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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.
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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
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2
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Alfieri M, Guerra F, Lofiego C, Fogante M, Ciliberti G, Vagnarelli F, Barbarossa A, Principi S, Stronati G, Volpato G, Compagnucci P, Valeri Y, Tofoni P, Brugiatelli L, Capodaglio I, Esposto Pirani P, Argalia G, Schicchi N, Messano L, Centanni M, Giovagnoni A, Perna GP, Dello Russo A, Casella M. A Novel Approach to Cardiac Magnetic Resonance Scar Characterization in Patients Affected by Cardiac Amyloidosis: A Pilot Study. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:613. [PMID: 38674259 PMCID: PMC11051713 DOI: 10.3390/medicina60040613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 03/29/2024] [Accepted: 04/03/2024] [Indexed: 04/28/2024]
Abstract
Background and Objectives: Cardiac magnetic resonance (CMR) imaging has become an essential instrument in the study of cardiomyopathies; it has recently been integrated into the diagnostic workflow for cardiac amyloidosis (CA) with remarkable results. An additional emerging role is the stratification of the arrhythmogenic risk by scar analysis and the possibility of merging these data with electro-anatomical maps. This is made possible by using a software (ADAS 3D, Galgo Medical, Barcelona, Spain) able to provide 3D heart models by detecting fibrosis along the whole thickness of the myocardial walls. Little is known regarding the applications of this software in the wide spectrum of cardiomyopathies and the potential benefits have yet to be discovered. In this study, we tried to apply the ADAS 3D in the context of CA. Materials and Methods: This study was a retrospectively analysis of consecutive CMR imaging of patients affected by CA that were treated in our center (Marche University Hospital). Wherever possible, the data were processed with the ADAS 3D software and analyzed for a correlation between the morphometric parameters and follow-up events. The outcome was a composite of all-cause mortality, unplanned cardiovascular hospitalizations, sustained ventricular arrhythmias (VAs), permanent reduction in left ventricular ejection fraction, and pacemaker implantation. The secondary outcomes were the need for a pacemaker implantation and sustained VAs. Results: A total of 14 patients were deemed eligible for the software analysis: 8 patients with wild type transthyretin CA, 5 with light chain CA, and 1 with transthyretin hereditary CA. The vast majority of imaging features was not related to the composite outcome, but atrial wall thickening displayed a significant association with both the primary (p = 0.003) and the secondary outcome of pacemaker implantation (p = 0.003). The software was able to differentiate between core zones and border zones of scars, with the latter being the most extensively represented in all patients. Interestingly, in a huge percentage of CMR images, the software identified the highest degree of core zone fibrosis among the epicardial layers and, in those patients, we found a higher incidence of the primary outcome, without reaching statistical significance (p = 0.18). Channels were found in the scar zones in a substantial percentage of patients without a clear correlation with follow-up events. Conclusions: CMR imaging plays a pivotal role in cardiovascular diagnostics. Our analysis shows the feasibility and applicability of such instrument for all types of CA. We could not only differentiate between different layers of scars, but we were also able to identify the presence of fibrosis channels among the different scar zones. None of the data derived from the ADAS 3D software seemed to be related to cardiac events in the follow-up, but this might be imputable to the restricted number of patients enrolled in the study.
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Affiliation(s)
- Michele Alfieri
- Cardiology and Arrhythmology Clinic, University Hospital “Azienda Ospedaliero-Universitaria delle Marche”, Via Conca 71, 60126 Ancona, Italy (G.C.); (P.C.); (Y.V.); (P.T.); (L.B.)
| | - Federico Guerra
- Cardiology and Arrhythmology Clinic, University Hospital “Azienda Ospedaliero-Universitaria delle Marche”, Via Conca 71, 60126 Ancona, Italy (G.C.); (P.C.); (Y.V.); (P.T.); (L.B.)
