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Lalario A, Saro R, Sinagra G, Merlo M, Porcari A. Clinical Use of Biomarkers in Cardiac Amyloidosis. Heart Fail Clin 2024; 20:283-294. [PMID: 38844299 DOI: 10.1016/j.hfc.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/12/2024]
Abstract
Amyloidosis is a systemic condition characterized by multiple organs involvement. A multidisciplinary and multimodal approach in assessing patients is pivotal and recommended by the international scientific societies. Biomarkers represent an essential noninvasive tool to increase the suspicion of disease and orient further workup and clinical management of patients. This review provides an updated contemporary focus on the clinical use of biomarkers in cardiac amyloidosis, emphasizing their role in both the diagnostic and prognostic setting and discussing future perspective of emerging biomarkers.
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Affiliation(s)
- Andrea Lalario
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Via P. Valdoni 7, 34100, Trieste, Italy; European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Via P. Valdoni 7, 34100, Trieste, Italy
| | - Riccardo Saro
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Via P. Valdoni 7, 34100, Trieste, Italy; European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Via P. Valdoni 7, 34100, Trieste, Italy
| | - Gianfranco Sinagra
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Via P. Valdoni 7, 34100, Trieste, Italy; European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Via P. Valdoni 7, 34100, Trieste, Italy
| | - Marco Merlo
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Via P. Valdoni 7, 34100, Trieste, Italy; European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Via P. Valdoni 7, 34100, Trieste, Italy
| | - Aldostefano Porcari
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Via P. Valdoni 7, 34100, Trieste, Italy; European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Via P. Valdoni 7, 34100, Trieste, Italy; National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK.
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2
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Ioannou A, Fumagalli C, Razvi Y, Porcari A, Rauf MU, Martinez-Naharro A, Venneri L, Moody W, Steeds RP, Petrie A, Whelan C, Wechalekar A, Lachmann H, Hawkins PN, Solomon SD, Gillmore JD, Fontana M. Prognostic Value of a 6-Minute Walk Test in Patients With Transthyretin Cardiac Amyloidosis. J Am Coll Cardiol 2024:S0735-1097(24)06893-1. [PMID: 38739065 DOI: 10.1016/j.jacc.2024.04.011] [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: 03/13/2024] [Revised: 04/03/2024] [Accepted: 04/10/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND The 6-minute walk test (6MWT) represents a comprehensive functional assessment that is commonly used in patients with heart failure; however, data are lacking in patients with transthyretin cardiac amyloidosis (ATTR-CA). OBJECTIVES This study aimed to assess the prognostic importance of the 6MWT in patients with ATTR-CA. METHODS A retrospective analysis of patients diagnosed with ATTR-CA at the National Amyloidosis Centre who underwent a baseline 6MWT between 2011 and 2023 identified 2,141 patients, of whom 1,118 had follow-up at 1 year. RESULTS The median baseline 6MWT distance was 347 m (Q1-Q3: 250-428 m) and analysis by quartiles demonstrated an increased death rate with each distance reduction (deaths per 100 person-years: 6.3 vs 9.2 vs 13.6 vs 19.0; log-rank P < 0.001). A 6MWT distance of <350 m was associated with a 2.2-fold higher risk of mortality (HR: 2.15; 95% CI: 1.85-2.50; P < 0.001), with a similar increased risk across National Amyloidosis Centre disease stages (P for interaction = 0.761) and genotypes (P for interaction = 0.172). An absolute (reduction of >35 m) and relative worsening (reduction of >5%) of 6MWT at 1 year was associated with an increased risk of mortality (HR: 1.80; 95% CI: 1.51-2.15; P < 0.001 and HR: 1.89; 95% CI: 1.59-2.24; P < 0.001, respectively), which was similar across the aforementioned subgroups. When combined with established measures of disease progression (N-terminal pro-B-type natriuretic peptide progression and outpatient diuretic intensification), each incremental increase in progression markers was associated with an increased death rate (deaths per 100 person-years: 7.6 vs 13.9 vs 22.4 vs 32.9; log-rank P < 0.001). CONCLUSIONS The baseline 6MWT distance can refine risk stratification beyond traditional prognosticators. A worsening 6MWT distance can stratify disease progression and, when combined with established markers, identifies patients at the highest risk of mortality.
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Affiliation(s)
- Adam Ioannou
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Carlo Fumagalli
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom; Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - 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, University of Trieste, Trieste, Italy
| | - Muhammad U Rauf
- 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
| | - Lucia Venneri
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - William Moody
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom; Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham, United Kingdom
| | - Richard P Steeds
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom; Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham, United Kingdom
| | - Aviva Petrie
- University College London, London, United Kingdom
| | - Carol Whelan
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Ashutosh Wechalekar
- 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
| | - Philip N Hawkins
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Julian D Gillmore
- 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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3
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Porcari A, Sinagra G, Gillmore JD, Fontana M, Hawkins PN. Breakthrough advances enhancing care in ATTR amyloid cardiomyopathy. Eur J Intern Med 2024; 123:29-36. [PMID: 38184468 DOI: 10.1016/j.ejim.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 01/02/2024] [Indexed: 01/08/2024]
Abstract
Transthyretin amyloid cardiomyopathy (ATTR-CM) has been traditionally considered a rare and inexorably fatal condition. ATTR-CM now is an increasingly recognized cause of heart failure (HF) and mortality worldwide with effective pharmacological treatments. Advances in non-invasive diagnosis, coupled with the development of effective treatments, have transformed the diagnosis of ATTR-CM, which is now possible without recourse to endomyocardial biopsy in ≈70 % of cases. Many patients are now diagnosed at an earlier stage. Echocardiography and cardiac magnetic resonance have enabled identification of patients with possible ATTR-CM and more accurate prognostic stratification. Although radionuclide scintigraphy with 'bone' tracers has an established diagnostic value, the diagnostic performance of the bone tracers validated for non-invasive confirmation of ATTR-CM may not be equal. Characterising the wider clinical phenotype of patients with ATTR-CM has enabled identification of features with potential for earlier diagnosis such as carpal tunnel syndrome. Therapies able to slow or halt ATTR-CM progression and increase survival are now available and there is also evidence that patients may benefit from specific conventional HF medications. Cutting-edge research in the field of antibody-mediated removal of ATTR deposits compellingly suggest that ATTR-CM is a truly reversible disorder, bringing hope for patients even with advanced disease. A wide horizon of possibilities is unfolding and awaits discovery.
