Cardiology Pearls for the Hospitalist

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Cardiology Pearls for the Hospitalist Ronald

might seem standard but Can we do better?

1 Cardiology Pearls for the Hospitalist Ronald Witteles, M.D. Stanford University School of Medicine October 20, A common patient scenario It might seem standard but Can we do better? News hot off the presses Outline A diagnosis not to be missed anymore and one you certainly see! Final thoughts 1

significantly changed since then): Moderately dilated LV, LVEF 25%, 3+ MR Course over 4 years: 3 hospitalizations for ADHF (last 6 months ago)

2 A Familiar Patient 78 y.o. man with dilated nonischemic cardiomyopathy Diagnosis: 4 years ago, normal coronary angiogram, LBBB present Echo at diagnosis (not significantly changed since then): Moderately dilated LV, LVEF 25%, 3+ MR Course over 4 years: 3 hospitalizations for ADHF (last 6 months ago) Generally adherent with meds Usually NYHA 2-3 symptoms BP typically runs in 105/70 range NT-proBNP 4 months ago = 3000 pg/ml Outpatient Medications Furosemide 40 mg bid Metoprolol tartrate 25 mg bid Lisinopril 10 mg qd Digoxin 0.5 mg qd Rosuvastatin 10 mg qhs KCl 20 meq qd 2

Now admitted to hospital A Familiar Patient 7 kg weight gain over last 3 weeks Worsening DOE, now SOB with a few steps No chest pain, dizziness, or any other symptoms Exam & Labs Exam (pertinent):

3 Now admitted to hospital A Familiar Patient 7 kg weight gain over last 3 weeks Worsening DOE, now SOB with a few steps No chest pain, dizziness, or any other symptoms Exam & Labs Exam (pertinent): Afebrile, HR 72, BP 105/70, RR 16, SaO2 95% RA JVP 15 cm H2O Laterally displaced PMI, RRR with 2/6 systolic murmur at apex Scattered bibasilar rales 3+ bilateral LE edema Labs: Na 136, K 4.4 BUN 26, Cr 1.4 (baseline 1.4) NT-pro-BNP 6500 pg/ml Troponin I: <0.1 Digoxin: 0.9 (therapeutic) Lipids: LDL 115, HDL 45, TG 115 3

4 Hospital Course EKG/Echo EF 25%, 3+MR, LBBB (similar to baseline) Diuresed with IV furosemide over 4 days Symptoms improve to close to baseline Discharged home same meds, augmented furosemide/k Labs on day of discharge: Na 134 K 4.2 BUN 35 Cr 1.6 NT-pro-BNP 5500 pg/ml Digoxin 0.9 (therapeutic) Could we have done any better for this patient? What about the lisinopril? What Do You Do? 1) Continue lisinopril unchanged 2) Uptitrate lisinopril dose to 20 mg qd 3) Change lisinopril to ARB 4) Stop lisinopril & start sacubitril/valsartan next day 5) Change lisinopril to ARB x 36 hours, then change to sacubitril/valsartan 4

5 What about the lisinopril? What Do You Do? 1) Continue lisinopril unchanged 2) Uptitrate lisinopril dose to 20 mg qd 3) Change lisinopril to ARB 4) Stop lisinopril & start sacubitril/valsartan next day 5) Change lisinopril to ARB x 36 hours, then change to sacubitril/valsartan PARADIGM-HF Neprilysin: Breaks down natriuretic peptides & angiotensin II Trial: Sacubitril-valsartan vs. Enalapril Double-blind, randomized trial of 8442 patients LVEF 40% NYHA II-IV Primary end-point: Time to CV death or HF hospitalization Stopped early after median follow-up of 27 months ACC/AHA/HFSA Guidelines: SWITCH NYHA Class 2-3 HFrEF patients from ACEi or ARB to sacubitril-valsartan (Class 1 recommendation!) Adapted from McMurray et al. New Engl J Med. 2014;371:

6 Breakdown of Outcomes Adapted from McMurray et al. New Engl J Med. 2014;371: Breakdown of Outcomes Adapted from McMurray et al. New Engl J Med. 2014;371:

Breakdown of Outcomes Adapted from McMurray et al. New Engl J Med. 2014;371:993-1004.

