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Pascoe MA, Kolodziej A, Birks EJ, Vaidya G. Using electronic medical records to identify patients at risk for underlying cardiac amyloidosis. J Cardiol 2024:S0914-5087(24)00131-X. [PMID: 38992805 DOI: 10.1016/j.jjcc.2024.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2024] [Revised: 07/02/2024] [Accepted: 07/04/2024] [Indexed: 07/13/2024]
Abstract
BACKGROUND Identification of transthyretin cardiac amyloidosis (ATTR-CA) patients is largely based on pattern recognition by providers, and this can be automated through electronic medical systems (EMR). METHODS All patients in a large academic hospital with age > 60, ICD-10 code for chronic diastolic heart failure and no previous diagnosis of any amyloidosis were included. An Epic EMR scoring logic assigned risk scores to patients for ICD-10 and CPT codes associated with ATTR-CA, as follows: carpal tunnel syndrome (score 5), aortic stenosis/TAVR (Donnellan et al., 2020 (5)), neuropathy (Longhi et al., 2015 (4)), bundle branch block (Longhi et al., 2015 (4)), etc. The individual patients' scores were added, and patients were arranged in descending order of total scores- ranging from 50 to 0. Data is reported as median (interquartile range) and analyzed with non-parametric tests. RESULTS Of the total 11,648 patients identified, 132 consecutive patients with highest risk scores (score ≥ 30) were enrolled as cases, while 132 patients with scores between 10 and 19 with available echocardiography data served as age-matched controls. Strain echocardiography is not routinely performed. Patients with high scores were more likely to have CA associated findings- African-American race, higher left ventricular (LV) mass index and left atrial volume and lower LV ejection fraction. High score patients had higher troponin and a trend towards high NT-proBNP. CONCLUSION The modern EMR can be used to flag patients with high risk for ATTR-CA (score ≥ 30 using the proposed logic) through best practice advisory. This could encourage screening during echocardiography using strain or during unsuspected clinic visits.
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Affiliation(s)
- Michael A Pascoe
- Department of Internal Medicine, University of Kentucky, Lexington, KY, USA.
| | - Andrew Kolodziej
- Gill Heart and Vascular Institute, University of Kentucky, Lexington, KY, USA
| | - Emma J Birks
- Gill Heart and Vascular Institute, University of Kentucky, Lexington, KY, USA
| | - Gaurang Vaidya
- Kaiser Permanente-Santa Clara, Santa Clara Homestead Medical Center, Santa Clara, CA, USA
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2
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Shankar B, Yanek L, Jefferson A, Jani V, Brown E, Tsottles D, Barranco J, Zampino S, Ranek M, Sharma K, Polydefkis M, Vaishnav J. Race and Socioeconomic Status Impact Diagnosis and Clinical Outcomes in Transthyretin Cardiac Amyloidosis. JACC CardioOncol 2024; 6:454-463. [PMID: 38983379 PMCID: PMC11229544 DOI: 10.1016/j.jaccao.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 05/08/2024] [Accepted: 05/08/2024] [Indexed: 07/11/2024] Open
Abstract
Background Transthyretin amyloid cardiomyopathy (ATTR-CM) is associated with significant mortality. The Val122Ile variant, highly prevalent in Black patients, portends poorer survival compared with other ATTR-CM subtypes. Although Val122Ile is biologically more aggressive, the contribution of race and socioeconomic status (SES) to disease outcomes in patients with ATTR-CM is undefined. Objectives The aim of this study was to evaluate the impact of race and SES on clinical outcomes in patients with ATTR-CM. Methods Patients with ATTR-CM who received care at Johns Hopkins Hospital between 2006 and 2022 were included. SES was assessed using area deprivation index (ADI). Associations of race and ADI with heart failure (HF) hospitalization and/or death were measured using multivariable logistic or Cox proportional hazards models. Results Of 282 patients, 225 (80%) were men, and 129 (46%) were Black. Black vs White patients disproportionately constituted the highest ADI (most deprived) category (66% vs 28%; P = 0.004), and Black patients were more likely to have HF hospitalization or death over 5 years compared with White patients (log-rank P < 0.001). Among those with ADI >25, Black patients had a significantly greater hazard of HF hospitalization or death compared with White patients, independent of disease stage at diagnosis (HR: 2.77; 95% CI: 1.45-5.32; P = 0.002). Conclusions Black patients with low SES may be at greater risk for underdiagnosis and adverse outcomes compared with White patients. Ongoing efforts are needed to improve outcomes in this subset of patients with ATTR-CM.
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Affiliation(s)
- Bairavi Shankar
- Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Lisa Yanek
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Artrish Jefferson
- Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Vivek Jani
- Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Emily Brown
- Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Daniel Tsottles
- Department of Neurology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Jennifer Barranco
- Department of Neurology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Serena Zampino
- Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Mark Ranek
- Department of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Kavita Sharma
- Department of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Michael Polydefkis
- Department of Neurology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Joban Vaishnav
- Department of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland, USA
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3
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Martyn T, Simkowski JM, Hanna M. Understanding Race, Genotype, and Socioeconomic Status in Transthyretin Amyloid Cardiomyopathy: An Area of Deprivation. JACC CardioOncol 2024; 6:464-466. [PMID: 38983385 PMCID: PMC11229539 DOI: 10.1016/j.jaccao.2024.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2024] Open
Affiliation(s)
- Trejeeve Martyn
- Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
- George and Linda Kaufman Center for Heart Failure and Recovery, Cleveland Clinic, Cleveland Ohio, USA
- Amyloidosis Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Julia M. Simkowski
- Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
- George and Linda Kaufman Center for Heart Failure and Recovery, Cleveland Clinic, Cleveland Ohio, USA
| | - Mazen Hanna
- Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
- George and Linda Kaufman Center for Heart Failure and Recovery, Cleveland Clinic, Cleveland Ohio, USA
- Amyloidosis Center, Cleveland Clinic, Cleveland, Ohio, USA
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4
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Niewold TB, Aksentijevich I, Gorevic PD, Gibson G, Yao Q. Genetically transitional disease: conceptual understanding and applicability to rheumatic disease. Nat Rev Rheumatol 2024; 20:301-310. [PMID: 38418715 DOI: 10.1038/s41584-024-01086-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2024] [Indexed: 03/02/2024]
Abstract
In genomic medicine, the concept of genetically transitional disease (GTD) refers to cases in which gene mutation is necessary but not sufficient to cause disease. In this Perspective, we apply this novel concept to rheumatic diseases, which have been linked to hundreds of genetic variants via association studies. These variants are in the 'grey zone' between monogenic variants with large effect sizes and common susceptibility alleles with small effect sizes. Among genes associated with rare autoinflammatory diseases, many low-frequency and/or low-penetrance variants are known to increase susceptibility to systemic inflammation. In autoimmune diseases, hundreds of HLA and non-HLA genetic variants have been revealed to be modest- to moderate-risk alleles. These diseases can be reclassified as GTDs. The same concept could apply to many other human diseases. GTD could improve the reporting of genetic testing results, diagnostic yields, genetic counselling and selection of therapy, as well as facilitating research using a novel approach to human genetic diseases.
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Affiliation(s)
- Timothy B Niewold
- Department of Rheumatology, Hospital for Special Surgery, New York, NY, USA
| | - Ivona Aksentijevich
- Inflammatory Disease Section, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - Peter D Gorevic
- Division of Rheumatology, Allergy and Immunology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, USA
| | - Greg Gibson
- Center for Integrative Genomics, School of Biological Sciences, Georgia Institute of Technology, Atlanta, GA, USA
| | - Qingping Yao
- Division of Rheumatology, Allergy and Immunology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, USA.
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5
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Darden FK, Patel A, Merrell G. Being a Better Starfish Thrower, Carpal Tunnel Syndrome, and Cardiac Amyloidosis: The Hand Surgeon's Opportunity to Make a Profound Difference. J Hand Surg Am 2024; 49:373-376. [PMID: 38363260 DOI: 10.1016/j.jhsa.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 01/12/2024] [Indexed: 02/17/2024]
Abstract
In recent years, there is increasing literature in cardiac and hand surgery journals demonstrating a stronger association between seemingly idiopathic carpal tunnel and amyloidosis. Despite this, it can be difficult for hand surgeons to identify who need biopsies, and this is further complicated by the cost of a biopsy and the low likelihood that a patient has cardiac amyloidosis. In patients with cardiac amyloidosis and carpal tunnel syndrome (CTS), CTS is typically diagnosed 5-10 years prior. Early diagnosis of cardiac amyloidosis is crucial, as current medications work to slow disease progression, but do not treat existing amyloid deposits. Hand surgeons can play an essential role in early diagnosis. The patient case discussed describes a man who had a carpal tunnel biopsy because of his bilateral CTS, recurrent trigger fingers, and his age. After confirmation of amyloidosis, he was referred for cardiac amyloidosis evaluation. Testing confirmed this diagnosis, and he was started on tafamidis, which studies show provide patients an opportunity for increased survival and quality of life. The responsibility falls on cardiologists and hand surgeons to continue refining the indications for carpal tunnel biopsy and spreading awareness of carpal tunnel biopsy and amyloid testing, as much work is still needed.
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Affiliation(s)
| | - Amit Patel
- Department of Cardiology, Saint Vincent Medical Group, Indianapolis, IN
| | - Greg Merrell
- Indiana Hand to Shoulder Center, Indianapolis, IN.
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Bullock-Palmer RP, Chareonthaitawee P, Fox E, Beache GM. Microvascular vasoregulatory dysfunction in African Americans - An enhanced opportunity for early prevention and treatment of atherosclerotic cardiovascular disease. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2024; 40:100382. [PMID: 38586429 PMCID: PMC10994957 DOI: 10.1016/j.ahjo.2024.100382] [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: 02/07/2024] [Revised: 03/03/2024] [Accepted: 03/05/2024] [Indexed: 04/09/2024]
Abstract
Atherosclerotic cardiovascular disease and its risk factors and precursors are a major driver of disparities in cardiovascular health. This review examines reported evidence that vascular endothelial dysfunction, and its manifestation as coronary microvascular dysfunction, underlies observed excess morbidity and mortality in African Americans. Advanced imaging insights that reveal patho-mechanisms, along with population evidence from the Jackson Heart Study, and the growing evidence emanating from national and international clinical trials and registries are presented. We examine a physiological framework that recognizes insulin-resistant cardiometabolic underpinnings of the conditions of the American Heart Associations' Life's Essential Eight construct of cardiovascular health as a unifying basis that affords early prevention. Mechanistic-based therapeutic approaches, can subsequently be implemented to interrupt progression to adverse outcomes employing layered, or personalized, treatment strategies of a well-defined set of conditions or diseases. Remaining knowledge gaps are acknowledged.
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Affiliation(s)
- Renee P. Bullock-Palmer
- Department of Cardiology, Deborah Heart and Lung Center, Browns Mills NJ, Department of Medicine, Division of Cardiology, Thomas Jefferson University, Philadelphia, PA, United States of America
| | | | - Ervin Fox
- Division of Cardiology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS, United States of America
| | - Garth M. Beache
- Department of Radiology, University of Louisville School of Medicine, Louisville, KY, United States of America
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Sha Q, Zhang Y, Wang M, Sun J, Zhang Y, Zhang X, Wang N, Liu Y, Liu Y. Biochemical and biophysical properties of a rare TTRA81V mutation causing mild transthyretin amyloid cardiomyopathy. ESC Heart Fail 2024; 11:112-125. [PMID: 37827496 PMCID: PMC10804152 DOI: 10.1002/ehf2.14543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 09/01/2023] [Accepted: 09/15/2023] [Indexed: 10/14/2023] Open
Abstract
AIMS We conducted a presentation on an 84-year-old male patient who has been diagnosed with TTRA81V (p. TTRA101V) hereditary transthyretin cardiac amyloidosis (hATTR-CM). In order to establish its pathogenicity, we extensively investigated the biochemical and biophysical properties of the condition. METHODS AND RESULTS Transthyretin amyloid cardiomyopathy (ATTR-CM) is an increasingly acknowledged progressive infiltrative cardiomyopathy that leads to heart failure and potentially fatal arrhythmias. Gaining a comprehensive understanding of the biochemical and biophysical characteristics of genetically mutated TTR proteins serves as the fundamental cornerstone for delivering precise medical care to individuals affected by ATTR. Laboratory assessments indicated a brain natriuretic peptide of 200.12 ng/L (normal range: 0-100 ng/L) and high-sensitivity cardiac troponin I of 0.189 μg/L (normal range: 0-0.1 μg/L). Echocardiography identified left atrial enlargement, symmetrical left ventricular hypertrophy (16 mm septal and 16 mm posterior wall), and a left ventricular ejection fraction of 56%. Cardiac-enhanced magnetic resonance imaging revealed subendocardial late gadolinium enhancement. Tc-99m-PYP nuclear scintigraphy confirmed grade 3 myocardial uptake, showing an increased heart-to-contralateral ratio (H/CL = 2.33). Genetic testing revealed a heterozygous missense mutation in the TTR gene (c.302C>T), resulting in an alanine-to-valine residue change (p. Ala81Val, following the first 20 residues of signal sequence nomenclature). Biochemical analysis of this variant displayed compromised kinetic stability in both the TTRA81V:WT (wild-type) heterozygote protein (half-life, t1/2 = 21 h) and the TTRA81V homozygote protein (t1/2 = 17.5 h). The kinetic stability fell between that of the TTRWT (t1/2 = 42 h) and the early-onset TTRL55P mutation (t1/2 = 4.4 h), indicating the patient's late-onset condition. Kinetic stabilizers (Tafamidis, Diflunisal, and AG10) all exhibited the capacity to inhibit TTRA81V acid- and mechanical force-induced fibril formation, albeit less effectively than with TTRWT. Chromatographic assessment of the patient's serum TTR tetramers indicated a slightly lower concentration (3.0 μM) before oral administration of Tafamidis compared with the normal range (3.6-7.2 μM). CONCLUSIONS We identified a patient with hATTR-CM who possesses a rare TTRA81V mutation solely associated with cardiac complications. The slightly reduced kinetic stability of this mutation indicates its late-onset nature and contributes to the gradual progression of the disease.
