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Fragner M, Elsaygh J, Srivats SS, Pink K. Gender Differences in the Evaluation and Management of New Acute CHF Due to ATTRwt Cardiac Amyloidosis. Cureus 2024; 16:e59058. [PMID: 38800288 PMCID: PMC11128148 DOI: 10.7759/cureus.59058] [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: 04/26/2024] [Indexed: 05/29/2024] Open
Abstract
Cardiac amyloidosis can be grouped into two main categories: immunoglobulin light chain (AL) and transthyretin (hATTR or hereditary and ATTRwt or wild type). Cardiac infiltration of misfolded proteins can lead to significant infiltrative processes and subsequent heart failure. Diagnosis of ATTRwt heavily relies on clinical suspicion, as it typically appears later in life and is limited to the heart. It is routinely reported that ATTRwt significantly affects males more than females; however, older patients diagnosed with ATTRwt and those diagnosed at autopsy are significantly more likely to be female. Earlier, a more precise diagnosis in females could detect disease at an earlier stage and expedite treatment.
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Affiliation(s)
- Michael Fragner
- Internal Medicine, New York-Presbyterian Brooklyn Methodist, Brooklyn, USA
| | - Jude Elsaygh
- Internal Medicine, New York-Presbyterian Brooklyn Methodist, Brooklyn, USA
| | | | - Kevin Pink
- Internal Medicine, New York-Presbyterian Brooklyn Methodist, Brooklyn, USA
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2
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Takahashi K, Iwamura T, Hiratsuka Y, Sasaki D, Yamamura N, Ueda M, Yoshino M, Enomoto D, Morioka H, Uemura S, Okura T, Sakaue T, Ikeda S. Iatrogenic intramuscular hematoma of the oblique muscles as a complication of technetium-99m-labeled pyrophosphate imaging-based computed tomography-guided core-needle biopsy in a patient with wild-type transthyretin cardiac amyloidosis. Radiol Case Rep 2024; 19:330-340. [PMID: 38028290 PMCID: PMC10661599 DOI: 10.1016/j.radcr.2023.09.107] [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: 09/29/2023] [Accepted: 09/30/2023] [Indexed: 12/01/2023] Open
Abstract
Technetium-99m-labeled pyrophosphate imaging-based computed tomography-guided core-needle biopsy of the internal oblique muscle with tracer uptake is a safe and sensitive extracardiac screening biopsy. It can provide histopathological confirmation of the deposition of amyloid transthyretin in patients with wild-type transthyretin cardiac amyloidosis. This case report presents the case of a 73-year-old man receiving triple anti-thrombotic therapy for atrial flutter and coronary stenting who underwent this biopsy to confirm the diagnosis of transthyretin cardiac amyloidosis. The biopsy needle reached the internal oblique muscle via the external oblique muscle between the skin and the target. A type 1 intramuscular hematoma involving these muscles developed subsequently; however, manual compression hemostasis prevented further increase in size. Since this biopsy often targets elderly patients receiving anti-thrombotic therapy who are at high risk of bleeding owing to multimorbidity and polypharmacy, efforts should be made to reduce the frequency of complications, particularly bleeding, which can lead to the development of intramuscular hematoma.
