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Martins LDA, Ferreira PS, Leitão Dos Santos OA, Martins LO, Cabral Fernandes Barroso LG, Pereira HM, Waddington-Cruz M, Palhano FL, Foguel D. Structural and thermodynamic characterization of a highly amyloidogenic dimer of transthyretin involved in a severe cardiomyopathy. J Biol Chem 2024:107495. [PMID: 38925327 DOI: 10.1016/j.jbc.2024.107495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 06/09/2024] [Accepted: 06/13/2024] [Indexed: 06/28/2024] Open
Abstract
Transthyretin (TTR) is a homotetrameric protein involved in the transport of thyroxine. More than 150 different mutations have been described in the TTR gene, several of them associated with familial amyloid cardiomyopathy (FAC). Recently, our group described a new variant of TTR in Brazil, namely A39D-TTR, which causes a severe cardiac condition. Position 39 is in the AB loop, a region of the protein that is located within the thyroxine-binding channels and is involved in tetramer formation. In the present study we solved the structure and characterize the thermodynamic stability of this new variant of TTR using urea and high hydrostatic pressure (HHP). Interestingly, during the process of purification, A39D-TTR turned out to be a dimer and not a tetramer, a variation that might be explained by the close contact of the four aspartic acids at position 39, where they face each other inside the thyroxine channel. In the presence of sub-denaturing concentrations of urea, bis-ANS binding and dynamic light scattering revealed A39D-TTR in the form of a molten-globule dimer. Co-expression of A39D and WT isoforms in the same bacterial cell did not produce heterodimers or heterotetramers, suggesting that somehow a negative charge at the AB loop precludes tetramer formation. A39D-TTR proved to be highly amyloidogenic, even at mildly acidic pH values where WT-TTR does not aggregate. Interestingly, despite being a dimer, aggregation of A39D-TTR was inhibited by diclofenac, which binds to the thyroxine channel in the tetramer, suggesting the existence of other pockets in A39D-TTR able to accommodate this molecule.
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Affiliation(s)
- Lucas do Amaral Martins
- Instituto de Bioquímica Médica Leopoldo De Meis, Universidade Federal do Rio de Janeiro, Brazil
| | - Priscila S Ferreira
- Instituto de Bioquímica Médica Leopoldo De Meis, Universidade Federal do Rio de Janeiro, Brazil
| | | | | | | | - Humberto M Pereira
- Instituto de Física de São Carlos, Universidade São Paulo, São Carlos, Brazil
| | - Márcia Waddington-Cruz
- Centro de Estudos de Paramiloidose Antônio Rodrigues de Mello, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Brazil
| | - Fernando Lucas Palhano
- Instituto de Bioquímica Médica Leopoldo De Meis, Universidade Federal do Rio de Janeiro, Brazil
| | - Debora Foguel
- Instituto de Bioquímica Médica Leopoldo De Meis, Universidade Federal do Rio de Janeiro, Brazil
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2
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Almeida ZL, Vaz DC, Brito RMM. Transthyretin mutagenesis: impact on amyloidogenesis and disease. Crit Rev Clin Lab Sci 2024:1-25. [PMID: 38850014 DOI: 10.1080/10408363.2024.2350379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 04/29/2024] [Indexed: 06/09/2024]
Abstract
Transthyretin (TTR), a homotetrameric protein found in plasma, cerebrospinal fluid, and the eye, plays a pivotal role in the onset of several amyloid diseases with high morbidity and mortality. Protein aggregation and fibril formation by wild-type TTR and its natural more amyloidogenic variants are hallmarks of ATTRwt and ATTRv amyloidosis, respectively. The formation of soluble amyloid aggregates and the accumulation of insoluble amyloid fibrils and deposits in multiple tissues can lead to organ dysfunction and cell death. The most frequent manifestations of ATTR are polyneuropathies and cardiomyopathies. However, clinical manifestations such as carpal tunnel syndrome, leptomeningeal, and ocular amyloidosis, among several others may also occur. This review provides an up-to-date listing of all single amino-acid mutations in TTR known to date. Of approximately 220 single-point mutations, 93% are considered pathogenic. Aspartic acid is the residue mutated with the highest frequency, whereas tryptophan is highly conserved. "Hot spot" mutation regions are mainly assigned to β-strands B, C, and D. This manuscript also reviews the protein aggregation models that have been proposed for TTR amyloid fibril formation and the transient conformational states that convert native TTR into aggregation-prone molecular species. Finally, it compiles the various in vitro TTR aggregation protocols currently in use for research and drug development purposes. In short, this article reviews and discusses TTR mutagenesis and amyloidogenesis, and their implications in disease onset.
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Affiliation(s)
- Zaida L Almeida
- Chemistry Department and Coimbra Chemistry Centre - Institute of Molecular Sciences (CQC-IMS), University of Coimbra, Coimbra, Portugal
| | - Daniela C Vaz
- Chemistry Department and Coimbra Chemistry Centre - Institute of Molecular Sciences (CQC-IMS), University of Coimbra, Coimbra, Portugal
- School of Health Sciences, Polytechnic Institute of Leiria, Leiria, Portugal
- LSRE-LCM - Leiria, Portugal & ALiCE - Associate Laboratory in Chemical Engineering, University of Porto, Porto, Portugal
| | - Rui M M Brito
- Chemistry Department and Coimbra Chemistry Centre - Institute of Molecular Sciences (CQC-IMS), University of Coimbra, Coimbra, Portugal
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Argon A, Nart D, Yılmaz Barbet F. Cardiac Amyloidosis: Clinical Features, Pathogenesis, Diagnosis, and Treatment. Turk Patoloji Derg 2024; 40:1-9. [PMID: 38111336 PMCID: PMC10823787 DOI: 10.5146/tjpath.2023.12923] [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: 06/30/2022] [Accepted: 09/02/2023] [Indexed: 12/20/2023] Open
Abstract
Cardiac amyloidosis is a type of amyloidosis that deserves special attention as organ involvement significantly worsens the prognosis. Cardiac amyloidosis can be grouped under three main headings: immunoglobulin light chain (AL) amyloidosis that is dependent on amyloidogenic monoclonal light chain production; hereditary Transthyretin (TTR) amyloidosis that results from accumulation of mutated TTR; and wild-type (non-hereditary) TTR amyloidosis formerly known as senile amyloidosis. Although all three types cause morbidity and mortality due to severe heart failure when untreated, they contain differences in their pathogenesis, clinical findings, and treatment. In this article, the clinical features, pathogenesis, diagnosis, and treatment methods of cardiac amyloidosis will be explained with an overview, and an awareness will be raised in the diagnosis of this disease.
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Affiliation(s)
- Asuman Argon
- Department of Pathology, Health Sciences University, Izmir Faculty of Medicine, Izmir, Turkey
| | - Deniz Nart
- Ege University, Faculty of Medicine, Izmir, Turkey
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4
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Pack AP, Zuleta A, Daugerdas E, Huang W, Batio S, Svoboda S, Zeitler EP, Kumar N, Watt S, Fernandez-Arias MI, Bader M, Assaf AR, Bailey SC. Developing, optimizing, and evaluating patient infographics for diagnosing cardiac amyloidosis. PEC INNOVATION 2023; 3:100212. [PMID: 37743956 PMCID: PMC10514075 DOI: 10.1016/j.pecinn.2023.100212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 09/05/2023] [Accepted: 09/08/2023] [Indexed: 09/26/2023]
Abstract
Objective Advancements in diagnostics and treatment options for cardiac amyloidosis have improved patient outcomes, yet few patient education materials exist to help patients understand the disease and diagnosis process. We sought to develop and evaluate a set of plain language, patient-centered infographics describing the condition and common diagnostic tests. Methods Using health literacy best practices, we developed 7 infographics which were further revised based on multilevel stakeholder feedback. To evaluate the materials, we recruited 100 patients from healthcare settings in Chicago, IL; participants completed a web-assisted interview during which they were randomized 1:1 to first view either our infographics or a standard material. Participants completed a knowledge assessment on their assigned material and subsequently reported impressions of both materials. Results No differences were found between study arms in knowledge. The infographics took significantly less time to read and were more highly rated by participants in terms of appearance and understandability. Over two-thirds of participants preferred the infographics to the standard. Conclusions The infographics created may improve the learning process about a complex condition and diagnosis process unknown to most adults. Innovation These infographics are the first of their kind for cardiac amyloidosis and were created using health literacy best practices.
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Affiliation(s)
- Allison P. Pack
- Division of General Internal Medicine, Feinberg School of Medicine at Northwestern University, United States of America
| | - Andrea Zuleta
- Division of General Internal Medicine, Feinberg School of Medicine at Northwestern University, United States of America
| | - Eleanor Daugerdas
- Division of General Internal Medicine, Feinberg School of Medicine at Northwestern University, United States of America
| | - Wei Huang
- Division of General Internal Medicine, Feinberg School of Medicine at Northwestern University, United States of America
| | - Stephanie Batio
- Division of General Internal Medicine, Feinberg School of Medicine at Northwestern University, United States of America
| | - Sophia Svoboda
- Division of General Internal Medicine, Feinberg School of Medicine at Northwestern University, United States of America
| | - Emily P. Zeitler
- Dartmouth Hitchcock Medical Center, Heart and Vascular Center, Cardiovascular Section, The Dartmouth Institute, Geisel School of Medicine at Dartmouth, United States of America
| | | | | | | | | | - Annlouise R. Assaf
- Pfizer, Inc, United States of America
- Brown University School of Public Health, United States of America
| | - Stacy Cooper Bailey
- Division of General Internal Medicine, Feinberg School of Medicine at Northwestern University, United States of America
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Vitali F, Sciarrone MA, Romano A, Guglielmino V, Luigetti M. Neurological onset in patients with V122I hereditary transthyretin amyloidosis: a glitch in the paradigm. Neurol Sci 2023; 44:4569-4571. [PMID: 37515707 DOI: 10.1007/s10072-023-06977-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 07/20/2023] [Indexed: 07/31/2023]
Affiliation(s)
- Francesca Vitali
- Università Cattolica del Sacro Cuore, Dipartimento di Neuroscienze, Rome, Italy.
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, UOC Neurologia, Rome, Italy.
| | - Maria A Sciarrone
- Università Cattolica del Sacro Cuore, Dipartimento di Neuroscienze, Rome, Italy
| | - Angela Romano
- Università Cattolica del Sacro Cuore, Dipartimento di Neuroscienze, Rome, Italy
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, UOC Neurologia, Rome, Italy
| | - Valeria Guglielmino
- Università Cattolica del Sacro Cuore, Dipartimento di Neuroscienze, Rome, Italy
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, UOC Neurologia, Rome, Italy
| | - Marco Luigetti
- Università Cattolica del Sacro Cuore, Dipartimento di Neuroscienze, Rome, Italy
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, UOC Neurologia, Rome, Italy
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Quarta CC, Fontana M, Damy T, Catini J, Simoneau D, Mercuri M, Garcia-Pavia P, Maurer MS, Palladini G. Changing paradigm in the treatment of amyloidosis: From disease-modifying drugs to anti-fibril therapy. Front Cardiovasc Med 2022; 9:1073503. [PMID: 36606280 PMCID: PMC9808970 DOI: 10.3389/fcvm.2022.1073503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 11/24/2022] [Indexed: 12/24/2022] Open
Abstract
Cardiac amyloidosis is a rare, debilitating, and usually fatal disease increasingly recognized in clinical practice despite patients presenting with non-specific symptoms of cardiomyopathy. The current standard of care (SoC) focuses on preventing further amyloid formation and deposition, either with anti-plasma cell dyscrasia (anti-PCD) therapies in light-chain (AL) amyloidosis or stabilizers of transthyretin (TTR) in transthyretin amyloidosis (ATTR). The SoC is supplemented by therapies to treat the complications arising from organ dysfunction; for example, heart failure, arrhythmia, and proteinuria. Advancements in treatments have improved patient survival, especially for those whose disease is detected and for whom treatment is initiated at an early stage. However, there still are many unmet medical needs, particularly for patients with severe disease for whom morbidity and mortality remain high. There currently are no approved treatments to reverse amyloid infiltration and deplete the amyloid fibrils already deposited in organs, which can continue to cause progressive dysfunction. Anti-fibril therapies aimed at removing the deposited fibrils are being investigated for safety and efficacy in improving outcomes for patients with severe disease. However, there is no clinical evidence yet that removing deposited amyloid fibrils will improve organ function, thereby improving quality of life or extending life. Nevertheless, anti-fibril therapies are actively being investigated in clinical trials to evaluate their ability to complement and synergize with current SoC.
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Affiliation(s)
| | | | - Thibaud Damy
- University Hospital Henri Mondor, Creteil, France
| | - Julia Catini
- Alexion, AstraZeneca Rare Disease, Boston, MA, United States
| | - Damien Simoneau
- Alexion, AstraZeneca Rare Disease, Boston, MA, United States
| | - Michele Mercuri
- Alexion, AstraZeneca Rare Disease, Boston, MA, United States
| | - Pablo Garcia-Pavia
- Hospital Universitario Puerta de Hierro Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana (IDIPHISA), Centro de Investigación Biomédica en Red Enfermedades Cardiovasulares (CIBERCV), Madrid, Spain
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Mathew S. Maurer
- Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY, United States
| | - Giovanni Palladini
- Department of Molecular Medicine, University of Pavia, and Amyloidosis Research and Treatment Center, Foundation “Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo”, Pavia, Italy
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Radiolabeled Thioflavin-T Derivative PET Imaging for the Assessment of Cardiac Amyloidosis. Curr Cardiol Rep 2022; 24:1883-1891. [PMID: 36378483 DOI: 10.1007/s11886-022-01811-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/13/2022] [Indexed: 11/16/2022]
Abstract
PURPOSE OF REVIEW Cardiac amyloidosis (CA) is an often under-recognized cause of heart failure with preserved ejection fraction. The goal of the current paper was to review imaging modalities available for detecting cardiac amyloidosis. We wished to determine what modalities are available for the diagnosis of cardiac amyloidosis and what modalities could be utilized in the future. RECENT FINDINGS Early and delayed planar imaging of the chest currently plays a central role in the workup and diagnosis of CA. However, novel positron emission tomography (PET) tracers could play a large role in CA imaging in the future. There is an increasing body of literature supporting the use of targeted amyloid-binding PET radiotracers such as 11C-Pittsburgh compound B (11C-PIB), 18F-florbetapir, -flutemetamol, and -florbetaben for the detection of cardiac amyloid. While planar imaging currently plays a large role in the workup of CA, PET imaging could play an increasing important role in the future. The quantitative abilities of novel PET tracers could theoretically allow for the serial monitoring of patients and detection of response to therapy, and the sensitive nature of the tracers could allow for even earlier disease detection. Further work with large randomized controlled trial data is needed in the development and validation of PET tracers for cardiac amyloid and represents an exciting development within the realm of nuclear cardiology.
