1
|
Monga TS, Ekong M, Patrick K, Bommana Boyena TG, Ravanam AS, Vargas S, Mavus NB, Lakshmi AP, Singh K, Vegesna RR, Abbas K. Anticoagulation in Atrial Fibrillation Associated With Cardiac Amyloidosis: A Narrative Review. Cureus 2024; 16:e61557. [PMID: 38962633 PMCID: PMC11221388 DOI: 10.7759/cureus.61557] [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: 06/02/2024] [Indexed: 07/05/2024] Open
Abstract
Cardiac amyloidosis (CA) involves the abnormal deposition and accumulation of amyloid proteins in the heart muscle. A hallmark of disease progression is declining heart function, which can lead to structural irregularities, arrhythmias, and ultimately heart failure. Atrial fibrillation (AF) is the most common arrhythmia that presents in CA patients, and this arrhythmia is significant because it can moderately increase the risk of patients developing intracardiac thrombi, thereby putting them at risk for thromboembolic events. The management of this complication entails the use of anticoagulants like vitamin K antagonists and direct oral anticoagulants to reduce the risk of thrombus formation. This article seeks to review AF in CA and the use of anticoagulation therapy for the management and reduction of thromboembolic risk. The major conclusions of this review are centered around the need for safe administration of anticoagulant therapy to CA patients, regardless of their CHA2DS2-VASc risk score. This review highlights the importance of taking a multidisciplinary or collaborative approach to CA treatment to ensure that all aspects of this multifaceted disease can be properly managed while minimizing adverse events like bleeding risk and drug-drug interactions.
Collapse
Affiliation(s)
- Tejbir S Monga
- Internal Medicine, Spartan Health Sciences University, Vieux Fort, LCA
| | - Mfonido Ekong
- Internal Medicine, St. George's University School of Medicine, True Blue, GRD
| | - Kayé Patrick
- Anesthesiology, Spanish Town Hospital, Spanish Town, JAM
| | | | | | | | | | | | - Kanwaraj Singh
- Internal Medicine, Maharishi Markandeshwar Institute of Medical Sciences and Research, Ambala, IND
| | | | - Kiran Abbas
- Community Health Sciences, Aga Khan University, Karachi, PAK
| |
Collapse
|
2
|
Di Lisi D, Brighina F, Manno G, Comparato F, Di Stefano V, Macaione F, Damerino G, Di Caccamo L, Cannizzo N, Ortello A, Galassi AR, Novo G. Hereditary Transthyretin Amyloidosis: How to Differentiate Carriers and Patients Using Speckle-Tracking Echocardiography. Diagnostics (Basel) 2023; 13:3634. [PMID: 38132218 PMCID: PMC10743162 DOI: 10.3390/diagnostics13243634] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 12/02/2023] [Accepted: 12/05/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Hereditary transthyretin amyloidosis is a rare disease caused by transthyretin (TTR) gene mutations. The aim of our study was to identify early signs of cardiac involvement in patients with a TTR gene mutation in order to differentiate carriers from patients with neurological or cardiac disease. METHODS A case-control study was carried out on 31 subjects with the TTR mutation. Patients were divided into three groups: 23% with cardiac amyloidosis and polyneuropathy (group A), 42% with only polyneuropathy (group B) and 35% carriers (group C). Speckle-tracking echocardiography (left-ventricular global longitudinal strain-GLS, atrial stiffness) was performed in all patients. The apical/basal longitudinal strain ratio (SAB) and relative apical sparing (RAS) were assessed in all subjects. RESULTS Analyzing groups C and B, we only found a significant difference in the SAB (p-value 0.001) and RAS (p-value 0.039). These parameters were significantly more impaired in group A compared to group B (SAB p-value 0.008; RAS p-value 0.002). Also, atrial stiffness was significantly impaired in groups A and B compared to group C. CONCLUSIONS Our study suggests the diagnostic role of the SAB and RAS in cardiac amyloidosis. The SAB and RAS showed a gradual increase from carriers to patients with neurological and cardiac diseases. Thus, these parameters, in addition to atrial stiffness, could be used to monitor carriers. More extensive data are needed.