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Affiliation(s)
- Koji Takahashi
- Department of Community Emergency Medicine, Ehime University Graduate School of Medicine, Ehime, Japan
- Department of Cardiology, Yawatahama City General Hospital, 1-638, Ohira, Yawatahama, Ehime 796-8502, Japan
| | - Takaaki Iwamura
- Department of Radiology, Yawatahama City General Hospital, Ehime, Japan
| | | | - Daisuke Sasaki
- Department of Radiology, Yawatahama City General Hospital, Ehime, Japan
| | - Nobuhisa Yamamura
- Department of Clinical Pathology, Yawatahama City General Hospital, Ehime, Japan
| | - Mitsuharu Ueda
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Mako Yoshino
- Department of Cardiology, Yawatahama City General Hospital, 1-638, Ohira, Yawatahama, Ehime 796-8502, Japan
| | - Daijiro Enomoto
- Department of Cardiology, Yawatahama City General Hospital, 1-638, Ohira, Yawatahama, Ehime 796-8502, Japan
| | - Hiroe Morioka
- Department of Cardiology, Yawatahama City General Hospital, 1-638, Ohira, Yawatahama, Ehime 796-8502, Japan
| | - Shigeki Uemura
- Department of Cardiology, Yawatahama City General Hospital, 1-638, Ohira, Yawatahama, Ehime 796-8502, Japan
| | - Takafumi Okura
- Department of Cardiology, Yawatahama City General Hospital, 1-638, Ohira, Yawatahama, Ehime 796-8502, Japan
| | - Tomoki Sakaue
- Department of Community Emergency Medicine, Ehime University Graduate School of Medicine, Ehime, Japan
- Department of Cardiology, Yawatahama City General Hospital, 1-638, Ohira, Yawatahama, Ehime 796-8502, Japan
| | - Shuntaro Ikeda
- Department of Community Emergency Medicine, Ehime University Graduate School of Medicine, Ehime, Japan
- Department of Cardiology, Yawatahama City General Hospital, 1-638, Ohira, Yawatahama, Ehime 796-8502, Japan
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3
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Takahashi K, Hiratsuka Y, Sasaki D, Sakaue T, Enomoto D, Morioka H, Uemura S, Okura T, Ikeda S, Kono T, Iwamura T, Yamamura N, Kitazawa S, Ueda M. 99mTc-Pyrophosphate Scintigraphy Can Image Tracer Uptake in Skeletal Trunk Muscles of Transthyretin Cardiac Amyloidosis. Clin Nucl Med 2023; 48:18-24. [PMID: 36469058 DOI: 10.1097/rlu.0000000000004397] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE 99mTc-pyrophosphate (99mTc-PYP) uptake in the skeletal muscles is minimal in patients with transthyretin cardiac amyloidosis (ATTR-CA) when assessed qualitatively and quantitatively. We previously demonstrated moderate- to high-grade 99mTc-PYP uptake in the subcutaneous abdominal fat of some patients with ATTR-CA and showed that this abnormal finding could reflect the regional amyloid burden of this tissue. We aimed to investigate the frequency of 99mTc-PYP uptake in skeletal trunk muscles of patients with ATTR-CA. METHODS Chest- and abdomen-centered 99mTc-PYP scintigraphy images were obtained 2 hours after IV injections of the tracer (20 mCi) in 36 patients with ATTR-CA. The frequency of 99mTc-PYP uptake in the following 11 skeletal trunk muscles was investigated: pectoralis major, deltoid, subscapularis, infraspinatus, trapezius, latissimus dorsi, erector spinae, psoas major, abdominal oblique, rectus abdominis, and the gluteus muscles. RESULTS Ten of the 11 muscles were involved in patients with the highest number of 99mTc-PYP uptake in the skeletal trunk muscles examined, whereas no muscle was involved in a patient with the least uptake. The muscle with the highest rate of 99mTc-PYP uptake, observed in 34 of 36 patients (94.4%), was the abdominal oblique. No tracer uptake was observed in the psoas major. The frequency of radiotracer uptake in the remaining examined muscles was between those of abdominal oblique and psoas major muscles. CONCLUSIONS Radiotracer uptake was often detectable in some skeletal trunk muscles of ATTR-CA, although the muscles of patients examined and the skeletal trunk muscles of 1 patient showed heterogeneity in the uptake of 99mTc-PYP.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Sohei Kitazawa
- Department of Molecular Pathology, Ehime University Graduate School of Medicine, Ehime
| | - Mitsuharu Ueda
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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4
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Patel RK, Ioannou A, Razvi Y, Chacko L, Venneri L, Bandera F, Knight D, Kotecha T, Martinez‐Naharro A, Masi A, Porcari A, Brown J, Patel K, Manisty C, Moon J, Rowczenio D, Gilbertson JA, Sinagra G, Lachmann H, Wechalekar A, Petrie A, Whelan C, Hawkins PN, Gillmore JD, Fontana M. Sex differences among patients with transthyretin amyloid cardiomyopathy - from diagnosis to prognosis. Eur J Heart Fail 2022; 24:2355-2363. [PMID: 36575133 PMCID: PMC10087683 DOI: 10.1002/ejhf.2646] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 07/29/2022] [Accepted: 07/29/2022] [Indexed: 01/18/2023] Open
Abstract
