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Nicol M, Siguret V, Vergaro G, Aimo A, Emdin M, Dillinger JG, Baudet M, Cohen‐Solal A, Villesuzanne C, Harel S, Royer B, Arnulf B, Logeart D. Thromboembolism and bleeding in systemic amyloidosis: a review. ESC Heart Fail 2022; 9:11-20. [PMID: 34784656 PMCID: PMC8787981 DOI: 10.1002/ehf2.13701] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 09/18/2021] [Accepted: 10/29/2021] [Indexed: 11/25/2022] Open
Abstract
The assessment of both thromboembolic and haemorrhagic risks and their management in systemic amyloidosis have been poorly emphasized so far. This narrative review summarizes main evidence from literature with clinical perspective. The rate of thromboembolic events is as high as 5-10% amyloidosis patients, at least in patients with cardiac involvement, with deleterious impact on prognosis. The most known pro-thrombotic factors are heart failure, atrial fibrillation, and atrial myopathy. Atrial fibrillation could occur in 20% to 75% of systemic amyloidosis patients. Cardiac thrombi are frequently observed in patients, particularly in immunoglobulin light chains (AL) amyloidosis, up to 30%, and it is advised to look for them systematically before cardioversion. In AL amyloidosis, nephrotic syndrome and the use of immunomodulatory drugs also favour thrombosis. On the other hand, the bleeding risk increases because of frequent amyloid digestive involvement as well as factor X deficiency, renal failure, and increased risk of dysautonomia-related fall.
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Affiliation(s)
- Martin Nicol
- Cardiology departmentLariboisière Hospital, APHP2 rue Ambroise ParéParisFrance
- Université de ParisParisFrance
| | - Virginie Siguret
- Université de ParisParisFrance
- INSERM UMR‐S‐1140 University of ParisParisFrance
- Laboratory of HematologyLariboisière Hospital, APHPParisFrance
| | - Giuseppe Vergaro
- Division of Cardiology and Cardiovascular MedicineFondazione Toscana Gabriele MonasterioPisaItaly
| | - Alberto Aimo
- Division of Cardiology and Cardiovascular MedicineFondazione Toscana Gabriele MonasterioPisaItaly
| | - Michele Emdin
- Division of Cardiology and Cardiovascular MedicineFondazione Toscana Gabriele MonasterioPisaItaly
| | - Jean Guillaume Dillinger
- Cardiology departmentLariboisière Hospital, APHP2 rue Ambroise ParéParisFrance
- Université de ParisParisFrance
| | - Mathilde Baudet
- Cardiology departmentLariboisière Hospital, APHP2 rue Ambroise ParéParisFrance
| | - Alain Cohen‐Solal
- Cardiology departmentLariboisière Hospital, APHP2 rue Ambroise ParéParisFrance
- Université de ParisParisFrance
| | | | - Stephanie Harel
- Immuno‐hematology DepartmentSaint Louis Hospital, APHPParisFrance
| | - Bruno Royer
- Immuno‐hematology DepartmentSaint Louis Hospital, APHPParisFrance
| | - Bertrand Arnulf
- Université de ParisParisFrance
- Immuno‐hematology DepartmentSaint Louis Hospital, APHPParisFrance
| | - Damien Logeart
- Cardiology departmentLariboisière Hospital, APHP2 rue Ambroise ParéParisFrance
- Université de ParisParisFrance
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Hausfater P, Costedoat-Chalumeau N, Amoura Z, Cacoub P, Papo T, Grateau G, Leblond V, Godeau P, Piette JC. AL cardiac amyloidosis and arterial thromboembolic events. Scand J Rheumatol 2009; 34:315-9. [PMID: 16195166 DOI: 10.1080/03009740510015203] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To study the prevalence and characteristics of arterial thromboembolic events (ATEE) in the course of AL amyloidosis. METHODS We report the case of a non-anticoagulated patient with AL amyloidosis restrictive cardiomyopathy who developed acute lower limb ischaemia. We then prospectively determined the prevalence of ATEE in all patients with AL amyloidosis who were evaluated in our institution for autologous peripheral stem cell transplantation. RESULTS Nine out of 15 non-anticoagulated patients (60%) developed ATEE: ischaemic stroke (3), transient cerebral ischaemic attack (2), multiple peripheral arterial emboli (1), bilateral iliac artery thrombosis (1), bilateral optic nerve ischaemia (1), and mesenteric ischaemia (1). Haemodynamic stasis seemed to play a leading role in the pathophysiology of ATEE, in that all patients were on sinus rhythm and only one had a thrombus on echocardiography. We identified possible contributing factors to ATEE occurrence: concomitant treatments with oestroprogestogen regimen, thalidomide, granulocyte-macrophage colony-stimulating factor (GM-CSF) and extracellular volume disturbances related to the cytapheresis procedure. CONCLUSION We report on an unusual frequency of ATEE among patients with AL cardiac amyloidosis. Despite its theoretical risks, anticoagulation should be discussed for patients with amyloid cardiomyopathy.