Collapse
Affiliation(s)
- Daniela Di Lisi
- Division of Cardiology, University Hospital Paolo Giaccone, 90127 Palermo, Italy (G.D.)
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE) “G. D’Alessandro”, University of Palermo, 90127 Palermo, Italy
| | - Filippo Brighina
- Section of Neurology, Department of Biomedicine, Neuroscience and Advanced Diagnostic (BIND), University of Palermo, 90127 Palermo, Italy
| | - Girolamo Manno
- Division of Cardiology, University Hospital Paolo Giaccone, 90127 Palermo, Italy (G.D.)
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE) “G. D’Alessandro”, University of Palermo, 90127 Palermo, Italy
| | - Francesco Comparato
- Division of Cardiology, University Hospital Paolo Giaccone, 90127 Palermo, Italy (G.D.)
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE) “G. D’Alessandro”, University of Palermo, 90127 Palermo, Italy
| | - Vincenzo Di Stefano
- Section of Neurology, Department of Biomedicine, Neuroscience and Advanced Diagnostic (BIND), University of Palermo, 90127 Palermo, Italy
| | - Francesca Macaione
- Division of Cardiology, University Hospital Paolo Giaccone, 90127 Palermo, Italy (G.D.)
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE) “G. D’Alessandro”, University of Palermo, 90127 Palermo, Italy
| | - Giuseppe Damerino
- Division of Cardiology, University Hospital Paolo Giaccone, 90127 Palermo, Italy (G.D.)
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE) “G. D’Alessandro”, University of Palermo, 90127 Palermo, Italy
| | - Leandro Di Caccamo
- Division of Cardiology, University Hospital Paolo Giaccone, 90127 Palermo, Italy (G.D.)
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE) “G. D’Alessandro”, University of Palermo, 90127 Palermo, Italy
| | - Noemi Cannizzo
- Division of Cardiology, University Hospital Paolo Giaccone, 90127 Palermo, Italy (G.D.)
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE) “G. D’Alessandro”, University of Palermo, 90127 Palermo, Italy
| | - Antonella Ortello
- Division of Cardiology, University Hospital Paolo Giaccone, 90127 Palermo, Italy (G.D.)
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE) “G. D’Alessandro”, University of Palermo, 90127 Palermo, Italy
| | - Alfredo R. Galassi
- Division of Cardiology, University Hospital Paolo Giaccone, 90127 Palermo, Italy (G.D.)
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE) “G. D’Alessandro”, University of Palermo, 90127 Palermo, Italy
| | - Giuseppina Novo
- Division of Cardiology, University Hospital Paolo Giaccone, 90127 Palermo, Italy (G.D.)
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE) “G. D’Alessandro”, University of Palermo, 90127 Palermo, Italy
| |
Collapse
|
3
|
Seferović PM, Polovina M, Rosano G, Bozkurt B, Metra M, Heymans S, Mullens W, Bauersachs J, Sliwa K, de Boer RA, Farmakis D, Thum T, Olivotto I, Rapezzi C, Linhart A, Corrado D, Tschöpe C, Milinković I, Bayes Genis A, Filippatos G, Keren A, Ašanin M, Krljanac G, Maksimović R, Skouri H, Ben Gal T, Moura B, Volterrani M, Abdelhamid M, Lopatin Y, Chioncel O, Coats AJS. State-of-the-art document on optimal contemporary management of cardiomyopathies. Eur J Heart Fail 2023; 25:1899-1922. [PMID: 37470300 DOI: 10.1002/ejhf.2979] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 06/27/2023] [Accepted: 07/05/2023] [Indexed: 07/21/2023] Open
Abstract
Cardiomyopathies represent significant contributors to cardiovascular morbidity and mortality. Over the past decades, a progress has occurred in characterization of the genetic background and major pathophysiological mechanisms, which has been incorporated into a more nuanced diagnostic approach and risk stratification. Furthermore, medications targeting core disease processes and/or their downstream adverse effects have been introduced for several cardiomyopathies. Combined with standard care and prevention of sudden cardiac death, these novel and emerging targeted therapies offer a possibility of improving the outcomes in several cardiomyopathies. Therefore, the aim of this document is to summarize practical approaches to the treatment of cardiomyopathies, which includes the evidence-based novel therapeutic concepts and established principles of care, tailored to the individual patient aetiology and clinical presentation of the cardiomyopathy. The scope of the document encompasses contemporary treatment of dilated, hypertrophic, restrictive and arrhythmogenic cardiomyopathy. It was based on an expert consensus reached at the Heart Failure Association online Workshop, held on 18 March 2021.