AIMS Transthyretin amyloid cardiomyopathy (ATTR-CM) is predominantly diagnosed in men. The few available studies suggest affected women have a more favourable cardiac phenotype. We aimed to characterize sex differences among consecutive patients with non-hereditary and two prevalent forms of hereditary (h)ATTR-CM diagnosed over a 20-year period. METHODS AND RESULTS Analysis of deep phenotyping at presentation, changes on serial echocardiography and overall prognosis were evaluated. In total, 1732 consecutive patients were studied, comprising: 1095 with wild-type (wt)ATTR-CM; 206 with T60A-hATTR-CM; and 431 with V122I-hATTR-CM. Female prevalence was greater in T60A-hATTR-CM (29.6%) and V122I-hATTR-CM (27.8%) compared to wtATTR-CM (6%). At presentation, females were 3.3 years older than males (wtATTR-CM: 81.9 vs. 77.8 years; T60A-hATTR-CM: 68.7 vs. 65.1 years; V122I-hATTR-CM: 77.1 vs. 74.9 years). Body size significantly influenced measures of disease severity; when indexed, overall structural and functional phenotype was similar between sexes, the few significant differences suggested a mildly worse phenotype in females. No significant differences were observed in both disease progression on serial echocardiography and mortality across the overall population (p = 0.459) and when divided by genotype (wtATTR-CM: p = 0.730; T60A-hATTR-CM: p = 0.161; V122I-hATTR-CM: p = 0.056). CONCLUSION This study of a well-characterized large cohort of ATTR-CM patients did not demonstrate overall differences between sexes in either clinical phenotype, when indexed, or with respect to disease progression and prognosis. Non-indexed wall thickness measurements may have contributed to both under-representation and delays in diagnosis for affected females and highlights the potential role of utilizing indexed echocardiographic parameters for a more accurate assessment of patients at diagnosis and for disease prognostication.
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Affiliation(s)
- Rishi K. Patel
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Adam Ioannou
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Yousuf Razvi
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Liza Chacko
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Lucia Venneri
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Francesco Bandera
- Heart Failure Unit, Cardiology University DepartmentIRCCS Policlinico San DonatoMilanItaly
- Department for Biomedical Sciences for HealthUniversity of MilanoMilanItaly
| | - Daniel Knight
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Tushar Kotecha
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Ana Martinez‐Naharro
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Ambra Masi
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Aldostefano Porcari
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular DepartmentAzienda Sanitaria Universitaria Giuliano‐Isontina (ASUGI), University of TriesteTriesteItaly
| | - James Brown
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Kiara Patel
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Charlotte Manisty
- Barts Heart Centre, The Cardiovascular Magnetic Resonance Imaging Unit, and the Inherited Cardiovascular Diseases UnitSt Bartholomew's HospitalLondonUK
| | - James Moon
- Barts Heart Centre, The Cardiovascular Magnetic Resonance Imaging Unit, and the Inherited Cardiovascular Diseases UnitSt Bartholomew's HospitalLondonUK
| | - Dorota Rowczenio
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Janet A. Gilbertson
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Gianfranco Sinagra
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular DepartmentAzienda Sanitaria Universitaria Giuliano‐Isontina (ASUGI), University of TriesteTriesteItaly
| | - Helen Lachmann
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Ashutosh Wechalekar
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Aviva Petrie
- Eastman Dental Institute, University College LondonLondonUK
| | - Carol Whelan
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Philip N. Hawkins
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Julian D. Gillmore
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Marianna Fontana
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
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Lin W, Chattranukulchai P, Lee AP, Lin YH, Yu WC, Liew HB, Oomman A. Clinical recommendations to diagnose and monitor patients with transthyretin amyloid cardiomyopathy in Asia. Clin Cardiol 2022; 45:898-907. [PMID: 35795903 PMCID: PMC9451661 DOI: 10.1002/clc.23882] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 06/10/2022] [Accepted: 06/15/2022] [Indexed: 11/11/2022] Open
Abstract
Transthyretin amyloid cardiomyopathy (ATTR‐CM) is a debilitating and life‐threatening condition with a heterogeneous clinical presentation. Recent guidelines from the United States and Europe have been published to guide clinical practice and to facilitate management conformity by covering current diagnostic and treatment strategies for patients with ATTR‐CM. These guidelines highlight the importance of an early diagnosis to optimize therapeutic outcomes, specifying the use of tests and imaging techniques to allow accurate, noninvasive diagnosis of ATTR‐CM. However, as regional practice variations across Asia may limit access to healthcare, availability of specific tests, and expertise in assessing diagnostic images, there is an ongoing need to provide an Asian perspective on these clinical guidelines. This review article provides practical recommendations for the diagnosis and monitoring of patients with ATTR‐CM in Asia, highlighting the need for additional guidelines to support a broad and diverse population, consider differing healthcare systems and diagnostic testing availability, and provide a flexible yet robust algorithm.
