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Bukhari S, Khan SZ, Ghoweba M, Khan B, Bashir Z. Arrhythmias and Device Therapies in Cardiac Amyloidosis. J Clin Med 2024; 13:1300. [PMID: 38592132 PMCID: PMC10932014 DOI: 10.3390/jcm13051300] [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: 01/13/2024] [Revised: 02/20/2024] [Accepted: 02/22/2024] [Indexed: 04/10/2024] Open
Abstract
Cardiac amyloidosis is caused by amyloid fibrils that deposit in the myocardial interstitium, causing restrictive cardiomyopathy and eventually death. The electromechanical, inflammatory, and autonomic changes due to amyloid deposition result in arrhythmias. Atrial fibrillation is by far the most common arrhythmia. The rate control strategy is generally poorly tolerated due to restrictive filling physiology and heart rate dependance, favoring adoption of the rhythm control strategy. Anticoagulation for stroke prophylaxis is warranted, irrespective of CHA2DS2-VASc score in patients with a favorable bleeding profile; data on left appendage closure devices are still insufficient. Ventricular arrhythmias are also not uncommon, and the role of implantable cardioverter-defibrillator in cardiac amyloidosis is controversial. There is no evidence of improvement in outcomes when used for primary prevention in these patients. Bradyarrhythmia is most commonly associated with sudden cardiac death in cardiac amyloidosis. Pacemaker implantation can help provide symptomatic relief but does not confer mortality benefit.
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Affiliation(s)
- Syed Bukhari
- Department of Cardiovascular Medicine, Section of Vascular Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, USA; (S.Z.K.); (M.G.)
| | - Syed Zamrak Khan
- Department of Cardiovascular Medicine, Section of Vascular Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, USA; (S.Z.K.); (M.G.)
| | - Mohamed Ghoweba
- Department of Cardiovascular Medicine, Section of Vascular Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, USA; (S.Z.K.); (M.G.)
| | - Bilal Khan
- Department of Hospital Medicine, Temple University-Jeanes Campus, Philadelphia, PA 19111, USA;
| | - Zubair Bashir
- Department of Hospital Medicine, Alpert Medical School of Brown University, Providence, RI 02903, USA;
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2
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Smith MA, Feinglass NG. Perioperative implications of amyloidosis and amyloid cardiomyopathy: A review for anesthesiologists. J Clin Anesth 2024; 92:111271. [PMID: 37820520 DOI: 10.1016/j.jclinane.2023.111271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 09/17/2023] [Accepted: 09/22/2023] [Indexed: 10/13/2023]
Abstract
It is well recognized that amyloid protein can infiltrate many regions of the body. This can include the peripheral nerves, the liver, kidney, spleen, the gastrointestinal tract, and most importantly the myocardium. The amyloid proteins that cause cardiomyopathy may come from genetically altered liver genes (transthyretin amyloid, ATTR) or from the bone marrow with malignant plasma cells (light chain amyloid, AL) generating the aberrant protein. These two types of amyloidosis cause significant damaging effects on both the myocardial cells as well as the conduction system of the heart. The resultant changes can produce dyspnea and exercise intolerance which is thought to be secondary to diastolic dysfunction and reduced stroke volume. This subclinical decompensation poses a significant problem for members of a care team as it often goes unrecognized. In the operating room patients are exposed to dramatic hemodynamic changes and may have difficult airways, autonomic dysfunction, and conduction abnormalities. Although the topic of amyloidosis is well described in cardiology literature, it is underdiagnosed. The purpose of this review is to describe some of the pathophysiology behind the principle proteins that cause cardiac amyloidosis and to comprehensively describe perioperative considerations for anesthesia providers.
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Affiliation(s)
- Michael A Smith
- Mayo Clinic Dept. Anesthesiology and Perioperative Medicine, Critical Care Medicine, Mayo Graduate School of Medicine, USA.
| | - Neil G Feinglass
- Mayo Clinic Dept. Anesthesiology and Perioperative Medicine, Mayo Graduate School of Medicine, USA
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3
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Brito D, Albrecht FC, de Arenaza DP, Bart N, Better N, Carvajal-Juarez I, Conceição I, Damy T, Dorbala S, Fidalgo JC, Garcia-Pavia P, Ge J, Gillmore JD, Grzybowski J, Obici L, Piñero D, Rapezzi C, Ueda M, Pinto FJ. World Heart Federation Consensus on Transthyretin Amyloidosis Cardiomyopathy (ATTR-CM). Glob Heart 2023; 18:59. [PMID: 37901600 PMCID: PMC10607607 DOI: 10.5334/gh.1262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 08/12/2023] [Indexed: 10/31/2023] Open
Abstract
Transthyretin amyloid cardiomyopathy (ATTR-CM) is a progressive and fatal condition that requires early diagnosis, management, and specific treatment. The availability of new disease-modifying therapies has made successful treatment a reality. Transthyretin amyloid cardiomyopathy can be either age-related (wild-type form) or caused by mutations in the TTR gene (genetic, hereditary forms). It is a systemic disease, and while the genetic forms may exhibit a variety of symptoms, a predominant cardiac phenotype is often present. This document aims to provide an overview of ATTR-CM amyloidosis focusing on cardiac involvement, which is the most critical factor for prognosis. It will discuss the available tools for early diagnosis and patient management, given that specific treatments are more effective in the early stages of the disease, and will highlight the importance of a multidisciplinary approach and of specialized amyloidosis centres. To accomplish these goals, the World Heart Federation assembled a panel of 18 expert clinicians specialized in TTR amyloidosis from 13 countries, along with a representative from the Amyloidosis Alliance, a patient advocacy group. This document is based on a review of published literature, expert opinions, registries data, patients' perspectives, treatment options, and ongoing developments, as well as the progress made possible via the existence of centres of excellence. From the patients' perspective, increasing disease awareness is crucial to achieving an early and accurate diagnosis. Patients also seek to receive care at specialized amyloidosis centres and be fully informed about their treatment and prognosis.
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Affiliation(s)
- Dulce Brito
- Department of Cardiology, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL@RISE, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Fabiano Castro Albrecht
- Dante Pazzanese Institute of Cardiology – Cardiac Amyloidosis Center Dante Pazzanese Institute, São Paulo, Brazil
| | | | - Nicole Bart
- St Vincent’s Hospital, Victor Chang Cardiac Research Institute, University of New South Wales, Sydney, Australia
| | - Nathan Better
- Cabrini Health, Malvern, Royal Melbourne Hospital, Parkville, Monash University and University of Melbourne, Victoria, Australia
| | | | - Isabel Conceição
- Department of Neurosciences and Mental Health, CHULN – Hospital de Santa Maria, Portugal
- Centro de Estudos Egas Moniz Faculdade de Medicina da Universidade de Lisboa Portugal, Portugal
| | - Thibaud Damy
- Department of Cardiology, DHU A-TVB, CHU Henri Mondor, AP-HP, INSERM U955 and UPEC, Créteil, France
- Referral Centre for Cardiac Amyloidosis, GRC Amyloid Research Institute, Reseau amylose, Créteil, France. Filière CARDIOGEN
| | - Sharmila Dorbala
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Cardiac Amyloidosis Program, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- CV imaging program, Cardiovascular Division and Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Pablo Garcia-Pavia
- Hospital Universitario Puerta de Hierro Majadahonda, IDIPHISA, CIBERCV, Madrid, Spain
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China
| | - Julian D. Gillmore
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom
| | - Jacek Grzybowski
- Department of Cardiomyopathy, National Institute of Cardiology, Warsaw, Poland
| | - Laura Obici
- Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Claudio Rapezzi
- Cardiovascular Institute, University of Ferrara, Ferrara, Italy
| | - Mitsuharu Ueda
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Japan
| | - Fausto J. Pinto
- Department of Cardiology, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL@RISE, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
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4
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Arbelo E, Protonotarios A, Gimeno JR, Arbustini E, Barriales-Villa R, Basso C, Bezzina CR, Biagini E, Blom NA, de Boer RA, De Winter T, Elliott PM, Flather M, Garcia-Pavia P, Haugaa KH, Ingles J, Jurcut RO, Klaassen S, Limongelli G, Loeys B, Mogensen J, Olivotto I, Pantazis A, Sharma S, Van Tintelen JP, Ware JS, Kaski JP. 2023 ESC Guidelines for the management of cardiomyopathies. Eur Heart J 2023; 44:3503-3626. [PMID: 37622657 DOI: 10.1093/eurheartj/ehad194] [Citation(s) in RCA: 231] [Impact Index Per Article: 231.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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5
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Medarametla GD, Kahlon RS, Mahitha L, Shariff S, Vakkalagadda NP, Chopra H, Kamal MA, Patel N, Sethi Y, Kaka N. Cardiac amyloidosis: evolving pathogenesis, multimodal diagnostics, and principles of treatment. EXCLI JOURNAL 2023; 22:781-808. [PMID: 37720240 PMCID: PMC10502203 DOI: 10.17179/excli2023-6284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 07/24/2023] [Indexed: 09/19/2023]
Abstract
Amyloidosis is a protein deposition disorder in which insoluble fibril structures accumulate in the bodily tissues damaging the organ function. Cardiac amyloidosis is a severe but under-reported medical condition characterized by the accumulation of amyloid in the extracellular area of the myocardium, which results in thickening and stiffening of ventricular walls. Cardiac amyloidosis has recently gained much attention with its slowly surging incidence. With this study, we seek to comprehensively compile the pathophysiology and clinical picture of cardiac amyloidosis subtypes, extending a clinically oriented, up-to-date clinical approach to diagnosis and therapy. Cardiac amyloidosis can be caused by rare genetic mutations which may be inherited or acquired. The growing incidence can be attributed to advancements in imaging methods and other diagnostic modalities. Most occurrences of cardiac amyloidosis result from two forms of precursor protein: transthyretin [TTR] amyloid and immunoglobulin-derived light-chain amyloid. Prompt identification of cardiac amyloidosis can facilitate the implementation of evolving therapeutic interventions to enhance the outcomes. The modalities for the management of CA have evolved significantly in the last ten years. Apart from therapies for modifying disease and heart failure, a myriad of novel therapeutic approaches that target specific aspects of the disease, including gene therapies, are being researched. These aim at impeding its progression and improving clinical outcomes. See also Figure 1(Fig. 1).
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Affiliation(s)
| | | | - Lampimukhi Mahitha
- Pear Research, Dehradun, India
- Rangaraya Medical College, Kakinada, Andhra Pradesh, India
| | - Sanobar Shariff
- Pear Research, Dehradun, India
- Yerevan State Medical University, Yerevan, Armenia
| | | | - Hitesh Chopra
- Department of Biosciences, Saveetha School of Engineering, Saveetha Institute of Medical and Technical Sciences, Chennai, Tamil Nadu-602105, India
| | - Mohammad Amjad Kamal
- Institutes for Systems Genetics, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, China
- King Fahd Medical Research Center, King Abdulaziz University, Saudi Arabia
- Department of Pharmacy, Faculty of Allied Health Sciences, Daffodil International University, Bangladesh
- Enzymoics, 7 Peterlee Place, Hebersham, NSW 2770; Novel Global Community Educational Foundation, Australia
| | - Neil Patel
- Pear Research, Dehradun, India
- GMERS Medical College, Himmatnagar, Gujarat, India
| | - Yashendra Sethi
- Pear Research, Dehradun, India
- Government Doon Medical College, Dehradun, Uttarakhand, India
| | - Nirja Kaka
- Pear Research, Dehradun, India
- GMERS Medical College, Himmatnagar, Gujarat, India
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6
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Bukhari S, Oliveros E, Parekh H, Farmakis D. Epidemiology, Mechanisms, and Management of Atrial Fibrillation in Cardiac Amyloidosis. Curr Probl Cardiol 2023; 48:101571. [PMID: 36584731 DOI: 10.1016/j.cpcardiol.2022.101571] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 12/23/2022] [Indexed: 12/29/2022]
Abstract
Cardiac amyloidosis (CA) is a restrictive disease that results from intramyocardial amyloid deposition due to immunoglobulin light chain or transthyretin proteins. Up to two-third of CA patients have atrial fibrillation (AF) due to electromechanical, autonomic, and hemodynamic disturbances. AF in CA carries particularly increased risk of thromboembolism, prompting anticoagulation therapy irrespective of CHA2DS2VASc score. However, CA is also associated with enhanced bleeding risk that warrants thorough assessment of bleeding profile before initiation of anticoagulation. Management of AF in CA is challenging because these patients poorly tolerate rate control agents, while cardiomyopathy precludes most antiarrhythmic agents, leaving amiodarone as the preferred antiarrhythmic drug. The effectiveness of direct current cardioversion in restoring sinus rhythm in CA is comparable with that in the general population, although intraprocedural complication rates could be higher. Transesophageal echocardiogram should be performed prior to direct current cardioversion, given high incidence of intracardiac thrombus in these patients. Finally, the data on catheter ablation is limited.