Collapse
Affiliation(s)
- Petar M Seferović
- Faculty of Medicine, Belgrade University, Belgrade, Serbia
- Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | - Marija Polovina
- Faculty of Medicine, Belgrade University, Belgrade, Serbia
- Department of Cardiology, University Clinical Centre of Serbia, Belgrade, Serbia
| | | | - Biykem Bozkurt
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Marco Metra
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Stephane Heymans
- Department of Cardiology, CARIM, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Wilfried Mullens
- Hasselt University, Hasselt, Belgium
- Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Karen Sliwa
- Cape Heart Institute, Division of Cardiology, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Rudolf A de Boer
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, Hannover, Germany
- Fraunhofer Cluster of Excellence Immune-Mediated Diseases (CIMD), Hannover, Germany
- Fraunhofer Institute for Toxicology and Experimental Medicine (ITEM), Hannover, Germany
| | - Iacopo Olivotto
- Department of Experimental and Clinical Medicine, University of Florence, Meyer Children's Hospital and Careggi University Hospital, Florence, Italy
| | - Claudio Rapezzi
- Cardiology Centre, University of Ferrara, Ferrara, Italy
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Aleš Linhart
- Second Department of Medicine-Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Domenico Corrado
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Carsten Tschöpe
- Berlin Institute of Health (BIH) at Charité-Universitätsmedizin Berlin, BIH Center for Regenerative Therapies (BCRT), Berlin, Germany
- German Centre for Cardiovascular Research, Berlin, Germany
- Department of Cardiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Ivan Milinković
- Faculty of Medicine, Belgrade University, Belgrade, Serbia
- Department of Cardiology, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Antoni Bayes Genis
- Servicio de Cardiología, Hospital Universitari Germans Trias i Pujol, CIBERCV, Universidad Autónoma de Barcelona, Badalona, Spain
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Athens, Greece
| | - Andre Keren
- Heart Institute, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Milika Ašanin
- Faculty of Medicine, Belgrade University, Belgrade, Serbia
- Department of Cardiology, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Gordana Krljanac
- Faculty of Medicine, Belgrade University, Belgrade, Serbia
- Department of Cardiology, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Ružica Maksimović
- Faculty of Medicine, Belgrade University, Belgrade, Serbia
- Center for Radiology and Magnetic Resonance, University Clinical Center of Serbia, Belgrade, Serbia
| | - Hadi Skouri
- Division of Cardiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Tuvia Ben Gal
- Heart Failure Unit, Cardiology Department, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Brenda Moura
- Armed Forces Hospital, Porto, & Faculty of Medicine, University of Porto, Porto, Portugal
| | - Maurizio Volterrani
- IRCCS San Raffaele Pisana, Rome, Italy
- Department of Human Science and Promotion of Quality of Life, San Raffaele Open University of Rome, Rome, Italy
| | - Magdy Abdelhamid
- Department of Cardiovascular Medicine, Faculty of Medicine, Kasr Al Ainy, Cairo University, Giza, Egypt
| | - Yuri Lopatin
- Volgograd Medical University, Cardiology Centre, Volgograd, Russian Federation
