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Moore AB, Gershon C, Fiske C, Sun B, Nazer B, Kea B. Changes in Clinical Management Following 14-Day Ambulatory ECG Monitoring Following Emergency Department Evaluation for Unexplained Syncope. Ann Emerg Med 2024; 83:503-505. [PMID: 38276938 PMCID: PMC11066886 DOI: 10.1016/j.annemergmed.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 12/07/2023] [Accepted: 12/08/2023] [Indexed: 01/27/2024]
Affiliation(s)
- Andrew B Moore
- Department of Emergency Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA.
| | - Colin Gershon
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR
| | - Christa Fiske
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR
| | - Benjamin Sun
- Department of Emergency Medicine, University of Pennsylvania Scholl of Medicine, Philadelphia, PA
| | - Babek Nazer
- Division of Cardiology, University of Washington School of Medicine, Seattle, WA
| | - Bory Kea
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR
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Moore A, Fiske C, Gershon C, Nazer B, Kea B. 22 Efficacy of Emergency Department-Initiated 14-Day Ambulatory ECG Patch Monitors in Patients With Unexplained Syncope. Ann Emerg Med 2022. [DOI: 10.1016/j.annemergmed.2022.08.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Chandrashekar P, Rashdan L, Dale Z, Warner S, Gill S, Fischer K, Kim M, Nazer B, Masri A. Phenotypic presentation trends of transthyretin amyloid cardiomyopathy: are we getting better? Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Transthyretin amyloid cardiomyopathy (ATTR-CM) is being increasingly recognized due to recent advances in non-invasive imaging notably bone scintigraphy and newer effective therapies - particularly tafamidis, which was shown to improve survival and decrease heart failure hospitalizations in the ATTR-ACT trial. Earlier tafamidis use appeared to be more beneficial, as reflected by NYHA class I and II patients being associated with lower mortality and hospitalizations compared to NYHA class III. Increased awareness will likely lead to an increasing number of ATTR-CM patients being diagnosed with concerns regarding applicability of ATTR-ACT criteria on these patients.
Purpose
To investigate ATTR-CM phenotypic presentation trends based on initial clinical, biomarkers and transthoracic echocardiographic (TTE) data.
Methods
From 2005–2020, 116 ATTR-CM patients were seen at our amyloidosis center, who were stratified into 3 time periods based on the date of diagnosis: Early (21 patients, pre-2016), Mid (46 patients, 2016–2018), and Recent (49 patients, 2018–2020). ATTR-CM diagnosis was established based on the standard criteria of confirmed ATTR variant + typical TTE features; histological confirmation endomyocardial biopsy; or typical diffuse cardiac tracer uptake on bone scintigraphy while ruling out light chain amyloidosis. With less typical imaging, cardiac MRI typically served as a confirmatory test prior to pursuing histological confirmation. Demographics, cardiac biomarkers, diagnostic method used, and TTE variables that raise the suspicion of ATTR-CM were compared across time periods using one-way ANOVA test and Fischer's exact test.
Results
There was a significant change in the predominant method of diagnosis with the majority of patients in the Early time period diagnosed by endomyocardial biopsy, whereas in the Recent time period the majority of patients were diagnosed via pyrophosphate scintigraphy (Figure). Despite increasing number of patients being diagnosed, the clinical phenotype at diagnosis did not change significantly with similar proportion of patients NYHA class I/II, median daily diuretic dose, biomarkers, having at least one heart failure hospitalization prior to diagnosis, and similar TTE phenotype (Table). Only the age at diagnosis significantly increased across time periods. Women represented the minority of patients across all time periods.
Conclusion
Despite the increased awareness of ATTR-CM, there have been no major changes in the clinical, cardiac biomarker, or TTE phenotype on presentation in patients referred to our center for suspicion or a diagnosis of ATTR-CM. Our findings challenge the assumption that patients with ATTR-CM are being identified earlier with milder phenotypes. Women with ATTR-CM likely remain largely undiagnosed in our community. Continued education and knowledge dissemination are essential to identify ATTR-CM patients earlier to achieve better outcomes in this population.
Funding Acknowledgement
Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Pranav Chandrashekar is supported by an educational grant from Pfizer, Inc paid to Oregon Health and Science University. Table 1
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Affiliation(s)
- P Chandrashekar
- Oregon Health and Science University, Knight Cardiovascular Institute, Portland, United States of America
| | - L Rashdan
- Oregon Health and Science University, Knight Cardiovascular Institute, Portland, United States of America
| | - Z Dale
- Oregon Health and Science University, Knight Cardiovascular Institute, Portland, United States of America
| | - S Warner
- Oregon Health and Science University, Knight Cardiovascular Institute, Portland, United States of America
| | - S Gill
- Oregon Health and Science University, Knight Cardiovascular Institute, Portland, United States of America
| | - K Fischer
- Oregon Health and Science University, Knight Cardiovascular Institute, Portland, United States of America
| | - M Kim
- Oregon Health and Science University, Knight Cardiovascular Institute, Portland, United States of America
| | - B Nazer
- Oregon Health and Science University, Knight Cardiovascular Institute, Portland, United States of America
| | - A Masri
- Oregon Health and Science University, Knight Cardiovascular Institute, Portland, United States of America
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Dale Z, Chandrashekar P, Al-Rashdan L, Kim M, Masri A, Nazer B. Management strategies for atrial fibrillation and flutter in patients with transthyretin cardiac amyloidosis. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Atrial fibrillation (AF) and flutter (AFL) are common in transthyretin cardiac amyloidosis (ATTR-CM). Ventricular rate control drugs in ATTR-CM are poorly tolerated but data addressing tolerability and efficacy of rhythm control strategies is limited.
