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Badwan O, Berglund F, Rosenzveig A, Persits I, Gharaibeh A, Kumar A, Agrawal A, Sul L, Chan N, Wang TKM, Hanna M, Klein AL. Pericardial Disease in Cardiac Amyloidosis. Am J Cardiol 2024:S0002-9149(24)00360-6. [PMID: 38740164 DOI: 10.1016/j.amjcard.2024.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 05/02/2024] [Accepted: 05/08/2024] [Indexed: 05/16/2024]
Abstract
In patients with cardiac amyloidosis, pericardial involvement is common, with up to half of patients presenting with pericardial effusions. The pathophysiological mechanisms of pericardial pathology in cardiac amyloidosis include chronic elevations in right-sided filling pressures, myocardial and pericardial inflammation due to cytotoxic effects of amyloid deposits, and renal involvement with subsequent uremia and hypoalbuminemia. The pericardial effusions are typically small; however, several cases of life-threatening cardiac tamponade with hemorrhagic effusions have been described as a presenting clinical scenario. Constrictive pericarditis can also occur due to amyloidosis and its identification presents a clinical challenge in patients with cardiac amyloidosis who concurrently manifest signs of restrictive cardiomyopathy. Multimodality imaging, including echocardiography, cardiac computed tomography, and cardiac magnetic resonance imaging, is useful in the evaluation and management of this patient population. The recognition of pericardial effusion is important in the risk stratification of patients with cardiac amyloidosis as its presence confers a poor prognosis. However, specific treatment aimed at the effusions themselves is seldom indicated. Cardiac tamponade and constrictive pericarditis may necessitate pericardiocentesis and pericardiectomy, respectively.
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Affiliation(s)
- Osamah Badwan
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Felix Berglund
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell, and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Akiva Rosenzveig
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ian Persits
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ahmad Gharaibeh
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ashwin Kumar
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell, and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ankit Agrawal
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell, and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lidiya Sul
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Nicholas Chan
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Tom Kai Ming Wang
- Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell, and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Mazen Hanna
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell, and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Allan L Klein
- Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell, and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
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Aimo A, Panichella G, Garofalo M, Gasparini S, Arzilli C, Castiglione V, Vergaro G, Emdin M, Maffei S. Sex differences in transthyretin cardiac amyloidosis. Heart Fail Rev 2024; 29:321-330. [PMID: 37566193 PMCID: PMC10942898 DOI: 10.1007/s10741-023-10339-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/03/2023] [Indexed: 08/12/2023]
Abstract
Transthyretin cardiac amyloidosis (ATTR-CA) is a progressive disease characterized by the deposition of abnormal transthyretin protein fibrils in the heart, leading to cardiac dysfunction. Recent evidence suggests that sex differences may play a significant role in various steps of ATTR-CA, including clinical presentation, diagnostic challenges, disease progression, and treatment outcomes. ATTR-CA predominantly affects men, whereas women are older at presentation. Women generally present with a history of heart failure with preserved ejection fraction and/or carpal tunnel syndrome. When indexed, left ventricular (LV) wall thickness is equal, or even increased, than men. Women also have smaller LV cavities, more preserved ejection fractions, and apparently a slightly worse right ventricular and diastolic function. Given the under-representation on women in clinical trials, no data regarding sex influence on the treatment response are currently available. Finally, it seems there are no differences in overall prognosis, even if premenopausal women may have a certain level of myocardial protection. Genetic variations, environmental factors, and hormonal changes are considered as potential contributors to observed disparities. Understanding sex differences in ATTR-CA is vital for accurate diagnosis and management. By considering these differences, clinicians can improve diagnostic accuracy, tailor treatments, and optimize outcomes for both sexes with ATTR-CA.
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Affiliation(s)
- Alberto Aimo
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy.
| | - Giorgia Panichella
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Manuel Garofalo
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Simone Gasparini
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
- Paediatric Neurology Unit and Laboratories, Neuroscience Department, Meyer Children's Hospital IRCCS, Florence, Italy
| | | | - Vincenzo Castiglione
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Giuseppe Vergaro
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Michele Emdin
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy
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3
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Ota S, Izumiya Y, Kitada R, Nishi T, Taruya A, Wada T, Takahata M, Ozaki Y, Kashiwagi M, Shiono Y, Kuroi A, Takemoto K, Tanimoto T, Kitabata H, Fukuda D, Tanaka A. Diagnostic significance of paradoxical left ventricular hypertrophy in detecting cardiac amyloidosis. IJC HEART & VASCULATURE 2023; 49:101279. [PMID: 37859641 PMCID: PMC10582063 DOI: 10.1016/j.ijcha.2023.101279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 10/06/2023] [Accepted: 10/09/2023] [Indexed: 10/21/2023]
Abstract
Background Cardiac amyloidosis (CA) progresses rapidly with a poor prognosis. Therefore, methods for early diagnosis that are easily accessible in any hospital, are required. We hypothesized that based on the pathology of CA, morphological left ventricular hypertrophy (LVH) without electrical augmentation, namely paradoxical LVH, could be used to diagnose CA. This study aimed to investigate whether paradoxical LVH has diagnostic significance in identifying CA in patients with LVH. Methods Patients who presented with left ventricular (LV) wall thickness ≥ 12 mm on cardiac magnetic resonance (CMR) were enrolled from a multicentre CMR registry. Paradoxical LVH was defined as a LV wall thickness ≥ 12 mm on CMR, SV1 + RV5 < 3.5 mV, and a lack of secondary ST-T abnormalities. The diagnostic significance of paradoxical LVH in identifying CA was assessed. Results Of the 110 patients enrolled, 30 (27 %) were diagnosed with CA and 80 (73 %) with a non-CA aetiology. The CA group demonstrated paradoxical LVH more frequently than the non-CA group (80 % vs. 16 %, P < 0.001). It was an independent predictor for detecting CA in patients with LVH (odds ratio: 33.44, 95 % confidence interval: 8.325-134.3, P < 0.001). The sensitivity, specificity, positive predict value, negative predict value and accuracy of paradoxical LVH for CA detection were 80 %, 84 %, 65 %, 92 % and 83 %, respectively. Conclusions Paradoxical LVH can be used for identifying CA in patients with LVH. Our findings could contribute to the early diagnosis of CA, even in non-specialized hospitals.
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Affiliation(s)
- Shingo Ota
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Yasuhiro Izumiya
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Ryoko Kitada
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Takahiro Nishi
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Akira Taruya
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Teruaki Wada
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Masahiro Takahata
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Yuichi Ozaki
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Manabu Kashiwagi
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Yasutsugu Shiono
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Akio Kuroi
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Kazushi Takemoto
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Takashi Tanimoto
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Hironori Kitabata
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Daiju Fukuda
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Atsushi Tanaka
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
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Barbieri A, Imberti JF, Bartolomei M, Bonini N, Laus V, Torlai Triglia L, Chiusolo S, Stuani M, Mari C, Muto F, Righelli I, Gerra L, Malaguti M, Mei DA, Vitolo M, Boriani G. Quantification of Myocardial Contraction Fraction with Three-Dimensional Automated, Machine-Learning-Based Left-Heart-Chamber Metrics: Diagnostic Utility in Hypertrophic Phenotypes and Normal Ejection Fraction. J Clin Med 2023; 12:5525. [PMID: 37685592 PMCID: PMC10488495 DOI: 10.3390/jcm12175525] [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: 06/30/2023] [Revised: 08/09/2023] [Accepted: 08/17/2023] [Indexed: 09/10/2023] Open
Abstract
Aims: The differentiation of left ventricular (LV) hypertrophic phenotypes is challenging in patients with normal ejection fraction (EF). The myocardial contraction fraction (MCF) is a simple dimensionless index useful for specifically identifying cardiac amyloidosis (CA) and hypertrophic cardiomyopathy (HCM) when calculated by cardiac magnetic resonance. The purpose of this study was to evaluate the value of MCF measured by three-dimensional automated, machine-learning-based LV chamber metrics (dynamic heart model [DHM]) for the discrimination of different forms of hypertrophic phenotypes. Methods and Results: We analyzed the DHM LV metrics of patients with CA (n = 10), hypertrophic cardiomyopathy (HCM, n = 36), isolated hypertension (IH, n = 87), and 54 healthy controls. MCF was calculated by dividing LV stroke volume by LV myocardial volume. Compared with controls (median 61.95%, interquartile range 55.43-67.79%), mean values for MCF were significantly reduced in HCM-48.55% (43.46-54.86% p < 0.001)-and CA-40.92% (36.68-46.84% p < 0.002)-but not in IH-59.35% (53.22-64.93% p < 0.7). MCF showed a weak correlation with EF in the overall cohort (R2 = 0.136) and the four study subgroups (healthy adults, R2 = 0.039 IH, R2 = 0.089; HCM, R2 = 0.225; CA, R2 = 0.102). ROC analyses showed that MCF could differentiate between healthy adults and HCM (sensitivity 75.9%, specificity 77.8%, AUC 0.814) and between healthy adults and CA (sensitivity 87.0%, specificity 100%, AUC 0.959). The best cut-off values were 55.3% and 52.8%. Conclusions: The easily derived quantification of MCF by DHM can refine our echocardiographic discrimination capacity in patients with hypertrophic phenotype and normal EF. It should be added to the diagnostic workup of these patients.
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Affiliation(s)
- Andrea Barbieri
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Jacopo F. Imberti
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Mario Bartolomei
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Niccolò Bonini
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Vera Laus
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Laura Torlai Triglia
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Simona Chiusolo
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Marco Stuani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Chiara Mari
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Federico Muto
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Ilaria Righelli
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Luigi Gerra
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Mattia Malaguti
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Davide A. Mei
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Marco Vitolo
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy
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5
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Matteo S, Anna C, Federico S, Daniele M, Gioele F, Beatrice DP, Rita P, Elisabetta T, Giulia P, Claudio R, Gianluca C. Stroke volume and myocardial contraction fraction in transthyretin amyloidosis cardiomyopathy: A systematic review. Front Cardiovasc Med 2023; 10:1085824. [PMID: 36776259 PMCID: PMC9911429 DOI: 10.3389/fcvm.2023.1085824] [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] [Received: 10/31/2022] [Accepted: 01/06/2023] [Indexed: 01/28/2023] Open
Abstract
Background Cardiac amyloidosis (CA) is primarily a restrictive cardiomyopathy in which the impairment of diastolic function is dominant. Despite this, the left ventricular ejection fraction (LVEF) may be depressed in the late stage of the disease, but it poorly predicts prognosis in the earlier phases and does not represent well the pathophysiology of CA. Many echocardiographic parameters resulted important diagnostic and prognostic tools in patients with CA. Stroke volume (SV) and myocardial contraction fraction (MCF) may be obtained both with echocardiography and cardiac magnetic resonance (MRI). They reflect many factors intrinsically related to the pathophysiology of CA and are therefore potentially associated with symptoms and prognosis in CA. Objectives To collect and summarize the current evidence on SV and MCF and their clinical and prognostic role in transthyretin (TTR-CA). Methods and results We performed a systematic review following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. We searched the literature database for studies focusing on SV and MCF in patients with TTR-CA. We analysed the following databases: PUBMED, Cochrane Library, EMBASE, and Web of Science database. Fourteen studies were included in the review. Both SV and MCF have important prognostic implications and are related to mortality. Furthermore, SV is more related to symptoms than LVEF and predicts tolerability of beta-blocker therapy in TTR-CA. Finally, SV showed to be an excellent measure to suggest the presence of TTR-CA in patients with severe aortic stenosis. Conclusion Stroke volume and MCF are very informative parameters that should be routinely assessed during the standard echocardiographic examination of all patients with TTR-CA. They carry a prognostic role while being associated with patients' symptoms. Systematic review registration https://doi.org/10.17605/OSF.IO/ME7DS.
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Patel RK, Ioannou A, Razvi Y, Chacko L, Venneri L, Bandera F, Knight D, Kotecha T, Martinez‐Naharro A, Masi A, Porcari A, Brown J, Patel K, Manisty C, Moon J, Rowczenio D, Gilbertson JA, Sinagra G, Lachmann H, Wechalekar A, Petrie A, Whelan C, Hawkins PN, Gillmore JD, Fontana M. Sex differences among patients with transthyretin amyloid cardiomyopathy - from diagnosis to prognosis. Eur J Heart Fail 2022; 24:2355-2363. [PMID: 36575133 PMCID: PMC10087683 DOI: 10.1002/ejhf.2646] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 07/29/2022] [Accepted: 07/29/2022] [Indexed: 01/18/2023] Open
Abstract
AIMS Transthyretin amyloid cardiomyopathy (ATTR-CM) is predominantly diagnosed in men. The few available studies suggest affected women have a more favourable cardiac phenotype. We aimed to characterize sex differences among consecutive patients with non-hereditary and two prevalent forms of hereditary (h)ATTR-CM diagnosed over a 20-year period. METHODS AND RESULTS Analysis of deep phenotyping at presentation, changes on serial echocardiography and overall prognosis were evaluated. In total, 1732 consecutive patients were studied, comprising: 1095 with wild-type (wt)ATTR-CM; 206 with T60A-hATTR-CM; and 431 with V122I-hATTR-CM. Female prevalence was greater in T60A-hATTR-CM (29.6%) and V122I-hATTR-CM (27.8%) compared to wtATTR-CM (6%). At presentation, females were 3.3 years older than males (wtATTR-CM: 81.9 vs. 77.8 years; T60A-hATTR-CM: 68.7 vs. 65.1 years; V122I-hATTR-CM: 77.1 vs. 74.9 years). Body size significantly influenced measures of disease severity; when indexed, overall structural and functional phenotype was similar between sexes, the few significant differences suggested a mildly worse phenotype in females. No significant differences were observed in both disease progression on serial echocardiography and mortality across the overall population (p = 0.459) and when divided by genotype (wtATTR-CM: p = 0.730; T60A-hATTR-CM: p = 0.161; V122I-hATTR-CM: p = 0.056). CONCLUSION This study of a well-characterized large cohort of ATTR-CM patients did not demonstrate overall differences between sexes in either clinical phenotype, when indexed, or with respect to disease progression and prognosis. Non-indexed wall thickness measurements may have contributed to both under-representation and delays in diagnosis for affected females and highlights the potential role of utilizing indexed echocardiographic parameters for a more accurate assessment of patients at diagnosis and for disease prognostication.
