treatment strategies that are at various stages of development include Clustered Regularly Interspaced Short Palindromic Repeats-Cas9 gene-editing technology (nexiguran ziclumeran), which, if successful, offers the prospect of a single-dose treatment, and monoclonal (cormitug and ALXN220) and pan-amyloid antibodies (AT-02) that seek to target and remove amyloid fibrils that have deposited in the myocardium. Amyloid removal remains a significant unmet clinical need, and hence, the ability to promote amyloid degradation and clearance through the use of antiamyloid therapies would represent a groundbreaking advancement in the treatment of ATTR amyloidosis. The success of ATTR-specific disease-modifying therapies has already altered the treatment landscape and changed the perception of ATTR amyloidosis from a progressive and fatal disease to one that is treatable through the availability of highly effective disease-modifying therapies. However, important questions remain, including the long-term safety of these drugs, whether combining therapies with different mechanisms of action has an additive prognostic benefit and how best to monitor the treatment response.

Early Increase in Serum Transthyretin by Acoramidis Independently Predicts Improved Survival in TTR Amyloid Cardiomyopathy

BACKGROUND

Acoramidis is a novel, high-affinity stabilizer that achieves ≥90% transthyretin (TTR) stabilization. The phase 3 study, ATTRibute-CM (Efficacy and Safety of AG10 in Subjects With Transthyretin Amyloid Cardiomyopathy), met its primary hierarchical efficacy endpoint with mortality, morbidity, and functional components at 30 months. Stabilization of TTR (prealbumin) by acoramidis results in an immediate and sustained rise in serum transthyretin (sTTR) levels, but the association between this pharmacodynamic effect and all-cause mortality (ACM) has not been elucidated.

OBJECTIVES

The purpose of this study was to assess the prognostic implication of acoramidis-mediated early change in sTTR and its relationship to ACM.

METHODS

We evaluated sTTR levels in 557 participants with ATTR-CM from the ATTRibute-CM study population. For the Kaplan-Meier overall survival assessment, univariate and multivariate modeling were used to evaluate factors associated with ACM. Modeling and simulation analyses described acoramidis population pharmacokinetics.

RESULTS

Treatment with acoramidis resulted in a sharp and significant early rise in sTTR levels (mean 9.1 mg/dL) within 28 days which was sustained throughout the 30-month treatment period. Participants with ≥20 mg/dL sTTR at baseline had significantly (P < 0.0001) greater overall survival probability than those with <20 mg/dL. An early increase in sTTR levels on day 28 of dosing (early ΔTTR) was associated with reduced ACM in univariate analysis (HR: 0.96 per 1 mg/dL increase in early ΔTTR; 95% CI: 0.93-0.98; P = 0.002). In the multivariate analysis, after adjusting for TTR variant status, baseline New York Heart Association functional class, baseline National Amyloidosis Centre stage, and baseline sTTR level, early ΔTTR remained independently associated with reduced ACM (P < 0.001). Bootstrap mediation analyses showed that early ΔTTR fully mediates the effect of acoramidis treatment on ACM probability (average causal mediation effect = -0.117; P = 0.002; average direct effect = 0.0366; P = 0.448). Logistic modeling demonstrated that among participants treated with acoramidis, early ΔTTR was associated with reduced ACM, whereas no such association was observed in participants treated with placebo. For every 5 mg/dL increase in sTTR levels, a logistic model predicted a 31.6% relative reduction in odds of ACM.

CONCLUSIONS

Acoramidis-mediated early ΔTTR is independently associated with improved survival after adjusting for known predictors. This provides strong evidence for a direct association between a prompt and sustained increase in sTTR upon initiation of treatment with acoramidis and survival. Early changes in sTTR could be used as a marker of the degree of TTR stabilization. (Efficacy and Safety of AG10 in Subjects With Transthyretin Amyloid Cardiomyopathy [ATTRibute-CM]; NCT03860935).

Design and Mechanistic Analysis of a Potent Bivalent Inhibitor of Transthyretin Amyloid Fibrillogenesis

Transthyretin amyloidosis (ATTR) is a systemic disease that primarily affects the heart and the peripheral nervous system. Despite available therapeutic options, advanced ATTR amyloidosis still presents unmet medical needs. We have therefore focused on the design of bivalent small molecules starting from our prototype palindromic ligand mds84, whose binding by transthyretin (TTR) greatly improves stability of the native structure by overcoming the negative cooperativity which is typical of monovalent stabilizers. Among the newly designed compounds here, we present B26, which is pseudoirreversibly bound by native TTR with faster entry kinetics into the protein molecule compared to mds84. It retains the ability to inhibit fibril formation in vitro, together with improved solubility. Using solution NMR, we show that B26 occupies both TTR binding sites simultaneously, leading to conformational effects distant from the binding site, including the proteolytic cleavage site involved in fibril formation by the mechano-enzymatic mechanism.