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Affiliation(s)
- Qiuyan Sha
- Department of CardiologyThe First Affiliated Hospital of Dalian Medical University222 Zhongshan RoadDalianLiaoningChina
- CAS Key Laboratory of Separation Science for Analytical Chemistry, Dalian Institute of Chemical PhysicsChinese Academy of ScienceDalianLiaoningChina
| | - Yanli Zhang
- Department of CardiologyThe First Affiliated Hospital of Dalian Medical University222 Zhongshan RoadDalianLiaoningChina
| | - Mengdie Wang
- CAS Key Laboratory of Separation Science for Analytical Chemistry, Dalian Institute of Chemical PhysicsChinese Academy of ScienceDalianLiaoningChina
- University of Chinese Academy of SciencesBeijingChina
| | - Jialu Sun
- CAS Key Laboratory of Separation Science for Analytical Chemistry, Dalian Institute of Chemical PhysicsChinese Academy of ScienceDalianLiaoningChina
| | - Yunlong Zhang
- Department of CardiologyThe First Affiliated Hospital of Dalian Medical University222 Zhongshan RoadDalianLiaoningChina
| | - Xinxin Zhang
- Department of CardiologyThe First Affiliated Hospital of Dalian Medical University222 Zhongshan RoadDalianLiaoningChina
| | - Ning Wang
- Department of CardiologyThe First Affiliated Hospital of Dalian Medical University222 Zhongshan RoadDalianLiaoningChina
| | - Yu Liu
- CAS Key Laboratory of Separation Science for Analytical Chemistry, Dalian Institute of Chemical PhysicsChinese Academy of ScienceDalianLiaoningChina
| | - Ying Liu
- Department of CardiologyThe First Affiliated Hospital of Dalian Medical University222 Zhongshan RoadDalianLiaoningChina
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8
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Choy CH, Steeds RP, Pinney J, Baig S, Turvey-Haigh L, Wahid Y, Cox H, Zaphiriou A, Srinivasan V, Wilson D, Fryearson J, Ahamed M, Lim S, Chue C, Pratt G, Fontana M, Gillmore JD, Moody WE. Extending the reach of expert amyloidosis care: A feasibility study exploring the staged implementation of a UK amyloidosis network. Clin Med (Lond) 2024; 24:100004. [PMID: 38377730 PMCID: PMC10907332 DOI: 10.1016/j.clinme.2023.100004] [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] [Indexed: 02/22/2024]
Abstract
There has been an exponential increase in the diagnosis of transthyretin amyloid cardiomyopathy (ATTR-CA). In response, the Midlands Amyloidosis Service was launched with the aim of providing patients with a timely diagnosis, remote expertise from the National Amyloidosis Centre and access to emerging transthyretin (TTR)-directed therapies. This was a descriptive study of a pilot hub-and-spoke model of delivering specialist amyloidosis care. Patients with suspected amyloidosis were referred from the wider Midlands region, and seen in a consultant-led multidisciplinary clinic. The diagnosis of ATTR-CA was established according to either the validated non-biopsy criteria or histological confirmation of ATTR deposits with imaging evidence of amyloid. Study endpoints were the volume of service provision and the time to diagnosis from the receipt of referral. Patients (n=173, age 75±2 years; male 72 %) were referred between 2019 and 2021. Eighty patients (46 %) were found to have cardiac amyloidosis, of whom 68 (85 %) had ATTR-CA. The median time from referral to diagnosis was 43 days. By removing the need for patients to travel to London, an average of 187 patient-miles was saved. Fifteen (9 %) patients with wild-type ATTR-CA received tafamidis under the Early Access to Medicine scheme; 10 (6 %) were enrolled into phase 3 clinical trials of RNA interference or antisense oligonucleotide therapies. Our results suggest that implementing a UK amyloidosis network appears feasible and would enhance equity of access to specialised amyloidosis healthcare for the increasing numbers of older patients found to have ATTR-CA.
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Affiliation(s)
- Chern Hsiang Choy
- Midlands Amyloidosis Service, Centre for Rare Diseases, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Richard P Steeds
- Midlands Amyloidosis Service, Centre for Rare Diseases, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Jennifer Pinney
- Midlands Amyloidosis Service, Centre for Rare Diseases, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Shanat Baig
- Midlands Amyloidosis Service, Centre for Rare Diseases, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Lauren Turvey-Haigh
- Midlands Amyloidosis Service, Centre for Rare Diseases, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Yasmin Wahid
- Midlands Amyloidosis Service, Centre for Rare Diseases, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Helen Cox
- Midlands Amyloidosis Service, Centre for Rare Diseases, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Alex Zaphiriou
- Midlands Amyloidosis Service, Centre for Rare Diseases, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Venkataramanan Srinivasan
- Midlands Amyloidosis Service, Centre for Rare Diseases, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - David Wilson
- Department of Cardiology, Worcestershire Royal Hospital, Worcester, UK
| | - John Fryearson
- Department of Cardiology, Warwick Hospital, South Warwickshire University NHS Foundation Trust, Warwick, UK
| | - Mubarak Ahamed
- Department of Cardiology, Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Sern Lim
- Midlands Amyloidosis Service, Centre for Rare Diseases, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Colin Chue
- Midlands Amyloidosis Service, Centre for Rare Diseases, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Guy Pratt
- Midlands Amyloidosis Service, Centre for Rare Diseases, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Marianna Fontana
- Centre for Amyloidosis, Division of Medicine (Royal Free Campus), University College London, London, UK
| | - Julian D Gillmore
- Centre for Amyloidosis, Division of Medicine (Royal Free Campus), University College London, London, UK
| | - William E Moody
- Midlands Amyloidosis Service, Centre for Rare Diseases, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
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9
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Appunni S, Rubens M, Ramamoorthy V, Saxena A, Doke M, Roy M, Ruiz-Pelaez JG, Zhang Y, Ahmed A, Zhang Z, McGranaghan P, Chaparro S, Jimenez J. Adverse Outcomes in Hospitalizations for Amyloid-Related Heart Failure. Am J Cardiol 2023; 203:169-174. [PMID: 37499596 DOI: 10.1016/j.amjcard.2023.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 06/30/2023] [Accepted: 07/06/2023] [Indexed: 07/29/2023]
Abstract
Transthyretin amyloid cardiomyopathy is being increasingly recognized as an important cause of heart failure (HF). In this study, we looked at adverse outcomes in hospitalizations with amyloid-related HF. This study was a retrospective analysis of the National Inpatient Sample data, collected from 2016 to 2019. Patients ≥41 years of age and admitted for HF were included in the study. In these hospitalizations, amyloid-related HF was identified through the International Classification of Diseases, Tenth Revision, Clinical Modification codes for amyloidosis. The primary outcome of the study was in-hospital mortality, whereas secondary outcomes were prolonged length of stay, mechanical ventilation, mechanical circulatory support, vasopressors use, and dispositions other than home. From 2016 to 2019, there were 4,705,274 HF hospitalizations, of which 16,955 (0.4%) had amyloid cardiomyopathy. In all HF hospitalizations, amyloid-related increased from 0.26% in 2016 to 0.46% in 2019 (relative increase, 76.9%, P for trend <0.001). Amyloid-related HF hospitalizations were more common in older, male, and Black patients. The odds of in-hospital mortality (odds ratio [OR], 1.29; 95% confidence interval [CI]: 1.11 to 1.38), prolonged hospital length (OR, 1.61; 95% CI: 1.49 to 1.73) and vasopressors use (OR, 1.59; 95% CI: 1.23 to 2.05) were significantly higher for amyloid-related hospitalizations. Amyloid-related HF hospitalizations are increasing substantially and are associated with adverse hospital outcomes. These hospitalizations were disproportionately higher for older, male, and Black patients. Amyloid-related HF is rare and underdiagnosed yet has several adverse outcomes. Hence, healthcare providers should be watchful of this condition for early identification and prompt management.
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Affiliation(s)
| | - Muni Rubens
- Office of Clinical Research, Baptist Health South Florida, Miami, Florida; Department of Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida; Department of Health Science, Universidad Espíritu Santo, Ecuador
| | | | - Anshul Saxena
- Department of Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida; Center for Advanced Analytics, Baptist Health South Florida, Miami, Florida
| | - Mayur Doke
- Diabetic Research Institute, Miller School of Medicine, University of Miami, Miami, Florida
| | - Mukesh Roy
- Office of Clinical Research, Baptist Health South Florida, Miami, Florida
| | - Juan Gabriel Ruiz-Pelaez
- Department of Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
| | - Yanjia Zhang
- Center for Advanced Analytics, Baptist Health South Florida, Miami, Florida
| | - Ashfaq Ahmed
- Center for Advanced Analytics, Baptist Health South Florida, Miami, Florida
| | - Zhenwei Zhang
- Center for Advanced Analytics, Baptist Health South Florida, Miami, Florida
| | - Peter McGranaghan
- Office of Clinical Research, Baptist Health South Florida, Miami, Florida; Department of Internal Medicine and Cardiology, Charité Campus Virchow-Klinikum, Berlin, Germany
| | - Sandra Chaparro
- Department of Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida; Department of Medicine, Miami Cardiac & Vascular Institute, Baptist Health South Florida, Miami, Florida
| | - Javier Jimenez
- Department of Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida; Department of Medicine, Miami Cardiac & Vascular Institute, Baptist Health South Florida, Miami, Florida.
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10
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Haring B, Hunt RP, Shadyab AH, Eaton C, Kaplan R, Martin LW, Panjrath G, Kuller LH, Assimes T, Kooperberg C, Wassertheil-Smoller S. Cardiovascular Disease and Mortality in Black Women Carrying the Amyloidogenic V122I Transthyretin Gene Variant. JACC. HEART FAILURE 2023; 11:1189-1199. [PMID: 36930136 PMCID: PMC10508305 DOI: 10.1016/j.jchf.2023.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 02/08/2023] [Accepted: 02/15/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND Long-term data on cardiovascular disease (CVD) and mortality in female carriers of the transthyretin (TTR) V122I (pV142I) variant, one of the most common variants of hereditary transthyretin cardiac amyloidosis, are sparse and the effects of blood pressure, heart rate, body mass index, and physical activity on CVD outcomes remain largely unknown. OBJECTIVES The aim was to first examine the relationship of TTR V122I (pV142I) carrier status with CVD and mortality and second to investigate the effects of blood pressure, heart rate, body mass index, and physical activity in a large cohort of postmenopausal women. METHODS The study population consisted of 9,862 non-Hispanic Black/African American women, 9,529 noncarriers and 333 TTR V122I carriers, enrolled in the Women's Health Initiative at 40 centers in the United States. Women were generally healthy and postmenopausal at the time of enrollment (1993-1998). CVD was defined as a composite endpoint consisting of coronary heart disease, stroke, acute heart failure or CVD death, and all-cause mortality. CVD cases were based on self-reported annual mailed health updates. All information was centrally adjudicated by trained physicians. HRs and 95% CIs were obtained from adjusted Cox proportional hazards models. RESULTS Among 9,862 Black female participants (mean age: 62 years [IQR: 56-67 years]), the population frequency of the TTR V122I variant was 3.4% (333 variant carriers and 9,529 noncarriers). During a mean follow-up of 16.1 years (IQR: 9.7-22.2 years), incident CVD occurred in 2,229 noncarriers and 96 carriers, whereas 2,689 noncarriers and 108 carriers died. In adjusted models including demographic, lifestyle, and medical history covariates, TTR V122I carriers were at higher risk of the composite endpoint CVD (HR: 1.52; 95% CI: 1.22-1.88), acute heart failure (HR: 2.21; 95% CI: 1.53-3.18), coronary heart disease (HR: 1.80; 95% CI: 1.30-2.47), CVD death (HR: 1.70; 95% CI: 1.26-2.30), and all-cause mortality (HR: 1.28; 95% CI: 1.04-1.56). The authors found a significant interaction by age but not by blood pressure, heart rate, body mass index, or physical activity. CONCLUSIONS Black female TTR V122I (pV142I) carriers have a higher CVD and all-cause mortality risk compared to noncarriers. In case of clinical suspicion of amyloidosis, they should be screened for TTR V122I (pV142I) carrier status to ensure early treatment onset.