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Affiliation(s)
- Rishi K. Patel
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Adam Ioannou
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Yousuf Razvi
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Liza Chacko
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Lucia Venneri
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Francesco Bandera
- Heart Failure Unit, Cardiology University DepartmentIRCCS Policlinico San DonatoMilanItaly
- Department for Biomedical Sciences for HealthUniversity of MilanoMilanItaly
| | - Daniel Knight
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Tushar Kotecha
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Ana Martinez‐Naharro
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Ambra Masi
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Aldostefano Porcari
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular DepartmentAzienda Sanitaria Universitaria Giuliano‐Isontina (ASUGI), University of TriesteTriesteItaly
| | - James Brown
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Kiara Patel
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Charlotte Manisty
- Barts Heart Centre, The Cardiovascular Magnetic Resonance Imaging Unit, and the Inherited Cardiovascular Diseases UnitSt Bartholomew's HospitalLondonUK
| | - James Moon
- Barts Heart Centre, The Cardiovascular Magnetic Resonance Imaging Unit, and the Inherited Cardiovascular Diseases UnitSt Bartholomew's HospitalLondonUK
| | - Dorota Rowczenio
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Janet A. Gilbertson
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Gianfranco Sinagra
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular DepartmentAzienda Sanitaria Universitaria Giuliano‐Isontina (ASUGI), University of TriesteTriesteItaly
| | - Helen Lachmann
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Ashutosh Wechalekar
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Aviva Petrie
- Eastman Dental Institute, University College LondonLondonUK
| | - Carol Whelan
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Philip N. Hawkins
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Julian D. Gillmore
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Marianna Fontana
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
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7
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Argiro' A, Zampieri M, Mazzoni C, Catalucci T, Biondo B, Tomberli A, Gabriele M, Di Mario C, Perfetto F, Cappelli F. Red flags for the diagnosis of cardiac amyloidosis: simple suggestions to raise suspicion and achieve earlier diagnosis. J Cardiovasc Med (Hagerstown) 2022; 23:493-504. [PMID: 35904994 DOI: 10.2459/jcm.0000000000001337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Cardiac amyloidosis is an infiltrative disease characterized by extracellular deposition of insoluble amyloid fibrils in the heart leading to organ dysfunction. Despite recent diagnostic advances, the diagnosis of cardiac amyloidosis is often delayed or even missed. Furthermore, a long diagnostic delay is associated with adverse outcomes, with the early diagnosed patients showing the longest survival. In this narrative review we aimed to summarize the 'red flags' that may facilitate the correct diagnosis. The red flags may be classified as clinical, biohumoral, electrocardiographic, echocardiographic, and cardiac magnetic resonance features and should promptly raise the suspicion of cardiac amyloidosis in order to start a correct diagnostic pathway and targeted treatment strategies that may improve patients' outcomes.
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Affiliation(s)
| | | | | | | | | | | | | | - Carlo Di Mario
- Tuscan Regional Amyloidosis Centre
- Division of Interventional Structural Cardiology, Cardiothoracovascular Department
| | - Federico Perfetto
- Tuscan Regional Amyloidosis Centre
- IV Internal Medicine Division, Careggi University Hospital, Florence, Italy
| | - Francesco Cappelli
- Tuscan Regional Amyloidosis Centre
- Division of Interventional Structural Cardiology, Cardiothoracovascular Department
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8
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Roy A, Peterson A, Marchant N, Alvir J, Bhambri R, Bredl Z, Benjumea D, Kemner J, Parasuraman B. Baseline characteristics and secondary medication adherence among Medicare patients diagnosed with transthyretin amyloid cardiomyopathy and/or receiving tafamidis prescriptions: A retrospective analysis of a Medicare cohort. J Manag Care Spec Pharm 2022; 28:766-777. [PMID: 35737856 PMCID: PMC10372989 DOI: 10.18553/jmcp.2022.28.7.766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND: Transthyretin amyloid cardiomyopathy (ATTR-CM) is an underdiagnosed, life-threatening condition that mostly affects older persons. In May 2019, regulatory approval of tafamidis provided the first pharmacologic treatment of ATTR-CM. In the pivotal phase 3 Transthyretin Amyloidosis Cardiomyopathy Clinical Trial (ATTR-ACT), 97.2% of patients were classified as adherent (defined as taking ≥ 80% of scheduled doses). Given its recent approval, there is limited real-world evidence examining patient adherence to tafamidis. OBJECTIVE: To evaluate adherence patterns, demographics, and clinical characteristics of patients in the United States receiving tafamidis prescriptions through Medicare. Secondarily, we aimed to evaluate concomitant medications filled by this patient population. METHODS: We conducted a retrospective cohort study of US Medicare claims data, limited by the Health Insurance Portability and Accountability Act of 1996, in adult patients with an adjudicated pharmacy claim for tafamidis (tafamidis free acid 61-mg capsule once daily or tafamidis meglumine four 20-mg capsules once daily) between May 1, 2019, and June 30, 2021. Gaps in therapy were measured using day gaps between prescription refills and continuous measure of medication gaps. Implementation adherence was assessed through modified medication possession ratio (MPRm), medication refill adherence (MRA), and proportion of days covered (PDC). Patients were grouped based on Medicare coverage. Patients were analyzed by subgroups based on age and at the zip code level, via distressed communities index quartiles and rural-urban tiers. RESULTS: A total of 3,558 patients who received a prescription fill of a tafamidis formulation were identified using Medicare Fee-for-Service (FFS) and Medicare Advantage (MA) claims data from May 1, 2019, to June 30, 2021. The characteristics of this patient population were consistent with published literature, as 98.6% were older than 65 years, 53.4% were between 75 years and 84 years, and 81.5% were male. In the patient population receiving tafamidis refills, adherence was high across all 3 measures, with mean MPRm greater than 90% and mean MRA greater than 80%, across all age groups. Mean PDC adherence rates were 79% or more across all age groups. Concomitant medications were generally indicated for heart failure and thrombosis. Among monotherapy groups with similar demographic makeup, adherence was significantly higher among users of tafamidis free acid vs tafamidis meglumine (P < 0.0001 across all mean adherence measures). CONCLUSIONS: Our results demonstrate that real-world adherence to tafamidis in the Medicare population is high, regardless of age, zip code-level socioeconomic quartile, or geography. Adherence was higher among patients receiving tafamidis free acid, suggesting that the enhanced convenience of a single capsule once daily may positively contribute to adherence among patients with ATTR-CM. DISCLOSURES: Darrin Benjumea is an employee of Genesis Research who has been contracted by Pfizer, Inc., for involvement in this study. Andrew Peterson is an employee of University of the Sciences who has been contracted by Pfizer, Inc., for involvement in this study. Zach Bredl is an employee of Care Journey who has been contracted by Pfizer, Inc., for involvement in this study. Anuja Roy, Nick Marchant, Jose Alvir, Rahul Bhambri, Jason Kemner, and Bhash Parasuraman are employees of Pfizer, Inc., and own stock and/or stock options. This study was supported by Pfizer, Inc.
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Affiliation(s)
| | - Andrew Peterson
- Department of Pharmacy Practice and Pharmacy Administration, Philadelphia College of Pharmacy, University of the Sciences, Philadelphia, PA
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9
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Badr Eslam R, Öztürk B, Rettl R, Capelle CDJ, Qin H, Binder C, Dachs TM, Camuz Ligios L, Duca F, Dalos D, Schrutka L, Alasti F, Kastner J, Vila G, Bonderman D. Impact of Tafamidis and Optimal Background Treatment on Physical Performance in Patients With Transthyretin Amyloid Cardiomyopathy. Circ Heart Fail 2022; 15:e008381. [PMID: 35766028 DOI: 10.1161/circheartfailure.121.008381] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In patients with transthyretin amyloid cardiomyopathy, tafamidis was shown to slow the decline in 6-minute walking distance as compared with placebo. We aimed to define the impact of tafamidis and optimal background treatment on functional capacity as determined by cardiopulmonary exercise testing (CPET). METHODS Seventy-eight consecutive patients were enrolled in the study. They underwent CPET at baseline, and outcome defined as death or heart failure hospitalization was obtained for a time period of up to 30 months. Fifty-four patients completed a follow-up CPET at 9±3 months (range, 4-16 months). Improvement in peak VO2 at follow-up was defined as ∆peak VO2≥1.0 mL/(kg·min), stable peak VO2 was defined as 0≤∆peak VO2<1.0 mL/(kg·min), and decline in peak VO2 was defined by ∆peak VO2<0 mL/(kg·min). RESULTS Baseline peak VO2>14 mL/(kg·min) as well as minute ventilation/carbon dioxide production slope≤34 were associated with a lower risk of death or heart failure hospitalization (P=0.002, P=0.007, respectively). In 54 patients, who received tafamidis and underwent repeat CPET testing, an improvement in physical performance (P=0.002) was observed at follow-up. When comparing pre and post-treatment parameters, 29 patients (54%) showed an increase in percent predicted peak VO2 (P<0.0001), an improvement of peak VO2 (P<0.0001), and better physical performance at follow-up (P<0.0001). Patients with stable or improved peak VO2 had less advanced heart disease at baseline (P=0.046). CONCLUSIONS Our findings demonstrate that baseline peak VO2 and baseline minute ventilation/carbon dioxide production slope predict outcomes and an improvement in physical performance as measured by CPET was observed in patients receiving tafamidis, who had less advanced disease at baseline, emphasizing the importance of early diagnosis.
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Affiliation(s)
- Roza Badr Eslam
- Division of Cardiology, Department of Internal Medicine II (R.B.E., B.O., R.R., C.D.J.C., H.Q., C.B., T.-M.D., L.C.L., F.D., D.D., L.S., J.K., D.B.), Medical University of Vienna, Austria
| | - Begüm Öztürk
- Division of Cardiology, Department of Internal Medicine II (R.B.E., B.O., R.R., C.D.J.C., H.Q., C.B., T.-M.D., L.C.L., F.D., D.D., L.S., J.K., D.B.), Medical University of Vienna, Austria
| | - René Rettl
- Division of Cardiology, Department of Internal Medicine II (R.B.E., B.O., R.R., C.D.J.C., H.Q., C.B., T.-M.D., L.C.L., F.D., D.D., L.S., J.K., D.B.), Medical University of Vienna, Austria
| | - Christophe Denis Josef Capelle
- Division of Cardiology, Department of Internal Medicine II (R.B.E., B.O., R.R., C.D.J.C., H.Q., C.B., T.-M.D., L.C.L., F.D., D.D., L.S., J.K., D.B.), Medical University of Vienna, Austria
| | - Hong Qin
- Division of Cardiology, Department of Internal Medicine II (R.B.E., B.O., R.R., C.D.J.C., H.Q., C.B., T.-M.D., L.C.L., F.D., D.D., L.S., J.K., D.B.), Medical University of Vienna, Austria
| | - Christina Binder
- Division of Cardiology, Department of Internal Medicine II (R.B.E., B.O., R.R., C.D.J.C., H.Q., C.B., T.-M.D., L.C.L., F.D., D.D., L.S., J.K., D.B.), Medical University of Vienna, Austria
| | - Theresa-Marie Dachs
- Division of Cardiology, Department of Internal Medicine II (R.B.E., B.O., R.R., C.D.J.C., H.Q., C.B., T.-M.D., L.C.L., F.D., D.D., L.S., J.K., D.B.), Medical University of Vienna, Austria
| | - Luciana Camuz Ligios
- Division of Cardiology, Department of Internal Medicine II (R.B.E., B.O., R.R., C.D.J.C., H.Q., C.B., T.-M.D., L.C.L., F.D., D.D., L.S., J.K., D.B.), Medical University of Vienna, Austria
| | - Franz Duca
- Division of Cardiology, Department of Internal Medicine II (R.B.E., B.O., R.R., C.D.J.C., H.Q., C.B., T.-M.D., L.C.L., F.D., D.D., L.S., J.K., D.B.), Medical University of Vienna, Austria
| | - Daniel Dalos
- Division of Cardiology, Department of Internal Medicine II (R.B.E., B.O., R.R., C.D.J.C., H.Q., C.B., T.-M.D., L.C.L., F.D., D.D., L.S., J.K., D.B.), Medical University of Vienna, Austria
| | - Lore Schrutka
- Division of Cardiology, Department of Internal Medicine II (R.B.E., B.O., R.R., C.D.J.C., H.Q., C.B., T.-M.D., L.C.L., F.D., D.D., L.S., J.K., D.B.), Medical University of Vienna, Austria
| | - Farideh Alasti
- Ludwig Boltzmann Institute for Arthritis and Rehabilitation, Vienna, Austria (F.A.)
