Clinical characteristics, patient selection and clinical outcomes of tafamidis treatment in transthyretin amyloidosis cardiomyopathy

Background

Tafamidis is a stabilizer of transthyretin, specifically designed to decrease or prevent amyloidogenesis, and improves prognosis in patients with transthyretin amyloid cardiomyopathy (ATTR-CM). However, clinical coarse, selection of appropriate patients and monitoring therapeutic effect of tafamidis remained unclear.

Purpose

The aim of this study was to clarify the patients' characteristics, clinical coarse, and clinical outcomes of tafamidis in patients with ATTR-CM and to evaluate prognostic factors and changes in clinical data over time.

Methods

We evaluated consecutive 180 patients with ATTR-CM considering tafamids treatment. A total of 107 patients had tafamidis treatment (tafamidis treatment group) and 65 patients did not treat with tafamidis (treatment naïve group). The remaining 8 patients were preclinical. Clinical data were obtained at the consideration of tafamidis treatment. We divided the following the cut-off values of high-sensitivity cardiac troponin T (hs-cTnT); >0.05 ng/mL, B-type natriuretic peptide (BNP); >250 pg/ml, and estimated glomerular filtration rate (eGFR); <45 mL/min/1.73 m2 and calculated the score by adding 1 point if increased or decreased by more than the cut-off value. We divided patients into a low score group (0–1 point) and high score group (2–3 points).

Results

All of study patients in the tafamidis treatment group were wild-type ATTR-CM. Compared to tafamidis treatment group, tafamidis naïve group were significantly older (75.6±5.3 vs. 82.8±4.6 years; p<0.01), female dominant (8% vs. 28%; p<0.01), increased BNP levels (median 209 vs 306 pg/ml; p<0.01), and lower haemoglobin levels (14.1±1.8 vs. 12.4±1.8 g/dl; p<0.01). Tafamidis treatment group was significantly favourable clinical outcomes competed to treatment naïve group (p<0.05; log rank test). According to multivariate logistic regression analysis, prior heart failure hospitalization (hazard ratio [HR]: 5.93, 95% confidence interval [CI]: 1.25–28.03, p=0.03) and high score group (HR: 1.56, 95% CI: 0.37–7.25; <0.01) were the significant poor prognostic factors in tafamids treatment group. Among tafamidis treatment group, Hs-cTnT levels were significantly decreased after 12 months tafamidis treatment (0.055 [0.037–0.082] vs. 0.044 [0.033–0.077]; p<0.01) instead of no significant differences in BNP and significant decline of eGFR levels. There were no significant changes over time in the echocardiographic parameters after 12 months, and native T1 and extracellular volume fraction obtained by cardiac magnetic resonance in a limited number of patients.

Conclusion

The prognosis of ATTR-CM patients treated with tafamidis was favorable compared to tafamidis naïve group. Patient stratification combined with biomarkers predicted favorable prognosis in patients with tafamidis treatment. Hs-cTnT may be a useful maker for evaluating the therapeutic effect by tafamidis.

Funding Acknowledgement

Type of funding sources: None.

Change in echocardiography in patients with transthyretin amyloid cardiomyopathy with tafamidis treatment

Background

Transthyretin amyloid cardiomyopathy (ATTR-CM) is a progressive and infiltrative disease caused by the deposition of insoluble transthyretin (TTR) amyloid fibrils in the myocardium, which leads to cardiomyopathy characterized by increased ventricular wall thickness and diastolic dysfunction. TTR amyloid fibrils are performed by dissociation of the tetrameric TTR into monomers and misfolding and misassemble into insoluble fibrils. Tafamidis stabilizes the tetramers and inhibits the TTR monomerization, leads to inhibit the formation and deposition of TTR fibril. Clinical trials suggested tafamidis could improve prognosis by slowing the progression of amyloidosis. Evaluation of serial measurement echocardiographic findings by tafamidis treatment is important, but these data has not been fully revealed.

Purpose

The aim of study was to evaluate the change of echocardiographic parameter in patients with ATTR-CM received tafamidis for 12 months. Especially in strain echocardiogram, global longitudinal strain (GLS) has reported to be associated with prognosis, and apical sparing pattern, which longitudinal strain (LS) in the basal and middle segments is more severely impaired than the apical segments, is specific finding in ATTR-CM.

Method

Echocardiographic findings before and 12 months were compared in 68 patients with ATTR-CM who started a new prescription of tafamidis and 18 tafamidis naïve patients with ATTR-CM patients who underwent echocardiography annually prior to the approval of tafamidis.