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Affiliation(s)
- Bernhard Haring
- Department of Medicine III, Saarland University Hospital, Homburg, Saarland, Germany; Department of Medicine I, University of Würzburg, Würzburg, Bavaria, Germany; Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA.
| | - Rebecca P Hunt
- Division of Public Health Sciences, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Aladdin H Shadyab
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California-San Diego, La Jolla, California, USA
| | - Charles Eaton
- Center for Primary Care and Prevention, Department of Family Medicine, Department of Epidemiology, Warren Alpert Medical Scholl of Brown University, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Robert Kaplan
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA; Division of Public Health Sciences, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Lisa Warsinger Martin
- Division of Cardiology, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Gurusher Panjrath
- Division of Cardiology, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Lewis H Kuller
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Themistocles Assimes
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA; VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Charles Kooperberg
- Division of Public Health Sciences, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Sylvia Wassertheil-Smoller
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA
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Rushakoff JA, Kransdorf EP, Kittleson MM, Neyer JR, Luthringer D, Patel JK. Atypical cardiac amyloidosis phenotypes identified at transplant: a case series. Eur Heart J Case Rep 2023; 7:ytad105. [PMID: 36923113 PMCID: PMC10010473 DOI: 10.1093/ehjcr/ytad105] [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: 10/03/2022] [Revised: 11/22/2022] [Accepted: 02/23/2023] [Indexed: 03/02/2023]
Abstract
Background Transthyretin amyloidosis (TTR) is increasingly implicated as an aetiology of advanced cardiomyopathy. Typically, both genetic variant (TTRv) and wild-type (TTRwt) amyloidosis present with a restrictive phenotype. We present a series of three patients who were found to have cardiac amyloidosis on explant following heart transplant (HT) who had atypical, non-restrictive phenotypes. Case Summary All three patients were men, three were Black, and only one had an alternative pre-HT explanation for their advanced, dilated cardiomyopathy. Pre-HT transthoracic echocardiograms were notable for left ventricular (LV) dilation (>95th percentile for height and gender), low EF, and normal LV wall thickness. Explants showed varying amounts of amyloid deposition, ranging from diffuse biventricular patterns to perivascular involvement. Mass spectrometry confirmed the presence of TTRv (two cases) and TTRwt (one case). Discussion Patients with dilated cardiomyopathy may harbour cardiac amyloidosis. Uncertainty remains regarding the contribution of amyloidosis to the development of a dilated phenotype. The pathogenic Val142Ile variant seen in two of these patients, a variant common in Black patients, suggests a need for further investigation into the potential relationship between TTRv amyloidosis and dilated cardiomyopathy.
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Affiliation(s)
- Joshua A Rushakoff
- Smidt Heart Institute, Cedars-Sinai Medical Center, 127 S. San Vicente Blvd, A3107, Los Angeles, CA 90048, USA
| | - Evan P Kransdorf
- Smidt Heart Institute, Cedars-Sinai Medical Center, 127 S. San Vicente Blvd, A3107, Los Angeles, CA 90048, USA
| | - Michelle M Kittleson
- Smidt Heart Institute, Cedars-Sinai Medical Center, 127 S. San Vicente Blvd, A3107, Los Angeles, CA 90048, USA
| | - Jonathan R Neyer
- Division of Cardiology, Kaiser Permanente, 1526 N Edgemont St., Fl 2, Los Angeles, CA 90027, USA
| | - Daniel Luthringer
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, 8700 Beverly Blvd., Los Angeles, CA 90048, USA
| | - Jignesh K Patel
- Smidt Heart Institute, Cedars-Sinai Medical Center, 127 S. San Vicente Blvd, A3107, Los Angeles, CA 90048, USA
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12
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Ream S, Ma J, Rodriguez T, Sarabia-Gonzalez A, Alvarado LA, Dwivedi AK, Mukherjee D. Ethnic/racial differences in risk factors and clinical outcomes among patients with amyloidosis. Am J Med Sci 2023; 365:232-241. [PMID: 36543303 DOI: 10.1016/j.amjms.2022.12.009] [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: 07/18/2022] [Revised: 10/21/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Cardiac amyloidosis is caused by abnormal extracellular deposition of insoluble fibrils in cardiac tissue. It can be fatal when untreated and is often underdiagnosed. Understanding the ethnic/racial differences in risk factors is critical for early diagnosis and treatment to improve clinical outcomes. METHODS We performed a retrospective cross-sectional study utilizing the National Inpatient Sample database from 2015 to 2018 using ICD-10-CM codes. The primary variables of interest were race/ethnicity and amyloidosis subtypes, while the primary outcomes were in-hospital mortality, gastrointestinal bleeding, renal failure, and hospital length-of-stay. RESULTS Amyloidosis was reported in 0.17% of all hospitalizations (N = 19,678,415). Of these, 0.09% were non-Hispanic whites, 0.04% were non-Hispanic blacks, and 0.02% were Hispanic. Hospitalizations with ATTR amyloidosis subtype were frequently observed in older individuals and males with coronary artery disease, whereas AL amyloidosis subtype was associated with non-Hispanic whites, congestive heart failure, and longer hospital length of stay. Renal failure was associated with non-Hispanic blacks (adjusted relative risk [RR] = 1.31, p < 0.001), Hispanics (RR = 1.08, p = 0.028) and had an increased risk of mortality. Similarly, the hospital length of stay was longer with non-Hispanic blacks (RR = 1.19, p < 0.001) and Hispanics (RR = 1.05, p = 0.03) compared to non-Hispanic whites. Hispanics had a reduced risk of mortality (RR = 0.77, p = 0.028) compared to non-Hispanic whites and non-Hispanic blacks, and no significant difference in mortality was seen between non-Hispanic whites and non-Hispanic blacks (RR = 1.00, p = 0.963). CONCLUSIONS Our findings highlight significant ethnic/racial differences in risk factors and outcomes among amyloidosis-related US hospitalizations that can possibly be used for early detection, treatment, and better clinical outcomes.
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Affiliation(s)
- Sarah Ream
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, United States
| | - Jennifer Ma
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, United States
| | - Tayana Rodriguez
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, United States
| | - Alejandro Sarabia-Gonzalez
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, United States
| | - Luis A Alvarado
- Biostatitsics and Epidemiology Consulting Lab (BECL), Office of Research, Texas Tech University of Health Sciences Center, El Paso, TX, United States
| | - Alok Kumar Dwivedi
- Biostatitsics and Epidemiology Consulting Lab (BECL), Office of Research, Texas Tech University of Health Sciences Center, El Paso, TX, United States; Department of Molecular and Translational Medicine, Paul L. Foster School of Medicine, Texas Tech University of Health Sciences Center, El Paso, TX, United States
| | - Debabrata Mukherjee
- Department of Internal Medicine, Texas Tech University Health Sciences Center at El Paso, TX, United States.
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13
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Muacevic A, Adler JR, Gajjar K, Kashyap K, Alpert C. Acute Decompensated Heart Failure Due to Combined Ischemic Cardiomyopathy and Cardiac Amyloidosis. Cureus 2022; 14:e32281. [PMID: 36628045 PMCID: PMC9816919 DOI: 10.7759/cureus.32281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2022] [Indexed: 12/12/2022] Open
Abstract
There are no established guidelines for the management of concurrent ischemic cardiomyopathy and cardiac amyloidosis due to the rarity of this phenomenon. We present the case of an African American woman in her 70s who was found to be in acute decompensated heart failure after she presented with progressive dyspnea. Initial workup revealed severe left ventricular systolic dysfunction with an ejection fraction of 20% and severe multivessel coronary artery disease, including severe left main disease. Multimodality imaging with cardiac MRI and technetium-99m pyrophosphate scintigraphy (PYP) during this hospital course revealed concurrent cardiac amyloidosis. Her systolic dysfunction was attributed to a combination of cardiac amyloidosis and ischemic cardiomyopathy. A multidisciplinary team comprised of interventional cardiology, cardiac surgery, and advanced heart failure amyloid specialists worked collaboratively to formulate an optimal treatment plan based on their collective clinical experiences and the limited literature, which ultimately resulted in a positive clinical outcome. Further investigation is needed to define treatment strategies specific to this patient population.
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14
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Barker N, Judge DP. Counseling Family Members and Monitoring for Evidence of Disease in Asymptomatic Carriers of Amyloid Transthyretin Cardiac Amyloidosis. Am J Cardiol 2022; 185 Suppl 1:S43-S50. [PMID: 36216601 DOI: 10.1016/j.amjcard.2022.09.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 09/09/2022] [Indexed: 01/30/2023]
Abstract
Transthyretin (TTR), a plasma transport protein produced in the liver, is prone to misfolding, leading to the deposition of amyloid fibrils and progressive dysfunction of cardiac and nervous system tissues, a condition known as amyloid TTR (ATTR) amyloidosis. More than 140 different pathogenic variants in TTR have been documented, most of which cause hereditary forms of ATTR amyloidosis. The most common mutations, traditionally known as Val30Met, Val122Ile, and Thr60Ala, lead to predominantly sensory, motor, and autonomic neuropathies, cardiomyopathy, and mixed presentations, respectively, although each mutation may cause symptoms across the neurologic and cardiac spectrum. Val30Met is endemic to Brazil, Japan, Portugal, and Sweden. The Val122Ile variant is present in 3.4% of people with West African ancestry, whereas Thr60Ala originated in northwestern Ireland and spread to the rest of the United Kingdom, the United States, and elsewhere. Val30Met and Thr60Ala tend to have more aggressive clinical presentations at younger ages, whereas Val122Ile predominantly affects older Black men. Due to similarities with hypertrophic cardiomyopathy, heart failure with preserved ejection fraction, and other overlapping conditions, ATTR cardiomyopathy is often under recognized and underdiagnosed, especially in Val122Ile carriers. Understanding these carrier populations and differences in ATTR amyloidosis characteristics associated with each variant is essential for appropriate diagnosis and genetic counseling of affected patients and their relatives.
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Affiliation(s)
- Naomi Barker
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Daniel P Judge
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina.
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15
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Banydeen R, Signate A, Tran TH, Monfort A, Neviere R, Inamo J. Cerebral Ischemic Events: An Overlooked Complication of Transthyretin Cardiac Amyloidosis in Afro-Caribbean Patients. Front Neurol 2022; 13:878292. [PMID: 35665045 PMCID: PMC9161261 DOI: 10.3389/fneur.2022.878292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 04/06/2022] [Indexed: 11/13/2022] Open
Abstract
AimThe link between transthyretin cardiac amyloidosis (CATTR), and cerebral ischemic events (CIE) has only been hinted at till now, impeding progress in patient management. We seek to evaluate the frequency and characteristics of CIE in Afro-Caribbean patients followed for CATTR at our institution.MethodsIn this single-center retrospective observational study, Afro-Caribbean patients followed for CATTR between July 2005 and October 2019 were included. Occurrence of CIE was investigated, and their cardioembolic origin determined. Analysis of patient characteristics was conducted according to CIE and CATTR profiles.ResultsOverall, 120 CATTR patients were included: 17 wild-type ATTR (14.2%), 73 ATTR-V122I (60.8%), and 22 ATTR-I107V (18.3%). Thirty-six patients (30.0%) presented with CIE, including three transient ischemic attacks and 33 permanent ischemic strokes (75.8% with a cardioembolic pattern). CIE was concomitant with CATTR diagnosis in 16 (16/36: 44.4%) patients, while 14 patients (14/36: 38.9 %) experienced CIE over a median CATTR follow-up of 2.0 years (min-max range: 0.8–4.4 years). CATTR-CIE patients presented with atrial fibrillation (66.7%), left atrial enlargement (77.8%), a CHA2DS2-VASc ≥ 3 (97.2%) and a high anticoagulant intake (75.0%). Multivariate analysis retained only a high CHA2DS2-VASc score as an independent predictor of CIE risk (Hazard Ratio [95% CI]: 12.03 [1.62–89.24]).ConclusionConcomitant CIE, and CATTR diagnosis, potentially carries a worse prognosis. A CHA2DS2-VASc score ≥3 seems to be a strong and independent predictive factor of CIE in CATTR patients. Further studies are needed to assess the efficacy and timeliness of anticoagulation in CATTR patients, independently of atrial fibrillation.