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. Dr. C.C. Iliescu' Bucharest; University for Medicine and Pharmacy 'Carol Davila' Bucharest, Bucharest, Romania
| | | |
Collapse
|
4
|
Porcari A, Sinagra G, Gillmore JD. Editorial: Proceedings and predictions in cardiac amyloidosis: unsolved mysteries and challenges for the future. Front Med (Lausanne) 2023; 10:1232212. [PMID: 37529239 PMCID: PMC10389709 DOI: 10.3389/fmed.2023.1232212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 07/05/2023] [Indexed: 08/03/2023] Open
Affiliation(s)
- Aldostefano Porcari
- Division of Medicine, National Amyloidosis Centre, University College London, London, United Kingdom
- Centre for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
- European Reference Network for RARE, Low Prevalence and Complex Diseases of the Heart (ERN GUARD-Heart)
| | - Gianfranco Sinagra
- Centre for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
- European Reference Network for RARE, Low Prevalence and Complex Diseases of the Heart (ERN GUARD-Heart)
| | - Julian D. Gillmore
- Division of Medicine, National Amyloidosis Centre, University College London, London, United Kingdom
| |
Collapse
|
5
|
Di Fusco SA, Alonzo A, Aimo A, Matteucci A, Intravaia RCM, Aquilani S, Cipriani M, De Luca L, Navazio A, Valente S, Gulizia MM, Gabrielli D, Oliva F, Colivicchi F. ANMCO position paper on vericiguat use in heart failure: from evidence to place in therapy. Eur Heart J Suppl 2023; 25:D278-D286. [PMID: 37213802 PMCID: PMC10194817 DOI: 10.1093/eurheartjsupp/suad106] [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] [Indexed: 05/23/2023]
Abstract
In the growing therapeutic armamentarium for heart failure (HF) management, vericiguat represents an innovative therapeutic option. The biological target of this drug is different from that of other drugs for HF. Indeed, vericiguat does not inhibit neuro-hormonal systems overactivated in HF or sodium-glucose co-transporter 2 but stimulates the biological pathway of nitric oxide and cyclic guanosine monophosphate, which is impaired in patients with HF. Vericiguat has recently been approved by international and national regulatory authorities for the treatment of patients with HF and reduced ejection fraction who are symptomatic despite optimal medical therapy and have worsening HF. This ANMCO position paper summarises key aspects of vericiguat mechanism of action and provides a review of available clinical evidence. Furthermore, this document reports use indications based on international guideline recommendations and local regulatory authority approval at the time of writing.
Collapse
Affiliation(s)
| | - Alessandro Alonzo
- U.O.C. Cardiologia Clinica e Riabilitativa, Presidio Ospedaliero San Filippo Neri—, ASL Roma 1, 00135, Italy
| | - Alberto Aimo
- Interdisciplinary Center for Health Science, Scuola Superiore Sant’Anna, Piazza Martiri della Libertà 33, Pisa, 56127, Italy
| | - Andrea Matteucci
- U.O.C. Cardiologia Clinica e Riabilitativa, Presidio Ospedaliero San Filippo Neri—, ASL Roma 1, 00135, Italy
| | - Rita Cristina Myriam Intravaia
- Cardiologia 4-Diagnostica e Riabilitativa, Dipartimento Cardiotoracovascolare ‘A. De Gasperis’, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, Milan, 20162, Italy
| | - Stefano Aquilani
- U.O.C. Cardiologia Clinica e Riabilitativa, Presidio Ospedaliero San Filippo Neri—, ASL Roma 1, 00135, Italy
| | - Manlio Cipriani
