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Baghaee M, Mohammadi M, Moradi A, Ghadirzadeh E, Karimi H, Ghorbani P, Rajabnia M, Forootan M. Unusual presentation of transthyretin (ATTR) cardiac amyloidosis: A case report of pruritus as a possible initial symptom and challenging diagnosis. Clin Case Rep 2023; 11:e7883. [PMID: 37675414 PMCID: PMC10477467 DOI: 10.1002/ccr3.7883] [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: 07/17/2023] [Revised: 08/19/2023] [Accepted: 08/25/2023] [Indexed: 09/08/2023] Open
Abstract
Key Clinical Message This case emphasizes the significance of cardiac amyloidosis as a potential diagnosis in individuals manifesting with lesion-free pruritus and normal liver tests. Abstract Amyloidosis is a complex disorder in which misfolded proteins accumulate in various organs of the body. Cardiac amyloidosis (CA) can lead to heart failure, cardiac arrhythmia, sudden cardiac death, and deposition of proteins in coronary arteries. Diagnosing CA can be difficult, as the cardiac manifestations of amyloidosis can be similar to more prevalent etiologies. In addition, the accumulation of proteins in soft tissues, including the skin, can cause pruritus. In this paper, we present a 70-year-old man with generalized pruritus and no skin lesions, later diagnosed as CA after detecting ascites fluid. This case underscores the importance of considering amyloidosis in patients presenting with nonspecific symptoms, particularly those affecting the skin, and highlights the need for increased awareness of this disease among clinicians.
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Affiliation(s)
- Massood Baghaee
- Gastroenterology and Liver Diseases Research CenterResearch Institute for Gastroenterology and Liver Diseases, Guilan University of Medical SciencesRashtIran
| | - Mahsa Mohammadi
- Gastroenterology and Liver Diseases Research CenterResearch Institute for Gastroenterology and Liver Diseases, Guilan University of Medical SciencesRashtIran
| | - Amir Moradi
- Atherosclerosis Research CenterJundishapur University of Medical SciencesAhvazIran
| | - Erfan Ghadirzadeh
- Cardiovascular Research CenterMazandaran University of Medical SciencesSariIran
| | - Hanie Karimi
- School of Medicine, Tehran University of Medical SciencesTehranIran
| | - Parastoo Ghorbani
- Department of Internal Medicine, Faculty of MedicineMazandaran University of Medical SciencesSariIran
| | - Mohsen Rajabnia
- Non‐Communicable Diseases Research Center, Alborz University of Medical SciencesKarajIran
| | - Mojgan Forootan
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical SciencesTehranIran
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Bi X, Xu B, Liu J, Wang G, An J, Zhang X, Wang R, Dong W, Guan Z. Diagnostic Value of 11C-PIB PET/MR in Cardiac Amyloidosis. Front Cardiovasc Med 2022; 9:830572. [PMID: 35369284 PMCID: PMC8966842 DOI: 10.3389/fcvm.2022.830572] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 02/07/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThe thioflavin T derivative, 11C-Pittsburgh-B (PIB), is used for Alzheimer's disease imaging because it specifically binds to β-amyloid protein deposits in the brain. The aim of this study was to estimate the diagnostic value of combined 11C-PIB positron emission tomography/magnetic resonance (PET/MR) in cardiac amyloidosis (CA).MethodsWe enrolled 23 heart failure patients with suspected CA based on echocardiographic and electrocardiograph findings. All patients underwent cardiac 11C-PIB PET/MR and non-cardiac biopsy within one week. We also enrolled eight healthy volunteers that underwent cardiac 11C-PIB PET/MR as a control group. The cardiac magnetic resonance (CMR) protocol included cine imaging, late gadolinium enhancement (LGE), and native and post-contrast T1 mapping. Extracellular volume (ECV) was measured using pre- and post-contrast T1 mapping images. LVEF, IVSD, LVPW, LVmass, LVESV, LVEDV, native T1 value, ECV, and maximum uptake of myocardial tissue-to-blood background ratio (TBR) values were obtained from PET/MR images in all patients and healthy subjects.ResultsThirteen out of twenty-three heart failure patients were clinically diagnosed with CA. The remaining 10 patients were CA-negative (non-CA patient group). Twelve of the thirteen CA patients showed diffuse transmural LGE patterns, whereas LGE was either absent or patchy in the non-CA patients. The diagnostic sensitivity and specificity of TBRmax were 92.3 and 100%, respectively, at a cut-off value of 1.09. Several CMR imaging parameters (LVEF, IVSD, LVmass, LVEDV, LVESV, LVPW, native T1 value and ECV) and TBR showed significant differences between CA patients, non-CA patients, and healthy controls (P < 0.05). Native T1 mapping values positively correlated with TBRmax values in CA and non-CA patients (r = 0.38, P = 0.0004).Conclusions11C-PIB PET/MRI is a valuable tool for the accurate and non-invasive diagnosis of CA because it distinguishes CA patients from non-CA patients and healthy subjects with high specificity and sensitivity. Moreover, native T1 mapping values positively correlated with TBRmax values in CA and non-CA patients. In the future, larger cohort studies are necessary to confirm our findings.