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Affiliation(s)
- Rishika Banydeen
- Clinical Research Department, CHU Martinique (University Hospital of Martinique), Fort de France, France
- Cardiovascular Research Team EA7525, Université des Antilles (University of the French West Indies), Fort de France, France
| | - Aissatou Signate
- Department of Neurology, CHU Martinique (University Hospital of Martinique), Fort de France, France
| | - Tuan-Huy Tran
- Department of Neurology, CHU Martinique (University Hospital of Martinique), Fort de France, France
| | - Astrid Monfort
- Cardiovascular Research Team EA7525, Université des Antilles (University of the French West Indies), Fort de France, France
- Department of Cardiology, CHU Martinique (University Hospital of Martinique), Fort de France, France
| | - Remi Neviere
- Cardiovascular Research Team EA7525, Université des Antilles (University of the French West Indies), Fort de France, France
- Department of Cardiology, CHU Martinique (University Hospital of Martinique), Fort de France, France
- *Correspondence: Remi Neviere
| | - Jocelyn Inamo
- Cardiovascular Research Team EA7525, Université des Antilles (University of the French West Indies), Fort de France, France
- Department of Cardiology, CHU Martinique (University Hospital of Martinique), Fort de France, France
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16
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Morris A, Shah KS, Enciso JS, Hsich E, Ibrahim NE, Page R, Yancy C. HFSA Position Statement The Impact of Healthcare Disparities on Patients with Heart Failure. J Card Fail 2022; 28:1169-1184. [PMID: 35595161 DOI: 10.1016/j.cardfail.2022.04.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 04/06/2022] [Accepted: 04/06/2022] [Indexed: 01/17/2023]
Abstract
Heart Failure (HF) remains a condition associated with high morbidity, mortality, and associated costs. Although the number of medical and device-based therapies available to treat HF are expanding at a remarkable rate, disparities in the risk for incident HF and treatments delivered to patients are also of growing concern. These disparities span across racial and ethnic groups, socioeconomic status, and apply across the spectrum of HF from Stage A to Stage D. The complexity of HF risk and treatment is further impacted by the number of patients who experience the downstream impact of social determinants of health. The purpose of this document is to highlight the known healthcare disparities that exist in the care of patients with HF, and to provide a context for how clinicians and researchers should assess both biologic and social determinants of HF risk in vulnerable populations. Furthermore, this document will provide a framework for future steps that can be utilized to help diminish inequalities in access and clinical outcomes over time, and offer solutions to help reduce disparities within HF care.
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Affiliation(s)
| | | | | | | | | | - Robert Page
- 1462 Clifton Road Suite 504, Atlanta GA 30322
| | - Clyde Yancy
- 1462 Clifton Road Suite 504, Atlanta GA 30322
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17
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Nunes NSV, Mesquita ET, Mesquita CT, Benchimol-Barbosa PR. First-degree Atrioventricular Block as an Early Marker of Advanced Disease of the Conduction System in a Patient with Hereditary Val142Ile Cardiac Amyloidosis. INTERNATIONAL JOURNAL OF CARDIOVASCULAR SCIENCES 2022. [DOI: 10.36660/ijcs.20210081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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18
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Hong CC. The grand challenge of discovering new cardiovascular drugs. FRONTIERS IN DRUG DISCOVERY 2022; 2:1027401. [PMID: 37123434 PMCID: PMC10134778 DOI: 10.3389/fddsv.2022.1027401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
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19
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Piña IL, Jimenez S, Lewis EF, Morris AA, Onwuanyi A, Tam E, Ventura HO. Race and Ethnicity in Heart Failure: JACC Focus Seminar 8/9. J Am Coll Cardiol 2021; 78:2589-2598. [PMID: 34887145 DOI: 10.1016/j.jacc.2021.06.058] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/03/2021] [Accepted: 06/04/2021] [Indexed: 12/15/2022]
Abstract
Heart failure (HF) affects >6 million Americans, with variations in incidence, prevalence, and clinical outcomes by race/ethnicity. Black adults have the highest risk for HF, with earlier age of onset and the highest risk of death and hospitalizations. The risk of hospitalizations for Hispanic patients is higher than White patients. Data on HF in Asian individuals are more limited. However, the higher burden of traditional cardiovascular risk factors, particularly among South Asian adults, is associated with increased risk of HF. The role of environmental, socioeconomic, and other social determinants of health, more likely for Black and Hispanic patients, are increasingly recognized as independent risk factors for HF and worse outcomes. Structural racism and implicit bias are drivers of health care disparities in the United States. This paper will review the clinical, physiological, and social determinants of HF risk, unique for race/ethnic minorities, and offer solutions to address systems of inequality that need to be recognized and dismantled/eradicated.
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Affiliation(s)
| | | | | | - Alanna A Morris
- Emory University, Atlanta, Georgia, USA. https://twitter.com/morrismd
| | | | - Edlira Tam
- Montefiore Medical Center, Bronx, New York, USA
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20
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Elliott P, Drachman BM, Gottlieb SS, Hoffman JE, Hummel SL, Lenihan DJ, Ebede B, Gundapaneni B, Li B, Sultan MB, Shah SJ. Long-Term Survival With Tafamidis in Patients With Transthyretin Amyloid Cardiomyopathy. Circ Heart Fail 2021; 15:e008193. [PMID: 34923848 PMCID: PMC8763250 DOI: 10.1161/circheartfailure.120.008193] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background: Tafamidis is approved in many countries for the treatment of transthyretin amyloid cardiomyopathy. This study reports data on the long-term efficacy of tafamidis from an ongoing long-term extension (LTE) to the pivotal ATTR-ACT (Tafamidis in Transthyretin Cardiomyopathy Clinical Trial). Methods: Patients with transthyretin amyloid cardiomyopathy who completed ATTR-ACT could enroll in an LTE, continuing with the same tafamidis dose or, if previously treated with placebo, randomized (2:1) to tafamidis meglumine 80 or 20 mg. All patients in the LTE transitioned to tafamidis free acid 61 mg (bioequivalent to tafamidis meglumine 80 mg) following a protocol amendment. In this interim analysis, all-cause mortality was assessed in patients treated with tafamidis meglumine 80 mg in ATTR-ACT continuing in the LTE, compared with those receiving placebo in ATTR-ACT transitioning to tafamidis in the LTE. Results: Median follow-up was 58.5 months in the continuous tafamidis group (n=176) and 57.1 months in the placebo to tafamidis group (n=177). There were 79 (44.9%) deaths with continuous tafamidis and 111 (62.7%) with placebo to tafamidis (hazard ratio, 0.59 [95% CI, 0.44–0.79]; P<0.001). Mortality was also reduced in the continuous tafamidis (versus placebo to tafamidis) subgroups of: variant transthyretin amyloidosis (0.57 [0.33–0.99]; P=0.05) and wild-type transthyretin amyloidosis (0.61 [0.43–0.87]; P=0.006); and baseline New York Heart Association class I and II (0.56 [0.38–0.82]; P=0.003) and class III (0.65 [0.41–1.01]; P=0.06). Conclusions: In the LTE, patients initially treated with tafamidis in ATTR-ACT had substantially better survival than those first treated with placebo, highlighting the importance of early diagnosis and treatment in transthyretin amyloid cardiomyopathy. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01994889 and NCT02791230.
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Affiliation(s)
| | - Brian M Drachman
- Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia (B.M.D.)
| | | | | | - Scott L Hummel
- University of Michigan and Ann Arbor Veterans Affairs Health System (S.L.H.)
| | - Daniel J Lenihan
- Washington University School of Medicine, St. Louis, MO (D.J.L.)
| | | | | | | | | | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.)
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Kyrouac D, Schiffer W, Lennep B, Fergestrom N, Zhang KW, Gorcsan J, Lenihan DJ, Mitchell JD. Echocardiographic and clinical predictors of cardiac amyloidosis: limitations of apical sparing. ESC Heart Fail 2021; 9:385-397. [PMID: 34877800 PMCID: PMC8788049 DOI: 10.1002/ehf2.13738] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 10/22/2021] [Accepted: 11/11/2021] [Indexed: 01/15/2023] Open
Abstract
Aims The accuracy of an apical‐sparing strain pattern on transthoracic echocardiography (TTE) for predicting cardiac amyloidosis (CA) has varied in prior studies depending on the underlying cohort. We sought to evaluate the performance of apical sparing and other TTE strain findings to screen for CA in an unselected population and determine the frequency that patients with echocardiographic concern for CA undergo evaluation for amyloidosis in clinical practice. Methods and results As strain is routinely performed at our institution on all clinical TTEs, we identified all TTEs performed from 2016 through 2019 with reported concern for CA or apical sparing. We determined the performance characteristics for echocardiographic strain findings in discriminating CA including apical sparing, the ejection fraction to global longitudinal strain ratio (EF/GLS), and the septal apical–septal basal ratio (SA/SB); other clinical predictors of confirmed CA; and predictors of patients who underwent complete evaluation for CA. CA was confirmed by endomyocardial biopsy or diagnostic cardiac imaging. A total of 547 TTEs, representing 451 patients, reported concern for CA and had adequate strain for analysis. A total of 111 patients underwent complete evaluation for amyloidosis with 100 patients undergoing complete cardiac evaluation for CA. In those 100 patients, multivariable predictors of confirmed CA were age [odds ratio (OR) 3.37 per 5 years], a visual apical‐sparing pattern (OR 10.85), and left ventricular ejection fraction (LVEF)/GLS > 4.1 (OR 35.37). CA was less likely in those with coronary artery disease (OR 0.04), hypertension (OR 0.18), and increased systolic blood pressure (OR 0.60 per 5 mm Hg increase). SA/SB [area under the curve (AUC) 0.72, 95% confidence interval (CI) 0.60–0.84] and LVEF/GLS (AUC 0.72, 95% CI 0.60–0.84) both had improved discrimination for CA compared with the apical‐sparing ratio (AUC 0.66, 95% CI 0.54–0.79). Many patients with suggestive TTE findings did not receive an evaluation for amyloidosis. Complete evaluation was more likely with Caucasian race (OR 2.1), increased septal thickness (OR 1.4), increased body mass index (OR 1.2), and if the report specifically stated ‘amyloid’ (OR 1.9). Evaluations were less likely in patients with comorbidities. While hypertension reduced the likelihood of evaluating for CA, 34% of patients with CA had hypertension (>130/80 mm Hg) at time of diagnosis. Conclusions In a broad population of patients undergoing TTE, apical sparing on strain imaging increased the likelihood of CA diagnosis but with modest sensitivity and specificity. GLS/EF ratio may be a more reliable tool to screen for CA. The low rate of complete evaluation in patients with concerning TTE findings indicates a strong need for practice improvement and enhanced disease awareness.
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Affiliation(s)
- Douglas Kyrouac
- Division of General Medical Sciences, Washington University School of Medicine, St. Louis, MO, USA
| | - Walter Schiffer
- Division of General Medical Sciences, Washington University School of Medicine, St. Louis, MO, USA
| | - Brandon Lennep
- Cardiovascular Division, University of Mississippi School of Medicine, Jackson, MS, USA
| | - Nicole Fergestrom
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Kathleen W Zhang
- Cardio-Oncology Center of Excellence, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO, USA
| | - John Gorcsan
- Cardio-Oncology Center of Excellence, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO, USA
| | - Daniel J Lenihan
- Cardio-Oncology Center of Excellence, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO, USA
| | - Joshua D Mitchell
- Cardio-Oncology Center of Excellence, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO, USA
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22
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Zhao H, Hu H, Cui W. Performance of bone tracer for diagnosis and differentiation of transthyretin cardiac amyloidosis: a systematic review and meta-analysis. DIAGNOSTIC AND INTERVENTIONAL RADIOLOGY (ANKARA, TURKEY) 2021; 27:802-810. [PMID: 34792038 DOI: 10.5152/dir.2021.20662] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE Bone tracers have been validated for many years in detecting transthyretin cardiac amyloidosis (TTR-CA). However, several new studies suggest conflicting results. Our study aimed to systematically evaluate the accuracy of bone radiotracers for diagnosis and differentiation of TTR-CA via a systematic review and meta-analysis. METHODS We retrieved articles assessing the performance of bone tracer in diagnosing and differentiating TTR-CA from PubMed, the Cochrane Library, ScienceDirect, and DOAJ databases, dating up to 10 July 2020. The meta-analysis was conducted through Stata 16 software, and the risk of bias for the included studies was assessed by the QUADAS-2 tool. Moreover, we made a comprehensive review. RESULTS Fourteen articles were included in the systematic review, and 9 in the meta-analysis. The pooled sensitivity was 0.97 (95% confidence interval [95% CI] 0.85-0.99) with heterogeneity (I2=73.5, 95% CI 55.6-91.2), and the specificity was 0.92 (95% CI 0.82-0.96) with heterogeneity (I2=42.0, 95% CI 0.0-86.9). The pooled positive and negative likelihood ratios were 11.49 (95% CI 5.07-26.0) and 0.03 (95% CI 0.01-0.18), respectively. The diagnostic odds ratio was 341 (95% CI 53-2194), and the area under the receiver operating characteristic curve was 0.96 (95% CI 0.94-0.97). CONCLUSION The findings evidence that the bone radiotracer is a valuable noninvasive approach that provides high accuracy for diagnosing TTR-CA and plays a modest role in differentiating TTR-CA from immunoglobulin amyloid light-chain cardiac amyloidosis. 99mTc-HMDP may be more accurate than 99mTc-PYP, 99mTc-DPD, and 18F-NaF in the TTR-CA detecting process, and 18F-NaF is a promising bone tracer to diagnose and differentiate TTR-CA.