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, 60121 Ancona, Italy
| | - Carla Lofiego
- Division of Cardiology, University Hospital “Azienda Ospedaliero-Universitaria delle Marche”, Via Conca 71, 60126 Ancona, Italy
| | - Marco Fogante
- Cardiovascular Radiological Diagnostics, Department of Radiological Sciences, University Hospital “Azienda Ospedaliero-Universitaria delle Marche”, Via Conca 71, 60126 Ancona, Italy; (M.F.)
| | - Giuseppe Ciliberti
- Cardiology and Arrhythmology Clinic, University Hospital “Azienda Ospedaliero-Universitaria delle Marche”, Via Conca 71, 60126 Ancona, Italy (G.C.); (P.C.); (Y.V.); (P.T.); (L.B.)
| | - Fabio Vagnarelli
- Division of Cardiology, University Hospital “Azienda Ospedaliero-Universitaria delle Marche”, Via Conca 71, 60126 Ancona, Italy
| | - Alessandro Barbarossa
- Cardiology and Arrhythmology Clinic, University Hospital “Azienda Ospedaliero-Universitaria delle Marche”, Via Conca 71, 60126 Ancona, Italy (G.C.); (P.C.); (Y.V.); (P.T.); (L.B.)
| | - Samuele Principi
- Cardiology and Arrhythmology Clinic, University Hospital “Azienda Ospedaliero-Universitaria delle Marche”, Via Conca 71, 60126 Ancona, Italy (G.C.); (P.C.); (Y.V.); (P.T.); (L.B.)
| | - Giulia Stronati
- Cardiology and Arrhythmology Clinic, University Hospital “Azienda Ospedaliero-Universitaria delle Marche”, Via Conca 71, 60126 Ancona, Italy (G.C.); (P.C.); (Y.V.); (P.T.); (L.B.)
| | - Giovanni Volpato
- Cardiology and Arrhythmology Clinic, University Hospital “Azienda Ospedaliero-Universitaria delle Marche”, Via Conca 71, 60126 Ancona, Italy (G.C.); (P.C.); (Y.V.); (P.T.); (L.B.)
| | - Paolo Compagnucci
- Cardiology and Arrhythmology Clinic, University Hospital “Azienda Ospedaliero-Universitaria delle Marche”, Via Conca 71, 60126 Ancona, Italy (G.C.); (P.C.); (Y.V.); (P.T.); (L.B.)
| | - Yari Valeri
- Cardiology and Arrhythmology Clinic, University Hospital “Azienda Ospedaliero-Universitaria delle Marche”, Via Conca 71, 60126 Ancona, Italy (G.C.); (P.C.); (Y.V.); (P.T.); (L.B.)
| | - Paolo Tofoni
- Cardiology and Arrhythmology Clinic, University Hospital “Azienda Ospedaliero-Universitaria delle Marche”, Via Conca 71, 60126 Ancona, Italy (G.C.); (P.C.); (Y.V.); (P.T.); (L.B.)
| | - Leonardo Brugiatelli
- Cardiology and Arrhythmology Clinic, University Hospital “Azienda Ospedaliero-Universitaria delle Marche”, Via Conca 71, 60126 Ancona, Italy (G.C.); (P.C.); (Y.V.); (P.T.); (L.B.)
| | - Irene Capodaglio
- Division of Cardiology, University Hospital “Azienda Ospedaliero-Universitaria delle Marche”, Via Conca 71, 60126 Ancona, Italy
| | - Paolo Esposto Pirani
- Cardiovascular Radiological Diagnostics, Department of Radiological Sciences, University Hospital “Azienda Ospedaliero-Universitaria delle Marche”, Via Conca 71, 60126 Ancona, Italy; (M.F.)
| | - Giulio Argalia
- Cardiovascular Radiological Diagnostics, Department of Radiological Sciences, University Hospital “Azienda Ospedaliero-Universitaria delle Marche”, Via Conca 71, 60126 Ancona, Italy; (M.F.)
| | - Nicolò Schicchi
- Cardiovascular Radiological Diagnostics, Department of Radiological Sciences, University Hospital “Azienda Ospedaliero-Universitaria delle Marche”, Via Conca 71, 60126 Ancona, Italy; (M.F.)
| | - Loredana Messano
- Cardiology and Arrhythmology Clinic, University Hospital “Azienda Ospedaliero-Universitaria delle Marche”, Via Conca 71, 60126 Ancona, Italy (G.C.); (P.C.); (Y.V.); (P.T.); (L.B.)
| | - Maurizio Centanni
- Cardiology and Arrhythmology Clinic, University Hospital “Azienda Ospedaliero-Universitaria delle Marche”, Via Conca 71, 60126 Ancona, Italy (G.C.); (P.C.); (Y.V.); (P.T.); (L.B.)
| | - Andrea Giovagnoni
- Cardiovascular Radiological Diagnostics, Department of Radiological Sciences, University Hospital “Azienda Ospedaliero-Universitaria delle Marche”, Via Conca 71, 60126 Ancona, Italy; (M.F.)