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8
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Trujillo L, Colombo R. Hereditary Transthyretin Amyloidosis Cardiomyopathy: The South Florida Experience. Am J Cardiol 2022; 180:140-148. [DOI: 10.1016/j.amjcard.2022.06.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 06/05/2022] [Accepted: 06/13/2022] [Indexed: 11/01/2022]
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Adams D, Algalarrondo V, Polydefkis M, Sarswat N, Slama MS, Nativi-Nicolau J. Expert opinion on monitoring symptomatic hereditary transthyretin-mediated amyloidosis and assessment of disease progression. Orphanet J Rare Dis 2021; 16:411. [PMID: 34602081 PMCID: PMC8489116 DOI: 10.1186/s13023-021-01960-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 07/18/2021] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Hereditary transthyretin-mediated amyloidosis, also known as ATTRv amyloidosis (v for variant), is a rare, autosomal dominant, fatal disease, in which systemic amyloid progressively impairs multiple organs, leading to disability and death. The recent approval of disease-modifying therapies offers the hope of stabilization or eventual reversal of disease progression, and yet highlights a lack of disease-management guidance. A multidisciplinary panel of expert clinicians from France and the US came to consensus on monitoring the disease and identifying progression through a clinical opinion questionnaire, a roundtable meeting, and multiple rounds of feedback. MONITORING DISEASE AND PROGRESSION A multidisciplinary team should monitor ATTRv amyloidosis disease course by assessing potential target organs at baseline and during follow-up for signs and symptoms of somatic and autonomic neuropathy, cardiac dysfunction and restrictive cardiomyopathy, and other manifestations. Variability in penetrance, symptoms, and course of ATTRv amyloidosis requires that all patients, regardless of variant status, undergo regular and standardized assessment in all these categories. Progression in ATTRv amyloidosis may be indicated by: worsening of several existing quantifiable symptoms or signs; the appearance of a new symptom; or the worsening of a single symptom that results in a meaningful functional impairment. CONCLUSIONS We suggest that a multisystem approach to monitoring the signs and symptoms of ATTRv amyloidosis best captures the course of the disease. We hope this work will help form the basis of further, consensus-based guidance for the treatment of ATTRv amyloidosis.
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Affiliation(s)
- David Adams
- Université Paris-Saclay, U1195, INSERM, Le Kremlin Bicêtre, France
- Neurology Department, AP-HP, CHU Bicêtre, Le Kremlin Bicêtre, France
| | - Vincent Algalarrondo
- Cardiology Department, CHU Bichat-Claude-Bernard, 46 rue Henri Huchard, 75018, Paris, France
| | - Michael Polydefkis
- Department of Neurology, Johns Hopkins Hospital, 855 North Wolfe Street, Baltimore, MD, 21205, USA
| | - Nitasha Sarswat
- Department of Medicine, University of Chicago, 5841 S Maryland Ave, Chicago, IL, 60637, USA
| | - Michel S Slama
- Cardiology Department, CHU Bichat-Claude-Bernard, 46 rue Henri Huchard, 75018, Paris, France
| | - Jose Nativi-Nicolau
- Department of Internal Medicine, University of Utah, 30 N 1900 E, Salt Lake City, UT, 84132, USA.
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Hussain M, Hanna M, Jaber W, Collier P. Atypical Case of Wild-Type Cardiac Amyloidosis with Septal Predominance and a Nonapical Sparing Strain Pattern. CASE 2021; 5:313-317. [PMID: 34712876 PMCID: PMC8530817 DOI: 10.1016/j.case.2021.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We present an atypical variant case of wild-type transthyretin cardiac amyloidosis. Amyloid deposition occurred mainly in the interventricular septum. The classic apical sparing pattern was absent, despite other suggestive findings. A high index of suspicion for amyloid should still be sought in such cases. Multimodality imaging should be considered to investigate variant amyloid forms.
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11
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Variable Presentation of Hereditary Transthyretin-Mediated Amyloidosis at a Single Center. J Clin Neuromuscul Dis 2021; 23:7-17. [PMID: 34431796 DOI: 10.1097/cnd.0000000000000356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Describe atypical presentations of hereditary transthyretin-mediated (hATTR) amyloidosis with polyneuropathy. METHODS Initial symptoms, diagnoses, and follow-up were recorded at the Austin Neuromuscular Center for 12 patients with nonclassical presentation of hATTR amyloidosis. RESULTS Common initial symptoms were hand and/or feet sensory manifestations (83%), muscle weakness (58%), and, less frequently, gastrointestinal and orthostatic impairment and carpal tunnel syndrome. Initial diagnoses were polyneuropathy (83%) and/or myopathy (25%). During follow-up, 10 patients (83%) developed cardiac symptoms (dyspnea, 67% and ankle edema, 17%), resulting in revised diagnoses of heart disease. Multisystem involvement raised suspicion of amyloidosis, which was confirmed by biopsy or nuclear scintigraphy, and genetic testing. All patients had polyneuropathy; 8 (67%) had cardiomyopathy-associated transthyretin mutations (V122I or T60A). Time from symptom onset to diagnosis was up to 10 years (median 5 years), during which patients' health deteriorated, although with recognition of disease signs/symptoms the diagnosis of hATTR amyloidosis was made in approximately 2-6 months from presentation at our center. CONCLUSIONS Increased awareness of the diverse initial hATTR amyloidosis symptoms could shorten time to diagnosis, enabling earlier treatment and improved patient outcomes.
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Parker MM, Damrauer SM, Tcheandjieu C, Erbe D, Aldinc E, Hawkins PN, Gillmore JD, Hull LE, Lynch JA, Joseph J, Ticau S, Flynn-Carroll AO, Deaton AM, Ward LD, Assimes TL, Tsao PS, Chang KM, Rader DJ, Fitzgerald K, Vaishnaw AK, Hinkle G, Nioi P. Association of the transthyretin variant V122I with polyneuropathy among individuals of African ancestry. Sci Rep 2021; 11:11645. [PMID: 34079032 PMCID: PMC8172853 DOI: 10.1038/s41598-021-91113-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 05/21/2021] [Indexed: 11/18/2022] Open
Abstract
Hereditary transthyretin-mediated (hATTR) amyloidosis is an underdiagnosed, progressively debilitating disease caused by mutations in the transthyretin (TTR) gene. V122I, a common pathogenic TTR mutation, is found in 3-4% of individuals of African ancestry in the United States and has been associated with cardiomyopathy and heart failure. To better understand the phenotypic consequences of carrying V122I, we conducted a phenome-wide association study scanning 427 ICD diagnosis codes in UK Biobank participants of African ancestry (n = 6062). Significant associations were tested for replication in the Penn Medicine Biobank (n = 5737) and the Million Veteran Program (n = 82,382). V122I was significantly associated with polyneuropathy in the UK Biobank (odds ratio [OR] = 6.4, 95% confidence interval [CI] 2.6-15.6, p = 4.2 × 10-5), which was replicated in the Penn Medicine Biobank (OR = 1.6, 95% CI 1.2-2.4, p = 6.0 × 10-3) and Million Veteran Program (OR = 1.5, 95% CI 1.2-1.8, p = 1.8 × 10-4). Polyneuropathy prevalence among V122I carriers was 2.1%, 9.0%, and 4.8% in the UK Biobank, Penn Medicine Biobank, and Million Veteran Program, respectively. The cumulative incidence of common hATTR amyloidosis manifestations (carpal tunnel syndrome, polyneuropathy, cardiomyopathy, heart failure) was significantly enriched in V122I carriers compared with non-carriers (HR = 2.8, 95% CI 1.7-4.5, p = 2.6 × 10-5) in the UK Biobank, with 37.4% of V122I carriers having at least one of these manifestations by age 75. Our findings show that V122I carriers are at increased risk of polyneuropathy. These results also emphasize the underdiagnosis of disease in V122I carriers with a significant proportion of subjects showing phenotypic changes consistent with hATTR amyloidosis. Greater understanding of the manifestations associated with V122I is critical for earlier diagnosis and treatment.
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Affiliation(s)
| | - Scott M Damrauer
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
- The Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, 19104, USA
| | - Catherine Tcheandjieu
- 12 VA Palo Alto Health Care System, Palo Alto, CA, 94304, USA
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, 94304, USA
| | - David Erbe
- Alnylam Pharmaceuticals, 300 3rd St., Cambridge, MA, 02142, USA
| | - Emre Aldinc
- Alnylam Pharmaceuticals, 300 3rd St., Cambridge, MA, 02142, USA
| | - Philip N Hawkins
- Centre for Amyloidosis & Acute Phase Proteins, Division of Medicine UCL (Royal Free Campus), London, NW3 2PF, UK
| | - Julian D Gillmore
- Centre for Amyloidosis & Acute Phase Proteins, Division of Medicine UCL (Royal Free Campus), London, NW3 2PF, UK
| | - Leland E Hull
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, 02114, USA
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, 01730, USA
| | - Julie A Lynch
- School of Nursing & Health Sciences, University of Massachusetts, Boston, MA, 02125, USA
- VA Informatics and Computing Infrastructure (VINCI), VA Salt Lake City Health Care System, Salt Lake City, UT, 84148, USA
| | - Jacob Joseph
- Department of Medicine, Veterans Affairs Boston Healthcare System, Boston, MA, 02130, USA
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Simina Ticau
- Alnylam Pharmaceuticals, 300 3rd St., Cambridge, MA, 02142, USA
| | | | - Aimee M Deaton
- Alnylam Pharmaceuticals, 300 3rd St., Cambridge, MA, 02142, USA
| | - Lucas D Ward
- Alnylam Pharmaceuticals, 300 3rd St., Cambridge, MA, 02142, USA
| | - Themistocles L Assimes
- 12 VA Palo Alto Health Care System, Palo Alto, CA, 94304, USA
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, 94304, USA
| | - Philip S Tsao
- 12 VA Palo Alto Health Care System, Palo Alto, CA, 94304, USA
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, 94304, USA
| | - Kyong-Mi Chang
- The Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, 19104, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Daniel J Rader
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
- Department of Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | | | | | - Gregory Hinkle
- Alnylam Pharmaceuticals, 300 3rd St., Cambridge, MA, 02142, USA
| | - Paul Nioi
- Alnylam Pharmaceuticals, 300 3rd St., Cambridge, MA, 02142, USA.
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Burton A, Castaño A, Bruno M, Riley S, Schumacher J, Sultan MB, See Tai S, Judge DP, Patel JK, Kelly JW. Drug Discovery and Development in Rare Diseases: Taking a Closer Look at the Tafamidis Story. Drug Des Devel Ther 2021; 15:1225-1243. [PMID: 33776421 PMCID: PMC7987260 DOI: 10.2147/dddt.s289772] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 01/20/2021] [Indexed: 12/25/2022] Open
Abstract
Rare diseases are increasingly recognized as a global public health priority. Governments worldwide currently provide important incentives to stimulate the discovery and development of orphan drugs for the treatment of these conditions, but substantial scientific, clinical, and regulatory challenges remain. Tafamidis is a first-in-class, disease-modifying transthyretin (TTR) kinetic stabilizer that represents a major breakthrough in the treatment of transthyretin amyloidosis (ATTR amyloidosis). ATTR amyloidosis is a rare, progressive, and fatal systemic disorder caused by aggregation of misfolded TTR and extracellular deposition of amyloid fibrils in various tissues and organs, including the heart and nervous systems. In this review, we present the successful development of tafamidis spanning 3 decades, marked by meticulous laboratory research into disease mechanisms and natural history, and innovative clinical study design and implementation. These efforts established the safety and efficacy profile of tafamidis, leading to its regulatory approval, and enabled post-approval initiatives that further support patients with ATTR amyloidosis.
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Affiliation(s)
| | | | | | - Steve Riley
- Clinical Pharmacology, Pfizer Inc, Groton, CT, USA
| | | | - Marla B Sultan
- Global Product Development, Pfizer Inc, New York, NY, USA
| | - Sandi See Tai
- Global Product Development, Pfizer Inc, Collegeville, PA, USA
| | - Daniel P Judge
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Jignesh K Patel
- Department of Cardiology, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, USA
| | - Jeffery W Kelly
- Department of Chemistry, The Scripps Research Institute, La Jolla, CA, USA
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Martineau P, Finnerty V, Giraldeau G, Authier S, Harel F, Pelletier-Galarneau M. Examining the sensitivity of 18F-NaF PET for the imaging of cardiac amyloidosis. J Nucl Cardiol 2021; 28:209-218. [PMID: 30834499 DOI: 10.1007/s12350-019-01675-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 02/21/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Conventional nuclear imaging with bone-seeking radiopharmaceuticals has been shown to be a sensitive test for the detection of transthyretin cardiac amyloidosis (ATTR); however, to date, few data exist on the utility of 18F-sodium fluoride (NaF) positron emission tomography (PET) in subjects with cardiac amyloidosis (CA). METHODS Myocardial perfusion imaging and cardiac 18F-NaF PET/CT of 7 subjects with ATTR, four with light-chain CA (AL), and four controls were retrospectively reviewed. Qualitative interpretation and quantitative analyses with average left ventricular standardized uptake values (SUVmean) and target-to-background ratios (TBRmean) were performed. RESULTS Average TBRmean was significantly increased in subjects with ATTR (0.98 ± 0.09) compared to AL (0.85 ± 0.08, P = .026) and CTL (0.82 ± 0.07, P = .020), while SUVmean was not (P = .14). Receiver-operator characteristic (ROC) analysis yielded an area under the curve (AUC) of 0.91, with a sensitivity/specificity of 75%/100% for TBRmean using a cutoff value of 0.89 for the diagnosis of ATTR. Qualitative interpretation resulted in a sensitivity/specificity of 57%/100% for ATTR. CONCLUSIONS While 18F-NaF PET/CT demonstrates good diagnostic accuracy for ATTR, particularly when using quantitative analysis, the low TBRmean values observed in ATTR indicate poor myocardial signal. 18F-NaF PET/CT is not yet ready for clinical use in CA until further comparison studies are performed with 99mTc-DPD/PYP.
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Affiliation(s)
- Patrick Martineau
- Department of Radiology, Health Sciences Centre, University of Manitoba, Winnipeg, MB, Canada
- Gordon Center for Medical Imaging, Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - Vincent Finnerty
- Department of Medical Imaging, Institut de Cardiologie de Montréal, 5000 Belanger, Montreal, QC, H1T1C8, Canada
| | - Geneviève Giraldeau
- Department of Medicine, Institut de Cardiologie de Montréal, Montréal, Canada
| | - Sébastien Authier
- Department of Medical Imaging, Institut de Cardiologie de Montréal, 5000 Belanger, Montreal, QC, H1T1C8, Canada
| | - Francois Harel
- Department of Medical Imaging, Institut de Cardiologie de Montréal, 5000 Belanger, Montreal, QC, H1T1C8, Canada
| | - Matthieu Pelletier-Galarneau
- Gordon Center for Medical Imaging, Massachusetts General Hospital, Harvard University, Boston, MA, USA.
- Department of Medical Imaging, Institut de Cardiologie de Montréal, 5000 Belanger, Montreal, QC, H1T1C8, Canada.
