Amyloidosis and 30-Day Outcomes Among Patients With Heart Failure: A Nationwide Readmissions Database Study

Comparative Insights on Inpatient Outcomes in Diastolic Heart Failure with and Without Amyloidosis: A Nationwide Propensity-Matched Analysis

Cardiac amyloidosis (CA), an infiltrative restrictive cardiomyopathy, is a frequently underrecognized etiology of diastolic heart failure (HF). This study aimed to evaluate inpatient outcomes among patients hospitalized with decompensated diastolic HF with and without a secondary diagnosis of amyloidosis, utilizing data from the National Inpatient Sample (2018-2021). Among 2,444,699 patients hospitalized for decompensated diastolic HF, 9205 (0.3%) had a documented secondary diagnosis of amyloidosis. After 1:1 propensity-score matching, 1841 patients in each group were analyzed. Multivariate logistic regression revealed that the presence of amyloidosis was associated with significantly higher odds of in-hospital mortality (4.0% vs. 2.7%), cardiogenic shock (5.4% vs. 2.4%), acute kidney injury (28.3% vs. 22.0%), ventricular tachycardia (12.4% vs. 6.0%), and acute myocardial injury (9.5% vs. 6.0%) (all p < 0.05). Additionally, patients with amyloidosis had a longer mean length of stay (7.1 vs. 5.7 days) and higher mean hospitalization costs ($85,594 vs. $48,484, p < 0.05). Although the overall incidence of acute myocardial injury was elevated, subgroup analysis of ST-elevation and non-ST-elevation myocardial infarction revealed no significant differences. These findings underscore the considerable clinical and economic burden of amyloidosis in patients hospitalized with decompensated diastolic heart failure.

A propensity-matched analysis of cardiac operation in patients with and without cardiac amyloidosis

Objective

There are limited data on the outcome of routine cardiac operations in patients with cardiac amyloidosis. This study studied the impact of amyloidosis on early and late results of cardiac operations.

Methods

This was a retrospective, propensity-matched, case-control study of patients with cardiac amyloidosis undergoing cardiac surgery. Heart transplantation and ventricular assist implantation were excluded. Controls were patients without known cardiac amyloidosis matched on baseline patient characteristics, echocardiographic findings, and type of operation. Outcomes included operative complications and survival.

Results

In total, 42 patients with cardiac amyloidosis (amyloid group [AG]) were matched with 168 controls (CON group). The median left ventricular ejection fraction was 63% in the AG group (vs 64% CON). Aortic valve replacement and septal myectomy were the most common operations. Cardiopulmonary bypass (P = .374) and crossclamp (P = .185) times were similar in the 2 groups. Complication rates were similar in the 2 groups, including the need for mechanical circulatory support (n = 1 AG group vs n = 1 CON; P = .361) and intra-aortic balloon pump use (n = 3 AG group vs n = 13 CON; P = 1.000). There were no operative deaths. Survival was similar in the 2 groups at 1 year (AG 93% vs 89% CON; P = .1) but was worse in the AG at 5 years (59% vs 68% CON; P = .1).

Conclusions

Early procedural outcomes and 1-year survival are similar in patients with and without cardiac amyloidosis with preserved cardiac function. Diagnosis of amyloidosis should not be a contraindication to cardiac surgery.

Cardiac amyloidosis worsens prognosis in patients with heart failure: findings from the PREVAMIC study

BACKGROUND AND OBJECTIVES

Cardiac amyloidosis (CA) is a common pathology in elderly patients that usually presents as heart failure (HF). However, it is not clear whether CA associated with HF has a worse prognosis compared with HF due to other etiologies.

MATERIAL AND METHODS

Prospective, observational cohort study that recruited patients ≥65 years of age with HF in 30 Spanish centers. The cohort was divided according to whether the patients had AC or not. Patients were followed for 1 year.

RESULTS

A total of 484 patients were included in the analysis. The population was elderly (median 86 years) and 49% were women CA was present in 23.8 % of the included patients. In the CA group, there was a lower prevalence of diabetes mellitus and valvular disease. At one year of follow-up, mortality was significantly more frequent in patients with CA compared to those without (33.0 vs.14.9%, p < 0.001). However, there were no differences between both groups in visits to the emergency room or readmissions. In the multivariate analysis, the variables that were shown to predict all-cause mortality at one year of follow-up were chronic kidney disease (HR 1.75 (1.01-3.05) p 0.045), NT-proBNP levels (HR 2.51 (1.46-4.30) p < 0.001), confusion (HR 2.05 (1.01-4.17), p 0.048), and the presence of CA (HR 1.77 (1.11-2.84), p 0.017).

CONCLUSION

The presence of CA in elderly patients with HF is related to a worse prognosis at one year of follow-up. Early diagnosis of the pathology and multidisciplinary management can help improve patient outcomes.

Clinical and genetic profiles of patients with hereditary and wild-type transthyretin amyloidosis: the Transthyretin Cardiac Amyloidosis Registry in the state of São Paulo, Brazil (REACT-SP)

BACKGROUND

Transthyretin amyloidosis (ATTR) is a multisystem disease caused by the deposition of fibrillar protein in organs and tissues. ATTR genotypes and phenotypes are highly heterogeneous. We present data on physical signs and symptoms, cardiac and neurological assessments and genetic profile of patients enrolled in the Transthyretin Cardiac Amyloidosis Registry of the State of São Paulo, Brazil.

