Determinants of health status in older patients with transthyretin cardiac amyloidosis: a prospective cohort study

BACKGROUND

Whether, and to what extent, frailty and other geriatric domains are linked to health status in patients with transthyretin cardiac amyloidosis (ATTR-CA) is unknown.

AIMS

To determine the association of frailty with health status [defined by the Kansas City Cardiomyopathy Questionnaire (KCCQ)] in patients with ATTR-CA.

METHODS

Consecutive ATTR-CA patients undergoing cardiovascular assessment at a tertiary care clinic from September 2021 to September 2023 were invited to participate. KCCQ, frailty and social environment were recorded. Frailty was assessed using the modified Frailty Index (mFI), mapping 11 variables from the Canadian Study of Health and Aging (frailty ≥0.36).

RESULTS

Of 168 screened ATTR-CA patients, 138 [83% men, median age of 79 (75-84) years] were enrolled in the study. Median KCCQ was 66 (50-75). wtATTR-CA was the most prevalent form (N = 113, 81.9%). The most frequent cardiac variant was Ile68Leu (17/25 individuals with vATTR-CA). Twenty (14.5%) patients were considered frail, and prevalence of overt disability was 6.5%. At multivariable linear regression analysis, factors associated with worsening KCCQ were age at evaluation, the mFI, NYHA Class, and NAC Score. Gender, ATTR-CA type, phenotype, and LVEF were not associated with health status.

DISCUSSION

In older patients diagnosed with ATTR-CA, frailty, symptoms, and disease severity were associated with KCCQ.

CONCLUSIONS

Functional status is a determinant of quality of life and health status in older individuals with a main diagnosis of ATTR-CA. Future research may provide more in-depth knowledge on the association of frailty in patients with ATTR-CA with respect to quality of life and prognosis.

Temporal outcomes of patients diagnosed with transthyretin cardiac amyloidosis

BACKGROUND

Transthyretin cardiac amyloidosis (ATTR-CA) is increasingly recognized. Clinical outcomes have evolved over time amidst changes in the diagnostic pathway and advances in therapeutics.

OBJECTIVE

To evaluate clinical outcomes over time of ATTR-CA patients with access to disease-modifying therapy.

METHODS

This is a retrospective cohort study of 419 patients diagnosed with ATTR-CA during 2001-2021, comparing clinical characteristics across eras. The primary endpoint was composite all-cause mortality or orthotopic heart transplant (OHT). Time-to-event analysis was performed using Cox proportional hazard modeling controlling for differences amongst cohorts.

RESULTS

Patients diagnosed in the more recent years had higher median age (2017-2021: 78 years, 2014-2016: 75 years, 2001-2013: 74 years) and more often had ATTRwt (81.9% vs 82.5% vs. 56.4%) but less severe phenotypes as evidenced by more individuals with Columbia stage I disease (47.6% vs 35.9% vs 22.4%), due to lower biomarkers, more NYHA Class I-II patients (68.9% vs 47.6% vs. 43.6%), and lower use of loop diuretics (67.0% vs 78.6% vs 89.1%). Over time, patients were more frequently treated with Tafamidis (74% vs 37% vs 32%). On multivariable analysis, greater Columbia score (HR 1.42, 95% CI 1.30-1.54, p<0.001) was predictive of death or OHT, while Tafamidis (HR 0.31, 95% CI 0.22-0.44, p<0.001) was associated with greater survival and freedom from OHT.

CONCLUSIONS

Recently diagnosed ATTR-CA patients have earlier stage disease and substantially lower mortality. Tafamidis is associated with significantly improved survival and freedom from OHT.