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15
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Soper ER, Suckiel SA, Braganza GT, Kontorovich AR, Kenny EE, Abul-Husn NS. Genomic Screening Identifies Individuals at High Risk for Hereditary Transthyretin Amyloidosis. J Pers Med 2021; 11:49. [PMID: 33467513 PMCID: PMC7829706 DOI: 10.3390/jpm11010049] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/08/2021] [Accepted: 01/09/2021] [Indexed: 12/21/2022] Open
Abstract
The TTR V142I variant associated with hereditary transthyretin amyloidosis (hATTR) is present in up to 4% of African American (AA) and 1% of Hispanic/Latinx (HL) individuals and increases risk for heart failure. Delayed and missed diagnoses could potentiate health disparities in these populations. We evaluated whether population-based genomic screening could effectively identify individuals at risk for hATTR and prompt initiation of risk management. We identified participants of the BioMe Biobank in New York City who received TTR V142I results through a pilot genomic screening program. We performed a retrospective medical record review to evaluate for the presence hATTR-related systemic features, uptake of recommended follow-up, and short-term outcomes. Thirty-two AA (N = 17) and HL (N = 15) individuals received a TTR V142I result (median age 57, 81% female). None had a previous diagnosis of hATTR. Eighteen (56%) had hATTR-related systemic features, including 4 (13%) with heart failure, 10 (31%) with carpal tunnel syndrome, and 10 (31%) with spinal stenosis. Eighteen (56%) pursued follow-up with a cardiologist within 8 months. One person received a diagnosis of hATTR. Thus, we found that the majority of V142I-positive individuals had hATTR-related systemic features at the time of result disclosure, including well-described red flags. Genomic screening can help identify hATTR risk and guide management early on, avoiding potential delays in diagnosis and treatment.
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Affiliation(s)
- Emily R. Soper
- The Institute for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (E.R.S.); (S.A.S.); (G.T.B.); (E.E.K.)
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Sabrina A. Suckiel
- The Institute for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (E.R.S.); (S.A.S.); (G.T.B.); (E.E.K.)
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Giovanna T. Braganza
- The Institute for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (E.R.S.); (S.A.S.); (G.T.B.); (E.E.K.)
| | - Amy R. Kontorovich
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine, New York, NY 10029, USA;
| | - Eimear E. Kenny
- The Institute for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (E.R.S.); (S.A.S.); (G.T.B.); (E.E.K.)
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Noura S. Abul-Husn
- The Institute for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (E.R.S.); (S.A.S.); (G.T.B.); (E.E.K.)
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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16
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Akinboboye O, Shah K, Warner AL, Damy T, Taylor HA, Gollob J, Powell C, Karsten V, Vest J, Maurer MS. DISCOVERY: prevalence of transthyretin ( TTR) mutations in a US-centric patient population suspected of having cardiac amyloidosis. Amyloid 2020; 27:223-230. [PMID: 32456532 DOI: 10.1080/13506129.2020.1764928] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Hereditary transthyretin-mediated amyloidosis (hATTR amyloidosis) is a multisystem disease that presents with polyneuropathy and/or cardiomyopathy. METHODS DISCOVERY, a multicenter screening study, enrolled patients with clinically suspected cardiac amyloidosis to determine the frequency of transthyretin (TTR) mutations and assess disease characteristics. RESULTS Of 1007 patients, the majority were from the US (84%), Black/African American (56%), male (63%), and with a mean (standard deviation) age of 65 (13) years. Among 1001 patients with genotyping results, 74 (7%) had a pathogenic TTR mutation (71/836 [8%] from the US). Val122Ile was the most common mutation, found in 11% of Black/African American patients overall; Black/African American ethnicity was an independent predictor of having a pathogenic TTR mutation. Additional independent predictors of such mutations in the total population and Black/African American group were interventricular septum thickness, low electrocardiogram voltage, and age. CONCLUSIONS Pathogenic TTR mutations occurred in 8% of US patients with suspected cardiac amyloidosis. Most mutations were Val122Ile, almost exclusively found in Black/African American patients. Disease often remains undetected until advanced and difficult to treat, therefore, clinicians should assess at-risk patients for hATTR amyloidosis as early as possible.
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Affiliation(s)
| | - Keyur Shah
- Virginia Commonwealth University Medical Center, Richmond, VA, USA
| | - Alberta L Warner
- VA Greater Los Angeles Health Care System, University of California, Los Angeles, CA, USA
| | - Thibaud Damy
- Mondor Amyloidosis Network and GRC Amyloid Research Institute and Department of Cardiology at AP-HP Henri-Mondor Teaching Hospital and UPEC, Créteil, France
| | - Herman A Taylor
- Cardiovascular Research Institute, Morehouse School of Medicine, Atlanta, GA, USA
| | | | | | | | - John Vest
- Alnylam Pharmaceuticals, Cambridge, MA, USA
| | - Mathew S Maurer
- Cardiovascular Research Lab for the Elderly at New York-Presbyterian/Columbia Allen Hospital, Columbia University Medical Center, New York, NY, USA
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17
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Judge DP, Kristen AV, Grogan M, Maurer MS, Falk RH, Hanna M, Gillmore J, Garg P, Vaishnaw AK, Harrop J, Powell C, Karsten V, Zhang X, Sweetser MT, Vest J, Hawkins PN. Phase 3 Multicenter Study of Revusiran in Patients with Hereditary Transthyretin-Mediated (hATTR) Amyloidosis with Cardiomyopathy (ENDEAVOUR). Cardiovasc Drugs Ther 2020; 34:357-370. [PMID: 32062791 PMCID: PMC7242280 DOI: 10.1007/s10557-019-06919-4] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Purpose The Phase 3 ENDEAVOUR study evaluated revusiran, an investigational RNA interference therapeutic targeting hepatic transthyretin (TTR) production, for treating cardiomyopathy caused by hereditary transthyretin-mediated (hATTR) amyloidosis. Methods Patients with hATTR amyloidosis with cardiomyopathy were randomized 2:1 to receive subcutaneous daily revusiran 500 mg (n = 140) or placebo (n = 66) for 5 days over a week followed by weekly doses. Co-primary endpoints were 6-min walk test distance and serum TTR reduction. Results Revusiran treatment was stopped after a median of 6.71 months; the study Sponsor prematurely discontinued dosing due to an observed mortality imbalance between treatment arms. Eighteen (12.9%) patients on revusiran and 2 (3.0%) on placebo died during the on-treatment period. Most deaths in both treatment arms were adjudicated as cardiovascular due to heart failure (HF), consistent with the natural history of the disease. A post hoc safety investigation of patients treated with revusiran found that, at baseline, a greater proportion of those who died were ≥ 75 years and showed clinical evidence of more advanced HF compared with those who were alive throughout treatment. Revusiran pharmacokinetic exposures and TTR lowering did not show meaningful differences between patients who died and who were alive. Revusiran did not deleteriously affect echocardiographic parameters, cardiac biomarkers, or frequency of cardiovascular and HF hospitalization events. Conclusions Causes for the observed mortality imbalance associated with revusiran were thoroughly investigated and no clear causative mechanism could be identified. Although the results suggest similar progression of cardiac parameters in both treatment arms, a role for revusiran cannot be excluded. Clinical Trial Registration NCT02319005. Electronic supplementary material The online version of this article (10.1007/s10557-019-06919-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Daniel P Judge
- Johns Hopkins Hospital, Baltimore, MD, USA.,Medical University of South Carolina, Charleston, SC, USA
| | - Arnt V Kristen
- Department of Cardiology, University of Heidelberg, Heidelberg, Germany
| | | | | | | | | | - Julian Gillmore
- National Amyloidosis Centre, Division of Medicine, UCL Medical School Royal Free Hospital Rowland Hill Street, NW3 2PF, London, UK
| | | | | | | | | | | | | | | | - John Vest
- Alnylam Pharmaceuticals, Cambridge, MA, USA
| | - Philip N Hawkins
- National Amyloidosis Centre, Division of Medicine, UCL Medical School Royal Free Hospital Rowland Hill Street, NW3 2PF, London, UK.
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18
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Rehorn MR, Loungani RS, Black-Maier E, Coniglio AC, Karra R, Pokorney SD, Khouri MG. Cardiac Implantable Electronic Devices: A Window Into the Evolution of Conduction Disease in Cardiac Amyloidosis. JACC Clin Electrophysiol 2020; 6:1144-1154. [PMID: 32972550 DOI: 10.1016/j.jacep.2020.04.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 03/30/2020] [Accepted: 04/17/2020] [Indexed: 12/28/2022]
Abstract
OBJECTIVES This study characterized the relationship between conduction disease and cardiac amyloidosis (CA) through longitudinal analysis of cardiac implantable electronic device (CIED) data. BACKGROUND Bradyarrhythmias and tachyarrhythmias are commonly reported in CA and may precede a CA diagnosis, although the natural history of conduction disease in CA is not well-described. METHODS Patients with CA (transthyretin amyloidosis cardiomyopathy [ATTR-CM] and light-chain amyloidosis [AL-CA]) and a CIED were identified within the Duke University Health System. Patient characteristics at the time of implantation, including demographics and data relevant to CA diagnosis, cardiac imaging, and CIED were recorded. CIED interrogations were analyzed for pacing and atrial fibrillation (AF) burden, activity level, lead parameters, and ventricular arrhythmia incidence and/or therapy. RESULTS Thirty-four patients with CA (7 with AL-CA, 27 with ATTR-CM [78% with wild-type]; 82% men) with median age of 75 years and a mean ejection fraction of 42 ± 13% had a CIED implanted for bradycardia (65%) or prevention of sudden cardiac death (35%). CIED implantation preceded CA diagnosis in 14 patients (41%). Over a mean follow-up of 3.1 ± 4.0 years, right ventricular sensing amplitudes decreased but did not result in device malfunction; lead impedances and capture thresholds remained stable. Between post-implantation years 1 and 5, mean ventricular pacing increased from 56 ± 9% to 96 ± 1% (p = 0.003) and AF burden increased from 2 ± 1.3 to 17 ± 3 h/day (p = 0.0002). Ventricular arrhythmias were common (mean episodes per patient per year: 6.7 ± 2.3 [ATTR-CM] and 5.1 ± 3.2 [AL-CA]) but predominately nonsustained; only 1 patient with AL-CA required implantable cardioverter-defibrillator therapy. CONCLUSIONS Longitudinal analysis of CIED data in patients with CA revealed progressive conduction disease, with high AF burden and eventual dependence on ventricular pacing, although lead parameters remained stable. Ventricular arrhythmias were common but predominantly nonsustained, particularly in ATTR-CM.
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Affiliation(s)
- Michael R Rehorn
- Division of Cardiology, Duke University Hospital, Durham, North Carolina, USA
| | - Rahul S Loungani
- Division of Cardiology, Duke University Hospital, Durham, North Carolina, USA
| | - Eric Black-Maier
- Division of Cardiology, Duke University Hospital, Durham, North Carolina, USA
| | - Amanda C Coniglio
- Division of Cardiology, Duke University Hospital, Durham, North Carolina, USA
| | - Ravi Karra
- Division of Cardiology, Duke University Hospital, Durham, North Carolina, USA
| | - Sean D Pokorney
- Division of Cardiology, Duke University Hospital, Durham, North Carolina, USA
| | - Michel G Khouri
- Division of Cardiology, Duke University Hospital, Durham, North Carolina, USA.
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19
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Schwartzlow C, Kazamel M. Hereditary Transthyretin Amyloidosis: Clinical Presentation and Management Updates. J Clin Neuromuscul Dis 2020; 21:144-156. [PMID: 32073460 DOI: 10.1097/cnd.0000000000000270] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Hereditary transthyretin amyloidosis, once a rare progressive neuropathy and/or cardiomyopathy, is now recognized with increasing worldwide frequency, various phenotypes, and over 130 gene mutations identified to date. This inherited disorder develops as a result of mutated transthyretin amyloid aggregation and systematic deposition throughout the body. With increasing knowledge about the pathophysiology of this disease, new disease-modifying therapies are being developed. In addition to slowing progression, these new agents were found to improve quality of life and reduce the severity of neuropathic symptoms. Two new gene-modifying therapies recently received Food and Drug Administration approval following the positive results from phase III trials. These include an antisense oligonucleotide, inotersen, and small interfering RNA, patisiran, which were reported to reduce the production of transthyretin and had promising safety profiles. Additional novel therapies are being explored with hopes to prolong survival. Therefore, early diagnosis of this treatable disorder has become increasingly important in clinical practice.
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Affiliation(s)
- Coreen Schwartzlow
- Department of Neurology, The University of Alabama at Birmingham, Birmingham, AL
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20
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Manrique A, Dudoignon D, Brun S, N'Ganoa C, Cassol E, Legallois D, Lavie-Badie Y, Agostini D, Lairez O. Quantification of myocardial 99mTc-labeled bisphosphonate uptake with cadmium zinc telluride camera in patients with transthyretin-related cardiac amyloidosis. EJNMMI Res 2019; 9:117. [PMID: 31873816 PMCID: PMC6928186 DOI: 10.1186/s13550-019-0584-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 12/06/2019] [Indexed: 01/15/2023] Open
Abstract
PURPOSE We aimed to compare different methods for semi-quantitative analysis of cardiac retention of bone tracers in patients with cardiac transthyretin amyloidosis (ATTR). METHODS Data from 67 patients with ATTR who underwent both conventional whole-body scan and a CZT myocardial SPECT (DSPECT, Spectrum Dynamics) 3 h after injection of 99mTc-labeled bone tracer were analyzed. Visual scoring of cardiac retention was performed on whole-body scan according to Perugini 4-point grading system from 0 (no uptake) to 3 (strong cardiac uptake with mild/absent bone uptake). A planar heart-to-background (H:B) ratio was calculated using whole-body scan (wb-H:B). CZT SPECT was quantified using three methods: planar H:B ratio calculated from anterior reprojection (ant-H:B), left anterior oblique reprojection (LAO-H:B), and 3D-H:B ratio calculated from transaxial slices as mean counts in a VOI encompassing the heart divided by background VOI in the contralateral lung. Interventricular septal thickness was obtained using echocardiography. RESULTS H:Bs obtained from planar and reprojected data were not statistically different (wb-H:B, 2.05 ± 0.64, ant-H:B, 1.97 ± 0.61, LAO-H:B, 2.06 ± 0.64, all p = ns). However, 3D-H:B was increased compared to planar H:Bs (3D-H:B, 4.06 ± 1.77, all p < 0.0001 vs. wb-H:B, ant-H:B, and LAO-H:B). Bland-Altman plots demonstrated that the difference between 3D and planar H:Bs increased with the mean value of myocardial uptake. 3D-H:B was best correlated to septal thickness (r = 0.45, p < 0.001). Finally, abnormal right ventricular uptake was associated with higher values of cardiac retention. CONCLUSION 3D semi-quantitative analysis of CZT SPECT optimized the assessment of 99mTc-labeled bone tracer myocardial uptake in patients with cardiac amyloidosis.