Alzheimer's Disease With Cardiac Transthyretin Amyloidosis: A Clinicopathological Study of Autopsy Cases

The relationship between Alzheimer's disease and cardiac transthyretin amyloidosis (ATTR) has been reported epidemiologically. However, the details of its clinicopathological characteristics are unclear. To clarify the pathogenesis of Alzheimer's disease combined with cardiac ATTR, 50 autopsy cases of Alzheimer's disease with cardiac hypertrophy were examined. Transthyretin amyloid deposition was studied by immunostaining in cases where amyloid deposition was suspected in various organs by HE staining. ATTR in systemic organs was also examined. The pathological diagnosis of Alzheimer's disease was done based on the National Institute on Aging and Alzheimer's Association (NIA-AA) guidelines. Cerebral amyloid angiopathy (CAA) was rated on a 3-point scale according to the Vonsattel scale. The pathological diagnosis of cardiac ATTR was done using a 3-point scale based on previously published findings on amyloid amounts. Six out of 50 patients were found to have cardiac ATTR by immunostaining and protein mass analysis of myocardial tissue. The sex distribution of the six patients was two males (Cases 3 and 6) and four females (Cases 1, 2, 4, and 5), and their ages were 97, 89, 91, 104, 86, and 77 years in Cases 1-6, respectively. In Cases 1-6, the NIAA score/CAA assessment/ATTR stages were intermediate/severe/G3, intermediate/moderate/G3, high/severe/G3, high/severe/G2, high/severe/G2, and intermediate/moderate/G2, respectively. Cases 1-5 also had cerebral infarction. In all cases, Transthyretin amyloid deposition was seen mainly in the vessel walls of various organs throughout the body. In the heart, transthyretin amyloid deposition was observed in the myocardial vessel walls and between myocardial fibers. On autopsy, cardiogenic cerebral infarction or heart failure was considered to be the main cause of death in Cases 1-5. These results indicate that Alzheimer's disease could be regarded as a systemic disease rather than just a localized disease presenting with dementia.

The American College of Cardology/American Heart Association Heart Failure Staging System Highlights Diagnostic Delay and Predicts Outcome in Transthyretin Cardiac Amyloidosis

OBJECTIVE

To apply the American College of Cardiology (ACC) and American Heart Association (AHA) heart failure (HF) staging system to patients with transthyretin cardiac amyloidosis (TTR-CA) in order to assess diagnostic delay and evaluate prognosis.

PATIENTS AND METHODS

Consecutive patients with TTR-CA enrolled in an Italian registry were classified according to the ACC/AHA HF staging system at diagnosis. Outcome was assessed as all-cause mortality during a 3-year follow-up.

RESULTS

At diagnosis, of 549 patients with TTR-CA, 115 (20.9%) presented with HF stage B, 172 (31.3%) with stage C1, 198 (36.1%) with stage C2, and 64 (11.7%) with stage D. Patients with stages B, C1, C2, and D presented with hierarchically higher prevalence of left ventricular systolic impairment, advanced diastolic dysfunction, advanced New York Heart Association functional class, hospitalization for HF, and N-terminal pro-B-type natriuretic peptide values. At 3 years, the survival rate was 94% in patients with stage B HF, decreasing to 69% with stage C1, 43% with stage C2, and 17% with stage D. At multivariable analysis, considering stage B as the reference, risk increase for all-cause mortality was 4, 5, and 11 for stages C1, C2, and D, respectively.

CONCLUSION

At diagnosis, almost half of patients with TTR-CA present with advanced stages of HF (C2 or D), suggesting marked diagnostic delay. The ACC/AHA HF staging system accurately stratifies prognosis and may be usefully added to the multiparametric evaluation of patients with TTR-CA.

Pharmacological Management of Transthyretin Amyloid Cardiomyopathy: Where We Are and Where We Are Going

Transthyretin (TTR) amyloid cardiomyopathy (ATTR-CM) is a progressive disease that has emerged as a significant cause of heart failure. Advances in the understanding of ATTR-CM pathophysiology have revolutionised its therapeutic landscape over the past decade, with the development of targeted therapies that are able to improve survival and quality of life. TTR stabilizers, such as tafamidis and acoramidis, can reduce TTR instability and subsequent amyloid fibril formation. Clinical trials have demonstrated their efficacy both in improving survival and quality of life in patients with ATTR-CM. Gene-silencing therapies using small interfering RNAs (siRNAs), such as patisiran and vutrisiran, or antisense oligonucleotide inhibitors (ASOs), such as inotersen and eplontersen, serve as powerful therapeutic options by decreasing TTR production; trials on patients with ATTR-CM have been recently published or are ongoing. Novel, emerging therapies aim to enhance fibril clearance using monoclonal antibodies, such as NI006, that target amyloid deposits in the myocardium, promoting their depletion, plausibly with regression of the structural and functional impairments caused by the disease. Concurrently, advancements in diagnostic modalities have facilitated earlier detection of this disease, allowing the timely initiation of treatment with a more significant impact on patients' survival and quality of life. Despite these strides, challenges remain, including the high cost of disease-modifying therapy and the need for response criteria to monitor treatment's efficacy. Future directions will involve improving patients' screening to achieve earlier diagnoses, optimising patients' selection for disease-modifying therapy and identifying criteria for the treatment's response or lack thereof to possibly consider therapy switch or associations. In this review, we will explore the more recent therapeutic advancements in ATTR-CM, starting from traditional heart failure therapies and moving to disease-modifying therapies with a detailed evaluation of the registration trials to explore the strengths and shortcomings of each treatment.

High-Sensitivity Cardiac Troponin I for Risk Stratification in Wild-Type Transthyretin Amyloid Cardiomyopathy

BACKGROUND

Thresholds to define prognosis with hs-cTnI (high-sensitivity cardiac troponin I) have not been systematically addressed in wild-type transthyretin amyloid cardiomyopathy, in part because of the multiplicity of hs-cTnI assays. The aims of this study were, first, to assess the prognostic performance of hs-cTnI measured with different assays in patients with wild-type transthyretin amyloid cardiomyopathy and, second, to identify assay-specific hs-cTnI thresholds for prognosis that could be integrated into staging systems for risk stratification.

METHODS

Observational multicenter study of stable wild-type transthyretin amyloid cardiomyopathy patients from different cohorts using the Abbott Architect Stat hs-cTnI assay and the Beckman Coulter Access hs-cTnI assay (testing cohorts) and the Siemens Centaur XPT hs-cTnI assay (validation cohort). Outcome was all-cause mortality.