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7
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Laptseva N, Rossi VA, Sudano I, Schwotzer R, Ruschitzka F, Flammer AJ, Duru F. Arrhythmic Manifestations of Cardiac Amyloidosis: Challenges in Risk Stratification and Clinical Management. J Clin Med 2023; 12:jcm12072581. [PMID: 37048664 PMCID: PMC10095126 DOI: 10.3390/jcm12072581] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/23/2023] [Accepted: 03/27/2023] [Indexed: 03/31/2023] Open
Abstract
Amylodiosis is a systemic disease characterized by extracellular deposits of insoluble amyloid in various tissues and organs. Cardiac amyloidosis is a frequent feature of the disease, causing a progressive, restrictive type of cardiomyopathy, and is associated with adverse clinical outcomes and increased mortality. The typical clinical presentation in patients with cardiac amyloidosis is heart failure (HF) with preserved ejection fraction. Most patients present with typical symptoms and signs of HF, such as exertional dyspnea, pretibial edema, pleural effusions and angina pectoris due to microcirculatory dysfunction. However, patients may also frequently encounter various arrhythmias, such as atrioventricular nodal block, atrial fibrillation and ventricular tachyarrhythmias. The management of arrhythmias in cardiac amyloidosis patients with drugs and devices is often a clinical challenge. Moreover, predictors of life-threatening arrhythmic events are not well defined. This review intends to give a deepened insight into the arrhythmic features of cardiac amyloidosis by discussing the pathogenesis of these arrhythmias, addressing the challenges in risk stratification and strategies for management in these patients.
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8
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Kittleson MM, Ruberg FL, Ambardekar AV, Brannagan TH, Cheng RK, Clarke JO, Dember LM, Frantz JG, Hershberger RE, Maurer MS, Nativi-Nicolau J, Sanchorawala V, Sheikh FH. 2023 ACC Expert Consensus Decision Pathway on Comprehensive Multidisciplinary Care for the Patient With Cardiac Amyloidosis: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2023; 81:1076-1126. [PMID: 36697326 DOI: 10.1016/j.jacc.2022.11.022] [Citation(s) in RCA: 92] [Impact Index Per Article: 92.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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9
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Vergaro G, Aimo A, Rapezzi C, Castiglione V, Fabiani I, Pucci A, Buda G, Passino C, Lupón J, Bayes-Genis A, Emdin M, Braunwald E. Atrial amyloidosis: mechanisms and clinical manifestations. Eur J Heart Fail 2022; 24:2019-2028. [PMID: 35920110 PMCID: PMC10087817 DOI: 10.1002/ejhf.2650] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 07/12/2022] [Accepted: 08/01/2022] [Indexed: 01/18/2023] Open
Abstract
Cardiac amyloidosis (CA) is now recognized as an important cause of heart failure. Increased wall thickness and diastolic dysfunction of the left ventricle are the most easily detectable manifestations of CA, but amyloid accumulates in all cardiac structures. Involvement of the left and right atria may be due to the haemodynamic effects of ventricular diastolic dysfunction, the effects of amyloid infiltration into the atrial wall, and the cardiotoxic damage of atrial cardiomyocytes by amyloid precursors. Atrial amyloidosis is an early manifestation of CA, and is associated with an increased risk of atrial fibrillation and thromboembolic events. Furthermore, atrial amyloidosis can be found even in the absence of systemic disease and ventricular involvement. This condition is named isolated atrial amyloidosis and is due to a local overproduction of atrial natriuretic peptide. In this review we summarize the evidence on the mechanisms and clinical relevance of atrial amyloidosis.
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Affiliation(s)
- Giuseppe Vergaro
- Interdisciplinary Center Health Science, Scuola Superiore Sant'Anna, Pisa, Italy.,Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Alberto Aimo
- Interdisciplinary Center Health Science, Scuola Superiore Sant'Anna, Pisa, Italy.,Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Claudio Rapezzi
- Cardiology Centre, University of Ferrara, Ferrara, Italy.,Maria Cecilia Hospital, GVM Care & Research, Ravenna, Italy
| | - Vincenzo Castiglione
- Interdisciplinary Center Health Science, Scuola Superiore Sant'Anna, Pisa, Italy
| | | | | | | | - Claudio Passino
- Interdisciplinary Center Health Science, Scuola Superiore Sant'Anna, Pisa, Italy.,Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Josep Lupón
- Heart Institute, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Antoni Bayes-Genis
- Heart Institute, Hospital Universitari Germans Trias i Pujol, Badalona, Spain.,CIBERCV, Instituto de Salud Carlos III, Madrid, Spain
| | - Michele Emdin
- Interdisciplinary Center Health Science, Scuola Superiore Sant'Anna, Pisa, Italy.,Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Eugene Braunwald
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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10
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Ibrahim R, Takamatsu C. Digoxin in amyloidosis: Is it associated with a greater incidence of arrhythmogenic potential? J Arrhythm 2022; 38:831. [PMID: 36237874 PMCID: PMC9535793 DOI: 10.1002/joa3.12775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 08/22/2022] [Accepted: 08/26/2022] [Indexed: 12/01/2022] Open
Affiliation(s)
- Ramzi Ibrahim
- Department of Medicine Banner University Medical Center‐University of Arizona Tucson Arizona USA
| | - Chelsea Takamatsu
- Department of Medicine Banner University Medical Center‐University of Arizona Tucson Arizona USA
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11
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Touboul O, Algalarrondo V, Oghina S, Elbaz N, Rouffiac S, Hamon D, Extramiana F, Gandjbakhch E, D'Humieres T, Marijon E, Dhanjal TS, Teiger E, Damy T, Lellouche N. Electrical cardioversion of atrial arrhythmias with cardiac amyloidosis in the era of direct oral anticogulants. ESC Heart Fail 2022; 9:3556-3564. [PMID: 35903879 DOI: 10.1002/ehf2.14082] [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: 03/10/2022] [Revised: 06/10/2022] [Accepted: 07/18/2022] [Indexed: 11/10/2022] Open
Abstract
AIMS Atrial fibrillation (AF)/atrial flutter is common during cardiac amyloidosis (CA). Electrical cardioversion (EC) is a strategy to restore sinus rhythm (SR). However, left atrial thrombus (LAT) represents a contraindication for EC. CA patients with AF/atrial flutter have a high prevalence of LAT. We aimed to evaluate EC characteristics, LAT prevalence and risk factors, and AF/atrial flutter outcome in CA patients undergoing EC, predominantly treated with direct oral anticoagulants (DOACs). METHODS AND RESULTS All patients with CA and AF/atrial flutter referred for the first time to our national referral centre of amyloidosis for EC from June 2017 to February 2021 were included in this study. In total, 66 patients (median age 74.5 [70;80.75] years, 67% male) were included with anticoagulation consisted of DOAC in 74% of cases. All patients underwent cardiac imaging before EC to rule out LAT. EC was cancelled due to LAT in 14% of cases. Complete thrombus resolution was observed in only 17% of cases. The two independent parameters associated with LAT were creatinine [hazard ratio (HR) = 1.01; confidence interval (CI) = 1.00-1.03, P = 0.036] and the use of antiplatelet agents (HR = 13.47; CI = 1.85-98.02). EC acute success rate was 88%, and we observed no complication after EC. With 64% of patients under amiodarone, AF/atrial flutter recurrence rate following EC was 51% after a mean follow-up of 30 ± 27 months. CONCLUSIONS Left atrial thrombus was observed in 14% of CA patients listed for EC and mainly treated with DOAC. The acute EC success rate was high with no complication. The long-term EC success rate was acceptable (49%).
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Affiliation(s)
- Olivier Touboul
- Department of Cardiology, AP-HP, University Hospital Henri Mondor, 51, Avenue du Maréchal de Lattre de Tassigny, 94000, Creteil, France
| | | | - Silvia Oghina
- Department of Cardiology, AP-HP, University Hospital Henri Mondor, 51, Avenue du Maréchal de Lattre de Tassigny, 94000, Creteil, France
| | - Nathalie Elbaz
- Department of Cardiology, AP-HP, University Hospital Henri Mondor, 51, Avenue du Maréchal de Lattre de Tassigny, 94000, Creteil, France
| | - Segolene Rouffiac
- Department of Cardiology, AP-HP, University Hospital Henri Mondor, 51, Avenue du Maréchal de Lattre de Tassigny, 94000, Creteil, France
| | - David Hamon
- Department of Cardiology, AP-HP, University Hospital Henri Mondor, 51, Avenue du Maréchal de Lattre de Tassigny, 94000, Creteil, France
| | - Fabrice Extramiana
- Department of Cardiology, AP-HP, University Hospital Bichat, Paris, France
| | - Estelle Gandjbakhch
- Department of Cardiology, AP-HP, University Hospital Pitié-Salpétrière, Paris, France
| | - Thomas D'Humieres
- Department of Physiology, AP-HP, University Hospital Henri Mondor, Creteil, France
| | - Eloi Marijon
- Department of Cardiology, AP-HP, University Hopital Européen Georges Pompidou, Paris, France
| | - Tarvinder S Dhanjal
- Department of Cardiac Electrophysiology, University of Warwick, Gibbet Hill, Coventry, UK
| | - Emmanuel Teiger
- Department of Cardiology, AP-HP, University Hospital Henri Mondor, 51, Avenue du Maréchal de Lattre de Tassigny, 94000, Creteil, France
| | - Thibaud Damy
- Department of Cardiology, AP-HP, University Hospital Henri Mondor, 51, Avenue du Maréchal de Lattre de Tassigny, 94000, Creteil, France
| | - Nicolas Lellouche
- Department of Cardiology, AP-HP, University Hospital Henri Mondor, 51, Avenue du Maréchal de Lattre de Tassigny, 94000, Creteil, France
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12
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Oghina S, Delbarre MA, Poullot E, Belhadj K, Fanen P, Damy T. [Cardiac amyloidosis: State of art in 2022]. Rev Med Interne 2022; 43:537-544. [PMID: 35870985 DOI: 10.1016/j.revmed.2022.04.036] [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: 01/19/2022] [Revised: 04/17/2022] [Accepted: 04/30/2022] [Indexed: 10/17/2022]
Abstract
The 3 main types of cardiac amyloidosis are linked to two protein precursors: AL amyloidosis secondary to free light chain deposits in the context of monoclonal gammopathy (mainly of undetermined significance or myeloma) and transthyretin amyloidosis (ATTR), comprising wild-type transthyretin amyloidosis (ATTRwt for wild type) and hereditary transthyretin amyloidosis (ATTRv for variant). These diseases are underdiagnosed and highly prevalent in common cardiac phenotypes in recent studies (heart failure with preserved ejection fraction, severe aortic stenosis, hypertrophic cardiomyopathy). Myocardial amyloid infiltration affects all cardiac structures and clinically promotes predominantly heart failure, conductive disorders and cardioembolic events. The search for extracardiac signs makes it possible to arouse diagnostic suspicion. Electrocardiogram, echocardiography and cardiac MRI can suspect cardiac amyloidosis. The diagnostic confirmation follows a simple algorithm including a systematic search for monoclonal gammapathy and a disphosphonate scintigraphy. Histological proof is necessary in case of AL or ATTR amyloidosis with concomitant monoclonal gammopathy in order to initiate specific treatment. Due to the late disease onset in ATTRv, genetic testing must be routine in all cases of ATTR. These diseases are no longer perceived as incurable since recent therapeutic innovations. A better knowledge of the disease is more than ever necessary.