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Affiliation(s)
- Alain Manrique
- Department of Nuclear Medicine, Normandie Univ, UNICAEN, EA4650 SEILIRM, CHU de Caen, 14000, Caen, France. .,GIP Cyceron, Campus Jules Horowitz, Boulevard Henri Becquerel, BP 5229, 14074, Caen, France.
| | - David Dudoignon
- Department of Nuclear Medicine, Normandie Univ, UNICAEN, EA4650 SEILIRM, CHU de Caen, 14000, Caen, France
| | - Stéphanie Brun
- Department of Nuclear Medicine, Toulouse University Hospital, Toulouse, France.,Medical School, Toulouse III Paul Sabatier University, Toulouse, France
| | - Catherine N'Ganoa
- Department of Nuclear Medicine, Normandie Univ, UNICAEN, EA4650 SEILIRM, CHU de Caen, 14000, Caen, France
| | - Emmanuelle Cassol
- Department of Nuclear Medicine, Toulouse University Hospital, Toulouse, France.,Medical School, Toulouse III Paul Sabatier University, Toulouse, France
| | - Damien Legallois
- Department of Cardiology, Normandie Univ, UNICAEN, EA4650 SEILIRM, CHU de Caen, 14000, Caen, France
| | - Yoan Lavie-Badie
- Department of Cardiology, Rangueil University Hospital, Toulouse, France
| | - Denis Agostini
- Department of Nuclear Medicine, Normandie Univ, UNICAEN, EA4650 SEILIRM, CHU de Caen, 14000, Caen, France
| | - Olivier Lairez
- Department of Nuclear Medicine, Toulouse University Hospital, Toulouse, France.,Medical School, Toulouse III Paul Sabatier University, Toulouse, France
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Zhang X, Goel V, Robbie GJ. Pharmacokinetics of Patisiran, the First Approved RNA Interference Therapy in Patients With Hereditary Transthyretin-Mediated Amyloidosis. J Clin Pharmacol 2019; 60:573-585. [PMID: 31777097 PMCID: PMC7187331 DOI: 10.1002/jcph.1553] [Citation(s) in RCA: 91] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 10/16/2019] [Indexed: 12/12/2022]
Abstract
Hereditary transthyretin‐mediated (hATTR) amyloidosis is a rare, inherited, progressively debilitating, and often fatal disease caused by deposition of mutated transthyretin (TTR) protein. Patisiran is an RNA interference therapeutic comprising a novel small interfering ribonucleic acid (ALN‐18328) formulated with 2 novel lipid excipients, DLin‐MC3‐DMA and PEG2000‐C‐DMG, in a lipid nanoparticle targeted to inhibit hepatic TTR synthesis. Here we report the pharmacokinetics (PK) of ALN‐18328, DLin‐MC3‐DMA, and PEG2000‐C‐DMG from a phase 2 multiple‐ascending‐dose study and its open‐label extension (OLE) in patients with hATTR amyloidosis. Twenty‐nine patients received 2 intravenous infusions of patisiran of 0.01, 0.05, 0.15, or 0.3 mg/kg at 3‐ or 4‐week intervals; of these, 27 patients received 0.3 mg/kg once every 3 weeks over 24 months in the OLE study. Plasma PK profiles of ALN‐18328 and DLin‐MC3‐DMA exhibited 2 phases, the first characterized by a short distribution half‐life and the second by a minor peak and relatively long terminal elimination half‐life. PK exposures to 3 analytes increased proportionally across the dose range of 0.01 to 0.3 mg/kg. For ALN‐18328, mean terminal elimination half‐life was 3.2 days, mean total clearance was 3.0 mL/h/kg, and urinary excretion was negligible. All 3 analytes exhibited stable PK profiles with chronic dosing over 2 years. The 2‐ to 3‐fold plasma accumulation (AUCτ) of ALN‐18328 at steady state is attributable to the association of ALN‐18328 with the cationic lipid DLin‐MC3‐DMA. There was no appreciable accumulation of PEG2000‐C‐DMG.
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Affiliation(s)
| | - Varun Goel
- Alnylam Pharmaceuticals, Cambridge, Massachusetts, USA
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22
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González-Duarte A, Berk JL, Quan D, Mauermann ML, Schmidt HH, Polydefkis M, Waddington-Cruz M, Ueda M, Conceição IM, Kristen AV, Coelho T, Cauquil CA, Tard C, Merkel M, Aldinc E, Chen J, Sweetser MT, Wang JJ, Adams D. Analysis of autonomic outcomes in APOLLO, a phase III trial of the RNAi therapeutic patisiran in patients with hereditary transthyretin-mediated amyloidosis. J Neurol 2019; 267:703-712. [PMID: 31728713 PMCID: PMC7035216 DOI: 10.1007/s00415-019-09602-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 10/21/2019] [Accepted: 10/23/2019] [Indexed: 12/13/2022]
Abstract
Hereditary transthyretin-mediated (hATTR) amyloidosis is a progressive, debilitating disease often resulting in early-onset, life-impacting autonomic dysfunction. The effect of the RNAi therapeutic, patisiran, on autonomic neuropathy manifestations in patients with hATTR amyloidosis with polyneuropathy in the phase III APOLLO study is reported. Patients received patisiran 0.3 mg/kg intravenously (n = 148) or placebo (n = 77) once every 3 weeks for 18 months. Patisiran halted or reversed polyneuropathy and improved quality of life from baseline in the majority of patients. At baseline, patients in APOLLO had notable autonomic impairment, as demonstrated by the Composite Autonomic Symptom Score-31 (COMPASS-31) questionnaire and Norfolk Quality of Life-Diabetic Neuropathy (Norfolk QOL-DN) questionnaire autonomic neuropathy domain. At 18 months, patisiran improved autonomic neuropathy symptoms compared with placebo [COMPASS-31, least squares (LS) mean difference, − 7.5; 95% CI: − 11.9, − 3.2; Norfolk QOL-DN autonomic neuropathy domain, LS mean difference, − 1.1; − 1.8, − 0.5], nutritional status (modified body mass index, LS mean difference, 115.7; − 82.4, 149.0), and vasomotor function (postural blood pressure, LS mean difference, − 0.3; − 0.5, − 0.1). Patisiran treatment also led to improvement from baseline at 18 months for COMPASS-31 (LS mean change from baseline, − 5.3; 95% CI: − 7.9, − 2.7) and individual domains, orthostatic intolerance (− 4.6; − 6.3, − 2.9) and gastrointestinal symptoms (− 0.8; − 1.5, − 0.2). Rapid worsening of all study measures was observed with placebo, while patisiran treatment resulted in stable or improved scores compared with baseline. Patisiran demonstrates benefit across a range of burdensome autonomic neuropathy manifestations that deteriorate rapidly without early and continued treatment.
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Affiliation(s)
- Alejandra González-Duarte
- Instituto Nacional de Ciencias Médicas Y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Sección XVI, Tlalpan, CdMx, CP 01400, México City, Mexico.
| | | | | | | | | | | | | | | | - Isabel M Conceição
- CHULN, Hospital de Santa Maria and Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | | | - Teresa Coelho
- Hospital de Santo António, Centro Hospitalar Universitário Do Porto, Porto, Portugal
| | - Cécile A Cauquil
- AP-HP Université Paris Saclay, CHU Bicêtre, Le Kremlin Bicêtre, France
| | | | | | | | | | | | | | - David Adams
- AP-HP, Université Paris Saclay, CHU Bicêtre, Université Paris-Sud, INSERM 1195, Paris, France
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23
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Cannie DE, Akhtar MM, Elliott P. Hidden in Heart Failure. Eur Cardiol 2019; 14:89-96. [PMID: 31360229 PMCID: PMC6659034 DOI: 10.15420/ecr.2019.19.2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 06/06/2019] [Indexed: 02/06/2023] Open
Abstract
Current diagnostic strategies fail to illuminate the presence of rare disease in the heart failure population. One-third of heart failure patients are categorised as suffering an idiopathic dilated cardiomyopathy, while others are labelled only as heart failure with preserved ejection fraction. Those affected frequently suffer from delays in diagnosis, which can have a significant impact on quality of life and prognosis. Traditional rhetoric argues that delineation of this patient population is superfluous to treatment, as elucidation of aetiology will not lead to a deviation from standard management protocols. This article emphasises the importance of identifying genetic, inflammatory and infiltrative causes of heart failure to enable patients to access tailored management strategies.
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Affiliation(s)
- Douglas Ewan Cannie
- University College London Institute for Cardiovascular Science London, UK.,Barts Heart Centre, Barts Health NHS Trust London, UK
| | - Mohammed Majid Akhtar
- University College London Institute for Cardiovascular Science London, UK.,Barts Heart Centre, Barts Health NHS Trust London, UK
| | - Perry Elliott
- University College London Institute for Cardiovascular Science London, UK.,Barts Heart Centre, Barts Health NHS Trust London, UK
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24
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Gilstrap LG, Dominici F, Wang Y, El-Sady MS, Singh A, Di Carli MF, Falk RH, Dorbala S. Epidemiology of Cardiac Amyloidosis-Associated Heart Failure Hospitalizations Among Fee-for-Service Medicare Beneficiaries in the United States. Circ Heart Fail 2019; 12:e005407. [PMID: 31170802 PMCID: PMC6557425 DOI: 10.1161/circheartfailure.118.005407] [Citation(s) in RCA: 111] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background Cardiac amyloidosis is a substantially underdiagnosed disease, and contemporary estimates of the epidemiology of amyloidosis are lacking. This study aims to determine the incidence and prevalence of cardiac amyloidosis among Medicare beneficiaries from 2000 to 2012. Methods and Results Medicare beneficiaries were counted in the prevalence cohort in each year they had (1) ≥1 principal or secondary International Classification of Diseases, Ninth Revision code for amyloidosis and (2) ≥1 principal or secondary International Classification of Diseases, Ninth Revision code for heart failure or cardiomyopathy within 2 years after the systemic amyloidosis code. A beneficiary was counted in the incidence cohort only during the first year in which they met criteria. Primary outcomes included the prevalence and incidence of hospitalizations for cardiac amyloidosis. There were 4746 incident cases of cardiac amyloidosis in 2012 and 15 737 prevalent cases in 2012. There was also a significant increase in the prevalence rate (8 to 17 per 100 000 person-years) and incidence rate (18 to 55 per 100 000 person-years) from 2000 to 2012, most notable after 2006. Incidence and prevalence increased substantially more among men, the elderly, and in blacks. Conclusions The incidence and prevalence rates of cardiac amyloidosis are higher than previously thought. The incidence and prevalence rates of cardiac amyloidosis among hospitalized patients have increased since 2000, particularly among specific patient subgroups and after 2006, suggesting improved amyloidosis awareness and higher diagnostic rates with noninvasive imaging. In light of these trends, cardiac amyloidosis should be considered during the initial work up of patients ≥65 years old hospitalized with heart failure.
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Affiliation(s)
- Lauren G. Gilstrap
- Dartmouth Hitchcock Medical Center, Heart and Vascular Center, Lebanon, NH
- The Dartmouth Institute, Geisel Medical School at Dartmouth, Hanover, NH
| | - Francesca Dominici
- T.H. Chan Harvard School of Public Health, Department of Biostatistics, Boston, MA
| | - Yun Wang
- T.H. Chan Harvard School of Public Health, Department of Biostatistics, Boston, MA
| | - M. Samir El-Sady
- Brigham and Women’s Hospital, Cardiac Amyloidosis Program, Boston, MA
| | - Amitoj Singh
- Brigham and Women’s Hospital, Division of Nuclear Medicine and Department of Radiology, Boston, MA
| | - Marcelo F. Di Carli
- Brigham and Women’s Hospital, Division of Cardiovascular Medicine, Boston, MA
- Brigham and Women’s Hospital, Division of Nuclear Medicine and Department of Radiology, Boston, MA
| | - Rodney H. Falk
- Brigham and Women’s Hospital, Division of Cardiovascular Medicine, Boston, MA
- Brigham and Women’s Hospital, Cardiac Amyloidosis Program, Boston, MA
| | - Sharmila Dorbala
- Brigham and Women’s Hospital, Division of Cardiovascular Medicine, Boston, MA
- Brigham and Women’s Hospital, Cardiac Amyloidosis Program, Boston, MA
- Brigham and Women’s Hospital, Division of Nuclear Medicine and Department of Radiology, Boston, MA
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25
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Hanson JLS, Arvanitis M, Koch CM, Berk JL, Ruberg FL, Prokaeva T, Connors LH. Use of Serum Transthyretin as a Prognostic Indicator and Predictor of Outcome in Cardiac Amyloid Disease Associated With Wild-Type Transthyretin. Circ Heart Fail 2019; 11:e004000. [PMID: 29449366 DOI: 10.1161/circheartfailure.117.004000] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 12/11/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Wild-type transthyretin amyloidosis (ATTRwt), an underappreciated cause of heart failure in older adults, is challenging to diagnose and monitor in the absence of validated, disease-specific biomarkers. We examined the prognostic use and survival association of serum TTR (transthyretin) concentration in ATTRwt. METHODS AND RESULTS Patients with biopsy-proven ATTRwt were retrospectively identified. Serum TTR, cardiac biomarkers, and echocardiographic parameters were assessed at baseline and follow-up evaluations. Statistical analyses included Kaplan-Meier method, Cox proportional hazard survival models, and receiver-operating characteristic curve analysis. Median serum TTR concentration at presentation was 23 mg/dL (n=116). Multivariate predictors of shorter overall survival were decreased TTR, left ventricular ejection fraction and elevated cTn-I (cardiac troponin I); an inclusive model demonstrated superior accuracy in 4-year survival prediction by receiver-operating characteristic curve analysis (area under the curve, 0.77). TTR values lower than the normal limit, <18 mg/dL, were associated with shorter survival (2.8 versus 4.1 years; P=0.03). Further, TTR values at 1- and 2-year follow-ups were significantly lower (P<0.001) in untreated patients (n=23) compared with those treated with TTR stabilizer, diflunisal (n=12), after baseline evaluation. During 2-year follow-up, unchanged TTR corresponded to increased cTn-I (P=0.006) in untreated patients; conversely, the diflunisal-treated group showed increased TTR (P=0.001) and stabilized cTn-I and left ventricular ejection fraction at 1 year. CONCLUSIONS In this series of biopsy-proven ATTRwt, lower baseline serum TTR concentration was associated with shorter survival as an independent predictor of outcome. Longitudinal analysis demonstrated that decreasing TTR corresponded to worsening cardiac function. These data suggest that TTR may be a useful prognostic marker and predictor of outcome in ATTRwt.
