Conventional heart failure therapy in cardiac ATTR amyloidosis

Ioannou, A. et al. (2023) Conventional heart failure therapy in cardiac ATTR amyloidosis. European Heart Journal, 44(31), pp. 2893-2907. (doi: 10.1093/eurheartj/ehad347) (PMID:37216684) (PMCID:PMC10424879)

Abstract

Background and Aims: The aims of this study were to assess prescription patterns, dosages, discontinuation rates and association with prognosis of conventional heart failure (HF) medications in patients with transthyretin cardiac amyloidosis (ATTR-CA). Methods: A retrospective analysis of all consecutive patients diagnosed with ATTR-CA at the National Amyloidosis Centre between 2000-2022 identified 2371 patients with ATTR-CA. Results: Prescription of HF medications was greater among patients with a more severe cardiac phenotype, comprising beta-blockers in 55.4%, angiotensin-converting enzyme inhibitors (ACEi)/angiotensin-II receptor blockers (ARB) in 57.4%, and mineralocorticoid receptor antagonists (MRAs) in 39.0% of cases. During a median follow-up of 27.8 months (IQR 10.6-51.3), 21.7% had beta-blockers discontinued, and 32.9% had ACEi/ARB discontinued. In contrast, only 7.5% had MRAs discontinued. Propensity score-matched analysis demonstrated that treatment with MRAs was independently associated with a reduced risk of mortality in the overall population (HR 0.77 [95% CI 0.66-0.89], P<0.001) and in a pre-specified subgroup of patients with a left ventricular ejection fraction (LVEF) >40% (HR 0.75 [95% CI 0.63-0.90], P=0.002); and treatment with low-dose beta-blockers was independently associated with a reduced risk of mortality in a pre-specified subgroup of patients with a LVEF ≤40% (HR 0.61 [95% CI 0.45-0.83], P=0.002). No convincing differences were found for treatment with ACEi/ARBs. Conclusions: Conventional HF medications are currently not widely prescribed in ATTR-CA, and those that received medication had more severe cardiac disease. Beta-blockers and ACEi/ARBs were often discontinued, but low-dose beta-blockers were associated with reduced risk of mortality in patients with a LVEF ≤40%. In contrast, MRAs were rarely discontinued and were associated with reduced risk of mortality in the overall population; but these findings require confirmation in prospective randomized controlled trials.

• Item Type: Articles
• Status: Published
• Refereed: Yes
• Glasgow Author(s) Enlighten ID: McMurray, Professor John and Petrie, Professor Mark
• Authors: Ioannou, A., Massa, P., Patel, R. K., Razvi, Y., Porcari, A., Rauf, M. U., Jiang, A., Cabras, G., Filisetti, S., Bolhuis, R. E., Bandera, F., Venneri, L., Martinez-Naharro, A., Law, S., Kotecha, T., Virsinskaite, R., Knight, D. S., Emdin, M., Petrie, A., Lachmann, H., Wechelakar, A., Petrie, M., Hughes, A., Freemantle, N., Hawkins, P. N., Whelan, C., McMurray, J. J.V., Gillmore, J. D., and Fontana, M.
• College/School: College of Medical Veterinary and Life Sciences > School of Cardiovascular & Metabolic Health
• Journal Name: European Heart Journal
• Publisher: Oxford University Press
• ISSN: 0195-668X
• ISSN (Online): 1522-9645
• Published Online: 22 May 2023
• Copyright Holders: Copyright © 2023 The Authors
• First Published: First published in European Heart Journal 44(31):2893-2907
• Publisher Policy: Reproduced under a Creative Commons License