RESULTS

Six hundred-forty-four patients were enrolled, 505 with the variant form (ATTRv) and 139 with wild-type (ATTRwt). Eleven different mutations were detected, the most common being Val50Met (47.5%) and V142Ile (39.2%). Overall, more than half of the patients presented cardiac involvement, and the difference in this proportion between the ATTRv and ATTRwt groups was significant (43.9 vs. 89.9%; p < 0.001). The prevalence of the neurological phenotype also differed between ATTRv and ATTRwt (56.8 vs. 31.7%; p < 0.001). The mixed phenotype was found in 25.6% of the population, without a significant difference between ATTRv and ATTRwt groups. A group of patients remained asymptomatic (10.4%), with a lower proportion of asymptomatic ATTRwt patients.

CONCLUSIONS

This study details the clinical and genetic spectrum of patients with ATTR in São Paulo, Brazil. This preliminary analysis highlights the considerable phenotypic heterogeneity of neurological and cardiac manifestations in patients with variant and wild-type ATTR.

Transthyretin amyloid cardiomyopathy among patients hospitalized for heart failure and performance of an adapted wild-type ATTR-CM machine learning model: Findings from GWTG-HF

BACKGROUND

An 11-factor random forest model has been developed among ambulatory heart failure (HF) patients for identifying potential wild-type amyloidogenic TTR cardiomyopathy (wtATTR-CM). The model has not been evaluated in a large sample of patients hospitalized for HF.

METHODS

This study included Medicare beneficiaries aged ≥65 years hospitalized for HF in the Get With The Guidelines-HF® Registry from 2008-2019. Patients with and without a diagnosis of ATTR-CM were compared, as defined by inpatient and outpatient claims data within 6 months pre- or post-index hospitalization. Within a cohort matched 1:1 by age and sex, univariable logistic regression was used to evaluate relationships between ATTR-CM and each of the 11 factors of the established model. Discrimination and calibration of the 11-factor model were assessed.

RESULTS

Among 205,545 patients (median age 81 years) hospitalized for HF across 608 hospitals, 627 patients (0.31%) had a diagnosis code for ATTR-CM. Univariable analysis within the 1:1 matched cohort of each of the 11-factors in the ATTR-CM model found pericardial effusion, carpal tunnel syndrome, lumbar spinal stenosis, and elevated serum enzymes (e.g., troponin elevation) to be strongly associated with ATTR-CM. The 11-factor model showed modest discrimination (c-statistic 0.65) and good calibration within the matched cohort.

CONCLUSIONS

Among US patients hospitalized for HF, the number of patients with ATTR-CM defined by diagnosis codes on an inpatient/outpatient claim within 6 months of admission was low. Most factors within the prior 11-factor model were associated with greater odds of ATTR-CM diagnosis. In this population, the ATTR-CM model demonstrated modest discrimination.

Patients with cardiac amyloidosis are at a greater risk of mortality and hospital readmission after acute heart failure

AIMS

Cardiac amyloidosis (CA) is an under-diagnosed cause of heart failure (HF) and has a worse prognosis than other forms of HF. The frequency of death or rehospitalization following discharge for acute heart failure (AHF) in CA (relative to other causes) has not been documented. The study aims to compare hospital readmission and death rates 90 days after discharge for AHF in patients with vs. without CA and to identify risk factors associated with these events in each group.

METHODS AND RESULTS

Patients with HF and CA (HF + CA+) were recruited from the ICREX cohort, after screening of their medical records. The cases were matched 1:5 by sex and age with control HF patients without CA (HF + CA-). There were 27 HF + CA + and 135 HF + CA- patients from the ICREX cohort included in the study. Relative to the HF + CA- group, HF + CA+ patients had a higher heart rate (P = 0.002) and N-terminal prohormone of brain natriuretic peptide levels (P < 0.001) and lower blood pressure (P < 0.001), weight, and body mass index values (P < 0.001) on discharge. Ninety days after discharge, the HF + CA+ group displayed a higher death rate, a higher all-cause hospital readmission rate, and a higher hospital readmission rate for AHF. Death and hospital readmissions occurred sooner after discharge in the HF + CA+ group than in the HF + CA- group.

CONCLUSIONS

The presence of CA in patients with HF was associated with a three-fold greater risk of death and a two-fold greater risk of all-cause hospital readmission 90 days after discharge. These findings emphasize the importance of close, active management of patients with CA and AHF.

Cardiac AL amyloidosis presenting as recurrent dyspnoea in a patient with cancer: an important clinical clue to an early diagnosis

Cardiac amyloidosis (CA) is challenging to diagnose due to its non-specific clinical manifestations early in the disease process. We report the case of a patient who presented with dyspnoea, abdominal distension and leg swelling. Medical history was notable for hypertension, recurrent vulvar squamous cell carcinoma and polysubstance abuse. Over 1 year before the official diagnosis of CA, the patient had multiple hospital readmissions for dyspnoea. Our case illustrates the importance of having a high index of clinical suspicion for an early diagnosis of CA. Furthermore, it highlights the need to re-evaluate a presumed diagnosis when a patient's symptoms recur or do not respond to appropriate treatment and to consider the influence of social factors on diagnostic processes.