Pathophysiology and Therapeutic Approaches to Cardiac Amyloidosis.

Published on May 14, 2021in Circulation Research14.467
· DOI :10.1161/CIRCRESAHA.121.318187
Jan M. Griffin4
Estimated H-index: 4
(Columbia University),
Hannah Rosenblum5
Estimated H-index: 5
(Columbia University),
Mathew S. Maurer65
Estimated H-index: 65
(Columbia University)
Often considered a rare disease, cardiac amyloidosis is increasingly recognized by practicing clinicians. The increased rate of diagnosis is in part due the aging of the population and increasing incidence and prevalence of cardiac amyloidosis with advancing age, as well as the advent of noninvasive methods using nuclear scintigraphy to diagnose transthyretin cardiac amyloidosis due to either variant or wild type transthyretin without a biopsy. Perhaps the most important driver of the increased awareness is the elucidation of the biologic mechanisms underlying the pathogenesis of cardiac amyloidosis which have led to the development of several effective therapies with differing mechanisms of actions. In this review, the mechanisms underlying the pathogenesis of cardiac amyloidosis due to light chain (AL) or transthyretin (ATTR) amyloidosis are delineated as well as the rapidly evolving therapeutic landscape that has emerged from a better pathophysiologic understanding of disease development.
#1Nicholas J. VineyH-Index: 8
#2Shuling GuoH-Index: 23
Last. Brett P. MoniaH-Index: 41
view all 18 authors...
AIMS Amyloidogenic transthyretin (ATTR) amyloidosis is a fatal disease characterized by progressive cardiomyopathy and/or polyneuropathy. AKCEA-TTR-LRx (ION-682884) is a ligand-conjugated antisense drug designed for receptor-mediated uptake by hepatocytes, the primary source of circulating transthyretin (TTR). Enhanced delivery of the antisense pharmacophore is expected to increase drug potency and support lower, less frequent dosing in treatment. METHODS AND RESULTS AKCEA-TTR-LRx demonstrated a...
8 CitationsSource
#1Luke T. Nelson (Scripps Research Institute)H-Index: 2
#2Ryan J Paxman (Scripps Research Institute)H-Index: 8
Last. Jeffery W. Kelly (Scripps Research Institute)H-Index: 119
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Transthyretin (TTR) tetramer dissociation is rate limiting for aggregation and subunit exchange. Slowing of TTR tetramer dissociation via kinetic stabiliser binding slows cardiomyopathy progression...
4 CitationsSource
#1Jan M. Griffin (Columbia University)H-Index: 4
#2Ersilia M. DeFilippis (Columbia University)H-Index: 13
Last. Kevin J. Clerkin (Columbia University)H-Index: 17
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The new heart transplantation (HT) allocation policy was introduced on 10/18/2018. Using the UNOS registry, we examined early outcomes following HT for restrictive cardiomyopathy, hypertrophic cardiomyopathy, cardiac sarcoidosis, or cardiac amyloidosis compared to the old system. Those listed who had an event (transplant, death, or waitlist removal) prior to 10/17/2018 were in Era 1, and those listed on or after 10/18/2018 were in Era 2. The primary endpoint was death on the waitlist or delistin...
3 CitationsSource
#1Peter Lockwood (Pfizer)H-Index: 11
#2Vu Le (Pfizer)H-Index: 7
Last. Steve Riley (Pfizer)H-Index: 9
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Tafamidis, a non-nonsteroidal anti-inflammatory benzoxazole derivative, acts as a transthyretin (TTR) stabilizer to slow progression of TTR amyloidosis (ATTR). Tafamidis meglumine, available as 20-mg capsules, is approved in more than 40 countries worldwide for the treatment of adults with early-stage symptomatic ATTR polyneuropathy. This agent, administered as an 80-mg, once-daily dose (4 x 20-mg capsules), is approved in the United States, Japan, Canada, and Brazil for the treatment of heredit...