Purpose
We report characteristics and outcomes of AF/AFL in a cohort with ATTR-CM.
Methods
A single center observational study of patients seen at our Amyloidosis Center with wild-type or hereditary ATTR-CM diagnosed between 2005–2019. Treatment was prescribed as per treating cardiologists.
Results
Eighty-four patients with ATTR-CM (average age 74±10 years, 94% male) had mean follow-up of 27.6±22.8 months. AF/AFL occurred in 61 patients (73%). Clinically significant rapid ventricular response (RVR) was common as well attempted rate control with AV node blockers (Table 1). However, discontinuation was frequent (80%), often for adverse effects of hypotension (33%), bradycardia (15%), or presyncope/syncope (10%). Rhythm control was initiated in 64%, most often with cardioversion (DCCV) or ablation (Table 2). Post-DCCV recurrence was common (91%) and time to recurrence did not differ with use of anti-arrhythmic drugs (AAD; 5.8 months (IQR 1.9–12.5) vs without AAD 6.2 months (IQR 1.9–12.5) p=0.83). TEE was performed for 33% of DCCV with thrombus seen in 11% of cases – all patients who were not anticoagulated at the time. TEE was otherwise deferred due to known AF/AFL duration <48 hours (13%) or adequate anticoagulation (54%). Ablation was performed in 23% of patients with AFL (all for typical AFL) with 2 patients (14%) having recurrence after mean of 60.9 months. Pulmonary vein isolation for AF was performed in 12% (86% for persistent AF) with 86% recurrence after median of 6.2 months (IQR 5.6–12.3). Most patients (62%) with rhythm control had subjective improvement (≥1 NYHA class or resolved palpitations). Among AAD, amiodarone was most well tolerated with only 8% of patient discontinuing due to side effects. DCCV and ablation resulted in no direct complications although one patient had a perforation of a previously unknown Zenker diverticulum during TEE pre-DCCV.
Conclusions
In our ATTR-CM cohort, AF/AFL was common. Rate control was poorly tolerated and often abandoned. While rhythm control of AF/AFL had a favorable safety profile and successful conversion to sinus rhythm led to symptomatic improvement in a majority of cases, durable success with rhythm control was limited, often requiring multiple therapies. DCCV is only modestly successful and not significant improved with AAD. Ablation was successful in cases of cavo-tricuspid isthmus dependent AFL but had limited success in AF.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- Z Dale
- Oregon Health and Science University, Knight Cardiovascular Institute, Portland, United States of America
| | - P Chandrashekar
- Oregon Health and Science University, Knight Cardiovascular Institute, Portland, United States of America
| | - L Al-Rashdan
- Oregon Health and Science University, Knight Cardiovascular Institute, Portland, United States of America
| | - M Kim
- Oregon Health and Science University, Knight Cardiovascular Institute, Portland, United States of America
| | - A Masri
- Oregon Health and Science University, Knight Cardiovascular Institute, Portland, United States of America
| | - B Nazer
- Oregon Health and Science University, Knight Cardiovascular Institute, Portland, United States of America
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Roldan P, Nazer B, Steiner J. Like Father, Like Son. J Heart Lung Transplant 2021. [DOI: 10.1016/j.healun.2021.01.1975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Pampaloni MH, Nazer B, Botvinick E. Erratum to: Isolated right ventricular cardiac sarcoidosis demonstrated by (18)FDG positron emission tomography. J Nucl Cardiol 2015; 22:221. [PMID: 25342216 DOI: 10.1007/s12350-014-9953-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Hernandez Pampaloni M, Nazer B, Nazar B, Botvinick E. Isolated right ventricular cardiac sarcoidosis demonstrated by ¹⁸FDG positron emission tomography. J Nucl Cardiol 2014; 21:652-4. [PMID: 24429936 DOI: 10.1007/s12350-013-9848-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 12/13/2013] [Indexed: 10/25/2022]
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Nazer B, Hayward RM, Boyle AJ. Simultaneous thrombotic culprit lesions in two separate coronary arteries in a patient with ST-elevation myocardial infarction. Eur Heart J 2012; 33:2622. [DOI: 10.1093/eurheartj/ehs251] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Nazer B, Ray KK, Sloan S, Scirica B, Morrow DA, Cannon CP, Braunwald E. Prognostic utility of neopterin and risk of heart failure hospitalization after an acute coronary syndrome. Eur Heart J 2011; 32:1390-7. [DOI: 10.1093/eurheartj/ehr032] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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