RESULTS

In the Abbott cohort (n=136; median follow-up, 22 [13-41] months; 31 [23%] deaths) and Beckman cohort (n=98; median follow-up, 19 [12-28] months; 16 [16%] deaths), natural log-transformed hs-cTnI was an independent predictor of mortality (age- and sex-adjusted hazard ratio, 1.62 [95% CI, 1.11-2.35]; P=0.012 and 2.47 [95% CI, 1.48-4.14]; P<0.001, respectively). The best hs-cTnI threshold for 18-month mortality of the combined Abbott/Beckman cohorts (n=234) was 81 ng/L, rounded to 80 ng/L for simplicity of clinical use. A 2-variable staging system (based on the Mayo Clinic system) using hs-cTnI (>80 ng/L) and NPs (natriuretic peptides, NT-proBNP [N-terminal pro-B-type NP] >3000 ng/L or BNP (B-type natriuretic peptide) >250 ng/L) identified 3 groups with progressively worse prognosis. The staging system (using hs-cTnI >80 ng/L and NT-proBNP>3000 ng/L) was then applied to an independent cohort evaluated with the hs-cTnI Siemens assay (n=345, median follow-up 32 (24-42) months, 119 (34%) deaths). The significant differences between the groups were maintained.

CONCLUSIONS

In patients with wild-type transthyretin amyloid cardiomyopathy, hs-cTnI is a strong and independent predictor of mortality. A threshold of hs-cTnI of 80 ng/L for these 3 assays provides effective risk stratification alone and in a staging system with NP.

Cardiac Amyloidosis in Older Adults With a Focus on Frailty: JACC: Advances Expert Consensus

Amyloidosis, which is caused by misfolded proteins that form amyloid fibrils, is predominantly diagnosed in older adults. Although previously considered a rare disease, increased awareness and noninvasive diagnostic methods have resulted in a rise in diagnoses. As a multisystem disease that affects multiple organ systems (cardiac, gastrointestinal, renal, and neurological), there is significant overlap with both geriatric conditions and common conditions in heart failure. Frailty is recognized as a distinct biological syndrome of declines across multiple physiological systems, which prevents maintenance of homeostasis and limits the ability to respond to stressors. Frailty was initially characterized as physical frailty alone; however, it is increasingly recognized that it is multidimensional with components including nutrition, cognitive, psychological, and social. Frailty in cardiovascular disease has become an important risk factor, indicator for disease severity, and can help guide decisions around intervention. In certain patients, frailty may be reversible. Given the lack of consensus definitions, tools, and implementation of frailty in both clinical and research settings in the field of amyloidosis, we convened a group of experts from cardiology, geriatric cardiology, geriatrics, hematology, and allied health to form this state-of-the-art review. There are many points of intersectionality between amyloidosis, aging, and frailty which herald a need for multidisciplinary care. This review document aims to provide guidance in how to understand and address frailty in older patients with a specific focus on cardiac amyloidosis.

New pharmacological agents and novel cardiovascular pharmacotherapy strategies in 2024

Despite substantial advances in cardiovascular pharmacotherapy and devices in recent years, prevention and treatment of many cardiovascular diseases (CVDs) remain limited, thus reflecting the need for more effective and safer pharmacological strategies. In this review, we summarize the most relevant studies in cardiovascular pharmacotherapy in 2024, including the approval of first-in-class drugs for the treatment of resistant hypertension and pulmonary arterial hypertension, label expansions for bempedoic acid and semaglutide, and the results of major randomized clinical trials (RCTs) that have met the pre-specified primary endpoints, thereby filling some gaps in knowledge and opening new perspectives in the management of CVD, and those RCTs whose results did not confirm the proposed research hypotheses. We also include a section on drug safety, where we describe the newest data on adverse reactions and drug-drug interactions that may complicate treatment and/or reduce drug adherence with the consequent decrease in drug effectiveness. Finally, we present the most important ongoing phase 2 and phase 3 clinical trials assessing the efficacy and safety of cardiovascular drugs for the prevention and treatment of CVD.

Diagnosis and Management of Mixed Phenotype Hereditary Transthyretin Amyloidosis: A Case-Based, Canadian Perspective

Hereditary amyloid transthyretin variant (ATTRv) amyloidosis is a rare, life-threatening disease, characterized by the deposition of aggregated transthyretin (TTR) protein in multiple organs and tissues. Diagnosis is often delayed due to its heterogeneity in presentation, which includes a wide range of cardiac and/or neurologic symptoms. Thus, awareness of ATTRv amyloidosis across multiple specialties is needed for its early diagnosis and management. This paper provides a review surrounding the diagnosis and management of mixed phenotype ATTRv amyloidosis, addressed through 3 clinical questions. This paper discusses: (i) the need for patients with ATTRv amyloidosis to be screened for mixed cardiac and neurologic phenotypes through early multidisciplinary referral; (ii) the therapeutic landscape for ATTRv amyloidosis in Canada, with emphasis on the need for prompt therapy selection and initiation, based on multidisciplinary collaboration; and (iii) how disease can be monitored pre- and post-treatment. Case studies are provided to illustrate how the available evidence impacts practice.

On approximate equality of Z-values of the statistical tests for win statistics (win ratio, win odds, and net benefit)

Dong et al. (2023) showed that the win statistics (win ratio, win odds, and net benefit) can complement each another to demonstrate the strength of treatment effects in randomized trials with prioritized multiple outcomes. This result was built on the connections among the point and variance estimates of the three statistics, and the approximate equality of Z-values in their statistical tests. However, the impact of this approximation was not clear. This Discussion refines this approach and shows that the approximate equality of Z-values for the win statistics holds more generally. Thus, the three win statistics consistently yield closely similar p-values. In addition, our simulations show an example that the naive approach without adjustment for censoring bias may produce a completely opposite conclusion from the true results, whereas the IPCW (inverse-probability-of-censoring weighting) approach can effectively adjust the win statistics to the corresponding true values (i.e. IPCW-adjusted win statistics are unbiased estimators of treatment effect).