| | - Johannes Kastner
- Division of Cardiology, Department of Internal Medicine II (R.B.E., B.O., R.R., C.D.J.C., H.Q., C.B., T.-M.D., L.C.L., F.D., D.D., L.S., J.K., D.B.), Medical University of Vienna, Austria
| | - Greisa Vila
- Division of Endocrinology and Metabolism, Department of Internal Medicine III (G.V.), Medical University of Vienna, Austria
| | - Diana Bonderman
- Division of Cardiology, Department of Internal Medicine II (R.B.E., B.O., R.R., C.D.J.C., H.Q., C.B., T.-M.D., L.C.L., F.D., D.D., L.S., J.K., D.B.), Medical University of Vienna, Austria
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10
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Antonopoulos AS, Panagiotopoulos I, Kouroutzoglou A, Koutsis G, Toskas P, Lazaros G, Toutouzas K, Tousoulis D, Tsioufis K, Vlachopoulos C. Prevalence and Clinical Outcomes of Transthyretin Amyloidosis: A Systematic Review and Meta-analysis. Eur J Heart Fail 2022; 24:1677-1696. [PMID: 35730461 DOI: 10.1002/ejhf.2589] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 06/10/2022] [Accepted: 06/18/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Systematic evidence on the prevalence and clinical outcome of transthyretin amyloidosis (ATTR) is missing. We explored: a) the prevalence of cardiac amyloidosis in various patient subgroups, b) survival estimates for ATTR subtypes and c) the effects of novel therapeutics on the natural course of disease. METHODS A systematic review of literature published in Medline before 31/12/2021 was performed for the prevalence of cardiac amyloidosis & all-cause mortality of ATTR patients. Extracted data included sample size, age, sex, and all-cause mortality at 1, 2 and 5-years. Subgroup analyses were performed for ATTR subtype i.e., wild type ATTR (wtATTR) vs. hereditary ATTR (htATTR), htATTR genotypes and treatment subgroups. RESULTS We identified a total of 62 studies (n=277,882 individuals) reporting the prevalence of cardiac amyloidosis, which was high among patients with a hypertrophic cardiomyopathy phenotype, HFpEF, and elderly with aortic stenosis. Data on ATTR mortality were extracted from 95 studies (n=18,238 ATTR patients). Patients with wtATTR were older (p=7x10-10 ) and more frequently male (p=5x10-20 ) vs. htATTR. The 2-year survival of ATTR was 73.3% (95%CI 71.6-76.2); for non-subtyped ATTR 70.4% (95%CI 66.9-73.9), for wtATTR (76.0%, 95%CI: 73.0-78.9) and for htATTR (77.2%, 95%CI: 74.0-80.4); in meta-regression analysis wtATTR was associated with higher survival after adjusting for confounders. There was an interaction between survival and htATTR genotypes (p=10-15 , Val30Met having the lowest and Val122Ile/Thr60Ala the highest mortality). ATTR 2-year survival was higher on tafamidis/patisiran compared to natural disease course (79.9%, 95%CI: 74.4-85.3 vs. 72.4%, 95%CI 69.8-74.9, p<0.05). CONCLUSIONS We report the prevalence of ATTR in various population subgroups and provide survival estimates for the natural course of disease and the effects of novel therapeutics. Important gaps in worldwide epidemiology research in ATTR were identified. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Alexios S Antonopoulos
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Ioannis Panagiotopoulos
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Alexandrina Kouroutzoglou
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Georgios Koutsis
- Neurogenetics Unit, 1st Department of Neurology, National and Kapodistrian University of Athens, Eginition University Hospital, Athens, Greece
| | - Pantelis Toskas
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Georgios Lazaros
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Konstantinos Toutouzas
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Dimitris Tousoulis
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Konstantinos Tsioufis
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Charalambos Vlachopoulos
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
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11
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Stamatelopoulos K, Delialis D, Georgiopoulos G, Tselegkidi MI, Theodorakakou F, Dialoupi I, Bambatsias D, Petropoulos I, Vergaro G, Ikonomidis I, Tzortzis S, Briasoulis A, Kanakakis J, Trougakos I, Dimopoulos MA, Kastritis E. Determining patterns of vascular function and structure in wild-type transthyretin cardiac amyloidosis. A comparative study. Int J Cardiol 2022; 363:102-110. [PMID: 35716935 DOI: 10.1016/j.ijcard.2022.06.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 05/26/2022] [Accepted: 06/10/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND The impact of wild-type transthyretin-related cardiac amyloidosis (ATTRwt) on functional and structural peripheral vascular measures is unknown. In the present study, we explored patterns of vascular dysfunction in patients with ATTRwt in comparison to diseases with similar cardiac phenotype. METHODS Treatment-naïve patients with ATTRwt (n = 32) were compared to: 1. Age-and sex-matched reference population without amyloidosis (n = 32), 2. Age-and sex-matched patients with systemic AL amyloidosis (n = 32), and 3. patients with cardiac AL amyloidosis (AL-HF, n = 23) or elderly patients with heart failure with preserved ejection fraction (HFpEF) (n = 16). All subjects underwent peripheral vascular assessment using carotid artery ultrasonography, brachial artery flow-mediated dilation (FMD), measurement of arterial stiffness and aortic hemodynamics including heart rate-adjusted time of return of reflected waves (Tr/HR). RESULTS After adjustment for traditional cardiovascular risk factors and coronary artery disease (core model), peripheral and aortic blood pressures (BP) were lower in patients with ATTRwt (p < 0.05) whereas other vascular markers were preserved compared to the reference non-amyloidosis group. ATTRwt was independently associated with lower BP and longer Tr/HR compared to AL. Compared to AL-HF, FMD was lower in ATTRwt (p = 0.033). ATTRwt patients had lower BP and higher Tr/HR than HFpEF (p < 0.05). By ROC analysis, Tr/HR discriminated ATTRwt vs. AL-HF (sensitivity 93%, specificity 75%) and HFpEF (sensitivity 100%, specificity 94%) and lower FMD increased the likelihood for ATTRwt at low Tr/HR values. CONCLUSION ATTRwt patients present a distinct peripheral vascular fingerprint which is different from AL-HF or HFpEF, consisting of lower peripheral and aortic BP, prolonged Tr/HR and FMD at reference-population range.
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Affiliation(s)
- Kimon Stamatelopoulos
- Department of Clinical Therapeutics, University of Athens Medical School, Athens, Greece..
| | - Dimitrios Delialis
- Department of Clinical Therapeutics, University of Athens Medical School, Athens, Greece.; Department of Clinical Therapeutics, University of Athens Medical School, Athens, Greece.; Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy; Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Georgios Georgiopoulos
- Department of Clinical Therapeutics, University of Athens Medical School, Athens, Greece.; Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy; Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Maria-Irini Tselegkidi
- Department of Clinical Therapeutics, University of Athens Medical School, Athens, Greece.; Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy; Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Foteini Theodorakakou
- Department of Clinical Therapeutics, University of Athens Medical School, Athens, Greece.; Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy; Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Ioanna Dialoupi
- Department of Clinical Therapeutics, University of Athens Medical School, Athens, Greece.; Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy; Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Dimitrios Bambatsias
- Department of Clinical Therapeutics, University of Athens Medical School, Athens, Greece.; Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy; Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Ioannis Petropoulos
- Department of Clinical Therapeutics, University of Athens Medical School, Athens, Greece.; Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy; Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Giuseppe Vergaro
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy; Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy.; Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy; Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Ignatios Ikonomidis
- 2(nd) Department of Cardiology, School of Medicine of the National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece.; Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy; Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Stavros Tzortzis
- 2(nd) Department of Cardiology, School of Medicine of the National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece.; Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy; Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Alexandros Briasoulis
- Department of Clinical Therapeutics, University of Athens Medical School, Athens, Greece.; Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy; Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - John Kanakakis
- Department of Clinical Therapeutics, University of Athens Medical School, Athens, Greece.; Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy; Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Ioannis Trougakos
- Department of Cell Biology and Biophysics, Faculty of Biology, National and Kapodistrian University of Athens; Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy; Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Meletios A Dimopoulos
- Department of Clinical Therapeutics, University of Athens Medical School, Athens, Greece.; Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy; Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, University of Athens Medical School, Athens, Greece.; Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy; Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy..
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12
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Campbell CM, LoRusso S, Dispenzieri A, Kristen AV, Maurer MS, Rapezzi C, Lairez O, Drachman B, Garcia-Pavia P, Grogan M, Chapman D, Amass L. Sex Differences in Wild-Type Transthyretin Amyloidosis: An Analysis from the Transthyretin Amyloidosis Outcomes Survey (THAOS). Cardiol Ther 2022; 11:393-405. [PMID: 35583798 PMCID: PMC9381661 DOI: 10.1007/s40119-022-00265-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 04/30/2022] [Indexed: 12/24/2022] Open
Abstract
Introduction Wild-type transthyretin amyloidosis (ATTRwt amyloidosis) is a progressive disease resulting from the accumulation of wild-type transthyretin (TTR) amyloid fibrils, and is diagnosed primarily in males. This analysis examined sex differences in patients with ATTRwt amyloidosis from the Transthyretin Amyloidosis Outcomes Survey (THAOS). Methods THAOS is an ongoing, global, longitudinal, observational survey of patients with transthyretin amyloidosis, including both inherited and wild-type disease, and asymptomatic carriers of TTR mutations. THAOS data were analyzed to identify potential differences in demographic and clinical characteristics between males and females with ATTRwt amyloidosis (data cutoff: August 1, 2021). Results Of 1386 patients with ATTRwt amyloidosis, 84 (6%) were female and 1302 (94%) were male. Females had a higher median age at enrollment (80 vs. 78 years; p = 0.002) and symptom onset (75 vs. 73 years; p = 0.045) than males. Mean left ventricular (LV) ejection fraction was higher (53% vs. 48%; p = 0.001) and mean LV diastolic diameter lower (42 vs. 46 mm; p < 0.001) in females versus males, but sex was not identified as a predictor of LV mean wall thickness adjusted for height (beta coefficient − 0.22; p = 0.460) or a predominantly cardiac phenotype (odds ratio 1.60; p = 0.191). Modified polyneuropathy disability scores differed between groups (p < 0.001), with a larger proportion of scores ≥ IIIa among females (23% vs. 7%). Conclusions Females with ATTRwt amyloidosis in THAOS tended to present at a later age and showed signs of less severe cardiac impairment and more severe walking impairment. Trial Registration ClinicalTrials.gov: NCT00628745.
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Affiliation(s)
- Courtney M Campbell
- The Ohio State University, Columbus, OH, USA. .,Cardio-Oncology Center of Excellence, Washington University, 660 S Euclid Ave, St. Louis, MO, 63110, USA.
| | | | | | - Arnt V Kristen
- Department of Cardiology, Angiology, Respiratory Medicine, Medical University of Heidelberg, Heidelberg, Germany
| | - Mathew S Maurer
- Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Claudio Rapezzi
- Cardiological Centre, University of Ferrara, Ferrara, Italy.,Maria Cecilia Hospital, GVM Care and Research, Cotignola, RA, Italy
| | - Olivier Lairez
- Department of Cardiology and Nuclear Medicine, Toulouse University Hospital, Toulouse, France
| | - Brian Drachman
- Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Pablo Garcia-Pavia
- Hospital Universitario Puerta de Hierro Majadahonda, IDIPHISA, CIBERCV, Madrid, Spain.,Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Martha Grogan
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
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13
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Sayin BY, Oto A. Left Ventricular Hypertrophy: Etiology-Based Therapeutic Options. Cardiol Ther 2022; 11:203-230. [PMID: 35353354 PMCID: PMC9135932 DOI: 10.1007/s40119-022-00260-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Indexed: 11/28/2022] Open
Abstract
Determining the etiologies of left ventricular hypertrophy (LVH) can be challenging due to the similarities of the different manifestations in clinical presentation and morphological features. Depending on the underlying cause, not only left ventricular mass but also left ventricular cavity size, or both, may increase. Patients with LVH remain asymptomatic for a few years, but disease progression will lead to the development of systolic or diastolic dysfunction and end-stage heart failure. As hypertrophied cardiac muscle disrupts normal conduction, LVH predisposes to arrhythmias. Distinguishing individuals with treatable causes of LVH is important for prevention of cardiovascular events and mortality. Athletic’s heart with physiological LVH does not require treatment. Frequent causes of hypertrophy include etiologies due to pressure/volume overload, such as systemic hypertension, hypertrophic cardiomyopathy, or infiltrative cardiac processes such as amyloidosis, Fabry disease, and sarcoidosis. Hypertension and aortic valve stenosis are the most common causes of LVH. Management of LVH involves lifestyle changes, medications, surgery, and implantable devices. In this review we systematically summarize treatments for the different patterns of cardiac hypertrophy and their impacts on outcomes while informing clinicians on advances in the treatment of LVH due to Fabry disease, cardiac amyloidosis, and hypertrophic cardiomyopathy.