7 Breakdown of Outcomes Adapted from McMurray et al. New Engl J Med. 2014;371: What You Should Be Asking Yourself Which systolic HF patients should I not be putting on sacubitril/valsartan? 7

Practicalities of Use Greater BP drop than with ACEi or ARB alone Must be off of ACEi for at least 36 hours (angioedema risk) All the more reason to get away from ACEi for new heart failure patients

8 Practicalities of Use Greater BP drop than with ACEi or ARB alone Must be off of ACEi for at least 36 hours (angioedema risk) All the more reason to get away from ACEi for new heart failure patients Make sure insurance approval in place! Adapted from McMurray et al. New Engl J Med. 2014;371: What Should You Do with the Metoprolol 25 mg bid? 1) Stop the beta-blocker (ADHF admission) 2) Change to carvedilol 6.25 mg bid 3) Change to carvedilol 25 mg bid 4) Continue metoprolol tartrate 25 mg bid 5) Change to metoprolol succinate 50 mg qd 8

9 What Should You Do with the Metoprolol 25 mg bid? 1) Stop the beta-blocker (ADHF admission) 2) Change to carvedilol 6.25 mg bid 3) Change to carvedilol 25 mg bid 4) Continue metoprolol tartrate 25 mg bid 5) Change to metoprolol succinate 50 mg qd COMET Trial 3029 patients LVEF < 35% NYHA Class II-IV HF Admission within last 2 years Randomized to: Carvedilol mg bid 25 mg bid vs. Metoprolol tartrate 5 mg bid 50 mg bid Mean follow-up: 4.8 years 9

10 COMET: Mortality P= Adapted from Poole-Wilson et al. Lancet. 2003;362:7-13. COMET: Heart Rates Adapted from Poole-Wilson et al. Lancet. 2003;362:

11 What should you do with the digoxin 0.5 mg/day? 1) Get rid of it. 2) Continue at a lower dose. 3) Continue unchanged. What should you do with the digoxin 0.5 mg/day? 1) Get rid of it. 2) Continue at a lower dose. 3) Continue unchanged. 11

12 Digoxin DIG Trial (1997) 6800 patients with EF 45% Digoxin vs. placebo All patients in sinus rhythm Outcomes: Primary: All-cause mortality Secondary: CV death, worsened HF & hospitalizations All-Cause Mortality Adapted from NEJM. 1997;336:

Death or HF Hospitalization placebo digoxin Adapted from NEJM. 1997;336:525-33.

13 Death or HF Hospitalization placebo digoxin Adapted from NEJM. 1997;336: Cochrane Review: Risk of Clinical Deterioration if Stop Dig Adapted from Hood et al. Cochrane Library. 2004, Issue 4. 13

(Z-pack, etc.) Patient gets dig-toxic NOTE: This is the reason for antibiotic-digoxin medication interactions! How to Avoid This? Step 1: Recognize we live in a world of antibiotics.

14 An Inevitable Sequence of Events... Well-meaning physician targets digoxin levels for treatment of HF or atrial fibrillation A patient with eggerthella lenta ends up on an extremely high dose of digoxin Patient receives antibiotics (Z-pack, etc.) Patient gets dig-toxic NOTE: This is the reason for antibiotic-digoxin medication interactions! How to Avoid This? Step 1: Recognize we live in a world of antibiotics. It is not realistic to think your patient will not ultimately get an antibiotic prescription. Step 2: Don t target digoxin levels! You can estimate daily dose by 2 main things: GFR Amiodarone use Nobody should require a maintenance dose > 0.25 mg Remember: For the most part, low levels are okay! Particularly true if using for heart failure indication rather than rate control Reasons for checking digoxin levels: You suspect toxicity To check medication adherence 14

15 DIG Trial: Post-hoc Analysis of Mortality vs. 1-month Digoxin Levels Adapted from Adams et al. J Am Coll Cardiol. 2005;46: What Should You Do With the Rosuvastatin 10 mg? 1) Get rid of it. 2) Continue rosuvastatin 10 mg 3) Increase to rosuvastatin 40 mg 4) Switch to atorvastatin 40 mg 5) Switch to PCSK9 inhibitor 15