MRI-Extracellular Volume Fraction Versus Histological Amyloid Load in Cardiac Amyloidosis: The Importance of T2 Mapping

BACKGROUND

Magnetic resonance imaging (MRI)-derived myocardial extracellular volume fraction (ECV) is elevated in the presence of fibrosis, amyloid deposition, inflammation, and edema. In patients with cardiac amyloidosis and prolonged T2 due to concomitant inflammation or edema, MRI-ECV may not correctly reflect histological amyloid load. The authors sought to determine whether MRI-ECV can accurately reflect histological amyloid load in 2 groups of patients with wild-type transthyretin amyloid cardiomyopathy (ATTRwt-CM), with and without T2 prolongation.

METHODS

This retrospective study included consecutive patients with ATTRwt-CM who underwent endomyocardial biopsy and cardiac MRI from March 2017 to October 2021 for initial evaluation of ATTRwt-CM. We measured MRI-ECV and T2, and evaluated correlation between MRI-ECV and amyloid load from endomyocardial biopsy by means of Pearson correlation analysis.

RESULTS

Of 44 patients (mean age, 75±6 years [SD]; 40 men), 24 showed T2 prolongation (T2≥50 milliseconds). All specimens obtained by endomyocardial biopsy were suitable for analysis. The interval between endomyocardial biopsy and cardiac MRI examination was a median of 3 days (interquartile range, 2-4). In the absence of T2 prolongation due to increased water content, MRI-ECV and amyloid load showed a moderately significant correlation (Spearman ρ=0.50, P=0.03). However, in the presence of T2 prolongation, there was no significant correlation between MRI-ECV and amyloid load (Spearman ρ=-0.05, P=0.83).

CONCLUSIONS

In patients with ATTRwt-CM and prolonged T2, MRI-ECV did not accurately reflect histological amyloid load. Our findings underscore the need for a multiparametric imaging approach, combining both ECV and T2 mapping, to better characterize myocardial tissue in patients with ATTRwt-CM, and further prospective research in larger and more diverse cohorts is needed to validate our results.

A year in pharmacology: new drugs approved by the US Food and Drug Administration in 2024

The US Food and Drug Administration approved 50 new drugs and nine new cellular and gene therapy products in 2024, i.e., a total of 59 new medical therapies. The latter group represented three treatments each for oncology and hematology/immunotherapy, and one each for neurology, genetic disorders, and cardiovascular disorders. Oncology, hematology/immunotherapy, and neurological disorders (14, six, and seven, respectively) also were highly prevalent among classic medications. Looking at trends over the past 5 years, we observe a greater share in first-in-class medications, more fast-track approvals, and mRNA/gene/cell-based therapies. While small molecules remain the largest fraction, their percentage has been declining substantially over the past 5 years. Taking together, these findings testify to the commitment of the pharmaceutical industry for innovative treatments, including conditions for which no approved therapies existed. On the other hand, there also is a trend for approvals for narrowly focused conditions such as tumors defined by genetic alterations.

Current Landscape of Therapies for Transthyretin Amyloid Cardiomyopathy

Transthyretin amyloid cardiomyopathy (ATTR-CM) is an infiltrative cardiomyopathy that results from myocardial deposition of misfolded transthyretin (TTR) protein. The biology of amyloid formation has been elucidated resulting in several effective therapeutic strategies. Accordingly, the therapeutic landscape for ATTR-CM is rapidly evolving, with multiple disease-modifying therapies (DMTs) approved and others anticipated to be imminently available. Currently, DMT strategies involve either stabilization of TTR, thereby inhibiting misfolding, or reduction of hepatic TTR production, and antibodies ("depleters") that facilitate amyloid fibril removal are under development. In this review, available evidence is synthesized and expert experience provided to assist clinicians in the complex navigation of treatment selection and the role of advanced therapies (heart transplantation and left ventricular assist device), as well as to identify key areas for future research.

Fluorine in the Pharmaceutical Industry: FDA-Approved Fluorine-Containing Drugs in 2024

Fluorine has become an essential element in the development of modern pharmaceuticals, due to its unique chemical properties that can significantly enhance the biological activity, metabolic stability, and lipophilicity of drug molecules. This review explores recent advancements in the synthesis and application of fluorine-containing drugs approved by the US Food and Drug Administration (FDA) in 2024. These novel drugs demonstrate improved efficacy and safety profiles, addressing a range of therapeutic areas including oncology, infectious diseases, metabolic disorders and genetic disorders that affect the adrenal glands. The incorporation of fluorine atoms into drug candidates has facilitated the development of molecules with optimized pharmacokinetic and pharmacodynamic properties, leading to better patient outcomes. The review further discusses the synthetic methodologies employed, the structural characteristics of these drugs, and their clinical implications, providing insights into the ongoing innovation within the pharmaceutical industry driven by fluorine chemistry.

Clinical Phenotype and Prognosis of Asymptomatic Patients With Transthyretin Cardiac Amyloid Infiltration

Importance

Patients with transthyretin (ATTR) cardiac amyloid infiltration are increasingly diagnosed at earlier disease stages with no heart failure (HF) symptoms and a wide range of cardiac amyloid infiltration.

Objective

To characterize the clinical phenotype and natural history of asymptomatic patients with ATTR cardiac amyloid infiltration.