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Affiliation(s)
- Jacquelyn L S Hanson
- From the Amyloidosis Center (J.L.S.H., C.M.K., J.L.B., F.L.R., T.P., L.H.C.), Department of Pathology and Laboratory Medicine (J.L.S.H., C.M.K., L.H.C.), Department of Medicine (M.A., J.L.B., F.L.R.), and Section of Cardiovascular Medicine, Department of Medicine (F.L.R.), Boston University School of Medicine, MA. The current affiliation for C.M.H. is the Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University, Chicago, IL
| | - Marios Arvanitis
- From the Amyloidosis Center (J.L.S.H., C.M.K., J.L.B., F.L.R., T.P., L.H.C.), Department of Pathology and Laboratory Medicine (J.L.S.H., C.M.K., L.H.C.), Department of Medicine (M.A., J.L.B., F.L.R.), and Section of Cardiovascular Medicine, Department of Medicine (F.L.R.), Boston University School of Medicine, MA. The current affiliation for C.M.H. is the Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University, Chicago, IL
| | - Clarissa M Koch
- From the Amyloidosis Center (J.L.S.H., C.M.K., J.L.B., F.L.R., T.P., L.H.C.), Department of Pathology and Laboratory Medicine (J.L.S.H., C.M.K., L.H.C.), Department of Medicine (M.A., J.L.B., F.L.R.), and Section of Cardiovascular Medicine, Department of Medicine (F.L.R.), Boston University School of Medicine, MA. The current affiliation for C.M.H. is the Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University, Chicago, IL
| | - John L Berk
- From the Amyloidosis Center (J.L.S.H., C.M.K., J.L.B., F.L.R., T.P., L.H.C.), Department of Pathology and Laboratory Medicine (J.L.S.H., C.M.K., L.H.C.), Department of Medicine (M.A., J.L.B., F.L.R.), and Section of Cardiovascular Medicine, Department of Medicine (F.L.R.), Boston University School of Medicine, MA. The current affiliation for C.M.H. is the Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University, Chicago, IL
| | - Frederick L Ruberg
- From the Amyloidosis Center (J.L.S.H., C.M.K., J.L.B., F.L.R., T.P., L.H.C.), Department of Pathology and Laboratory Medicine (J.L.S.H., C.M.K., L.H.C.), Department of Medicine (M.A., J.L.B., F.L.R.), and Section of Cardiovascular Medicine, Department of Medicine (F.L.R.), Boston University School of Medicine, MA. The current affiliation for C.M.H. is the Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University, Chicago, IL
| | - Tatiana Prokaeva
- From the Amyloidosis Center (J.L.S.H., C.M.K., J.L.B., F.L.R., T.P., L.H.C.), Department of Pathology and Laboratory Medicine (J.L.S.H., C.M.K., L.H.C.), Department of Medicine (M.A., J.L.B., F.L.R.), and Section of Cardiovascular Medicine, Department of Medicine (F.L.R.), Boston University School of Medicine, MA. The current affiliation for C.M.H. is the Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University, Chicago, IL
| | - Lawreen H Connors
- From the Amyloidosis Center (J.L.S.H., C.M.K., J.L.B., F.L.R., T.P., L.H.C.), Department of Pathology and Laboratory Medicine (J.L.S.H., C.M.K., L.H.C.), Department of Medicine (M.A., J.L.B., F.L.R.), and Section of Cardiovascular Medicine, Department of Medicine (F.L.R.), Boston University School of Medicine, MA. The current affiliation for C.M.H. is the Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University, Chicago, IL.
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26
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Newton VL, Riba-Garcia I, Griffiths CEM, Rawlings AV, Voegeli R, Unwin RD, Sherratt MJ, Watson REB. Mass spectrometry-based proteomics reveals the distinct nature of the skin proteomes of photoaged compared to intrinsically aged skin. Int J Cosmet Sci 2019; 41:118-131. [PMID: 30661253 DOI: 10.1111/ics.12513] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 12/15/2018] [Indexed: 12/15/2022]
Abstract
OBJECTIVE With increasing age, skin is subject to alterations in its organization, which impact on its function as well as having clinical consequences. Proteomics is a useful tool for non-targeted, semi-quantitative simultaneous investigation of high numbers of proteins. In the current study, we utilize proteomics to characterize and contrast age-associated differences in photoexposed and photoprotected skin, with a focus on the epidermis, dermal-epidermal junction and papillary dermis. METHODS Skin biopsies from buttock (photoprotected) and forearm (photoexposed) of healthy volunteers (aged 18-30 or ≥65 years) were transversely sectioned from the stratum corneum to a depth of 250 μm. Following SDS-PAGE, each sample lane was segmented prior to analysis by liquid chromatography-mass spectrometry/mass spectrometry. Pathway analysis was carried out using Ingenuity IPA. RESULTS Comparison of skin proteomes at buttock and forearm sites revealed differences in relative protein abundance. Ageing in skin on the photoexposed forearm resulted in 80% of the altered proteins being increased with age, in contrast to the photoprotected buttock where 74% of altered proteins with age were reduced. Functionally, age-altered proteins in the photoexposed forearm were associated with conferring structure, energy and metabolism. In the photoprotected buttock, proteins associated with gene expression, free-radical scavenging, protein synthesis and protein degradation were most frequently altered. CONCLUSION This study highlights the necessity of not considering photoageing as an accelerated intrinsic ageing, but as a distinct physiological process.
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Affiliation(s)
- V L Newton
- Centre for Dermatology Research, Division of Musculoskeletal & Dermatological Sciences, School of Biological Sciences, Manchester Academic Health Science Centre, University of Manchester, and Salford Royal NHS Foundation Trust, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - I Riba-Garcia
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Core Technology facility (3rd Floor), 46 Grafton Street, Manchester, M13 9NT, UK
| | - C E M Griffiths
- Centre for Dermatology Research, Division of Musculoskeletal & Dermatological Sciences, School of Biological Sciences, Manchester Academic Health Science Centre, University of Manchester, and Salford Royal NHS Foundation Trust, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | | | - R Voegeli
- DSM Nutritional Products Ltd, Kaiseraugst, Switzerland
| | - R D Unwin
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Core Technology facility (3rd Floor), 46 Grafton Street, Manchester, M13 9NT, UK
| | - M J Sherratt
- Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - R E B Watson
- Centre for Dermatology Research, Division of Musculoskeletal & Dermatological Sciences, School of Biological Sciences, Manchester Academic Health Science Centre, University of Manchester, and Salford Royal NHS Foundation Trust, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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27
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Pelletier-Galarneau M, Abikhzer G, Giraldeau G, Harel F. Molecular Imaging of Cardiac Amyloidosis. Curr Cardiol Rep 2019; 21:12. [DOI: 10.1007/s11886-019-1097-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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28
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Morgenstern R, Yeh R, Castano A, Maurer MS, Bokhari S. 18Fluorine sodium fluoride positron emission tomography, a potential biomarker of transthyretin cardiac amyloidosis. J Nucl Cardiol 2018; 25:1559-1567. [PMID: 28176254 DOI: 10.1007/s12350-017-0799-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 01/07/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND Non-invasive imaging to diagnose and quantify amyloid load, progression, and response to treatment are central for the care of patients with cardiac amyloidosis. 18Fluorine-labeled sodium fluoride (18F-NaF) is a widely available radioisotope and PET imaging allows for absolute quantification of tracer uptake. METHODS Patients with biopsy-proven transthyretin (ATTR-CA) and light-chain cardiac amyloidosis (AL) (3 ATTRwt, 2 ATTRV122I, 2 AL) and controls (n = 5), underwent 18F-NaF PET imaging. Scans were assessed visually for radiotracer uptake and analyzed using standard uptake values in the entire myocardium (SUVm) and in a 17-segment cardiac model. Wilcoxon rank-sum tests were used for statistical analyses. RESULTS Qualitative 18F-NaF uptake was absent in controls and AL patients. There was qualitative 18F-NaF uptake in ATTR-CA patients, with slightly increased uptake in wild-type patients. SUVm for controls and AL patients overlapped at 0.8(0.4-0.9) and 0.95(0.9-1.0), respectively (P = 0.434). At 1.5(1.4-1.7), SUVm for ATTR-CA patients was ≈1.5*SUVm of controls (P = 0.012) and AL patients (P = 0.078). While there was diffuse 18F-NaF myocardial in ATTR-CA patients, the degree of uptake varied according to cardiac segment. CONCLUSION 18F-NaF PET effectively imaged and differentiated ATTR-CA patients. Semi-automatic software enabled quantification of radiotracer uptake and regional distribution. 18F-NaF PET may be useful for disease monitoring and localizing amyloid deposition in ATTR-CA patients.
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Affiliation(s)
- Rachelle Morgenstern
- Nuclear Cardiology Lab, Columbia University College of Physicians and Surgeons, 622 West 168th street, PH10-203E, New York, NY, 10032, USA.
| | - Randy Yeh
- Department of Radiology, Columbia University College of Physicians and Surgeons, Box 28, New York, NY, 10032, USA
| | - Adam Castano
- Nuclear Cardiology Lab, Columbia University College of Physicians and Surgeons, 622 West 168th street, PH10-203E, New York, NY, 10032, USA
| | - Mathew S Maurer
- Center for Advanced Center for Heart Failure, Columbia University College of Physicians and Surgeons, 622 West 168th street, PH12-1391, New York, NY, 10032, USA
| | - Sabahat Bokhari
- Nuclear Cardiology Lab, Columbia University College of Physicians and Surgeons, 622 West 168th street, PH10-203E, New York, NY, 10032, USA
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29
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Ruiz-Guerrero L, Barriales-Villa R. Storage diseases with hypertrophic cardiomyopathy phenotype. Glob Cardiol Sci Pract 2018; 2018:28. [PMID: 30393640 PMCID: PMC6209457 DOI: 10.21542/gcsp.2018.28] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Never judge a book by its cover, nor assume hypertrophic cardiomyopathy (HCM) as sarcomeric, as appearances can deceive. HCM phenocopies account for a 5–10% of the cases, mainly represented by storage diseases, flagged by the increasing prevalence of senile cardiac amyloid in developing countries. Multisystemic and heterogeneous presentation of these entities is a challenge for clinicians, and time delay in diagnosis is a major concern. Promising drugs and gene-specific tailored therapies are under development, therefore, more than ever, appropriate understanding of these conditions is mandatory for adequate early treatment and counselling. In this review, storage disorders will be classified as extracellular and intracellular deposit storage diseases, focusing our attention on the most prevalent conditions from the cardiologist’s perspective.
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Affiliation(s)
- Luis Ruiz-Guerrero
- Cardiology Service, Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Marqués de Valdecilla (IDIVAL), Santander, Spain
| | - Roberto Barriales-Villa
- Inherited Cardiovascular Diseases Unit, Cardiology Service, Complexo Hospitalario Universitario de A Coruña, Instituto de Investigación Biomédica de A Coruña (INIBIC), Servizo Galego de Saúde (SERGAS), Universidade da Coruña, A Coruña, Spain.,Centro de Investigación Biomédica en Red. Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
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30
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Echocardiographic and pathologic findings of wild-type transthyretin senile systemic amyloidosis developed in early 50s. J Echocardiogr 2018; 16:187-188. [PMID: 29700757 DOI: 10.1007/s12574-018-0380-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 04/02/2018] [Accepted: 04/12/2018] [Indexed: 10/17/2022]
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31
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Bokhari S, Morgenstern R, Weinberg R, Kinkhabwala M, Panagiotou D, Castano A, DeLuca A, Kontak A, Jin Z, Maurer MS. Standardization of 99mTechnetium pyrophosphate imaging methodology to diagnose TTR cardiac amyloidosis. J Nucl Cardiol 2018; 25:181-190. [PMID: 27580616 DOI: 10.1007/s12350-016-0610-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 07/01/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Technetium pyrophosphate (99mTc-PYP) imaging to diagnose transthyretin cardiac amyloidosis (ATTR-CA) has been increasingly utilized. The objective of this study is to provide a standardized 99mTc-PYP imaging protocol to diagnose ATTR-CA. METHODS 104 scans from 45 subjects with biopsy-proven ATTR-CA or light-chain cardiac amyloidosis (AL) were assessed. Multiple scans were obtained using different counts (750 vs 2000 K), times to acquisition (1 vs 2 to 4 hours), processing matrix (256 vs 128), and 99mTc-PYP dose. Image quality and extracardiac activity was assessed. Quantitative methods using heart-to-contralateral ratios (H/CL) and a visual semiquantitative scale were used to diagnose ATTR-CA.19 The correlation between H/CL ratios and reproducibility of semiquantitative visual scores, acquired using various imaging parameters, were evaluated. RESULTS All imaging parameters had good to excellent image quality. 750 vs 2000 K counts, 1 hour acquisition and 256 matrix, had lower extracardiac activity (P = .00018). 10 mCi of 99mTc-PYP v. higher doses showed excellent image quality and less extracardiac activity (P = .0015). Correlation of H/CL ratios was strong (r ≥ 0.92) and reproducibility of semiquantitative visual scores was high (Kappa = 95%). CONCLUSION An imaging protocol using 750 K counts, 10 mCi of 99mTc-PYP, and a 256 matrix was chosen as the standardized imaging protocol since it provided the shortest overall study time (1 vs 2 to 4 hours) and lowest radiation exposure (3 vs 8 to 10 mSv).
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Affiliation(s)
- Sabahat Bokhari
- Department of Medicine and Division of Cardiology, Columbia University Medical Center, 622 West 168th street, PH10-203E, New York, NY, 10032, USA.
| | - Rachelle Morgenstern
- Department of Medicine and Division of Cardiology, Columbia University Medical Center, 622 West 168th street, PH10-203E, New York, NY, 10032, USA
| | - Richard Weinberg
- Department of Medicine and Division of Cardiology, Columbia University Medical Center, 622 West 168th street, PH10-203E, New York, NY, 10032, USA
| | - Mona Kinkhabwala
- Department of Medicine and Division of Cardiology, Columbia University Medical Center, 622 West 168th street, PH10-203E, New York, NY, 10032, USA
| | - Demetrios Panagiotou
- Department of Medicine and Division of Cardiology, Columbia University Medical Center, 622 West 168th street, PH10-203E, New York, NY, 10032, USA
| | - Adam Castano
- Department of Medicine and Division of Cardiology, Columbia University Medical Center, 622 West 168th street, PH10-203E, New York, NY, 10032, USA
| | - Albert DeLuca
- Department of Medicine and Division of Cardiology, Columbia University Medical Center, 622 West 168th street, PH10-203E, New York, NY, 10032, USA
| | - Andrew Kontak
- Department of Medicine and Division of Cardiology, Columbia University Medical Center, 622 West 168th street, PH10-203E, New York, NY, 10032, USA
| | - Zhezhen Jin
- Department of Biostatistics, Columbia University Medical Center, New York, USA
| | - Mathew S Maurer
- Department of Medicine and Division of Cardiology, Columbia University Medical Center, 622 West 168th street, PH10-203E, New York, NY, 10032, USA
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32
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Sekijima Y, Ueda M, Koike H, Misawa S, Ishii T, Ando Y. Diagnosis and management of transthyretin familial amyloid polyneuropathy in Japan: red-flag symptom clusters and treatment algorithm. Orphanet J Rare Dis 2018; 13:6. [PMID: 29343286 PMCID: PMC5773042 DOI: 10.1186/s13023-017-0726-x] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 11/23/2017] [Indexed: 01/05/2023] Open
Abstract
Hereditary ATTR (ATTRm) amyloidosis (also called transthyretin-type familial amyloid polyneuropathy [ATTR-FAP]) is an autosomal-dominant, adult-onset, rare systemic disorder predominantly characterized by irreversible, progressive, and persistent peripheral nerve damage. TTR gene mutations (e.g. replacement of valine with methionine at position 30 [Val30Met (p.Val50Met)]) lead to destabilization and dissociation of TTR tetramers into variant TTR monomers, which form amyloid fibrils that deposit in peripheral nerves and various organs, giving rise to peripheral and autonomic neuropathy and several non-disease specific symptoms. Phenotypic and genetic variability and non–disease-specific symptoms often delay diagnosis and lead to misdiagnosis. Red-flag symptom clusters simplify diagnosis globally. However, in Japan, types of TTR variants, age of onset, penetrance, and clinical symptoms of Val30Met are more varied than in other countries. Hence, development of a Japan-specific red-flag symptom cluster is warranted. Presence of progressive peripheral sensory-motor polyneuropathy and ≥1 red-flag sign/symptom (e.g. family history, autonomic dysfunction, cardiac involvement, carpal tunnel syndrome, gastrointestinal disturbances, unexplained weight loss, and immunotherapy resistance) suggests ATTR-FAP. Outside of Japan, pharmacotherapeutic options are first-line therapy. However, because of positive outcomes (better life expectancy and higher survival rates) with living donor transplant in Japan, liver transplantation remains first-line treatment, necessitating a Japan-specific treatment algorithm. Herein, we present a consolidated review of the ATTR-FAP Val30Met landscape in Japan and summarize findings from a medical advisory board meeting held in Tokyo on 18th August 2016, at which a Japan-specific ATTR-FAP red-flag symptom cluster and treatment algorithm was developed. Beside liver transplantation, a TTR-stabilizing agent (e.g. tafamidis) is a treatment option. Early diagnosis and timely treatment using the Japan-specific red-flag symptom cluster and treatment algorithm might help guide clinicians regarding apt and judicious use of available treatment modalities.