Result

Among tafamidis treatment group, echocardiographic parameters were not significant changes before and after 12 months tafamidis treatment [left ventricular ejection fraction (LVEF): 49.6±10.6% vs. LVEF: 49.9±10.7% (p=0.767), interventricular septum diameter (IVSd):16.0±2.3mm vs 15.7±2.1mm (p=0.241), left ventricular posterior wall diameter (LVPWd):16.1±2.5mm vs 16.1±2.5mm (p=0.964), GLS: −8.4±2.7% vs −8.2±2.8% (p=0.419), LS at base: −4.6±2.6% vs −4.2±2.4% (p=0.291), LS at middle: −6.9±3.6% vs −6.9±2.8% (p=0.922), LS at apical:-12.7±4.2% vs −12.4±4.4% (p=0.615). Among tafamidis naïve group, these parameters remained almost unchanged in 12 months as well, except for GLS and LS at apical. LS at apical showed a significant impairment. [LVEF: 53.8±9.2% vs 51.7±9.3% (p=0.244), IVSd: 15.5±2.3mm vs 16.0±1.8mm (p=0.321), LVPWd: 15.4±2.3mm vs 15.9±2.3mm (p=0.267), GLS: −10.4±2.4% vs −9.0±2.9% (p=0.065), LS at base: −5.0±2.7% vs −5.1±2.9% (p=0.865), LS at middle: −8.9±3.1% vs −8.5±3.5% (p=0.565), LS at apical: −15.4±4.0% vs −12.6±4.4% (p=0.02); Table 1]

Conclusion

We evaluated changes in echocardiographic findings with tafamidis treatment for 12 months. The echocardiographic parameters did not change over the course of 12 months, but the decrease in LS at apex observed in the tafamidis naïve group.Segmental LS could reflect a slight progression of cardiac amyloidosis and the short-term effects of tafamidis.

Funding Acknowledgement

Type of funding sources: None.

Correlations between pathological deposition and non-invasive diagnostic modalities like 99mTc-PYP scintigraphy, cardiac magnetic resonance, GLS in patients with transthyretin cardiac amyloidosis

Background

Although wild-type transthyretin amyloid cardiomyopathy (ATTRwt-CM) was previously considered a rare disease, recent diagnostic imaging modalities have revealed that it is considerably underdiagnosed among elderly patients with heart failure. The severity of CM is thought to be related to the extent of amyloid deposition in heart.

99mTc-labeled pyrophosphate (99mTc-PYP) scintigraphy, cardiovascular magnetic resonance (CMR), global longitudinal strain (GLS) provide diagnostic and prognostic information in ATTRwt-CM. However, the relevance of these imaging modalities and their association with cardiac amyloid load has not been fully evaluated.

Purpose

The aim of study was to elucidate the associations between pathological amyloid load and cardiac retention evaluated by 99mTc-PYP scintigraphy, CMR, GLS in patients with ATTRwt-CM.

Method

Cardiac amyloid load was calculated as (amyloid deposition area/ total myocardium area)×100 using endomyocardial biopsy specimen. Cardiac retention was quantified by heart to contralateral (H/CL) ratio by 99mTc-PYP scintigraphy. Native T1 and extracellular volume (ECV) were obtained by CMR. GLS was analyzed using the 2D echo at the time of diagnosis.

Result

The mean cardiac amyloid load was 23.0±15.2% (n=57) and correlation with H/CL ratio (1.94±0.36 n=57), native T1 (1426.7±52.5 n=57), ECV (57.9±12.9 n=54), GLS (−9.1±2.4 n=57) were positive (r=0.375 p=0.004, r=0.496 r=0.304 p<0.001, r=0.304 p=0.025, r=0.473 p<0.001).

Conclusion

Increased cardiac amyloid load correlated with an increased 99mTc-PYP positivity, native T1, ECV, and an impaired GLS. These results suggest that imaging parameters may reflect histological and functional changes due to amyloid deposition in the myocardium.

Funding Acknowledgement

Type of funding sources: None.

Gender differences in clinical characteristics in wild-type transthyretin amyloidosis cardiomyopathy

Aims

A significant male predominance has been reported in wild-type transthyretin amyloid cardiomyopathy (ATTRwt-CM). In other words, the female ATTRwt-CM may be overlooked and gender differences in ATTRwt-CM remain unclear. This study aims to examine gender differences in clinical characteristics and diagnostic approaches in ATTRwt-CM.