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Affiliation(s)
- Xiao Bi
- Department of Nuclear Medicine, The First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Baixuan Xu
- Department of Nuclear Medicine, The First Medical Centre, Chinese PLA General Hospital, Beijing, China
- Baixuan Xu
| | - Jiajin Liu
- Department of Nuclear Medicine, The First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Guanyun Wang
- Department of Nuclear Medicine, The First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Jing An
- Department of Cardiology, The Sixth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Xiaojun Zhang
- Department of Nuclear Medicine, The First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Ruimin Wang
- Department of Nuclear Medicine, The First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Wei Dong
- Siemens Healthcare Ltd., Guangdong, China
- Wei Dong
| | - Zhiwei Guan
- Department of Nuclear Medicine, The First Medical Centre, Chinese PLA General Hospital, Beijing, China
- National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
- *Correspondence: Zhiwei Guan
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Diagnosing Cardiac Amyloidosis: From Heart Failure to Electrical Storm. Case Rep Med 2021; 2021:3293728. [PMID: 34239572 PMCID: PMC8238623 DOI: 10.1155/2021/3293728] [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: 03/27/2020] [Revised: 06/01/2021] [Accepted: 06/13/2021] [Indexed: 11/18/2022] Open
Abstract
Cardiac amyloidosis is a condition when amyloid fibers are deposited in the extracellular space of the heart causing tachyarrhythmias, heart failure, or sudden cardiac death. We present a 71-year-old woman presenting with dyspnea on admission. Echocardiogram revealed diastolic heart failure and left ventricular hypertrophy with strain pattern concerning for an infiltrative process. She was discharged with diuretic therapy and scheduled for a cardiac magnetic resonance imaging. One week after discharge, she was readmitted with progressive shortness of breath and syncope. She was found to be in shock and had multiple episodes of cardiac arrest with both ventricular tachycardia and pulseless electrical activity. She developed electrical storm and eventually passed within 24 hours. Autopsy revealed gross cardiomegaly and left ventricular hypertrophy with Congo red staining revealing amyloid fibrils with apple-green birefringence. This case demonstrates the rapid progression of cardiac amyloidosis from acute-onset diastolic heart failure to uncontrollable ventricular tachycardia, and eventually death. We review the literature regarding multiple diagnostic modalities that facilitate the confirmation of cardiac amyloidosis.
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Yamada S, Yoshihisa A, Hijioka N, Kamioka M, Kaneshiro T, Yokokawa T, Misaka T, Ishida T, Takeishi Y. Autonomic dysfunction in cardiac amyloidosis assessed by heart rate variability and heart rate turbulence. Ann Noninvasive Electrocardiol 2020; 25:e12749. [PMID: 32083399 PMCID: PMC7358876 DOI: 10.1111/anec.12749] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 12/03/2019] [Accepted: 01/08/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Cardiac amyloidosis (CA) is characterized by left ventricular hypertrophy (LVH) and autonomic nervous imbalance due to amyloid infiltration. However, autonomic dysfunction is often seen in heart failure (HF) with LVH from other etiologies. We aimed to characterize autonomic dysfunction in CA from other etiologies of LVH. METHODS Fifty-five HF patients with LVH (35 males, mean age 65 ± 16 years) were enrolled. LVH was defined as left ventricular mass index measured by echocardiography >95 g/m2 in women and 115 g/m2 in men. The etiology was as follows: amyloid light chain (AL)-CA, n = 14; hypertrophic cardiomyopathy, n = 21; and aortic stenosis (AS), n = 20. With the patient in a clinically stable condition, heart rate variability (HRV) and heart rate turbulence (HRT), which reflect autonomic dysfunction, were measured using Holter monitoring and compared among the three groups. RESULTS Brain natriuretic peptide levels, LVH severity, left ventricular ejection fraction, and tissue Doppler index E/e' did not differ among the three groups. However, severe abnormalities of HRV and HRT were obtained in AL-CA. In the ROC analysis to identify AL-CA in HF with LVH, the best cutoff value for standard deviation of all R-R intervals, standard deviation of the 5-min mean R-R intervals, turbulence onset, and turbulence slope were 68.5 ms (AUC: 0.865), 58.5 ms (AUC: 0.834), 0.25% (AUC: 0.813), and 1.00 ms/RR (AUC 0.736), respectively. CONCLUSION Autonomic dysfunction is a hallmark of AL-CA, and its noninvasive assessment by Holter monitoring may be a useful tool for differential diagnosis of HF with LVH.