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Affiliation(s)
- S Oghina
- Service de cardiologie, Centre Hospitalier Universitaire Henri-Mondor, AP-HP (Assistance Publique-Hôpitaux de Paris), 1, rue Gustave-Eiffel, 94010 Créteil, France; Centre de référence national des amyloses cardiaques et réseau amylose Mondor, Filière Cardiogen, Centre Hospitalier Universitaire Henri-Mondor, AP-HP (Assistance Publique-Hôpitaux de Paris), 1, rue Gustave-Eiffel, 94010 Créteil, France.
| | - M A Delbarre
- Service de cardiologie, Centre Hospitalier Universitaire Henri-Mondor, AP-HP (Assistance Publique-Hôpitaux de Paris), 1, rue Gustave-Eiffel, 94010 Créteil, France; Centre de référence national des amyloses cardiaques et réseau amylose Mondor, Filière Cardiogen, Centre Hospitalier Universitaire Henri-Mondor, AP-HP (Assistance Publique-Hôpitaux de Paris), 1, rue Gustave-Eiffel, 94010 Créteil, France
| | - E Poullot
- Centre de référence national des amyloses cardiaques et réseau amylose Mondor, Filière Cardiogen, Centre Hospitalier Universitaire Henri-Mondor, AP-HP (Assistance Publique-Hôpitaux de Paris), 1, rue Gustave-Eiffel, 94010 Créteil, France; Service d'anatomo-pathologie, Centre Hospitalier Universitaire Henri-Mondor, AP-HP (Assistance Publique-Hôpitaux de Paris), 1, rue Gustave-Eiffel, 94010 Créteil, France
| | - K Belhadj
- Centre de référence national des amyloses cardiaques et réseau amylose Mondor, Filière Cardiogen, Centre Hospitalier Universitaire Henri-Mondor, AP-HP (Assistance Publique-Hôpitaux de Paris), 1, rue Gustave-Eiffel, 94010 Créteil, France; Service d'hématologie lymphoïde, Centre Hospitalier Universitaire Henri-Mondor, AP-HP (Assistance Publique-Hôpitaux de Paris), 1, rue Gustave-Eiffel, 94010 Créteil, France
| | - P Fanen
- Centre de référence national des amyloses cardiaques et réseau amylose Mondor, Filière Cardiogen, Centre Hospitalier Universitaire Henri-Mondor, AP-HP (Assistance Publique-Hôpitaux de Paris), 1, rue Gustave-Eiffel, 94010 Créteil, France; Service de génétique, Centre Hospitalier Universitaire Henri-Mondor, AP-HP (Assistance Publique-Hôpitaux de Paris), 1, rue Gustave-Eiffel, 94010 Créteil, France; Centre Hospitalier Universitaire Henri-Mondor, AP-HP (Assistance Publique-Hôpitaux de Paris), FHU SENEC, 1, rue Gustave-Eiffel, 94010 Créteil, France
| | - T Damy
- Service de cardiologie, Centre Hospitalier Universitaire Henri-Mondor, AP-HP (Assistance Publique-Hôpitaux de Paris), 1, rue Gustave-Eiffel, 94010 Créteil, France; Centre de référence national des amyloses cardiaques et réseau amylose Mondor, Filière Cardiogen, Centre Hospitalier Universitaire Henri-Mondor, AP-HP (Assistance Publique-Hôpitaux de Paris), 1, rue Gustave-Eiffel, 94010 Créteil, France; Centre Hospitalier Universitaire Henri-Mondor, AP-HP (Assistance Publique-Hôpitaux de Paris), FHU SENEC, 1, rue Gustave-Eiffel, 94010 Créteil, France
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13
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Jensen CE, Byku M, Hladik GA, Jain K, Traub RE, Tuchman SA. Supportive Care and Symptom Management for Patients With Immunoglobulin Light Chain (AL) Amyloidosis. Front Oncol 2022; 12:907584. [PMID: 35814419 PMCID: PMC9259942 DOI: 10.3389/fonc.2022.907584] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 05/26/2022] [Indexed: 11/17/2022] Open
Abstract
Immunoglobulin light chain (AL) amyloidosis is a disorder of clonal plasma cells characterized by deposition of amyloid fibrils in a variety of tissues, leading to end-organ injury. Renal or cardiac involvement is most common, though any organ outside the central nervous system can develop amyloid deposition, and symptomatic presentations may consequently vary. The variability and subtlety of initial clinical presentations may contribute to delayed diagnoses, and organ involvement is often quite advanced and symptomatic by the time a diagnosis is established. Additionally, while organ function can improve with plasma-cell-directed therapy, such improvement lags behind hematologic response. Consequently, highly effective supportive care, including symptom management, is essential to improve quality of life and to maximize both tolerance of therapy and likelihood of survival. Considering the systemic nature of the disease, close collaboration between clinicians is essential for effective management.
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Affiliation(s)
- Christopher E. Jensen
- Division of Hematology, University of North Carolina School of Medicine, Chapel Hill, NC, United States
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, United States
| | - Mirnela Byku
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, NC, United States
| | - Gerald A. Hladik
- Division of Nephrology and Hypertension, University of North Carolina School of Medicine, Chapel Hill, NC, United States
| | - Koyal Jain
- Division of Nephrology and Hypertension, University of North Carolina School of Medicine, Chapel Hill, NC, United States
| | - Rebecca E. Traub
- Department of Neurology, University of North Carolina School of Medicine, Chapel Hill, NC, United States
| | - Sascha A. Tuchman
- Division of Hematology, University of North Carolina School of Medicine, Chapel Hill, NC, United States
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, United States
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14
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Maroun BZ, Allam S, Chaulagain CP. Multidisciplinary supportive care in systemic light chain amyloidosis. Blood Res 2022; 57:106-116. [PMID: 35593003 PMCID: PMC9242830 DOI: 10.5045/br.2022.2021227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 04/30/2022] [Accepted: 05/04/2022] [Indexed: 11/17/2022] Open
Abstract
The immunoglobulin light-chain amyloidosis is a multisystemic disease which manifests by damage to the vital organs by light chain-derived amyloid fibril. Traditionally, the treatment has been directed to the underlying plasma cell clone with or without high dose chemotherapy followed by autologous stem cell transplantation using melphalan based conditioning. Now with the approval of highly tolerable anti-CD38 monoclonal antibody daratumumab based anti-plasma cell therapy in 2021, high rates of hematologic complete responses are possible even in patients who are otherwise deemed not a candidate for autologous stem cell transplantation. However, despite the progress, there remains a limitation in the strategies to improve symptoms particularly in patients with advanced cardiac involvement, those with nephrotic syndrome and autonomic dysfunction due to underlying systemic AL amyloidosis. The symptoms can be an ordeal for the patients and their caregivers and effective strategies are urgently needed to address them. The supportive care is aimed to counteract the symptoms of the disease and the effects of the treatment on involved organs’ function and preserve patients’ quality of life. Here we discuss multidisciplinary approach in a system-based fashion to address the symptom management in this dreadful disease. In addition to achieving excellent anti-plasma cell disease control, using treatment directed to remove amyloid from the vital organs can theoretically hasten recovery of the involved organs thereby improving symptoms at a faster pace. Ongoing phase III clinical trials of CAEL-101 and Birtamimab will address this question.
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Affiliation(s)
- Bou Zerdan Maroun
- Department of Hematology-Oncology, Myeloma and Amyloidosis Program, Maroone Cancer Center, Cleveland Clinic Florida, Weston FL, USA
| | - Sabine Allam
- Faculty of Medicine, University of Balamand, Beirut, Lebanon
| | - Chakra P Chaulagain
- Department of Hematology-Oncology, Myeloma and Amyloidosis Program, Maroone Cancer Center, Cleveland Clinic Florida, Weston FL, USA
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15
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Rapezzi C, Aimo A, Serenelli M, Barison A, Vergaro G, Passino C, Panichella G, Sinagra G, Merlo M, Fontana M, Gillmore J, Quarta CC, Maurer MS, Kittleson MM, Garcia-Pavia P, Emdin M. Critical Comparison of Documents From Scientific Societies on Cardiac Amyloidosis: JACC State-of-the-Art Review. J Am Coll Cardiol 2022; 79:1288-1303. [PMID: 35361352 DOI: 10.1016/j.jacc.2022.01.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/14/2022] [Accepted: 01/18/2022] [Indexed: 12/22/2022]
Abstract
Over the last year, 5 national or international scientific societies have issued documents regarding cardiac amyloidosis (CA) to highlight the emerging clinical science, raise awareness, and facilitate diagnosis and management of CA. These documents provide useful guidance for clinicians managing patients with CA, and all include: 1) an algorithm to establish a diagnosis; 2) an emphasis on noninvasive diagnosis with the combined use of bone scintigraphy and the exclusion of a monoclonal protein; and 3) indications for novel disease-modifying therapies for symptomatic CA, either with or without peripheral neuropathy. Nonetheless, the documents diverge on specific details of diagnosis, risk stratification, and treatment. Highlighting the similarities and differences of the documents by the 5 scientific societies with respect to diagnosis, risk stratification, and treatment offers useful insight into the knowledge gaps and unmet needs in the management of CA. An analysis of these documents, therefore, highlights "gray zones" requiring further investigation.
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Affiliation(s)
- Claudio Rapezzi
- Cardiologic Centre, University of Ferrara, Cona, Italy; Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy.
| | - Alberto Aimo
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy; Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | | | - Andrea Barison
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy; Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Giuseppe Vergaro
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy; Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Claudio Passino
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy; Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | | | - Gianfranco Sinagra
- Cardiovascular Department, Azienda Ospedaliero-Universitaria "Ospedali Riuniti" of Trieste, Trieste, Italy
| | - Marco Merlo
- Cardiovascular Department, Azienda Ospedaliero-Universitaria "Ospedali Riuniti" of Trieste, Trieste, Italy
| | - Marianna Fontana
- National Amyloidosis Centre, Division of Medicine, Royal Free Hospital, University College London, London, United Kingdom
| | - Julian Gillmore
- National Amyloidosis Centre, Division of Medicine, Royal Free Hospital, University College London, London, United Kingdom
| | | | - Mathew S Maurer
- Cardiac Amyloidosis Program, Centre for Advanced Cardiac Care, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, New York, USA
| | - Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Pablo Garcia-Pavia
- Heart Failure and Inherited Cardiac Diseases Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro Majadahonda, CIBERCV, Madrid, Spain; Universidad Francisco de Vitoria, Pozuelo de Alarcón, Spain; European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart
| | - Michele Emdin
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy; Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
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16
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Management of Cardiac Symptoms in Amyloidosis. Am J Med 2022; 135 Suppl 1:S9-S12. [PMID: 35235819 DOI: 10.1016/j.amjmed.2022.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/09/2022] [Accepted: 02/10/2022] [Indexed: 11/22/2022]
Abstract
Cardiac amyloidosis (CA) results in symptoms of heart failure, atrial and ventricular arrhythmias, conduction disturbances, and profound autonomic dysfunction. These symptoms present unique management challenges as compared with patients without CA, and can be very debilitating. Thus, management of the cardiovascular symptoms of these patients plays a central role in their care. This review presents an overview of the typical cardiovascular manifestations encountered in patients with CA and highlights the key management considerations for each.
