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Vogel J, Carpinteiro A, Luedike P, Buehning F, Wernhart S, Rassaf T, Michel L. Current Therapies and Future Horizons in Cardiac Amyloidosis Treatment. Curr Heart Fail Rep 2024; 21:305-321. [PMID: 38809394 PMCID: PMC11333534 DOI: 10.1007/s11897-024-00669-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/20/2024] [Indexed: 05/30/2024]
Abstract
PURPOSE OF REVIEW Cardiac amyloidosis (CA) is a condition characterized by misfolding and extracellular deposition of proteins, leading to organ dysfunction. While numerous forms of CA exist, two subtypes dominate clinical prevalence: Transthyretin amyloid (ATTR) and immunoglobulin light chain amyloid. RECENT FINDINGS The current scientific landscape reflects the urgency to advance therapeutic interventions with over 100 ongoing clinical trials. Heart failure treatment is affected by CA phenotype with poor tolerance of otherwise frequently used medications. Treating comorbidities including atrial fibrillation and valvular disease remains a challenge in CA, driven by technical difficulties and uncertain outcomes. Tafamidis is the first ATTR-stabilizer approved with a rapidly growing rate of clinical use. In parallel, various new therapeutic classes are in late-stage clinical trials including silencers, antibodies and genetic therapy. Managing CA is a critical challenge for future heart failure care. This review delineates the current standard-of-care and scientific landscape of CA therapy.
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Affiliation(s)
- Julia Vogel
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Alexander Carpinteiro
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Peter Luedike
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Florian Buehning
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Simon Wernhart
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Lars Michel
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany.
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Fernandes F, Luzuriaga GDCJ, da Fonseca GWP, Correia EB, Carvalho AAS, Macedo AVS, Coelho-Filho OR, Scheinberg P, Antunes MO, Schwartzmann PV, Mangini S, Marques W, Simões MV. Clinical and genetic profiles of patients with hereditary and wild-type transthyretin amyloidosis: the Transthyretin Cardiac Amyloidosis Registry in the state of São Paulo, Brazil (REACT-SP). Orphanet J Rare Dis 2024; 19:273. [PMID: 39033298 PMCID: PMC11264909 DOI: 10.1186/s13023-024-03281-z] [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: 03/14/2024] [Accepted: 07/03/2024] [Indexed: 07/23/2024] Open
Abstract
BACKGROUND Transthyretin amyloidosis (ATTR) is a multisystem disease caused by the deposition of fibrillar protein in organs and tissues. ATTR genotypes and phenotypes are highly heterogeneous. We present data on physical signs and symptoms, cardiac and neurological assessments and genetic profile of patients enrolled in the Transthyretin Cardiac Amyloidosis Registry of the State of São Paulo, Brazil. RESULTS Six hundred-forty-four patients were enrolled, 505 with the variant form (ATTRv) and 139 with wild-type (ATTRwt). Eleven different mutations were detected, the most common being Val50Met (47.5%) and V142Ile (39.2%). Overall, more than half of the patients presented cardiac involvement, and the difference in this proportion between the ATTRv and ATTRwt groups was significant (43.9 vs. 89.9%; p < 0.001). The prevalence of the neurological phenotype also differed between ATTRv and ATTRwt (56.8 vs. 31.7%; p < 0.001). The mixed phenotype was found in 25.6% of the population, without a significant difference between ATTRv and ATTRwt groups. A group of patients remained asymptomatic (10.4%), with a lower proportion of asymptomatic ATTRwt patients. CONCLUSIONS This study details the clinical and genetic spectrum of patients with ATTR in São Paulo, Brazil. This preliminary analysis highlights the considerable phenotypic heterogeneity of neurological and cardiac manifestations in patients with variant and wild-type ATTR.
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Affiliation(s)
- Fábio Fernandes
- Academic Research Organization, Instituto do Coração InCor, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.