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Affiliation(s)
- Aldostefano Porcari
- National Amyloidosis Centre, Division of Medicine, Royal Free Campus, University College London, Rowland Hill Street, London NW3 2PF, UK; Centre for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste 34149, Italy; European Reference Network for rare, low prevalence and complex diseases of the heart (ERN GUARD-Heart), Italy.
| | - Gianfranco Sinagra
- Centre for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste 34149, Italy; European Reference Network for rare, low prevalence and complex diseases of the heart (ERN GUARD-Heart), Italy
| | - Julian D Gillmore
- National Amyloidosis Centre, Division of Medicine, Royal Free Campus, University College London, Rowland Hill Street, London NW3 2PF, UK
| | - Marianna Fontana
- National Amyloidosis Centre, Division of Medicine, Royal Free Campus, University College London, Rowland Hill Street, London NW3 2PF, UK
| | - Philip N Hawkins
- National Amyloidosis Centre, Division of Medicine, Royal Free Campus, University College London, Rowland Hill Street, London NW3 2PF, UK
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4
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Ioannou A, Nitsche C, Porcari A, Patel RK, Razvi Y, Rauf MU, Martinez‐Naharro A, Venneri L, Accietto A, Netti L, Bandera F, Virsinskaite R, Kotecha T, Knight D, Petrie A, Whelan C, Wechalekar A, Lachmann H, Hawkins PN, Gillmore JD, Fontana M. Multiorgan Dysfunction and Associated Prognosis in Transthyretin Cardiac Amyloidosis. J Am Heart Assoc 2024; 13:e033094. [PMID: 38314569 PMCID: PMC11010096 DOI: 10.1161/jaha.123.033094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 01/08/2024] [Indexed: 02/06/2024]
Abstract
BACKGROUND Transthyretin cardiac amyloidosis (ATTR-CA) is a progressive and ultimately fatal cardiomyopathy. Biomarkers reflecting multiorgan dysfunction are of increasing importance in patients with heart failure; however, their significance in ATTR-CA remains largely unknown. The aims of this study were to characterize the multifaceted nature of ATTR-CA using blood biomarkers and assess the association between blood biomarkers and prognosis. METHODS AND RESULTS This is a retrospective cohort study of 2566 consecutive patients diagnosed with ATTR-CA between 2007 and 2023. Anemia (39%), high urea (52%), hyperbilirubinemia (18%), increased alkaline phosphatase (16%), increased CRP (C-reactive protein; 27%), and increased troponin (98.2%) were common findings in the overall population, whereas hyponatremia (6%) and hypoalbuminemia (2%) were less common. These abnormalities were most common in patients with p.(V142I) hereditary ATTR-CA, and became more prevalent as the severity of cardiac disease increased. Multivariable Cox regression analysis demonstrated that anemia (hazard ratio [HR], 1.19 [95% CI, 1.04-1.37]; P=0.01), high urea (HR, 1.23 [95% CI, 1.04-1.45]; P=0.01), hyperbilirubinemia (HR, 1.32 [95% CI, 1.13-1.57; P=0.001), increased alkaline phosphatase (HR, 1.20 [95% CI, 1.01-1.42; P=0.04), hyponatremia (HR, 1.65 [95% CI, 1.28-2.11]; P<0.001), and troponin-T >56 ng/L (HR, 1.72 [95% CI, 1.46-2.03]; P<0.001) were all independently associated with mortality in the overall population. The association between biomarkers and mortality varied across the spectrum of genotypes and left ventricular ejection fraction, with anemia remining independently associated with mortality in p.(V142I) hereditary ATTR-CA (HR, 1.58 [95% CI, 1.17-2.12]; P=0.003) and in a subgroup of the overall population with a left ventricular ejection fraction ≤40% (HR, 1.39 [95% CI, 1.08-1.81]; P=0.01). CONCLUSIONS Cardiac and noncardiac biomarker abnormalities were common and reflect the complex and multifaceted nature of ATTR-CA, with a wide range of biomarkers remaining independently associated with mortality. Clinical trials are needed to investigate whether biomarker abnormalities represent modifiable risk factors that if specifically targeted could improve outcomes.