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Affiliation(s)
- Hongliang Zhao
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China;Institute of Cardiocerebrovascular Disease of Hebei Province, Shijiazhuang, China; Department of Cardiology, The First Hospital of Hebei Medical University, Shijiazhuang, China
| | - Haijuan Hu
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China; Institute of Cardiocerebrovascular Disease of Hebei Province, Shijiazhuang, China
| | - Wei Cui
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China;Institute of Cardiocerebrovascular Disease of Hebei Province, Shijiazhuang, China
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Tushak ZJ, Doshi A, Trankle CR, Rao K, Cei L, Shah KB. Phenotypic Spectrum of Transthyretin Cardiac Amyloidosis in a Family: Impact of Mutation Zygosity and Sex. JACC CardioOncol 2021; 3:602-605. [PMID: 34729535 PMCID: PMC8543089 DOI: 10.1016/j.jaccao.2021.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 07/27/2021] [Accepted: 07/28/2021] [Indexed: 01/15/2023] Open
Key Words
- ATTR, transthyretin amyloidosis
- CMR, cardiac magnetic resonance imaging
- HCL, heart to contralateral lung (uptake ratio for PYP scan)
- NT-proBNP, N-terminal pro–B-type natriuretic peptide
- PYP, technetium-99m pyrophosphate (scan)
- SPECT, single-photon emission computed tomography
- TTE, transthoracic echocardiogram
- TTR, transthyretin
- V122I, valine substitution for isoleucine at position 122
- amyloidosis
- cardiomyopathy
- gender differences
- genetic variability
- hATTR, hereditary transthyretin amyloidosis
- heart failure
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Affiliation(s)
- Zackary J Tushak
- Division of Cardiology, Virginia Commonwealth University Health, Pauley Heart Center, Richmond, Virginia, USA
| | - Amar Doshi
- Division of Cardiology, Virginia Commonwealth University Health, Pauley Heart Center, Richmond, Virginia, USA
| | - Cory R Trankle
- Division of Cardiology, Virginia Commonwealth University Health, Pauley Heart Center, Richmond, Virginia, USA
| | - Kris Rao
- Division of Cardiology, Virginia Commonwealth University Health, Pauley Heart Center, Richmond, Virginia, USA
| | - Laura Cei
- Division of Cardiology, Virginia Commonwealth University Health, Pauley Heart Center, Richmond, Virginia, USA
| | - Keyur B Shah
- Division of Cardiology, Virginia Commonwealth University Health, Pauley Heart Center, Richmond, Virginia, USA
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Warner AL. Advances in the treatment of transthyretin cardiac amyloidosis: Current and emerging therapies. Pharmacotherapy 2021; 41:1081-1091. [PMID: 34669976 DOI: 10.1002/phar.2639] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 09/04/2021] [Accepted: 09/29/2021] [Indexed: 12/11/2022]
Abstract
Transthyretin cardiac amyloidosis (ATTR-CA) has been recognized as an underdiagnosed and undertreated cause of heart failure with often unrecognized multiorgan involvement. Guideline development and the establishment of nonbiopsy criteria for diagnosis of ATTR-CA have led to an increased rate of diagnosis and hence patients referred for therapies. ATTR is a protein misfolding disorder where the TTR tetramer disassociates into monomers which form insoluble amyloid depositions in organs, including the heart. ATTR-CA can be due to autosomal dominant transmitted gene mutation or due to misfolding of wild-type TTR. Prior to 2019, there were no FDA-approved pharmacological treatments for ATTR-CA. Understanding of ATTR-CA pathogenesis has enabled development of targeted strategies with novel disease-modifying therapies. Current and emerging therapies for ATTR-CA include (1) TTR gene silencing (siRNA, ASO, CRISPR/Cas9), (2) TTR tetramer stabilization, and (3) TTR amyloid fibril degradation. This review focuses on the pathophysiology of ATTR-CA, diagnostic criteria, and addresses current and emerging treatments for this diverse disorder.
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Affiliation(s)
- Alberta L Warner
- Division of Cardiology, Veterans Affairs Greater Los Angeles Healthcare System and University of California, Los Angeles, California, USA
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Singal AK, Bansal R, Singh A, Dorbala S, Sharma G, Gupta K, Saxena A, Bhargava B, Karthikeyan G, Ramakrishnan S, Bisoi AK, Hote MP, Rajashekar P, Chowdhury UK, Devagourou V, Patel C, Ray R, Arawa SK, Mishra S. Concomitant Transthyretin Amyloidosis and Severe Aortic Stenosis in Elderly Indian Population: A Pilot Study. JACC CardioOncol 2021; 3:565-576. [PMID: 34746852 PMCID: PMC8551518 DOI: 10.1016/j.jaccao.2021.08.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 08/15/2021] [Accepted: 08/18/2021] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Prevalence of both degenerative severe aortic stenosis (AS) and transthyretin cardiac amyloidosis (ATTR-CA) increases with age. Dual disease (AS+myocardial ATTR-CA) occurs in significant proportion of patients undergoing surgical aortic valve replacement (SAVR). OBJECTIVES This study aimed to determine the prevalence of ATTR-CA in severe AS in the Indian population, identify noninvasive predictors of its diagnosis, and understand its impact on prognosis. METHODS Symptomatic severe AS patients aged ≥65 years undergoing SAVR were enrolled. ATTR-CA diagnosis was based on preoperative 99m-technetium pyrophosphate (PYP) scan and intraoperatively obtained basal interventricular septum biopsy for myocardial ATTR-CA, and excised native aortic valve for isolated valvular ATTR-CA. Primary amyloidosis was excluded by serum/urine protein electrophoresis with serum immunofixation. RESULTS SAVR was performed in 46 AS patients (age 70 ± 5 years, 70% men). PYP scan was performed for 32 patients, with significant PYP uptake in 3 (n = 3 of 32, 9.4%), suggestive of myocardial ATTR-CA. On histopathological examination, none of the interventricular septum biopsy specimens had amyloid deposits, whereas 33 (71.7%) native aortic valves showed amyloid deposits, of which 19 (57.6%) had transthyretin deposition suggestive of isolated valvular amyloidosis. Noninvasive markers of dual disease included low myocardial contraction fraction (median [interquartile range], 28.8% [23.8% to 39.1%] vs 15.3% [9.3% to 16.1%]; P = 0.006), deceleration time (215 [144 to 236] ms vs 88 [60 to 106] ms; P = 0.009) and global longitudinal strain (-18.7% [-21.1% to -16.9%] vs -14.2% [-17.0% to -9.7%]; P = 0.030). At 1-year follow-up, 2 patients died (4.3%); 1 each in myocardial ATTR-CA negative and positive groups (3.4% vs 33.3%; P = 0.477). CONCLUSIONS Dual disease is not uncommon in India. Isolated valvular amyloidosis in severe AS is much more common.
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Key Words
- 99m-technetium pyrophosphate scan
- 99mTc-PYP, 99m-technetium pyrophosphate
- AL-CA, light chain cardiac amyloidosis
- AS, aortic stenosis
- ATTR-CA, transthyretin cardiac amyloidosis
- EMB, endomyocardial biopsy
- GLS, global longitudinal strain
- IHC, immunohistochemistry
- LfLg AS, low-flow, low-gradient aortic stenosis
- SAVR, surgical aortic valve replacement
- TAVR, transcatheter aortic valve replacement
- TTR, transthyretin
- dual aortic stenosis transthyretin cardiac amyloidosis
- severe aortic stenosis
- transthyretin cardiac amyloidosis
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Affiliation(s)
| | | | - Avinainder Singh
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Sharmila Dorbala
- Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Kartik Gupta
- Department of Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| | - Anita Saxena
- Department of Cardiology, AIIMS, New Delhi, India
| | - Balram Bhargava
- Department of Cardiology, AIIMS, New Delhi, India
- Indian Council of Medical Research, New Delhi, India, and Department of Health Research (Ministry of Health and Family Welfare), Government of India, New Delhi, India
| | | | | | | | | | | | | | | | - Chetan Patel
- Department of Nuclear Medicine, AIIMS, New Delhi, India
| | - Ruma Ray
- Department of Pathology, AIIMS, New Delhi, India
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Abstract
Heritable cardiac amyloidosis (CA) is an underrecognized cause of morbidity and mortality in the USA. It results from the accumulation of the misfolded protein transthyretin within the myocardium, resulting in amyloid transthyretin-associated cardiomyopathy (ATTR-CM). Over 150 different pathologic point mutations within the transthyretin gene have been identified, each carrying variable clinical phenotypes and penetrance. In the USA, the most common cause of hereditary ATTR is the Val122Ile point mutation, with a prevalence of 3.4-4.0% in North Americans of African and Caribbean descent. Among Caucasians with hereditary ATTR-CM, the V30M mutation is the most commonly identified variant. Overall, the incidence of ATTR disease in the USA has been increasing, likely due to an increase in practitioner awareness, utilization of new non-invasive imaging technologies for ATTR diagnosis, and the growth of multidisciplinary amyloid programs across the country. Yet significant numbers of patients with evidence of left ventricular thickening on cardiac imaging, senile aortic stenosis, and/or symptoms of heart failure with preserved ejection fraction likely have undiagnosed CA, especially within the African American population. With the emergence of new disease-modifying therapies for ATTR, recognition and the prompt diagnosis of CA is important for patients and their potentially affected progeny. Herein, we review the genetics of heritable CA as well as the importance of genetic counseling and testing for patients and their families.
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Affiliation(s)
- Scott Arno
- Henry Ford Hospitals, 2799 W. Grand Blvd, K14 Cardiology, Detroit, MI, 48202, USA
| | - Jennifer Cowger
- Henry Ford Hospitals, 2799 W. Grand Blvd, K14 Cardiology, Detroit, MI, 48202, USA.
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Oye M, Dhruva P, Kandah F, Oye M, Missov E. Cardiac amyloid presenting as cardiogenic shock: case series. EUROPEAN HEART JOURNAL-CASE REPORTS 2021; 5:ytab252. [PMID: 34377906 PMCID: PMC8343451 DOI: 10.1093/ehjcr/ytab252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 10/28/2020] [Accepted: 06/09/2021] [Indexed: 11/17/2022]
Abstract
Background Amyloidosis is a systemic infiltrative disease that can affect nearly every organ in the human body. It is characterized by the deposition of misfolded protein within various tissues and organs. Once there is cardiac involvement this portends a worse prognosis. Case summary We describe a case series of two patients with cardiac amyloidosis presenting as a cardiogenic shock. There were several missed opportunities in diagnosing cardiac amyloid prior to their fatal presentations. In the first case, a 65-year-old African-American male patient presented with worsening shortness of breath and signs of heart failure. Echocardiography revealed preserved ejection fraction. He was diagnosed with light chain subtype of cardiac amyloidosis, and rapidly deteriorated during his admission. Patient in the second case is a 75-year-old African-American female who presented with worsening heart failure and hypotension. Echocardiography revealed reduced ejection fraction. She was diagnosed with transthyretin cardiac amyloid. Her clinical status worsened during admission and she went into cardiogenic shock requiring multiple vasopressors. Discussion This case series discusses two incidences of cardiac amyloidosis presenting as cardiogenic shock in African-American patients. This article postulates that cardiac amyloidosis may be misdiagnosed for more common causes of heart failure especially among this demographic group. Once patients with cardiac amyloid present with cardiogenic shock their clinical course is typically rapidly fatal despite aggressive measures. Earlier detection is imperative to prevent poor outcomes.
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Affiliation(s)
- Monique Oye
- Department of Internal Medicine, Internal Medicine Resident, UF Health Jacksonville, 655, W 8th street, Jacksonville, FL 32209-6595, USA
| | - Pooja Dhruva
- Department of Internal Medicine, Internal Medicine Resident, UF Health Jacksonville, 655, W 8th street, Jacksonville, FL 32209-6595, USA
| | - Fadi Kandah
- Department of Internal Medicine, Internal Medicine Resident, UF Health Jacksonville, 655, W 8th street, Jacksonville, FL 32209-6595, USA
| | - Melissa Oye
- Department of Internal Medicine, Internal Medicine Resident, UF Health Jacksonville, 655, W 8th street, Jacksonville, FL 32209-6595, USA
| | - Emil Missov
- Department of Cardiology, UF Health Jacksonville, 655 W 8th street, Jacksonville, FL 32209-6595, USA
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Ohiomoba RO, Youmans QR, Ezema A, Akanyirige P, Anderson AS, Bryant A, Jackson K, Mandieka E, Pham DT, Rich JD, Yancy CW, Okwuosa IS. Cardiac transplantation outcomes in patients with amyloid cardiomyopathy. Am Heart J 2021; 236:13-21. [PMID: 33621542 DOI: 10.1016/j.ahj.2021.02.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 02/16/2021] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Amyloid cardiomyopathy (ACM) is a progressive and life-threatening disease caused by abnormal protein deposits within cardiac tissue. The most common forms of ACM are caused by immunoglobulin derived light chains (AL) and transthyretin (TTR). Orthotopic heart transplantation (OHT) remains the definitive treatment for patients with end stage heart failure. In this study, we perform a contemporary multicenter analysis evaluating post OHT survival in patients with ACM. METHODS We conducted a multicenter analysis of 40,044 adult OHT recipients captured in the United Network for Organ Sharing (UNOS) registry from 1987-2018. Patients were characterized as ACM or non-ACM. Baseline characteristics were obtained, and summary characteristics were calculated. Outcomes of interest included post-transplant survival, infection, treated rejection, and the ability to return to work. Racial differences in OHT survival were also analyzed. Unadjusted associations between ACM and non-ACM survival were determined using the Kaplan-Meier estimations and confounding was addressed using multivariable Cox proportional hazards models. RESULTS Three hundred ninety-eight patients with a diagnosis of ACM were identified of which 313 underwent heart only OHT. ACM patients were older (61 vs 53; P < .0001) and had a higher proportion of African Americans (30.7% vs 17.6%; P < .0001). Median survival for ACM was 10.2 years vs 12.5 years in non-ACM (P = .01). After adjusting for confounding, ACM patients had a higher likelihood of death post-OHT (HR 1.39 CI: 1.14, 1.70; P = .001). African American ACM patients had a higher likelihood of survival compared to White ACM patients (HR 0.51 CI 0.31-0.85; P = .01). No difference was observed in episodes of treated rejection (OR 0.63 CI 0.23, 1.78; P = .39), hospitalizations for infections (OR 1.24 CI: 0.85, 1.81; P = .26), or likelihood of returning to work for income (OR 1.23 CI: 0.84, 1.80; P = .30). CONCLUSIONS In this analysis of OHT in ACM, ACM was associated with a higher likelihood of post-OHT mortality. Racial differences in post-OHT were observed with African American patients with ACM having higher likelihood of survival compared to White patients with ACM. No differences were observed in episodes of treated rejection, hospitalization for infection, or likelihood to return to work for income.