10 CitationsSource
#1Graham Lohrmann (BU: Boston University)H-Index: 1
#1Graham Lohrmann (BU: Boston University)H-Index: 1
Last. Frederick L. Ruberg (BU: Boston University)H-Index: 34
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Abstract BACKGROUND Transthyretin amyloidosis cardiomyopathy (ATTR-CM) is an underappreciated cause of heart failure that results from misfolded TTR (prealbumin) protein. Diflunisal is an approved non-steroidal anti-inflammatory drug (NSAID) that stabilizes TTR, with limited data available regarding effects on cardiac structure and function. METHODS AND RESULTS ATTR-CM patients (n=81, 41% treated with 250 mg twice-daily diflunisal by clinical practice) were retrospectively identified with baseli...
17 CitationsSource
#1Jan M. Griffin (Columbia University)H-Index: 4
#2Leonard Chiu (Columbia University)H-Index: 10
Last. Mathew S. Maurer (Columbia University)H-Index: 65
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Light-chain (AL) cardiac amyloidosis (CA) has a worse prognosis than transthyretin (ATTR) CA. In this single-center study, we compared post heart transplant (OHT) survival for AL and ATTR amyloidosis, hypothesizing that these differences would persist post-OHT. Thirty-nine patients with CA (AL, n=18; ATTR, n=21) and 1,023 non-amyloidosis subjects undergoing OHT were included. Cox-proportional hazards modeling was used to evaluate the impact of amyloid subtype and era (early era: from 2001-2007; ...
3 CitationsSource
#1Anita D'SouzaH-Index: 23
#2Aniko SzaboH-Index: 40
Last. Parameswaran HariH-Index: 62
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Abstract Background Although, doxycycline use is associated with improved outcomes in amyloidosis in retrospective studies, evidence from clinical trials is limited. Methods This phase 2 trial of doxycycline ( NCT02207556) in newly diagnosed light chain (AL) amyloidosis enrolled 25 patients with systemic AL amyloidosis on treatment with doxycycline for 1 year along with chemotherapy. Outcomes of interest included mortality, organ response, and hematologic response rates at 1 y...
10 CitationsSource
#1Christopher D. Barrett (University of Colorado Denver)H-Index: 3
#2Kevin M. Alexander (Stanford University)H-Index: 10
Last. Ronald M. Witteles (Stanford University)H-Index: 31
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Abstract Objectives The purpose of this study is to report outcomes after heart transplantation in patients with cardiac amyloidosis based on a large single-center experience. Background Cardiac amyloidosis causes significant morbidity and mortality, often leading to restrictive cardiomyopathy, progressive heart failure, and death. Historically, heart transplantation outcomes have been worse in patients with cardiac amyloidosis compared with other heart failure populations, in part due to the sy...
18 CitationsSource
#1Efstathios Kastritis (UoA: National and Kapodistrian University of Athens)H-Index: 66
#2Angela Dispenzieri (Mayo Clinic)H-Index: 138
Last. Giampaolo Merlini (UNIPV: University of Pavia)H-Index: 108
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8546Background: The PI bortezomib is commonly used in first-line therapy of AL, but new therapies are needed that are tolerable in the context of multi-organ dysfunction and that, in RRAL, offer im...
4 CitationsSource
#1Dhruv S. Kazi (Harvard University)H-Index: 35
#2Brandon K. Bellows (Columbia University)H-Index: 11
Last. Sanjiv J. Shah (NU: Northwestern University)H-Index: 80
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Background: In patients with transthyretin amyloid cardiomyopathy (ATTR-CM), tafamidis reduces all-cause mortality and cardiovascular hospitalizations, and slows decline in quality-oflife compared ...
50 CitationsSource
Cited By2
#1Haruki Koike (Nagoya University)H-Index: 44
#2Masahisa Katsuno (Nagoya University)H-Index: 66
Amyloidosis is a group of diseases that includes Alzheimer’s disease, prion diseases, transthyretin (ATTR) amyloidosis, and immunoglobulin light chain (AL) amyloidosis. The mechanism of organ dysfunction resulting from amyloidosis has been a topic of debate. This review focuses on the ultrastructure of tissue damage resulting from amyloid deposition and therapeutic insights based on the pathophysiology of amyloidosis. Studies of nerve biopsy or cardiac autopsy specimens from patients with ATTR a...
#1Douglas L. Mann (WashU: Washington University in St. Louis)H-Index: 114