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Affiliation(s)
- Shinya Yamada
- Department of Cardiovascular MedicineFukushima Medical UniversityFukushimaJapan
| | - Akiomi Yoshihisa
- Department of Cardiovascular MedicineFukushima Medical UniversityFukushimaJapan
- Department of Advanced Cardiac TherapeuticsFukushima Medical UniversityFukushimaJapan
| | - Naoko Hijioka
- Department of Cardiovascular MedicineFukushima Medical UniversityFukushimaJapan
| | - Masashi Kamioka
- Department of Cardiovascular MedicineFukushima Medical UniversityFukushimaJapan
| | - Takashi Kaneshiro
- Department of Cardiovascular MedicineFukushima Medical UniversityFukushimaJapan
- Department of Arrhythmia and Cardiac PacingFukushima Medical UniversityFukushimaJapan
| | - Tetsuro Yokokawa
- Department of Cardiovascular MedicineFukushima Medical UniversityFukushimaJapan
| | - Tomofumi Misaka
- Department of Cardiovascular MedicineFukushima Medical UniversityFukushimaJapan
- Department of Advanced Cardiac TherapeuticsFukushima Medical UniversityFukushimaJapan
| | - Takafumi Ishida
- Department of Cardiovascular MedicineFukushima Medical UniversityFukushimaJapan
| | - Yasuchika Takeishi
- Department of Cardiovascular MedicineFukushima Medical UniversityFukushimaJapan
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Suleiman S, Coughlan JJ, Moore D. Cardiac amyloidosis presenting with recurrent ischaemic strokes. BMJ Case Rep 2020; 13:e231910. [PMID: 32094234 PMCID: PMC7046391 DOI: 10.1136/bcr-2019-231910] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2020] [Indexed: 01/03/2023] Open
Abstract
A 72-year-old man presented to our service with sudden onset right-sided weakness, aphasia and gaze palsy with diplopia. CT angiogram demonstrated an acute thrombotic occlusion of the distal basilar artery, a basilar infarct and the patient underwent successful thrombectomy. ECG and telemetry demonstrated slow atrial fibrillation (AF). His transthoracic echocardiogram (TTE) showed a reduced ejection fraction of 25% with global hypo-kinesis, a dilated left ventricle (LV) and LV hypertrophy (LVH). Repeat TTE appeared suspicious for an infiltrative cardiomyopathy with LVH and a speckled appearance to the myocardium. Approximately 10 months later, he suffered another ischaemic stroke post-elective cardioversion for AF while on anticoagulation. Cardiac MRI demonstrated areas of delayed gadolinium enhancement consistent with amyloidosis. Fat pad biopsy was positive for amyloidosis. Our patient has made an excellent recovery from the ischaemic strokes and is being managed in our heart failure clinic.
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Affiliation(s)
- Suleiman Suleiman
- Department of Cardiology, Tallaght University Hospital, Dublin, Ireland
| | | | - David Moore
- Department of Cardiology, Tallaght University Hospital, Dublin, Ireland
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[The prognostic value of baseline serum free light chain in immunoglobulin light-chain cardiac amyloidosis]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2020; 41:47-53. [PMID: 32023754 PMCID: PMC7357907 DOI: 10.3760/cma.j.issn.0253-2727.2020.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Objective: To analyze the prognostic value of baseline serum free light chain (sFLC) in immunoglobulin light-chain cardiac amyloidosis (AL-CA) . Methods: Thirty patients diagnosed with AL-CA from January 2012 to December 2016 at Beijing Chaoyang Hospital were included in this study to retrospectively evaluate the clinical data. The cut-off value of dFLC (involved sFLC minus uninvolved sFLC) was determined according to the receiver operator characteristic curve (ROC) and grouped, the prognoses of both groups were evaluated. Results: The onset age of all AL-CA patients was 57 years old. It occurred more commonly in men (21 cases, 70%) and the light chains of immunoglobulin composed mainly of type λ (22 cases, 73.3%) . Renal involvements occurred in 17 cases (56.7%) . The median value of difference between involved and uninvolved serum immunoglobulin free light chain levels (dFLC) was 162.9 (57.9-401.6) mg/L. More subjects in the high dFLC group had higher BNP (P=0.005) , and shorter median survival than those in the low dFLC group (15 months vs 47 months, P<0.001) . Similar results of median survival were observed when the patients were redivided by a new cut-off value of 180 mg/L for dFLC (high dFLC group: 22 months, low dFLC group: 40 months, P=0.001) , or a κ/λ ratio in which patients with κ type sFLC-ratio<3.79 and λ type sFLC-ratio≥0.06 were grouped into the low sFLC-ratio (37 months) , and the reverse the high sFLC-ratio ones (25 months, P=0.021) . In multivariate analysis, dFLC and New York Heart Association (NYHA) classification of cardiac function were two risk factors associated with all-cause mortality in patients, of them the hazard ratio for higher dFLC was 12.13 (95%CI 2.98-49.30, P<0.001) . Conclusion: Measurement of the sFLC level could implicate the prognosis of AL-CA.