Feasibility of PiB positron emission tomography/computed tomography for treatment monitoring with Tafamidis in a patient with transthyretin cardiac amyloidosis

We present a 77-year-old woman with wild-type ATTR cardiac amyloidosis (ATTR-CA) who presented with dyspnea, arrhythmia, and elevated NT-pro BNP. Initial imaging including cardiac MRI, PYP scintigraphy, PiB PET/CT and NaF PET/CT revealed cardiac abnormalities. Tafamidis treatment was initiated. After 14 months, symptomatic improvement and reduced NT-pro BNP were observed. Cardiac MRI and PYP scintigraphy showed no significant change and increased NaF accumulation, while PiB PET/CT showed decreased amyloid deposition, suggesting that it may be superior to NaF PET/CT in assessing the therapeutic effect of tafamidis in ATTR-CA.

Feasibility of 11C-Pittsburgh compound B positron emission tomography/computed tomography for treatment monitoring with Tafamidis in a patient with transthyretin cardiac amyloidosis

We present a 77-year-old woman with wild-type ATTR cardiac amyloidosis (ATTR-CA) who presented with dyspnea, arrhythmia, and elevated NT-pro BNP. Initial imaging including cardiac MRI, PYP scintigraphy, PiB PET/CT and NaF PET/CT revealed cardiac abnormalities. Tafamidis treatment was initiated. After 14 months, symptomatic improvement and reduced NT-pro BNP were observed. Cardiac MRI and PYP scintigraphy showed no significant change and increased NaF accumulation, while PiB PET/CT showed decreased amyloid deposition, suggesting that it may be superior to NaF PET/CT in assessing the therapeutic effect of tafamidis in ATTR-CA.

Frailty and caregiver relationship quality in older patients diagnosed with transthyretin cardiac amyloidosis

Aim of the study was to explore frailty and quality of the relationship with the caregiver in a cohort of older patients with transthyretin cardiac amyloidosis (ATTR-CA). Sixty-eight consecutive ATTR-CA patients were recruited and assessed for frailty, depressive symptoms, quality of the relationship in terms of social support, or conflict toward caregivers, New York Heart Association Class (NYHA), and National Amyloid Center score (NAC Score) for grading disease severity. Results showed that 10% of patients were frail. Depressive symptoms were present in 46% of patients. Regression analyses showed that both mFI and depression were associated with worse perception of social support, and that mFI and NAC score were associated with higher levels of conflict perceived in the caregivers' relationship. Overall, the mFI score was associated with worse perceived social support and caregiver relationship quality. Tertiary care heart failure clinics should actively support the patient-caregiver relationship to improve quality of life.

Standardization of 99mTechnetium pyrophosphate imaging methodology to diagnose TTR cardiac amyloidosis

BACKGROUND

Technetium pyrophosphate (99mTc-PYP) imaging to diagnose transthyretin cardiac amyloidosis (ATTR-CA) has been increasingly utilized. The objective of this study is to provide a standardized 99mTc-PYP imaging protocol to diagnose ATTR-CA.

METHODS

104 scans from 45 subjects with biopsy-proven ATTR-CA or light-chain cardiac amyloidosis (AL) were assessed. Multiple scans were obtained using different counts (750 vs 2000 K), times to acquisition (1 vs 2 to 4 hours), processing matrix (256 vs 128), and 99mTc-PYP dose. Image quality and extracardiac activity was assessed. Quantitative methods using heart-to-contralateral ratios (H/CL) and a visual semiquantitative scale were used to diagnose ATTR-CA.19 The correlation between H/CL ratios and reproducibility of semiquantitative visual scores, acquired using various imaging parameters, were evaluated.

RESULTS

All imaging parameters had good to excellent image quality. 750 vs 2000 K counts, 1 hour acquisition and 256 matrix, had lower extracardiac activity (P = .00018). 10 mCi of 99mTc-PYP v. higher doses showed excellent image quality and less extracardiac activity (P = .0015). Correlation of H/CL ratios was strong (r ≥ 0.92) and reproducibility of semiquantitative visual scores was high (Kappa = 95%).

CONCLUSION

An imaging protocol using 750 K counts, 10 mCi of 99mTc-PYP, and a 256 matrix was chosen as the standardized imaging protocol since it provided the shortest overall study time (1 vs 2 to 4 hours) and lowest radiation exposure (3 vs 8 to 10 mSv).