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Löfbacka V, Axelsson J, Pilebro B, Suhr OB, Lindqvist P, Sundström T. Cardiac transthyretin amyloidosis 99mTc-DPD SPECT correlates with strain echocardiography and biomarkers. Eur J Nucl Med Mol Imaging 2020; 48:1822-1832. [PMID: 33367948 PMCID: PMC8113207 DOI: 10.1007/s00259-020-05144-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 12/01/2020] [Indexed: 11/29/2022]
Abstract
Purpose Hereditary transthyretin-amyloid amyloidosis (ATTRv) is an underdiagnosed condition commonly manifesting as congestive heart failure. Recently, scintigraphy utilizing DPD as a tracer was shown to identify ATTRv and wild-type ATTR cardiomyopathy. The aim of this study was to determine the value of quantified scintigraphy utilizing 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) single-photon emission computed tomography (SPECT)/CT, and to correlate its uptake with well-established cardiac functional parameters. Methods Forty-eight patients with genetically verified ATTRv type-A fibril composition, positive 99mTc-DPD SPECT/CT, were retrospectively analyzed. Manual mapping of volumes of interest (VOIs) on DPD SPECT/CT examinations was used to quantify heart uptake. DPD mean and maximum uptake together with a calculated DPD-based amyloid burden (DPDload) was correlated with echocardiographic strain values and cardiac biomarkers. Results Statistically significant correlations were seen in VOIs between DPD uptakes and the corresponding echocardiographic strain values. Furthermore, DPDload had a strong correlation with echocardiographic strain parameters and also correlated with biomarkers troponin T and logarithmic NT-ProBNP. Conclusions In patients with ATTRv cardiomyopathy, DPD SPECT/CT measures the amyloid distribution and provides information on cardiac amyloid load. DPD amyloid load correlates with functional cardiac parameters.
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Affiliation(s)
- Viktor Löfbacka
- Heart Centre, Clinical Physiology, Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Jan Axelsson
- Radiation Physics, Department of Radiation Sciences, Umeå University, Umeå, Sweden
| | - Björn Pilebro
- Heart Centre, Cardiology, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Ole B Suhr
- Heart Centre, Cardiology, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Per Lindqvist
- Heart Centre, Clinical Physiology, Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Torbjörn Sundström
- Diagnostic Radiology, Department of Radiation Sciences, Umeå University, Umeå, Sweden.
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Hanson JLS, Arvanitis M, Koch CM, Berk JL, Ruberg FL, Prokaeva T, Connors LH. Use of Serum Transthyretin as a Prognostic Indicator and Predictor of Outcome in Cardiac Amyloid Disease Associated With Wild-Type Transthyretin. Circ Heart Fail 2019; 11:e004000. [PMID: 29449366 DOI: 10.1161/circheartfailure.117.004000] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 12/11/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Wild-type transthyretin amyloidosis (ATTRwt), an underappreciated cause of heart failure in older adults, is challenging to diagnose and monitor in the absence of validated, disease-specific biomarkers. We examined the prognostic use and survival association of serum TTR (transthyretin) concentration in ATTRwt. METHODS AND RESULTS Patients with biopsy-proven ATTRwt were retrospectively identified. Serum TTR, cardiac biomarkers, and echocardiographic parameters were assessed at baseline and follow-up evaluations. Statistical analyses included Kaplan-Meier method, Cox proportional hazard survival models, and receiver-operating characteristic curve analysis. Median serum TTR concentration at presentation was 23 mg/dL (n=116). Multivariate predictors of shorter overall survival were decreased TTR, left ventricular ejection fraction and elevated cTn-I (cardiac troponin I); an inclusive model demonstrated superior accuracy in 4-year survival prediction by receiver-operating characteristic curve analysis (area under the curve, 0.77). TTR values lower than the normal limit, <18 mg/dL, were associated with shorter survival (2.8 versus 4.1 years; P=0.03). Further, TTR values at 1- and 2-year follow-ups were significantly lower (P<0.001) in untreated patients (n=23) compared with those treated with TTR stabilizer, diflunisal (n=12), after baseline evaluation. During 2-year follow-up, unchanged TTR corresponded to increased cTn-I (P=0.006) in untreated patients; conversely, the diflunisal-treated group showed increased TTR (P=0.001) and stabilized cTn-I and left ventricular ejection fraction at 1 year. CONCLUSIONS In this series of biopsy-proven ATTRwt, lower baseline serum TTR concentration was associated with shorter survival as an independent predictor of outcome. Longitudinal analysis demonstrated that decreasing TTR corresponded to worsening cardiac function. These data suggest that TTR may be a useful prognostic marker and predictor of outcome in ATTRwt.