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Affiliation(s)
| | | | - Ashley Ezema
- Northwestern University, Feinberg School of Medicine
| | - P Akanyirige
- Northwestern University, Feinberg School of Medicine
| | | | | | | | | | - Duc T Pham
- Northwestern University, Department of Cardiac Surgery
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Rozenbaum MH, Large S, Bhambri R, Stewart M, Whelan J, van Doornewaard A, Dasgupta N, Masri A, Nativi-Nicolau J. Impact of Delayed Diagnosis and Misdiagnosis for Patients with Transthyretin Amyloid Cardiomyopathy (ATTR-CM): A Targeted Literature Review. Cardiol Ther 2021; 10:141-159. [PMID: 33877591 PMCID: PMC8126532 DOI: 10.1007/s40119-021-00219-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Transthyretin amyloid cardiomyopathy (ATTR-CM) is a progressive, fatal and under-recognized disease. This targeted literature review assessed the extent and consequences of diagnostic delay and misdiagnosis in ATTR-CM. METHODS The Embase database was searched together with proceedings of eight cardiology conferences to identify publications or abstracts on ATTR-CM. Outcomes of interest were time from symptom onset to diagnosis, rates of delayed diagnosis and misdiagnosis, and costs, healthcare resource use or clinical outcomes whilst undiagnosed/misdiagnosed. RESULTS Twenty-three articles were included. Weighted means of reported mean and median diagnostic delays were 6.1 and 3.4 years for wild-type (ATTRwt-CM) and 5.7 and 2.6 years for hereditary (ATTRv-CM). Misdiagnosis occurred in 34-57% of patients when reported. Evaluation and misdiagnosis by multiple healthcare providers before receiving an ATTR-CM diagnosis was common, and there was evidence that patients undergo unnecessary or inappropriate evaluations or treatments while misdiagnosed. Diagnostic "red flags" were reported to be underused. Data on the consequences of delay for patients and health systems were sparse, but given the progressive nature of ATTR-CM, delay is likely to have adverse consequences. CONCLUSION ATTR-CM patients commonly experience diagnostic delay and misdiagnosis. Efforts are required to provide timely diagnosis so that patients can benefit from earlier access to new disease-modifying therapies.
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Affiliation(s)
| | | | | | | | | | | | - Noel Dasgupta
- Division of Cardiology and Department of Pathology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ahmad Masri
- Division of Cardiovascular Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Jose Nativi-Nicolau
- University of Utah Health Sciences Center and Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA.
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Cardiac Amyloidosis Presenting as Biventricular Systolic Heart Failure. Case Rep Cardiol 2021; 2021:6671469. [PMID: 33868731 PMCID: PMC8035018 DOI: 10.1155/2021/6671469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 03/18/2021] [Accepted: 03/24/2021] [Indexed: 11/29/2022] Open
Abstract
A previously healthy octogenarian presented with new onset heart failure symptoms. Comprehensive multimodality imaging including complete echocardiography with longitudinal strain analysis, cardiac magnetic resonance imaging (cMRI), nuclear medicine pyrophosphate (99-mcTcPYP) scan along with biomarker, monoclonal protein analysis, and fat pad biopsy confirmed diagnosis of transthyretin cardiac amyloidosis.
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31
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Pathak GA, Wendt FR, De Lillo A, Nunez YZ, Goswami A, De Angelis F, Fuciarelli M, Kranzler HR, Gelernter J, Polimanti R. Epigenomic Profiles of African-American Transthyretin Val122Ile Carriers Reveals Putatively Dysregulated Amyloid Mechanisms. CIRCULATION-GENOMIC AND PRECISION MEDICINE 2021; 14:e003011. [PMID: 33428857 DOI: 10.1161/circgen.120.003011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The Val122Ile mutation in Transthyretin (TTR) gene causes a rare, difficult to diagnose hereditary form of cardiac amyloidosis. This mutation is most common in the United States and mainly present in people of African descent. The carriers have an increased risk of congestive heart failure, peripheral edema, and several other noncardiac phenotypes such as carpal tunnel syndrome, and arthroplasty which are top reasons for ambulatory/outpatient surgeries (OSs) in the country. METHODS We conducted first-ever epigenome-wide association study using the Illumina's EPIC array, in Val122Ile carriers of African descent for heart disease and multiple OSs-an early disease indicator. Differential methylation across genome wide cytosine-phosphate guanine (CpG) sites was tested between carriers with and without heart disease and OS. Significant CpG sites were investigated for cis-mQTLs loci, followed by gene ontology and protein-protein interaction network. We also investigated the significant CpG sites in a secondary cohort of carriers for replication. RESULTS Five differentially methylated sites (P≤2.1×10-8) in genes-FAM129B, SKI, WDR27, GLS, and an intergenic site near RP11-550A5.2, and one differentially methylated region containing KCNA6 and GALNT3 (P=1.1×10-12) were associated with heart disease. For OS, we observe 4 sites-2 sites in UBE2E3 and SEC14L5, and other 2 in intergenic regions (P≤1.8×10-7) and 3 regions overlapping SH3D21, EVA1B, LTB4R2, and CIDEB (P≤3.9×10-7). Functional protein-interaction module analysis identified ABCA1 (P=0.001) for heart disease. Six cis-mQTLs were associated with one of the significant CpG sites (FAM129B; P=4.1×10-24). We replicated 2 CpG sites (cg18546846 and cg06641417; P<0.05) in an external cohort of biopsy-confirmed cases of TTR (transthyretin) amyloidosis. The genes identified are involved in transport and clearance of amyloid deposits (GLS, ABCA1, FAM129B); cardiac fibrosis (SKI); and muscle tissue regulation (SKI, FAM129B). CONCLUSIONS These findings highlight the link between a complex amyloid circuit and diverse symptoms of Val122Ile.
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Affiliation(s)
- Gita A Pathak
- Department of Psychiatry, Yale School of Medicine, Yale University, New Haven (G.A.P., F.R.W., Y.Z.N., A.G., F.D.A., J.G., R.P.).,Veteran Affairs Connecticut Healthcare System, West Haven, CT (G.A.P., F.R.W., Y.Z.N., A.G., F.D.A., J.G., R.P.)
| | - Frank R Wendt
- Department of Psychiatry, Yale School of Medicine, Yale University, New Haven (G.A.P., F.R.W., Y.Z.N., A.G., F.D.A., J.G., R.P.).,Veteran Affairs Connecticut Healthcare System, West Haven, CT (G.A.P., F.R.W., Y.Z.N., A.G., F.D.A., J.G., R.P.)
| | - Antonella De Lillo
- Department of Biology, University of Rome Tor Vergata, Italy (A.D.L., F.D.A., M.F.)
| | - Yaira Z Nunez
- Department of Psychiatry, Yale School of Medicine, Yale University, New Haven (G.A.P., F.R.W., Y.Z.N., A.G., F.D.A., J.G., R.P.).,Veteran Affairs Connecticut Healthcare System, West Haven, CT (G.A.P., F.R.W., Y.Z.N., A.G., F.D.A., J.G., R.P.)
| | - Aranyak Goswami
- Department of Psychiatry, Yale School of Medicine, Yale University, New Haven (G.A.P., F.R.W., Y.Z.N., A.G., F.D.A., J.G., R.P.).,Veteran Affairs Connecticut Healthcare System, West Haven, CT (G.A.P., F.R.W., Y.Z.N., A.G., F.D.A., J.G., R.P.)
| | - Flavio De Angelis
- Department of Psychiatry, Yale School of Medicine, Yale University, New Haven (G.A.P., F.R.W., Y.Z.N., A.G., F.D.A., J.G., R.P.).,Veteran Affairs Connecticut Healthcare System, West Haven, CT (G.A.P., F.R.W., Y.Z.N., A.G., F.D.A., J.G., R.P.).,Department of Biology, University of Rome Tor Vergata, Italy (A.D.L., F.D.A., M.F.)
| | - Maria Fuciarelli
- Department of Biology, University of Rome Tor Vergata, Italy (A.D.L., F.D.A., M.F.)
| | - Henry R Kranzler
- University of Pennsylvania Perelman School of Medicine and VISN 4 MIRECC, Crescenz VAMC, Philadelphia (H.R.K.)
| | - Joel Gelernter
- Department of Psychiatry, Yale School of Medicine, Yale University, New Haven (G.A.P., F.R.W., Y.Z.N., A.G., F.D.A., J.G., R.P.).,Veteran Affairs Connecticut Healthcare System, West Haven, CT (G.A.P., F.R.W., Y.Z.N., A.G., F.D.A., J.G., R.P.)
| | - Renato Polimanti
- Department of Psychiatry, Yale School of Medicine, Yale University, New Haven (G.A.P., F.R.W., Y.Z.N., A.G., F.D.A., J.G., R.P.).,Veteran Affairs Connecticut Healthcare System, West Haven, CT (G.A.P., F.R.W., Y.Z.N., A.G., F.D.A., J.G., R.P.)
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Rapezzi C, Elliott P, Damy T, Nativi-Nicolau J, Berk JL, Velazquez EJ, Boman K, Gundapaneni B, Patterson TA, Schwartz JH, Sultan MB, Maurer MS. Efficacy of Tafamidis in Patients With Hereditary and Wild-Type Transthyretin Amyloid Cardiomyopathy: Further Analyses From ATTR-ACT. JACC-HEART FAILURE 2020; 9:115-123. [PMID: 33309574 DOI: 10.1016/j.jchf.2020.09.011] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/02/2020] [Accepted: 09/18/2020] [Indexed: 01/21/2023]
Abstract
OBJECTIVES Tafamidis is an effective treatment for transthyretin amyloid cardiomyopathy (ATTR-CM), this study aimed to determine whether there is a differential effect between variant transthyretin amyloidosis (ATTRv) and wild-type transthyretin (ATTRwt). BACKGROUND ATTR-CM is a progressive, fatal disorder resulting from mutations in the ATTRv or the deposition of denatured ATTRwt. METHODS In pre-specified analyses from ATTR-ACT (Tafamidis in Transthyretin Cardiomyopathy Clinical Trial), baseline characteristics, all-cause mortality, and change from baseline to month 30 in 6-min walk test distance and Kansas City Cardiomyopathy Questionnaire Overall Summary score were compared in patients with ATTRwt and ATTRv. RESULTS There were 335 patients with ATTRwt (201 tafamidis, 134 placebo) and 106 with ATTRv (63 tafamidis, 43 placebo) enrolled in ATTR-ACT. Patients with ATTRwt (vs. ATTRv) had less advanced disease at baseline and a lower rate of disease progression over the study. The reduction in all-cause mortality with tafamidis compared with placebo was not different between ATTRwt (hazard ratio: 0.706 [95% confidence interval (CI): 0.474 to 1.052]; p = 0.0875) and ATTRv (hazard ratio: 0.690 [95% CI: 0.408 to 1.167]; p = 0.1667). Tafamidis was associated with a similar reduction (vs. placebo) in the decline in 6-min walk test distance in ATTRwt (mean ± SE difference from placebo, 77.14 ± 10.78; p < 0.0001) and ATTRv (79.61 ± 29.83 m; p = 0.008); and Kansas City Cardiomyopathy Questionnaire Overall Summary score in ATTRwt (12.72 ± 2.10; p < 0.0001) and ATTRv (18.18 ± 7.75; p = 0.019). CONCLUSIONS Pre-specified analyses from ATTR-ACT confirm the poor prognosis of untreated ATTRv-related cardiomyopathy compared with ATTRwt, but show the reduction in mortality and functional decline with tafamidis treatment is similar in both disease subtypes. (Safety and Efficacy of Tafamidis in Patients With Transthyretin Cardiomyopathy [ATTR-ACT]; NCT01994889).
