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Ioannou A, Patel RK, Martinez-Naharro A, Razvi Y, Porcari A, Rauf MU, Bolhuis RE, Fernando-Sayers J, Virsinskaite R, Bandera F, Kotecha T, Venneri L, Knight D, Manisty C, Moon J, Lachmann H, Whelan C, Kellman P, Hawkins PN, Gillmore JD, Wechalekar A, Fontana M. Tracking Treatment Response in Cardiac Light-Chain Amyloidosis With Native T1 Mapping. JAMA Cardiol 2023; 8:848-852. [PMID: 37466990 PMCID: PMC10357357 DOI: 10.1001/jamacardio.2023.2010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 04/28/2023] [Indexed: 07/20/2023]
Abstract
Importance Cardiac magnetic resonance (CMR) imaging-derived extracellular volume (ECV) mapping, generated from precontrast and postcontrast T1, accurately determines treatment response in cardiac light-chain amyloidosis. Native T1 mapping, which can be derived without the need for contrast, has demonstrated accuracy in diagnosis and prognostication, but it is unclear whether serial native T1 measurements could also track the cardiac treatment response. Objective To assess whether native T1 mapping can measure the cardiac treatment response and the association between changes in native T1 and prognosis. Design, Setting, and Participants This single-center cohort study evaluated patients diagnosed with cardiac light-chain amyloidosis (January 2016 to December 2020) who underwent CMR scans at diagnosis and a repeat scan following chemotherapy. Analysis took place between January 2016 and October 2022. Main Outcomes and Measures Comparison of biomarkers and cardiac imaging parameters between patients with a reduced, stable, or increased native T1 and association between changes in native T1 and mortality. Results The study comprised 221 patients (mean [SD] age, 64.7 [10.6] years; 130 male [59%]). At 6 months, 183 patients (mean [SD] age, 64.8 [10.5] years; 110 male [60%]) underwent repeat CMR imaging. Reduced native T1 of 50 milliseconds or more occurred in 8 patients (4%), all of whom had a good hematological response; by contrast, an increased native T1 of 50 milliseconds or more occurred in 42 patients (23%), most of whom had a poor hematological response (27 [68%]). At 12 months, 160 patients (mean [SD] age, 63.8 [11.1] years; 94 male [59%]) had a repeat CMR scan. A reduced native T1 occurred in 24 patients (15%), all of whom had a good hematological response, and was associated with a reduction in N-terminal pro-brain natriuretic peptide (median [IQR], 2638 [913-5767] vs 423 [128-1777] ng/L; P < .001), maximal wall thickness (mean [SD], 14.8 [3.6] vs 13.6 [3.9] mm; P = .009), and E/e' (mean [SD], 14.9 [6.8] vs 12.0 [4.0]; P = .007), improved longitudinal strain (mean [SD], -14.8% [4.0%] vs -16.7% [4.0%]; P = .004), and reduction in both myocardial T2 (mean [SD], 52.3 [2.9] vs 49.4 [2.0] milliseconds; P < .001) and ECV (mean [SD], 0.47 [0.07] vs 0.42 [0.08]; P < .001). At 12 months, an increased native T1 occurred in 24 patients (15%), most of whom had a poor hematological response (17 [71%]), and was associated with an increased N-terminal pro-brain natriuretic peptide (median [IQR], 1622 [554-5487] vs 3150 [1161-8745] ng/L; P = .007), reduced left ventricular ejection fraction (mean [SD], 65.8% [11.4%] vs 61.5% [12.4%]; P = .009), and an increase in both myocardial T2 (mean [SD], 52.5 [2.7] vs 55.3 [4.2] milliseconds; P < .001) and ECV (mean [SD], 0.48 [0.09] vs 0.56 [0.09]; P < .001). Change in myocardial native T1 at 6 months was independently associated with mortality (hazard ratio, 2.41 [95% CI, 1.36-4.27]; P = .003). Conclusions and Relevance Changes in native T1 in response to treatment, reflecting a composite of changes in T2 and ECV, are associated with in changes in traditional markers of cardiac response and associated with mortality. However, as a single-center study, these results require external validation in a larger cohort.
