1
|
Ioannou A, Fumagalli C, Razvi Y, Porcari A, Rauf MU, Martinez-Naharro A, Venneri L, Moody W, Steeds RP, Petrie A, Whelan C, Wechalekar A, Lachmann H, Hawkins PN, Solomon SD, Gillmore JD, Fontana M. Prognostic Value of a 6-Minute Walk Test in Patients With Transthyretin Cardiac Amyloidosis. J Am Coll Cardiol 2024:S0735-1097(24)06893-1. [PMID: 38739065 DOI: 10.1016/j.jacc.2024.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 04/03/2024] [Accepted: 04/10/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND The 6-minute walk test (6MWT) represents a comprehensive functional assessment that is commonly used in patients with heart failure; however, data are lacking in patients with transthyretin cardiac amyloidosis (ATTR-CA). OBJECTIVES This study aimed to assess the prognostic importance of the 6MWT in patients with ATTR-CA. METHODS A retrospective analysis of patients diagnosed with ATTR-CA at the National Amyloidosis Centre who underwent a baseline 6MWT between 2011 and 2023 identified 2,141 patients, of whom 1,118 had follow-up at 1 year. RESULTS The median baseline 6MWT distance was 347 m (Q1-Q3: 250-428 m) and analysis by quartiles demonstrated an increased death rate with each distance reduction (deaths per 100 person-years: 6.3 vs 9.2 vs 13.6 vs 19.0; log-rank P < 0.001). A 6MWT distance of <350 m was associated with a 2.2-fold higher risk of mortality (HR: 2.15; 95% CI: 1.85-2.50; P < 0.001), with a similar increased risk across National Amyloidosis Centre disease stages (P for interaction = 0.761) and genotypes (P for interaction = 0.172). An absolute (reduction of >35 m) and relative worsening (reduction of >5%) of 6MWT at 1 year was associated with an increased risk of mortality (HR: 1.80; 95% CI: 1.51-2.15; P < 0.001 and HR: 1.89; 95% CI: 1.59-2.24; P < 0.001, respectively), which was similar across the aforementioned subgroups. When combined with established measures of disease progression (N-terminal pro-B-type natriuretic peptide progression and outpatient diuretic intensification), each incremental increase in progression markers was associated with an increased death rate (deaths per 100 person-years: 7.6 vs 13.9 vs 22.4 vs 32.9; log-rank P < 0.001). CONCLUSIONS The baseline 6MWT distance can refine risk stratification beyond traditional prognosticators. A worsening 6MWT distance can stratify disease progression and, when combined with established markers, identifies patients at the highest risk of mortality.
Collapse
Affiliation(s)
- Adam Ioannou
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Carlo Fumagalli
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom; Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Yousuf Razvi
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Aldostefano Porcari
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom; Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina, University of Trieste, Trieste, Italy
| | - Muhammad U Rauf
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Ana Martinez-Naharro
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Lucia Venneri
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - William Moody
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom; Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham, United Kingdom
| | - Richard P Steeds
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom; Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham, United Kingdom
| | - Aviva Petrie
- University College London, London, United Kingdom
| | - Carol Whelan
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Ashutosh Wechalekar
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Helen Lachmann
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Philip N Hawkins
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Julian D Gillmore
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Marianna Fontana
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom.
| |
Collapse
|
3
|
Ioannou A, Cappelli F, Emdin M, Nitsche C, Longhi S, Masri A, Cipriani A, Zampieri M, Colio F, Poledniczek M, Porcari A, Razvi Y, Aimo A, Vergaro G, De Michieli L, Rauf MU, Patel RK, Villanueva E, Lustig Y, Venneri L, Martinez-Naharro A, Lachmann H, Wechalekar A, Whelan C, Petrie A, Hawkins PN, Solomon S, Gillmore JD, Fontana M. Stratifying Disease Progression in Patients With Cardiac ATTR Amyloidosis. J Am Coll Cardiol 2024; 83:S0735-1097(24)00251-1. [PMID: 38530684 PMCID: PMC11004588 DOI: 10.1016/j.jacc.2023.12.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 12/26/2023] [Accepted: 12/28/2023] [Indexed: 03/28/2024]
Abstract
BACKGROUND Transthyretin cardiac amyloidosis (ATTR-CA) is a progressive cardiomyopathy. The clinical course varies among individuals and there are no established measures to assess disease progression. OBJECTIVES The goal of this study was to assess the prognostic importance of an increase in N-terminal pro-B-type natriuretic peptide (NT-proBNP) and outpatient diuretic intensification (ODI) as markers of disease progression in a large cohort of patients with ATTR-CA. METHODS We evaluated landmark survival analysis based on worsening of NT-proBNP and requirement for ODI between time of diagnosis and a 1-year visit, and subsequent mortality in 2,275 patients with ATTR-CA from 7 specialist centers. The variables were developed in the National Amyloidosis Centre (NAC) cohort (n = 1,598) and validated in the external cohort from the remaining centers (n = 677). RESULTS Between baseline and 1-year visits, 551 (34.5%) NAC patients and 204 (30.1%) patients in the external validation cohort experienced NT-proBNP progression (NT-proBNP increase >700 ng/L and >30%), which was associated with mortality (NAC cohort: HR: 1.82; 95% CI: 1.57-2.10; P < 0.001; validation cohort: HR: 1.75; 95% CI: 1.32-2.33; P < 0.001). At 1 year, 451 (28.2%) NAC patients and 301 (44.5%) patients in the external validation cohort experienced ODI, which was associated with mortality (NAC cohort: HR: 1.88; 95% CI: 1.62-2.18; P < 0.001; validation cohort: HR: 2.05; 95% CI: 1.53-2.74; P < 0.001). When compared with patients with a stable NT-proBNP and stable diuretic dose, a higher risk of mortality was observed in those experiencing either NT-proBNP progression or ODI (NAC cohort: HR: 1.93; 95% CI: 1.65-2.27; P < 0.001; validation cohort: HR: 1.94; 95% CI: 1.36-2.77; P < 0.001), and those experiencing both NT-proBNP progression and ODI (NAC cohort: HR: 2.98; 95% CI: 2.42-3.67; P < 0.001; validation cohort: HR: 3.23; 95% CI: 2.17-4.79; P < 0.001). CONCLUSIONS NT-proBNP progression and ODI are frequent and consistently associated with an increased risk of mortality. Combining both variables produces a simple, universally applicable model that detects disease progression in ATTR-CA.