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Kim YJ, Ha S, Kim YI. Cardiac amyloidosis imaging with amyloid positron emission tomography: A systematic review and meta-analysis. J Nucl Cardiol 2020; 27:123-132. [PMID: 30022405 DOI: 10.1007/s12350-018-1365-x] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 07/04/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Recent progress in amyloid positron emission tomography (PET) has enabled the targeted imaging of cardiac amyloidosis with accuracy. We performed a systematic review and meta-analysis on the diagnostic performance of cardiac amyloidosis using amyloid PET. METHODS A systematic search was performed using key words: cardiac amyloidosis, amyloid, and PET. We estimated the pooled sensitivity, specificity, positive and negative likelihood ratio (LR), and diagnostic odds ratio (DOR). Furthermore, the semiquantitative parameters of PET were evaluated to diagnose cardiac amyloidosis and discern its type [systemic light chain amyloidosis (AL) vs transthyretin amyloidosis (ATTR)] using the pooled standardized mean difference (SMD). RESULTS In total, six eligible studies with a total of 98 subjects were included in this meta-analysis. The pooled sensitivity was 0.95, the specificity was 0.98, positive LR was 10.130, negative LR was 0.1, and DOR was 148.83. The semiquantitative parameters of amyloid PET showed significantly higher values for cardiac amyloidosis patients than those for controls (pooled SMD = 1.42; P < .001), and in AL than ATTR (pooled SMD = 0.96; P < .001). CONCLUSION Amyloid PET imaging can be a useful method for diagnosing cardiac amyloidosis. The semiquantitative parameters of amyloid PET can help diagnose cardiac amyloidosis and discern its type.
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Affiliation(s)
- Yong Joong Kim
- Department of Family Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Sejin Ha
- Department of Nuclear Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Yong-Il Kim
- Department of Nuclear Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
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Kimishima Y, Yoshihisa A, Kiko T, Yokokawa T, Miyata-Tatsumi M, Misaka T, Oikawa M, Kobayashi A, Takeishi Y. Utility of B-Type Natriuretic Peptide for Detecting Cardiac Involvement in Immunoglobulin Amyloidosis. Int Heart J 2019; 60:1106-1112. [DOI: 10.1536/ihj.19-043] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Yusuke Kimishima
- Department of Cardiovascular Medicine, Fukushima Medical University
| | - Akiomi Yoshihisa
- Department of Cardiovascular Medicine, Fukushima Medical University
- Department of Advanced Cardiac Therapeutics, Fukushima Medical University
| | - Takatoyo Kiko
- Department of Cardiovascular Medicine, Fukushima Medical University
| | - Tetsuro Yokokawa
- Department of Cardiovascular Medicine, Fukushima Medical University
| | | | - Tomofumi Misaka
- Department of Cardiovascular Medicine, Fukushima Medical University
- Department of Advanced Cardiac Therapeutics, Fukushima Medical University
| | - Masayoshi Oikawa
- Department of Cardiovascular Medicine, Fukushima Medical University
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Ishaq S, Lin F, Martins J, Huggett R. Unexpected manifestation of cardiac amyloidosis. BMJ Case Rep 2018; 2018:bcr-2017-222852. [PMID: 30077977 DOI: 10.1136/bcr-2017-222852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
This report discusses an unusual case of cardiac amyloidosis. We report a patient who presented with unexplained ascites on a background of stable hypertension and mild left ventricular systolic dysfunction, cardiovascular complaints commonly associated with age. Due to the unspecific nature of his cardiovascular symptoms, it took 2 years of recurrent, unresolved ascites, numerous investigations, shifting differential diagnoses and significant cardiovascular deterioration before cardiac amyloidosis was recognised, by which the disease was at end stage. This case emphasises the need for more discriminating clinical features in the diagnosis of cardiac amyloidosis and advocates unexplained, recurrent ascites as a possible candidate.