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Affiliation(s)
- Adam Ioannou
- National Amyloidosis CentreUniversity College LondonLondonUnited Kingdom
| | - Christian Nitsche
- National Amyloidosis CentreUniversity College LondonLondonUnited Kingdom
| | - Aldostefano Porcari
- National Amyloidosis CentreUniversity College LondonLondonUnited Kingdom
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular DepartmentAzienda Sanitaria Universitaria Giuliano‐Isontina, University of TriesteTriesteItaly
| | - Rishi K. Patel
- National Amyloidosis CentreUniversity College LondonLondonUnited Kingdom
| | - Yousuf Razvi
- National Amyloidosis CentreUniversity College LondonLondonUnited Kingdom
| | - Muhammad U. Rauf
- National Amyloidosis CentreUniversity College LondonLondonUnited Kingdom
| | | | - Lucia Venneri
- National Amyloidosis CentreUniversity College LondonLondonUnited Kingdom
| | - Antonella Accietto
- Cardiology Unit, Department of Cardiac Thoracic and VascularIstituto di Ricovero e Cura a Carattere Scientifico Azienda Ospedaliero–Universitaria di BolognaBolognaItaly
| | - Lucrezia Netti
- Department of Clinical, Internal, Anesthesiological and Cardiovascular SciencesSapienza University of RomeRomeItaly
| | - Francesco Bandera
- Heart Failure and Rehabilitation Unit, IRCCS MultiMedica, Sesto San GiovanniMilanItaly
- Department for Biomedical Sciences for HealthUniversity of MilanoMilanItaly
| | - Ruta Virsinskaite
- National Amyloidosis CentreUniversity College LondonLondonUnited Kingdom
| | - Tushar Kotecha
- National Amyloidosis CentreUniversity College LondonLondonUnited Kingdom
| | - Dan Knight
- National Amyloidosis CentreUniversity College LondonLondonUnited Kingdom
| | | | - Carol Whelan
- National Amyloidosis CentreUniversity College LondonLondonUnited Kingdom
| | | | - Helen Lachmann
- National Amyloidosis CentreUniversity College LondonLondonUnited Kingdom
| | - Philip N. Hawkins
- National Amyloidosis CentreUniversity College LondonLondonUnited Kingdom
| | - Julian D. Gillmore
- National Amyloidosis CentreUniversity College LondonLondonUnited Kingdom
| | - Marianna Fontana
- National Amyloidosis CentreUniversity College LondonLondonUnited Kingdom
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5
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Alwan L, Benz DC, Cuddy SAM, Dobner S, Shiri I, Caobelli F, Bernhard B, Stämpfli SF, Eberli F, Reyes M, Kwong RY, Falk RH, Dorbala S, Gräni C. Current and Evolving Multimodality Cardiac Imaging in Managing Transthyretin Amyloid Cardiomyopathy. JACC Cardiovasc Imaging 2024; 17:195-211. [PMID: 38099914 DOI: 10.1016/j.jcmg.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/06/2023] [Accepted: 10/18/2023] [Indexed: 01/29/2024]
Abstract
Amyloid transthyretin (ATTR) amyloidosis is a protein-misfolding disease characterized by fibril accumulation in the extracellular space that can result in local tissue disruption and organ dysfunction. Cardiac involvement drives morbidity and mortality, and the heart is the major organ affected by ATTR amyloidosis. Multimodality cardiac imaging (ie, echocardiography, scintigraphy, and cardiac magnetic resonance) allows accurate diagnosis of ATTR cardiomyopathy (ATTR-CM), and this is of particular importance because ATTR-targeting therapies have become available and probably exert their greatest benefit at earlier disease stages. Apart from establishing the diagnosis, multimodality cardiac imaging may help to better understand pathogenesis, predict prognosis, and monitor treatment response. The aim of this review is to give an update on contemporary and evolving cardiac imaging methods and their role in diagnosing and managing ATTR-CM. Further, an outlook is presented on how artificial intelligence in cardiac imaging may improve future clinical decision making and patient management in the setting of ATTR-CM.
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Affiliation(s)
- Louhai Alwan
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Dominik C Benz
- Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; CV Imaging Program, Cardiovascular Division, Department of Medicine and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; Cardiac Imaging, Department of Cardiology and Nuclear Medicine, Zurich University Hospital, Zurich, Switzerland
| | - Sarah A M Cuddy
- Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; CV Imaging Program, Cardiovascular Division, Department of Medicine and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Stephan Dobner
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Isaac Shiri
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Federico Caobelli
- University Clinic of Nuclear Medicine, Inselspital, Bern University Hospital, Switzerland
| | - Benedikt Bernhard
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; CV Imaging Program, Cardiovascular Division, Department of Medicine and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Simon F Stämpfli
- Department of Cardiology, Heart Centre Lucerne, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Franz Eberli
- Department of Cardiology, Triemli Hospital (Triemlispital), Zurich, Switzerland
| | - Mauricio Reyes
- Insel Data Science Center, Inselspital, Bern University Hospital, Bern, Switzerland; Artificial Intelligence in Medical Imaging, ARTORG Center for Biomedical Research, University of Bern, Bern, Switzerland
| | - Raymond Y Kwong
- CV Imaging Program, Cardiovascular Division, Department of Medicine and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Rodney H Falk
- Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Sharmila Dorbala
- Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; CV Imaging Program, Cardiovascular Division, Department of Medicine and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Christoph Gräni
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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6
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Tingen HSA, Berends M, Tubben A, Bijzet J, Houwerzijl EJ, Muntinghe FLH, Kroesen BJ, van der Zwaag PA, van der Meer P, Slart RHJA, Hazenberg BPC, Nienhuis HLA. High-Sensitivity Cardiac Troponin T to Exclude Cardiac Involvement in TTR Variant Carriers and ATTRv Amyloidosis Patients. J Clin Med 2024; 13:810. [PMID: 38337504 PMCID: PMC10856062 DOI: 10.3390/jcm13030810] [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: 12/22/2023] [Revised: 01/17/2024] [Accepted: 01/19/2024] [Indexed: 02/12/2024] Open
Abstract
(1) Background: Individuals carrying a pathogenic transthyretin gene variant (TTRv) are at high risk for developing hereditary transthyretin (ATTRv) amyloidosis and are routinely screened for the development of cardiomyopathy (ATTRv-CM). This study aims to evaluate whether the cardiac biomarkers N-terminal pro B-type natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin T (hs-cTnT) can be used to rule out ATTRv-CM. (2) Methods: In this retrospective case-control study, data from 46 ATTRv-CM patients and 101 TTRv carriers and ATTRv amyloidosis patients without cardiomyopathy were included. Binary logistic regression models were used to assess the ability of NT-proBNP and hs-cTnT to predict the diagnosis of ATTRv-CM. An optimal cutoff for the relevant biomarker(s) was determined based on a sensitivity of ≥99% and the highest possible percentage of additional tests avoided (%ATA) in the index dataset. (3) Results: Hs-cTnT demonstrated the highest predictive capabilities for ATTRv-CM. The addition of NT-proBNP did not improve the predictive model. A hs-cTnT cutoff of <6 ng/L resulted in a 97% sensitivity and a negative predictive value of 95% with a %ATA of 30% in the validation dataset. (4) Conclusion: In conclusion, hs-cTnT is a useful biomarker for excluding cardiac involvement in TTRv carriers and ATTRv amyloidosis patients and it has the potential to prevent unnecessary diagnostic procedures.