Design, Setting, and Participants

This cohort study analyzed data of all patients at 12 international centers for amyloidosis from January 1, 2008, through December 31, 2023. Inclusion criteria were asymptomatic ATTR cardiac amyloid infiltration, defined as an absence of HF history, HF signs and symptoms, diuretic therapy, and plasma cell dyscrasia with evidence of myocardial uptake on bone scintigraphy. If plasma cell dyscrasia was present, histologic confirmation of ATTR amyloid was required.

Exposure

Asymptomatic ATTR cardiac amyloid infiltration.

Main Outcomes and Measures

The primary outcomes were all-cause and cardiovascular (CV) mortality. The secondary outcomes were unplanned HF hospitalization, unplanned CV-related hospitalization, and a composite outcome of CV mortality and HF hospitalization.

Results

The study comprised 485 patients with asymptomatic ATTR cardiac amyloid infiltration (mean [SD] age, 74.9 [9.9] years, 85.8% male, 112 [23.1%] with hereditary ATTR amyloidosis), with 369 (76.1%) having grade 2 or 3 and 116 (23.9%) having grade 1 cardiac uptake at baseline. Patients with grade 2 or 3 uptake exhibited significantly more cardiac functional and structural abnormalities vs patients with grade 1 uptake. At 3 years, compared with grade 1 uptake, patients with grade 2 or 3 uptake had greater development of HF (54.3% [95% CI, 47.7%-61.3%] vs 23.1% [95% CI, 14.8%-35.1%]), greater outpatient diuretic initiation and N-terminal pro-B-type natriuretic peptide progression (35.0% [95% CI, 28.0%-43.2%] vs 12.4% [95% CI, 6.3%-23.7%]), and greater HF hospitalization (8.7% [95% CI, 5.9%-12.9%] vs 0%) and unplanned CV hospitalization (20.0% [95% CI, 15.7%-25.3%] vs 4.3% [95% CI, 1.6%-11.3%]). Over a median follow-up of 37 months (IQR, 20-64 months), the all-cause death rate was similar between patients with grade 1 vs 2 and 3 uptake; however, those with grade 2 or 3 compared with grade 1 uptake had a significantly higher risk of CV mortality (unadjusted hazard ratio, 5.30; 95% CI, 1.92-14.65).

Conclusions and Relevance

This study shows that asymptomatic ATTR cardiac amyloid infiltration encompasses a wide spectrum of disease severity, with patients with grade 2 or 3 cardiac uptake experiencing an increased rate of CV events and CV mortality and patients with grade 1 uptake experiencing a lower CV event rate and predominantly non-CV mortality. These findings support the use of disease-modifying treatments in asymptomatic patients with grade 2 or 3 uptake and highlight the need of large-scale studies to assess their role in grade 1 uptake.

Vutrisiran Improves Survival and Reduces Cardiovascular Events in ATTR Amyloid Cardiomyopathy: HELIOS-B

BACKGROUND

Patients with transthyretin amyloidosis with cardiomyopathy (ATTR-CM) have high mortality and morbidity. Vutrisiran, a subcutaneous RNA interference therapeutic, reduced the composite of all-cause mortality (ACM) and cardiovascular (CV) events (CV hospitalizations and urgent heart failure [HF] visits) in HELIOS-B (A Study to Evaluate Vutrisiran in Patients With Transthyretin Amyloidosis With Cardiomyopathy) in patients with ATTR-CM.

OBJECTIVES

Here we present data from HELIOS-B evaluating the impact of vutrisiran on ACM and CV mortality with additional patient follow-up through 42 months, and CV events such as CV hospitalizations, HF hospitalizations, and urgent HF visits.

METHODS

The HELIOS-B trial randomized 655 patients to vutrisiran 25 mg or placebo once every 3 months for up to 33 to 36 months in the double-blind (DB) period, followed by an open-label extension. Prespecified mortality and CV mortality analyses used data through 39 to 42 months of follow-up (DB period and up to 6 months of the open-label extension). CV hospitalizations and HF events were evaluated over the DB period of 33 to 36 months. Differences between vutrisiran and placebo were evaluated in the overall population, and in those stratified by baseline tafamidis use.

RESULTS

In the overall population, vutrisiran reduced the risk of ACM (HR: 0.64; 95% CI: 0.46-0.88) and CV mortality (HR: 0.67; 95% CI: 0.47-0.96) vs placebo. Vutrisiran also reduced the risk of a composite of CV mortality and CV events (HR: 0.72; 95% CI: 0.55-0.94), and lowered rates of CV hospitalizations (rate ratio [RR]: 0.75; 95% CI: 0.62-0.91), urgent HF visits (RR: 0.54; 95% CI: 0.30-0.98), and HF hospitalizations (RR: 0.67; 95% CI: 0.52-0.86) vs placebo. Consistent trends were seen regardless of baseline tafamidis use.

CONCLUSIONS

Consistent with the primary trial results, vutrisiran reliably reduced the risk of ACM, CV mortality, CV hospitalizations, HF hospitalizations, and urgent HF visits vs placebo in patients with ATTR-CM. (HELIOS-B: A Study to Evaluate Vutrisiran in Patients With Transthyretin Amyloidosis With Cardiomyopathy; NCT04153149).

Delays in diagnosis and treatment of ATTR cardiac amyloidosis: A real-world data analysis

AIMS AND BACKGROUND

Cardiac amyloidosis leads to functional cardiac impairment and heart failure. Transthyretin amyloid cardiomyopathy (ATTR-CM) is the most common form. After initial suspicion, diagnosis involves imaging techniques, biopsy and genetic tests, prompting transthyretin stabilizer therapy to slow disease progression. The study aims to assess delays in diagnosis in ATTR-CM patients.