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Affiliation(s)
- Sauid Ishaq
- Department of Gastroenterology and Cardiology, Dudley group of Hospital, Dudley, UK.,Health and science department, Birmingham City University, Birmingham
| | - Fei Lin
- Department of Gastroenterology and Cardiology, Dudley group of Hospital, Dudley, UK
| | - Joe Martins
- Department of Cardiology, Dudley Group of Hospital, NHS Trust, Dudley
| | - Robert Huggett
- Department of Cardiology, Dudley Group of Hospital, NHS Trust, Dudley
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Siegismund CS, Escher F, Lassner D, Kühl U, Gross U, Fruhwald F, Wenzel P, Münzel T, Frey N, Linke RP, Schultheiss HP. Intramyocardial inflammation predicts adverse outcome in patients with cardiac AL amyloidosis. Eur J Heart Fail 2018; 20:751-757. [PMID: 29067795 DOI: 10.1002/ejhf.1039] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 09/08/2017] [Accepted: 09/18/2017] [Indexed: 12/19/2022] Open
Abstract
AIMS To evaluate the influence of endomyocardial biopsy (EMB)-proven intramyocardial inflammation on mortality in patients with cardiac transthyretin amyloid (ATTR) or amyloid light-chain (AL) amyloidosis. METHODS AND RESULTS We included 54 consecutive patients (mean age 68.83 ± 9.59 years; 45 men) with EMB-proven cardiac amyloidosis. We followed up patients from first diagnostic biopsy to as long as 36 months (mean 11.5 ± 12 months) and compared their outcome with information on all-cause mortality with or without proof of inflammation on EMB. Intramyocardial inflammation was assessed by quantitative immunohistology. Patients suffering from amyloidosis revealed a significant poor prognosis with proof of intramyocardial inflammation in contrast to those without inflammation (log-rank P = 0.019). Re-grouping of patients indicated AL amyloidosis to have a significant impact on all-cause mortality (log-rank P = 0.012). The detailed subgroup analysis showed that patients suffering from AL amyloidosis with intramyocardial inflammation have a significantly worse prognosis compared with AL amyloidosis without inflammation and ATTR with or without inflammation, respectively (log-rank P = 0.014, contingency Fisher's exact test, P = 0.008). CONCLUSION Our study reports for the first time a high incidence (48.1%) of intramyocardial inflammation in a series of patients with EMB-proven cardiac amyloidosis and could show that in patients with AL amyloidosis, intramyocardial inflammation correlated significantly with increased mortality. Our data have a direct clinical impact because one can hypothesize that additional immunomodulating/anti-inflammatory treatment regimens in patients with biopsy-proven inflammation of heart muscle tissue could be beneficial for patients suffering from cardiac AL amyloidosis.
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Affiliation(s)
| | - Felicitas Escher
- Institute for Cardiac Diagnostics and Therapy (IKDT), Berlin, Germany
- Department of Cardiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Deutsches Zentrum für Herz-Kreislaufforschung (DZHK), Berlin, Germany
| | - Dirk Lassner
- Institute for Cardiac Diagnostics and Therapy (IKDT), Berlin, Germany
| | - Uwe Kühl
- Institute for Cardiac Diagnostics and Therapy (IKDT), Berlin, Germany
- Department of Cardiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Ulrich Gross
- Institute for Cardiac Diagnostics and Therapy (IKDT), Berlin, Germany
| | - Friedrich Fruhwald
- Division of Cardiology, Department of Internal Medicine, Medical University Graz, Graz, Austria
| | - Philip Wenzel
- Center for Cardiology - Cardiology I and Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany
| | - Thomas Münzel
- Center for Cardiology - Cardiology I and Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany
| | - Norbert Frey
- Department of Internal Medicine III - Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Reinhold P Linke
- amYmed, Reference Center of Amyloid Diseases, Martinsried, Germany
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Abstract
The heart, like any organ in the body, is susceptible to amyloid deposition. Although more than 30 types of protein can cause amyloidosis, only two types commonly deposit in the ventricular myocardium: amyloid light chain and amyloid transthyretin. Amyloid cardiomyopathy is usually a major determinant of patient outcomes, and the diagnosis of heart involvement can be often relatively under-diagnosed, owing to nonspecific presenting symptoms and signs at a subclinical stage. The diagnosis of cardiac amyloidosis is usually performed by endomyocardial biopsy; however, the invasive nature and related high-risk complications restrict its wide use in clinical settings. Recently, with the advent of innovative techniques used for evaluating cardiac amyloidosis, noninvasive methods become increasingly important, especially in earlier diagnosis, distinguishing typing, risk prediction and response to treatment. Here, we will review recent developments in the noninvasive methods used in the assessment of cardiac amyloidosis, focused on the laboratory biomarkers and imaging modalities.