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Affiliation(s)
- Jacquelyn L S Hanson
- From the Amyloidosis Center (J.L.S.H., C.M.K., J.L.B., F.L.R., T.P., L.H.C.), Department of Pathology and Laboratory Medicine (J.L.S.H., C.M.K., L.H.C.), Department of Medicine (M.A., J.L.B., F.L.R.), and Section of Cardiovascular Medicine, Department of Medicine (F.L.R.), Boston University School of Medicine, MA. The current affiliation for C.M.H. is the Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University, Chicago, IL
| | - Marios Arvanitis
- From the Amyloidosis Center (J.L.S.H., C.M.K., J.L.B., F.L.R., T.P., L.H.C.), Department of Pathology and Laboratory Medicine (J.L.S.H., C.M.K., L.H.C.), Department of Medicine (M.A., J.L.B., F.L.R.), and Section of Cardiovascular Medicine, Department of Medicine (F.L.R.), Boston University School of Medicine, MA. The current affiliation for C.M.H. is the Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University, Chicago, IL
| | - Clarissa M Koch
- From the Amyloidosis Center (J.L.S.H., C.M.K., J.L.B., F.L.R., T.P., L.H.C.), Department of Pathology and Laboratory Medicine (J.L.S.H., C.M.K., L.H.C.), Department of Medicine (M.A., J.L.B., F.L.R.), and Section of Cardiovascular Medicine, Department of Medicine (F.L.R.), Boston University School of Medicine, MA. The current affiliation for C.M.H. is the Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University, Chicago, IL
| | - John L Berk
- From the Amyloidosis Center (J.L.S.H., C.M.K., J.L.B., F.L.R., T.P., L.H.C.), Department of Pathology and Laboratory Medicine (J.L.S.H., C.M.K., L.H.C.), Department of Medicine (M.A., J.L.B., F.L.R.), and Section of Cardiovascular Medicine, Department of Medicine (F.L.R.), Boston University School of Medicine, MA. The current affiliation for C.M.H. is the Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University, Chicago, IL
| | - Frederick L Ruberg
- From the Amyloidosis Center (J.L.S.H., C.M.K., J.L.B., F.L.R., T.P., L.H.C.), Department of Pathology and Laboratory Medicine (J.L.S.H., C.M.K., L.H.C.), Department of Medicine (M.A., J.L.B., F.L.R.), and Section of Cardiovascular Medicine, Department of Medicine (F.L.R.), Boston University School of Medicine, MA. The current affiliation for C.M.H. is the Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University, Chicago, IL
| | - Tatiana Prokaeva
- From the Amyloidosis Center (J.L.S.H., C.M.K., J.L.B., F.L.R., T.P., L.H.C.), Department of Pathology and Laboratory Medicine (J.L.S.H., C.M.K., L.H.C.), Department of Medicine (M.A., J.L.B., F.L.R.), and Section of Cardiovascular Medicine, Department of Medicine (F.L.R.), Boston University School of Medicine, MA. The current affiliation for C.M.H. is the Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University, Chicago, IL
| | - Lawreen H Connors
- From the Amyloidosis Center (J.L.S.H., C.M.K., J.L.B., F.L.R., T.P., L.H.C.), Department of Pathology and Laboratory Medicine (J.L.S.H., C.M.K., L.H.C.), Department of Medicine (M.A., J.L.B., F.L.R.), and Section of Cardiovascular Medicine, Department of Medicine (F.L.R.), Boston University School of Medicine, MA. The current affiliation for C.M.H. is the Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University, Chicago, IL.
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Connors LH, Sam F, Skinner M, Salinaro F, Sun F, Ruberg FL, Berk JL, Seldin DC. Heart Failure Resulting From Age-Related Cardiac Amyloid Disease Associated With Wild-Type Transthyretin: A Prospective, Observational Cohort Study. Circulation 2015; 133:282-90. [PMID: 26660282 DOI: 10.1161/circulationaha.115.018852] [Citation(s) in RCA: 231] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 11/09/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Heart failure caused by wild-type transthyretin amyloidosis (ATTRwt) is an underappreciated cause of morbidity and mortality in the aging population. The aims of this study were to examine features of disease and to characterize outcomes in a large ATTRwt cohort. METHODS AND RESULTS Over 20 years, 121 patients with ATTRwt were enrolled in a prospective, observational study. Median age at enrollment was 75.6 years (range, 62.6-87.8 years); 97% of patients were white. The median survival, measured from biopsy diagnosis, was 46.69 months (95% confidence interval, 41.95-56.77); 78% of deaths were attributable to cardiac causes. By Kaplan-Meier analysis, 5-year survival was 35.7% (95% confidence interval, 25-46). Impaired functional capacity (mean Vo2max, 13.5 mL·kg(-1)·min(-1)) and atrial fibrillation (67%) were common clinical features. Multivariate predictors of reduced survival were elevated serum brain natriuretic peptide (482 ± 337 pg/mL) and uric acid (8.2 ± 2.6 mg/dL), decreased left ventricular ejection fraction (50% median; range, 10%-70%), and increased relative wall thickness (0.75 ± 0.19). CONCLUSIONS In this series of patients with biopsy-proven ATTRwt, poor functional capacity and atrial arrhythmias were common clinical features. Elevated brain natriuretic peptide and uric acid, decreased left ventricular ejection fraction, and increased relative wall thickness were associated with limited survival of only 35.7% at 5 years for the group as a whole. These data establish the natural history of ATTRwt, provide statistical basis for the design of future interventional clinical trials, and highlight the need for more sensitive diagnostic tests and disease-specific treatments for this disease.