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17
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Stern LK, Patel J. Cardiac Amyloidosis Treatment. Methodist Debakey Cardiovasc J 2022; 18:59-72. [PMID: 35414852 PMCID: PMC8932359 DOI: 10.14797/mdcvj.1050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 12/07/2021] [Indexed: 01/17/2023] Open
Abstract
Cardiac amyloidosis (CA) is a restrictive cardiomyopathy with a traditionally poor prognosis. Until recently, CA treatment options were limited and consisted predominantly of managing symptoms and disease-related complications. However, the last decade has seen significant advances in disease-modifying therapies, increased awareness of CA, and improved diagnostic methods resulting in earlier diagnoses. In this review, we provide an overview of current and experimental treatments for the predominant types of CA: transthyretin cardiac amyloidosis (ATTR-CA) and immunoglobulin light chain (AL)-mediated CA (AL-CA). The mainstay of AL-CA treatment is proteasome inhibitor-based chemotherapy with daratumumab and, when feasible, autologous stem cell transplantation. For ATTR-CA, the stabilizer tafamidis is the only US Food and Drug Administration (FDA)-approved treatment. However, promising novel therapies on the horizon target various points in the ATTR-CA amyloidogenic cascade. These include transthyretin gene (TTR) silencing agents to prevent TTR formation, TTR tetramer stabilization and inhibition of oligomer aggregation to prevent fibril formation, anti-TTR fiber antibodies, and amyloid degradation. For end-stage CA, advanced interventions may need to be considered, including heart, heart-kidney, and, for hereditary ATTR-CA, heart-liver transplantation. Despite the evolution of treatment options, CA management remains complex due to patient frailty and therapeutic side effects or intolerance with advanced cardiac disease. This is particularly relevant for those with AL-CA, when active teamwork between the hematologist-oncologist and the cardiologist is critical for treatment success. Often, referral to an expert center is necessary for timely diagnosis, initiation of treatment, and participation in clinical trials.
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Affiliation(s)
- Lily K. Stern
- Smidt Heart Institute, Cedars-Sinai, Los Angeles, California, US
| | - Jignesh Patel
- Smidt Heart Institute, Cedars-Sinai, Los Angeles, California, US
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18
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Westin O, Butt JH, Gustafsson F, Schou M, Salomo M, Køber L, Maurer M, Fosbøl EL. Two Decades of Cardiac Amyloidosis: A Danish Nationwide Study. JACC: CARDIOONCOLOGY 2021; 3:522-533. [PMID: 34729524 PMCID: PMC8543084 DOI: 10.1016/j.jaccao.2021.05.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 05/26/2021] [Indexed: 12/17/2022]
Abstract
Background Cardiac amyloidosis (CA) has been associated with poor outcomes. Screening studies suggest that CA is overlooked-especially in the elderly. Recent advances in treatment have brought attention to the disease, but data on temporal changes in CA epidemiology are sparse. Objectives The aim of this work was to describe all patients with CA in Denmark, examining changes in patient characteristics from 1998 to 2017. Methods All patients with any form of amyloidosis diagnosed from 1998 to 2017, as well as their comorbidities and pharmacotherapy, were identified in Danish nationwide registries. CA was defined as any diagnosis code for amyloidosis combined with a diagnosis code for heart failure, cardiomyopathy, or atrial fibrillation or a procedural code for pacemaker implantation, regardless of the order. The index date was defined as the date of meeting those criteria. Patients were divided into 5-year periods by index date. For comparison, we also included control subjects (1:4 ratio) from the general population. Results CA criteria were met by 619 patients. Comparing 1998-2002 vs 2013-2017, the median age at baseline increased from 67.4 years (interquartile range [IQR]: 53.9-75.2 years) to 72.3 years (IQR: 66.0-79.3 years). The frequency of male patients increased from 62.1% to 66.2%. The incidence of CA rose from 0.88 to 3.56 per 100,000 person-years in the Danish population aged ≥65 years, and the 2-year mortality decreased from 82.6% (IQR: 69.9%-90.5%) to 50.2% (IQR: 43.1%-56.9%). Compared with control subjects, the mortality among CA patients was significantly higher (log-rank test: P < 0.0001). Conclusions CA, as defined in this study, was increasingly diagnosed on a national scale. The increasing frequency of male patients and median age suggest that wild-type transthyretin amyloidosis is driving this increase. Greater recognition of earlier, less advanced cases might explain decreasing mortality.
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Affiliation(s)
- Oscar Westin
- The Heart Center, University Hospital of Copenhagen, Rigshospitalet, Denmark
| | - Jawad H Butt
- The Heart Center, University Hospital of Copenhagen, Rigshospitalet, Denmark
| | - Finn Gustafsson
- The Heart Center, University Hospital of Copenhagen, Rigshospitalet, Denmark
| | - Morten Schou
- Department of Cardiology, University Hospital of Copenhagen, Herlev and Gentofte Hospital, Denmark
| | - Morten Salomo
- Department of Hematology, University Hospital of Copenhagen, Rigshospitalet, Denmark
| | - Lars Køber
- The Heart Center, University Hospital of Copenhagen, Rigshospitalet, Denmark
| | - Mathew Maurer
- Columbia University Irving Medical Center, New York, New York, USA
| | - Emil L Fosbøl
- The Heart Center, University Hospital of Copenhagen, Rigshospitalet, Denmark
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19
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Kim MM, Kolseth CM, Carlson D, Masri A. Clinical management of amyloid cardiomyopathy. Heart Fail Rev 2021; 27:1549-1557. [PMID: 34471997 DOI: 10.1007/s10741-021-10159-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/16/2021] [Indexed: 01/04/2023]
Abstract
Clinical heart failure, restrictive cardiomyopathy, and arrhythmias are hallmark features of amyloid cardiomyopathy. In contrast to the advancements in targeted therapies, there is a general lack of evidence-based practice guidelines for clinical management of amyloid cardiomyopathy. In this review, we review the role of routine medical therapy in amyloid cardiomyopathy, from heart failure management to orthostatic hypotension, atrial arrhythmias, thromboembolic complications, and prevention of sudden death. We conclude by discussing approaches to patients with end-stage disease.
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Affiliation(s)
- Morris M Kim
- Center for Amyloidosis, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Clinton M Kolseth
- Center for Amyloidosis, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Dayna Carlson
- Center for Amyloidosis, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Ahmad Masri
- Center for Amyloidosis, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA.
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20
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Adam RD, Coriu D, Jercan A, Bădeliţă S, Popescu BA, Damy T, Jurcuţ R. Progress and challenges in the treatment of cardiac amyloidosis: a review of the literature. ESC Heart Fail 2021; 8:2380-2396. [PMID: 34089308 PMCID: PMC8318516 DOI: 10.1002/ehf2.13443] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 05/04/2021] [Accepted: 05/12/2021] [Indexed: 12/19/2022] Open
Abstract
Cardiac amyloidosis is a restrictive cardiomyopathy determined by the accumulation of amyloid, which is represented by misfolded protein fragments in the cardiac extracellular space. The main classification of systemic amyloidosis is determined by the amyloid precursor proteins causing a very heterogeneous disease spectrum, but the main types of amyloidosis involving the heart are light chain (AL) and transthyretin amyloidosis (ATTR). AL, in which the amyloid precursor is represented by misfolded immunoglobulin light chains, can involve almost any system carrying the worst prognosis among amyloidosis patients. This has however dramatically improved in the last few years with the increased usage of the novel therapies such as proteasome inhibitors and haematopoietic cell transplantation, in the case of timely diagnosis and initiation of treatment. The treatment for AL is directed by the haematologist working closely with the cardiologist when there is a significant cardiac involvement. Transthyretin (TTR) is a protein that is produced by the liver and is involved in the transportation of thyroid hormones, especially thyroxine and retinol binding protein. ATTR results from the accumulation of transthyretin amyloid in the extracellular space of different organs and systems, especially the heart and the nervous system. Specific therapies for ATTR act at various levels of TTR, from synthesis to deposition: TTR tetramer stabilization, oligomer aggregation inhibition, genetic therapy, amyloid fibre degradation, antiserum amyloid P antibodies, and antiserum TTR antibodies. Treatment of systemic amyloidosis has dramatically evolved over the last few years in both AL and ATTR, improving disease prognosis. Moreover, recent studies revealed that timely treatment can lead to an improvement in clinical status and in a regression of amyloid myocardial infiltration showed by imaging, especially by cardiac magnetic resonance, in both AL and ATTR. However, treating cardiac amyloidosis is a complex task due to the frequent association between systemic congestion and low blood pressure, thrombo-embolic and haemorrhagic risk balance, patient frailty, and generally poor prognosis. The aim of this review is to describe the current state of knowledge regarding cardiac amyloidosis therapy in this constantly evolving field, classified as treatment of the cardiac complications of amyloidosis (heart failure, rhythm and conduction disturbances, and thrombo-embolic risk) and the disease-modifying therapy.
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Affiliation(s)
- Robert Daniel Adam
- Department of CardiologyEmergency Institute for Cardiovascular Diseases ‘Prof. Dr. C. C. Iliescu’3rd Cardiology Department, 258 Fundeni StreetBucharest022328Romania
- University of Medicine and Pharmacy ‘Carol Davila’BucharestRomania
| | - Daniel Coriu
- University of Medicine and Pharmacy ‘Carol Davila’BucharestRomania
- Department of HematologyFundeni Clinical InstituteBucharestRomania
| | - Andreea Jercan
- University of Medicine and Pharmacy ‘Carol Davila’BucharestRomania
| | - Sorina Bădeliţă
- Department of HematologyFundeni Clinical InstituteBucharestRomania
| | - Bogdan A. Popescu
- Department of CardiologyEmergency Institute for Cardiovascular Diseases ‘Prof. Dr. C. C. Iliescu’3rd Cardiology Department, 258 Fundeni StreetBucharest022328Romania
- University of Medicine and Pharmacy ‘Carol Davila’BucharestRomania
| | - Thibaud Damy
- French Referral Center for Cardiac AmyloidosisAmyloidosis Mondor NetworkCréteilFrance
- Department of CardiologyHenri Mondor Hospital/AP‐HPCréteilFrance
| | - Ruxandra Jurcuţ
- Department of CardiologyEmergency Institute for Cardiovascular Diseases ‘Prof. Dr. C. C. Iliescu’3rd Cardiology Department, 258 Fundeni StreetBucharest022328Romania
- University of Medicine and Pharmacy ‘Carol Davila’BucharestRomania
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21
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Muchtar E, Dispenzieri A, Gertz MA, Kumar SK, Buadi FK, Leung N, Lacy MQ, Dingli D, Ailawadhi S, Bergsagel PL, Fonseca R, Hayman SR, Kapoor P, Grogan M, Abou Ezzeddine OF, Rosenthal JL, Mauermann M, Siddiqui M, Gonsalves WI, Kourelis TV, Larsen JT, Reeder CB, Warsame R, Go RS, Murray DL, McPhail ED, Dasari S, Jevremovic D, Kyle RA, Lin Y, Lust JA, Russell SJ, Hwa YL, Fonder AL, Hobbs MA, Rajkumar SV, Roy V, Sher T. Treatment of AL Amyloidosis: Mayo Stratification of Myeloma and Risk-Adapted Therapy (mSMART) Consensus Statement 2020 Update. Mayo Clin Proc 2021; 96:1546-1577. [PMID: 34088417 DOI: 10.1016/j.mayocp.2021.03.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 01/31/2021] [Accepted: 03/03/2021] [Indexed: 12/17/2022]
Abstract
Immunoglobulin light chain (AL) amyloidosis is a clonal plasma cell disorder leading to progressive and life-threatening organ failure. The heart and the kidneys are the most commonly involved organs, but almost any organ can be involved. Because of the nonspecific presentation, diagnosis delay is common, and many patients are diagnosed with advanced organ failure. In the era of effective therapies and improved outcomes for patients with AL amyloidosis, the importance of early recognition is further enhanced as the ability to reverse organ dysfunction is limited in those with a profound organ failure. As AL amyloidosis is an uncommon disorder and given patients' frailty and high early death rate, management of this complex condition is challenging. The treatment of AL amyloidosis is based on various anti-plasma cell therapies. These therapies are borrowed and customized from the treatment of multiple myeloma, a more common disorder. However, a growing number of phase 2/3 studies dedicated to the AL amyloidosis population are being performed, making treatment decisions more evidence-based. Supportive care is an integral part of management of AL amyloidosis because of the inherent organ dysfunction, limiting the delivery of effective therapy. This extensive review brings an updated summary on the management of AL amyloidosis, sectioned into the 3 pillars for survival improvement: early disease recognition, anti-plasma cell therapy, and supportive care.