16 What Should You Do With the Rosuvastatin 10 mg? 1) Get rid of it. 2) Continue rosuvastatin 10 mg 3) Increase to rosuvastatin 40 mg 4) Switch to atorvastatin 40 mg 5) Switch to PCSK9 inhibitor GISSI-HF Trial 4574 patients with HF (ischemic or nonischemic) NYHA Class II-IV EF <40% or EF>40% but HF hospitalization in past 12 months Ischemic (40%), Nonischemic (60%) Randomized: Rosuvastatin 10 mg daily vs. placebo Primary endpoints: Survival Mortality or CV hospitalization Adapted from GISSI-HF Investigators. Lancet. 2008;372:

17 GISSI-HF: Mortality Adapted from GISSI-HF Investigators. Lancet. 2008;372: GISSI-HF: Mortality or CV Hospitalization Adapted from GISSI-HF Investigators. Lancet. 2008;372:

A Mental Exercise You re a highly-paid executive at a big pharmaceutical company which makes an on-patent statin.

#1 concern: Get a positive result! What type of study would you pitch?

) Only patients with ischemic cardiomyopathy Primary endpoint: Vascular events!

18 A Mental Exercise You re a highly-paid executive at a big pharmaceutical company which makes an on-patent statin. You have been tasked with designing a heart failure clinical trial to test your statin s efficacy. #1 concern: Get a positive result! What type of study would you pitch? Large Placebo-controlled (not versus alternative lipidlowering agent!) Only patients with ischemic cardiomyopathy Primary endpoint: Vascular events! Only one problem No way this would ever be considered ethical Right? CORONA 5011 patients 60 years All with ischemic, systolic HF NYHA II: EF 35% NYHA III-IV: EF 40% Rosuvastatin 10 mg daily vs. placebo Primary endpoint : A vascular endpoint (!) CV death, nonfatal MI, nonfatal stroke 18

19 CORONA: Primary Endpoint Adapted from Kjekshus et al. NEJM. 2007;357: CORONA: All-Cause Mortality Adapted from Kjekshus et al. NEJM. 2007;357:

So What to Do With Statins in HF? For nonischemic heart failure forget it! For ischemic heart failure If angina, PVD, etc. still use Otherwise consider not using Polypharmacy issues are real!

20 So What to Do With Statins in HF? For nonischemic heart failure forget it! For ischemic heart failure If angina, PVD, etc. still use Otherwise consider not using Polypharmacy issues are real! Let s focus on what makes a real difference You are doubling the outpatient furosemide & plan to check a BMP within 5 days of discharge. What should you do with the potassium? 1) Get rid of it. 2) Increase KCl to 40 meq/day. 3) Switch to spironolactone. 20

You are doubling the outpatient furosemide & plan to check a BMP within 5 days of discharge. What should you do with the potassium? 1) Get rid of it. 2) Increase KCl to 40 meq/day.

21 You are doubling the outpatient furosemide & plan to check a BMP within 5 days of discharge. What should you do with the potassium? 1) Get rid of it. 2) Increase KCl to 40 meq/day. 3) Switch to spironolactone. RALES Trial 1663 patients with LVEF 35% NYHA Class III-IV Had been NYHA Class IV within 6 months of enrollment Excluded if Cr>2.5 mg/dl or K>5.0 mmol/l Randomized to spironolactone 25 mg qd vs. placebo Primary outcome: All-cause mortality 21

RALES Trial: Survival Adapted from Pitt et al. NEJM. 1999;341:709-17.