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Affiliation(s)
- Lawreen H Connors
- From Amyloidosis Center (L.H.C., F. Sam, M.S., F. Salinaro, F.L.R., J.L.B., D.C.S.), Department of Pathology and Laboratory Medicine (L.H.C), and Department of Medicine (F. Sam, M.S., F.L.R., J.L.B., D.C.S.), Boston University School of Medicine, MA; Department of Medicine, University of Pavia, Italy (F. Salinaro); and Department of Biostatistics, Boston University School of Public Health, MA (F. Sun).
| | - Flora Sam
- From Amyloidosis Center (L.H.C., F. Sam, M.S., F. Salinaro, F.L.R., J.L.B., D.C.S.), Department of Pathology and Laboratory Medicine (L.H.C), and Department of Medicine (F. Sam, M.S., F.L.R., J.L.B., D.C.S.), Boston University School of Medicine, MA; Department of Medicine, University of Pavia, Italy (F. Salinaro); and Department of Biostatistics, Boston University School of Public Health, MA (F. Sun)
| | - Martha Skinner
- From Amyloidosis Center (L.H.C., F. Sam, M.S., F. Salinaro, F.L.R., J.L.B., D.C.S.), Department of Pathology and Laboratory Medicine (L.H.C), and Department of Medicine (F. Sam, M.S., F.L.R., J.L.B., D.C.S.), Boston University School of Medicine, MA; Department of Medicine, University of Pavia, Italy (F. Salinaro); and Department of Biostatistics, Boston University School of Public Health, MA (F. Sun)
| | - Francesco Salinaro
- From Amyloidosis Center (L.H.C., F. Sam, M.S., F. Salinaro, F.L.R., J.L.B., D.C.S.), Department of Pathology and Laboratory Medicine (L.H.C), and Department of Medicine (F. Sam, M.S., F.L.R., J.L.B., D.C.S.), Boston University School of Medicine, MA; Department of Medicine, University of Pavia, Italy (F. Salinaro); and Department of Biostatistics, Boston University School of Public Health, MA (F. Sun)
| | - Fangui Sun
- From Amyloidosis Center (L.H.C., F. Sam, M.S., F. Salinaro, F.L.R., J.L.B., D.C.S.), Department of Pathology and Laboratory Medicine (L.H.C), and Department of Medicine (F. Sam, M.S., F.L.R., J.L.B., D.C.S.), Boston University School of Medicine, MA; Department of Medicine, University of Pavia, Italy (F. Salinaro); and Department of Biostatistics, Boston University School of Public Health, MA (F. Sun)
| | - Frederick L Ruberg
- From Amyloidosis Center (L.H.C., F. Sam, M.S., F. Salinaro, F.L.R., J.L.B., D.C.S.), Department of Pathology and Laboratory Medicine (L.H.C), and Department of Medicine (F. Sam, M.S., F.L.R., J.L.B., D.C.S.), Boston University School of Medicine, MA; Department of Medicine, University of Pavia, Italy (F. Salinaro); and Department of Biostatistics, Boston University School of Public Health, MA (F. Sun)
| | - John L Berk
- From Amyloidosis Center (L.H.C., F. Sam, M.S., F. Salinaro, F.L.R., J.L.B., D.C.S.), Department of Pathology and Laboratory Medicine (L.H.C), and Department of Medicine (F. Sam, M.S., F.L.R., J.L.B., D.C.S.), Boston University School of Medicine, MA; Department of Medicine, University of Pavia, Italy (F. Salinaro); and Department of Biostatistics, Boston University School of Public Health, MA (F. Sun)
| | - David C Seldin
- From Amyloidosis Center (L.H.C., F. Sam, M.S., F. Salinaro, F.L.R., J.L.B., D.C.S.), Department of Pathology and Laboratory Medicine (L.H.C), and Department of Medicine (F. Sam, M.S., F.L.R., J.L.B., D.C.S.), Boston University School of Medicine, MA; Department of Medicine, University of Pavia, Italy (F. Salinaro); and Department of Biostatistics, Boston University School of Public Health, MA (F. Sun)
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Greene MJ, Sam F, Soo Hoo PT, Patel RS, Seldin DC, Connors LH. Evidence for a functional role of the molecular chaperone clusterin in amyloidotic cardiomyopathy. THE AMERICAN JOURNAL OF PATHOLOGY 2010; 178:61-8. [PMID: 21224044 DOI: 10.1016/j.ajpath.2010.11.015] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2010] [Revised: 09/02/2010] [Accepted: 09/30/2010] [Indexed: 01/20/2023]
Abstract