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Affiliation(s)
- Lei Zhao
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1 Shuaifuyuan, Wangfujing, Dongcheng district, Beijing, 100730, China
| | - Quan Fang
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1 Shuaifuyuan, Wangfujing, Dongcheng district, Beijing, 100730, China.
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Gertz MA, Buadi FK, Lacy MQ, Hayman SR. Immunoglobulin Light Chain Amyloidosis (Primary Amyloidosis). Hematology 2018. [DOI: 10.1016/b978-0-323-35762-3.00088-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Zhang XD, Liu YX, Yan XW, Fang LG, Fang Q, Zhao DC, Wang YN. Cerebral embolism secondary to cardiac amyloidosis: A case report and literature review. Exp Ther Med 2017; 14:6077-6083. [PMID: 29250142 PMCID: PMC5729392 DOI: 10.3892/etm.2017.5301] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 10/12/2017] [Indexed: 01/07/2023] Open
Abstract
Cardiac amyloidosis (CA) describes a group of heterogeneous diseases that are characterized by the extracellular fibril deposition of amyloid protein in the myocardium. The abnormal protein is usually derived from light-chain amyloidosis, mutant transthyretin amyloidosis and wild-type transthyretin. Patients with ischemic strokes and amyloidosis have been sporadically reported, however, they are not well summarized. In the present study, a case of cerebral ischemic stroke, secondary to CA was described. This patient presented with dyspnea on exertion, without any evidence of atrial fibrillation. A biopsy revealed deposition of amyloid in the myocardium and Congo Red staining was positive. He suffered from acute infarction of left basal ganglia, resulting from occlusion of the left middle cerebral arterial 6 months prior to admission. However, re-examination of cerebral magnetic resonance imaging in the present hospital revealed an old infarction in the region of the left basal ganglia with a normal appearance of the left middle cerebral artery. Transesophageal echocardiography (TEE) and cardiac magnetic resonance (CMR) both discovered intra-cardiac thrombi, confirming the diagnosis of cardiogenic cerebral embolism. The present study indicates that patients with CA may additionally present with cardiogenic cerebral embolism, and TEE and CMR imaging may help to avoid missing the presence of intra-cardiac thrombi.
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Affiliation(s)
- Xu-Dong Zhang
- Department of Respirology, Peking Union Medical College Hospital, Beijing 100730, P.R. China
| | - Ying-Xian Liu
- Department of Cardiology, Peking Union Medical College Hospital, Beijing 100730, P.R. China
| | - Xiao-Wei Yan
- Department of Cardiology, Peking Union Medical College Hospital, Beijing 100730, P.R. China
| | - Li-Gang Fang
- Department of Cardiology, Peking Union Medical College Hospital, Beijing 100730, P.R. China
| | - Quan Fang
- Department of Cardiology, Peking Union Medical College Hospital, Beijing 100730, P.R. China
| | - Da-Chun Zhao
- Department of Pathology, Peking Union Medical College Hospital, Beijing 100730, P.R. China
| | - Yi-Ning Wang
- Department of Radiology, Peking Union Medical College Hospital, Beijing 100730, P.R. China
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Bhatti S, Hendel RC, Lopez-Mattei J, Schwartz RG, Raff G, Einstein AJ. Frequent MUGA testing in a myeloma patient: A case-based ethics discussion. J Nucl Cardiol 2017; 24:1350-1354. [PMID: 27272150 DOI: 10.1007/s12350-016-0540-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 05/03/2016] [Indexed: 12/30/2022]
Affiliation(s)
- Sabha Bhatti
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Robert C Hendel
- Departments of Medicine and Radiology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Juan Lopez-Mattei
- Division of Diagnostic Imaging, Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Division of Internal Medicine, Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ronald G Schwartz
- Cardiology Division, Department of Medicine, Nuclear Medicine Division, Department of Imaging Sciences, University of Rochester, Rochester, NY, USA
| | - Gilbert Raff
- Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI, USA
| | - Andrew J Einstein
- Department of Medicine, Division of Cardiology, Columbia University Medical Center and New York-Presbyterian Hospital, 622 West 168th Street, PH 10-203B, New York, NY, 10032, USA.