22 RALES Trial: Survival Adapted from Pitt et al. NEJM. 1999;341: EMPHASIS-HF Trial 2737 patients Age >55 years, NYHA II EF<30% (or 30-35% with QRS>130 ms) Cardiac hospitalization in last 6 months or high BNP Excluded if K > 5.0 or GFR <30 ml/min Randomized to eplerenone 50 mg qd vs. placebo Primary endpoint: CV Death or HF hospitalization Stopped early (21 months) due to + result Adapted from Zannad et al. NEJM. 2011;364:

23 EMPHASIS-HF: Primary Endpoint Adapted from Zannad et al. NEJM. 2011;364: EMPHASIS-HF: Overall Mortality Adapted from Zannad et al. NEJM. 2011;364:

24 Caution: Beware Unintended Consequences Examined the impact of the RALES trial on spironolactone prescriptions & events in Canada between (before/after RALES) Spironolactone Prescriptions vs. Time Adapted from Juurlink et al. NEJM. 2004;351:

No Change in HF Admissions Adapted from Juurlink et al. NEJM. 2004;351:543-51.

25 No Change in HF Admissions Adapted from Juurlink et al. NEJM. 2004;351: More Hospitalizations for Hyperkalemia Adapted from Juurlink et al. NEJM. 2004;351:

More In-Hospital Hyperkalemic Death Adapted from Juurlink et al. NEJM. 2004;351:543-51.

26 More In-Hospital Hyperkalemic Death Adapted from Juurlink et al. NEJM. 2004;351: Aldosterone Antagonists: Take-Home Points Two large trials with very + results in advanced systolic heart failure patients, but You must make sure the patient is set up for appropriate potassium monitoring as an outpatient (as was done in the trials). Is there really any higher risk of hyperkalemia than with supplemental K? 26

27 Is Any EP Device Indicated? 1) Consult for implantable loop monitor placement 2) Consult for ICD placement 3) Consult for biventricular pacemaker/icd placement 4) No device is indicated Is Any EP Device Indicated? 1) Consult for implantable loop monitor placement 2) Consult for ICD placement 3) Consult for biventricular pacemaker/icd placement 4) No device is indicated 27

28 COMPANION Trial (2004) 1520 patients NYHA Class III-IV LVEF 35% QRS 120 ms, PR > 150 ms Median QRS duration 160 ms Randomized to medical therapy vs. biventricular pacemaker vs. biventricular pacemaker/icd Median f/u: 16 months Primary endpoint: Survival without hospitalization COMPANION Trial: Survival Without Hospitalization P<0.001 Adapted from Bristow et al. NEJM. 2004;350:

29 COMPANION Trial: Survival P<0.001 Adapted from Bristow et al. NEJM. 2004;350: patients CARE-HF Trial NYHA Class III-IV LVEF 35% QRS 150 ms or ms with additional echo criteria Most patients = LBBB, Median QRS = 160 ms Randomized to resynchronization vs. no resynchronization No ICD therapy Median f/u: 29.4 months Primary endpoint: All-cause mortality or CV hospitalization 29

30 CARE-HF Trial: Survival Without CV Hospitalization P<0.001 Adapted from Cleland et al. NEJM. 2005;352: CARE-HF Trial: Overall Survival P<0.002 Adapted from Cleland et al. NEJM. 2005;352:

31 How About the NT-proBNP? Reminder NT-proBNP levels: 4 months PTA: 3000 pg/ml Admission: 6500 pg/ml Possible discharge: 5500 pg/ml What should you do based on this result? 1) Discharge the patient as planned 2) Push forward with further diuresis 3) Further uptitrate neurohormonal antagonists How About the NT-proBNP? Reminder NT-proBNP levels: 4 months PTA: 3000 pg/ml Admission: 6500 pg/ml Possible discharge: 5500 pg/ml What should you do based on this result? 1) Discharge the patient as planned 2) Push forward with further diuresis 3) Further uptitrate neurohormonal antagonists 31

TIME-CHF Trial 499 patients age >60 with NYHA II-IV HF All with HF hospitalizations within past year Intervention: Symptom-guided management or NT-proBNP-guided therapy Primary endpoints: 18 month

32 TIME-CHF Trial 499 patients age >60 with NYHA II-IV HF All with HF hospitalizations within past year Intervention: Symptom-guided management or NT-proBNP-guided therapy Primary endpoints: 18 month survival free of hospitalization Quality of life at 18 months Adapted from Pfisterer et al. JAMA 2009;301: No Difference in Hospital-Free Surivival Adapted from Pfisterer et al. JAMA 2009;301:

No Difference in QOL (If Anything Better Without NT-BNP!) Minnesota Living with Heart Failure Score Adapted from Pfisterer et al. JAMA 2009;301:383-92.