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Affiliation(s)
- P Hausfater
- Emergency Department, Pitie-Salpetriere University Hospital Centre, 75651 Paris Cedex 13, France.
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Feng D, Syed IS, Martinez M, Oh JK, Jaffe AS, Grogan M, Edwards WD, Gertz MA, Klarich KW. Intracardiac Thrombosis and Anticoagulation Therapy in Cardiac Amyloidosis. Circulation 2009; 119:2490-7. [DOI: 10.1161/circulationaha.108.785014] [Citation(s) in RCA: 163] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background—
Primary amyloidosis has a poor prognosis as a result of frequent cardiac involvement. We recently reported a high prevalence of intracardiac thrombus in cardiac amyloid patients at autopsy. However, neither the prevalence nor the effect of anticoagulation on intracardiac thrombus has been evaluated antemortem.
Methods and Results—
We studied all transthoracic and transesophageal echocardiograms of cardiac amyloid patients at the Mayo Clinic. The prevalence of intracardiac thrombosis, clinical and transthoracic/transesophageal echocardiographic risks for intracardiac thrombosis, and effect of anticoagulation were investigated. We identified 156 patients with cardiac amyloidosis who underwent transesophageal echocardiograms. Amyloidosis was the primary type (AL) in 80; other types occurred in 76 patients, including 56 with the wild transthyretin type, 17 with the mutant transthyretin type, and 3 with the secondary type. Fifth-eight intracardiac thrombi were identified in 42 patients (27%). AL amyloid had more frequent intracardiac thrombus than the other types (35% versus 18%;
P
=0.02), although the AL patients were younger and had less atrial fibrillation. Multivariate analysis showed that atrial fibrillation, poor left ventricular diastolic function, and lower left atrial appendage emptying velocity were independently associated with increased risk for intracardiac thrombosis, whereas anticoagulation was associated with a significantly decreased risk (odds ratio, 0.09; 95% CI, 0.01 to 0.51;
P
<0.006).
Conclusions—
Intracardiac thrombosis occurs frequently in cardiac amyloid patients, especially in the AL type and in those with atrial fibrillation. Risk for thrombosis increased if left ventricular diastolic dysfunction and atrial mechanical dysfunction were present. Anticoagulation therapy appears protective. Timely screening in high-risk patients may allow early detection of intracardiac thrombus. Anticoagulation should be carefully considered.
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Affiliation(s)
- DaLi Feng
- From the Metropolitan Heart and Vascular Institute, Minneapolis, Minn (D.F.), and Divisions of Cardiovascular Diseases (D.F., I.S.S., M.M., J.K.O., A.S.J., M.G., K.W.K.), Anatomic Pathology (W.D.E.), and Hematology (M.A.G.), Mayo Clinic, Mayo Clinic College of Medicine, Rochester, Minn
| | - Imran S. Syed
- From the Metropolitan Heart and Vascular Institute, Minneapolis, Minn (D.F.), and Divisions of Cardiovascular Diseases (D.F., I.S.S., M.M., J.K.O., A.S.J., M.G., K.W.K.), Anatomic Pathology (W.D.E.), and Hematology (M.A.G.), Mayo Clinic, Mayo Clinic College of Medicine, Rochester, Minn
| | - Matthew Martinez
- From the Metropolitan Heart and Vascular Institute, Minneapolis, Minn (D.F.), and Divisions of Cardiovascular Diseases (D.F., I.S.S., M.M., J.K.O., A.S.J., M.G., K.W.K.), Anatomic Pathology (W.D.E.), and Hematology (M.A.G.), Mayo Clinic, Mayo Clinic College of Medicine, Rochester, Minn
| | - Jae K. Oh
- From the Metropolitan Heart and Vascular Institute, Minneapolis, Minn (D.F.), and Divisions of Cardiovascular Diseases (D.F., I.S.S., M.M., J.K.O., A.S.J., M.G., K.W.K.), Anatomic Pathology (W.D.E.), and Hematology (M.A.G.), Mayo Clinic, Mayo Clinic College of Medicine, Rochester, Minn
| | - Allan S. Jaffe