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Affiliation(s)
- Eli Muchtar
- Division of Hematology, Mayo Clinic, Rochester, MN.
| | | | | | | | | | - Nelson Leung
- Division of Hematology, Mayo Clinic, Rochester, MN; Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | | | - David Dingli
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | | | - Rafael Fonseca
- Division of Hematology/Oncology, Mayo Clinic, Scottsdale, AZ
| | | | | | - Martha Grogan
- Division of Hematology, Mayo Clinic, Rochester, MN; Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | | | | | | | | | | | | | - Jeremy T Larsen
- Division of Hematology/Oncology, Mayo Clinic, Scottsdale, AZ
| | - Craig B Reeder
- Division of Hematology/Oncology, Mayo Clinic, Scottsdale, AZ
| | | | - Ronald S Go
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - David L Murray
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Ellen D McPhail
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Surendra Dasari
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Dragan Jevremovic
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | - Yi Lin
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - John A Lust
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | - Yi Lisa Hwa
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | | | - S Vincent Rajkumar
- Division of Hematology, Mayo Clinic, Rochester, MN; Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Vivek Roy
- Division of Hematology/Oncology, Mayo Clinic, Jacksonville, FL
| | - Taimur Sher
- Division of Hematology/Oncology, Mayo Clinic, Jacksonville, FL
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22
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Bistola V, Parissis J, Foukarakis E, Valsamaki PN, Anastasakis A, Koutsis G, Efthimiadis G, Kastritis E. Practical recommendations for the diagnosis and management of transthyretin cardiac amyloidosis. Heart Fail Rev 2021; 26:861-879. [PMID: 33452596 DOI: 10.1007/s10741-020-10062-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/30/2020] [Indexed: 01/01/2023]
Abstract
Cardiac amyloidosis (CA) is an infiltrative restrictive cardiomyopathy caused by accumulation in the heart interstitium of amyloid fibrils formed by misfolded proteins. Most common CA types are light chain amyloidosis (AL) caused by monoclonal immunoglobulin light chains and transthyretin amyloidosis (ATTR) caused by either mutated or wild-type transthyretin aggregates. Previously considered a rare disease, CA is increasingly recognized among patients who may be misdiagnosed as undifferentiated heart failure with preserved ejection fraction (HFPEF), paradoxical low-flow/low-gradient aortic stenosis, or otherwise unexplained left ventricular hypertrophy. Progress in diagnosis has been due to the refinement of cardiac echocardiographic techniques (speckle tracking imaging) and magnetic resonance (T1 mapping) and mostly due to the advent of bone scintigraphy that has enabled noninvasive diagnosis of ATTR, limiting the need for endomyocardial biopsy. Importantly, proper management of CA starts from early recognition of suspected cases among high prevalence populations, followed by advanced diagnostic evaluation to confirm diagnosis and typing, preferentially in experienced amyloidosis centers. Differentiating ATTR from other types of amyloidosis, especially AL, is critical. Emerging targeted ATTR therapies offer the potential to improve outcomes of these patients previously treated only palliatively.
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Affiliation(s)
- Vasiliki Bistola
- Department of Cardiology, Heart Failure Unit, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - John Parissis
- Department of Cardiology, Heart Failure Unit, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Emmanouil Foukarakis
- Cardiology Department, Venizeleion General Hospital of Heraklion, Heraklion, Greece
| | - Pipitsa N Valsamaki
- Nuclear Medicine Department, "Alexandra" University General Hospital, Athens, Greece
| | - Aris Anastasakis
- Unit of Inherited and Rare Cardiovascular Diseases, Onassis Cardiac Surgery Center, Athens, Greece
| | - Georgios Koutsis
- Neurogenetics Unit, 1st Department of Neurology, National and Kapodistrian University of Athens, Eginition University Hospital, Athens, Greece
| | - Georgios Efthimiadis
- 1st Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece.
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23
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Abstract
PURPOSE OF REVIEW Light chain (AL) amyloidosis is an insidious progressive disease which results in significant morbidity and inevitable mortality if not diagnosed and treated promptly. This review will highlight recent developments and summarize critical clinical points and updated practice changes for the clinician in 2020. RECENT FINDINGS Comparative analyses of staging systems, updated prognostic tools, and treatment response criteria now allow for improved patient stratification and treatment decisions; the role of minimal residual disease in response assessment is still being assessed. Clinical and genetic predictors for long-term survivors have been highlighted. Standard-of-care front-line bortezomib and the integration of anti-CD38 monoclonal antibodies in the relapsed disease have transformed treatment approach in recent years. Various clinical trials in the pipeline include novel anti-plasma cell therapies and therapies directed against amyloid deposits which promise to further advance the treatment landscape. Diagnosis, response assessment, and treatment paradigms for AL amyloidosis have evolved significantly in the past 15 years, translating into superior outcomes and increased chances of long-term survival for AL amyloidosis.
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Towbin JA, McKenna WJ, Abrams DJ, Ackerman MJ, Calkins H, Darrieux FCC, Daubert JP, de Chillou C, DePasquale EC, Desai MY, Estes NAM, Hua W, Indik JH, Ingles J, James CA, John RM, Judge DP, Keegan R, Krahn AD, Link MS, Marcus FI, McLeod CJ, Mestroni L, Priori SG, Saffitz JE, Sanatani S, Shimizu W, van Tintelen JP, Wilde AAM, Zareba W. 2019 HRS expert consensus statement on evaluation, risk stratification, and management of arrhythmogenic cardiomyopathy: Executive summary. Heart Rhythm 2020; 16:e373-e407. [PMID: 31676023 DOI: 10.1016/j.hrthm.2019.09.019] [Citation(s) in RCA: 113] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Indexed: 01/14/2023]
Abstract
Arrhythmogenic cardiomyopathy (ACM) is an arrhythmogenic disorder of the myocardium not secondary to ischemic, hypertensive, or valvular heart disease. ACM incorporates a broad spectrum of genetic, systemic, infectious, and inflammatory disorders. This designation includes, but is not limited to, arrhythmogenic right/left ventricular cardiomyopathy, cardiac amyloidosis, sarcoidosis, Chagas disease, and left ventricular noncompaction. The ACM phenotype overlaps with other cardiomyopathies, particularly dilated cardiomyopathy with arrhythmia presentation that may be associated with ventricular dilatation and/or impaired systolic function. This expert consensus statement provides the clinician with guidance on evaluation and management of ACM and includes clinically relevant information on genetics and disease mechanisms. PICO questions were utilized to evaluate contemporary evidence and provide clinical guidance related to exercise in arrhythmogenic right ventricular cardiomyopathy. Recommendations were developed and approved by an expert writing group, after a systematic literature search with evidence tables, and discussion of their own clinical experience, to present the current knowledge in the field. Each recommendation is presented using the Class of Recommendation and Level of Evidence system formulated by the American College of Cardiology and the American Heart Association and is accompanied by references and explanatory text to provide essential context. The ongoing recognition of the genetic basis of ACM provides the opportunity to examine the diverse triggers and potential common pathway for the development of disease and arrhythmia.
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Affiliation(s)
- Jeffrey A Towbin
- Le Bonheur Children's Hospital, Memphis, Tennessee; University of Tennessee Health Science Center, Memphis, Tennessee
| | - William J McKenna
- University College London, Institute of Cardiovascular Science, London, United Kingdom
| | | | | | | | | | | | | | | | | | - N A Mark Estes
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Wei Hua
- Fu Wai Hospital, Beijing, China
| | - Julia H Indik
- University of Arizona, Sarver Heart Center, Tucson, Arizona
| | - Jodie Ingles
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, Australia
| | | | - Roy M John
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Daniel P Judge
- Medical University of South Carolina, Charleston, South Carolina
| | - Roberto Keegan
- Hospital Privado Del Sur, Buenos Aires, Argentina; Hospital Español, Bahia Blanca, Argentina
| | | | - Mark S Link
- UT Southwestern Medical Center, Dallas, Texas
| | - Frank I Marcus
- University of Arizona, Sarver Heart Center, Tucson, Arizona
| | | | - Luisa Mestroni
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Silvia G Priori
- University of Pavia, Pavia, Italy; European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARD-Heart); ICS Maugeri, IRCCS, Pavia, Italy
| | | | | | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - J Peter van Tintelen
- University of Amsterdam, Academic Medical Center, Amsterdam, the Netherlands; Utrecht University Medical Center Utrecht, University of Utrecht, Department of Genetics, Utrecht, the Netherlands
| | - Arthur A M Wilde
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARD-Heart); University of Amsterdam, Academic Medical Center, Amsterdam, the Netherlands; Department of Medicine, Columbia University Irving Medical Center, New York, New York
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25
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Abstract
Cardiac amyloidosis (CA) is an infiltrative and restrictive cardiomyopathy that leads to heart failure, reduced quality of life, and death. The disease has two main subtypes, transthyretin cardiac amyloidosis (ATTR-CA) and immunoglobulin light chain cardiac amyloidosis (AL-CA), characterized by the nature of the infiltrating protein. ATTR-CA is further subdivided into wild-type (ATTRwt-CA) and variant (ATTRv-CA) based on the presence or absence of a mutation in the transthyretin gene. CA is significantly underdiagnosed and increasingly recognized as a cause of heart failure with preserved ejection fraction. Advances in diagnosis that employ nuclear scintigraphy to diagnose ATTR-CA without a biopsy and the emergence of effective treatments, including transthyretin stabilizers and silencers, have changed the landscape of this field and render early and accurate diagnosis critical. This review summarizes the epidemiology, pathophysiology, diagnosis, prognosis, and management of CA with an emphasis on the significance of recent developments and suggested future directions.
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Affiliation(s)
- Jonah Rubin
- Clinical Cardiovascular Research Laboratory for the Elderly, Columbia University Irving Medical Center, Allen Hospital of NewYork-Presbyterian Hospital, New York, NY 10032, USA; ,
| | - Mathew S Maurer
- Clinical Cardiovascular Research Laboratory for the Elderly, Columbia University Irving Medical Center, Allen Hospital of NewYork-Presbyterian Hospital, New York, NY 10032, USA; ,
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Spoladore R, Falasconi G, Marcatti M, Di Maio S, Fiore G, Slavich M, Margonato A, Turco A, Fragasso G. Advances in pharmacotherapy for cardiac amyloidosis. Expert Opin Pharmacother 2020; 22:469-481. [PMID: 33043721 DOI: 10.1080/14656566.2020.1836159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Amyloidosis is a group of progressive and devastating disorders resulting from extracellular deposition of misfolded proteins into tissues. When deposition of fibrils occurs in cardiac tissues, this systemic disease can lead to a very poor prognosis. Systemic amyloidosis can be acquired [light chain (AL) amyloidosis; AA amyloidosis], or hereditary [transthyretin (ATTR) amyloidosis]. Cardiac disease in amyloidosis is usually secondary to a systemic disease. The diagnosis of cardiac involvement is often delayed and yields an adverse prognosis. AREAS COVERED in this review, the authors report current literature on advances in pharmacotherapy for cardiac amyloidosis, mainly focused on AL and ATTR amyloidosis treatment. EXPERT OPINION Most pharmacological trials in amyloidosis patients, both AL and TTR, are directed to study the effects of drugs on polyneuropathy. However, since cardiac involvement carries a prominent negative survival impact in amyloidosis patients, future research should be more focused on amyloidosis cardiomyopathy as primary endpoint. Additionally, in AL amyloidosis therapies are mainly derived from experience on multiple myeloma treatment. In this specific setting, possible future research could particularly focus on immunotherapeutic agents able to optimize the standard chemotherapy results and, thus, allowing a larger population of patients to be treated by bone marrow stem cell transplantation.