NT-proBNP measurement), or NT-proBNP-guided treatment If NT-proBNP 3000 ng/l treatment intensified (more neurohormonal blockade, inotrope treatment, and/or more loop diuretics)

33 No Difference in QOL (If Anything Better Without NT-BNP!) Minnesota Living with Heart Failure Score Adapted from Pfisterer et al. JAMA 2009;301: BOT-AcuteHF Trial 271 patients hospitalized for ADHF Patients first treated with usual care until clinical stability, then randomized to: Conventional treatment (blinded to NT-proBNP measurement), or NT-proBNP-guided treatment If NT-proBNP 3000 ng/l treatment intensified (more neurohormonal blockade, inotrope treatment, and/or more loop diuretics) Primary endpoint: CV Death or CV rehospitalization at day 182 Mean furosemide discharge dose (P=0.077): Control: 164 mg NT-proBNP-guided: 198 mg Adapted from Castrini et al. J Cardiovasc Med. 2016;

Outcomes (at 182 Days) Adapted from Castrini et al. J Cardiovasc Med. 2016;828-839.

stability, then randomized to: Conventional treatment (blinded to NT-proBP measurement), or NT-proBNP-guided treatment (targeting >30% NT-proBNP reduction from

34 Outcomes (at 182 Days) Adapted from Castrini et al. J Cardiovasc Med. 2016; PRIMA II Trial 405 patients, randomized Inclusion criteria: ADHF admission NT-proBNP 1700 ng/l Patients first treated with usual care until clinical stability, then randomized to: Conventional treatment (blinded to NT-proBP measurement), or NT-proBNP-guided treatment (targeting >30% NT-proBNP reduction from admission to discharge) Followed treatment algorithm if NT-proBNP value <30% reduction at randomization Primary endpoint: All-cause mortality and HF readmissions in 180 days after randomization Adapted from Steinen et al. Circulation. 2018;137:

35 Primary Endpoint Adapted from Steinen et al. Circulation. 2018;137: Primary Endpoint Adapted from Steinen et al. Circulation. 2018;137:

2 Months Later Readmitted with declining exercise tolerance, volume overload despite close outpatient follow-up and medication adherence Repeat TTE: LVEF 25%, 4+ MR, RVSP 60 mmhg Surgical consult:

36 2 Months Later Readmitted with declining exercise tolerance, volume overload despite close outpatient follow-up and medication adherence Repeat TTE: LVEF 25%, 4+ MR, RVSP 60 mmhg Surgical consult: Too high-risk for mitral valve surgery or LVAD (age, frailty, severe LV dysfunction) Patient states he is not ready for hospice/bridge-to-hospice consideration. Is there anything else to do about the severe MR? What is the best option? 1) Continue optimal medical therapy alone. 2) Refer for a second surgical opinion for MV repair/replacement. 3) Refer for Mitraclip consideration. 36

What is the best option? 1) Continue optimal medical therapy alone. 2) Refer for a second surgical opinion for MV repair/replacement. 3) Refer for Mitraclip consideration.

37 What is the best option? 1) Continue optimal medical therapy alone. 2) Refer for a second surgical opinion for MV repair/replacement. 3) Refer for Mitraclip consideration. MitraClip trial: Mitra-FR 304 patients with severe secondary MR Ischemic or nonischemic EF 15-40%, NYHA 2-4 Nonsurgical candidates Maximal medical therapy Randomized to OMT or MitraClip + OMT Primary endpoint: Death or HF hospitalization at 12 months Adapted from Obadia et al. NEJM. 2018; online before print. Downloaded Sep 24,

Survival Without HF Hospitalization Adapted from Obadia et al. NEJM. 2018; online before print. Downloaded Sep 24, 2018.

