Clinical challenges in the management of cardiac amyloidosis complicating aortic stenosis and coronary artery disease

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Background: Interest in amyloidosis is increasing, primarily due to its high prevalence and recent advances in diagnostic and treatment modalities. The role of amyloidosis in aortic stenosis is established, and in coronary artery disease (CAD) outcomes are being reported. We aim to study the impact of amyloidosis on the outcomes of inpatient percutaneous coronary intervention (PCI) recipients. Methods: We conducted a cross-sectional cohort study using the nationwide inpatient sample (NIS) 2018-19. We included 457,730 adult inpatients with CAD managed with PCI and further divided by the presence of a co-diagnosis of amyloidosis. A logistic regression model was used to evaluate the odds ratio (OR) of the association between amyloidosis and various outcomes in PCI recipients. Results: Out of the total of 457,730 patients included, 30,905 (6.75%) had amyloidosis. Mean age (66.3 vs. 65.9), female sex (35.6% vs. 32.1%), and African American race (11.6% vs. 9.4%) were higher in the amyloidosis cohort (all P<0.001). The amyloidosis cohort also had a higher incidence of acute kidney injury (AKI) (29.9% vs. 15.5%), complications of surgical care (1.7% vs. 0.7%), complications of cardiovascular implant (9.5% vs. 8.5%), major loss of function (54.7% vs. 27.8%), length of stay (LOS) in days (6.3 vs. 3.8), total charges in $ (166,001 vs. 121,718), and in-hospital mortality (4.7% vs. 2.6%) compared to non-amyloidosis cohort (all P<0.001). Amyloidosis was associated with higher odds of in-hospital mortality (OR 1.3, 95CI 1.23-1.39, p<0.001), AKI (OR 1.89, 95CI 1.83-1.94, p<0.001), and complications of surgical care (OR 2.05, 95CI 1.87-2.26, p<0.001) but not with complications of cardiovascular implant (OR 1.01, 95CI 0.97-1.05, p=0.703). Conclusions: Amyloidosis is associated with worse outcomes in inpatient recipients of PCI. Further studies are needed to assess the implications, safety, and outcomes of elective PCI in patients with amyloidosis.

Section: Discussionmentioning

confidence: 99%

Impact of amyloidosis on the outcomes of percutaneous coronary intervention recipients: a nationwide analysis

Singh,

Pethani,

Alencar

et al. 2023

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“…32 Further studies looking specifically at the question of PCI versus CABG in patients with CA and triple vessel CAD are needed. 33 Aortic stenosis (AS) and its association with CA are well known now, with studies showing the incidence of CA in AS patients undergoing valve replacement as high as 29%. 34 It is still unclear precisely if CA contributes to AS or if they are independent and association is merely age-related.…”

Section: Diagnosismentioning

confidence: 99%

A review of recent advances in the diagnosis of cardiac amyloidosis, treatment of its cardiac complications, and disease-modifying therapies

Raval

Siddiq²,

Sharma³

et al. 2023

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Cardiac amyloidosis (CA), a significant condition resulting in infiltrative cardiomyopathy and heart failure with preserved ejection fraction (HFpEF), is caused by extracellular deposition of amyloid fibrils in the heart. Even though this has been known for an extended period, its prevalence in elderly patients with heart failure is increasingly being recognized. Recent advances in diagnosis with non-invasive methods like technetium pyrophosphate-labeled cardiac scintigraphy (i.e., Tc-PYP scan) and treatment options with tafamidis have played a pivotal role in awareness of the burden of this disease. Management of cardiac complications like heart failure, atrial arrhythmias, conduction block, ventricular arrhythmias, coronary artery disease, and aortic stenosis is now more critical than ever. We aim to review and outline the recent advances in diagnoses of CA. We also review management strategies for cardiac complications of CA with a brief summary of disease-modifying therapies.

“…8,9 However, a concrete link between cardiac amyloidosis and coronary artery disease (CAD), the leading cause of cardiovascular death in adults in the USA, has not been completely explored and elucidated in studies. [10][11][12] Cardiac amyloidosis and CAD may share a common ground in chest pain manifestation as the deposition of amyloid in the lumen of epicardial coronary arteries is analogous to atherosclerotic changes in CAD. [13][14][15] On the other hand, cardiac amyloidosis is also thought to accelerate preexisting CAD by precipitating endothelial dysfunction.…”

Section: Introductionmentioning

confidence: 99%

Impact of amyloidosis on the outcomes of patients with coronary artery disease: A nationwide analysis

Prakash Babu,

Layadi,

Singh

et al. 2024

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Background: Amyloidosis is a disease of increasing interest, primarily due to its high prevalence and advances in diagnostic and therapeutic options. It is known to be coexistent with a significant number of aortic stenosis patients (AS). Various studies have been done to evaluate its role in the clinical outcomes of AS. However, there is a lack of similar data on coronary artery disease (CAD) patients. Methods: We conducted a cross-sectional cohort study using the nationwide inpatient sample (NIS) 2018–19. We included 305,675 adult inpatients with CAD and further divided by the presence of a co-diagnosis of amyloidosis. A logistic regression model was used to evaluate the odds ratio (OR) of the association between in-hospital mortality in CAD inpatients with and without amyloidosis and other comorbidities. Results: The prevalence of amyloidosis in the total inpatient population with CAD was 7.3%, with the majority of the patients being in the older age group (mean age: 66.88 years), males (64.2%), and white (70.9%). Interestingly, the amyloidosis cohort had a higher prevalence of hypertension (89.3% vs. 85.1%). CAD inpatients with amyloidosis were noted to have higher in-hospital mortality (1.6% vs. 0.9%) with an OR of 1.87 (95% CI 1.66–2.11, p <0.001). These patients also had a higher length of stay (6.66 days vs. 4.68 days), total charges ($156,149.76 vs. $119,442.71), and major loss of function (56.5% vs. 30.5%). Amongst patients with CAD and amyloidosis, household income below the 50th percentile was a risk factor for in-hospital mortality (OR 1.5, 95% CI 1.39–1.63, p <0.001). Conclusions: Results from our study show that CAD inpatients who have comorbid amyloidosis have worse outcomes compared to those who do not. Further studies are needed to determine the etiology behind these outcomes and thus guide the management of stable CAD in amyloidosis patients.