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Affiliation(s)
- Hendrea S. A. Tingen
- Department of Nuclear Medicine and Molecular Imaging, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Milou Berends
- Department of Internal Medicine, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands (H.L.A.N.)
| | - Alwin Tubben
- Department of Cardiology, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Johan Bijzet
- Department of Laboratory Medicine, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Ewout J. Houwerzijl
- Department of Internal Medicine, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands (H.L.A.N.)
| | - Friso L. H. Muntinghe
- Department of Internal Medicine, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands (H.L.A.N.)
| | - Bart-Jan Kroesen
- Department of Laboratory Medicine, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Paul A. van der Zwaag
- Department of Genetics, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Peter van der Meer
- Department of Cardiology, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Riemer H. J. A. Slart
- Department of Nuclear Medicine and Molecular Imaging, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
- Biomedical Photonic Imaging Group, Faculty of Science and Technology, University of Twente, Drienerlolaan 5, 7522 NB Enschede, The Netherlands
| | - Bouke P. C. Hazenberg
- Department of Rheumatology & Clinical Immunology, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Hans L. A. Nienhuis
- Department of Internal Medicine, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands (H.L.A.N.)
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7
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Starr N, Ioannou A, Martinez-Naharro A. Monitoring cardiac amyloidosis with multimodality imaging. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:79-87. [PMID: 37696332 DOI: 10.1016/j.rec.2023.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 06/30/2023] [Indexed: 09/13/2023]
Abstract
Cardiac amyloidosis (CA) refers to an infiltrative process involving amyloid fibril deposition in the myocardium causing restrictive cardiomyopathy. While various types can affect the heart, the predominant forms are immunoglobulin light-chain (AL) amyloidosis and transthyretin (ATTR) amyloidosis. This review article explores the expanding field of imaging techniques used to diagnose AL-CA and ATTR-CA, highlighting their usefulness in prognostication and disease surveillance. Echocardiography is often the initial imaging modality to suspect CA and, since the incorporation of nonbiopsy criteria using bone scintigraphy, diagnosing ATTR-CA has become more attainable following exclusion of plasma cell dyscrasia. Cardiac magnetic resonance is progressively emerging as a vital tool for imaging CA, and is used in diagnosis, prognostication, and disease surveillance. The use of cardiac magnetic resonance in AL-CA is discussed, as it has been shown to accurately evaluate organ response to chemotherapy. As novel drug treatments emerge in the realm of ATTR-CA, the use of cardiovascular imaging surveillance to monitor disease progression is discussed, as it is gaining prominence as a critical consideration. The ongoing phase III trials investigating treatments for patients with ATTR-CA, will undoubtedly enhance our understanding of cardiac imaging surveillance.
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Affiliation(s)
- Neasa Starr
- National Amyloidosis Centre, Royal Free Hospital NHS Foundation Trust, London, United Kingdom
| | - Adam Ioannou
- National Amyloidosis Centre, Royal Free Hospital NHS Foundation Trust, London, United Kingdom
| | - Ana Martinez-Naharro
- National Amyloidosis Centre, Royal Free Hospital NHS Foundation Trust, London, United Kingdom.
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8
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Ioannou A, Rauf MU, Patel RK, Razvi Y, Porcari A, Martinez-Naharro A, Venneri L, Bandera F, Virsinskaite R, Kotecha T, Knight D, Petrie A, Whelan C, Wechalekar A, Lachmann H, Hawkins PN, Solomon SD, Gillmore JD, Fontana M. Albuminuria in transthyretin cardiac amyloidosis: Prevalence, progression and prognostic importance. Eur J Heart Fail 2024; 26:65-73. [PMID: 37997196 DOI: 10.1002/ejhf.3094] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 10/27/2023] [Accepted: 11/20/2023] [Indexed: 11/25/2023] Open
Abstract
AIMS Transthyretin cardiac amyloidosis (ATTR-CA) is an infiltrative cardiomyopathy that commonly presents with concomitant chronic kidney disease. Albuminuria is common in heart failure and associated with worse outcomes, but its prevalence and relationship to outcome in ATTR-CA remains unclear. METHODS AND RESULTS A total of 1181 patients with ATTR-CA were studied (mean age 78.1 ± 7.9 years; 1022 [86.5%] male; median estimated glomerular filtration rate 59 ml/min/1.73m2 [interquartile range: 47-74]). Albuminuria was present in 563 (47.7%) patients (499 [88.6%] with microalbuminuria and 64 [11.4%] with macroalbuminuria). Patients with albuminuria had a more severe cardiac phenotype evidenced by higher serum cardiac biomarkers (median N-terminal pro-B-type natriuretic peptide [NT-proBNP]: 4027 ng/L [2173-6889] vs. 1851 ng/L [997-3209], p < 0.001; median troponin T: 69 ng/L [46-101] vs. 48 ng/L [34-68], p < 0.001) and worse echocardiographic indices of systolic (longitudinal strain: -10.0 ± 3.6% vs. -11.6 ± 3.8%, p < 0.001) and diastolic function (E/e': 17.5 ± 6.4 vs. 16.4 ± 6.7, p < 0.001) than those with a normal urinary albumin to creatinine ratio (UACR). Microalbuminuria and macroalbuminuria were independently associated with mortality in the overall population (hazard ratio [HR] 1.47, 95% confidence interval [CI] 1.13-1.92, p = 0.005 and HR 1.87, 95% CI 1.15-3.05, p = 0.012, respectively). In a subgroup of patients (n = 349) without concomitant hypertension, diabetes mellitus or chronic kidney disease, albuminuria was also associated with mortality (HR 2.98, 95% CI 1.72-5.17, p < 0.001). At 12 months, 330 patients had a repeat UACR measurement; those in whom UACR increased by 30% or more (n = 148, 44.8%) had an increased risk of mortality (HR 1.84, 95% CI 1.06-3.19, p = 0.030). CONCLUSIONS Albuminuria is common in patients with ATTR-CA, and more prevalent in those with a more severe cardiac phenotype. Albuminuria at diagnosis and a significant increase in UACR during follow-up are associated with mortality.