- Department of Clinical, Special and Dental Sciences, Marche Polytechnic University, 60121 Ancona, Italy
| | - Gian Piero Perna
- Division of Cardiology, University Hospital “Azienda Ospedaliero-Universitaria delle Marche”, Via Conca 71, 60126 Ancona, Italy
| | - Antonio Dello Russo
- Cardiology and Arrhythmology Clinic, University Hospital “Azienda Ospedaliero-Universitaria delle Marche”, Via Conca 71, 60126 Ancona, Italy (G.C.); (P.C.); (Y.V.); (P.T.); (L.B.)
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, 60121 Ancona, Italy
| | - Michela Casella
- Cardiology and Arrhythmology Clinic, University Hospital “Azienda Ospedaliero-Universitaria delle Marche”, Via Conca 71, 60126 Ancona, Italy (G.C.); (P.C.); (Y.V.); (P.T.); (L.B.)
- Department of Clinical, Special and Dental Sciences, Marche Polytechnic University, 60121 Ancona, Italy
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De Lillo A, Pathak GA, Low A, De Angelis F, Abou Alaiwi S, Miller EJ, Fuciarelli M, Polimanti R. Clinical spectrum of Transthyretin amyloidogenic mutations among diverse population origins. Hum Genomics 2024; 18:31. [PMID: 38523305 PMCID: PMC10962184 DOI: 10.1186/s40246-024-00596-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 03/08/2024] [Indexed: 03/26/2024] Open
Abstract
PURPOSE Coding mutations in the Transthyretin (TTR) gene cause a hereditary form of amyloidosis characterized by a complex genotype-phenotype correlation with limited information regarding differences among worldwide populations. METHODS We compared 676 diverse individuals carrying TTR amyloidogenic mutations (rs138065384, Phe44Leu; rs730881165, Ala81Thr; rs121918074, His90Asn; rs76992529, Val122Ile) to 12,430 non-carriers matched by age, sex, and genetically-inferred ancestry to assess their clinical presentations across 1,693 outcomes derived from electronic health records in UK biobank. RESULTS In individuals of African descent (AFR), Val122Ile mutation was linked to multiple outcomes related to the circulatory system (fold-enrichment = 2.96, p = 0.002) with the strongest associations being cardiac congenital anomalies (phecode 747.1, p = 0.003), endocarditis (phecode 420.3, p = 0.006), and cardiomyopathy (phecode 425, p = 0.007). In individuals of Central-South Asian descent (CSA), His90Asn mutation was associated with dermatologic outcomes (fold-enrichment = 28, p = 0.001). The same TTR mutation was linked to neoplasms in European-descent individuals (EUR, fold-enrichment = 3.09, p = 0.003). In EUR, Ala81Thr showed multiple associations with respiratory outcomes related (fold-enrichment = 3.61, p = 0.002), but the strongest association was with atrioventricular block (phecode 426.2, p = 2.81 × 10- 4). Additionally, the same mutation in East Asians (EAS) showed associations with endocrine-metabolic traits (fold-enrichment = 4.47, p = 0.003). In the cross-ancestry meta-analysis, Val122Ile mutation was associated with peripheral nerve disorders (phecode 351, p = 0.004) in addition to cardiac congenital anomalies (fold-enrichment = 6.94, p = 0.003). CONCLUSIONS Overall, these findings highlight that TTR amyloidogenic mutations present ancestry-specific and ancestry-convergent associations related to a range of health domains. This supports the need to increase awareness regarding the range of outcomes associated with TTR mutations across worldwide populations to reduce misdiagnosis and delayed diagnosis of TTR-related amyloidosis.