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Affiliation(s)
| | - Ali Oto
- Department of Cardiology, Memorial Ankara Hospital, Ankara, Turkey
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14
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Scheel PJ, Mukherjee M, Hays AG, Vaishnav J. Multimodality Imaging in the Evaluation and Prognostication of Cardiac Amyloidosis. Front Cardiovasc Med 2022; 9:787618. [PMID: 35402557 PMCID: PMC8989413 DOI: 10.3389/fcvm.2022.787618] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 02/14/2022] [Indexed: 11/13/2022] Open
Abstract
Cardiac amyloidosis (CA) is an infiltrative cardiomyopathy resulting from deposition of misfolded immunoglobulin light chains (AL-CA) or transthyretin (ATTR-CA) proteins in the myocardium. Survival varies between the different subtypes of amyloidosis and degree of cardiac involvement, but accurate diagnosis is essential to ensure initiation of therapeutic interventions that may slow or potentially prevent morbidity and mortality in these patients. As there are now effective treatment options for CA, identifying underlying disease pathogenesis is crucial and can be guided by multimodality imaging techniques such as echocardiography, magnetic resonance imaging, and nuclear scanning modalities. However, as use of cardiac imaging is becoming more widespread, understanding optimal applications and potential shortcomings is increasingly important. Additionally, certain imaging modalities can provide prognostic information and may affect treatment planning. In patients whom imaging remains non-diagnostic, tissue biopsy, specifically endomyocardial biopsy, continues to play an essential role and can facilitate accurate and timely diagnosis such that appropriate treatment can be started. In this review, we examine the multimodality imaging approach to the diagnosis of CA with particular emphasis on the prognostic utility and limitations of each imaging modality. We also discuss how imaging can guide the decision to pursue tissue biopsy for timely diagnosis of CA.
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15
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Zampieri M, Argirò A, Allinovi M, Tassetti L, Zocchi C, Gabriele M, Andrei V, Fumagalli C, Di Mario C, Tomberli A, Olivotto I, Perfetto F, Cappelli F. Sex-related differences in clinical presentation and all-cause mortality in patients with cardiac transthyretin amyloidosis and light chain amyloidosis. Int J Cardiol 2022; 351:71-77. [PMID: 34990715 DOI: 10.1016/j.ijcard.2021.12.048] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 12/24/2021] [Accepted: 12/28/2021] [Indexed: 01/06/2023]
Abstract
We aimed to ascertain whether sex-related differences are relevant to clinical presentation, cardiac phenotype and all-cause mortality in different types of cardiac amyloidosis, a field still poorly investigated. Medical files from consecutive patients diagnosed with cardiac amyloidosis between 2000 and 2020, at Careggi University Hospital, were retrospectively evaluated. Over this period, 259 patients (12% females) were diagnosed with wild type transthyretin amyloidosis (wtATTR), 52 (25% females) with hereditary transthyretin amyloidosis (hATTR) and 143 (47% females) with light chain amyloidosis (AL). Women with wtATTR, compared to men, were significantly older at the time of diagnosis and showed higher National Amyloidosis Centre score, thicker normalized interventricular septum, higher diastolic dysfunction and worse right ventricular function. Females with hATTR and AL had lower normalized cardiac mass compared to men, otherwise, bio-humoral parameters, NYHA class, and ECG characteristics were similar. Comparing females and male with wtATTR, hATTR and AL, no differences in Kaplan-Meier curves for all-cause mortality were observed with regard to sex, p-value >0.05. In conclusion, we did not observe major differences in clinical expression related to sex in different types of cardiac amyloidosis: specifically, all-cause mortality was not affected. Nevertheless, women with wtATTR had echocardiographic signs of more advanced disease and higher NAC score at diagnosis suggesting a possible later recognition of disease compared to men.
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Affiliation(s)
- Mattia Zampieri
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy; Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Alessia Argirò
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy; Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy.
| | - Marco Allinovi
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Luigi Tassetti
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy; Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Chiara Zocchi
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy; Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Martina Gabriele
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Valentina Andrei
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Carlo Fumagalli
- Geriatric Cardiology, Careggi University Hospital, Florence, Italy
| | - Carlo Di Mario
- Division of Interventional Structural Cardiology, Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
| | - Alessia Tomberli
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Iacopo Olivotto
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Federico Perfetto
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy; IV Internal Medicine Division, Careggi University Hospital, Florence, Italy
| | - Francesco Cappelli
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy; Division of Interventional Structural Cardiology, Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
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Roy A, Peterson A, Marchant N, Alvir J, Bhambri R, Lynn J, Benjumea D, Prasad S, O’Brien A, Chen Y, Kemner J, Parasuraman B. Baseline Characteristics and Secondary Medication Adherence Patterns Among Patients Receiving Tafamidis Prescriptions: A Retrospective Analysis Using a National Specialty Pharmacy Dispensing Database. Patient Prefer Adherence 2022; 16:1115-1129. [PMID: 35517043 PMCID: PMC9064174 DOI: 10.2147/ppa.s352332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 04/14/2022] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Transthyretin amyloid cardiomyopathy (ATTR-CM) is a serious, underrecognized condition, which leads to heart failure and early mortality if left untreated. Until recently, heart transplantation was the only treatment for ATTR-CM. Regulatory approval of tafamidis transformed treatment for patients. In the phase 3 Transthyretin Amyloidosis Cardiomyopathy Clinical Trial (ATTR-ACT), which established the safety and efficacy of tafamidis, medication adherence was high with 97.2% of patients taking ≥80% of scheduled doses. Evidence of real-world adherence to cardiology drugs demonstrates low adherence and suboptimal outcomes; however, real-world adherence to tafamidis has not been investigated. The main objective of this study was to describe adherence patterns of patients filling tafamidis in the Symphony Health database. METHODS This retrospective analysis of the Symphony Health Solutions claims database used secondary adherence measures, including modified medication possession ratio (MPRm), days between fills adherence rate, and compliance rate, to assess adherence patterns of 2020 patients filling tafamidis free acid 61-mg capsules or tafamidis meglumine 4x20-mg capsules from June 1, 2019 to August 31, 2020. RESULTS Patients receiving a tafamidis formulation had characteristics consistent with the expected patient population; 71.6% were aged 75-84 years, 83.2% were male, and the highest proportion resided in the Northeast region (30.5%) of the United States. Adherence for tafamidis was high, as 75% to 100% of the patients across subgroups met or exceeded the commonly defined adherence threshold of 80%. Median number of refills ordered and received was six refills per patient. Most patients received refills with no gap (n=1633) or a gap <30 days (n=1267/1317 patients). Adherence was high across follow-up time, sex, and age subgroups. Adherence varied by geographic region, with the Northeast being significantly higher than the Midwest (mean MPRm 94.41% vs 88.21%, p=0.0007). CONCLUSION These results provide evidence that real-world adherence to tafamidis in patients with ATTR-CM is high.
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Affiliation(s)
- Anuja Roy
- Global HEOR, Patient & Health Impact, Rare Diseases BU, Pfizer Inc, New York, NY, USA
- Correspondence: Anuja Roy, Global HEOR, Patient & Health Impact, Rare Diseases BU, Pfizer Inc, New York, NY, USA, Email
| | - Andrew Peterson
- Department of Pharmacy Practice/Pharmacy Administration, University of the Sciences, Philadelphia, PA, USA
| | - Nick Marchant
- Global HEOR, Patient & Health Impact, Rare Diseases BU, Pfizer Inc, New York, NY, USA
| | - Jose Alvir
- Statistical Research and Data Science Center Global Product Development, Pfizer Inc, New York, NY, USA
| | | | - Jason Lynn
- Medical Affairs, Pfizer Inc, New York, NY, USA
| | | | - Sapna Prasad
- Clarify Insights Services, Clarify Health Solutions, New York, NY, USA
| | - Alex O’Brien
- Clarify Insights Services, Clarify Health Solutions, New York, NY, USA
| | - Yong Chen
- Rare Disease, Pfizer Inc, Collegeville, PA, USA
| | - Jason Kemner
- Patient & Health Impact, Pfizer Inc, Collegeville, PA, USA
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Guo X, Chen Z, Wan K, Song R, Yang T, Xu Y, Zhang Q, Alexander KM, Han Y, Chen Y. Electrocardiogram Characteristics and Prognostic Value in Light-Chain Amyloidosis: A Comparison With Cardiac Magnetic Resonance Imaging. Front Cardiovasc Med 2021; 8:751422. [PMID: 34938781 PMCID: PMC8685267 DOI: 10.3389/fcvm.2021.751422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 11/10/2021] [Indexed: 02/05/2023] Open
Abstract
Background: An electrocardiogram (ECG) is a simple and cheap non-invasive tool that shows various abnormalities and has prognostic value for patients with light-chain amyloidosis (AL). The present study aimed to explore the association between ECG characteristics and cardiac magnetic resonance (CMR)-detected amyloid burden and to investigate the prognostic value of ECG in AL amyloidosis. Methods: We prospectively enrolled 99 patients with AL amyloidosis (56 male patients; median age, 58 y). Detailed clinical information, 12-lead ECG, and CMR data were collected. All patients were followed up longitudinally, and the endpoint was all-cause mortality. ECG characteristics were analyzed and correlated with the degree of late gadolinium enhancement (LGE) and extracellular volume (ECV) by T1 mapping on CMR. The prognostic value of ECG characteristics was analyzed using Kaplan–Meier survival analysis and multivariate Cox regression. Results: During a median follow-up period of 33 months, 69 of the 99 patients died. Fragmented Q wave-R wave-S wave (QRS), pathological Q waves, the Sokolow index, QRS duration, and voltages were significantly associated with the extent of LGE, native T1, and ECV by CMR (p < 0.05). Fragmented QRS and Sokolow index showed independent prognostic value in AL amyloidosis (p = 0.001; p = 0.026, respectively). Fragmented QRS remained independent after adjusting for clinical values (hazard ratio: 2.034; 95% confidence interval: 1.148–3.603; p = 0.015). However, no ECG characteristics were independent predictors for prognosis in AL amyloidosis when LGE and ECV were included in the multivariate analysis. Conclusion: ECG abnormalities showed significant association with CMR indicators of amyloid burden. Fragmented QRS has an independent prognostic value in AL amyloidosis and could be used as an alternative marker when CMR is not available.
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Affiliation(s)
- Xinli Guo
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Zhian Chen
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Ke Wan
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China.,Department of Geriatrics and National Clinical Research Centre for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Rizhen Song
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Tingjie Yang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Yuanwei Xu
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Qing Zhang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Kevin Michael Alexander
- Stanford Amyloid Center, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, United States.,Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, United States
| | - Yuchi Han
- Department of Medicine (Cardiovascular Division), University of Pennsylvania, Philadelphia, PA, United States
| | - Yucheng Chen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China.,Center of Rare Diseases, West China Hospital, Sichuan University, Chengdu, China
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18
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Izumida T, Imamura T, Nakamura M, Kinugawa K. Optimal Heart Rate and Prognosis in Patients with Cardiac Amyloidosis. J Cardiovasc Dev Dis 2021; 8:jcdd8120182. [PMID: 34940536 PMCID: PMC8706408 DOI: 10.3390/jcdd8120182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 12/05/2021] [Accepted: 12/10/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Optimal heart rate (HR) that associates with higher cardiac output and greater clinical outcomes in patients with cardiac amyloidosis remains unknown. Methods: Consecutive patients with sinus rhythm who were diagnosed with cardiac amyloidosis at our institute between February 2015 and February 2021 were retrospectively included. Ideal HR, at which E-wave and A-wave stand adjacent without any overlaps in the trans-mitral flow echocardiography, was calculated by the formula: 86.8−0.08 × deceleration time (msec). The association between optimal HR and cardiac death or heart failure readmission was investigated. Results: Ten patients (median 74 years old, 8 men) were included. On median, actual HR was 64 bpm and ideal HR was 69 bpm. An incidence rate of the primary endpoint in the sub-optimal HR group tended to be higher than optimal HR group: one of the four patients in optimal HR group had events (25%); two of the two patients in higher HR group had events (100%); two of the four patients in lower HR group had events (50%). Conclusions: The optimal HR was associated with greater clinical outcomes in patients with cardiac amyloidosis. The clinical impact of aggressive HR optimization in this cohort remains the next concern.
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19
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Ochi Y, Kubo T, Baba Y, Sugiura K, Ueda M, Miyagawa K, Noguchi T, Hirota T, Hamada T, Yamasaki N, Kitaoka H. Wild-Type Transthyretin Amyloidosis in Female Patients - Consideration of Sex Differences. Circ Rep 2021; 3:465-471. [PMID: 34414336 PMCID: PMC8338431 DOI: 10.1253/circrep.cr-21-0067] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 05/31/2021] [Indexed: 12/12/2022] Open
Abstract
Background:
With recent advances in non-invasive diagnostic tools, some studies indicate that wild-type transthyretin amyloidosis (ATTRwt) may be more common in females than previously reported. However, the clinical characteristics of female ATTRwt patients have not been determined. Methods and Results:
Of the 78 consecutive patients with ATTRwt in our cohort, 14 (17.9 %) were female. Compared with male patients, female ATTRwt patients had smaller left ventricular (LV) wall thicknesses (ventricular septum thickness 12.9 vs. 14.2 mm [P=0.081]; posterior wall thickness 12.7 vs. 13.6 mm [P=0.035]) and a higher LV ejection fraction (EF; mean [±SD] 58.4±8.9% vs. 48.9±11.8%; P=0.006). However, the severity of heart failure (HF), as assessed by HF stage, New York Heart Association functional class and B-type natriuretic peptide concentrations, did not differ between female and male patients. Moreover, LV mass index and relative wall thickness were increased and the stroke volume index was reduced in both female and male patients. In organ biopsies, female patients had a higher sensitivity to transthyretin deposition from abdominal fat than male patients (positive abdominal fat biopsy 80.0 % vs. 26.5%; P=0.016). Conclusions:
This study suggests that a relatively large proportion of elderly females have ATTRwt. Female ATTRwt patients had HF symptoms even at the stage of mild LV hypertrophy and preserved EF. Abdominal fat biopsy may be useful to diagnose ATTRwt, especially in female patients with HF.