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Affiliation(s)
- Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Mitsuharu Ueda
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto-shi, Kumamoto, 860-8556, Japan
| | - Haruki Koike
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Sonoko Misawa
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | | | - Yukio Ando
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto-shi, Kumamoto, 860-8556, Japan.
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Maurer MS, Elliott P, Merlini G, Shah SJ, Cruz MW, Flynn A, Gundapaneni B, Hahn C, Riley S, Schwartz J, Sultan MB, Rapezzi C. Design and Rationale of the Phase 3 ATTR-ACT Clinical Trial (Tafamidis in Transthyretin Cardiomyopathy Clinical Trial). Circ Heart Fail 2017; 10:CIRCHEARTFAILURE.116.003815. [PMID: 28611125 DOI: 10.1161/circheartfailure.116.003815] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 05/04/2017] [Indexed: 12/17/2022]
Abstract
Transthyretin amyloidosis is a rare, life-threatening disease resulting from aggregation and deposition of transthyretin amyloid fibrils in various tissues. There are 2 predominate phenotypic presentations of the disease: transthyretin familial amyloid polyneuropathy, which primarily affects the peripheral nerves, and transthyretin cardiomyopathy (TTR-CM), which primarily affects the heart. However, there is a wide overlap with symptoms at presentation and disease course being highly variable and influenced by the underlying transthyretin mutation, age of the affected individual, sex, and geographic location. Treatment of transthyretin amyloidosis is typically focused on symptom management. Although tafamidis has been shown to delay neurologic progression of transthyretin familial amyloid polyneuropathy, there are no approved pharmacologic therapies shown to improve survival in TTR-CM. The natural history of TTR-CM is poorly characterized, which presents difficulties for the design of large-scale trials for new treatments. This review provides a brief overview of TTR-CM and the challenges of identifying clinically meaningful end points and study parameters to determine the efficacy of treatments for rare diseases. The design and rationale behind the ongoing phase 3 ATTR-ACT study (Tafamidis in Transthyretin Cardiomyopathy Clinical Trial), an international, multicenter, double-blind, placebo-controlled, randomized clinical trial, is also outlined. The ATTR-ACT study will provide important insight into the efficacy and safety of tafamidis for the treatment of TTR-CM. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01994889.
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Affiliation(s)
- Mathew S Maurer
- From the Center for Advanced Cardiac Care, Columbia University College of Physicians and Surgeons, NY (M.S.M); Cardiovascular Medicine, University College London, United Kingdom (P.E.); IRCCS Policlinico San Matteo, University of Pavia, Italy (G.M.); Division of Cardiology, Northwestern University, Chicago, IL (S.J.S.); National Amyloidosis Referral Center, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello, Federal University of Rio de Janeiro, Brazil (M.W.C.); Pfizer, Inc, Collegeville, PA (A.F., C.H.); inVentiv Health, Burlington, MA (B.G.); Pfizer, Inc, Groton, CT (S.R., J.S.); Pfizer, Inc, NY (M.B.S.); and Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy (C.R.).
| | - Perry Elliott
- From the Center for Advanced Cardiac Care, Columbia University College of Physicians and Surgeons, NY (M.S.M); Cardiovascular Medicine, University College London, United Kingdom (P.E.); IRCCS Policlinico San Matteo, University of Pavia, Italy (G.M.); Division of Cardiology, Northwestern University, Chicago, IL (S.J.S.); National Amyloidosis Referral Center, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello, Federal University of Rio de Janeiro, Brazil (M.W.C.); Pfizer, Inc, Collegeville, PA (A.F., C.H.); inVentiv Health, Burlington, MA (B.G.); Pfizer, Inc, Groton, CT (S.R., J.S.); Pfizer, Inc, NY (M.B.S.); and Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy (C.R.)
| | - Giampaolo Merlini
- From the Center for Advanced Cardiac Care, Columbia University College of Physicians and Surgeons, NY (M.S.M); Cardiovascular Medicine, University College London, United Kingdom (P.E.); IRCCS Policlinico San Matteo, University of Pavia, Italy (G.M.); Division of Cardiology, Northwestern University, Chicago, IL (S.J.S.); National Amyloidosis Referral Center, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello, Federal University of Rio de Janeiro, Brazil (M.W.C.); Pfizer, Inc, Collegeville, PA (A.F., C.H.); inVentiv Health, Burlington, MA (B.G.); Pfizer, Inc, Groton, CT (S.R., J.S.); Pfizer, Inc, NY (M.B.S.); and Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy (C.R.)
| | - Sanjiv J Shah
- From the Center for Advanced Cardiac Care, Columbia University College of Physicians and Surgeons, NY (M.S.M); Cardiovascular Medicine, University College London, United Kingdom (P.E.); IRCCS Policlinico San Matteo, University of Pavia, Italy (G.M.); Division of Cardiology, Northwestern University, Chicago, IL (S.J.S.); National Amyloidosis Referral Center, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello, Federal University of Rio de Janeiro, Brazil (M.W.C.); Pfizer, Inc, Collegeville, PA (A.F., C.H.); inVentiv Health, Burlington, MA (B.G.); Pfizer, Inc, Groton, CT (S.R., J.S.); Pfizer, Inc, NY (M.B.S.); and Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy (C.R.)
| | - Márcia Waddington Cruz
- From the Center for Advanced Cardiac Care, Columbia University College of Physicians and Surgeons, NY (M.S.M); Cardiovascular Medicine, University College London, United Kingdom (P.E.); IRCCS Policlinico San Matteo, University of Pavia, Italy (G.M.); Division of Cardiology, Northwestern University, Chicago, IL (S.J.S.); National Amyloidosis Referral Center, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello, Federal University of Rio de Janeiro, Brazil (M.W.C.); Pfizer, Inc, Collegeville, PA (A.F., C.H.); inVentiv Health, Burlington, MA (B.G.); Pfizer, Inc, Groton, CT (S.R., J.S.); Pfizer, Inc, NY (M.B.S.); and Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy (C.R.)
| | - Alison Flynn
- From the Center for Advanced Cardiac Care, Columbia University College of Physicians and Surgeons, NY (M.S.M); Cardiovascular Medicine, University College London, United Kingdom (P.E.); IRCCS Policlinico San Matteo, University of Pavia, Italy (G.M.); Division of Cardiology, Northwestern University, Chicago, IL (S.J.S.); National Amyloidosis Referral Center, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello, Federal University of Rio de Janeiro, Brazil (M.W.C.); Pfizer, Inc, Collegeville, PA (A.F., C.H.); inVentiv Health, Burlington, MA (B.G.); Pfizer, Inc, Groton, CT (S.R., J.S.); Pfizer, Inc, NY (M.B.S.); and Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy (C.R.)
| | - Balarama Gundapaneni
- From the Center for Advanced Cardiac Care, Columbia University College of Physicians and Surgeons, NY (M.S.M); Cardiovascular Medicine, University College London, United Kingdom (P.E.); IRCCS Policlinico San Matteo, University of Pavia, Italy (G.M.); Division of Cardiology, Northwestern University, Chicago, IL (S.J.S.); National Amyloidosis Referral Center, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello, Federal University of Rio de Janeiro, Brazil (M.W.C.); Pfizer, Inc, Collegeville, PA (A.F., C.H.); inVentiv Health, Burlington, MA (B.G.); Pfizer, Inc, Groton, CT (S.R., J.S.); Pfizer, Inc, NY (M.B.S.); and Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy (C.R.)
| | - Carolyn Hahn
- From the Center for Advanced Cardiac Care, Columbia University College of Physicians and Surgeons, NY (M.S.M); Cardiovascular Medicine, University College London, United Kingdom (P.E.); IRCCS Policlinico San Matteo, University of Pavia, Italy (G.M.); Division of Cardiology, Northwestern University, Chicago, IL (S.J.S.); National Amyloidosis Referral Center, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello, Federal University of Rio de Janeiro, Brazil (M.W.C.); Pfizer, Inc, Collegeville, PA (A.F., C.H.); inVentiv Health, Burlington, MA (B.G.); Pfizer, Inc, Groton, CT (S.R., J.S.); Pfizer, Inc, NY (M.B.S.); and Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy (C.R.)
| | - Steven Riley
- From the Center for Advanced Cardiac Care, Columbia University College of Physicians and Surgeons, NY (M.S.M); Cardiovascular Medicine, University College London, United Kingdom (P.E.); IRCCS Policlinico San Matteo, University of Pavia, Italy (G.M.); Division of Cardiology, Northwestern University, Chicago, IL (S.J.S.); National Amyloidosis Referral Center, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello, Federal University of Rio de Janeiro, Brazil (M.W.C.); Pfizer, Inc, Collegeville, PA (A.F., C.H.); inVentiv Health, Burlington, MA (B.G.); Pfizer, Inc, Groton, CT (S.R., J.S.); Pfizer, Inc, NY (M.B.S.); and Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy (C.R.)
| | - Jeffrey Schwartz
- From the Center for Advanced Cardiac Care, Columbia University College of Physicians and Surgeons, NY (M.S.M); Cardiovascular Medicine, University College London, United Kingdom (P.E.); IRCCS Policlinico San Matteo, University of Pavia, Italy (G.M.); Division of Cardiology, Northwestern University, Chicago, IL (S.J.S.); National Amyloidosis Referral Center, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello, Federal University of Rio de Janeiro, Brazil (M.W.C.); Pfizer, Inc, Collegeville, PA (A.F., C.H.); inVentiv Health, Burlington, MA (B.G.); Pfizer, Inc, Groton, CT (S.R., J.S.); Pfizer, Inc, NY (M.B.S.); and Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy (C.R.)
| | - Marla B Sultan
- From the Center for Advanced Cardiac Care, Columbia University College of Physicians and Surgeons, NY (M.S.M); Cardiovascular Medicine, University College London, United Kingdom (P.E.); IRCCS Policlinico San Matteo, University of Pavia, Italy (G.M.); Division of Cardiology, Northwestern University, Chicago, IL (S.J.S.); National Amyloidosis Referral Center, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello, Federal University of Rio de Janeiro, Brazil (M.W.C.); Pfizer, Inc, Collegeville, PA (A.F., C.H.); inVentiv Health, Burlington, MA (B.G.); Pfizer, Inc, Groton, CT (S.R., J.S.); Pfizer, Inc, NY (M.B.S.); and Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy (C.R.)
| | - Claudio Rapezzi
- From the Center for Advanced Cardiac Care, Columbia University College of Physicians and Surgeons, NY (M.S.M); Cardiovascular Medicine, University College London, United Kingdom (P.E.); IRCCS Policlinico San Matteo, University of Pavia, Italy (G.M.); Division of Cardiology, Northwestern University, Chicago, IL (S.J.S.); National Amyloidosis Referral Center, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello, Federal University of Rio de Janeiro, Brazil (M.W.C.); Pfizer, Inc, Collegeville, PA (A.F., C.H.); inVentiv Health, Burlington, MA (B.G.); Pfizer, Inc, Groton, CT (S.R., J.S.); Pfizer, Inc, NY (M.B.S.); and Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy (C.R.)
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Semi-quantitative models for identifying potent and selective transthyretin amyloidogenesis inhibitors. Bioorg Med Chem Lett 2017. [PMID: 28625364 DOI: 10.1016/j.bmcl.2017.05.080] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Rate-limiting dissociation of the tetrameric protein transthyretin (TTR), followed by monomer misfolding and misassembly, appears to cause degenerative diseases in humans known as the transthyretin amyloidoses, based on human genetic, biochemical and pharmacologic evidence. Small molecules that bind to the generally unoccupied thyroxine binding pockets in the native TTR tetramer kinetically stabilize the tetramer, slowing subunit dissociation proportional to the extent that the molecules stabilize the native state over the dissociative transition state-thereby inhibiting amyloidogenesis. Herein, we use previously reported structure-activity relationship data to develop two semi-quantitative algorithms for identifying the structures of potent and selective transthyretin kinetic stabilizers/amyloidogenesis inhibitors. The viability of these prediction algorithms, in particular the more robust in silico docking model, is perhaps best validated by the clinical success of tafamidis, the first-in-class drug approved in Europe, Japan, South America, and elsewhere for treating transthyretin aggregation-associated familial amyloid polyneuropathy. Tafamidis is also being evaluated in a fully-enrolled placebo-controlled clinical trial for its efficacy against TTR cardiomyopathy. These prediction algorithms will be useful for identifying second generation TTR kinetic stabilizers, should these be needed to ameliorate the central nervous system or ophthalmologic pathology caused by TTR aggregation in organs not accessed by oral tafamidis administration.
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Bhogal S, Ladia V, Sitwala P, Cook E, Bajaj K, Ramu V, Lavie CJ, Paul TK. Cardiac Amyloidosis: An Updated Review With Emphasis on Diagnosis and Future Directions. Curr Probl Cardiol 2017; 43:10-34. [PMID: 29173805 DOI: 10.1016/j.cpcardiol.2017.04.003] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Cardiac amyloidosis occurs because of abnormal protein (amyloid) deposition in the cardiac tissue. Even with advanced diagnostic techniques and treatments, the prognosis of amyloidosis remains poor. The diagnosis of cardiac amyloidosis particularly needs to be in the differential in patients presenting with heart failure with preserved ejection fraction. This entity remains underdiagnosed due to lack of suspicion on the part of many clinicians. Involvement of cardiac tissue is the utmost determinant factor for available treatment options and prognosis. Many cases of cardiac amyloidosis usually remain undiagnosed or diagnosed only in advanced stages when treatment options are limited and associated with poor survival. Hence, early recognition of cardiac amyloidosis is indispensable in halting the disease process before irreversible changes occur. The purpose of this review is to summarize the recent updates in the evaluation and management of cardiac amyloidosis and to discuss potential future treatments options.
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Brunjes DL, Castano A, Clemons A, Rubin J, Maurer MS. Transthyretin Cardiac Amyloidosis in Older Americans. J Card Fail 2016; 22:996-1003. [PMID: 27769906 PMCID: PMC5127719 DOI: 10.1016/j.cardfail.2016.10.008] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 10/12/2016] [Accepted: 10/12/2016] [Indexed: 12/20/2022]
Abstract
Wild-type transthyretin cardiac amyloidosis (ATTRwt), formerly called senile cardiac amyloidosis (SCA), is almost exclusively a disorder of older adults. As the population ages, the diagnosis of ATTRwt will increase, making it the most common form of cardiac amyloidosis. An important precondition to reduce underdiagnosis and misdiagnosis is to maintain a high index of suspicion for cardiac amyloidosis. Several clues can be gleaned from the clinical history, physical exam, electrocardiography, and noninvasive imaging techniques. Nuclear scintigraphy agents using 99mTc-phosphate derivatives combined with assessment for monoclonal proteins are eliminating the need for tissue confirmation in ATTR. Morbidity and mortality from ATTRwt cardiac amyloid is high and the emergence of numerous therapies based on a biologic understanding of the pathophysiology of this condition, including drugs to inhibit the synthesis of TTR, stabilize TTR, and degrade or extract amyloid, provides new hope for those afflicted. This review briefly covers the epidemiology, pathophysiology, and clinical manifestations, as well as diagnostic strategies and treatment, of ATTR in older adults.