Molecular chaperones, including the extracellular protein clusterin (CLU), play a significant role in maintaining proteostasis; they have a unique capacity to bind and stabilize non-native protein conformations, prevent aggregation, and keep proteins in a soluble folding-competent state. In this study, we investigated amyloid-infiltrated cardiac tissue for the presence of CLU and measured serum levels of CLU in patients with and without amyloidotic cardiomyopathy (CMP). Cardiac tissues containing amyloid deposits composed of either transthyretin (TTR) or Ig light chain from nine patients with amyloidotic CMP were examined for the presence of CLU using immunohistochemical techniques. CLU staining coincided with the extracellular myocardial amyloid deposits in tissues from patients with familial TTR, senile systemic, and Ig light chain amyloidosis. The association of CLU with cardiac amyloid deposits was confirmed by immunogold electron microscopy. Serum concentrations of CLU were measured in familial TTR, senile systemic, and Ig light chain amyloidosis patient groups and compared with both age-matched healthy controls and with patients with CMP unrelated to amyloid disease. Subset analysis of disease cohorts, based on cardiac involvement, indicated that decreased serum CLU concentrations were associated with amyloidotic CMP. Taken together, these results suggest that CLU may play a pathogenetic role in TTR and Ig light chain amyloidoses and amyloidotic CMP.
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Affiliation(s)
- Michael J Greene
- Department of Pathology, Boston University School of Medicine, Boston, Massachusetts, USA
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Biolo A, Ramamurthy S, Connors LH, O'Hara CJ, Meier-Ewert HK, Soo Hoo PT, Sawyer DB, Seldin DC, Seldin DS, Sam F. Matrix metalloproteinases and their tissue inhibitors in cardiac amyloidosis: relationship to structural, functional myocardial changes and to light chain amyloid deposition. Circ Heart Fail 2008; 1:249-57. [PMID: 19808299 DOI: 10.1161/circheartfailure.108.788687] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Cardiac amyloidosis is characterized by amyloid infiltration resulting in extracellular matrix disruption. Amyloid cardiomyopathy due to immunoglobulin light chain protein (AL-CMP) deposition has an accelerated clinical course and a worse prognosis compared with non-light chain cardiac amyloidoses (ie, forms associated with wild-type or mutated transthyretin [TTR]). We therefore tested the hypothesis that determinants of proteolytic activity of the extracellular matrix, the matrix metalloproteinases (MMPs), and their tissue inhibitors (TIMPs) would have distinct patterns and contribute to the pathogenesis of AL-CMP versus TTR-related amyloidosis. METHODS AND RESULTS We studied 40 patients with systemic amyloidosis: 10 AL-CMP patients, 20 patients with TTR-associated forms of cardiac amyloidosis, ie, senile systemic amyloidosis (involving wild-type TTR) or mutant TTR, and 10 patients with AL amyloidosis without cardiac involvement. Serum MMP-2 and -9, TIMP-1, -2, and -4, brain natriuretic peptide values, and echocardiography were determined. AL-CMP and TTR-related amyloidosis groups had similar degrees of increased left ventricular wall thickness. However, brain natriuretic peptide, MMP-9, and TIMP-1 levels were distinctly elevated accompanied by marked diastolic dysfunction in the AL-CMP group versus no or minimal increases in the TTR-related amyloidosis group. Brain natriuretic peptide, MMPs, and TIMPs were not correlated with the degree of left ventricular wall thickness but were correlated to each other and to measures of diastolic dysfunction. Immunostaining of human endomyocardial biopsies showed diffuse expression of MMP-9 and TIMP-1 in AL-CMP and limited expression in TTR-related amyloidosis hearts. CONCLUSIONS Despite comparable left ventricular wall thickness with TTR-related cardiac amyloidosis, AL-CMP patients have higher brain natriuretic peptide, MMPs, and TIMPs, which correlated with diastolic dysfunction. These findings suggest a relationship between light chains and extracellular matrix proteolytic activation that may play an important role in the functional and clinical manifestations of AL-CMP, distinct from the other non-light chain cardiac amyloidoses.
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Affiliation(s)
- Andreia Biolo
- Whitaker Cardiovascular Institute, Boston University School of Medicine, 715 Albany Street, Boston, MA 02118, USA
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