METHODS

Patients with ATTR-CM receiving transthyretin stabilizer therapy at the West German Amyloidosis Center (01/2018-12/2023) were included. Clinical, laboratory, and imaging data were analysed. Diagnostic timelines were compared across two periods (2018-2020 and 2021-2023).

RESULTS

After screening 254 patients, 154 were included in the analysis. ATTRwt was the most common form (96.8%). The median age was 80 (76-83) years, 87% were male and 46.6% were NYHA class ≥III. Time to diagnosis decreased from 398 to 277 days in the second period (P < 0.001). The median duration from diagnosis to stabilizer therapy was 84 (44-160) days, reducing from 111 (55-237) days in the first period to 57 (36-102) days in the second period (P < 0.001). Patients diagnosed in the first period had lower LVEF (P < 0.001) and more advanced NAC stages (P = 0.004). More women were diagnosed in the second period (P = 0.010).

CONCLUSION

ATTR-CM is associated with diagnostic delays from initial suspicion to therapy initiation. While diagnostic and treatment timelines have improved, enhanced awareness, supraregional networks, specialized centres and focused education are essential to improve diagnosis and outcomes. Increasing awareness has led to patients being diagnosed at earlier disease stages, underscoring the potential to positively impact patient prognosis.

Antibody ALXN2220 (Formerly NI006) for the Treatment of Transthyretin Cardiac Amyloidosis

Transthyretin cardiac amyloidosis is an increasingly recognized infiltrative cardiomyopathy that is implicated in a growing number of cases of heart failure. Although it was once considered a disease without a cure, there have been rapid advances in pharmacotherapy over recent decades. The agents currently approved by the United States Food and Drug Administration-tafamidis and acoramidis-are transthyretin stabilizers that prevent the breakdown of the physiologic transthyretin tetramer into fibril-forming monomers. While these agents help prevent disease progression, they do not reverse existing disease. ALXN2220 (previously called NI006) addresses this unmet need. A recombinant human IgG1 monoclonal antibody with high specificity for transthyretin monomers and amyloid fibrils, ALXN2220 stimulates macrophage-mediated phagocytosis of deposited amyloid fibrils. Phase 1 studies have demonstrated the tolerability of doses ranging from 0.3 to 60 mg/kg/month. At doses higher than 10 mg/kg/month, ALXN2220 has demonstrated the ability to decrease cardiac tracer uptake on scintigraphy and decrease the extracellular volume on cardiac magnetic resonance imaging at 4 and 12 months when compared with placebo. These imaging parameters are known surrogates for the burden of cardiac amyloid deposition. In addition, significant reductions in levels of n-terminal proBNP and troponin T, as well as improvements in Kansas City Cardiomyopathy Questionnaire scores were also noted. The adverse effect and immunogenicity profiles were encouraging as well. A multinational, placebo-controlled phase 3 trial (DepleTTR-CM) is ongoing to assess long-term efficacy, functional outcomes, and survival impact. These results are expected to provide critical real-world evidence on ALXN2220's role in transthyretin cardiac amyloidosis management.

The efficacy and safety of specific therapies for cardiac Transthyretin-mediated amyloidosis: a systematic review and meta-analysis of randomized trials

BACKGROUND

Transthyretin (TTR) Cardiomyopathy (ATTR-CM) is characterized by the deposition of misfolded TTR monomers in the heart, leading to progressive heart failure. TTR-specific therapies offer a pharmacological approach to slow disease progression. However, there remains limited data on the efficacy, comparative effectiveness, and safety of these therapies. Therefore, we aim to perform a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing TTR-specific therapies with placebo in patients with ATTR-CM.

METHODS

We searched through Pubmed, Cochrane, and Embase databases. Our primary outcome was: (1) All Cause Mortality. We also performed a subgroup analysis comparing TTR stabilizers versus TTR knock-down therapies (RNA inhibitors and antisense oligonucleotides).

RESULTS

Nine RCTs were included, involving 2,713 patients, of whom 1,160 (59.34%) were assigned to the TTR-specific therapies group. In the pooled analysis, TTR-specific therapies were associated with a significant reduction in all-cause mortality (RR 0.70; 95% CI 0.60, 0.83; p < 0.01; I² = 0%), with both TTR stabilizers and knock-down therapies showing equally effective reductions (p = 0.97). Additionally, TTR-specific therapies improved LV longitudinal strain (SMD - 0.22; 95% CI -0.34, -0.10; p < 0.01; I² = 17%) and reduced LV mass (SMD - 9.11 g; 95% CI -16.4 g, -1.82 g; p = 0.01; I² = 0%).

CONCLUSION

This meta-analysis highlights the potential of TTR-targeting therapies as an effective option for managing ATTR-CM, with significant improvements in survival. No efficacy differences were found between TTR stabilizers and knock-down therapies.

Efficacy and safety of RNA interference therapeutics in transthyretin cardiac amyloidosis: A systematic review and meta-analysis

RNAi therapeutics represent a promising advancement in the treatment of ATTR-CM, offering significant benefits over placebo. It demonstrated substantial improvements in survival, functional capacity, and quality of life, alongside a marked reduction in BNP levels and GLS-critical biomarkers of disease progression. These findings underscore the potential of RNAi therapy to alter the disease trajectory and improve patient outcomes.

Etiological Treatment of Cardiac Amyloidosis: Standard of Care and Future Directions

PURPOSE OF REVIEW

Cardiac amyloidosis (CA) is a condition caused by interstitial infiltration of misfolded proteins structured into amyloid fibrils. Transthyretin (ATTR) and immunoglobulin light chain (AL) amyloidosis represent the most common forms of CA. CA was traditionally perceived as a rare and incurable disease, but diagnostic and therapeutic advances have undermined the conventional paradigm.