- Department of Radiology, Columbia University Medical Center and New York-Presbyterian Hospital, 622 West 168th Street, PH 10-203B, New York, NY, 10032, USA.
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16
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Zhao L, Li J, Tian Z, Fang Q. Clinical correlates and prognostic values of pseudoinfarction in cardiac light-chain amyloidosis. J Cardiol 2016; 68:426-430. [DOI: 10.1016/j.jjcc.2015.11.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 10/26/2015] [Accepted: 11/07/2015] [Indexed: 02/04/2023]
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17
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Zhao L, Tian Z, Fang Q. Diagnostic accuracy of cardiovascular magnetic resonance for patients with suspected cardiac amyloidosis: a systematic review and meta-analysis. BMC Cardiovasc Disord 2016; 16:129. [PMID: 27267362 PMCID: PMC4897958 DOI: 10.1186/s12872-016-0311-6] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2015] [Accepted: 05/31/2016] [Indexed: 12/24/2022] Open
Abstract
Background This study is a systematic review and meta-analysis of the diagnostic value of cardiovascular magnetic resonance (CMR) in cardiac amyloidosis (CA). Methods A wide variety of electronic databases were searched for studies of CMR that reported the diagnostic accuracy in patients with suspected CA. Research manuscripts were subjected to further systematic review and meta-analysis. Methodological evaluation was performed under the guidance of the Quality Assessment of Diagnostic Accuracy Studies −2 (QUADAS–2). Heterogeneity was assessed, and a random-effects model was used to assess the diagnostic effects of CMR on pooled sensitivity, pooled specificity, and summary receiver operating characteristics (SROC). Results Seven studies that reported the performance of CMR for CA were included in the present systematic review, among which five studies (257 patients) that evaluated the diagnostic accuracy of late gadolinium enhancement (LGE) CMR were analyzed in the present meta-analysis. Heterogeneity was observed only in specificity. A summary sensitivity and specificity of 85 % (95 % CI: 77–91 %) and 92 % (95 % CI: 83–97 %) indicated a high diagnostic accuracy of LGE for CA. The AUC of SROC curve was 0.9530, suggesting that LGE is an effective way of diagnosing patients with possible cardiac involvement in amyloidosis. Conclusions LGE–CMR seems to have a relatively high diagnostic accuracy for amyloidosis patients with possible cardiac involvement. Combined CMR techniques may provide important information for the selection of suitable therapy. Electronic supplementary material The online version of this article (doi:10.1186/s12872-016-0311-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lei Zhao
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No.1 Shuaifuyuan, Wangfujing, Dongcheng District, Beijing, 100730, China
| | - Zhuang Tian
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No.1 Shuaifuyuan, Wangfujing, Dongcheng District, Beijing, 100730, China
| | - Quan Fang
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No.1 Shuaifuyuan, Wangfujing, Dongcheng District, Beijing, 100730, China.
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18
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Abstract
Baseline physiological function of the mammalian heart is under the constant threat of environmental or intrinsic pathological insults. Cardiomyocyte proteins are thus subject to unremitting pressure to function optimally, and this depends on them assuming and maintaining proper conformation. This review explores the multiple defenses a cell may use for its proteins to assume and maintain correct protein folding and conformation. There are multiple quality control mechanisms to ensure that nascent polypeptides are properly folded and mature proteins maintain their functional conformation. When proteins do misfold, either in the face of normal or pathological stimuli or because of intrinsic mutations or post-translational modifications, they must either be refolded correctly or recycled. In the absence of these corrective processes, they may become toxic to the cell. Herein, we explore some of the underlying mechanisms that lead to proteotoxicity. The continued presence and chronic accumulation of misfolded or unfolded proteins can be disastrous in cardiomyocytes because these misfolded proteins can lead to aggregation or the formation of soluble peptides that are proteotoxic. This in turn leads to compromised protein quality control and precipitating a downward spiral of the cell's ability to maintain protein homeostasis. Some underlying mechanisms are discussed and the therapeutic potential of interfering with proteotoxicity in the heart is explored.
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Affiliation(s)
- Patrick M McLendon
- From the Department of Pediatrics, Children's Hospital Research Foundation, Cincinnati, OH
| | - Jeffrey Robbins
- From the Department of Pediatrics, Children's Hospital Research Foundation, Cincinnati, OH.