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Affiliation(s)
- Yuri Ochi
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Toru Kubo
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Yuichi Baba
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Kenta Sugiura
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Motoko Ueda
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Kazuya Miyagawa
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Tatsuya Noguchi
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Takayoshi Hirota
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Tomoyuki Hamada
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Naohito Yamasaki
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Hiroaki Kitaoka
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
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20
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Santarelli MF, Scipioni M, Genovesi D, Giorgetti A, Marzullo P, Landini L. Imaging Techniques as an Aid in the Early Detection of Cardiac Amyloidosis. Curr Pharm Des 2021; 27:1878-1889. [PMID: 32787756 DOI: 10.2174/1381612826666200813133557] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 06/23/2020] [Indexed: 11/22/2022]
Abstract
The idea that performing a proper succession of imaging tests and techniques allows an accurate and early diagnosis of cardiac amyloidosis, avoiding the need to perform the myocardial biopsy, is becoming increasingly popular. Furthermore, being imaging techniques non-invasive, it is possible to perform the follow-up of the pathology through repeated image acquisitions. In the present review, the various innovative imaging methodologies are presented, and it is discussed how they have been applied for early diagnosis of cardiac amyloidosis (CA), also to distinguish the two most frequent subtypes in CA: immunoglobulin light chain amyloidosis (AL) and transthyretin amyloidosis (ATTR); this allows to perform the therapy in a targeted and rapid manner.
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Affiliation(s)
| | - M Scipioni
- CNR Institute of Clinical Physiology, Pisa, Italy
| | - D Genovesi
- Fondazione Toscana "G. Monasterio", Pisa, Italy
| | - A Giorgetti
- Fondazione Toscana "G. Monasterio", Pisa, Italy
| | - P Marzullo
- Fondazione Toscana "G. Monasterio", Pisa, Italy
| | - L Landini
- Fondazione Toscana "G. Monasterio", Pisa, Italy
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21
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Wild-type TTR amyloidosis among patients with unexplained heart failure and systolic LV dysfunction. PLoS One 2021; 16:e0254104. [PMID: 34242301 PMCID: PMC8270434 DOI: 10.1371/journal.pone.0254104] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 06/18/2021] [Indexed: 01/15/2023] Open
Abstract
AIM Transthyretin cardiac amyloidosis (ATTR-CA) is an increasingly recognized cause of heart failure (HF) with preserved left ventricular ejection fraction (LVEF), typically presenting as restrictive cardiomyopathy. The potential co-existence of ATTR-CA with systolic heart failure has not been studied. The aim of this study is to describe the prevalence of ATTR-CA and its clinical characteristics in HF patients with reduced LVEF. METHODS Patients with an unexplained cause of LV systolic dysfunction were screened for ATTR-CA by a 99mTc-PYP planar scintigraphy. Patients in whom presence of ≥ 2 uptake was confirmed by SPECT imaging were included. Their clinical, laboratory and echocardiographic data were collected. RESULTS Out of 75 patients (mean age 65±12 years, LVEF 35.8±7.9%) included in this study, 7 (9.3%) patients (mean age 75±6 years, LVEF 32.0±8.3%) had ATTR-CA. Patients with ATTR-CA were more symptomatic at diagnosis (NYHA FC 3-4 (86% vs 35% (p = 0.03)) and had a more severe clinical course evident by recurrent hospitalizations for HF, and a need for intravenous diuretic treatment (p = 0.04 and p<0.01, respectively) at follow-up, compared with patients with no ATTR-CA. Patients with ATTR-CA had similar LVEF but a clear trend for larger LV mass index (157.1±60.6 g/m2 vs. 121.0±39.5 g/m2, p = 0.07) and a larger proportions of ATTR-CA patients had IVS thickness >13 mm (57.1% vs 13.1%, p = 0.02) as compared to HF patients with no ATTR-CA. CONCLUSION In our study, a meaningful percentage of patients with unexplained LV dysfunction had a co-existing ATTR-CA indicating that the clinical heterogeneity of ATTR-CA is much broader than previously thought.
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22
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Dorbala S, Ando Y, Bokhari S, Dispenzieri A, Falk RH, Ferrari VA, Fontana M, Gheysens O, Gillmore JD, Glaudemans AWJM, Hanna MA, Hazenberg BPC, Kristen AV, Kwong RY, Maurer MS, Merlini G, Miller EJ, Moon JC, Murthy VL, Quarta CC, Rapezzi C, Ruberg FL, Shah SJ, Slart RHJA, Verberne HJ, Bourque JM. ASNC/AHA/ASE/EANM/HFSA/ISA/SCMR/SNMMI Expert Consensus Recommendations for Multimodality Imaging in Cardiac Amyloidosis: Part 1 of 2-Evidence Base and Standardized Methods of Imaging. Circ Cardiovasc Imaging 2021; 14:e000029. [PMID: 34196223 DOI: 10.1161/hci.0000000000000029] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Sharmila Dorbala
- Cardiac Amyloidosis Program, Cardiovascular Imaging Program, Departments of Radiology and Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Yukio Ando
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Japan
| | - Sabahat Bokhari
- Columbia University Medical Center/New York Presbyterian Hospital, Columbia University, NY
| | - Angela Dispenzieri
- Division of Hematology, Division of Cardiovascular Diseases, and Department of Radiology, Division of Nuclear Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Rodney H Falk
- Cardiac Amyloidosis Program, Cardiovascular Imaging Program, Departments of Radiology and Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Victor A Ferrari
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Marianna Fontana
- National Amyloidosis Centre, Division of Medicine, University College London, London, United Kingdom
| | - Olivier Gheysens
- Nuclear Medicine and Molecular Imaging, University Hospitals Leuven, Leuven, Belgium
| | - Julian D Gillmore
- National Amyloidosis Centre, Division of Medicine, University College London, London, United Kingdom
| | - Andor W J M Glaudemans
- Medical Imaging Center, Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Mazen A Hanna
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
| | - Bouke P C Hazenberg
- Department of Rheumatology & Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Arnt V Kristen
- Department of Cardiology, University of Heidelberg, Heidelberg, Germany
| | - Raymond Y Kwong
- Cardiac Amyloidosis Program, Cardiovascular Imaging Program, Departments of Radiology and Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Mathew S Maurer
- Columbia University Medical Center/New York Presbyterian Hospital, Columbia University, NY
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Center, Foundation Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, Pavia, Italy
- Department of Molecular Medicine, University of Pavia, Italy
| | - Edward J Miller
- Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
| | - James C Moon
- National Amyloidosis Centre, Division of Medicine, University College London, London, United Kingdom
| | | | - C Cristina Quarta
- National Amyloidosis Centre, Division of Medicine, University College London, London, United Kingdom
| | - Claudio Rapezzi
- Cardiology Unit, Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater-University of Bologna, Bologna, Italy
| | - Frederick L Ruberg
- Amyloidosis Center and Section of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA
| | - Sanjiv J Shah
- Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Riemer H J A Slart
- Medical Imaging Center, Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Hein J Verberne
- Division of Hematology, Division of Cardiovascular Diseases, and Department of Radiology, Division of Nuclear Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
- Department of Cardiology, University of Heidelberg, Heidelberg, Germany
| | - Jamieson M Bourque
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Molecular Medicine, University of Pavia, Italy
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23
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Inomata T, Tahara N, Nakamura K, Endo J, Ueda M, Ishii T, Kitano Y, Koyama J. Diagnosis of wild-type transthyretin amyloid cardiomyopathy in Japan: red-flag symptom clusters and diagnostic algorithm. ESC Heart Fail 2021; 8:2647-2659. [PMID: 34137515 PMCID: PMC8318452 DOI: 10.1002/ehf2.13473] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 04/09/2021] [Accepted: 05/31/2021] [Indexed: 01/04/2023] Open
Abstract
Wild‐type transthyretin amyloid cardiomyopathy (ATTRwt‐CM) is caused by the deposition of wild‐type transthyretin (TTR) amyloid fibrils in the heart. The age at diagnosis of ATTRwt‐CM is reported to be approximately 70–80 years, and patients commonly present with non‐disease‐specific cardiac abnormalities, such as heart failure with preserved ejection fraction and diastolic dysfunction. The disease can be fatal if left untreated, with an approximate survival of 3–5 years from diagnosis. An oral TTR stabilizer, tafamidis, has enabled early intervention for the treatment of ATTRwt‐CM. However, awareness of ATTRwt‐CM remains low, and misdiagnosis and a delay in diagnosis are common. This review discusses the epidemiology, characteristics, treatment strategy, and red‐flag symptoms and signs of ATTRwt‐CM based on the published literature, as well as recent advances in diagnostic modalities that enable early and accurate diagnosis of the disease. We also discuss an algorithm for early and accurate diagnosis of ATTRwt‐CM in daily clinical practice. In our diagnostic algorithm, a suspected diagnosis of ATTRwt‐CM should be triggered by unexplained left ventricular hypertrophy (LVH), which is LVH that cannot be explained by an increased afterload due to hypertension or valvular disease. In addition, heart failure symptoms, laboratory test results (N‐terminal pro‐B‐type natriuretic peptide, high‐sensitivity troponin T, or high‐sensitivity troponin I), electrocardiogram and imaging (echocardiogram or cardiac magnetic resonance) data, age (≥60 years), and medical history suggestive of ATTRwt‐CM (e.g. carpal tunnel syndrome) should be examined. Detailed examinations using bone scintigraphy and monoclonal protein detection tests followed by tissue biopsy, amyloid typing, and TTR genetic testing are warranted for a definite diagnosis of ATTRwt‐CM.
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Affiliation(s)
- Takayuki Inomata
- Department of Cardiovascular Medicine, Kitasato University Kitasato Institute Hospital, 5-9-1, Shirokane, Minato-ku, Tokyo, 108-8642, Japan
| | - Nobuhiro Tahara
- Division of Cardiovascular Medicine, Department of Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Kazufumi Nakamura
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Jin Endo
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Mitsuharu Ueda
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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Patel RK, Fontana M, Ruberg FL. Cardiac Amyloidosis: Multimodal Imaging of Disease Activity and Response to Treatment. Circ Cardiovasc Imaging 2021; 14:e009025. [PMID: 34129344 DOI: 10.1161/circimaging.121.009025] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Cardiac amyloidosis (CA) is a disease characterized by the deposition of misfolded protein deposits in the myocardial interstitium. Although advanced CA confers significant morbidity and mortality, the magnitude of deposition and ensuing clinical manifestations vary greatly. Thus, an improved understanding of disease pathogenesis at both cellular and functional levels would afford critical insights that may improve outcomes. This review will summarize contemporary therapies for the 2 major types of CA, transthyretin and light chain amyloidosis, and outline the capacity of imaging modalities to both diagnose CA, inform prognosis, and follow response to available therapies. We explore the current landscape of echocardiography, cardiac magnetic resonance, and bone scintigraphy in the assessment of functional and cellular parameters of dysfunction in CA throughout disease pathogenesis. Finally, we examine the impact of concurrent advances in both therapeutics and imaging on future research questions that improve our understanding of underlying disease mechanisms. Multimodal imaging in CA affords an indispensable tool to offer individualized treatment plans and improve outcomes in patients with CA.
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Affiliation(s)
- Rishi K Patel
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (R.K.P., M.F.)
| | - Marianna Fontana
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (R.K.P., M.F.)
| | - Frederick L Ruberg
- Section of Cardiovascular Medicine, Department of Medicine, Amyloidosis Center, Department of Radiology, Boston University School of Medicine, Boston Medical Center, MA (F.L.R.)
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25
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Volz MJ, Pleger ST, Weber A, Geis NA, Hamed S, Mereles D, Hegenbart U, Katus HA, Frey N, Raake PW, Kreusser MM. Initial experience with percutaneous mitral valve repair in patients with cardiac amyloidosis. Eur J Clin Invest 2021; 51:e13473. [PMID: 33326601 DOI: 10.1111/eci.13473] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 12/07/2020] [Accepted: 12/12/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Percutaneous mitral valve repair (PMVR) is a therapeutic option for severe mitral regurgitation (MR) in patients with heart failure due to differential aetiologies. However, only little is known about the safety and efficacy of this procedure in patients with amyloid cardiomyopathy. METHODS Five patients with cardiac amyloidosis and moderate to severe or severe MR undergoing PMVR were analysed retrospectively and compared to seven patients with cardiac amyloidosis and severe MR without intervention. Clinical and functional data, renal function and cardiac biomarkers as well as established risk scores for cardiac amyloidosis were assessed. Primary endpoint was the reduction in MR one year after PMVR. Secondary endpoints were safety, overall mortality after 12 months compared with the control group, as well as changes in clinical and functional parameters. RESULTS Amyloidosis risk assessment documented amyloid cardiomyopathy at an advanced stage in all patients. Procedural, technical and device success of PMVR were all 100% and residual MR remained mild to moderate at 12 months follow-up (P = .038 vs before PMVR). Differences in survival compared with the control (no PMVR) group pointed to a possible survival benefit in the PMVR group (P = .02). CONCLUSION PMVR is a feasible and safe procedure in patients with cardiac amyloidosis and might carry a possible survival benefit in this patient group.