Methods and results

We retrospectively evaluated 171 consecutive ATTRwt-CM patients diagnosed at our university hospital between December 2002 and December 2020. Twenty-two patients (12%) were women. Women were significantly older at diagnosis (77.3 years vs. 83.3 years; P<0.001) and had a higher advanced New York Health Association functional class (2.23±0.70 vs. 2.57±0.81; P=0.04) than men. In echocardiography, mean interventricular septum diameter was less thick (15.8 mm vs. 14.5 mm; P=0.03) and ejection fraction was preserved (51.7% vs. 57.7%; P=0.08) in women. The mean heart-to-contralateral ratio obtained using 99mTc-labeled pyrophosphate (99mTc-PYP) was significantly lower in women than in men (1.89 vs. 1.64; P=0.001). There was no significant gender difference in high-sensitivity median cardiac troponin T levels at diagnosis (0.055 ng/mL vs. 0.069 ng/mL; P=0.30) or history of carpal tunnel syndrome (57% vs. 55%; P=0.93) and electrocardiograms findings. However, the median B-type natriuretic peptide level was significantly higher (254 pg/mL vs. 434 pg/mL; P=0.02) in women. Moderate to severe aortic stenosis was more frequently observed in women (5% vs. 50%; P<0.001). Histological (78% vs. 59%; P=0.07) and genetic confirmation (78% vs. 59%; P=0.003) of ATTRwt-CM were not performed in women.

Conclusion

Women with ATTRwt-CM were predominantly octogenarians, less hypertrophic, and had weaker cardiac uptake of the 99mTc-PYP tracer than men with ATTRwt-CM. These characteristics contribute to the underdiagnosis of ATTRwt-CM in women. The diagnosis of ATTRwt-CM in women is challenging. Therefore, we must be familiar with the clinical characteristics of women with ATTRwt-CM.

Funding Acknowledgement

Type of funding sources: None.

P26 Soluble programed cell death ligand-1 is associated with acute coronary syndrome

Background

Immune checkpoint by programmed cell death (PD)-1 and its ligand (PD-L1) play crucial role in T cell tolerance toward vascular wall antigens. PD-L1 is widely expressed on a number of cells including immune cells and vascular endothelium. It was reported that increased expression of PD-L1 in dendritic cells implicates upregulated inflammation in atherosclerotic lesions that is associated with plaque instability. Although plaque rupture in coronary atherosclerosis is an important pathogenesis of acute coronary syndrome (ACS), the association between PD-L1 and ACS is still unknown.

Purpose

We hypothesize that circulating PD-L1 might be associated with ACS, reflecting endothelial damage and coronary plaque rupture. To elucidate this hypothesis, we compared serum levels of soluble PD-L1 (sPD-L1) in stable coronary artery disease (CAD) patients with those in ACS patients.

Methods

Serum levels of sPD-L1 were measured by using commercially available ELISA kit (Human PD-L1/B7-H1 DuoSet, R&D Systems) in consecutive patients with CAD admitted to our University Hospital from February 2016 to March 2017. Patients with any malignant disease or severe inflammatory disease were excluded from this study. Serum levels of sPD-L1 and clinical backgrounds were compared between stable-CAD and ACS patients.

Results

In total, 269 patients with CAD were enrolled (28 cases [10.4 %] with ACS and 241 cases [89.6 %] with stable-CAD). PD-L1 had no correlation to C-reactive protein, cardiac troponin, and classical atherosclerotic risks such as age, body mass index, estimated glomerular filtration rate, low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol, and hemoglobin A1c. Although age, sex, history of smoking, and the prevalences of hypertension, diabetes mellitus and dyslipidemia were comparable between both groups, the level of LDL-C was significantly higher in patients with ACS compared with those with stable-CAD (94.0 [77.0–112.0] mg/dL vs. 78.5 [65.0–97.0] mg/dL, P = 0.008). Also serum level of sPD-L1 was significantly increased in patients with ACS compared with those with stable-CAD (106.1 [60.9–157.7] pg/mL vs. 64.8 [30.9–102.5] pg/mL, P = 0.003). Univariate logistic regression analysis identified that serum levels of both sPD-L1 and LDL-C were independently associated with ACS. Moreover, multivariable logistic regression analysis with factors from univariate analysis identified that serum level of sPD-L1 was significantly and independently associated with ACS (odds ratio: 1.006, 95 % confidence interval: 1.001–1.012, P = 0.03).