- U.O. Cardiologia, Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione-ISMETT, Via Ernesto Tricomi 5, Palermo, 90127, Italy
| | - Leonardo De Luca
- U.O.C. Cardiologia, Dipartimento Cardio-Toraco-Vascolare, Azienda Ospedaliera San Camillo Forlanini, Circonvallazione Gianicolense 87, Rome, 00152, Italy
| | - Alessandro Navazio
- S.O.C. Cardiologia Ospedaliera, Presidio Ospedaliero Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia—IRCCS, Viale Risorgimento 80, Reggio Emilia, 42123, Italy
| | - Serafina Valente
- Dipartimento Cardio-Toracico, A.O.U. Senese, Ospedale Santa Maria alle Scotte, Viale Mario Bracci 16, Siena, 53100, Italy
| | - Michele Massimo Gulizia
- U.O.C. Cardiologia, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione ‘Garibaldi’, Via Palermo 636, Catania, 95122, Italy
| | - Domenico Gabrielli
- U.O.C. Cardiologia, Dipartimento Cardio-Toraco-Vascolare, Azienda Ospedaliera San Camillo Forlanini, Circonvallazione Gianicolense 87, Rome, 00152, Italy
- Fondazione per il Tuo cuore—Heart Care Foundation, Via Alfonso la Marmora 36, Firenze, 50121, Italy
| | - Fabrizio Oliva
- Cardiologia 1-Emodinamica, Dipartimento Cardiotoracovascolare ‘A. De Gasperis’, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, Milan, 20162, Italy
| | - Furio Colivicchi
- U.O.C. Cardiologia Clinica e Riabilitativa, Presidio Ospedaliero San Filippo Neri—, ASL Roma 1, 00135, Italy
| |
Collapse
|
6
|
Impaired Extracellular Proteostasis in Patients with Heart Failure. Arch Med Res 2023; 54:211-222. [PMID: 36797157 DOI: 10.1016/j.arcmed.2023.02.001] [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: 09/11/2022] [Revised: 01/11/2023] [Accepted: 02/02/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND Proteostasis impairment and the consequent increase of amyloid burden in the myocardium have been associated with heart failure (HF) development and poor prognosis. A better knowledge of the protein aggregation process in biofluids could assist the development and monitoring of tailored interventions. AIM To compare the proteostasis status and protein's secondary structures in plasma samples of patients with HF with preserved ejection fraction (HFpEF), patients with HF with reduced ejection fraction (HFrEF), and age-matched individuals. METHODS A total of 42 participants were enrolled in 3 groups: 14 patients with HFpEF, 14 patients with HFrEF, and 14 age-matched individuals. Proteostasis-related markers were analyzed by immunoblotting techniques. Fourier Transform Infrared (FTIR) Spectroscopy in Attenuated Total Reflectance (ATR) was applied to assess changes in the protein's conformational profile. RESULTS Patients with HFrEF showed an elevated concentration of oligomeric proteic species and reduced clusterin levels. ATR-FTIR spectroscopy coupled with multivariate analysis allowed the discrimination of HF patients from age-matched individuals in the protein amide I absorption region (1700-1600 cm-1), reflecting changes in protein conformation, with a sensitivity of 73 and a specificity of 81%. Further analysis of FTIR spectra showed significantly reduced random coils levels in both HF phenotypes. Also, compared to the age-matched group, the levels of structures related to fibril formation were significantly increased in patients with HFrEF, whereas the β-turns were significantly increased in patients with HFpEF. CONCLUSION Both HF phenotypes showed a compromised extracellular proteostasis and different protein conformational changes, suggesting a less efficient protein quality control system.