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Affiliation(s)
- Martin J Volz
- Division of Cardiology, Department of Internal Medicine III, University of Heidelberg, Heidelberg, Germany
| | - Sven T Pleger
- Division of Cardiology, Department of Internal Medicine III, University of Heidelberg, Heidelberg, Germany
| | - Andreas Weber
- Division of Cardiology, Department of Internal Medicine III, University of Heidelberg, Heidelberg, Germany
| | - Nicolas A Geis
- Division of Cardiology, Department of Internal Medicine III, University of Heidelberg, Heidelberg, Germany
| | - Sonja Hamed
- Division of Cardiology, Department of Internal Medicine III, University of Heidelberg, Heidelberg, Germany
| | - Derliz Mereles
- Division of Cardiology, Department of Internal Medicine III, University of Heidelberg, Heidelberg, Germany
| | - Ute Hegenbart
- Division of Hematology and Oncology, Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
| | - Hugo A Katus
- Division of Cardiology, Department of Internal Medicine III, University of Heidelberg, Heidelberg, Germany.,DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Heidelberg, Germany
| | - Norbert Frey
- Division of Cardiology, Department of Internal Medicine III, University of Heidelberg, Heidelberg, Germany.,DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Heidelberg, Germany
| | - Philip W Raake
- Division of Cardiology, Department of Internal Medicine III, University of Heidelberg, Heidelberg, Germany.,DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Heidelberg, Germany
| | - Michael M Kreusser
- Division of Cardiology, Department of Internal Medicine III, University of Heidelberg, Heidelberg, Germany.,DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Heidelberg, Germany
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A human antibody selective for transthyretin amyloid removes cardiac amyloid through phagocytic immune cells. Nat Commun 2021; 12:3142. [PMID: 34035264 PMCID: PMC8149704 DOI: 10.1038/s41467-021-23274-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 04/20/2021] [Indexed: 01/05/2023] Open
Abstract
Transthyretin amyloid (ATTR) cardiomyopathy is a debilitating disease leading to heart failure and death. It is characterized by the deposition of extracellular ATTR fibrils in the myocardium. Reducing myocardial ATTR load is a therapeutic goal anticipated to translate into restored cardiac function and improved patient survival. For this purpose, we developed the selective anti-ATTR antibody NI301A, a recombinant human monoclonal immunoglobulin G1. NI301A was cloned following comprehensive analyses of memory B cell repertoires derived from healthy elderly subjects. NI301A binds selectively with high affinity to the disease-associated ATTR aggregates of either wild-type or variant ATTR related to sporadic or hereditary disease, respectively. It does not bind physiological transthyretin. NI301A removes ATTR deposits ex vivo from patient-derived myocardium by macrophages, as well as in vivo from mice grafted with patient-derived ATTR fibrils in a dose- and time-dependent fashion. The biological activity of ATTR removal involves antibody-mediated activation of phagocytic immune cells including macrophages. These data support the evaluation of safety and tolerability of NI301A in an ongoing phase 1 clinical trial in patients with ATTR cardiomyopathy. Analyzing memory B cell repertoires of the healthy elderly enabled Michalon et al. to develop a recombinant human antibody selective for transthyretin amyloid. This antibody removes cardiac amyloid through recruitment of phagocytic immune cells.
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Kroi F, Fischer N, Gezin A, Hashim M, Rozenbaum MH. Estimating the Gender Distribution of Patients with Wild-Type Transthyretin Amyloid Cardiomyopathy: A Systematic Review and Meta-Analysis. Cardiol Ther 2020; 10:41-55. [PMID: 33315233 PMCID: PMC8126539 DOI: 10.1007/s40119-020-00205-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION This study investigates the gender distribution in patients diagnosed with wild-type transthyretin amyloidosis cardiomyopathy (ATTRwt). METHODS A systematic review and meta-analysis of the male proportion in diagnosed ATTRwt patients were conducted. To avoid overlapping population, pooled estimates in the primary analysis were based on all unique studies. In secondary analyses, we considered predefined subsets of studies based on study sample size, recruitment years, geography, study design, age at diagnosis, and method of diagnosis. Additional meta-regression analyses were tested for potential determinants of gender distribution. RESULTS Twenty-eight unique studies (2542 patients) were included in the meta-analysis. Male proportion in patients with ATTRwt was 86.9% (95% confidence interval 81.5-91.6%). Studies, including patients older than 80 years at diagnosis, had a 29.1% (p value < 0.001) lower male proportion compared to studies, including younger patients. After adjusting for age, studies using autopsy as a method of diagnosis had a 21.1% (p value 0.002) lower male proportion compared to other studies. CONCLUSIONS Studies conducted to date suggest ATTRwt disproportionally affects males. The proportion of males was significantly impacted by the age at diagnosis and method diagnosis, which may suggest important gender-based differences in the clinical manifestation and diagnostic challenges of ATTRwt in females that warrant future research.
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Affiliation(s)
| | | | - Ana Gezin
- Ingress-Health, Rotterdam, The Netherlands
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Prognostic implications of pericardial and pleural effusion in patients with cardiac amyloidosis. Clin Res Cardiol 2020; 110:532-543. [PMID: 32914241 PMCID: PMC8055634 DOI: 10.1007/s00392-020-01698-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 06/25/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Pericardial and pleural effusion are common findings in patients with cardiac amyloidosis (CA). It is not known, whether effusions correlate with right ventricular (RV) function in these patients. Furthermore, data on the prognostic significance of pleural and pericardial effusion in CA is scarce. METHODS Patients with transthyretin (ATTR) and light chain (AL) CA were included in a clinical registry. All patients underwent transthoracic echocardiography at baseline. The presence of pericardial and pleural effusion was determined in every patient. The clinical endpoint was defined as cardiac death or heart failure hospitalization. RESULTS In total, 143 patients were analysed. Of these, 85 patients were diagnosed with ATTR and 58 patients with AL. Twenty-four patients presented with isolated pericardial effusion and 35 with isolated pleural effusion. In 19 patients, both pericardial and pleural effusion were found and in 65 patients no effusion was present at baseline. The presence of pleural effusion correlated well with poor RV function, measured by global RV free-wall strain (p = 0.007) in patients with AL, but not in ATTR. No such correlation could be found for pericardial effusion in either amyloidosis subtype. Patients with AL presenting with pleural effusion had worse outcomes compared to patients with pericardial effusion alone or no effusion at baseline. In the ATTR group, there was no difference in outcomes according to presence and type of effusion. CONCLUSION More than 50% of patients with CA presented with pleural and/or pericardial effusions. While pleural effusion was clearly associated with poor RV function in AL, we were not able to detect this association with pericardial effusion.
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Utility of Biomarkers in Cardiac Amyloidosis. JACC-HEART FAILURE 2020; 8:701-711. [DOI: 10.1016/j.jchf.2020.03.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 02/20/2020] [Accepted: 03/05/2020] [Indexed: 01/17/2023]
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Abstract
Transthyretin amyloid cardiomyopathy (ATTR-CM) is a progressive, life-threatening disease characterized by deposition of insoluble amyloid fibrils in the myocardium, resulting in cardiac structural and functional abnormalities and ultimately heart failure. Disease frequency is reportedly lower in women than men, but sex-related differences have not been well established. We conducted a systematic literature review (SLR), based on PRISMA-P guidelines and registered with PROSPERO, to assess whether the epidemiology and clinical presentation of ATTR-CM differ between women and men. MEDLINE, Embase, and Cochrane databases and selected conference proceedings were searched (August 16, 2019) to identify observational and clinical studies reporting sex-specific data for patients with wild-type or hereditary ATTR-CM. Of 193 publications satisfying final eligibility criteria, 69 studies were included in our pooled analysis. Among the 4669 patients with ATTR-CM analyzed, 791 (17%) were women, including 174 (9%), 366 (29%), and 251 (18%) in studies of wild-type, hereditary, and undefined ATTR-CM, respectively. Data available on disease characteristics were limited and very heterogeneous, but trends suggested some cardiac structural/functional differences, i.e., lower interventricular septal and posterior wall thickness and left ventricular (LV) end diastolic diameter, and higher LV ejection fractions, in women versus men across ATTR-CM subtypes. Because LV wall thickness > 12 mm is generally the suggested threshold for ATTR-CM diagnosis in both sexes, smaller cardiac anatomy in women with the disease may lead to underdiagnosis. Additional research and studies are needed to elucidate potential disparities between sexes in ATTR-CM frequency, clinical characteristics, and underlying biological mechanisms. This study was registered within the International Prospective Register of Systematic Reviews (PROSPERO) database of the University of York (CRD42019146995).
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Habtemariam BA, Karsten V, Attarwala H, Goel V, Melch M, Clausen VA, Garg P, Vaishnaw AK, Sweetser MT, Robbie GJ, Vest J. Single‐Dose Pharmacokinetics and Pharmacodynamics of Transthyretin Targeting N‐acetylgalactosamine–Small Interfering Ribonucleic Acid Conjugate, Vutrisiran, in Healthy Subjects. Clin Pharmacol Ther 2020; 109:372-382. [DOI: 10.1002/cpt.1974] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 06/15/2020] [Indexed: 12/17/2022]
Affiliation(s)
| | | | | | - Varun Goel
- Alnylam Pharmaceuticals Cambridge Massachusetts USA
| | - Megan Melch
- Alnylam Pharmaceuticals Cambridge Massachusetts USA
| | | | - Pushkal Garg
- Alnylam Pharmaceuticals Cambridge Massachusetts USA
| | | | | | | | - John Vest
- Alnylam Pharmaceuticals Cambridge Massachusetts USA
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Ochi Y, Kubo T, Baba Y, Nakashima Y, Ueda M, Takahashi A, Miyagawa K, Noguchi T, Hirota T, Yamasaki N, Kitaoka H. Prediction of Medium-Term Mortality in Japanese Patients With Wild-Type Transthyretin Amyloidosis. Circ Rep 2020; 2:314-321. [PMID: 33693246 PMCID: PMC7925325 DOI: 10.1253/circrep.cr-20-0031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background: The prognostic factors in Japanese patients with wild-type transthyretin amyloidosis (ATTRwt) have not been elucidated. Methods and Results: In this study we retrospectively analyzed the clinical characteristics and outcomes of 47 patients with ATTRwt (mean (±SD) age at diagnosis 80.3±4.6 years; 41 males). Fifteen patients died within 2 years of their diagnosis. Receiver operating characteristic and Kaplan-Meier analyses revealed that the best predictors of 2-year mortality were low serum albumin (≤3.75 g/dL), elevated high-sensitivity cardiac troponin T (hs-cTnT; >0.086 ng/mL), and reduced left ventricular ejection fraction (LVEF; <50%). According to the total number of these 3 risk factors, patients were stratified into 4 subgroups: low risk (no risk factors; n=15), intermediate-low risk (1 risk factor; n=15), intermediate-high risk (2 risk factors; n=7), and high risk (3 risk factors; n=10). The estimated 2-year survival rate of patients classified as low risk, intermediate-low risk, intermediate-high risk, and high risk was 93%, 80%, 83%, and 11%, respectively (P<0.001). Conclusions: Low serum albumin, elevated hs-cTnT, and reduced LVEF are associated with a worse prognosis in Japanese patients with ATTRwt. The combination of these factors may be useful for predicting medium-term mortality in patients with ATTRwt.
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Affiliation(s)
- Yuri Ochi
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Toru Kubo
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Yuichi Baba
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Yasuteru Nakashima
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Motoko Ueda
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Asa Takahashi
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Kazuya Miyagawa
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Tatsuya Noguchi
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Takayoshi Hirota
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Naohito Yamasaki
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Hiroaki Kitaoka
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
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Renal AA amyloidosis leading to early diagnosis and treatment of takayasu arteritis: a case report and review of the literature. Clin Res Cardiol 2020; 109:1438-1441. [PMID: 32346768 PMCID: PMC7588381 DOI: 10.1007/s00392-020-01655-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 04/23/2020] [Indexed: 12/11/2022]
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Ladefoged B, Dybro A, Povlsen JA, Vase H, Clemmensen TS, Poulsen SH. Diagnostic delay in wild type transthyretin cardiac amyloidosis – A clinical challenge. Int J Cardiol 2020; 304:138-143. [DOI: 10.1016/j.ijcard.2019.12.063] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 12/04/2019] [Accepted: 12/29/2019] [Indexed: 12/16/2022]
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Chacko L, Martone R, Bandera F, Lane T, Martinez-Naharro A, Boldrini M, Rezk T, Whelan C, Quarta C, Rowczenio D, Gilbertson JA, Wongwarawipat T, Lachmann H, Wechalekar A, Sachchithanantham S, Mahmood S, Marcucci R, Knight D, Hutt D, Moon J, Petrie A, Cappelli F, Guazzi M, Hawkins PN, Gillmore JD, Fontana M. Echocardiographic phenotype and prognosis in transthyretin cardiac amyloidosis. Eur Heart J 2020; 41:1439-1447. [DOI: 10.1093/eurheartj/ehz905] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 10/01/2019] [Accepted: 12/07/2019] [Indexed: 12/15/2022] Open
Abstract
Abstract
Aims
Transthyretin amyloidosis cardiomyopathy (ATTR-CM) is an increasingly recognized cause of heart failure. We sought to characterize the structural and functional echocardiographic phenotype across the spectrum of wild-type (wtATTR-CM) and hereditary (hATTR-CM) transthyretin cardiomyopathy and the echocardiographic features predicting prognosis.
Methods and results
We studied 1240 patients with ATTR-CM who underwent prospective protocolized evaluations comprising full echocardiographic assessment and survival between 2000 and 2019, comprising 766 with wtATTR-CM and 474 with hATTR-CM, of whom 314 had the V122I variant and 127 the T60A variant. At diagnosis, patients with V122I-hATTR-CM had the most severe degree of systolic and diastolic dysfunction across all echocardiographic parameters and patients with T60AhATTR-CM the least; patients with wtATTR-CM had intermediate features. Stroke volume index, right atrial area index, longitudinal strain, and E/e’ were all independently associated with mortality (P < 0.05 for all). Severe aortic stenosis (AS) was also independently associated with prognosis, conferring a significantly shorter survival (median survival 22 vs. 53 months, P = 0.001).