38 Survival Without HF Hospitalization Adapted from Obadia et al. NEJM. 2018; online before print. Downloaded Sep 24, MitraClip trial: COAPT 614 patients with 3-4+ secondary MR Ischemic or nonischemic EF 20-50%, NYHA 2-4 Nonsurgical candidates Maximal medical therapy Randomized to OMT or MitraClip + OMT Primary endpoint: HF hospitalizations at 24 months Adapted from Stone et al. NEJM. 2018; online before print. Downloaded Sep 23,

39 All-Cause Mortality Adapted from Stone et al. NEJM. 2018; online before print. Downloaded Sep 23, HF Hospitalizations Adapted from Stone et al. NEJM. 2018; online before print. Downloaded Sep 23,

40 Mitra-FR & COAPT: Why the Differences? COAPT trial: Larger Longer follow-up More technical expertise of operators More intensive requirements of enrollment Extremely rigorous requirements for med uptitration, CRT if appropriate, HF expert involved in care Worse MR (ERO = 0.41 cm2 vs cm2) Higher NT-BNP (5500 vs. 3350) Adapted from Stone et al. NEJM. 2018; online before print. Downloaded Sep 23, Patient #2 76 y.o. man with gradually worsening HFpEF over last few years PMH: HTN (controlled on losartan 50 mg) No obstructive CAD on cath 6 months ago Baseline meds: Losartan 50 mg qd, furosemide 20 mg bid, spironolactone 25 mg qd Admitted with worsening SOB/edema Echo: Moderate-severe LVH, grade 3 diastolic dysfunction, LVEF 65%, no significant valvular disease 40

41 EKG Hospital Course Diuresed with IV furosemide, transitioned to po Cr stable in range (baseline) Getting ready for discharge 41

42 Is Any Other Testing Indicated? 1) No 2) Yes cardiac MRI with gadolinium contrast 3) Yes technetium pyrophosphate (PYP) nuclear scan 4) Yes exercise stress echo 5) Yes coronary angiography Is Any Other Testing Indicated? 1) No 2) Yes cardiac MRI with gadolinium contrast 3) Yes technetium pyrophosphate (PYP) nuclear scan 4) Yes exercise stress echo 5) Yes coronary angiography 42

Systemic: Light chains (AL) Primary Transthyretin (ATTR) Senile or Familial Serum amyloid A (AA) Secondary Localized Not to be memorized!

43 Amyloidosis: What is it? Amylum Starch (Latin) Generic term for many diseases: Protein misfolds into -sheets Forms into 8-10 nm fibrils Extracellular deposition into amyloid deposits Types of Amyloid Incomplete List Systemic: Light chains (AL) Primary Transthyretin (ATTR) Senile or Familial Serum amyloid A (AA) Secondary Localized Not to be memorized! Beta-2 microglobulin (A- 2) Dialysis (osteoarticular structures) Apolipoprotein A-1 (AApoA-I) Age-related (aortic intima, cardiac, neuropathic) Apolipoprotein A-2 (AApoA-2) Hereditary (kidney) Calcitonin (ACal) Complication of thyroid medullary CA Islet amyloid polypeptide (AIAPP) Age-related (seen in DM) Atrial natriuretic peptide (AANF) Age-related (atrial amyloidosis) Prolactin (APro) Age-related, pituitary tumors Insulin (AIns) Insulin-pump use (local effects) Amyloid precursor protein (ABeta) Age-related/hereditary (Alzheimers) Prion protein (APrPsc) Hereditary/sporadic (spongiform encephalopathies) Cystatin-C (ACys) Hereditary (cerebral hemorrhage) Fibrinogen alpha chain (AFib) Hereditary (kidney) Lysozome (ALys) Hereditary (Diffuse, especially kidney, spares heart) Medin/Lactadherin Age-related (medial aortic amyloidosis) Gelsolin (AGel) Hereditary (neuropathic, corneal) Keratin Cutaneous 43

44 Transthyretin (TTR) Transthyretin = Transports thyroxine and retinol Prealbumin by any other name Primary source: Liver Almost completely circulates as a tetramer In steady-state with monomeric form Thyroxine binding stabilizes tetramer Monomeric TTR is inherently amyloidogenic Mutations in TTR can make it even more amyloidogenic Some mutations favor cardiac deposition, others nerve deposition Study of wtttr Amyloid Prevalence Study from Mayo Clinic published in April 2014 Reviewed autopsies from: 109 patients with antemortem diagnosis of HFpEF without any clinical suspicion of amyloidosis Age-matched control patients without antemortem HF diagnosis Blinded pathology review Adapted from Mohammed et al. J Am Coll Cardiol HF. 2014;2:

ATTR Among TAVR Patients 151 patients referred for TAVR, 68% men, mean age 84 years PYP scans performed on all Findings: High incidence of undiagnosed ATTR amyloidosis!