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Affiliation(s)
- Adam Ioannou
- National Amyloidosis Centre, University College London, Royal Free Campus, London, UK
| | - Muhammad U Rauf
- National Amyloidosis Centre, University College London, Royal Free Campus, London, UK
| | - Rishi K Patel
- National Amyloidosis Centre, University College London, Royal Free Campus, London, UK
| | - Yousuf Razvi
- National Amyloidosis Centre, University College London, Royal Free Campus, London, UK
| | - Aldostefano Porcari
- National Amyloidosis Centre, University College London, Royal Free Campus, London, UK
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Ana Martinez-Naharro
- National Amyloidosis Centre, University College London, Royal Free Campus, London, UK
| | - Lucia Venneri
- National Amyloidosis Centre, University College London, Royal Free Campus, London, UK
| | - Francesco Bandera
- Cardiology University Department, IRCCS Policlinico San Donato, Milan, Italy
| | - Ruta Virsinskaite
- National Amyloidosis Centre, University College London, Royal Free Campus, London, UK
| | - Tushar Kotecha
- National Amyloidosis Centre, University College London, Royal Free Campus, London, UK
| | - Dan Knight
- National Amyloidosis Centre, University College London, Royal Free Campus, London, UK
| | | | - Carol Whelan
- National Amyloidosis Centre, University College London, Royal Free Campus, London, UK
| | - Ashutosh Wechalekar
- National Amyloidosis Centre, University College London, Royal Free Campus, London, UK
| | - Helen Lachmann
- National Amyloidosis Centre, University College London, Royal Free Campus, London, UK
| | - Philip N Hawkins
- National Amyloidosis Centre, University College London, Royal Free Campus, London, UK
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Julian D Gillmore
- National Amyloidosis Centre, University College London, Royal Free Campus, London, UK
| | - Marianna Fontana
- National Amyloidosis Centre, University College London, Royal Free Campus, London, UK
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9
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Saro R, Pavan D, Porcari A, Sinagra G, Mojoli M. Lights and Shadows of Clinical Applications of Cardiac Scintigraphy with Bone Tracers in Suspected Amyloidosis. J Clin Med 2023; 12:7605. [PMID: 38137674 PMCID: PMC10743682 DOI: 10.3390/jcm12247605] [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: 10/13/2023] [Revised: 11/20/2023] [Accepted: 12/07/2023] [Indexed: 12/24/2023] Open
Abstract
Radionuclide bone scintigraphy is the cornerstone of an imaging-based algorithm for accurate non-invasive diagnosis of transthyretin cardiac amyloidosis (ATTR-CA). In patients with heart failure and suggestive echocardiographic and/or cardiac magnetic resonance imaging findings, the positive predictive value of Perugini grade 2 or 3 myocardial uptake on a radionuclide bone scan approaches 100% for the diagnosis of ATTR-CA as long as there is no biochemical evidence of a clonal dyscrasia. The technetium-labelled tracers that are currently validated for non-invasive diagnosis of ATTR-CA include pyrophosphate (99mTc-PYP); hydroxymethylene diphosphonate (99mTc-HMDP); and 3,3-diphosphono-1,2-propanodicarboxylate (99mTc-DPD). Although nuclear scintigraphy has transformed the contemporary diagnostic approach to ATTR-CA, a number of grey areas remains, including the mechanism for binding tracers to the infiltrated heart, differences in the kinetics and distribution of these radiotracers, differences in protocols of image acquisition worldwide, the clinical significance of extra-cardiac uptake, and the use of this technique for prognostic stratification, monitoring disease progression and assessing the response to disease-modifying treatments. This review will deal with the most relevant unmet needs and clinical questions concerning scintigraphy with bone tracers in ATTR-CA, providing expert opinions on possible future developments in the clinical application of these radiotracers in order to offer practical information for the interpretation of nuclear images by physicians involved in the care of patients with this ATTR-CA.
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Affiliation(s)
- Riccardo Saro
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Via P. Valdoni 7, 34100 Trieste, Italy; (R.S.); (A.P.); (G.S.)
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Giuliano Isontina University Health Authority, 34149 Trieste, Italy
| | - Daniela Pavan
- Ospedale Santa Maria degli Angeli, Azienda Ospedaliera Friuli Occidentale (ASFO), 33170 Pordenone, Italy;
| | - Aldostefano Porcari
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Via P. Valdoni 7, 34100 Trieste, Italy; (R.S.); (A.P.); (G.S.)