Conclusion
The three distinct genotypes present with varying degrees of severity. Echocardiography indicates a complex pathophysiology in which both systolic and diastolic function are independently associated with mortality. The presence of severe AS was independently associated with significantly reduced patient survival.
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Affiliation(s)
- Liza Chacko
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Raffaele Martone
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
- Department of Heart, Lung and Vessels, Tuscan Regional Amyloid Center, Careggi University Hospital, Largo Brambilla 3, Florence 50134, Italy
| | - Francesco Bandera
- Heart Failure Unit, Cardiology University Department, IRCCS Policlinico San Donato, Piazza Malan, 1, San Donato Milanese, Milan 20097, Italy
- Department for Biomedical Sciences for Health, University of Milano, Via Luigi Mangiagalli, 31, Milan 20133, Italy
| | - Thirusha Lane
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Ana Martinez-Naharro
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Michele Boldrini
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Tamer Rezk
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Carol Whelan
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Cristina Quarta
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Dorota Rowczenio
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Janet A Gilbertson
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Tanakal Wongwarawipat
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Helen Lachmann
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Ashutosh Wechalekar
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Sajitha Sachchithanantham
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Shameem Mahmood
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Rossella Marcucci
- Department of Experimental and Clinical Medicine, Careggi University Hospital, University of Florence, Largo Brambilla 3, Florence 50134, Italy
| | - Daniel Knight
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - David Hutt
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - James Moon
- Barts Heart Centre, The Cardiovascular Magnetic Resonance Imaging Unit, and the Inherited Cardiovascular Diseases Unit, St Bartholomew's Hospital, West Smithfield, London EC1A 7BE, UK
- Institute of Cardiovascular Science, University College London, Gower Street, London WC1E 6BT, UK
| | - Aviva Petrie
- Biostatistics Unit, UCL Eastman Dental Institute, University College London, 256 Grays Inn Road, London WC1X 8LD, UK
| | - Francesco Cappelli
- Department of Heart, Lung and Vessels, Tuscan Regional Amyloid Center, Careggi University Hospital, Largo Brambilla 3, Florence 50134, Italy
| | - Marco Guazzi
- Heart Failure Unit, Cardiology University Department, IRCCS Policlinico San Donato, Piazza Malan, 1, San Donato Milanese, Milan 20097, Italy
- Department for Biomedical Sciences for Health, University of Milano, Via Luigi Mangiagalli, 31, Milan 20133, Italy
| | - Philip N Hawkins
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Julian D Gillmore
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Marianna Fontana
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
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Dorbala S, Ando Y, Bokhari S, Dispenzieri A, Falk RH, Ferrari VA, Fontana M, Gheysens O, Gillmore JD, Glaudemans AWJM, Hanna MA, Hazenberg BPC, Kristen AV, Kwong RY, Maurer MS, Merlini G, Miller EJ, Moon JC, Murthy VL, Quarta CC, Rapezzi C, Ruberg FL, Shah SJ, Slart RHJA, Verberne HJ, Bourque JM. ASNC/AHA/ASE/EANM/HFSA/ISA/SCMR/SNMMI expert consensus recommendations for multimodality imaging in cardiac amyloidosis: Part 1 of 2-evidence base and standardized methods of imaging. J Nucl Cardiol 2019; 26:2065-2123. [PMID: 31468376 DOI: 10.1007/s12350-019-01760-6] [Citation(s) in RCA: 198] [Impact Index Per Article: 39.6] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Sharmila Dorbala
- Cardiac Amyloidosis Program, Cardiovascular Imaging Program, Departments of Radiology and Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA.
| | - Yukio Ando
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Sabahat Bokhari
- Columbia University Medical Center/New York Presbyterian Hospital, Columbia University, New York, NY, USA
| | - Angela Dispenzieri
- Division of Hematology, Division of Cardiovascular Diseases, and Department of Radiology, Division of Nuclear Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Rodney H Falk
- Cardiac Amyloidosis Program, Cardiovascular Imaging Program, Departments of Radiology and Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | - Victor A Ferrari
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Marianna Fontana
- Division of Medicine, National Amyloidosis Centre, University College London, London, UK
| | - Olivier Gheysens
- Nuclear Medicine and Molecular Imaging, University Hospitals Leuven, Leuven, Belgium
| | - Julian D Gillmore
- Division of Medicine, National Amyloidosis Centre, University College London, London, UK
| | - Andor W J M Glaudemans
- Department of Nuclear Medicine and Molecular Imaging, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Mazen A Hanna
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Bouke P C Hazenberg
- Department of Rheumatology & Clinical Immunology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Arnt V Kristen
- Department of Cardiology, University of Heidelberg, Heidelberg, Germany
| | - Raymond Y Kwong
- Cardiac Amyloidosis Program, Cardiovascular Imaging Program, Departments of Radiology and Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | - Mathew S Maurer
- Columbia University Medical Center/New York Presbyterian Hospital, Columbia University, New York, NY, USA
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Center, Foundation Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, Pavia, Italy
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Edward J Miller
- Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - James C Moon
- Division of Medicine, National Amyloidosis Centre, University College London, London, UK
| | | | - C Cristina Quarta
- Division of Medicine, National Amyloidosis Centre, University College London, London, UK
| | - Claudio Rapezzi
- Cardiology Unit, Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater-University of Bologna, Bologna, Italy
| | - Frederick L Ruberg
- Amyloidosis Center and Section of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA, USA
| | - Sanjiv J Shah
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Riemer H J A Slart
- Department of Nuclear Medicine and Molecular Imaging, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Hein J Verberne
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jamieson M Bourque
- Departments of Medicine and Radiology, Cardiovascular Imaging Center, University of Virginia, Charlottesville, VA, USA
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Myocardial Amyloidosis. JACC Cardiovasc Imaging 2019; 12:2345-2356. [DOI: 10.1016/j.jcmg.2019.06.023] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 05/28/2019] [Accepted: 06/03/2019] [Indexed: 12/27/2022]
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Kreusser MM, Volz MJ, Knop B, Ehlermann P, Schmack B, Ruhparwar A, Hegenbart U, Schönland SO, Katus HA, Raake PW. A novel risk score to predict survival in advanced heart failure due to cardiac amyloidosis. Clin Res Cardiol 2019; 109:700-713. [PMID: 31630214 DOI: 10.1007/s00392-019-01559-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 09/27/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cardiac amyloidosis, caused by deposition of immunoglobulin light chains (AL) or transthyretin (ATTR), carries a poor prognosis. Established risk scores for amyloidosis may not predict outcomes in those patients who develop advanced heart failure and who are potential candidates for heart transplantation. Here, we aimed to identify predictive parameters for patients with severe heart failure due to amyloidosis. METHODS Out of > 1000 patients with cardiac amyloidosis (AL or ATTR) admitted to our centre between September 1998 and January 2016, a cohort of 120 patients with a complete cardiac assessment at diagnosis, including right heart catheterization, echocardiography and biomarkers, was analysed retrospectively in this study. Primary endpoint was all-cause mortality. We performed univariate and multivariate Cox regression analysis, generated risk scores to predict outcomes in AL and ATTR amyloidosis and compared those to established risk models for amyloidosis. RESULTS In the Cox multivariate model, high-sensitivity troponin T (hsTnT; hazard ratio (HR) 1.003; confidence interval (CI) 1.001-1.005; p = 0.009) and mean pulmonary artery pressure (HR 1.061; CI 1.024-1.100; p = 0.001) were found to significantly and independently predict outcomes for AL amyloidosis, whereas QRS duration (HR 1.021; CI 1.004-1.039; p = 0.013), hsTnT (HR 1.021; CI 1.006-1.036; p = 0.006) and N-terminal pro-brain natriuretic peptide (HR 1.0003; CI 1.0001-1.0004; p = 0.002) were the best predictors for ATTR amyloidosis. A simple risk score ("HeiRisk") including these parameters for AL and ATTR allowed a more precise risk stratification in our patient population compared to established risk models. CONCLUSIONS Risk stratification for cardiac amyloidosis with the newly developed "HeiRisk" score may be superior to other staging systems for patients with advanced heart failure due to amyloid cardiomyopathy.
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Affiliation(s)
- Michael M Kreusser
- Division of Cardiology, Department of Internal Medicine III, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
- DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Heidelberg, Germany.
| | - Martin J Volz
- Division of Cardiology, Department of Internal Medicine III, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Benjamin Knop
- Division of Cardiology, Department of Internal Medicine III, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Philipp Ehlermann
- Division of Cardiology, Department of Internal Medicine III, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Bastian Schmack
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Arjang Ruhparwar
- DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Ute Hegenbart
- Division of Hematology and Oncology, Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
| | - Stefan O Schönland
- Division of Hematology and Oncology, Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
| | - Hugo A Katus
- Division of Cardiology, Department of Internal Medicine III, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Philip W Raake
- Division of Cardiology, Department of Internal Medicine III, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
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Dorbala S, Ando Y, Bokhari S, Dispenzieri A, Falk RH, Ferrari VA, Fontana M, Gheysens O, Gillmore JD, Glaudemans AWJM, Hanna MA, Hazenberg BPC, Kristen AV, Kwong RY, Maurer MS, Merlini G, Miller EJ, Moon JC, Murthy VL, Quarta CC, Rapezzi C, Ruberg FL, Shah SJ, Slart RHJA, Verberne HJ, Bourque JM. ASNC/AHA/ASE/EANM/HFSA/ISA/SCMR/SNMMI Expert Consensus Recommendations for Multimodality Imaging in Cardiac Amyloidosis: Part 1 of 2-Evidence Base and Standardized Methods of Imaging. J Card Fail 2019; 25:e1-e39. [PMID: 31473268 DOI: 10.1016/j.cardfail.2019.08.001] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Sharmila Dorbala
- Cardiac Amyloidosis Program, Cardiovascular Imaging Program, Departments of Radiology and Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts.
| | - Yukio Ando
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Sabahat Bokhari
- Columbia University Medical Center/New York Presbyterian Hospital, Columbia University, New York, New York
| | - Angela Dispenzieri
- Division of Hematology, Division of Cardiovascular Diseases, and Department of Radiology, Division of Nuclear Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Rodney H Falk
- Cardiac Amyloidosis Program, Cardiovascular Imaging Program, Departments of Radiology and Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Victor A Ferrari
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marianna Fontana
- Division of Medicine, National Amyloidosis Centre, University College London, London, United Kingdom
| | - Olivier Gheysens
- Nuclear Medicine and Molecular Imaging, University Hospitals Leuven, Leuven, Belgium
| | - Julian D Gillmore
- Division of Medicine, National Amyloidosis Centre, University College London, London, United Kingdom
| | - Andor W J M Glaudemans
- Department of Nuclear Medicine and Molecular Imaging, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Mazen A Hanna
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Bouke P C Hazenberg
- Department of Rheumatology & Clinical Immunology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Arnt V Kristen
- Department of Cardiology, University of Heidelberg, Heidelberg, Germany
| | - Raymond Y Kwong
- Cardiac Amyloidosis Program, Cardiovascular Imaging Program, Departments of Radiology and Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Mathew S Maurer
- Columbia University Medical Center/New York Presbyterian Hospital, Columbia University, New York, New York
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Center, Foundation Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, Pavia, Italy; Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Edward J Miller
- Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - James C Moon
- Division of Medicine, National Amyloidosis Centre, University College London, London, United Kingdom
| | | | - C Cristina Quarta
- Division of Medicine, National Amyloidosis Centre, University College London, London, United Kingdom
| | - Claudio Rapezzi
- Cardiology Unit, Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater-University of Bologna, Bologna, Italy
| | - Frederick L Ruberg
- Amyloidosis Center and Section of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Sanjiv J Shah
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Riemer H J A Slart
- Department of Nuclear Medicine and Molecular Imaging, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Hein J Verberne
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jamieson M Bourque
- Departments of Medicine and Radiology, Cardiovascular Imaging Center, University of Virginia, Charlottesville, Virginia
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Abstract
PURPOSE OF REVIEW We summarize key features pertaining to the two most commonly encountered types of cardiac amyloidosis (CA), monoclonal immunoglobulin light chain (AL) and transthyretin type (ATTR), expanding upon the clinical application and utility of various imaging techniques in diagnosing CA. RECENT FINDINGS Advances in imaging have led to earlier identification, improved diagnosis of CA and higher discriminatory power to differentiate CA from other hypertrophic phenocopies. The application of cardiac magnetic resonance imaging (CMR) has led to a deeper understanding of underlying pathophysiological processes in CA, owing largely to its intrinsic tissue characterization properties. The widespread adoption of bone scintigraphy algorithms has reduced the need for cardiac biopsy and improved diagnostic confidence in ATTR CA. As new treatments for CA are rapidly developing, there will be even greater reliance on imaging, as the requirement to diagnose disease earlier, monitor response and amend treatment strategies accordingly intensifies.