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19
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Mielcarek M, Inuabasi L, Bondulich MK, Muller T, Osborne GF, Franklin SA, Smith DL, Neueder A, Rosinski J, Rattray I, Protti A, Bates GP. Dysfunction of the CNS-heart axis in mouse models of Huntington's disease. PLoS Genet 2014; 10:e1004550. [PMID: 25101683 PMCID: PMC4125112 DOI: 10.1371/journal.pgen.1004550] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 06/13/2014] [Indexed: 12/28/2022] Open
Abstract
Cardiac remodelling and contractile dysfunction occur during both acute and chronic disease processes including the accumulation of insoluble aggregates of misfolded amyloid proteins that are typical features of Alzheimer's, Parkinson's and Huntington's disease (HD). While HD has been described mainly as a neurological disease, multiple epidemiological studies have shown that HD patients exhibit a high incidence of cardiovascular events leading to heart failure, and that this is the second highest cause of death. Given that huntingtin is ubiquitously expressed, cardiomyocytes may be at risk of an HD-related dysfunction. In mice, the forced expression of an expanded polyQ repeat under the control of a cardiac specific promoter led to severe heart failure followed by reduced lifespan. However the mechanism leading to cardiac dysfunction in the clinical and pre-clinical HD settings remains unknown. To unravel this mechanism, we employed the R6/2 transgenic and HdhQ150 knock-in mouse models of HD. We found that pre-symptomatic animals developed connexin-43 relocation and a significant deregulation of hypertrophic markers and Bdnf transcripts. In the symptomatic animals, pronounced functional changes were visualised by cardiac MRI revealing a contractile dysfunction, which might be a part of dilatated cardiomyopathy (DCM). This was accompanied by the re-expression of foetal genes, apoptotic cardiomyocyte loss and a moderate degree of interstitial fibrosis. To our surprise, we could identify neither mutant HTT aggregates in cardiac tissue nor a HD-specific transcriptional dysregulation, even at the end stage of disease. We postulate that the HD-related cardiomyopathy is caused by altered central autonomic pathways although the pathogenic effects of mutant HTT acting intrinsically in the heart may also be a contributing factor. Huntington's disease (HD) is a neurodegenerative disorder for which the mutation results in an extra-long tract of glutamines that causes the huntingtin protein to aggregate. It is characterized by neurological symptoms and brain pathology that is associated with nuclear and cytoplasmic aggregates and with transcriptional dysregulation. Despite the fact that HD has been recognized principally as a neurological disease, there are multiple epidemiological studies showing that HD patients exhibit a high rate of cardiovascular events leading to heart failure. To unravel the cause of cardiac dysfunction in HD models, we employed a wide range of molecular and physiological methods using two well established genetic mouse models of this disease. We found that pre-symptomatic animals developed aberrant gap junction channel expression and a significant deregulation of hypertrophic markers that may predispose them to arrhythmia and an overall change in cardiac function. These changes were accompanied by the re-expression of foetal genes, apoptotic cardiomyocyte loss and a moderate degree of interstitial fibrosis in the symptomatic animals. Surprisingly, we could identify neither mutant HTT aggregates in cardiac tissue nor a HD-specific transcriptional dysregulation. Therefore, we conclude that the HD-related cardiomyopathy could be driven by altered central autonomic pathways.
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Affiliation(s)
- Michal Mielcarek
- Department of Medical and Molecular Genetics, King's College London, London, United Kingdom
| | - Linda Inuabasi
- Department of Medical and Molecular Genetics, King's College London, London, United Kingdom
| | - Marie K. Bondulich
- Department of Medical and Molecular Genetics, King's College London, London, United Kingdom
| | - Thomas Muller
- Department of Medical and Molecular Genetics, King's College London, London, United Kingdom
| | - Georgina F. Osborne
- Department of Medical and Molecular Genetics, King's College London, London, United Kingdom
| | - Sophie A. Franklin
- Department of Medical and Molecular Genetics, King's College London, London, United Kingdom
| | - Donna L. Smith
- Department of Medical and Molecular Genetics, King's College London, London, United Kingdom
| | - Andreas Neueder
- Department of Medical and Molecular Genetics, King's College London, London, United Kingdom
| | - Jim Rosinski
- CHDI Management Inc./CHDI Foundation Inc., Los Angeles, California, United States of America
| | - Ivan Rattray
- Department of Medical and Molecular Genetics, King's College London, London, United Kingdom
| | - Andrea Protti
- King's College London British Heart Foundation Centre of Excellence, Cardiovascular Division and Division of Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom
| | - Gillian P. Bates
- Department of Medical and Molecular Genetics, King's College London, London, United Kingdom
- * E-mail:
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