RECENT FINDINGS

The standard of care for ATTR-CA include agents capable of selectively stabilizing the precursor protein (e.g., tafamidis), whereas the plasma cell clone is the main target of chemotherapy for AL-CA. For long, tafamidis represented the only drug approved for patients with ATTR-CA. Recent data from ATTRibute-CM led to the approval of acoramidis, whereas patisiran received refusal based on the APOLLO-B trial. Novel CRISPR-Cas9-based drugs (i.e., NTLA-2001) hold great potential in the setting of ATTR-CA. Several hematological regimens are available to treat AL-CA. The main limit of current therapies is their inability to trigger removal of amyloid from tissues. However, the investigation of monoclonal antibodies targeting misfolded ATTR (e.g., PRX004, NI301A) or AL (e.g., birtamimab, anselamimab) has led to encouraging results. Various cutting-edge strategies are being tested for treatment of CA and may change the prognostic landscape of this condition in the next years.

A Tale of Two Diseases: Decoding Aortic Stenosis and Cardiac Amyloidosis

Background/Objectives: Transthyretin cardiac amyloidosis (ATTR-CA) is an infiltrative cardiomyopathy caused by transthyretin (TTR) amyloid deposition in the myocardium, increasingly recognized in patients with aortic stenosis (AS). This study aims to investigate the diagnostic challenges and therapeutic strategies for patients with both conditions, focusing on shared pathophysiological mechanisms and key diagnostic indicators. Methods: A multimodal diagnostic approach was applied, utilizing cardiac magnetic resonance (CMR) and bone scintigraphy with technetium-99m-labeled tracers to assess AS patients with suspected ATTR-CA. Clinical signs, such as disproportionate heart failure symptoms, conduction abnormalities, and low-flow, low-gradient AS, were evaluated. Electrocardiographic findings, including low-voltage QRS complexes and pseudo-infarction patterns, were also assessed. Treatment options, including transcatheter aortic valve replacement (TAVR) and emerging pharmacotherapies for ATTR-CA, were analyzed. Results: The study found that ATTR-CA is increasingly prevalent in AS patients, with shared mechanisms like oxidative stress and amyloid-induced tissue remodeling. Key diagnostic signs include disproportionate heart failure symptoms, conduction abnormalities, and specific electrocardiographic patterns. TAVR was effective in both isolated AS and AS with ATTR-CA, although patients with both conditions had a higher risk of heart failure hospitalization and persistent symptoms. Emerging pharmacotherapies, such as TTR stabilizers and gene-silencing agents, showed promise in slowing disease progression. Conclusions: A multimodal diagnostic approach is essential for the early detection of ATTR-CA in AS patients. Combining TAVR with emerging pharmacotherapies may improve long-term outcomes for this high-risk group, enhancing patient care in those with both conditions.

Hereditary transthyretin amyloidosis (ATTRv)

Hereditary transthyretin (TTR) amyloidosis (ATTRv amyloidosis) is a devastating disease characterized by broad range of clinical manifestations, including predominantly neurological, predominantly cardiac, and mixed phenotypes. This wide phenotypic variability hindered timely disease diagnosis and risk stratification in the past, especially in individuals with absent or uncharted family history. However, recent advances in noninvasive testing have led to greater awareness and earlier diagnosis. Further, medications have been discovered which proved effective in controlling the disease and improving outcomes including stabilizing TTR, silencing TTR variants, and removing TTR amyloid from affected tissues. Importantly, CRISPR gene editing, a groundbreaking technology, offers the unique potential to cure ATTRv amyloidosis, transforming lives and opening new doors in medical science. This review provides an update on ATTRv amyloidosis mechanisms, diagnosis, and management emphasizing the importance of early diagnosis as the steadfast underpinning for the capitalization of the advances in medical treatment to the benefit of the patients.

Prevalence of transthyretin cardiac amyloidosis in undifferentiated heart failure with preserved ejection fraction

AIMS

Transthyretin amyloid cardiomyopathy (ATTR-CM) is an increasinglyrecognized cause of heart failure with preserved ejection fraction (HFpEF), which may be diagnosed non-invasively using 99 mTc 3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) scintigraphy-based diagnostic criteria. Our aim was to determine the prevalence of ATTR-CM in an undifferentiated HFpEF cohort with a DPD scintigraphy-based screening protocol.

METHODS

Patients with HFpEF [ejection fraction (EF) ≥50%] aged ≥60 years and no prior evaluation for cardiac amyloidosis or known monoclonal gammopathy attending a regional cardiology network were screened with DPD scintigraphy. Patients with positive myocardial uptake (Perugini grade 2 or 3) were tested for a monoclonal protein and transthyretin gene variant.

RESULTS

Eighty-six subjects were prospectively enrolled: 56% female, mean age 77 ± 8 years, 63% New York Heart Association (NYHA) Class III and median N-terminal pro-brain natriuretic peptide (NT-proBNP) 1766 ng/L [inter-quartile range (IQR) 731-3703]. DPD scintigraphy was positive in seven patients (8%). Monoclonal gammopathy of undetermined significance was present in one out of seven patients, and no pathogenic TTR gene variant was identified. The prevalence of wild-type ATTR-CM was 8% of this cohort. Compared with the HFpEF DPD scintigraphy-negative cohort, DPD scintigraphy-positive patients were older (86 ± 3 vs. 76 ± 8 years), more frequently male (16% vs. 2%, P = 0.02), and had significantly greater left ventricular (LV) wall thickness (16 vs. 12 mm; P = 0.002) and higher high-sensitivity troponin levels at diagnosis [78 ng/L (IQR 21-116) vs. 11 ng/L (IQR 9-17); P < 0.001].