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Affiliation(s)
- Adam Ioannou
- National Amyloidosis Centre, Royal Free Campus, University College London, London, United Kingdom
| | - Rishi K. Patel
- National Amyloidosis Centre, Royal Free Campus, University College London, London, United Kingdom
| | - Ana Martinez-Naharro
- National Amyloidosis Centre, Royal Free Campus, University College London, London, United Kingdom
| | - Yousuf Razvi
- National Amyloidosis Centre, Royal Free Campus, University College London, London, United Kingdom
| | - Aldostefano Porcari
- National Amyloidosis Centre, Royal Free Campus, University College London, London, United Kingdom
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Muhammad U. Rauf
- National Amyloidosis Centre, Royal Free Campus, University College London, London, United Kingdom
| | - Roos E. Bolhuis
- National Amyloidosis Centre, Royal Free Campus, University College London, London, United Kingdom
| | - Jacob Fernando-Sayers
- National Amyloidosis Centre, Royal Free Campus, University College London, London, United Kingdom
| | - Ruta Virsinskaite
- National Amyloidosis Centre, Royal Free Campus, University College London, London, United Kingdom
| | - Francesco Bandera
- Cardiology University Department, IRCCS Policlinico San Donato, Milan, Italy
| | - Tushar Kotecha
- National Amyloidosis Centre, Royal Free Campus, University College London, London, United Kingdom
| | - Lucia Venneri
- National Amyloidosis Centre, Royal Free Campus, University College London, London, United Kingdom
| | - Daniel Knight
- National Amyloidosis Centre, Royal Free Campus, University College London, London, United Kingdom
| | | | - James Moon
- St Bartholomew’s Hospital, London, United Kingdom
| | - Helen Lachmann
- National Amyloidosis Centre, Royal Free Campus, University College London, London, United Kingdom
| | - Carol Whelan
- National Amyloidosis Centre, Royal Free Campus, University College London, London, United Kingdom
| | - Peter Kellman
- National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Philip N. Hawkins
- National Amyloidosis Centre, Royal Free Campus, University College London, London, United Kingdom
| | - Julian D. Gillmore
- National Amyloidosis Centre, Royal Free Campus, University College London, London, United Kingdom
| | - Ashutosh Wechalekar
- National Amyloidosis Centre, Royal Free Campus, University College London, London, United Kingdom
| | - Marianna Fontana
- National Amyloidosis Centre, Royal Free Campus, University College London, London, United Kingdom
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5
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Ioannou A, Patel RK, Martinez-Naharro A, Razvi Y, Porcari A, Hutt DF, Bandera F, Kotecha T, Venneri L, Chacko L, Massa P, Hanger M, Knight D, Manisty C, Moon J, Quarta C, Lachmann H, Whelan C, Kellman P, Hawkins PN, Gillmore JD, Wechelakar A, Fontana M. Tracking Multiorgan Treatment Response in Systemic AL-Amyloidosis With Cardiac Magnetic Resonance Derived Extracellular Volume Mapping. JACC Cardiovasc Imaging 2023; 16:1038-1052. [PMID: 37178079 PMCID: PMC10406611 DOI: 10.1016/j.jcmg.2023.02.019] [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] [Received: 10/11/2022] [Revised: 01/18/2023] [Accepted: 02/03/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Systemic light chain amyloidosis is a multisystem disorder that commonly involves the heart, liver, and spleen. Cardiac magnetic resonance with extracellular volume (ECV) mapping provides a surrogate measure of the myocardial, liver, and spleen amyloid burden. OBJECTIVES The purpose of this study was to assess multiorgan response to treatment using ECV mapping, and assess the association between multiorgan treatment response and prognosis. METHODS The authors identified 351 patients who underwent baseline serum amyloid-P-component (SAP) scintigraphy and cardiac magnetic resonance at diagnosis, of which 171 had follow-up imaging. RESULTS At diagnosis, ECV mapping demonstrated that 304 (87%) had cardiac involvement, 114 (33%) significant hepatic involvement, and 147 (42%) significant splenic involvement. Baseline myocardial and liver ECV independently predict mortality (myocardial HR: 1.03 [95% CI: 1.01-1.06]; P = 0.009; liver HR: 1.03; [95% CI: 1.01-1.05]; P = 0.001). Liver and spleen ECV correlated with amyloid load assessed by SAP scintigraphy (R = 0.751; P < 0.001; R = 0.765; P < 0.001, respectively). Serial measurements demonstrated ECV correctly identified changes in liver and spleen amyloid load derived from SAP scintigraphy in 85% and 82% of cases, respectively. At 6 months, more patients with a good hematologic response had liver (30%) and spleen (36%) ECV regression than myocardial regression (5%). By 12 months, more patients with a good response demonstrated myocardial regression (heart 32%, liver 30%, spleen 36%). Myocardial regression was associated with reduced median N-terminal pro-brain natriuretic peptide (P < 0.001), and liver regression with reduced median alkaline phosphatase (P = 0.001). Changes in myocardial and liver ECV, 6 months after initiating chemotherapy, independently predict mortality (myocardial HR: 1.11 [95% CI: 1.02-1.20]; P = 0.011; liver HR: 1.07 [95% CI: 1.01-1.13]; P = 0.014). CONCLUSIONS Multiorgan ECV quantification accurately tracks treatment response and demonstrates different rates of organ regression, with the liver and spleen regressing more rapidly than the heart. Baseline myocardial and liver ECV and changes at 6 months independently predict mortality, even after adjusting for traditional predictors of prognosis.
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Affiliation(s)
- Adam Ioannou
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Rishi K Patel
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Ana Martinez-Naharro
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Yousuf Razvi
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Aldostefano Porcari
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom; Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Italy
| | - David F Hutt
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Francesco Bandera
- Cardiology University Department, IRCCS Policlinico San Donato, Milan, Italy
| | - Tushar Kotecha
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Lucia Venneri
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Liza Chacko
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Paolo Massa
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Melissa Hanger
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Daniel Knight
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | | | - James Moon
- St Bartholomew's Hospital, London, United Kingdom
| | - Cristina Quarta
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Helen Lachmann
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Carol Whelan
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Peter Kellman
- National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Philip N Hawkins
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Julian D Gillmore
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Ashutosh Wechelakar
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Marianna Fontana
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom.
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10
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Ioannou A, Patel RK, Razvi Y, Porcari A, Sinagra G, Venneri L, Bandera F, Masi A, Williams GE, O’Beara S, Ganesananthan S, Massa P, Knight D, Martinez-Naharro A, Kotecha T, Chacko L, Brown J, Rauf MU, Manisty C, Moon J, Lachmann H, Wechelakar A, Petrie A, Whelan C, Hawkins PN, Gillmore JD, Fontana M. Impact of Earlier Diagnosis in Cardiac ATTR Amyloidosis Over the Course of 20 Years. Circulation 2022; 146:1657-1670. [PMID: 36325894 PMCID: PMC9698091 DOI: 10.1161/circulationaha.122.060852] [Citation(s) in RCA: 55] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Diagnostic and therapeutic advances have led to much greater awareness of transthyretin cardiac amyloidosis (ATTR-CA). We aimed to characterize changes in the clinical phenotype of patients diagnosed with ATTR-CA over the past 20 years. METHODS This is a retrospective observational cohort study of all patients referred to the National Amyloidosis Centre (2002-2021) in whom ATTR-CA was a differential diagnosis. RESULTS We identified 2995 patients referred with suspected ATTR-CA, of whom 1967 had a diagnosis of ATTR-CA confirmed. Analysis by 5-year periods revealed an incremental increase in referrals, with higher proportions of patients having been referred after bone scintigraphy and cardiac magnetic resonance imaging (2% versus 34% versus 51% versus 55%, chi-square P<0.001). This