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Affiliation(s)
- Antonella De Lillo
- Department of Psychiatry, Yale University School of Medicine, 60 Temple, Suite 7A, New Haven, CT, 06510, USA
- Department of Biology, University of Rome "Tor Vergata", Rome, Italy
| | - Gita A Pathak
- Department of Psychiatry, Yale University School of Medicine, 60 Temple, Suite 7A, New Haven, CT, 06510, USA
- VA CT Healthcare Center, West Haven, CT, USA
| | - Aislinn Low
- Department of Psychiatry, Yale University School of Medicine, 60 Temple, Suite 7A, New Haven, CT, 06510, USA
- VA CT Healthcare Center, West Haven, CT, USA
| | - Flavio De Angelis
- Department of Psychiatry, Yale University School of Medicine, 60 Temple, Suite 7A, New Haven, CT, 06510, USA
- Department of Physical and Mental Health, and Preventive Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Sarah Abou Alaiwi
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Edward J Miller
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Maria Fuciarelli
- Department of Biology, University of Rome "Tor Vergata", Rome, Italy
| | - Renato Polimanti
- Department of Psychiatry, Yale University School of Medicine, 60 Temple, Suite 7A, New Haven, CT, 06510, USA.
- VA CT Healthcare Center, West Haven, CT, USA.
- Wu Tsai Institute, Yale University, New Haven, CT, USA.
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4
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Mistrulli R, Ferrera A, Muthukkattil ML, Battistoni A, Gallo G, Barbato E, Spera FR, Magrì D. Atrial Fibrillation in Patients with Hypertrophic Cardiomyopathy and Cardiac Amyloidosis: From Clinical Management to Catheter Ablation Indication. J Clin Med 2024; 13:501. [PMID: 38256635 PMCID: PMC10816101 DOI: 10.3390/jcm13020501] [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: 11/06/2023] [Revised: 01/11/2024] [Accepted: 01/15/2024] [Indexed: 01/24/2024] Open
Abstract
Atrial fibrillation (AF) is the most common arrhythmia in patients affected by cardiomyopathies. Reports estimate a prevalence of 27% in patients with hypertrophic cardiomyopathy (HCM) and 40% in patients with cardiac amyloidosis (CA). The presence of AF typically results in progressive functional decline, an increased frequency of hospitalizations for heart failure, and a higher thromboembolic risk. Medical management using mainly beta-blockers or amiodarone has produced variable outcomes and a high rate of recurrence. Catheter ablation reduces symptom burden and complications despite a moderate rate of recurrence. Recent evidence suggests that an early rhythm control strategy may lead to more favorable short- and long-term outcomes. In this review, we summarize contemporary data on the management of AF in patients with cardiomyopathy (HCM and CA) with particular reference to the timing and outcomes of ablation procedures.
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Affiliation(s)
- Raffaella Mistrulli
- Clinical and Molecular Medicine Department, Sapienza University of Rome, 00185 Rome, Italy; (A.F.); (M.L.M.); (A.B.); (G.G.); (E.B.); (D.M.)
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5
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Korthals D, Eckardt L. The new European Society of Cardiology guideline for the management of cardiomyopathies: key messages for cardiac electrophysiologists. Herzschrittmacherther Elektrophysiol 2023; 34:311-323. [PMID: 37973628 PMCID: PMC10682323 DOI: 10.1007/s00399-023-00975-y] [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: 09/29/2023] [Accepted: 10/04/2023] [Indexed: 11/19/2023]
Abstract
Electrocardiographic findings and arrhythmias are common in cardiomyopathies. Both may be an early indication of a specific diagnosis or may occur due to myocardial fibrosis and/or reduced contractility. Brady- and tachyarrhythmias significantly contribute to increased morbidity and mortality in patients with cardiomyopathies. Antiarrhythmic therapy including risk stratification is often challenging and plays a major role for these patients. Thus, an "electrophysiological" perspective on guidelines on cardiomyopathies may be warranted. As the European Society of Cardiology (ESC) has recently published a new guideline for the management of cardiomyopathies, this overview aims to present key messages of these guidelines. Innovations include a new phenotype-based classification system with emphasis on a multimodal imaging approach for diagnosis and risk stratification. The guideline includes detailed chapters on dilated and hypertrophic cardiomyopathy and their phenocopies, arrhythmogenic right ventricular cardiomyopathy, and restrictive cardiomyopathy as well as syndromic and metabolic cardiomyopathies. Patient pathways guide clinicians from the initial presentation to diagnosis. The role of cardiovascular magnetic resonance imaging and genetic testing during diagnostic work-up is stressed. Concepts of rhythm and rate control for atrial fibrillation have led to new recommendations, and the role of defibrillator therapy in primary prevention is discussed in detail. Whilst providing general guidelines for management, the primary objective of the guideline is to ascertain the disease etiology and disease-specific, individualized management.