CONCLUSIONS

In an undifferentiated HFpEF cohort, 8% were found to have wild-type ATTR-CM using a DPD scintigraphy-based screening protocol. Screening undifferentiated HFpEF patients is associated with a significant diagnostic yield, which can be further increased by targeting older males with increased LV wall thickness and elevated high-sensitivity troponin levels.

The Last Decade in Cardiac Amyloidosis: Advances in Understanding Pathophysiology, Diagnosis and Quantification, Prognosis, Treatment Strategies, and Monitoring Response

Cardiac amyloidosis represents a unique disease process characterized by amyloid fibril deposition within the myocardial extracellular space. Advances in multimodality cardiac imaging enable accurate diagnosis and facilitate prompt initiation of disease-modifying therapies. Furthermore, rapid advances in multimodality imaging have enriched understanding of the underlying pathogenesis, enhanced prognostication, and resulted in the development of imaging-based markers that reflect the amyloid burden, which is of increasing importance when assessing the response to treatment. Whereas conventional therapies have focused on reducing amyloid formation and subsequent stabilization of the cardiac disease process, novel agents are being developed to accelerate the immune-mediated removal of amyloid fibrils from the heart. In this context, the ability to track changes in the amyloid burden over time is of paramount importance. Although advanced imaging techniques have shown efficacy in tracking the treatment response, future research focused on improved precision through use of artificial intelligence may augment the detection of changes earlier in the course of treatment.

Long-Term Clinical Outcomes in Patients With Transthyretin Cardiac Amyloidosis Versus Non-Ischemic Cardiomyopathy

Background

We sought to compare the long-term outcomes in patients with transthyretin cardiac amyloidosis (CA) compared to those with non-ischemic cardiomyopathy (NICM) from a large healthcare system database.

Methods

Patients with CA or NICM were identified from SSM Healthcare System's data warehouse using ICD codes. Inclusion criteria included at least 6 months of follow-up. Outcomes studied were heart failure hospitalization (HFH), ventricular tachyarrhythmias (VTA), implantable cardiac defibrillator (ICD) and pacemaker (PM) placement. Multivariate logistic analysis and Kaplan-Meier survival curves were constructed.

Results

We identified 231 patients with CA and 462 with NICM, matched for age, race, and gender. CA patients had higher incidence of peripheral vascular disease (48.5% vs. 35.5%) and coronary artery disease (10.4% vs. 6.1%). Mean follow-up was 48.1 ± 33.1 months. CA patients had a higher rate of HFH (57.6% vs. 46.1%) and a lower rate of ICD (1.7% vs. 5.9%). In the multivariate model, CA patients had significantly higher odds for HFH (odds ratio: 1.86; 95% confidence interval: 1.29 - 2.68). Kaplan-Meier survival curves showed a trend toward earlier HFH and later PM or ICD implantation in CA patients.

Conclusions

In this retrospective study from a large healthcare system database, compared to NICM, transthyretin CA patients had significantly higher rates of HFH, similar odds of VTA, and a lower likelihood of receiving an intracardiac device.

Novel drugs approved by the EMA, the FDA and the MHRA in 2024: A year in review

In the past year, the European Medicines Agency (EMA), the Food and Drug Administration (FDA) and the Medicines and Healthcare Products Regulatory Agency (MHRA) authorised 53 novel drugs. While the 2024 harvest is not as rich as in 2023, when 70 new chemical entities were approved, the number of 'orphan' drug authorisations in 2024 (21) is similar to that of 2023 (24), illustrating the dynamic development of therapeutics in areas of unmet need. The 2024 approvals of novel protein therapeutics (15) and advanced therapy medicinal products (ATMPs, 6) indicate a sustained trend also noticeable in the 2023 new drugs reviewed in this journal last year (16 and 11, respectively). Clearly, the most striking characteristic of the 2024 drug yield is the creative pharmacological design, which allows these medicines to employ a novel approach to target a disease. Some notable examples are the first drug successfully using a 'dock-and-block' mechanism of inhibition (zenocutuzumab), the first approved drug for schizophrenia designed as an agonist of M1/M4 muscarinic receptors (xanomeline), the first biparatopic antibody (zanidatamab), binding two distinct epitopes of the same molecule, the first haemophilia therapy that instead of relying on external supplementation of clotting factors, restores Factor Xa activity by inhibiting TFPI (marstacimab), or the first ever authorised direct telomerase inhibitor (imetelstat) that reprogrammes the oncogenic drive of tumour cells. In addition, an impressive percentage of novel drugs were first in class (28 out of 53 or 53% of the total) and a substantial number can be considered disease agnostic, indicating the possibility of future approved extensions of their use for additional indications. The 2024 harvest demonstrates the therapeutic potential of innovative pharmacological design, which allows the effective targeting of intractable disorders and addresses crucial, unmet therapeutic needs.

Amyloidosis of the heart: pathophysiology, diagnosis, and treatment

INTRODUCTION

Cardiac amyloidosis is characterized by amyloid fibril aggregation due to misfolded circulating proteins and their deposition in the heart, leading to cardiac damage and dysfunction. Given cardiac amyloidosis is associated with a poor prognosis without treatment, early diagnosis and management are critical to increase survival from the disease.

AREAS COVERED

This article provides an overview of the disease process, diagnostic modalities, and therapies for cardiac amyloidosis.

EXPERT OPINION

Recent technological advances have led to the development of reliable and accurate diagnostic modalities for identifying cardiac amyloidosis. Recent introduction of novel disease-modifying therapies for cardiac amyloidosis has resulted in improvements in the management and prognosis of the disease.