- From the Metropolitan Heart and Vascular Institute, Minneapolis, Minn (D.F.), and Divisions of Cardiovascular Diseases (D.F., I.S.S., M.M., J.K.O., A.S.J., M.G., K.W.K.), Anatomic Pathology (W.D.E.), and Hematology (M.A.G.), Mayo Clinic, Mayo Clinic College of Medicine, Rochester, Minn
| | - Martha Grogan
- From the Metropolitan Heart and Vascular Institute, Minneapolis, Minn (D.F.), and Divisions of Cardiovascular Diseases (D.F., I.S.S., M.M., J.K.O., A.S.J., M.G., K.W.K.), Anatomic Pathology (W.D.E.), and Hematology (M.A.G.), Mayo Clinic, Mayo Clinic College of Medicine, Rochester, Minn
| | - William D. Edwards
- From the Metropolitan Heart and Vascular Institute, Minneapolis, Minn (D.F.), and Divisions of Cardiovascular Diseases (D.F., I.S.S., M.M., J.K.O., A.S.J., M.G., K.W.K.), Anatomic Pathology (W.D.E.), and Hematology (M.A.G.), Mayo Clinic, Mayo Clinic College of Medicine, Rochester, Minn
| | - Morie A. Gertz
- From the Metropolitan Heart and Vascular Institute, Minneapolis, Minn (D.F.), and Divisions of Cardiovascular Diseases (D.F., I.S.S., M.M., J.K.O., A.S.J., M.G., K.W.K.), Anatomic Pathology (W.D.E.), and Hematology (M.A.G.), Mayo Clinic, Mayo Clinic College of Medicine, Rochester, Minn
| | - Kyle W. Klarich
- From the Metropolitan Heart and Vascular Institute, Minneapolis, Minn (D.F.), and Divisions of Cardiovascular Diseases (D.F., I.S.S., M.M., J.K.O., A.S.J., M.G., K.W.K.), Anatomic Pathology (W.D.E.), and Hematology (M.A.G.), Mayo Clinic, Mayo Clinic College of Medicine, Rochester, Minn
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Feng D, Edwards WD, Oh JK, Chandrasekaran K, Grogan M, Martinez MW, Syed IS, Syed II, Hughes DA, Lust JA, Jaffe AS, Gertz MA, Klarich KW. Intracardiac thrombosis and embolism in patients with cardiac amyloidosis. Circulation 2007; 116:2420-6. [PMID: 17984380 DOI: 10.1161/circulationaha.107.697763] [Citation(s) in RCA: 180] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with primary amyloidosis (AL type) have a poor prognosis, in part due to frequent cardiac involvement. Although intracardiac thrombus has been reported in anecdotal cases, neither its frequency nor its role in causing mortality is known. Furthermore, the clinical and echocardiographic variables that may be associated with thromboembolism in cardiac amyloidosis have not been defined. METHODS AND RESULTS A total of 116 autopsy or explanted cases of cardiac amyloidosis (55 AL and 61 other type) were identified in the Mayo Clinic. Forty-six fatal nonamyloid trauma cases served as controls. Each heart was examined for intracardiac thrombus. The cause of death was determined from autopsy and clinical notes. Intracardiac thrombosis was identified in 38 hearts (33%). Twenty-three had 1 thrombus, whereas 15 had 2 to 5 thrombi. Although subjects in the AL group were younger and had less atrial fibrillation than those with other types of amyloidosis, the AL group had significantly more intracardiac thrombus (51% versus 16%, P<0.001) and more fatal embolic events (26% versus 8%, P<0.03). Control hearts had no intracardiac thrombus. The presence of both atrial fibrillation and AL was associated with an extremely high risk for thromboembolism (odds ratio 55.0 [95% confidence interval 8.1 to 1131.4]). By multivariate analysis, AL type (odds ratio 8.4 [95% confidence interval 1.8 to 51.2]) and left ventricular diastolic dysfunction (odds ratio 12.2 [95% confidence interval 2.7 to 72.7]) were independently associated with thromboembolism. CONCLUSIONS A high frequency of intracardiac thrombosis was present in cardiac amyloidosis. Furthermore, thromboembolism caused significant fatality. Several risk factors for thromboembolism were identified. Early screening, especially in high-risk patients, and early anticoagulation might reduce morbidity and mortality.
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Affiliation(s)
- DaLi Feng
- Mayo Clinic College of Medicine, Rochester, MN 55905, USA
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