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Affiliation(s)
- Danielle L Brunjes
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Adam Castano
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Autumn Clemons
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Jonah Rubin
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Mathew S Maurer
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York.
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Castaño A, DeLuca A, Weinberg R, Pozniakoff T, Blaner WS, Pirmohamed A, Bettencourt B, Gollob J, Karsten V, Vest JA, Chiuzan C, Maurer MS, Bokhari S. Serial scanning with technetium pyrophosphate ( 99mTc-PYP) in advanced ATTR cardiac amyloidosis. J Nucl Cardiol 2016; 23:1355-1363. [PMID: 26453570 PMCID: PMC4826633 DOI: 10.1007/s12350-015-0261-x] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Accepted: 07/26/2015] [Indexed: 12/25/2022]
Abstract
BACKGROUND Development of noninvasive imaging modalities to quantify amyloid burden over time is an unmet clinical need. Technetium pyrophosphate (99mTc-PYP) scintigraphy is a simple and widely available radiotracer useful to differentiate transthyretin from light-chain amyloidosis in patients with advanced cardiac amyloidosis. We examined the utility of serial 99mTc-PYP scanning to quantify amyloid burden over time in TTR cardiac amyloidosis (ATTR-CA). METHODS AND RESULTS Twenty subjects with ATTR-CA (10 wild type, 10 mutant) underwent serial 99mTc-PYP planar cardiac imaging. Cardiac retention was assessed both semiquantitatively (visual score 0, no uptake to 3, uptake greater than bone) and quantitatively (region of interest drawn over the heart, copied, and mirrored over the contralateral chest) to calculate a heart-to-contralateral (H/CL) ratio. Index scan mean visual score and H/CL were 3.0 ± 0.2 and 1.79 ± 0.2, respectively, and after an average 1.5 ± 0.5 years follow-up, did not differ, 3.0 ± 0.2, P = .33 and 1.76 ± 0.2, P = .44. H/CL change was minimal, 0.03 ± 0.17, did not correlate with time between scans, r = 0.19, P = .43, and was observed despite obvious clinical progression (increase in troponin ≥ 0.1 ng/mL, BNP ≥ 400 pg/mL, NYHA class, and/or death). CONCLUSIONS Serial 99mTc-PYP scanning in subjects with advanced ATTR-CA does not show significant changes over an average 1.5 years of follow-up despite obvious clinical progression.
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Affiliation(s)
- Adam Castaño
- Nuclear Cardiology Laboratory, Columbia College of Physicians & Surgeons, 622 W 168th St. P.H. 10-203, New York, NY, 10032, USA.
- Division of Cardiology, Center for Advanced Cardiac Care, Columbia College of Physicians & Surgeons, New York, NY, USA.
| | - Albert DeLuca
- Nuclear Cardiology Laboratory, Columbia College of Physicians & Surgeons, 622 W 168th St. P.H. 10-203, New York, NY, 10032, USA
| | - Richard Weinberg
- Nuclear Cardiology Laboratory, Columbia College of Physicians & Surgeons, 622 W 168th St. P.H. 10-203, New York, NY, 10032, USA
| | - Ted Pozniakoff
- Nuclear Cardiology Laboratory, Columbia College of Physicians & Surgeons, 622 W 168th St. P.H. 10-203, New York, NY, 10032, USA
| | - William S Blaner
- Department of Medicine, Institute of Human Nutrition, Columbia College of Physicians & Surgeons, New York, NY, USA
| | - Altaf Pirmohamed
- Nuclear Cardiology Laboratory, Columbia College of Physicians & Surgeons, 622 W 168th St. P.H. 10-203, New York, NY, 10032, USA
| | | | | | | | | | - Codruta Chiuzan
- Mailman School of Public Health, Columbia College of Physicians & Surgeons, New York, NY, USA
| | - Mathew S Maurer
- Division of Cardiology, Center for Advanced Cardiac Care, Columbia College of Physicians & Surgeons, New York, NY, USA
| | - Sabahat Bokhari
- Nuclear Cardiology Laboratory, Columbia College of Physicians & Surgeons, 622 W 168th St. P.H. 10-203, New York, NY, 10032, USA
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Bodard Q, Roca F, Dilly B, Laurent D, Chassagne P. Acute cardiac failure secondary to senile systemic amyloidosis. Age Ageing 2016; 45:908-909. [PMID: 27103598 DOI: 10.1093/ageing/afw073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 03/14/2016] [Indexed: 11/14/2022] Open
Abstract
Hereditary or senile transthyretin (TTR) cardiac amyloidosis is a rare and underestimated cause of heart failure in old patients. New diagnostic methods, particularly cardiac MRI and proteomic analysis, have been recently developed that enable both earlier identification and development of specific treatments.We report a case of cardiac amyloidosis revealed through late-onset heart failure.
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Affiliation(s)
- Quentin Bodard
- Department of Geriatric Medicine, Rouen University Hospital, Rouen, France
| | - Frederic Roca
- Department of Geriatric Medicine, Rouen University Hospital, Rouen, France
| | - Baptiste Dilly
- Department of Geriatric Medicine, Rouen University Hospital, Rouen, France
| | - Druesne Laurent
- Department of Geriatric Medicine, Rouen University Hospital, Rouen, France
| | - Philippe Chassagne
- Department of Geriatric Medicine, Rouen University Hospital, Rouen, France
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Abstract
Amyloidosis is a disease in which proteins misfold, aggregate into fibrils, and deposit extracellularly disrupting organ architecture and function. There are two main types which affect the heart: light chain (AL) amyloidosis and transthyretin cardiac amyloidosis (ATTR). There is a misconception that cardiac amyloidosis has no effective treatment options. However, over the past decade, there has been extensive research and drug development. Outcomes are improving in AL amyloidosis with evolving chemotherapeutic regimens and novel monoclonal antibodies. In ATTR, therapies that decrease protein production, prevent dissociation, and promote clearance have the potential to slow or even halt a disease which is uniformly fatal. Selected patients may be candidates for heart and/or stem cell transplant and should be promptly referred to an experienced amyloid program. Herein, we discuss the emerging advances for the treatment of cardiac amyloidosis.
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Coelho T, Merlini G, Bulawa CE, Fleming JA, Judge DP, Kelly JW, Maurer MS, Planté-Bordeneuve V, Labaudinière R, Mundayat R, Riley S, Lombardo I, Huertas P. Mechanism of Action and Clinical Application of Tafamidis in Hereditary Transthyretin Amyloidosis. Neurol Ther 2016; 5:1-25. [PMID: 26894299 PMCID: PMC4919130 DOI: 10.1007/s40120-016-0040-x] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Indexed: 11/24/2022] Open
Abstract
Transthyretin (TTR) transports the retinol-binding protein-vitamin A complex and is a minor transporter of thyroxine in blood. Its tetrameric structure undergoes rate-limiting dissociation and monomer misfolding, enabling TTR to aggregate or to become amyloidogenic. Mutations in the TTR gene generally destabilize the tetramer and/or accelerate tetramer dissociation, promoting amyloidogenesis. TTR-related amyloidoses are rare, fatal, protein-misfolding disorders, characterized by formation of soluble aggregates of variable structure and tissue deposition of amyloid. The TTR amyloidoses present with a spectrum of manifestations, encompassing progressive neuropathy and/or cardiomyopathy. Until recently, the only accepted treatment to halt progression of hereditary TTR amyloidosis was liver transplantation, which replaces the hepatic source of mutant TTR with the less amyloidogenic wild-type TTR. Tafamidis meglumine is a rationally designed, non-NSAID benzoxazole derivative that binds with high affinity and selectivity to TTR and kinetically stabilizes the tetramer, slowing monomer formation, misfolding, and amyloidogenesis. Tafamidis is the first pharmacotherapy approved to slow the progression of peripheral neurologic impairment in TTR familial amyloid polyneuropathy. Here we describe the mechanism of action of tafamidis and review the clinical data, demonstrating that tafamidis treatment slows neurologic deterioration and preserves nutritional status, as well as quality of life in patients with early-stage Val30Met amyloidosis.
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Affiliation(s)
- Teresa Coelho
- Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal.
| | - Giampaolo Merlini
- Foundation IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | | | | | - Daniel P Judge
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Mathew S Maurer
- Columbia University College of Physicians and Surgeons, New York, NY, USA
| | | | | | | | | | | | - Pedro Huertas
- Massachusetts General and McLean Hospitals, Harvard Medical School, Boston, MA, USA
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Galant NJ, Bugyei-Twum A, Rakhit R, Walsh P, Sharpe S, Arslan PE, Westermark P, Higaki JN, Torres R, Tapia J, Chakrabartty A. Substoichiometric inhibition of transthyretin misfolding by immune-targeting sparsely populated misfolding intermediates: a potential diagnostic and therapeutic for TTR amyloidoses. Sci Rep 2016; 6:25080. [PMID: 27122057 PMCID: PMC4848561 DOI: 10.1038/srep25080] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 04/08/2016] [Indexed: 12/22/2022] Open
Abstract
Wild-type and mutant transthyretin (TTR) can misfold and deposit in the heart, peripheral nerves, and other sites causing amyloid disease. Pharmacological chaperones, Tafamidis(®) and diflunisal, inhibit TTR misfolding by stabilizing native tetrameric TTR; however, their minimal effective concentration is in the micromolar range. By immune-targeting sparsely populated TTR misfolding intermediates (i.e. monomers), we achieved fibril inhibition at substoichiometric concentrations. We developed an antibody (misTTR) that targets TTR residues 89-97, an epitope buried in the tetramer but exposed in the monomer. Nanomolar misTTR inhibits fibrillogenesis of misfolded TTR under micromolar concentrations. Pan-specific TTR antibodies do not possess such fibril inhibiting properties. We show that selective targeting of misfolding intermediates is an alternative to native state stabilization and requires substoichiometric concentrations. MisTTR or its derivative may have both diagnostic and therapeutic potential.
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Affiliation(s)
- Natalie J. Galant
- Princess Margaret Cancer Centre, University Health Network, Departments of Medical Biophysics and Biochemistry, University of Toronto, TMDT 4-305, 101 College Street, Toronto, Ontario, Canada M5G 1L7
| | - Antoinette Bugyei-Twum
- Princess Margaret Cancer Centre, University Health Network, Departments of Medical Biophysics and Biochemistry, University of Toronto, TMDT 4-305, 101 College Street, Toronto, Ontario, Canada M5G 1L7
| | - Rishi Rakhit
- Department of Chemical and Systems Biology, Stanford University, CA 94305, USA
| | - Patrick Walsh
- Molecular Structure and Function Program, the Hospital for Sick Children, Department of Biochemistry, University of Toronto, 1 King’s College Circle, Toronto, Ontario, Canada M5S 1A8
| | - Simon Sharpe
- Molecular Structure and Function Program, the Hospital for Sick Children, Department of Biochemistry, University of Toronto, 1 King’s College Circle, Toronto, Ontario, Canada M5S 1A8
| | - Pharhad Eli Arslan
- Princess Margaret Cancer Centre, University Health Network, Departments of Medical Biophysics and Biochemistry, University of Toronto, TMDT 4-305, 101 College Street, Toronto, Ontario, Canada M5G 1L7
| | - Per Westermark
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Jeffrey N. Higaki
- Departments of Biochemistry and Histopathology, Prothena Biosciences Inc., South San Francisco, CA 94080
| | - Ronald Torres
- Departments of Biochemistry and Histopathology, Prothena Biosciences Inc., South San Francisco, CA 94080
| | - José Tapia
- Departments of Biochemistry and Histopathology, Prothena Biosciences Inc., South San Francisco, CA 94080
| | - Avijit Chakrabartty
- Princess Margaret Cancer Centre, University Health Network, Departments of Medical Biophysics and Biochemistry, University of Toronto, TMDT 4-305, 101 College Street, Toronto, Ontario, Canada M5G 1L7
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Baranczak A, Kelly JW. A current pharmacologic agent versus the promise of next generation therapeutics to ameliorate protein misfolding and/or aggregation diseases. Curr Opin Chem Biol 2016; 32:10-21. [PMID: 26859714 DOI: 10.1016/j.cbpa.2016.01.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 01/14/2016] [Accepted: 01/14/2016] [Indexed: 12/18/2022]
Abstract
The list of protein aggregation-associated degenerative diseases is long and growing, while the portfolio of disease-modifying strategies is very small. In this review and perspective, we assess what has worked to slow the progression of an aggregation-associated degenerative disease, covering the underlying mechanism of pharmacologic action and what we have learned about the etiology of the transthyretin amyloid diseases and likely amyloidoses in general. Next, we introduce emerging therapies that should apply more generally to protein misfolding and/or aggregation diseases, approaches that rely on adapting the protein homeostasis or proteostasis network for disease amelioration.
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Affiliation(s)
- Aleksandra Baranczak
- Department of Chemistry and The Skaggs Institute for Chemical Biology, La Jolla, CA 92037, USA; Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, CA 92037, USA.
| | - Jeffery W Kelly
- Department of Chemistry and The Skaggs Institute for Chemical Biology, La Jolla, CA 92037, USA; Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, CA 92037, USA.
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Cappelli F, Frusconi S, Bergesio F, Grifoni E, Fabbri A, Giuliani C, Falconi S, Bonifacio S, Perfetto F. The Val142Ile transthyretin cardiac amyloidosis. J Cardiovasc Med (Hagerstown) 2016; 17:122-5. [DOI: 10.2459/jcm.0000000000000290] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Castaño A, Drachman BM, Judge D, Maurer MS. Natural history and therapy of TTR-cardiac amyloidosis: emerging disease-modifying therapies from organ transplantation to stabilizer and silencer drugs. Heart Fail Rev 2015; 20:163-78. [PMID: 25408161 DOI: 10.1007/s10741-014-9462-7] [Citation(s) in RCA: 149] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Transthyretin-cardiac amyloidoses (ATTR-CA) are an underdiagnosed but increasingly recognized cause of heart failure. Extracellular deposition of fibrillary proteins into tissues due to a variety of inherited transthyretin mutations in ATTRm or due to advanced age in ATTRwt eventually leads to organ failure. In the heart, amyloid deposition causes diastolic dysfunction, restrictive cardiomyopathy with progressive loss of systolic function, arrhythmias, and heart failure. While traditional treatments have consisted of conventional heart failure management and supportive care for systemic symptoms, numerous disease-modifying therapies have emerged over the past decade. From organ transplantation to transthyretin stabilizers (diflunisal, tafamidis, AG-1), TTR silencers (ALN-ATTR02, ISIS-TTR(Rx)), and degraders of amyloid fibrils (doxycycline/TUDCA), the potential for effective transthyretin amyloid therapy is greater now than ever before. In light of these multiple agents under investigation in human clinical trials, clinicians should be familiar with the systemic cardiac amyloidoses, their differing pathophysiology, natural histories, and unique treatment strategies.