Collapse
Affiliation(s)
- Adam Ioannou
- National Amyloidosis Centre, University College London, London, United Kingdom
| | - Francesco Cappelli
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Michele Emdin
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy; Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Christian Nitsche
- Division of Cardiology, Department of Internal Medicine, Medical University of Vienna, Vienna, Austria
| | - Simone Longhi
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Ahmad Masri
- OHSU Center for Hypertrophic Cardiomyopathy and Amyloidosis, Portland, Oregon, USA
| | - Alberto Cipriani
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy; Cardiology Unit, University Hospital Padua, Padua, Italy
| | - Mattia Zampieri
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Federica Colio
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Michael Poledniczek
- Division of Cardiology, Department of Internal Medicine, Medical University of Vienna, Vienna, Austria
| | - Aldostefano Porcari
- National Amyloidosis Centre, University College London, London, United Kingdom; Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Yousuf Razvi
- National Amyloidosis Centre, University College London, London, United Kingdom
| | - Alberto Aimo
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy; Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Giuseppe Vergaro
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy; Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Laura De Michieli
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Muhammad U Rauf
- National Amyloidosis Centre, University College London, London, United Kingdom
| | - Rishi K Patel
- National Amyloidosis Centre, University College London, London, United Kingdom
| | - Eugenia Villanueva
- National Amyloidosis Centre, University College London, London, United Kingdom
| | - Yael Lustig
- National Amyloidosis Centre, University College London, London, United Kingdom
| | - Lucia Venneri
- National Amyloidosis Centre, University College London, London, United Kingdom
| | | | - Helen Lachmann
- National Amyloidosis Centre, University College London, London, United Kingdom
| | - Ashutosh Wechalekar
- National Amyloidosis Centre, University College London, London, United Kingdom
| | - Carol Whelan
- National Amyloidosis Centre, University College London, London, United Kingdom
| | - Aviva Petrie
- University College London, Biostatistics Unit, UCL Eastman Dental Institute, London, United Kingdom
| | - Philip N Hawkins
- National Amyloidosis Centre, University College London, London, United Kingdom
| | - Scott Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Julian D Gillmore
- National Amyloidosis Centre, University College London, London, United Kingdom
| | - Marianna Fontana
- National Amyloidosis Centre, University College London, London, United Kingdom.
| |
Collapse
|
4
|
Ungericht M, Wanschitz J, Kroiss AS, Röcken C, Schuetz T, Messner M, Zaruba MM, Loescher WN, Poelzl G. Amyloid myopathy: expanding the clinical spectrum of transthyretin amyloidosis-case report and literature review. J Nucl Cardiol 2023; 30:1420-1426. [PMID: 35581484 PMCID: PMC10371878 DOI: 10.1007/s12350-022-02990-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/09/2022] [Indexed: 11/29/2022]
Abstract
We identified two patients with transthyretin (ATTR) amyloid myopathy (one ATTR variant amyloidosis, ATTRv; one wild-type ATTR amyloidosis, ATTRwt). Myopathy was the initial manifestation in ATTRwt, whereas it followed neuropathy and cardiomyopathy in ATTRv. The ATTRwt patient showed muscular tracer uptake on 99mTc-DPD planar scintigraphy at the time of initial diagnosis, consistent with ATTR amyloid myopathy. The ATTRv patient underwent heart transplantation because of progressive heart failure. Within the next two years, progressive myopathic symptoms and extracardiac tracer uptake on 99mTc-DPD planar scintigraphy were documented, attributable to ATTR amyloid myopathy. Interstitial amyloid deposits were confirmed by muscle biopsy in both patients, with a particularly high amyloid burden in the adipose tissue. This case report highlights the frequent concomitant presence of cardiac ATTR amyloidosis and ATTR amyloid myopathy. ATTR amyloid myopathy may precede cardiac manifestation in ATTRwt or occur after heart transplantation in ATTRv. Due to the high diagnostic accuracy of 99mTc-DPD scintigraphy for detecting ATTR amyloid myopathy and the emergence of novel therapeutics, it is important to increase the awareness of its presence.
Collapse
Affiliation(s)
- Maria Ungericht
- Department of Internal Medicine III, Cardiology & Angiology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Julia Wanschitz
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Alexander S Kroiss
- Department of Nuclear Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Christoph Röcken
- Department of Pathology, Christian-Albrechts-University, Kiel, Germany
| | - Thomas Schuetz
- Department of Internal Medicine III, Cardiology & Angiology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Moritz Messner
- Department of Internal Medicine III, Cardiology & Angiology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Marc-Michael Zaruba
- Department of Internal Medicine III, Cardiology & Angiology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Wolfgang N Loescher
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Gerhard Poelzl
- Department of Internal Medicine III, Cardiology & Angiology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria.
| |
Collapse
|