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Affiliation(s)
- Liza Chacko
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, NW3 2PF, London, UK
| | - Raffaele Martone
- Tuscan Regional Amyloid Center, Careggi University Hospital, Florence, Italy
| | - Francesco Cappelli
- Tuscan Regional Amyloid Center, Careggi University Hospital, Florence, Italy
| | - Marianna Fontana
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, NW3 2PF, London, UK
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Abstract
Background Cardiac amyloidosis (CA) is an underappreciated cause of morbidity and mortality. Light-chain (AL) and transthyretin (ATTR) amyloidosis have different disease trajectories. No data are available on subtype-specific modes of death (MOD) in patients with CA. Methods and results We retrospectively investigated 66 with AL and 48 with wild-type ATTR amyloidosis (ATTRwt) from 2000 to 2018. ATTRwt differed from AL by age (74.6 ± 5.4 years vs. 63 ± 10.8 years), posterior wall thickness (16.8 ± 3.3 mm vs. 14.3 ± 2.2 mm), left ventricular mass index (180.7 ± 63.2 g/m2 vs. 133.5 ± 42.2 g/m2), and the proportions of male gender (91.7% vs. 59.1%), atrial enlargement (92% vs. 68.2%) and atrial fibrillation (50% vs. 12.1%). In AL NYHA Functional Class and proteinuria (72.7% vs. 39.6%) were greater; mean arterial pressure (84.4 ± 13.5 mmHg vs. 90.0 ± 11.3 mmHg) was lower. Unadjusted 5-year mortality rate was 65% in AL-CA vs. 44% in the ATTRwt group. Individuals with AL-CA were 2.28 times ([95%CI 1.27–4.10]; p = 0.006) more likely to die than were individuals with ATTRwt-CA. Information on MOD was available in 56 (94.9%) of 59 deceased patients. MOD was cardiovascular in 40 (66.8%) and non-cardiovascular in 16 (27.1%) patients. Cardiovascular [28 (68.3%) vs. 13 (80%)] death events were distributed equally between AL and ATTRwt (p = 0.51). Conclusion Our data indicate no differences in MOD between patients with AL and ATTRwt cardiac amyloidosis despite significant differences in clinical presentation and disease progression. Cardiovascular events account for more than two-thirds of fatal casualties in both groups. Graphic abstract ![]()
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Perry R, Selvanayagam JB. Echocardiography in Infiltrative Cardiomyopathy. Heart Lung Circ 2019; 28:1365-1375. [PMID: 31109889 DOI: 10.1016/j.hlc.2019.04.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 02/14/2019] [Accepted: 04/11/2019] [Indexed: 01/18/2023]
Abstract
Left ventricular (LV) wall thickening can occur due to both physiological and pathological processes. Some LV wall thickening is caused by infiltrative cardiac deposition diseases - rare disorders from both inherited and acquired conditions, with varying systemic manifestations. They portend a poor prognosis and are generally not reversible except in rare circumstances when early diagnosis and treatment may alter the outcome (e.g., Fabry disease). Cardiac involvement is variable and depends on the degree of infiltration and type of infiltrate. These changes often lead to the development of abnormalities in both the relaxation and contractile function of the heart ultimately resulting in heart failure. Echocardiography is generally the first investigation of choice as it is easily available and gives valuable information about the thickness of the ventricular walls as well as systolic and diastolic function. It is also able to identify unique, characteristic features of the disease as well as detecting any haemodynamic sequelae. This review looks at the role of echocardiography in the diagnosis and prognosis of infiltrative cardiac deposition diseases.
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Affiliation(s)
- Rebecca Perry
- College of Medicine, Flinders University, Adelaide, SA, Australia; Department of Cardiovascular Medicine, Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, SA, Australia; Cardiac Imaging Research, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Joseph B Selvanayagam
- College of Medicine, Flinders University, Adelaide, SA, Australia; Department of Cardiovascular Medicine, Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, SA, Australia; Cardiac Imaging Research, South Australian Health and Medical Research Institute, Adelaide, SA, Australia.
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Correction to: Reference Ranges for the Size of the Fetal Cardiac Outflow Tracts From 13 to 36 Weeks Gestation: A Single-Center Study of Over 7000 Cases. Circ Cardiovasc Imaging 2019; 12:e000025. [PMID: 30866649 DOI: 10.1161/hci.0000000000000025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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45
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Role of echocardiography in assessing cardiac amyloidoses: a systematic review. J Echocardiogr 2019; 17:64-75. [PMID: 30741395 DOI: 10.1007/s12574-019-00420-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 01/29/2019] [Accepted: 01/30/2019] [Indexed: 12/21/2022]
Abstract
Cardiac amyloidosis is a manifestation of one of several systemic amyloidoses, and is characterized by increased left-ventricular (LV) wall thickness and normal or decreased LV cavity size. Congestive heart failure in cardiac amyloidosis is characterized by a predominant diastolic LV dysfunction, and systolic dysfunction occurs only in late-stage disease. Echocardiography is a noninvasive, reproducible method for assessing cardiac morphology and function in cardiac amyloidosis, and some echocardiographic indices are prognostic for amyloidoses. This review describes the advances in echocardiography and its role in the diagnosis and management of cardiac amyloidoses. Our review suggests that LV longitudinal function and the cyclic variation of myocardial integrated backscatter may be the best predictors of adverse outcomes. In the future, new echocardiographic techniques, such as fully automated echocardiogram interpretation, should provide further useful information for assessing cardiac function and prognosis in cardiac amyloidosis patients.
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Lee SP, Park JB, Kim HK, Kim YJ, Grogan M, Sohn DW. Contemporary Imaging Diagnosis of Cardiac Amyloidosis. J Cardiovasc Imaging 2019; 27:1-10. [PMID: 30701710 PMCID: PMC6358430 DOI: 10.4250/jcvi.2019.27.e9] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 12/26/2018] [Indexed: 02/07/2023] Open
Abstract
Cardiac amyloidosis is a rare disease that frequently presents as ventricular hypertrophy. However, diagnosis is not always easy or straightforward as there are several myocardial disorders that phenocopy cardiac amyloidosis. Here, we present a narrative review of the current modalities that are actively used or being developed for diagnosis and follow-up of cardiac amyloidosis. Although not all of the findings may be present in those with cardiac amyloidosis, there are some clues in each diagnostic step that help lead to confirmatory diagnosis of cardiac amyloidosis; we believe that cardiologists should be familiar with these clues.
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Affiliation(s)
- Seung Pyo Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.
| | - Jun Bean Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hyung Kwan Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Yong Jin Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Martha Grogan
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Dae Won Sohn
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
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Baron T, Berglund L, Hedin EM, Flachskampf FA. Test-retest reliability of new and conventional echocardiographic parameters of left ventricular systolic function. Clin Res Cardiol 2018; 108:355-365. [PMID: 30368567 PMCID: PMC6426804 DOI: 10.1007/s00392-018-1363-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Accepted: 08/22/2018] [Indexed: 11/29/2022]
Abstract
Background Reliability of left ventricular function measurements depends on actual biological conditions, repeated registrations and their analyses. Objective To investigate test–retest reliability of speckle-tracking-derived strain measurements and its determinants compared to the conventional parameters, such as ejection fraction (EF), LV volumes and mitral annular plane systolic excursion (MAPSE). Methods In 30 patients with a wide range of left ventricular function (mean EF 46.4 ± 16.4%, range 14–73%), standard echo views were acquired independently in a blinded fashion by two different echocardiographers in immediate sequence and analyzed off-line by two independent readers, creating 4 data sets per patient. Test–retest reliability of studied parameters was calculated using the smallest detectable change (SDC) and a total, inter-acquisition and inter-reader intra-class correlation coefficient (ICC). Results The smallest detectable change normalized to the mean absolute value of the measured parameter (SDCrel) was lowest for MAPSE (10.7%). SDCrel for EF was similar to GLS (14.2 and 14.7%, respectively), while SDCrel for CS was much higher (35.6%). The intra-class correlation coefficient was excellent (> 0.9) for all measures of the left ventricular function. Intra-patient inter-acquisition reliability (ICCacq) was significantly better than inter-reader reliability (ICCread) (0.984 vs. 0.950, p = 0.03) only for EF, while no significant difference was observed for any other LV function parameter. Mean intra-subject standard deviations were significantly correlated to the mean values for CS and LV volumes, but not for the other studied parameters. Conclusions In a test–retest setting, both with normal and impaired left ventricular function, the smallest relative detectable change of EF, GLS and MAPSE was similar (11–15%), but was much higher for CS (35%). Surprisingly, reliability of GLS was not superior to that of EF. Acquisition and reader to a similar extent influenced the reliability of measurements of all left ventricular function measures except for ejection fraction, where the reliability was more dependent on the reader than on the acquisition.
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Affiliation(s)
- Tomasz Baron
- Department of Medical Sciences, Cardiology and Clinical Physiology, Uppsala University, Uppsala, Sweden. .,Department of Radiology, Uppsala University Hospital, Uppsala, Sweden. .,Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden.
| | - Lars Berglund
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden.,Department of Public Health and Caring Sciences/Geriatrics, Uppsala University, Uppsala, Sweden
| | - Eva-Maria Hedin
- Department of Medical Sciences, Cardiology and Clinical Physiology, Uppsala University, Uppsala, Sweden
| | - Frank A Flachskampf
- Department of Medical Sciences, Cardiology and Clinical Physiology, Uppsala University, Uppsala, Sweden
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48
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Myocardial Contraction Fraction by M-Mode Echocardiography Is Superior to Ejection Fraction in Predicting Mortality in Transthyretin Amyloidosis. J Card Fail 2018; 24:504-511. [PMID: 30010028 DOI: 10.1016/j.cardfail.2018.07.001] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 06/28/2018] [Accepted: 07/03/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Transthyretin amyloidosis (ATTR) is often associated with cardiac involvement manifesting as conduction disease as well as restrictive cardiomyopathy causing heart failure and death. Myocardial contraction fraction (MCF), the ratio of left ventricular stroke volume (SV) to myocardial volume (MV), is a volumetric measure of myocardial shortening that is superior to ejection fraction (EF) in predicting mortality in patients with primary amyloid light chain cardiac amyloidosis. We hypothesized that MCF would be an independent predictor of survival in TTR-CA. METHODS AND RESULTS MCF was derived from 2-dimensional echocardiography-guided M-mode data for 530 subjects in the Transthyretin Amyloidosis Outcomes Survey (THAOS) database: age 61 ± 16years, 74% male, 158 wild-type (ATTRwt) and 372 mutant (ATTRm), follow-up 1.5 ± 1.7years. Using multivariate Cox proportional hazard regression models, MCF <25% was highly associated with survival (hazard ratio [HR] 8.5, 95% confidence interval [CI] 4.8-14.9,-P < .0001), which was stronger than the association of EF dichotomized at 50% (HR 2.8, 95% CI 1.8-4.4; P < .0001). MCF <25% remained significantly predictive of survival in a multivariate model that included systolic blood pressure, estimated glomerular filtration rate <65 mL·min-1·m-2, New York Heart Association (NYHA) functional class, and health status based on the EuroQol-5D-3L questionnaire (area under the receiver operating characteristic curve [AUC] = 0.83, 95% CI 0.78-0.89). CONCLUSIONS MCF was superior to EF in predicting mortality in patients with ATTR. A predictive model combining MCF with systolic blood pressure, renal function, NYHA functional class, and health status was strongly associated with survival in patients with ATTR. CLINICALTRIALS. GOV IDENTIFIER NCT00628745.
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49
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Henein MY, Suhr OB, Arvidsson S, Pilebro B, Westermark P, Hörnsten R, Lindqvist P. Reduced left atrial myocardial deformation irrespective of cavity size: a potential cause for atrial arrhythmia in hereditary transthyretin amyloidosis. Amyloid 2018; 25:46-53. [PMID: 29369708 DOI: 10.1080/13506129.2018.1430027] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Cardiac amyloidosis (CA) is a myocardial disease and commonly under-diagnosed condition. In CA patients, atrial fibrillation might occur in the absence of left atrial (LA) enlargement. OBJECTIVES The aim of this study is to assess LA size and function, and its relationship with atrial arrhythmia in patients with hereditary transthyretin amyloidosis (ATTR). METHODS Forty-six patients with confirmed ATTR amyloidosis on abdominal biopsy were studied. Assessment with 2D echocardiography and 2D strain showed 31 patients had increased LV wall thickness (LVWT) (septal thickness >12 mm), and 15 had normal LVWT. In addition to conventional measurements, LV and LA global longitudinal strain (GLS%) and strain rate (SR) were obtained. Western blot analysis was done to assess fibril type. ATTR patients with increased LVWT were compared with 23 patients with hypertrophic cardiomyopathy (HCM) and 31 healthy controls. ATTR amyloidosis patients also underwent 24 hour Holter monitoring to determine the presence of atrial arrhythmia. RESULTS Atrial deformation during atrial systole was reduced in ATTR amyloidosis patients with increased LVWT independent of LA size and in contrast to HCM. Twenty of the ATTR amyloidosis patients (54%) had ECG evidence of significant atrial arrhythmic events. LA strain rate, during atrial systole, was the only independent predictor of atrial arrhythmia (β = 3.28, p = .012). CONCLUSION In ATTR cardiomyopathy with increased LVWT, LA myocardial function is abnormal, irrespective of atrial cavity size. Reduced LA myocardial SR during atrial systole, irrespective of cavity volume, E/e' and LV deformation, is also a strong predictor for atrial arrhythmic events.
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Affiliation(s)
- Michael Y Henein
- a Public Health and Clinical Medicine , Umeå University , Umeå , Sweden
| | - Ole B Suhr
- a Public Health and Clinical Medicine , Umeå University , Umeå , Sweden
| | - Sandra Arvidsson
- b Clinical Physiology, Heart Centre, Umeå University , Umeå , Sweden
| | - Björn Pilebro
- a Public Health and Clinical Medicine , Umeå University , Umeå , Sweden
| | - Per Westermark
- c Immunology, Genetics and Pathology , Uppsala University , Uppsala , Sweden
| | - Rolf Hörnsten
- b Clinical Physiology, Heart Centre, Umeå University , Umeå , Sweden
| | - Per Lindqvist
- a Public Health and Clinical Medicine , Umeå University , Umeå , Sweden
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