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Affiliation(s)
- R Spoladore
- Hypertrophic Cardiomyopathy Unit, IRCCS San Raffaele University Hospital, Milan, Italy.,Clinical Cardiology Unit, IRCCS San Raffaele University Hospital, Milan, Italy
| | - G Falasconi
- Clinical Cardiology Unit, IRCCS San Raffaele University Hospital, Milan, Italy
| | - M Marcatti
- Haematology Unit, IRCCS San Raffaele University Hospital, Milan, Italy
| | - S Di Maio
- Clinical Cardiology Unit, IRCCS San Raffaele University Hospital, Milan, Italy
| | - G Fiore
- Clinical Cardiology Unit, IRCCS San Raffaele University Hospital, Milan, Italy
| | - M Slavich
- Clinical Cardiology Unit, IRCCS San Raffaele University Hospital, Milan, Italy
| | - A Margonato
- Clinical Cardiology Unit, IRCCS San Raffaele University Hospital, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - A Turco
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - G Fragasso
- Clinical Cardiology Unit, IRCCS San Raffaele University Hospital, Milan, Italy.,Heart Failure Unit, IRCCS San Raffaele University Hospital, Milan, Italy
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Garcia-Pavia P, Domínguez F, Gonzalez-Lopez E. Transthyretin amyloid cardiomyopathy. Med Clin (Barc) 2020; 156:126-134. [PMID: 33138983 DOI: 10.1016/j.medcli.2020.06.064] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 06/25/2020] [Accepted: 06/27/2020] [Indexed: 12/11/2022]
Abstract
Transthyretin (TTR) cardiac amyloidosis is a severe, progressive, infiltrative disease caused by the deposition of TTR at cardiac level. It may be due to a genetic alteration in its hereditary form (ATTRv) or as a consequence of an age-related degenerative process (ATTRwt). Thanks to advances in imaging techniques and the possibility of achieving a non-invasive diagnosis, we now know that ATTR is more frequent than traditionally considered and that it is particularly relevant in patients over 65 years with heart failure or with aortic stenosis. With the appearance of several treatment options capable of modifying the natural history of ATTR, it is necessary for clinicians to be familiar with the diagnostic process and treatment of this disease. This review will cover the clinical spectrum of presentation of ATTR, its diagnosis and treatment.
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Affiliation(s)
- Pablo Garcia-Pavia
- Unidad de Insuficiencia Cardíaca y Cardiopatías Familiares, Servicio de Cardiología, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, España; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, España; Universidad Francisco de Vitoria (UFV), Pozuelo de Alarcón, España.
| | - Fernando Domínguez
- Unidad de Insuficiencia Cardíaca y Cardiopatías Familiares, Servicio de Cardiología, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, España; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, España
| | - Esther Gonzalez-Lopez
- Unidad de Insuficiencia Cardíaca y Cardiopatías Familiares, Servicio de Cardiología, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, España; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, España
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28
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Wong SW, Fogaren T. Supportive Care for Patients with Systemic Light Chain Amyloidosis. Hematol Oncol Clin North Am 2020; 34:1177-1191. [PMID: 33099432 DOI: 10.1016/j.hoc.2020.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Light chain amyloidosis is a disease in which clonal plasma cells produce toxic immunoglobulin light chains that form amyloid fibrils with deposition in organs, most commonly the heart and kidneys, but also the nervous system, gastrointestinal tract, and soft tissues. Treatment directed at the clonal cells eliminates light chain production and further deposition and may enable organ improvement and decrease the risk of organ failure. Supportive care manages the symptoms of organ involvement and the side effects of treatment. Supportive care also addresses the psychological and social issues that may arise in patients with light chain amyloidosis.
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Affiliation(s)
- Sandy W Wong
- Hematology/Blood and Marrow Transplantation, Comprehensive Amyloid Program, University of California, 400 Parnassus Avenue, San Francisco, CA 94143, USA.
| | - Teresa Fogaren
- Division of Hematology/Oncology, Tufts Medical Center, 800 Washington Street, Boston, MA 02111, USA
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29
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Emdin M, Aimo A, Rapezzi C, Fontana M, Perfetto F, Seferović PM, Barison A, Castiglione V, Vergaro G, Giannoni A, Passino C, Merlini G. Treatment of cardiac transthyretin amyloidosis: an update. Eur Heart J 2020; 40:3699-3706. [PMID: 31111153 DOI: 10.1093/eurheartj/ehz298] [Citation(s) in RCA: 114] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 02/11/2019] [Accepted: 04/23/2019] [Indexed: 12/21/2022] Open
Abstract
Transthyretin (TTR) is a tetrameric protein synthesized mostly by the liver. As a result of gene mutations or as an ageing-related phenomenon, TTR molecules may misfold and deposit in the heart and in other organs as amyloid fibrils. Cardiac involvement in TTR-related amyloidosis (ATTR) manifests typically as left ventricular pseudohypertrophy and/or heart failure with preserved ejection fraction. ATTR is an underdiagnosed disorder as well as a crucial determinant of morbidity and mortality, thus justifying the current quest for a safe and effective treatment. Therapies targeting cardiac damage and its direct consequences may yield limited benefit, mostly related to dyspnoea relief through diuretics. For many years, liver or combined heart and liver transplantation have been the only available treatments for patients with mutations causing ATTR, including those with cardiac involvement. The therapeutic options now include several pharmacological agents that inhibit hepatic synthesis of TTR, stabilize the tetramer, or disrupt fibrils. Following the positive results of a phase 3 trial on tafamidis, and preliminary findings on patisiran and inotersen in patients with ATTR-related neuropathy and cardiac involvement, we provide an update on this rapidly evolving field, together with practical recommendations on the management of cardiac involvement.
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Affiliation(s)
- Michele Emdin
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà 33, Pisa, Italy.,Cardiology Department, Fondazione Toscana Gabriele Monasterio, Via G. Moruzzi 1, Pisa, Italy
| | - Alberto Aimo
- Cardiology Division, University Hospital of Pisa, via Paradisa 2, Pisa, Italy
| | - Claudio Rapezzi
- Cardiology Division, University Hospital of Bologna, via Massarenti 9, Bologna, Italy
| | - Marianna Fontana
- Institute of Cardiovascular Science, University College London, 62 Huntley St, Fitzrovia, London, UK.,National Amyloidosis Centre, University College London, Royal Free Hospital, Gower Street, London, UK
| | - Federico Perfetto
- Regional Amyloid Centre, Azienda Ospedaliero Universitaria Careggi, Largo Piero Palagi 1, Florence, Italy.,Department of Internal and Experimental Medicine, University of Florence, Largo Piero Palagi 1, Florence, Italy
| | - Petar M Seferović
- Department of Internal Medicine, Belgrade University School of Medicine, Dr Subotica 8, Belgrade, Serbia.,Cardiology Department, University Institute for Cardiovascular Diseases, Heroja Milana Tepića 1, Belgrade, Serbia
| | - Andrea Barison
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà 33, Pisa, Italy.,Cardiology Department, Fondazione Toscana Gabriele Monasterio, Via G. Moruzzi 1, Pisa, Italy
| | - Vincenzo Castiglione
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà 33, Pisa, Italy.,Cardiology Division, University Hospital of Pisa, via Paradisa 2, Pisa, Italy
| | - Giuseppe Vergaro
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà 33, Pisa, Italy.,Cardiology Department, Fondazione Toscana Gabriele Monasterio, Via G. Moruzzi 1, Pisa, Italy
| | - Alberto Giannoni
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà 33, Pisa, Italy.,Cardiology Department, Fondazione Toscana Gabriele Monasterio, Via G. Moruzzi 1, Pisa, Italy
| | - Claudio Passino
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà 33, Pisa, Italy.,Cardiology Department, Fondazione Toscana Gabriele Monasterio, Via G. Moruzzi 1, Pisa, Italy
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Centre, Fondazione IRCCS Policlinico San Matteo, Viale Camillo Golgi 19, Pavia, Italy.,Department of Molecular Medicine, University of Pavia, Via C Forlanini 6, Pavia, Italy
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30
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Donnelly JP, Sperry BW, Gabrovsek A, Ikram A, Tang WHW, Estep J, Hanna M. Digoxin Use in Cardiac Amyloidosis. Am J Cardiol 2020; 133:134-138. [PMID: 32800294 DOI: 10.1016/j.amjcard.2020.07.034] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 07/05/2020] [Accepted: 07/13/2020] [Indexed: 12/14/2022]
Abstract
Despite limited options for rate control of atrial fibrillation and for low-output heart failure seen in cardiac amyloidosis (CA), digoxin use is discouraged due to a reported increased risk of sensitivity and toxicity. We present our experience with digoxin use in patients with CA and report the event rate of suspected digoxin-related arrhythmias and toxicity. This is a retrospective study of patients with CA seen at our institution between November 1995 and October 2018. Patients were screened for a history of ≥7 days of continuous digoxin use and stratified based on amyloid precursor protein-transthyretin (ATTR) and immunoglobulin light chain (AL). Medical records were used to identify suspected digoxin-related arrhythmias and toxicity events. Digoxin was used in 69 patients (42 ATTR, 27 AL) for a median duration of 6 months (IQR, 1 to 16). Indication for use was rate control in 64% of patients and symptomatic heart failure management in 36%. Suspected digoxin-related arrhythmias and toxicity events occurred in 12% of patients. No deaths were attributed to digoxin use or toxicity, but 11 patients died while on digoxin-most due to progressive heart failure in the setting of CA. In conclusion, digoxin may be a therapeutic option for rate and symptom control for some patients with AL-CA and ATTR-CA. Rigorous patient selection is recommended, and patients should be closely monitored during digoxin administration.
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Affiliation(s)
- Joseph P Donnelly
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio; Department of Chemistry, The Scripps Research Institute, La Jolla, California
| | - Brett W Sperry
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - Andrej Gabrovsek
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Asad Ikram
- Department of Neurology, The University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Jerry Estep
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Mazen Hanna
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio.
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Abstract
PURPOSE OF REVIEW The review's main focus centers on the genetics of hereditary cardiac amyloidosis, highlighting the opportunities and challenges posed by the widespread availability of genetic screening and diagnostic cardiac imaging. RECENT FINDINGS Advancements in cardiac imaging, heightened awareness of the ATTR amyloidosis diagnosis, and greater access to genetic testing have all led to an increased appreciation of the prevalence of ATTR cardiac amyloidosis. Elucidation of the TTR molecular structure and effect of mutations on TTR function have allowed for novel TTR therapy development leading to clinical implementation of transthyretin stabilizers and transthyretin gene silencers. The transthyretin amyloidoses are a diverse group of protein misfolding disorders with cardiac and peripheral/autonomic nervous system manifestations due to protein deposition. Genetic screening allows for the early identification of asymptomatic TTR mutation carriers. With the advent of TTR-specific therapeutics, clinical guidance is necessary for the management of individuals with mutations in the TTR gene without evidence of disease.
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32
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Abstract
PURPOSE Amyloidosis represents an increasingly recognized but still frequently missed cause of heart failure. In the light of many effective therapies for light chain (AL) amyloidosis and promising new treatment options for transthyretin (ATTR) amyloidosis, awareness among caregivers needs to be raised to screen for amyloidosis as an important and potentially treatable differential diagnosis. This review outlines the diversity of cardiac amyloidosis, its relation to heart failure, the diagnostic algorithm, and therapeutic considerations that should be applied depending on the underlying type of amyloidosis. RECENT FINDINGS Non-biopsy diagnosis is feasible in ATTR amyloidosis in the absence of a monoclonal component resulting in higher detection rates of cardiac ATTR amyloidosis. Biomarker-guided staging systems have been updated to facilitate risk stratification according to currently available biomarkers independent of regional differences, but have not yet prospectively been tested. Novel therapies for hereditary and wild-type ATTR amyloidosis are increasingly available. The complex treatment options for AL amyloidosis are improving continuously, resulting in better survival and quality of life. Mortality in advanced cardiac amyloidosis remains high, underlining the importance of early diagnosis and treatment initiation. Cardiac amyloidosis is characterized by etiologic and clinical heterogeneity resulting in a frequently delayed diagnosis and an inappropriately high mortality risk. New treatment options for this hitherto partially untreatable condition have become and will become available, but raise challenges regarding their implementation. Referral to specialized centers providing access to extensive and targeted diagnostic investigations and treatment initiation may help to face these challenges.