. Familial ATTR Amyloidosis Mutant transthyretin protein more amyloidogenic Predominant manifestations: Cardiomyopathy Peripheral neuropathy Dozens of mutations described!

45 ATTR Among TAVR Patients 151 patients referred for TAVR, 68% men, mean age 84 years PYP scans performed on all Findings: High incidence of undiagnosed ATTR amyloidosis! Adapted from Castano et al. Eur Heart J. 2017;38: Familial ATTR Amyloidosis Mutant transthyretin protein more amyloidogenic Predominant manifestations: Cardiomyopathy Peripheral neuropathy Dozens of mutations described! Type of mutation correlates with severity, age of onset, and clinical manifestations of disease V30M mutation: Most common in Portugal (1/600) Familial amyloid polyneuropathy ( FAP ) V122I mutation: Seen in 3+% of individuals of African descent (!) By far the most common mutation encountered in USA Familial amyloid cardiomyopathy ( FAC ) 45

46 V-122I: How Common, How Important? 3856 black participants in Atherosclerosis Risk in Community (ARIC) study recruited from Note: Only 36% male, average age 52 at entry Each participant genotyped for TTR gene Findings: Mutation in self-reported black population: 124/3732 (3.2%) Mutation in non-black population: 2/10893 (0.02%) More systolic/diastolic dysfunction, higher NT- BNP in V-122I carriers 7% of carriers with overt amyloid CM Adapted from Quarta et al. NEJM :21-9. Technetium Pyrophosphate (PYP) Scanning 99m Tc-pyrophosphate (PYP) Old nuclear bone scan agent Taken up by hearts infiltrated with ATTR but typically not AL amyloidosis Adapted from Bokhari et al. Circ Cardiovasc Imaging. 2013;6: and Castano et al. JAMA Cardiol. 2016;1:

Largest Study of Bone Scintigraphy Study across 8 centers in 5 countries (N=1217) All patients with suspected or proven ATTR amyloidosis received: Bone scintigraphy (PYP or DPD or HMDP)

47 Largest Study of Bone Scintigraphy Study across 8 centers in 5 countries (N=1217) All patients with suspected or proven ATTR amyloidosis received: Bone scintigraphy (PYP or DPD or HMDP) SPIE/UPIE Serum FLC 100% specificity for ATTR amyloidosis when you combine scintigraphy & no monoclonal protein Adapted from Gillmore et al. Circulation. 2016;133: Treatment: ATTR Amyloidosis 47

Strategies to Prevent TTR Amyloid Deposition Stabilize tetrameric form of TTR Knock down production of TTR in all forms Adapted from Penchala et al. PNAS.

placebo (2:1 randomization), double-blind Premeds: Dexamethasone, acetaminophen, diphenhydramine, H2 blocker Primary endpoint Change in mnis+7 score at 18 months

48 Strategies to Prevent TTR Amyloid Deposition Stabilize tetrameric form of TTR Knock down production of TTR in all forms Adapted from Penchala et al. PNAS. 2013;110: Patisiran: APOLLO Trial 225 patients with hattr polyneuropathy Randomized to patisirian (q3 week IV) vs. placebo (2:1 randomization), double-blind Premeds: Dexamethasone, acetaminophen, diphenhydramine, H2 blocker Primary endpoint Change in mnis+7 score at 18 months Well-tolerated only mild infusion reactions Results Spectacular! Data adapted from TRL_CAPELLA_FINAL_2Nov2017.pdf, and Adams et al, NEJM. 2018;379:

49 APOLLO Results: mnis+7 Data adapted from TRL_CAPELLA_FINAL_2Nov2017.pdf, and Adams et al, NEJM. 2018;379: APOLLO Results: mnis+7 Data adapted from TRL_CAPELLA_FINAL_2Nov2017.pdf, and Adams et al, NEJM. 2018;379:

APOLLO Cardiac Subgroup Data Data adapted from http://www.alnylam.

pdf, and Adams et al, NEJM. 2018;379:11-21.