- Instituto do Coração InCor, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.
| | | | - Guilherme Wesley Peixoto da Fonseca
- Academic Research Organization, Instituto do Coração InCor, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | | | | | | | | | | | | | | | - Wilson Marques
- Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Ribeirão Preto, Brazil
| | - Marcus Vinicius Simões
- Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Ribeirão Preto, Brazil
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Ibrahim AA, Gaffar Mohammed M, Elmasharaf HB, Osman IY, Ali NM. Challenges and Uncertainties in the Diagnosis of Cardiac Amyloidosis: A Case Report. Cureus 2024; 16:e60954. [PMID: 38800774 PMCID: PMC11126321 DOI: 10.7759/cureus.60954] [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: 05/23/2024] [Indexed: 05/29/2024] Open
Abstract
Amyloidosis is the condition when starch-like misfolded proteins form insoluble fibrils that deposit in tissues and cause dysfunction. Cardiac amyloidosis occurs due to the deposition of amyloid fibrils at the cardiac level and is an important cause of heart failure. This case reveals a patient with significant heart failure and arrhythmia, which later on turned out to be caused by cardiac amyloidosis. While regarded as a rare disease in practice, in retrospect, there are a lot of signs and imaging indicators, particularly in echocardiography that warrant an investigation of cardiac amyloidosis. In this case review, red flags in echocardiography that should endorse further testing for underlying cardiac amyloidosis are highlighted.
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Affiliation(s)
- Alia A Ibrahim
- Internal Medicine, Dr. Sulaiman Al-Habib Hospital - Al Sweidi Branch, Riyadh, SAU
| | | | | | - Ibrahim Y Osman
- Cardiology, Prince Sultan Military Medical City, Riyadh, SAU
| | - Nagoud M Ali
- Pathology, Prince Sultan Military Medical City, Riyadh, SAU
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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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Kwok CS, Moody WE. The importance of pathways to facilitate early diagnosis and treatment of patients with cardiac amyloidosis. Ther Adv Cardiovasc Dis 2023; 17:17539447231216318. [PMID: 38099406 PMCID: PMC10725150 DOI: 10.1177/17539447231216318] [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: 07/18/2023] [Accepted: 11/07/2023] [Indexed: 12/18/2023] Open
Abstract
Cardiac amyloidosis (CA) is a condition caused by extracellular deposition of amyloid fibrils in the heart. It is an underdiagnosed disease entity which can present with a variety of cardiac and non-cardiac manifestations. Diagnosis usually follows an initial suspicion based on clinical evaluation or imaging findings before confirmation with subsequent imaging (echocardiography, cardiac magnetic resonance imaging, 3,3-diphosphono-1,2-propanodicarboxylic acid scintigraphy) in combination with biochemical screening for monoclonal dyscrasia (serum free light chains and serum and urine electrophoresis) and/or histology (bone marrow trephine, fat or endomyocardial biopsy). More than 95% of CA can be classified as either amyloid light-chain (AL) CA or amyloid transthyretin (ATTR) CA; these two conditions have very different management strategies. AL-CA, which may be associated with multiple myeloma, can be managed with chemotherapy agents, autologous stem cell transplantation, cardiac transplant and supportive therapies. For ATTR-CA, there is increasing importance in making an early diagnosis because of novel treatments in development, which have transformed this once incurable disease to a potentially treatable disease. Timely diagnosis is crucial as there may only be a small window of opportunity where patients can benefit from treatment beyond which therapies may be less effective. Reviewing the existing patient pathway provides a basis to better understand the complexities of real-world activities which may be important to help reduce missed opportunities related to diagnosis and treatment for patients with CA. With healthcare provider interest in improving the care of patients with CA, the development of an optimal care pathway for the condition may help reduce delays in diagnosis and treatment and thus enhance patient outcomes.
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Affiliation(s)
- Chun Shing Kwok
- Department of Cardiology, University Hospitals of North Midlands NHS Trust, Newcastle Rd, Stoke-on-Trent ST4 6QG, UK
| | - William E. Moody
- Department of Cardiology, University Hospitals of Birmingham NHS Trust, Birmingham, UK
- Chun Shing Kwok is now affiliated to Department of Cardiology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
- William E. Moody is also affiliated to University of Birmingham, Birmingham, UK
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