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Affiliation(s)
- Claudio Rapezzi
- Cardiovascular Center, University of Ferrara, Ferrara, Italy; Maria Cecilia Hospital, GVM Care & Research, Cotignola (RA), Italy.
| | - Perry Elliott
- University College London and St. Bartholomew's Hospital, London, United Kingdom
| | - Thibaud Damy
- French Referral Center for Cardiac Amyloidosis, Amyloidosis Mondor Network, GRC Amyloid Research Institute and Department of Cardiology, all at APHP, CHU Henri Mondor, and INSERM U955, Clinical Investigation Center 006, and DHU ATVB all at Créteil, France
| | - Jose Nativi-Nicolau
- Department of Medicine, University of Utah Health Care, Salt Lake City, Utah, USA
| | - John L Berk
- Boston University School of Medicine, Boston, Massachusetts, USA
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Kurt Boman
- Research Unit, Skellefteå County Hospital, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | | | | | | | | | - Mathew S Maurer
- Columbia University College of Physicians and Surgeons, New York, New York, USA
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Kaur D, Tiwana H, Stino A, Sandroni P. Autonomic neuropathies. Muscle Nerve 2020; 63:10-21. [PMID: 32926436 DOI: 10.1002/mus.27048] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 08/07/2020] [Accepted: 08/11/2020] [Indexed: 12/17/2022]
Abstract
Autonomic neuropathies represent a complex group of disorders that preferentially target autonomic fibers and can be classified as either acute/subacute or chronic in onset. Acute-onset autonomic neuropathies manifest with such conditions as paraneoplastic syndromes, Guillain-Barre syndrome, Sjögren syndrome, infection, or toxins/chemotherapy. When the presentation is acute, immune-mediated, and without a secondary cause, autoimmune autonomic ganglionopathy is likely, and should be considered for immunotherapy. Of the chronic-onset forms, diabetes is the most widespread and disabling, with autonomic impairment portending increased mortality and cardiac wall remodeling risk. Acquired light chain (AL) and transthyretin (TTR) amyloidosis represent two other key etiologies, with TTR amyloidosis now amenable to newly-approved gene-modifying therapies. The COMPASS-31 questionnaire is a validated outcome measure that can be used to monitor autonomic severity and track treatment response. Symptomatic treatments targeting orthostatic hypotension, among other symptoms, should be individualized and complement disease-modifying therapy, when possible.
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Affiliation(s)
- Divpreet Kaur
- Department of Neurology, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Harmanpreet Tiwana
- Department of Neurology, Dartmouth-Hitchcok Medical Center, Lebanon, New Hampshire, USA
| | - Amro Stino
- Department of Neurology, Division of Neuromuscular Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Paola Sandroni
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
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Monfort A, Banydeen R, Demoniere F, Courty B, Codiat R, Neviere R, Inamo J. Restrictive cardiac phenotype as primary cause of impaired aerobic capacity in Afro-Caribbean patients with val122ile variant transthyretin amyloid cardiomyopathy. Amyloid 2020; 27:145-152. [PMID: 32024385 DOI: 10.1080/13506129.2020.1722098] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background: Impaired aerobic capacity in cardiac amyloidosis patients may be related to limited inotropic myocardial reserve and heart rate (HR) response limiting cardiac output rise. This study sought to investigate whether chronotropic incompetence (CI) and blunted HR recovery would be prevalent in patients with mutant transthyretin (ATTRv) cardiomyopathy.Methods and results: Eighteen ATTRv (Val122Ile) patients (72 ± 8-year) and 15 age-matched controls (73 ± 3-year) were prospectively enrolled. Patients' medical records, pulmonary function and cardiopulmonary exercise testing, including non-invasive cardiac hemodynamics and chronotropic response were studied. Compared with age-matched controls, maximal workload (91 ± 8 vs. 65 ± 20 watts) and peak VO2 (19.5 ± 3.0 vs. 14.4 ± 4.1 mL.kg-1.min-1) were lower in ATTRv patients. Despite reaching similar age-predicted maximal HR, ATTRv patients displayed smaller changes in stroke volume (SV) index relative to change in VO2 (49 ± 26 vs. 67 ± 18%). Adequate chronotropic-metabolic index was prevalent in ATTRv patients. HR recovery, as percent decrease in peak HR at 1 and 3-min, was blunded ATTv patients.Conclusions: In Val122Ile ATTRv patients, chronotropic response was appropriate relative to exercise intensity with only few patients displaying CI. HR response to exercise was further characterised by blunted HR recovery in ATTRv patients suggesting lower parasympathetic activity and greater sympathetic stimulation compared with controls.
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Affiliation(s)
- Astrid Monfort
- Department of Cardiology CHU Martinique, University Hospital of Martinique, Fort de France, France.,Cardiovascular Research Team EA7525, Antilles University, Pointe-à-Pitre, France
| | - Rishika Banydeen
- Cardiovascular Research Team EA7525, Antilles University, Pointe-à-Pitre, France.,Department of Epidemiology and Biostatistics CHU Martinique, University Hospital of Martinique, Fort de France, France
| | - Fabrice Demoniere
- Department of Cardiology CHU Martinique, University Hospital of Martinique, Fort de France, France
| | - Baptiste Courty
- Department of Cardiology CHU Martinique, University Hospital of Martinique, Fort de France, France
| | - Rebecca Codiat
- Department of Cardiology CHU Martinique, University Hospital of Martinique, Fort de France, France
| | - Remi Neviere
- Department of Cardiology CHU Martinique, University Hospital of Martinique, Fort de France, France.,Cardiovascular Research Team EA7525, Antilles University, Pointe-à-Pitre, France
| | - Jocelyn Inamo
- Department of Cardiology CHU Martinique, University Hospital of Martinique, Fort de France, France.,Cardiovascular Research Team EA7525, Antilles University, Pointe-à-Pitre, France
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Abstract
Although care of patients with heart failure (HF) has improved in the past decade, important disparities in HF outcomes persist based on race/ethnicity. Age-adjusted HF-related cardiovascular disease death rates are higher for Black patients, particularly among young Black men and women whose rates of death are 2.6- and 2.97-fold higher, respectively, than White men and women. Similarly, the rate of HF hospitalization for Black men and women is nearly 2.5-fold higher when compared with Whites, with costs that are significantly higher in the first year after HF hospitalization. While the relative rate of HF hospitalization has improved for other race/ethnic minorities, the disparity in HF hospitalization between Black and White patients has not decreased during the last decade. Although access to care and socioeconomic status have been traditional explanations for the observed racial disparities in HF outcomes, contemporary data suggest that novel factors including genetic susceptibility as well as social determinants of health and implicit bias may play a larger role in health outcomes than previously appreciated. The purpose of this review is to describe the complex interplay of factors that influence racial disparities in HF incidence, prevalence, and disease severity, with a highlight on evolving knowledge that will impact the clinical care and address future research needs to improve HF disparities in Blacks.
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Affiliation(s)
- Aditi Nayak
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA (A.N., A.A.M.)
| | - Albert J Hicks
- Division of Cardiology, Baylor Scott & White, Temple, TX (A.J.H.)
| | - Alanna A Morris
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA (A.N., A.A.M.)
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36
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Flaherty KR, Morgenstern R, Pozniakoff T, DeLuca A, Castano A, Maurer MS, Bokhari S. 99mTechnetium pyrophosphate scintigraphy with cadmium zinc telluride cameras is a highly sensitive and specific imaging modality to diagnose transthyretin cardiac amyloidosis. J Nucl Cardiol 2020; 27:371-380. [PMID: 31463816 DOI: 10.1007/s12350-019-01831-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 04/24/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Transthyretin cardiac amyloidosis (ATTR) is a rare, but underdiagnosed, cardiomyopathy. Traditionally diagnosed invasively, ATTR can be diagnosed with non-invasive 99mTechnetium pyrophosphate (99mTc-PYP) planar scintigraphy. Non-planar imaging has not been validated for ATTR diagnosis. Here, we develop and validate a Cadmium Zinc Telluride (CZT) protocol for diagnosing ATTR. METHODS Forty-three subjects (24 ATTR, 19 non-ATTR) were imaged with Philips Dual-Head Anger (planar) and General Electric CZT cameras. Myocardial uptake was quantified by heart-to-contralateral (H/CL) ratios. CZT scans were quantified by two readers blinded to planar H/CL, with one repeating blinded quantification. Using the previously validated diagnostic threshold (H/CL ≥ 1.5), sensitivity and specificity of CZT scintigraphy was measured. McNemar's test and Pearson's correlation coefficient were calculated. RESULTS Among subjects (76.7% male, age 77 ± 9), there was no significant difference in proportion of ATTR-positive identification between modalities. There was high correlation between CZT and planar H/CL ratios (r = 0.92, P < 0.0001), with low intra- [ICC = 0.89 (0.80-0.94)] and inter-observer [ICC = 0.80 (0.65-0.89)] variability. CZT scintigraphy had 100% sensitivity and specificity for diagnosing ATTR. CONCLUSION 99mTc-PYP CZT imaging is as highly sensitive and specific diagnosing ATTR as planar imaging. These findings are clinically salient given the emergence of disease-modifying ATTR therapies, as it could expand diagnostic capability.
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Affiliation(s)
- Kathleen R Flaherty
- Division of Cardiology, Department of Internal Medicine, Columbia University Medical Center, 630 West 168th Street, P&S 10-445(4), New York, NY, 10032, USA.
- Laboratory of Nuclear Cardiology, Columbia University Medical Center, New York, USA.
| | | | - Ted Pozniakoff
- Division of Cardiology, Department of Internal Medicine, Columbia University Medical Center, 630 West 168th Street, P&S 10-445(4), New York, NY, 10032, USA
- Laboratory of Nuclear Cardiology, Columbia University Medical Center, New York, USA
| | - Albert DeLuca
- Division of Cardiology, Department of Internal Medicine, Columbia University Medical Center, 630 West 168th Street, P&S 10-445(4), New York, NY, 10032, USA
- Laboratory of Nuclear Cardiology, Columbia University Medical Center, New York, USA
| | - Adam Castano
- Division of Cardiology, Department of Internal Medicine, Columbia University Medical Center, 630 West 168th Street, P&S 10-445(4), New York, NY, 10032, USA
| | - Mathew S Maurer
- Division of Cardiology, Department of Internal Medicine, Columbia University Medical Center, 630 West 168th Street, P&S 10-445(4), New York, NY, 10032, USA
- Center for Advanced Cardiac Care, Columbia University Medical Center, New York, NY, USA
| | - Sabahat Bokhari
- Division of Cardiology, Department of Internal Medicine, Columbia University Medical Center, 630 West 168th Street, P&S 10-445(4), New York, NY, 10032, USA
- Laboratory of Nuclear Cardiology, Columbia University Medical Center, New York, USA
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Zuo H, Zhang Y, Ma F, Li R, Wang Y, Li C, Wang H, Wang DW. Myocardial Deformation Pattern Differs between Ischemic and Non-ischemic Dilated Cardiomyopathy: The Diagnostic Value of Longitudinal Strains. ULTRASOUND IN MEDICINE & BIOLOGY 2020; 46:233-243. [PMID: 31718811 DOI: 10.1016/j.ultrasmedbio.2019.10.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 10/06/2019] [Accepted: 10/09/2019] [Indexed: 06/10/2023]
Abstract
Both ischemic cardiomyopathy (ICM) and non-ischemic cardiomyopathy (NICM) are characterized by left ventricular (LV) dysfunction and dilation. Differentiation between ICM and NICM using non-invasive image modalities is a clinical challenge. This study compared the myocardial deformation patterns of ICM and NICM using 2-D speckle tracking echocardiography (2-D STE) and sought to find parameters valuable in the diagnosis and management of dilated cardiomyopathy. The study population comprised 84 consecutive patients with LV end-diastolic dimension >55 mm and ejection fraction (EF) <45 %. Of these patients, 41 were diagnosed with ICM and 43 with NICM by coronary angiography. 2-D STE was performed in all patients. The LV dimension did not differ between ICM and NICM. Compared with patients with ICM, patients with NICM had lower EF (29.0% vs. 33.0%, p = 0.024), lower global longitudinal strain (-5.4 ± 2.6% vs. -7.0 ± 2.5%, p = 0.006) and lower global radial strain (7.5 ± 4.5% vs. 10.7 ± 4.7%, p = 0.019). In contrast, global longitudinal strains did not differ significantly. However, NICM patients had higher apical and lower basal longitudinal strains compared with those with ICM. The ratio of basal to sum of mid- and apical longitudinal strains could predict NICM with a sensitivity of 63.4% and specificity of 88.4% by receiver operating characteristic curve analysis (cutoff value: 0.47, area under the curve: 0.792). Moreover, the concomitant presence of non-significant coronary artery stenosis (>50% and <70%) had no significant influence on global longitudinal strain in NICM. In conclusion, LV dilation and systolic dysfunction, relative apical sparing and a basal worsening pattern of LV longitudinal strain by 2-D STE were observed in patients with NICM but not ICM. The ratio of basal to sum of mid- and apical longitudinal strains could help differentiate NICM from ICM.