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Affiliation(s)
- Weiqin Lin
- Department of Cardiology, National University Heart Centre, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Pairoj Chattranukulchai
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
| | - Alex Pw Lee
- Division of Cardiology, Department of Medicine and Therapeutics, Li Ka Shing Institutes of Health Science, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Yen-Hung Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan, Republic of China
| | - Wen-Chung Yu
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China.,Department of Internal Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, Republic of China
| | - Houng-Bang Liew
- Department of Cardiology, Clinical Research Centre, Queen Elizabeth Hospital II, Kota Kinabalu, Malaysia
| | - Abraham Oomman
- Department of Cardiology, Apollo Hospitals, Chennai, India
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6
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Campbell CM, LoRusso S, Dispenzieri A, Kristen AV, Maurer MS, Rapezzi C, Lairez O, Drachman B, Garcia-Pavia P, Grogan M, Chapman D, Amass L. Sex Differences in Wild-Type Transthyretin Amyloidosis: An Analysis from the Transthyretin Amyloidosis Outcomes Survey (THAOS). Cardiol Ther 2022; 11:393-405. [PMID: 35583798 PMCID: PMC9381661 DOI: 10.1007/s40119-022-00265-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 04/30/2022] [Indexed: 12/24/2022] Open
Abstract
Introduction Wild-type transthyretin amyloidosis (ATTRwt amyloidosis) is a progressive disease resulting from the accumulation of wild-type transthyretin (TTR) amyloid fibrils, and is diagnosed primarily in males. This analysis examined sex differences in patients with ATTRwt amyloidosis from the Transthyretin Amyloidosis Outcomes Survey (THAOS). Methods THAOS is an ongoing, global, longitudinal, observational survey of patients with transthyretin amyloidosis, including both inherited and wild-type disease, and asymptomatic carriers of TTR mutations. THAOS data were analyzed to identify potential differences in demographic and clinical characteristics between males and females with ATTRwt amyloidosis (data cutoff: August 1, 2021). Results Of 1386 patients with ATTRwt amyloidosis, 84 (6%) were female and 1302 (94%) were male. Females had a higher median age at enrollment (80 vs. 78 years; p = 0.002) and symptom onset (75 vs. 73 years; p = 0.045) than males. Mean left ventricular (LV) ejection fraction was higher (53% vs. 48%; p = 0.001) and mean LV diastolic diameter lower (42 vs. 46 mm; p < 0.001) in females versus males, but sex was not identified as a predictor of LV mean wall thickness adjusted for height (beta coefficient − 0.22; p = 0.460) or a predominantly cardiac phenotype (odds ratio 1.60; p = 0.191). Modified polyneuropathy disability scores differed between groups (p < 0.001), with a larger proportion of scores ≥ IIIa among females (23% vs. 7%). Conclusions Females with ATTRwt amyloidosis in THAOS tended to present at a later age and showed signs of less severe cardiac impairment and more severe walking impairment. Trial Registration ClinicalTrials.gov: NCT00628745.