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Giuliano Isontina University Health Authority, 34149 Trieste, Italy
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Gianfranco Sinagra
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Via P. Valdoni 7, 34100 Trieste, Italy; (R.S.); (A.P.); (G.S.)
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Giuliano Isontina University Health Authority, 34149 Trieste, Italy
| | - Marco Mojoli
- Ospedale Santa Maria degli Angeli, Azienda Ospedaliera Friuli Occidentale (ASFO), 33170 Pordenone, Italy;
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10
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Wall JS, Martin EB, Lands R, Ramchandren R, Stuckey A, Heidel RE, Whittle B, Powell D, Richey T, Williams AD, Foster JS, Guthrie S, Kennel SJ. Cardiac Amyloid Detection by PET/CT Imaging of Iodine ( 124I) Evuzamitide ( 124I-p5+14): A Phase 1/2 Study. JACC Cardiovasc Imaging 2023; 16:1433-1448. [PMID: 37940323 DOI: 10.1016/j.jcmg.2023.08.009] [Citation(s) in RCA: 2] [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: 05/23/2023] [Revised: 08/07/2023] [Accepted: 08/21/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND The noninvasive detection of cardiac amyloid, as well as deposits in other vital organs, is critical for early diagnosis and quantitative disease monitoring. Positron emission tomography is an intrinsically quantitative imaging modality suitable for high-resolution amyloid detection. OBJECTIVES This study sought to evaluate the safety and efficacy of a novel amyloid-reactive peptide, designated p5+14, labeled with iodine-124 (124I), in patients with diverse types of systemic amyloidosis. METHODS In a single-site, open label phase 1/2 study (NCT03678259), the safety, biodistribution, and sensitivity of a single intravenous infusion of 124I-evuzamitide was assessed in patients with systemic amyloidosis (n = 50), asymptomatic transthyretin sequence variant carriers (n = 2), and healthy volunteers (n = 5). Subjects were administered 1.4 ± 0.2 mg of 124I-evuzamitide (71.5 ± 12.4 MBq) and positron emission tomography/x-ray computed tomography images acquired at 5.2 hours (Q25-Q75: 4.9-5.4 hours) postinfusion. Images were assessed visually and semi-quantitatively for positive uptake of radiotracer in the heart and other major organs. RESULTS Uptake of 124I-evuzamitide in the heart and other abdominothoracic organs was consistent with the patient's clinical presentation and the type of amyloidosis. The patient- and cardiac-associated sensitivity for imaging and clinical observations was 93.6% (95% CI: 82.8%-97.8%) and 96.2% (95% CI: 81.8%-99.8%), respectively. Semi-quantitative uptake of the radiotracer correlated significantly with serum N-terminal pro-B-type natriuretic peptide measurements in patients with light chain-associated amyloidosis. Cardiac uptake was not observed in any healthy volunteers. The agent was well tolerated, with 1 drug-related adverse event and no deaths. CONCLUSIONS 124I-evuzamitide is an amyloid-binding radiotracer capable of detecting cardiac amyloid in patients with high sensitivity.
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Affiliation(s)
- Jonathan S Wall
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee, USA.
| | - Emily B Martin
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee, USA
| | - Ronald Lands
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee, USA
| | | | - Alan Stuckey
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee, USA
| | - R Eric Heidel
- Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee, USA
| | - Bryan Whittle
- Department of Radiology, University of Tennessee Medical Center, Knoxville, Tennessee, USA
| | - Dustin Powell
- Hendersonville Radiologic Consultants, Hendersonville, North Carolina, USA
| | - Tina Richey
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee, USA
| | - Angela D Williams
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee, USA
| | - James S Foster
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee, USA
| | | | - Stephen J Kennel
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee, USA
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11
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De Michieli L, Sinigiani G, De Gaspari M, Branca A, Rizzo S, Basso C, Trentin L, Iliceto S, Perazzolo Marra M, Cipriani A, Berno T. Light-chain cardiac amyloidosis for the non-expert: pearls and pitfalls. Intern Emerg Med 2023; 18:1879-1886. [PMID: 37338717 PMCID: PMC10543940 DOI: 10.1007/s11739-023-03335-3] [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: 01/11/2023] [Accepted: 06/01/2023] [Indexed: 06/21/2023]
Abstract
Cardiac amyloidosis (CA) is an uncommon, progressive, and fatal disease; the two main forms that can affect the heart are transthyretin CA and light chain CA (AL-CA). AL-CA is a medical urgency for which a diagnostic delay can be catastrophic for patients' outcome. In this manuscript, we focus on the pearls and pitfalls that are relevant to achieve a correct diagnosis and to avoid diagnostic and therapeutical delays. Through the aid of three unfortunate clinical cases, some fundamental diagnostic aspects are addressed, including the following: first, a negative bone scintigraphy does not exclude CA, with patients with AL-CA frequently showing no or mild cardiac uptake, and its execution should not delay hematological tests; second, fat pad biopsy does not have a 100% sensitivity for AL amyloidosis and, if negative, further investigations should be performed, particularly if the pre-test probability is high. Third, Congo Red staining is not sufficient to reach a definitive diagnosis and amyloid fibrils typing with mass spectrometry, immunohistochemistry, or immunoelectron microscopy is crucial. To achieve a timely and correct diagnosis, all the necessary investigations must be performed, always considering the yield and diagnostic accuracy of each examination.