Collapse
|
7
|
Di Lisi D, Di Stefano V, Brighina F, Galassi AR, Novo G. Therapy of ATTR Cardiac Amyloidosis: Current Indications. Curr Probl Cardiol 2023; 48:101487. [PMID: 36336119 DOI: 10.1016/j.cpcardiol.2022.101487] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 10/31/2022] [Indexed: 11/06/2022]
Abstract
Transthyretin cardiac amyloidosis is a restrictive cardiomyopathy caused by extracellular deposition in the heart of amyloid fibrils derived from plasma transthyretin (ATTR), either in its hereditary (ATTRh) or acquired (ATTRwt) forms. Cardiac amyloidosis has a very poor prognosis if therapy is not started promptly. Therefore, it is very important to recognize cardiac amyloidosis early in order to immediately start a treatment capable of modifying the prognosis. Treatment of cardiac amyloidosis is not easy, often requiring a multidisciplinary team. New RNA-interfering drugs (such as patisiran) have been devised and are effective in the treatment of ATTRh amyloidosis. Tafamidis (a stabilizer of the native tetramer structure of TTR) is recommended to treat patients with genetic testing-proven hereditary hTTR-cardiomyopathy or wild-type TTR cardiomyopathy and NYHA Class I or II to reduce symptoms, CV hospitalization and mortality (Class I, level of evidence B). Patisiran should be considered in ATTRh cardiomyopathy with polyneuropathy. Thus, this review is intended to be a simple practical guide for the treatment of ATTR cardiac amyloidosis.
Collapse
Affiliation(s)
- Daniela Di Lisi
- Division of Cardiology, University Hospital Paolo Giaccone, Palermo, Italy; Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE) "G. D'Alessandro", University of Palermo, Palermo, Italy..
| | - Vincenzo Di Stefano
- Section of Neurology, Department of Biomedicine, Neurosciences and Advanced Diagnostics (BiND), University of Palermo, Palermo, Italy
| | - Filippo Brighina
- Section of Neurology, Department of Biomedicine, Neurosciences and Advanced Diagnostics (BiND), University of Palermo, Palermo, Italy
| | - Alfredo Ruggero Galassi
- Division of Cardiology, University Hospital Paolo Giaccone, Palermo, Italy; Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE) "G. D'Alessandro", University of Palermo, Palermo, Italy
| | - Giuseppina Novo
- Division of Cardiology, University Hospital Paolo Giaccone, Palermo, Italy; Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE) "G. D'Alessandro", University of Palermo, Palermo, Italy
| |
Collapse
|
8
|
Treatment of Transthyretin Amyloid Cardiomyopathy: The Current Options, the Future, and the Challenges. J Clin Med 2022; 11:jcm11082148. [PMID: 35456241 PMCID: PMC9031576 DOI: 10.3390/jcm11082148] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/07/2022] [Accepted: 04/08/2022] [Indexed: 12/13/2022] Open
Abstract
Transthyretin amyloid cardiomyopathy (ATTR-CM) is a progressively debilitating, rare disease associated with high mortality. ATTR-CM occurs when TTR amyloid protein builds up in the myocardium along with different organs, most commonly the peripheral and the autonomic nervous systems. Managing the cardiac complications with standard heart failure medications is difficult due to the challenge to maintain a balance between the high filling pressure associated with restricted ventricular volume and the low cardiac output. To date, tafamidis is the only agent approved for ATTR-CM treatment. Besides, several agents, including green tea, tolcapone, and diflunisal, are used off-label in ATTR-CM patients. Novel therapies using RNA interference also offer clinical promise. Patisiran and inotersen are currently approved for ATTR-polyneuropathy of hereditary origin and are under investigation for ATTR-CM. Monoclonal antibodies in the early development phases carry hope for amyloid deposit clearance. Despite several drug candidates in the clinical development pipeline, the small ATTR-CM patient population raises several challenges. This review describes current and future therapies for ATTR-CM and sheds light on the clinical development hurdles facing them.