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33
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Cardiac Amyloidosis in Patients Undergoing TAVR: Why We Need to Think About It. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 22:109-114. [PMID: 32571759 DOI: 10.1016/j.carrev.2020.06.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 04/20/2020] [Accepted: 06/03/2020] [Indexed: 01/15/2023]
Abstract
Systemic amyloidosis encompasses a variety of diseases characterized by extracellular deposition of protein-derived fibrils in different tissues and organs. Immunoglobulin light-chain (AL) and transthyretin (ATTR) amyloid are the two types that more commonly affect the heart and in both subtypes cardiac involvement is the main determinant of prognosis. Recently, several studies have suggested that Cardiac Amyloidosis (CA) and Aortic Stenosis (AS) can coexist more frequently than previously suspected with prevalence ranging from 5,6% to 16% in different cohorts. The unexpected high prevalence of CA in AS and the availability of potentially effective treatment in CA should push us to carefully investigate elderly patients with aortic valve stenosis in order to identify those with coexistent amyloidosis. While the motivation to exclude amyloidosis was in the past their exclusion from active treatment of the valve disease, judged as futile because of their poor unavoidable prognosis, the improved therapeutic options available challenges this conservative approach. Aim of this review is to identify the triggers to investigate AS patients at risk of having concomitant ATTR-CA, to propose a diagnostic path to reach diagnosis and to discuss the changes in the therapeutic strategy caused by this discovery in the era of TAVR and active pharmacological treatments to slow down disease progression.
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34
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Heart transplantation in cardiac storage diseases: data on Fabry disease and cardiac amyloidosis. Curr Opin Organ Transplant 2020; 25:211-217. [DOI: 10.1097/mot.0000000000000756] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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35
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Itzhaki Ben Zadok O, Kornowski R. Cardiac Care of Patients with Cardiac Amyloidosis. Acta Haematol 2020; 143:343-351. [PMID: 32408301 DOI: 10.1159/000506919] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 02/28/2020] [Indexed: 12/20/2022]
Abstract
Cardiac amyloidosis, the majority of cases of which are due to immunoglobulin light chain amyloidosis (AL) and transthyretin amyloidosis (ATTR), affects different aspects of the heart and cardiovascular system. Amyloid-induced cardiomyopathy, clinically manifesting with heart failure and electrophysiological abnormalities, has distinct characteristics compared to non-amyloid cardiomyopathies. Accordingly, specific management strategies are required. This paper will review the cardiovascular manifestations of patients with cardiac amyloidosis and their suggested treatment strategies, emphasizing the importance of multidisciplinary care.
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Affiliation(s)
- Osnat Itzhaki Ben Zadok
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel,
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,
| | - Ran Kornowski
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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36
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Macedo AVS, Schwartzmann PV, de Gusmão BM, Melo MDTD, Coelho-Filho OR. Advances in the Treatment of Cardiac Amyloidosis. Curr Treat Options Oncol 2020; 21:36. [PMID: 32328845 PMCID: PMC7181421 DOI: 10.1007/s11864-020-00738-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OPINION STATEMENT Cardiac amyloidosis is associated with a high mortality rate, a long delay between the first signs and the diagnosis but a short interval between diagnosis and death. This scenario has changed recently due to improved disease awareness among doctors and significant progress in diagnosis thanks to multimodal imaging and a multidisciplinary approach. Therefore, during the last few years, we have had access to specific therapies for those patients. Those therapies are quite different depending on the type of amyloidosis, but there has been real progress. Systemic light chain amyloidosis (AL) with cardiac involvement is the most common form of cardiac amyloidosis. The severity of heart disease dictates the prognosis in AL amyloidosis. Advances in chemotherapy and immunotherapy that suppress light chain production have improved the outcomes. These recent improvements in survival rates have enabled therapies such as implanted cardiac defibrillators and heart transplantation that were usually not indicated for patients with advanced light chain amyloid cardiomyopathy to now be applied in selected patients. For transthyretin amyloidosis (ATTR), the second most common form of amyloidosis with cardiac involvement, there is also significant progress in treatment. Until recently, we had no specific therapy for ATTR cardiomyopathy (ATTR-CM), though now disease-modifying therapies are available. Therapies that stabilize transthyretin, such as tafamidis, have been shown to improve outcomes for patients with ATTR-CM. Modern treatments that stop the synthesis of TTR through gene silencing, such as patisiran and inotersen, have shown positive results for patients with TTR amyloidosis. Significant progress has been made in the treatment of amyloid cardiomyopathy, and hopefully, we will see even more progress with the spread of those treatments. We now can be optimistic about patients with this disease.
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Affiliation(s)
| | | | | | | | - Otávio Rizzi Coelho-Filho
- Department of Internal Medicine, Discipline of Cardiology, Faculty of Medical Science, State University of Campinas, Campinas, Brazil
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37
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Aimo A, Rapezzi C, Vergaro G, Giannoni A, Spini V, Passino C, Emdin M. Management of complications of cardiac amyloidosis: 10 questions and answers. Eur J Prev Cardiol 2020; 28:1000-1005. [PMID: 32299232 DOI: 10.1177/2047487320920756] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 03/31/2020] [Indexed: 01/15/2023]
Abstract
Amyloidosis is a systemic disorder characterized by extracellular deposition of insoluble fibrils. The most common forms are amyloid light chain and amyloid transthyretin (ATTR) amyloidoses. Cardiac involvement may be found in both these forms, and is an important cause of morbidity and mortality. The clinical presentation of cardiac amyloidosis (CA) may be represented by congestive heart failure (HF), possibly progressing to end-stage HF, as well as atrial fibrillation with possible thromboembolic events, and also conduction disturbances related to amyloid infiltration of conduction fibres. Beyond therapies targeting the blood dyscrasia or the ATTR amyloidogenic cascade, a careful choice of drug therapies, need for device implantation, and possibly treatments for advanced HF is then warranted. In the present review, we try to provide a useful guide to clinicians treating patients with CA by enucleating 10 main questions and answering them based on the evidence available as well as expert opinion and our clinical experience.
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Affiliation(s)
- Alberto Aimo
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Italy
| | | | - Giuseppe Vergaro
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Italy.,Fondazione Toscana Gabriele Monasterio, Italy
| | - Alberto Giannoni
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Italy.,Fondazione Toscana Gabriele Monasterio, Italy
| | | | - Claudio Passino
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Italy.,Fondazione Toscana Gabriele Monasterio, Italy
| | - Michele Emdin
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Italy.,Fondazione Toscana Gabriele Monasterio, Italy
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Giancaterino S, Urey MA, Darden D, Hsu JC. Management of Arrhythmias in Cardiac Amyloidosis. JACC Clin Electrophysiol 2020; 6:351-361. [DOI: 10.1016/j.jacep.2020.01.004] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 12/28/2019] [Accepted: 01/09/2020] [Indexed: 12/16/2022]
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Arrhythmias in Cardiac Amyloidosis: Challenges in Risk Stratification and Treatment. Can J Cardiol 2020; 36:416-423. [DOI: 10.1016/j.cjca.2019.11.039] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 11/08/2019] [Accepted: 11/18/2019] [Indexed: 12/16/2022] Open
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Muchtar E, Lin G, Grogan M. The Challenges in Chemotherapy and Stem Cell Transplantation for Light-Chain Amyloidosis. Can J Cardiol 2020; 36:384-395. [DOI: 10.1016/j.cjca.2019.11.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 11/27/2019] [Accepted: 11/27/2019] [Indexed: 11/30/2022] Open
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Bart NK, Thomas L, Korczyk D, Atherton JJ, Stewart GJ, Fatkin D. Amyloid Cardiomyopathy. Heart Lung Circ 2019; 29:575-583. [PMID: 32001152 DOI: 10.1016/j.hlc.2019.11.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 11/23/2019] [Accepted: 11/29/2019] [Indexed: 01/15/2023]
Abstract
Amyloid cardiomyopathy is emerging as an important and under-recognised cause of heart failure and cardiac arrhythmias, especially in older adults. This disorder is characterised by extracellular deposition of amyloid fibrils that form due to misfolding of secreted light chains (AL) or transthyretin protein (ATTR). In ATTR, amyloid aggregates typically result from excessive accumulation of wild-type transthyretin (ATTRwt) or from protein structural defects caused by TTR gene variants (ATTRv). Amyloid fibril deposition may predominantly affect the heart or show multi-system involvement. Previously considered to be rare and inexorably progressive with no specific therapy, there has been enormous recent interest in ATTR cardiomyopathy due to upwardly-revised estimates of disease prevalence together with development of disease-modifying interventions. Because of this, there is a clinical imperative to have a high index of suspicion to identify potential cases and to be aware of contemporary diagnostic methods and treatment options. Genetic testing should be offered to all patients with proven ATTR to access the benefits of new therapies specific to ATTRv and allow predictive testing of family members. With heightened awareness of amyloid cardiomyopathy and expanded use of genetic testing, a substantial rise in the numbers of asymptomatic individuals who are carriers of pathogenic variants is expected, and optimal strategies for monitoring and treatment of these individuals at risk need to be determined. Pre-emptive administration of fibril-modifying therapies provides an unprecedented opportunity for disease prevention and promises to change amyloid cardiomyopathy from being a fatal to a treatable disorder.
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Affiliation(s)
- Nicole K Bart
- Cardiology Department, St. Vincent's Hospital, Sydney NSW, Australia; Molecular Cardiology Division, Victor Chang Cardiac Research Institute, Sydney NSW, Australia; St. Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney NSW, Australia
| | - Liza Thomas
- Cardiology Department, Westmead Hospital, Sydney NSW, Australia; Westmead Clinical School, University of Sydney, Sydney NSW, Australia; South Western Clinical School, University of NSW, Sydney NSW, Australia
| | - Dariusz Korczyk
- Cardiology Department, Princess Alexandra Hospital, Brisbane Qld, Australia; University of Queensland, Brisbane Qld, Australia
| | - John J Atherton
- University of Queensland, Brisbane Qld, Australia; Cardiology Department, Royal Brisbane and Women's Hospital, Brisbane Qld, Australia
| | - Graeme J Stewart
- Westmead Clinical School, University of Sydney, Sydney NSW, Australia; Clinical Immunology Department & Westmead Amyloidosis Centre, Westmead Hospital, Sydney, NSW, Australia
| | - Diane Fatkin
- Cardiology Department, St. Vincent's Hospital, Sydney NSW, Australia; Molecular Cardiology Division, Victor Chang Cardiac Research Institute, Sydney NSW, Australia; St. Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney NSW, Australia.
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Ternacle J, Krapf L, Mohty D, Magne J, Nguyen A, Galat A, Gallet R, Teiger E, Côté N, Clavel MA, Tournoux F, Pibarot P, Damy T. Aortic Stenosis and Cardiac Amyloidosis. J Am Coll Cardiol 2019; 74:2638-2651. [DOI: 10.1016/j.jacc.2019.09.056] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 09/13/2019] [Accepted: 09/16/2019] [Indexed: 01/03/2023]
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Witteles RM, Liedtke M. AL Amyloidosis for the Cardiologist and Oncologist: Epidemiology, Diagnosis, and Management. JACC CardioOncol 2019; 1:117-130. [PMID: 34396169 PMCID: PMC8352106 DOI: 10.1016/j.jaccao.2019.08.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Revised: 08/09/2019] [Accepted: 08/11/2019] [Indexed: 02/07/2023] Open
Abstract
AL amyloidosis results from clonal production of immunoglobulin light chains, most commonly arising from a clonal plasma cell disorder. Once considered a nearly uniformly fatal disease, prognosis has improved markedly over the past 15 years, predominantly because of advances in light chain suppressive therapies. Cardiac deposition of amyloid fibrils is common, and the severity of cardiac involvement remains the primary driver of prognosis. Improvements in chemotherapy/immunotherapy have prompted a reassessment of the role of advanced cardiac therapies previously considered contraindicated in most patients, including the role of implantable cardioverter-defibrillators and cardiac transplantation. This state-of-the-art review highlights the current state of the field, including diagnosis, prognosis, and hematologic- and cardiac-specific therapies.