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Affiliation(s)
- Laura De Michieli
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128, Padua, Italy.
| | - Giulio Sinigiani
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128, Padua, Italy
| | - Monica De Gaspari
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128, Padua, Italy
- Cardiovascular Pathology Unit, University Hospital of Padua, Padua, Italy
| | - Antonio Branca
- Hematology and Clinical Immunology Branch, Department of Medicine, University of Padova, Padua, Italy
| | - Stefania Rizzo
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128, Padua, Italy
- Cardiovascular Pathology Unit, University Hospital of Padua, Padua, Italy
| | - Cristina Basso
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128, Padua, Italy
- Cardiovascular Pathology Unit, University Hospital of Padua, Padua, Italy
| | - Livio Trentin
- Hematology and Clinical Immunology Branch, Department of Medicine, University of Padova, Padua, Italy
| | - Sabino Iliceto
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128, Padua, Italy
- Cardiology Unit, University Hospital of Padua, Padua, Italy
| | - Martina Perazzolo Marra
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128, Padua, Italy
- Cardiology Unit, University Hospital of Padua, Padua, Italy
| | - Alberto Cipriani
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128, Padua, Italy
- Cardiology Unit, University Hospital of Padua, Padua, Italy
| | - Tamara Berno
- Hematology and Clinical Immunology Branch, Department of Medicine, University of Padova, Padua, Italy
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12
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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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13
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Ioannou A, Massa P, Patel RK, Razvi Y, Porcari A, Rauf MU, Jiang A, Cabras G, Filisetti S, Bolhuis RE, Bandera F, Venneri L, Martinez-Naharro A, Law S, Kotecha T, Virsinskaite R, Knight DS, Emdin M, Petrie A, Lachmann H, Wechelakar A, Petrie M, Hughes A, Freemantle N, Hawkins PN, Whelan C, McMurray JJV, Gillmore JD, Fontana M. Conventional heart failure therapy in cardiac ATTR amyloidosis. Eur Heart J 2023; 44:2893-2907. [PMID: 37216684 PMCID: PMC10424879 DOI: 10.1093/eurheartj/ehad347] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 05/09/2023] [Accepted: 05/19/2023] [Indexed: 05/24/2023] Open
Abstract
AIMS The aims of this study were to assess prescription patterns, dosages, discontinuation rates, and association with prognosis of conventional heart failure medications in patients with transthyretin cardiac amyloidosis (ATTR-CA). METHODS AND RESULTS A retrospective analysis of all consecutive patients diagnosed with ATTR-CA at the National Amyloidosis Centre between 2000 and 2022 identified 2371 patients with ATTR-CA. Prescription of heart failure medications was greater among patients with a more severe cardiac phenotype, comprising beta-blockers in 55.4%, angiotensin-converting enzyme inhibitors (ACEis)/angiotensin II receptor blockers (ARBs) in 57.4%, and mineralocorticoid receptor antagonists (MRAs) in 39.0% of cases. During a median follow-up of 27.8 months (interquartile range 10.6-51.3), 21.7% had beta-blockers discontinued, and 32.9% had ACEi/ARBs discontinued. In contrast, only 7.5% had MRAs discontinued. A propensity score-matched analysis demonstrated that treatment with MRAs was independently associated with a reduced risk of mortality in the overall population [hazard ratio (HR) 0.77 (95% confidence interval (CI) 0.66-0.89), P < .001] and in a pre-specified subgroup of patients with a left ventricular ejection fraction (LVEF) >40% [HR 0.75 (95% CI 0.63-0.90), P = .002]; and treatment with low-dose beta-blockers was independently associated with a reduced risk of mortality in a pre-specified subgroup of patients with a LVEF ≤40% [HR 0.61 (95% CI 0.45-0.83), P = .002]. No convincing differences were found for treatment with ACEi/ARBs. CONCLUSION Conventional heart failure medications are currently not widely prescribed in ATTR-CA, and those that received medication had more severe cardiac disease. Beta-blockers and ACEi/ARBs were often discontinued, but low-dose beta-blockers were associated with reduced risk of mortality in patients with a LVEF ≤40%. In contrast, MRAs were rarely discontinued and were associated with reduced risk of mortality in the overall population; but these findings require confirmation in prospective randomized controlled trials.
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Affiliation(s)
- Adam Ioannou
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Paolo Massa
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Rishi K Patel
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Yousuf Razvi
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Aldostefano Porcari
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Via Giacomo Puccini, Trieste 34100, Italy
| | - Muhammad U Rauf
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Anita Jiang
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Giacomo Cabras
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Stefano Filisetti
- Cardiology University Department, IRCCS Policlinico San Donato, Piazza Edmondo Malan, Milan 20097, Italy
| | - Roos E Bolhuis
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Francesco Bandera
- Cardiology University Department, IRCCS Policlinico San Donato, Piazza Edmondo Malan, Milan 20097, Italy
| | - Lucia Venneri
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Ana Martinez-Naharro
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Steven Law
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Tushar Kotecha
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Ruta Virsinskaite
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Daniel S Knight
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Michele Emdin
- Health Science Interdisciplinary Center, Scuola Superiore Sant’Anna, Via Giuseppe Moruzzi, Pisa 56127, Italy
- Cardiovascular Department, Fondazione Toscana Gabriele Monasterio, Via Giuseppe Moruzzi, Pisa 56124, Italy
| | - Aviva Petrie
- Biostatistics Unit, University College London Eastman Dental Institute, 256 Grays Inn Road, London WC1X 8LD, UK
| | - Helen Lachmann
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Ashutosh Wechelakar
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Mark Petrie
- BHF Cardiovascular Research Centre, University of Glasgow, 126 University Pl, Glasgow G12 8TA, UK
| | - Alun Hughes
- Institute of Cardiovascular Science, University College London, 1–19 Torrington Place, London WC1E 7HB, UK
| | | | - Philip N Hawkins
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Carol Whelan
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, 126 University Pl, Glasgow G12 8TA, UK
| | - Julian D Gillmore
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Marianna Fontana
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
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14
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Ioannou A, Fontana M, Gillmore JD. Patisiran for the Treatment of Transthyretin-mediated Amyloidosis with Cardiomyopathy. Heart Int 2023; 17:27-35. [PMID: 37456349 PMCID: PMC10339464 DOI: 10.17925/hi.2023.17.1.27] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 04/24/2023] [Indexed: 07/18/2023] Open
Abstract
Transthyretin (TTR) is a tetrameric protein, synthesized primarily by the liver, that acts as a physiological transport protein for retinol and thyroxine. TTR can misfold into pathogenic amyloid fibrils that deposit in the heart and nerves, causing a life-threatening transthyretin amyloidosis cardiomyopathy (ATTR-CM), and a progressive and debilitating polyneuropathy (ATTR-PN). Recent therapeutic advances have resulted in the development of drugs that reduce TTR production. Patisiran is a small interfering RNA that disrupts the complimentary mRNA and inhibits TTR synthesis, and is the first gene-silencing medication licensed for the treatment of ATTR amyloidosis. After encouraging results following the use of patisiran for the treatment of patients with ATTR-PN, there has been increasing interest in the use of patisiran for the treatment of ATTR-CM. Various studies have demonstrated improvements across a wide range of cardiac biomarkers following treatment with patisiran, and have changed the perception of ATTR-CM from being thought of as a terminal disease process, to now being regarded as a treatable disease. These successes represent a huge milestone and have the potential to revolutionize the landscape of treatment for ATTR-CM. However, the long-term safety of patisiran and how best to monitor cardiac response to treatment remain to be determined.