50 APOLLO Cardiac Subgroup Data Data adapted from TRL_CAPELLA_FINAL_2Nov2017.pdf, and Adams et al, NEJM. 2018;379: APOLLO Cardiac Subgroup: NTBNP Data adapted from TRL_CAPELLA_FINAL_2Nov2017.pdf, and Adams et al, NEJM. 2018;379:

APOLLO Cardiac Subgroup: NTBNP Data adapted from http://www.alnylam.com/wp-content/uploads/2017/11/eu-attr-2017_apollo- TRL_CAPELLA_FINAL_2Nov2017.pdf, and Adams et al, NEJM. 2018;379:11-21.

51 APOLLO Cardiac Subgroup: NTBNP Data adapted from TRL_CAPELLA_FINAL_2Nov2017.pdf, and Adams et al, NEJM. 2018;379: ATTR-ACT Study Tafamidis for ATTR Cardiomyopathy Phase 3, Randomized, Placebo- Controlled clinical trial of tafamidis for ATTR cardiomyopathy Wild-type or familial 441 patients worldwide x 2.5 years Primary endpoint: Mortality & CV Hospitalization Hierarchical endpoint (Finkelstein- Schoenfeld method) Key secondary endpoints: Change in Quality of life (KCCQ) Change in 6MWT Adapted from Maurer et al. N Engl J Med. Published online before print August 27,

52 Primary Endpoint Adapted from Maurer et al. N Engl J Med. Published online before print August 27, Primary Endpoint Adapted from Maurer et al. N Engl J Med. Published online before print August 27,

53 Primary Endpoint NNT to prevent 1 death at 30 months: 7.5 (!) Adapted from Maurer et al. N Engl J Med. Published online before print August 27, Survival Adapted from Maurer et al. N Engl J Med. Published online before print August 27,

54 CV Hospitalizations Adapted from Maurer et al. N Engl J Med. Published online before print August 27, CV Hospitalizations NNT to prevent 1 hospitalization/yr: 4.5 (!) Adapted from Maurer et al. N Engl J Med. Published online before print August 27,

55 Time to First CV Hospitalization Adapted from Maurer et al. N Engl J Med. Published online before print August 27, Minute Walk Test Adapted from Maurer et al. N Engl J Med. Published online before print August 27,

56 Quality of Life Adapted from Maurer et al. N Engl J Med. Published online before print August 27, NT-BNP: Placebo Safety - Tafamidis Remarkably safe/well-tolerated No adverse events at higher rate than placebo More discontinuation of placebo from adverse events 26% vs. 20% No dosing issues in renal dysfunction Adapted from Maurer et al. N Engl J Med. Published online before print August 27,

57 The Bottom Line: We Have Effective ATTR Treatments Now! Wild-type ATTR Cardiomyopathy: Tafamidis Familial ATTR Cardiomyopathy (FAC): Tafamidis Familial ATTR Polyneuropathy (FAP): Patisiran Mixed familial phenotype: Patisiran or tafamidis The future? Knockdown agents for ATTR cardiomyopathy Easier knockdown administration Better stabilizers (?AG10) Combined stabilizer/knockdown approach Summary Typical heart failure admission we can do more! Remember: Sacubitril-valsartan, digoxin, cardiac resynchronization, aldosterone antagonists, carvedilol>metoprolol Generally avoid: Statins, targeting NT-BNP levels, targeting digoxin level Mitral regurgitation this should be addressed in the right patient! Even high-risk patients can benefit from MitraClip ATTR amyloidosis Not rare you will see these patients every year (probably several times) Simple workup (PYP scan) We have highly effective treatment options now! 57

58 Thank 58

Amyloidosis: Challenges in Diagnosis and Management

Amyloidosis: Challenges in Diagnosis and Management Ronald Witteles, MD Co-Director, Stanford Amyloid Center Associate Professor of Cardiovascular Medicine Program Director, Internal Medicine Residency