Collapse
|
9
|
Lisi DD, Di Caccamo L, Damerino G, Portelli MC, Comparato F, Stefano VD, Brighina F, Corrado E, Galassi AR, Novo G. Effectiveness and Safety of oral anticoagulants in cardiac amyloidosis: lights and shadows. Curr Probl Cardiol 2022:101188. [DOI: 10.1016/j.cpcardiol.2022.101188] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 03/22/2022] [Indexed: 12/18/2022]
|
10
|
Vergaro G, Aimo A, Campora A, Castiglione V, Prontera C, Masotti S, Musetti V, Chianca M, Valleggi A, Spini V, Emdin M, Passino C. Patients with cardiac amyloidosis have a greater neurohormonal activation than those with non-amyloidotic heart failure. Amyloid 2021; 28:252-258. [PMID: 34396857 DOI: 10.1080/13506129.2021.1966624] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Neurohormonal activation has never been investigated in patients with cardiac amyloidosis (CA). METHODS Forty-seven patients with amyloid light-chain (AL)-CA and 61 with transthyretin (ATTR)-CA were matched to non-amyloidotic heart failure (HF) patients based on age, sex, left ventricular ejection fraction ranges, renal function and HF therapies. N-terminal pro-B-type natriuretic peptide (NT-proBNP), norepinephrine and renin were dosed. The primary and secondary endpoints were 1-year cardiovascular death or HF hospitalisation, and 5-year cardiovascular death, respectively. RESULTS Patients with AL-CA had a 10-fold higher NT-proBNP than HF patients (6548 ng/L [2059-15,097] vs. 692 [243-2241], p < 0.001), and slightly higher norepinephrine (595 ng/L [383-869] vs. 416 [250-693], p = 0.047). Patients with ATTR-CA had higher NT-proBNP (3984 ng/L [2275-9505] vs. 1751 [470-4768], p = 0.006), norepinephrine (552 ng/L [344-855] vs. 441 [323-601], p = 0.020), and renin (14 mU/L [8-80] vs. 10 [4-34], p = 0.017). Patients with AL- or ATTR-CA had more often 2 or 3 neurohormones above the corresponding upper reference limits than matched HF patients. NT-proBNP and aldosterone were univariate predictors of the primary endpoint in patients with ATTR-CA, but not in matched controls. NT-proBNP and renin predicted the secondary endpoint in patients with AL-CA, but not in matched controls. CONCLUSIONS Patients with CA display a neurohormonal activation, with some prognostic significance.
Collapse
Affiliation(s)
- Giuseppe Vergaro
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.,Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Alberto Aimo
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.,Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | | | | | - Concetta Prontera
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Silvia Masotti
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Veronica Musetti
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Michela Chianca
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | | | - Valentina Spini
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Michele Emdin
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.,Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Claudio Passino
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.,Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| |
Collapse
|
11
|
Porcari A, Merlo M, Rapezzi C, Sinagra G. Transthyretin amyloid cardiomyopathy: An uncharted territory awaiting discovery. Eur J Intern Med 2020; 82:7-15. [PMID: 33032855 PMCID: PMC7534738 DOI: 10.1016/j.ejim.2020.09.025] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 09/21/2020] [Accepted: 09/26/2020] [Indexed: 01/14/2023]
Abstract
Transthyretin amyloid cardiomyopathy (ATTR-AC) is an under-recognized and underdiagnosed disease. Although traditionally considered a rare condition, the epidemiology of the disease is rapidly changing due to the possibility of non-invasive diagnosis through cardiac scintigraphy with bone tracers and novel disease-modifying treatments providing survival advantages. Nevertheless, many questions and grey areas have to be addressed, such as the natural history of ATTR-AC, the role and implications of genotype-phenotype interactions, the best clinical management, prognostic stratification and the most appropriate treatments, including those already recommended for patients with heart failure. Clinicians have to cope with old beliefs and evolving concepts in ATTR-AC. A wide horizon of possibilities for physicians of many specialties is unfolding and awaits discovery.
Collapse
Affiliation(s)
- Aldostefano Porcari
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Italy
| | - Marco Merlo
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Italy
| | - Claudio Rapezzi
- Cardiovascular Center, University of Ferrara, Italy; GVM Care & Research, Cotignola, Italy
| | - Gianfranco Sinagra
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Italy.
| |
Collapse
|