Conclusions

This is the first study to elucidate that the increased serum levels of sPD-L1 was associated with ACS. This study suggests that sPD-L1 could be a risk marker and therapeutic target for ACS.

P2613Clinical significance of brachial-ankle pulse wave velocity in patients with heart failure with reduced left ventricular ejection fraction

Background

Heart failure (HF) is characterized as a complex syndrome of structural and functional cardiac disorder that impair ventricular filling and/or blood ejection. Peripheral arterial disease (PAD) is accompanied by systemic inflammation and is frequently associated with other cardiovascular diseases. Although PAD and HF share cardiovascular risk and pathophysiological features, and each has been associated with increased morbidity and mortality. Pulse wave velocity (PWV) is known to be an indicator of arterial stiffness. We previously reported the prognostic significance of brachial–ankle PWV (baPWV) in patients with HF with preserved left ventricular ejection fraction. However, its association with cardiovascular outcomes in HF with reduced EF (HFrEF) and HF with mid-range EF (HFmrEF) patients remains uncertain.

Purpose

The first aim of this study was to investigate the impact of PAD on prognosis in HFrEF and HFmrEF. The second aim was to investigate the relationship between baPWV and the occurrence of cardiovascular events in patients with HFrEF and HFmrEF.

Methods

We measured ankle-brachial pressure index (ABI) and baPWV values at stable condition after optimal therapy for HF in 201 consecutive HFrEF and HFmrEF patients admitted to Kumamoto University Hospital from 2007 to 2015 who were enrolled and followed until the occurrence of cardiovascular events.

Results

The mean age of the two groups of patients was 67.5±11.8 years. The prevalence of PAD, defined as an ABI 0.9 or less, was 14% in patients. Kaplan–Meier analysis revealed that HFrEF and HFmrEF patients with PAD had a significant higher risk of total cardiovascular and HF-related events than those without PAD (P=0.03 and P=0.01, respectively). The hazard ratio (HR) between HFrEF and HFmrEF patients without PAD and those with PAD was compared after adjustment for other confounders. The probabilities of total cardiovascular and HF-related events in HFrEF and HFmrEF patients with PAD were significantly higher than those in HFrEF and HFmrEF patients without PAD (HR: 2.19; 95% CI: 1.02–4.73; P=0.04, and HR: 3.5; 95% CI: 1.27–9.66; P=0.01, respectively). Next, we divided HFrEF and HFmrEF patients without PAD into three groups according to baPWV values. In the Kaplan–Meier analysis, total cardiovascular and HF-related events in the highest baPWV group (1800 cm/s ≤ baPWV) had a significantly higher frequency than those in the mid-level baPWV group (1400 cm/s ≤ baPWV < 1800 cm/s) (P=0.007 and P=0.004, respectively) (Figure A, B). The hazard ratio (HR) between HFrEF and HFmrEF patients in the mid-level baPWV group and those with other baPWV groups was compared after adjustment for other cofounders. The probabilities of total cardiovascular and HF-related events were significantly higher in the highest baPWV group.

Conclusion

Identifying complications of PAD and measuring baPWV values in HFrEF and HFmrEF patients were useful for predicting their prognosis.

P1647Prognostic significance of circulating leukocyte subtype counts in patients with chronic heart failure

Background

Inflammation, characterized by early leukocyte recruitment, is known to be associated with vascular endothelial dysfunction and atherosclerosis. Previous studies have reported that an increased leukocyte count is a risk factor for the progression of atherosclerosis in cardiovascular diseases, and we previously reported that a high monocyte count was an independent and incremental of cardiovascular events in patients with coronary artery disease. Furthermore, previous study also reported that inflammation play a role in the pathophysiology of heart failure (HF), but few studies have evaluated the prognostic role of monocyte in patients with HF.

Purpose

To elucidate the prognostic value of monocyte in HF, we investigated the association of monocyte counts in patients with HF with their future cardiovascular events, and compared them among new categories of HF in this study.

Methods

Consecutive HF patients referred for hospitalization at Kumamoto University Hospital between 2006 and 2015 were registered. Finally, a total of 678 HF patients were enrolled in the study, and were followed prospectively until 2016 or until the occurrence of cardiovascular events. We defined high monocyte group as monocyte counts ≥360/mm3 according to previous clinical reports. We further divided HF patients into three types according to left ventricular ejection fraction (LVEF) (HF with reduced LVEF (HFrEF), HF with mid-range LVEF (HFmrEF), and HF with preserved LVEF (HFpEF)).