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Affiliation(s)
- Houjuan Zuo
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yan Zhang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Fei Ma
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Rui Li
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yan Wang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chenze Li
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hong Wang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Dao Wen Wang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Alexander KM, Orav J, Singh A, Jacob SA, Menon A, Padera RF, Kijewski MF, Liao R, Di Carli MF, Laubach JP, Falk RH, Dorbala S. Geographic Disparities in Reported US Amyloidosis Mortality From 1979 to 2015: Potential Underdetection of Cardiac Amyloidosis. JAMA Cardiol 2019; 3:865-870. [PMID: 30046835 DOI: 10.1001/jamacardio.2018.2093] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Importance Cardiac amyloidosis is an underdiagnosed disease and is highly fatal when untreated. Early diagnosis and treatment with the emerging novel therapies significantly improve survival. A comprehensive analysis of amyloidosis-related mortality is critical to appreciate the nature and distribution of underdiagnosis and improve disease detection. Objective To evaluate the temporal and regional trends in age-adjusted amyloidosis-related mortality among men and women of various races/ethnicities in the United States. Design, Setting, and Participants In this observational cohort study, death certificate information from the Centers for Disease Control and Prevention's Wide-ranging ONline Data for Epidemiologic Research database and the National Vital Statistics System from 1979 to 2015 was analyzed. A total of 30 764 individuals in the United States with amyloidosis listed as the underlying cause of death and 26 591 individuals with amyloidosis listed as a contributing cause of death were analyzed. Exposures Region of residence. Main Outcomes and Measures Age-adjusted mortality rate from amyloidosis per 1 000 000 population stratified by year, sex, race/ethnicity, and state and county of residence. Results Of the 30 764 individuals with amyloidosis listed as the underlying cause of death, 17 421 (56.6%) were men and 27 312 (88.8%) were 55 years or older. From 1979 to 2015, the reported overall mean age-adjusted mortality rate from amyloidosis as the underlying cause of death doubled from 1.77 to 3.96 per 1 000 000 population (2.32 to 5.43 in men and 1.35 to 2.80 in women). Black men had the highest mortality rate (12.36 per 1 000 000), followed by black women (6.48 per 1 000 000). Amyloidosis contributed to age-adjusted mortality rates as high as 31.73 per 1 000 000 in certain counties. Most southern states reported the lowest US mortality rates despite having the highest proportions of black individuals. Conclusions and Relevance The increased reported mortality over time and in proximity to amyloidosis centers more likely reflects an overall increase in disease diagnosis rather than increased lethality. The reported amyloidosis mortality is highly variable in different US regions. The lack of higher reported mortality rates in states with a greater proportion of black residents suggests underdiagnosis of amyloidosis, including cardiac forms of the disease, in many areas of the United States. Better understanding of the determinants of geographic and racial disparity in the reporting of amyloidosis deaths are warranted.
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Affiliation(s)
- Kevin M Alexander
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Heart & Vascular Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - John Orav
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Avinainder Singh
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Heart & Vascular Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sophia A Jacob
- Cardiovascular Imaging Program, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Division of Nuclear Medicine and Molecular Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Adil Menon
- Cardiovascular Imaging Program, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Division of Nuclear Medicine and Molecular Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Robert F Padera
- Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Marie F Kijewski
- Cardiovascular Imaging Program, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Division of Nuclear Medicine and Molecular Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ronglih Liao
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Heart & Vascular Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marcelo F Di Carli
- Cardiovascular Imaging Program, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Division of Nuclear Medicine and Molecular Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jacob P Laubach
- Jerome Lipper Multiple Myeloma Center, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Rodney H Falk
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Heart & Vascular Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sharmila Dorbala
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Heart & Vascular Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Cardiovascular Imaging Program, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Division of Nuclear Medicine and Molecular Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Costache II, Buburuz AM, Crisu D, Statescu AM, Ungureanu C, Aursulesei V. The role of echocardiography and 99mTc-HDP scintigraphy in non-invasive diagnosis of cardiac amyloidosis: A case series and literature review. Medicine (Baltimore) 2019; 98:e17256. [PMID: 31567998 PMCID: PMC6756609 DOI: 10.1097/md.0000000000017256] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Cardiac amyloidosis, considered for the last years to be a rare disease, is one of the determinants of HFpEF. The non-specific clinical presentation and the difficulties related to endomyocardial biopsy have made cardiac amyloidosis an underdiagnosed clinical entity. Improvement of non-invasive diagnostic techniques and the development of new therapies increased clinical awareness for this form of restrictive cardiomyopathy. We here summarize echocardiography and Tc-HDP scintigraphy findings in 6 cases of cardiac amyloidosis and review the literature data of this progressive and fatal cardiomyopathy. PATIENTS CONCERNS The main clinical manifestations were fatigue, low exercise tolerance and edemas. The right heart failure symptoms usually dominated the clinical picture. DIAGNOSES All cases were evaluated by echocardiography; 3 cases were further examined by bone scintigraphy and 4 cases a peripheral biopsy was performed. Electrocardiography showed low-voltage QRS complexes and "pseudo-infarct" pattern in the precordial leads, contrary to the echocardiographic aspect, which revealed thickening of ventricle walls. Biatrial dilation and diastolic disfunction were observed. Impaired systolic function was detected in advanced stages of the disease. Tc-HDP scintigraphy revealed cardiac uptake of radiopharmaceutical and managed to confirm the diagnosis in 1 case of cardiac amyloidosis in which salivary gland biopsy was negative. INTERVENTIONS The treatment was based on managing fluid balance, with the mainstream therapy represented by diuretics. Neurohormonal agents, usually used in heart failure treatment were avoided, due to poor tolerance and worsening of disease course. The management of these 6 cases was challenging due to the refractory manifestation of congestive heart failure. OUTCOMES During follow-up, 4 of the 6 patients from the current study died in the first year after the final diagnosis was established. LESSONS Nuclear imaging of cardiac amyloidosis has a revolutionary development nowadays. Bone scintigraphy presents promising results for identifying patients at early stages of disease and to differentiate between cardiac amyloidosis types. Further studies are necessary for the standardization of imaging protocol and development of non-invasive diagnostic tools, especially in assessing the response to treatment and disease progression, for which little is known.
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Affiliation(s)
- Irina Iuliana Costache
- Department of Cardiology, “St. Spiridon” Emergency Clinical Hospital
- University of Medicine and Pharmacy “Grigore T. Popa”
| | - Ana Maria Buburuz
- Department of Cardiology, “St. Spiridon” Emergency Clinical Hospital
- University of Medicine and Pharmacy “Grigore T. Popa”
| | - Daniela Crisu
- Department of Cardiology, “St. Spiridon” Emergency Clinical Hospital
| | - Ana Maria Statescu
- Department of Nuclear Medicine, “St. Spiridon” Emergency Clinical Hospital
| | - Carmen Ungureanu
- University of Medicine and Pharmacy “Grigore T. Popa”
- Department of Pathology, “St. Spiridon” Emergency Clinical Hospital, Iasi, Romania
| | - Viviana Aursulesei
- Department of Cardiology, “St. Spiridon” Emergency Clinical Hospital
- University of Medicine and Pharmacy “Grigore T. Popa”
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40
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Myocardial Contraction Fraction by M-Mode Echocardiography Is Superior to Ejection Fraction in Predicting Mortality in Transthyretin Amyloidosis. J Card Fail 2018; 24:504-511. [PMID: 30010028 DOI: 10.1016/j.cardfail.2018.07.001] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 06/28/2018] [Accepted: 07/03/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Transthyretin amyloidosis (ATTR) is often associated with cardiac involvement manifesting as conduction disease as well as restrictive cardiomyopathy causing heart failure and death. Myocardial contraction fraction (MCF), the ratio of left ventricular stroke volume (SV) to myocardial volume (MV), is a volumetric measure of myocardial shortening that is superior to ejection fraction (EF) in predicting mortality in patients with primary amyloid light chain cardiac amyloidosis. We hypothesized that MCF would be an independent predictor of survival in TTR-CA. METHODS AND RESULTS MCF was derived from 2-dimensional echocardiography-guided M-mode data for 530 subjects in the Transthyretin Amyloidosis Outcomes Survey (THAOS) database: age 61 ± 16years, 74% male, 158 wild-type (ATTRwt) and 372 mutant (ATTRm), follow-up 1.5 ± 1.7years. Using multivariate Cox proportional hazard regression models, MCF <25% was highly associated with survival (hazard ratio [HR] 8.5, 95% confidence interval [CI] 4.8-14.9,-P < .0001), which was stronger than the association of EF dichotomized at 50% (HR 2.8, 95% CI 1.8-4.4; P < .0001). MCF <25% remained significantly predictive of survival in a multivariate model that included systolic blood pressure, estimated glomerular filtration rate <65 mL·min-1·m-2, New York Heart Association (NYHA) functional class, and health status based on the EuroQol-5D-3L questionnaire (area under the receiver operating characteristic curve [AUC] = 0.83, 95% CI 0.78-0.89). CONCLUSIONS MCF was superior to EF in predicting mortality in patients with ATTR. A predictive model combining MCF with systolic blood pressure, renal function, NYHA functional class, and health status was strongly associated with survival in patients with ATTR. CLINICALTRIALS. GOV IDENTIFIER NCT00628745.
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41
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diSibio G, Upadhyay K, Meyer P, Oddoux C, Ostrer H. Assessing risk for Mendelian disorders in a Bronx population. Mol Genet Genomic Med 2017; 5:516-523. [PMID: 28944235 PMCID: PMC5606885 DOI: 10.1002/mgg3.307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 05/21/2017] [Accepted: 05/23/2017] [Indexed: 11/21/2022] Open
Abstract
Background To identify variants likely responsible for Mendelian disorders among the three major ethnic groups in the Bronx that might be useful to include in genetic screening panels or whole exome sequencing filters and to estimate their likely prevalence in these populations. Methods Variants from a high‐density oligonucleotide screen of 192 members from each of the three ethnic‐national populations (African Americans, Puerto Ricans, and Dominicans) were evaluated for overlap with next generation sequencing data. Variants were curated manually for clinical validity and utility using the American College of Medical Genetics (ACMG) scoring system. Additional variants were identified through literature review. Results A panel of 75 variants displaying autosomal dominant, autosomal recessive, autosomal recessive/digenic recessive, X‐linked recessive, and X‐linked dominant inheritance patterns representing 39 Mendelian disorders were identified among these populations. Conclusion Screening for a broader range of disorders could offer the benefits of early or presymptomatic diagnosis and reproductive choice.
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Affiliation(s)
- Guy diSibio
- Department of Clinical Science; California Northstate University College of Medicine; Elk Grove California
| | - Kinnari Upadhyay
- Department of Pathology; Albert Einstein College of Medicine; Bronx New York
| | - Philip Meyer
- Department of Pathology; Albert Einstein College of Medicine; Bronx New York
| | - Carole Oddoux
- Department of Pathology; Albert Einstein College of Medicine; Bronx New York
| | - Harry Ostrer
- Department of Pathology; Albert Einstein College of Medicine; Bronx New York
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42
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Abstract
PURPOSE OF REVIEW Transthyretin (TTR)-related cardiac amyloidosis is a progressive infiltrative cardiomyopathy that mimics hypertensive, hypertrophic heart disease and may go undiagnosed. Transthyretin-derived amyloidosis accounts for 18% of all cases of cardiac amyloidosis. Thus, the study's purpose is to provide a comprehensive review of transthyretin cardiac amyloidosis. RECENT FINDINGS Wild-type transthyretin (ATTRwt) protein causes cardiac amyloidosis sporadically, with 25 to 36% of the population older than 80 years of age are at risk to develop a slowly progressive, infiltrative amyloid cardiomyopathy secondary to ATTRwt. In contrast, hereditary amyloidosis (ATTRm) is an autosomal dominant inherited disease associated with more than 100 point mutations in the transthyretin gene and has a tendency to affect the heart and nervous system. Up to 4% of African-Americans carry the Val122Ile mutation in the transthyretin gene, the most prevalent cause of hereditary cardiac amyloidosis in the USA. Identifying transthyretin cardiac amyloidosis requires increased awareness of the prevalence, signs and symptoms, and diagnostic tools available for discrimination of this progressive form of cardiomyopathy associated with left ventricular hypertrophy. While there are no FDA-approved medical treatments, investigation is underway on agents to reduce circulating mutated transthyretin.
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Affiliation(s)
- Anit K Mankad
- Division of Cardiology, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA, USA.
| | - Keyur B Shah
- The Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
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43
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Abstract
The amyloidoses are a complex group of disorders characterized by the deposition of proteinaceous amyloid fibrils in vital organs. The deposits are nonimmunogenic and may be composed of one of more than 35 proteins. We have developed a two-stage immunotherapeutic approach using peptides that recognize most, if not all, amyloid deposits to facilitate amyloid clearance. In the first embodiment, we have developed a bifunctional peptope to enhance and expand the utility of currently available antibodies. In the second, we have generated peptide-reactive antibodies that can be targeted to the amyloid deposits by peptides thereby providing alternative reagents for immunotherapy of amyloidosis. These technologies provide tools for treating the many forms of amyloid disease, restoring organ function and enhancing patient survival.
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Transthyretin amyloidosis: an under-recognized neuropathy and cardiomyopathy. Clin Sci (Lond) 2017; 131:395-409. [PMID: 28213611 DOI: 10.1042/cs20160413] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 12/07/2016] [Accepted: 12/15/2016] [Indexed: 12/18/2022]
Abstract
Transthyretin (TTR) amyloidosis (ATTR amyloidosis) is an underdiagnosed and important type of cardiomyopathy and/or polyneuropathy that requires increased awareness within the medical community. Raising awareness among clinicians about this type of neuropathy and lethal form of heart disease is critical for improving earlier diagnosis and the identification of patients for treatment. The following review summarizes current criteria used to diagnose both hereditary and wild-type ATTR (ATTRwt) amyloidosis, tools available to clinicians to improve diagnostic accuracy, available and newly developing therapeutics, as well as a brief biochemical and biophysical background of TTR amyloidogenesis.
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