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Affiliation(s)
- Courtney M Campbell
- The Ohio State University, Columbus, OH, USA. .,Cardio-Oncology Center of Excellence, Washington University, 660 S Euclid Ave, St. Louis, MO, 63110, USA.
| | | | | | - Arnt V Kristen
- Department of Cardiology, Angiology, Respiratory Medicine, Medical University of Heidelberg, Heidelberg, Germany
| | - Mathew S Maurer
- Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Claudio Rapezzi
- Cardiological Centre, University of Ferrara, Ferrara, Italy.,Maria Cecilia Hospital, GVM Care and Research, Cotignola, RA, Italy
| | - Olivier Lairez
- Department of Cardiology and Nuclear Medicine, Toulouse University Hospital, Toulouse, France
| | - Brian Drachman
- Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Pablo Garcia-Pavia
- Hospital Universitario Puerta de Hierro Majadahonda, IDIPHISA, CIBERCV, Madrid, Spain.,Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Martha Grogan
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
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Ochi Y, Kubo T, Baba Y, Yamasaki N, Kitaoka H. Diagnostic and Therapeutic Strategy for Female Patients With Cardiac Amyloidosis - Reply. Circ Rep 2021; 3:749-750. [PMID: 34950805 PMCID: PMC8651466 DOI: 10.1253/circrep.cr-21-0141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 10/19/2021] [Indexed: 11/09/2022] Open
Affiliation(s)
- Yuri Ochi
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Toru Kubo
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Yuichi Baba
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Naohito Yamasaki
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Hiroaki Kitaoka
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
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Imamura T, Nakamura M. Diagnostic and Therapeutic Strategy for Female Patients With Cardiac Amyloidosis. Circ Rep 2021; 3:748. [PMID: 34950804 PMCID: PMC8651464 DOI: 10.1253/circrep.cr-21-0120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 09/09/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
- Teruhiko Imamura
- Second Department of Internal Medicine, University of Toyama Toyama Japan
| | - Makiko Nakamura
- Second Department of Internal Medicine, University of Toyama Toyama Japan
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Sex-related differences in the clinical characteristics of wild-type transthyretin amyloidosis cardiomyopathy. J Cardiol 2021; 79:50-57. [PMID: 34756766 DOI: 10.1016/j.jjcc.2021.10.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 09/28/2021] [Accepted: 10/01/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND A significant male predominance has been reported in wild-type transthyretin amyloid cardiomyopathy (ATTRwt-CM). Hence, female cases of ATTRwt-CM are overlooked, and sex-related differences in ATTRwt-CM remain unclear. This study aimed to examine sex-related differences in clinical characteristics and diagnostic approaches in ATTRwt-CM. METHODS We retrospectively analyzed 199 consecutive patients who were diagnosed with ATTRwt-CM and evaluated sex-related differences in clinical characteristics, imaging parameters, biomarkers, and diagnostic approaches. RESULTS Twenty-nine patients (15%) were female. These female patients were significantly older at diagnosis (77.1 ± 6.5 years vs. 82.9 ± 4.8 years; p<0.001) and had a more advanced New York Health Association functional class (2.2 ± 0.7 vs. 2.6 ± 0.8; p = 0.006) than their male counterparts. The median B-type natriuretic peptide levels were significantly higher (236 pg/mL vs. 394 pg/mL; p = 0.017) in female patients. Echocardiography revealed that the mean interventricular septum diameter was thinner (15.7 ± 2.6 mm vs. 14.1 ± 2.5 mm; p = 0.004) and left ventricular ejection fraction (LVEF) was preserved (51.2 ± 10.2% vs. 57.2 ± 9.1%; p = 0.003) in female patients. The mean heart-to-contralateral ratio obtained using 99mTc-labeled pyrophosphate (99mTc-PYP) was significantly lower (1.89 ± 0.33 vs. 1.63 ± 0.20; p < 0.001), moderate to severe aortic stenosis was more frequently observed (5% vs. 45%; p < 0.001), and the frequency of histological diagnosis was significantly lower (77% vs. 59%; p = 0.036) in female patients. CONCLUSIONS Female patients with ATTRwt-CM were predominantly octogenarians and less hypertrophic and had preserved LVEF and weaker cardiac uptake of the 99mTc-PYP tracer compared with male patients. These characteristics contribute to the underdiagnosis of ATTRwt-CM in female patients.
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