Results

In this study, HFrEF was 82 patients, HFmrEF was 118 patients and HFpEF was 478 patients, respectively. The average of total monocyte counts were 397±136 in HFrEF and 375±172 in HFmrEF, and 341±138 in HFpEF patients. Kaplan-Meier analysis revealed that both HFrEF and HFmrEF patients with high monocyte group (≥360 /mm3) had a significant higher risk of HF-related events (P=0.03 and P=0.02, respectively) but not of total cardiovascular events compared with those with low monocyte groups (<360/mm3) (P=0.001). By contrast, high and low monocyte groups in HFpEF patients had no significant difference in both total cardiovascular and HF-related events. Multivariate Cox hazard analysis identified a high monocyte count as an independent and significant predictor of future HF-related events in HFrEF and HFmrEF patients (hazard ratio: 3.02, 95% confidence interval: 1.20–7.59, p=0.018).

Next, by whether they had ischemic heart disease (IHD), we divided HFrEF and HFmrEF patients into two groups. Non-ischemic HF group with high monocyte counts had a significant higher risk of HF-related events compared to those with low monocyte counts (P=0.014). By contrast, there was no statistically significant difference of the occurrences of future HF-related events between in ischemic HF group with high and low monocyte counts.

Conclusion

A high monocyte count was an independent and incremental predictor of HF-related events in HFrEF and HFmrEF especially with IHD, but not in HFpEF patients.

P2611The prognostic value of serum magnesium levels in patients with heart failure with preserved left ventricular ejection fraction

Background

In heart failure (HF) patients, various factors, such as hyperactivity of the renin-angiotensin system, influence of drug therapy such as loop and thiazide diuretics, undernutrition and others, can causes hypokalemia and hypomagnesemia. Although serum magnesium (Mg) levels are closely associated with the prognosis of HF patients, the clinical significance of serum Mg levels in cardiovascular outcomes of HF with preserved ejection fraction (HFpEF) patients is not fully understood.

Purpose

We examined the relationship between serum Mg and future HF-related events in patients with HFpEF.

Methods

This study was a retrospective, single-center, observational study. We enrolled 452 consecutive HFpEF patients admitted to our university hospital between January 2007 and September 2013 and followed them for 4 years or until occurrence of HF-related events. We defined lower serum Mg as <2.0 mg/dL (=0.8 mmol/L) and higher serum Mg as ≥2.0 mg/dL based on recent clinical evidences and compared their clinical characteristics and prognosis.

Results

The mean serum Mg level was 2.12 mg/dL (median, 2.1 mg/dL; interquartile range, 2.0–2.28 mg/dL). The follow-up period was 0–50 months (median, 47.3 months) and 48 HF-related events (10.6%) were recorded. The frequency of HF-related events was significantly higher in the lower serum Mg group compared with the higher serum Mg group (n=16, 17.4% vs. n=32, 8.9%; P=0.018). There were no significant differences between groups in the use of all drugs (loop diuretics, mineralcorticoid receptor antagonists, renin-angiotensin-aldosterone system inhibitors, calcium channel blockers, β-blockers, statins and Mg preparations). The lower serum Mg group (n=92) showed significantly higher prevalence of diabetes mellitus (DM), uric acid levels and B-type natriuretic peptide (BNP)levels compared with the higher serum Mg group (n=360). Kaplan-Meier curve revealed a significantly higher probability of HF-related events in the lower serum Mg group compared with the higher serum Mg group (log-rank test, P=0.012, Figure). Multivariate Cox proportional hazard analysis revealed that the lower serum Mg group had significantly and independently higher probabilities of HF-related events compared with those in the higher serum Mg group (hazard ratio: 2.37, 95% confidence intervals: 1.27–4.41, P=0.007). We reclassified the risk of a HF-related events after adding the lower serum Mg to the prognostic factors (age, previous hospitalization for HF, DM, ln-BNP); the continuous net reclassification improvement was 29.0% (p=0.041).

Conclusion

We first demonstrated that serum Mg was significantly correlated with the occurrence of future HF-related events in HFpEF patients. Lower serum Mg is able to successfully predict future HF-related events, and management of serum Mg in HFpEF patients is thus important.

Acknowledgement/Funding

None