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Affiliation(s)
- Adam Castaño
- Center for Advanced Cardiac Care, Columbia College of Physicians and Surgeons, New York City, NY, USA,
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Noninvasive Identification of ATTRwt Cardiac Amyloid: The Re-emergence of Nuclear Cardiology. Am J Med 2015; 128:1275-80. [PMID: 26091765 PMCID: PMC4798849 DOI: 10.1016/j.amjmed.2015.05.039] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2015] [Revised: 05/22/2015] [Accepted: 05/22/2015] [Indexed: 02/06/2023]
Abstract
More than half of all subjects with chronic heart failure are older adults with preserved ejection fraction (HFpEF). Effective therapy for this condition is yet to be delineated by clinical trials, suggesting that a greater understanding of underlying biologic mechanisms is needed, especially for the purpose of clinical intervention and future clinical trials. Amyloid infiltration of the myocardium is an underappreciated contributing factor to HFpEF that is often caused by misfolded monomers or oligomers of the protein transthyretin. While previously called senile cardiac amyloidosis and traditionally requiring endomyocardial biopsy for diagnosis, advances in our pathophysiologic understanding of this condition, coupled with nuclear imaging techniques using bone isotopes that can diagnose this condition noninvasively and the development of potential therapies, have resulted in a renewed interest in this previously considered "rare" condition. This reviewer focuses on the re-emergence of nuclear cardiology using pyrophosphate agents that hold promise for early, noninvasive identification of affected individuals.
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Hawkins PN, Ando Y, Dispenzeri A, Gonzalez-Duarte A, Adams D, Suhr OB. Evolving landscape in the management of transthyretin amyloidosis. Ann Med 2015; 47:625-38. [PMID: 26611723 PMCID: PMC4720049 DOI: 10.3109/07853890.2015.1068949] [Citation(s) in RCA: 159] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 06/30/2015] [Indexed: 12/12/2022] Open
Abstract
Transthyretin (TTR) amyloidosis (ATTR amyloidosis) is a multisystemic, multigenotypic disease resulting from deposition of insoluble ATTR amyloid fibrils in various organs and tissues. Although considered rare, the prevalence of this serious disease is likely underestimated because symptoms can be non-specific and diagnosis largely relies on amyloid detection in tissue biopsies. Treatment is guided by which tissues/organs are involved, although therapeutic options are limited for patients with late-stage disease. Indeed, enthusiasm for liver transplantation for familial ATTR amyloidosis with polyneuropathy was dampened by poor outcomes among patients with significant neurological deficits or cardiac involvement. Hence, there remains an unmet medical need for new therapies. The TTR stabilizers tafamidis and diflunisal slow disease progression in some patients with ATTR amyloidosis with polyneuropathy, and the postulated synergistic effect of doxycycline and tauroursodeoxycholic acid on dissolution of amyloid is under investigation. Another therapeutic approach is to reduce production of the amyloidogenic protein, TTR. Plasma TTR concentration can be significantly reduced with ISIS-TTR(Rx), an investigational antisense oligonucleotide-based drug, or with patisiran and revusiran, which are investigational RNA interference-based therapeutics that target the liver. The evolving treatment landscape for ATTR amyloidosis brings hope for further improvements in clinical outcomes for patients with this debilitating disease.
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Affiliation(s)
- Philip N. Hawkins
- National Amyloidosis Centre, Royal Free Hospital, University College London, London, UK
| | - Yukio Ando
- Department of Neurology, Graduate School of Medical Sciences Kumamoto University, Kumamoto, Japan
| | | | | | - David Adams
- National Reference Centre for FAP, APHP, CHU Bicêtre, Université Paris-Sud, INSERM U788, Paris, France
| | - Ole B. Suhr
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
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Eisele YS, Monteiro C, Fearns C, Encalada SE, Wiseman RL, Powers ET, Kelly JW. Targeting protein aggregation for the treatment of degenerative diseases. Nat Rev Drug Discov 2015; 14:759-80. [PMID: 26338154 PMCID: PMC4628595 DOI: 10.1038/nrd4593] [Citation(s) in RCA: 278] [Impact Index Per Article: 30.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The aggregation of specific proteins is hypothesized to underlie several degenerative diseases, which are collectively known as amyloid disorders. However, the mechanistic connection between the process of protein aggregation and tissue degeneration is not yet fully understood. Here, we review current and emerging strategies to ameliorate aggregation-associated degenerative disorders, with a focus on disease-modifying strategies that prevent the formation of and/or eliminate protein aggregates. Persuasive pharmacological and genetic evidence now supports protein aggregation as the cause of postmitotic tissue dysfunction or loss. However, a more detailed understanding of the factors that trigger and sustain aggregate formation and of the structure-activity relationships underlying proteotoxicity is needed to develop future disease-modifying therapies.
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Affiliation(s)
- Yvonne S. Eisele
- Department of Chemistry, The Scripps Research Institute, La Jolla, California 92037, USA
- Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, California 92037, USA
| | - Cecilia Monteiro
- Department of Chemistry, The Scripps Research Institute, La Jolla, California 92037, USA
- Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, California 92037, USA
| | - Colleen Fearns
- Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, California 92037, USA
| | - Sandra E. Encalada
- Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, California 92037, USA
- Dorris Neuroscience Center, The Scripps Research Institute, La Jolla, California 92037, USA
- Department of Molecular and Cellular Neuroscience, The Scripps Research Institute, La Jolla, California 92037, USA
| | - R. Luke Wiseman
- Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, California 92037, USA
- Department of Chemical Physiology, The Scripps Research Institute, La Jolla, California 92037, USA
| | - Evan T. Powers
- Department of Chemistry, The Scripps Research Institute, La Jolla, California 92037, USA
| | - Jeffery W. Kelly
- Department of Chemistry, The Scripps Research Institute, La Jolla, California 92037, USA
- Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, California 92037, USA
- The Skaggs Institute for Chemical Biology, The Scripps Research Institute, La Jolla, California 92037, USA
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Abstract
Baseline physiological function of the mammalian heart is under the constant threat of environmental or intrinsic pathological insults. Cardiomyocyte proteins are thus subject to unremitting pressure to function optimally, and this depends on them assuming and maintaining proper conformation. This review explores the multiple defenses a cell may use for its proteins to assume and maintain correct protein folding and conformation. There are multiple quality control mechanisms to ensure that nascent polypeptides are properly folded and mature proteins maintain their functional conformation. When proteins do misfold, either in the face of normal or pathological stimuli or because of intrinsic mutations or post-translational modifications, they must either be refolded correctly or recycled. In the absence of these corrective processes, they may become toxic to the cell. Herein, we explore some of the underlying mechanisms that lead to proteotoxicity. The continued presence and chronic accumulation of misfolded or unfolded proteins can be disastrous in cardiomyocytes because these misfolded proteins can lead to aggregation or the formation of soluble peptides that are proteotoxic. This in turn leads to compromised protein quality control and precipitating a downward spiral of the cell's ability to maintain protein homeostasis. Some underlying mechanisms are discussed and the therapeutic potential of interfering with proteotoxicity in the heart is explored.
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Affiliation(s)
- Patrick M McLendon
- From the Department of Pediatrics, Children's Hospital Research Foundation, Cincinnati, OH
| | - Jeffrey Robbins
- From the Department of Pediatrics, Children's Hospital Research Foundation, Cincinnati, OH.
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49
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Maurer MS, Grogan DR, Judge DP, Mundayat R, Packman J, Lombardo I, Quyyumi AA, Aarts J, Falk RH. Tafamidis in Transthyretin Amyloid Cardiomyopathy. Circ Heart Fail 2015; 8:519-26. [DOI: 10.1161/circheartfailure.113.000890] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 03/26/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Mathew S. Maurer
- From the Clinical Cardiovascular Research Laboratory for the Elderly (CCRLE), Columbia University Medical Center, New York Presbyterian Hospital (M.S.M.); Drug Development Department, FoldRx Pharmaceuticals/Pfizer Inc, Cambridge, MA (D.R.G., J.P.); Department of Medicine/Cardiology, Center for Inherited Heart Disease, Johns Hopkins University, Baltimore, MD (D.P.J.); Global Medicines Development (GMD) (J.A., I.L.) and Global Innovative Pharma – Statistics (R.M.), Pfizer Inc, New York, NY; Department
| | - Donna R. Grogan
- From the Clinical Cardiovascular Research Laboratory for the Elderly (CCRLE), Columbia University Medical Center, New York Presbyterian Hospital (M.S.M.); Drug Development Department, FoldRx Pharmaceuticals/Pfizer Inc, Cambridge, MA (D.R.G., J.P.); Department of Medicine/Cardiology, Center for Inherited Heart Disease, Johns Hopkins University, Baltimore, MD (D.P.J.); Global Medicines Development (GMD) (J.A., I.L.) and Global Innovative Pharma – Statistics (R.M.), Pfizer Inc, New York, NY; Department
| | - Daniel P. Judge
- From the Clinical Cardiovascular Research Laboratory for the Elderly (CCRLE), Columbia University Medical Center, New York Presbyterian Hospital (M.S.M.); Drug Development Department, FoldRx Pharmaceuticals/Pfizer Inc, Cambridge, MA (D.R.G., J.P.); Department of Medicine/Cardiology, Center for Inherited Heart Disease, Johns Hopkins University, Baltimore, MD (D.P.J.); Global Medicines Development (GMD) (J.A., I.L.) and Global Innovative Pharma – Statistics (R.M.), Pfizer Inc, New York, NY; Department
| | - Rajiv Mundayat
- From the Clinical Cardiovascular Research Laboratory for the Elderly (CCRLE), Columbia University Medical Center, New York Presbyterian Hospital (M.S.M.); Drug Development Department, FoldRx Pharmaceuticals/Pfizer Inc, Cambridge, MA (D.R.G., J.P.); Department of Medicine/Cardiology, Center for Inherited Heart Disease, Johns Hopkins University, Baltimore, MD (D.P.J.); Global Medicines Development (GMD) (J.A., I.L.) and Global Innovative Pharma – Statistics (R.M.), Pfizer Inc, New York, NY; Department
| | - Jeff Packman
- From the Clinical Cardiovascular Research Laboratory for the Elderly (CCRLE), Columbia University Medical Center, New York Presbyterian Hospital (M.S.M.); Drug Development Department, FoldRx Pharmaceuticals/Pfizer Inc, Cambridge, MA (D.R.G., J.P.); Department of Medicine/Cardiology, Center for Inherited Heart Disease, Johns Hopkins University, Baltimore, MD (D.P.J.); Global Medicines Development (GMD) (J.A., I.L.) and Global Innovative Pharma – Statistics (R.M.), Pfizer Inc, New York, NY; Department
| | - Ilise Lombardo
- From the Clinical Cardiovascular Research Laboratory for the Elderly (CCRLE), Columbia University Medical Center, New York Presbyterian Hospital (M.S.M.); Drug Development Department, FoldRx Pharmaceuticals/Pfizer Inc, Cambridge, MA (D.R.G., J.P.); Department of Medicine/Cardiology, Center for Inherited Heart Disease, Johns Hopkins University, Baltimore, MD (D.P.J.); Global Medicines Development (GMD) (J.A., I.L.) and Global Innovative Pharma – Statistics (R.M.), Pfizer Inc, New York, NY; Department
| | - Arshed A. Quyyumi
- From the Clinical Cardiovascular Research Laboratory for the Elderly (CCRLE), Columbia University Medical Center, New York Presbyterian Hospital (M.S.M.); Drug Development Department, FoldRx Pharmaceuticals/Pfizer Inc, Cambridge, MA (D.R.G., J.P.); Department of Medicine/Cardiology, Center for Inherited Heart Disease, Johns Hopkins University, Baltimore, MD (D.P.J.); Global Medicines Development (GMD) (J.A., I.L.) and Global Innovative Pharma – Statistics (R.M.), Pfizer Inc, New York, NY; Department
| | - Janske Aarts
- From the Clinical Cardiovascular Research Laboratory for the Elderly (CCRLE), Columbia University Medical Center, New York Presbyterian Hospital (M.S.M.); Drug Development Department, FoldRx Pharmaceuticals/Pfizer Inc, Cambridge, MA (D.R.G., J.P.); Department of Medicine/Cardiology, Center for Inherited Heart Disease, Johns Hopkins University, Baltimore, MD (D.P.J.); Global Medicines Development (GMD) (J.A., I.L.) and Global Innovative Pharma – Statistics (R.M.), Pfizer Inc, New York, NY; Department
| | - Rodney H. Falk
- From the Clinical Cardiovascular Research Laboratory for the Elderly (CCRLE), Columbia University Medical Center, New York Presbyterian Hospital (M.S.M.); Drug Development Department, FoldRx Pharmaceuticals/Pfizer Inc, Cambridge, MA (D.R.G., J.P.); Department of Medicine/Cardiology, Center for Inherited Heart Disease, Johns Hopkins University, Baltimore, MD (D.P.J.); Global Medicines Development (GMD) (J.A., I.L.) and Global Innovative Pharma – Statistics (R.M.), Pfizer Inc, New York, NY; Department
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50
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Kintsler S, Jäkel J, Brandenburg V, Kersten K, Knuechel R, Röcken C. Cardiac amyloidosis in a heart transplant patient - A case report and retrospective analysis of amyloidosis evolution. Intractable Rare Dis Res 2015; 4:60-4. [PMID: 25674390 PMCID: PMC4322597 DOI: 10.5582/irdr.2014.01036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Accepted: 01/07/2015] [Indexed: 12/23/2022] Open
Abstract
Cardiac amyloidosis is a very rare cause of heart failure in heart transplant recipients but an important differential diagnosis in cases of progressive cardiac failure. We report a 72-year-old male patient with the diagnosis of senile systemic amyloidosis (SSA) in a transplanted heart 15 years after transplantation by the initial diagnosis of the dilated cardiomyopathy. Additionally performed immunohistochemical analysis with anti-transthyretin antibody of the cardiac biopsies of the last 15 years enabled the possibility to show the evolution of this disease with characteristic biphasic pattern.
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Affiliation(s)
- Svetlana Kintsler
- Institute of Pathology of the University Hospital RWTH Aachen, Aachen, Germany
- Address correspondence to: Dr. Svetlana Kintsler, Insitute of Pathology of the University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany. E-mail:
| | - Jörg Jäkel
- Institute of Pathology of the University Hospital RWTH Aachen, Aachen, Germany
| | - Vincent Brandenburg
- Department of Cardiology, Pulmonology, Angiology and Internal Intensive Care Medicine of the University Hospital RWTH Aachen, Aachen, Germany
| | - Katrin Kersten
- Department of Cardiology, Pulmonology, Angiology and Internal Intensive Care Medicine of the University Hospital RWTH Aachen, Aachen, Germany
| | - Ruth Knuechel
- Institute of Pathology of the University Hospital RWTH Aachen, Aachen, Germany
| | - Christoph Röcken
- Institute of Pathology of the Christian-Albrechts-University Kiel, Kiel, Germany
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