was accompanied by a greater number of ATTR-CA diagnoses, predominantly of the wild-type nonhereditary form, which is now the most commonly diagnosed form of ATTR-CA (0% versus 54% versus 67% versus 66%, chi-square P<0.001). Over time, the median duration of associated symptoms before diagnosis fell from 36 months between 2002 and 2006 to 12 months between 2017 and 2021 (Mann-Whitney P<0.001), and a greater proportion of patients had early-stage disease at diagnosis across the 5-year periods (National Amyloidosis Centre stage 1: 34% versus 42% versus 44% versus 53%, chi-square P<0.001). This was associated with more favorable echocardiographic parameters of structure and function, including lesser interventricular septal thickness (18.0±3.8 mm versus 17.2±2.6 mm versus 16.9±2.3 mm versus 16.6±2.4 mm, P=0.01) and higher left ventricular ejection fraction (46.0%±8.9% versus 46.8%±11.0% versus 47.8%±11.0% versus 49.5%±11.1%, P<0.001). Mortality decreased progressively during the study period (2007-2011 versus 2012-2016: hazard ratio, 1.57 [95% CI, 1.31-1.89], P<0.001; and 2012-2016 versus 2017-2021: hazard ratio, 1.89 [95% CI, 1.55-2.30], P<0.001). The proportion of patients enrolled into clinical trials and prescribed disease-modifying therapy increased over the 20-year period, but even when censoring at the trial or medication start date, year of diagnosis remained a significant predictor of mortality (2012-2016 versus 2017-2021: hazard ratio, 1.05 [95% CI, 1.03-1.07], P<0.001). CONCLUSIONS There has been a substantial increase in ATTR-CA diagnoses, with more patients being referred after local advanced cardiac imaging. Patients are now more often diagnosed at an earlier stage of the disease, with substantially lower mortality. These changes may have important implications for initiation and outcome of therapy and urgently need to be factored into clinical trial design.
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Affiliation(s)
- Adam Ioannou
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.)
| | - Rishi K. Patel
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.)
| | - Yousuf Razvi
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.)
| | - Aldostefano Porcari
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.).,Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina, University of Trieste, Italy (A. Porcari, G.S.)
| | - Gianfranco Sinagra
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina, University of Trieste, Italy (A. Porcari, G.S.)
| | - Lucia Venneri
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.)
| | - Francesco Bandera
- Cardiology University Department, IRCCS Policlinico San Donato, Milan, Italy (F.B.)
| | - Ambra Masi
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.)
| | - Georgina E. Williams
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.)
| | - Sophie O’Beara
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.)
| | - Sharmananthan Ganesananthan
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.)
| | - Paolo Massa
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.)
| | - Daniel Knight
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.)
| | - Ana Martinez-Naharro
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.)
| | - Tushar Kotecha
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.)
| | - Liza Chacko
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.)
| | - James Brown
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.)
| | - Muhammad U. Rauf
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.)
| | | | - James Moon
- St Bartholomew’s Hospital, London, United Kingdom (C.M., J.M.)
| | - Helen Lachmann
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.)
| | - Ashutosh Wechelakar
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.)
| | - Aviva Petrie
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.)
| | - Carol Whelan
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.)
| | - Philip N. Hawkins
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.)
| | - Julian D. Gillmore
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.)
| | - Marianna Fontana
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom (A.I., R.K.P., Y.R., A. Porcari, L.V., A.M., G.E.W., S.O., S.G., P.M., D.K., A.M.-N., T.K., L.C., J.B., M.U.R., H.L., A.W., A. Petrie, C.W., P.N.H., J.D.G., M.F.)
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