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Key Words
- AL amyloidosis
- ASCT, autologous stem cell transplantation
- BNP, B-type natriuretic peptide
- CyBorD, cyclophosphamide, bortezomib, and dexamethasone
- FLC, free light chain
- ICD, implantable cardioverter-defibrillator
- MGUS, monoclonal gammopathy of undetermined significance
- NT-proBNP, N-terminal pro–B-type natriuretic peptide
- SAP, serum amyloid P
- SPIE, serum protein electrophoresis with immunofixation
- UPIE, urine protein electrophoresis with immunofixation
- amyloidosis
- diagnosis
- drug therapy
- heart failure
- imaging
- treatment
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Affiliation(s)
- Ronald M. Witteles
- Division of Cardiovascular Medicine, Stanford Amyloid Center, Stanford University School of Medicine, Stanford, California, USA
| | - Michaela Liedtke
- Division of Hematology, Stanford Amyloid Center, Stanford University School of Medicine, Stanford, California, USA
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Manolis AS, Manolis AA, Manolis TA, Melita H. Cardiac amyloidosis: An underdiagnosed/underappreciated disease. Eur J Intern Med 2019; 67:1-13. [PMID: 31375251 DOI: 10.1016/j.ejim.2019.07.022] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 07/15/2019] [Accepted: 07/23/2019] [Indexed: 12/14/2022]
Abstract
Cardiac amyloidosis or amyloid cardiomyopathy (ACM), commonly resulting from extracellular deposition of amyloid fibrils consisted of misfolded immunoglobulin light chain (AL) or transthyretin (TTR) protein, is an underestimated cause of heart failure and cardiac arrhythmias. Among the three types of cardiac amyloidosis (wild-type or familial TTR and light-chain), the wild-type (Wt) TTR-related amyloidosis (ATTR) is an increasingly recognized cause of heart failure with preserved ejection fraction (HFpEF), and amyloidosis should be considered in the differential diagnosis of this heart failure group of patients. Recent advances in the diagnosis and drug treatment of ACM have ushered in a new era in early disease detection and better management of these patients. Certain clues in cardiac and extracardiac manifestations of ACM may heighten clinical suspicion and guide further confirmatory testing. Newer noninvasive imaging methods (strain echocardiography, cardiac magnetic resonance and bone scintigraphy) may obviate the need for endomyocardial biopsy in ATTR patients, while newer targeted therapies may alter the adverse prognosis in these patients. Early recognition of ACM is crucial in halting the disease process before irreversible organ damage occurs. Chemotherapy and stem-cell transplantation combined with immunomodulatory therapy may also favorably affect the course and prognosis of light chain ACM. Finally, in select patients with end-stage disease, heart transplantation may render results comparable to non-ACM patients. All these issues are herein reviewed.
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Affiliation(s)
- Antonis S Manolis
- Third Department of Cardiology, Athens University School of Medicine, Athens, Greece.
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Puig-Carrion GD, Reyentovich A, Katz SD. Diagnosis and treatment of heart failure in hereditary transthyretin amyloidosis. Clin Auton Res 2019; 29:45-53. [PMID: 31452023 PMCID: PMC6763576 DOI: 10.1007/s10286-019-00629-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 08/02/2019] [Indexed: 01/15/2023]
Abstract
Amyloidosis describes a family of related disease states associated with the extracellular tissue deposition of fibrils composed of low-molecular-weight subunits of a variety of proteins circulating as constituents of plasma. Depending on the disease subtype, fibrillar deposits in a several organs including the heart, kidney, liver, and peripheral nerves cause organ dysfunction and associated morbidity and mortality. The most common amyloid fibril deposits associated with cardiac manifestations are of monoclonal light-chain or transthyretin (ATTR) types. This review will focus on the ATTR types of cardiac amyloidosis. ATTR amyloidosis may be associated with abnormal metabolism of wild-type transthyretin (previously called senile systemic amyloidosis) or with hereditary variants in the transthyretin gene. Cardiac amyloidosis is often under-recognized in its early stages, and when a diagnosis of cardiac amyloidosis is made, patients are often at the advanced stages of the disease. Treatments now available appear to exert their benefit predominantly in individuals with the early stages of disease. Increased awareness and early diagnosis of cardiac amyloidosis and continued discovery of effective therapies will increase opportunities to improve clinical outcomes in this patient population.
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Affiliation(s)
- Gisela D Puig-Carrion
- Leon H. Charney Division of Cardiology, NYU Langone Medical Center, New York University Langone Health, 530 First Avenue, Skirball Suite 9 N, New York, NY, 10016, USA
| | - Alex Reyentovich
- Leon H. Charney Division of Cardiology, NYU Langone Medical Center, New York University Langone Health, 530 First Avenue, Skirball Suite 9 N, New York, NY, 10016, USA
| | - Stuart D Katz
- Leon H. Charney Division of Cardiology, NYU Langone Medical Center, New York University Langone Health, 530 First Avenue, Skirball Suite 9 N, New York, NY, 10016, USA.
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46
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Affiliation(s)
- Christopher Strouse
- Department of Internal Medicine, Division of Hematology, Oncology, and Blood and Marrow Transplantation, University of Iowa, Iowa City, IA, USA
| | - Alexandros Briasoulis
- Cardiomyopathy Section, Cardiology Division, University of Iowa, Iowa City, Iowa, USA
| | - Rafael Fonseca
- Bone Marrow Transplant Program, Mayo Clinic, Phoenix, Arizona, USA
| | - Yogesh Jethava
- Department of Internal Medicine, Division of Hematology, Oncology, and Blood and Marrow Transplantation, University of Iowa, Iowa City, IA, USA
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Towbin JA, McKenna WJ, Abrams DJ, Ackerman MJ, Calkins H, Darrieux FCC, Daubert JP, de Chillou C, DePasquale EC, Desai MY, Estes NAM, Hua W, Indik JH, Ingles J, James CA, John RM, Judge DP, Keegan R, Krahn AD, Link MS, Marcus FI, McLeod CJ, Mestroni L, Priori SG, Saffitz JE, Sanatani S, Shimizu W, van Tintelen JP, Wilde AAM, Zareba W. 2019 HRS expert consensus statement on evaluation, risk stratification, and management of arrhythmogenic cardiomyopathy. Heart Rhythm 2019; 16:e301-e372. [PMID: 31078652 DOI: 10.1016/j.hrthm.2019.05.007] [Citation(s) in RCA: 413] [Impact Index Per Article: 82.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Indexed: 02/08/2023]
Abstract
Arrhythmogenic cardiomyopathy (ACM) is an arrhythmogenic disorder of the myocardium not secondary to ischemic, hypertensive, or valvular heart disease. ACM incorporates a broad spectrum of genetic, systemic, infectious, and inflammatory disorders. This designation includes, but is not limited to, arrhythmogenic right/left ventricular cardiomyopathy, cardiac amyloidosis, sarcoidosis, Chagas disease, and left ventricular noncompaction. The ACM phenotype overlaps with other cardiomyopathies, particularly dilated cardiomyopathy with arrhythmia presentation that may be associated with ventricular dilatation and/or impaired systolic function. This expert consensus statement provides the clinician with guidance on evaluation and management of ACM and includes clinically relevant information on genetics and disease mechanisms. PICO questions were utilized to evaluate contemporary evidence and provide clinical guidance related to exercise in arrhythmogenic right ventricular cardiomyopathy. Recommendations were developed and approved by an expert writing group, after a systematic literature search with evidence tables, and discussion of their own clinical experience, to present the current knowledge in the field. Each recommendation is presented using the Class of Recommendation and Level of Evidence system formulated by the American College of Cardiology and the American Heart Association and is accompanied by references and explanatory text to provide essential context. The ongoing recognition of the genetic basis of ACM provides the opportunity to examine the diverse triggers and potential common pathway for the development of disease and arrhythmia.
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Affiliation(s)
- Jeffrey A Towbin
- Le Bonheur Children's Hospital, Memphis, Tennessee; University of Tennessee Health Science Center, Memphis, Tennessee
| | - William J McKenna
- University College London, Institute of Cardiovascular Science, London, United Kingdom
| | | | | | | | | | | | | | | | | | - N A Mark Estes
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Wei Hua
- Fu Wai Hospital, Beijing, China
| | - Julia H Indik
- University of Arizona, Sarver Heart Center, Tucson, Arizona
| | - Jodie Ingles
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, Australia
| | | | - Roy M John
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Daniel P Judge
- Medical University of South Carolina, Charleston, South Carolina
| | - Roberto Keegan
- Hospital Privado Del Sur, Buenos Aires, Argentina; Hospital Español, Bahia Blanca, Argentina
| | | | - Mark S Link
- UT Southwestern Medical Center, Dallas, Texas
| | - Frank I Marcus
- University of Arizona, Sarver Heart Center, Tucson, Arizona
| | | | - Luisa Mestroni
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Silvia G Priori
- University of Pavia, Pavia, Italy; European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARD-Heart); ICS Maugeri, IRCCS, Pavia, Italy
| | | | | | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - J Peter van Tintelen
- University of Amsterdam, Academic Medical Center, Amsterdam, the Netherlands; Utrecht University Medical Center Utrecht, University of Utrecht, Department of Genetics, Utrecht, the Netherlands
| | - Arthur A M Wilde
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARD-Heart); University of Amsterdam, Academic Medical Center, Amsterdam, the Netherlands; Department of Medicine, Columbia University Irving Medical Center, New York, New York
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High-dose melphalan and autologous peripheral blood stem cell transplantation in patients with AL amyloidosis and cardiac defibrillators. Bone Marrow Transplant 2019; 54:1304-1309. [DOI: 10.1038/s41409-019-0440-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 12/19/2018] [Accepted: 12/22/2018] [Indexed: 11/08/2022]
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Abstract
Systemic immunoglobulin light chain amyloidosis is a protein misfolding disease caused by the conversion of immunoglobulin light chains from their soluble functional states into highly organized amyloid fibrillar aggregates that lead to organ dysfunction. The disease is progressive and, accordingly, early diagnosis is vital to prevent irreversible organ damage, of which cardiac damage and renal damage predominate. The development of novel sensitive biomarkers and imaging technologies for the detection and quantification of organ involvement and damage is facilitating earlier diagnosis and improved evaluation of the efficacy of new and existing therapies. Treatment is guided by risk assessment, which is based on levels of cardiac biomarkers; close monitoring of clonal and organ responses guides duration of therapy and changes in regimen. Several new classes of drugs, such as proteasome inhibitors and immunomodulatory drugs, along with high-dose chemotherapy and autologous haematopoietic stem cell transplantation, have led to rapid and deep suppression of amyloid light chain production in the majority of patients. However, effective therapies for patients with advanced cardiac involvement are an unmet need. Passive immunotherapies targeting clonal plasma cells and directly accelerating removal of amyloid deposits promise to further improve the overall outlook of this increasingly treatable disease.
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50
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Ruiz-Guerrero L, Barriales-Villa R. Storage diseases with hypertrophic cardiomyopathy phenotype. Glob Cardiol Sci Pract 2018; 2018:28. [PMID: 30393640 PMCID: PMC6209457 DOI: 10.21542/gcsp.2018.28] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Never judge a book by its cover, nor assume hypertrophic cardiomyopathy (HCM) as sarcomeric, as appearances can deceive. HCM phenocopies account for a 5–10% of the cases, mainly represented by storage diseases, flagged by the increasing prevalence of senile cardiac amyloid in developing countries. Multisystemic and heterogeneous presentation of these entities is a challenge for clinicians, and time delay in diagnosis is a major concern. Promising drugs and gene-specific tailored therapies are under development, therefore, more than ever, appropriate understanding of these conditions is mandatory for adequate early treatment and counselling. In this review, storage disorders will be classified as extracellular and intracellular deposit storage diseases, focusing our attention on the most prevalent conditions from the cardiologist’s perspective.
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Affiliation(s)
- Luis Ruiz-Guerrero
- Cardiology Service, Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Marqués de Valdecilla (IDIVAL), Santander, Spain
| | - Roberto Barriales-Villa
- Inherited Cardiovascular Diseases Unit, Cardiology Service, Complexo Hospitalario Universitario de A Coruña, Instituto de Investigación Biomédica de A Coruña (INIBIC), Servizo Galego de Saúde (SERGAS), Universidade da Coruña, A Coruña, Spain.,Centro de Investigación Biomédica en Red. Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
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