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Affiliation(s)
- Adam Ioannou
- National Amyloidosis Centre, University College London, Royal Free Campus, London, UK
| | - Marianna Fontana
- National Amyloidosis Centre, University College London, Royal Free Campus, London, UK
| | - Julian D Gillmore
- National Amyloidosis Centre, University College London, Royal Free Campus, London, UK
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15
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Machine Learning Approaches in Diagnosis, Prognosis and Treatment Selection of Cardiac Amyloidosis. Int J Mol Sci 2023; 24:ijms24065680. [PMID: 36982754 PMCID: PMC10051237 DOI: 10.3390/ijms24065680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 03/12/2023] [Accepted: 03/14/2023] [Indexed: 03/18/2023] Open
Abstract
Cardiac amyloidosis is an uncommon restrictive cardiomyopathy featuring an unregulated amyloid protein deposition that impairs organic function. Early cardiac amyloidosis diagnosis is generally delayed by indistinguishable clinical findings of more frequent hypertrophic diseases. Furthermore, amyloidosis is divided into various groups, according to a generally accepted taxonomy, based on the proteins that make up the amyloid deposits; a careful differentiation between the various forms of amyloidosis is necessary to undertake an adequate therapeutic treatment. Thus, cardiac amyloidosis is thought to be underdiagnosed, which delays necessary therapeutic procedures, diminishing quality of life and impairing clinical prognosis. The diagnostic work-up for cardiac amyloidosis begins with the identification of clinical features, electrocardiographic and imaging findings suggestive or compatible with cardiac amyloidosis, and often requires the histological demonstration of amyloid deposition. One approach to overcome the difficulty of an early diagnosis is the use of automated diagnostic algorithms. Machine learning enables the automatic extraction of salient information from “raw data” without the need for pre-processing methods based on the a priori knowledge of the human operator. This review attempts to assess the various diagnostic approaches and artificial intelligence computational techniques in the detection of cardiac amyloidosis.
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16
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Ioannou A, Fontana M, Gillmore JD. RNA Targeting and Gene Editing Strategies for Transthyretin Amyloidosis. BioDrugs 2023; 37:127-142. [PMID: 36795354 PMCID: PMC9933836 DOI: 10.1007/s40259-023-00577-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2023] [Indexed: 02/17/2023]
Abstract
Transthyretin (TTR) is a tetrameric protein synthesized primarily by the liver. TTR can misfold into pathogenic ATTR amyloid fibrils that deposit in the nerves and heart, causing a progressive and debilitating polyneuropathy (PN) and life-threatening cardiomyopathy (CM). Therapeutic strategies, which are aimed at reducing ongoing ATTR amyloid fibrillogenesis, include stabilization of the circulating TTR tetramer or reduction of TTR synthesis. Small interfering RNA (siRNA) or antisense oligonucleotide (ASO) drugs are highly effective at disrupting the complementary mRNA and inhibiting TTR synthesis. Since their development, patisiran (siRNA), vutrisiran (siRNA) and inotersen (ASO) have all been licensed for treatment of ATTR-PN, and early data suggest these drugs may have efficacy in treating ATTR-CM. An ongoing phase 3 clinical trial will evaluate the efficacy of eplontersen (ASO) in the treatment of both ATTR-PN and ATTR-CM, and a recent phase 1 trial demonstrated the safety of novel in vivo CRISPR-Cas9 gene-editing therapy in patients with ATTR amyloidosis. Recent results from trials of gene silencer and gene-editing therapies suggest these novel therapeutic agents have the potential to substantially alter the landscape of treatment for ATTR amyloidosis. Their success has already changed the perception of ATTR amyloidosis from a universally progressive and fatal disease to one that is treatable through availability of highly specific and effective disease-modifying therapies. However, important questions remain including long-term safety of these drugs, potential for off-target gene editing, and how best to monitor the cardiac response to treatment.Kindly check and confirm the processed running title.This is correct.
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Affiliation(s)
- Adam Ioannou
- National Amyloidosis Centre, Royal Free Hospital, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Marianna Fontana
- National Amyloidosis Centre, Royal Free Hospital, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Julian D Gillmore
- National Amyloidosis Centre, Royal Free Hospital, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK.
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