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Affiliation(s)
- Dennis Korthals
- Department of Cardiology II: Electrophysiology, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany.
| | - Lars Eckardt
- Department of Cardiology II: Electrophysiology, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
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Chaudhary MH, Dev S, Kumari A, Kanwal K, Jadav DN, Rasool S, Tayyab Saleem M, Bhagat R, Prachi F, Puri P, Kashif M, Varrassi G, Khatri M, Kumar S, Mohamad T. Holistic Approaches to Arrhythmia Management: Combining Medication, Ablation, and Device Interventions. Cureus 2023; 15:e45958. [PMID: 37900386 PMCID: PMC10600027 DOI: 10.7759/cureus.45958] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 09/25/2023] [Indexed: 10/31/2023] Open
Abstract
This narrative review investigates the severe health issue of arrhythmias, which affects millions of people worldwide. A multifaceted strategy incorporating medicine, catheter ablation, and advanced device interventions is necessary to manage these disorders effectively. Medication is the cornerstone, and as antiarrhythmic medications develop, their efficacy and side effects are reduced. Success depends on having individualized treatment strategies that consider patient profiles and arrhythmia type. Catheter ablation, a minimally invasive surgery that targets and removes faulty heart electrical circuits, has become a potent therapy when drugs are ineffective. Technological developments, including high-resolution mapping systems and customized catheters, improve precision. Pacemakers and implantable cardioverter-defibrillators (ICDs) are two examples of implantable cardiac devices essential to managing all types of arrhythmias. Pacemakers provide a regular heartbeat when the body's natural pacing mechanism fails. At the same time, ICDs, with cutting-edge algorithms, can identify and stop life-threatening arrhythmias and offer high-risk patients vital protection. As device technology advances, smaller, more durable devices become available, improving patient comfort and lowering the need for replacements. The seamless fusion of these three strategies is where holistic arrhythmia management shines. Even for difficult instances, customized combination therapy combining medicine, ablation, and device interventions offers complete solutions. Healthcare providers must collaborate for this integrated strategy to deliver personalized, efficient, and holistic care. In conclusion, the management of arrhythmias has developed into a dynamic, synergistic discipline where drugs, catheter ablation, and devices all work in concert to deliver comprehensive care. For those with arrhythmias, a patient-centered strategy that considers their particular patient features and best integrates different modalities can significantly enhance their quality of life. The effectiveness and accessibility of holistic arrhythmia management could be further improved because of ongoing developments in these fields, which is encouraging for patients and medical professionals.
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Affiliation(s)
| | - Shah Dev
- Medicine, Jinnah Sindh Medical University, Karachi, PAK
| | - Ankeeta Kumari
- Medicine, Liaquat University of Medical and Health Sciences, Jamshoro, PAK
| | - Kainat Kanwal
- Medicine, Khawaja Muhammad Safdar Medical College, Sialkot, PAK
| | | | - Sohaib Rasool
- Medicine, Bakhtawar Amin Medical and Dental College, Multan, PAK
| | | | - Ridhi Bhagat
- Internal Medicine, Teerthanker Mahaveer Medical College and Reseach Center, Moradabad , IND
| | - Fnu Prachi
- Medicine, Guru Teg Bahadur Hospital, Delhi, IND
| | - Piyush Puri
- Internal Medicine, Adesh Institute of Medical Science and Research, Bathinda, IND
| | - Maham Kashif
- Medicine, Khawaja Muhammad Safdar Medical College, Sialkot, PAK
| | | | - Mahima Khatri
- Medicine and Surgery, Dow University of Health Sciences, Karachi, PAK
| | - Satesh Kumar
- Medicine and Surgery, Shaheed Mohtarma Benazir Bhutto Medical College, Karachi, PAK
| | - Tamam Mohamad
- Cardiovascular Medicine, Wayne State University, Detroit, USA
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