Systemic embolism in amyloid transthyretin cardiomyopathy

Abstract

Aims Although systemic embolism is a potential complication in transthyretin amyloid cardiomyopathy (ATTR‐CM), data about its incidence and prevalence are scarce. We studied the incidence, prevalence and factors associated with embolic events in ATTR‐CM. Additionally, we evaluated embolic events according to the type of oral anticoagulation (OAC) and the performance of the CHA2DS2‐VASc score in this setting. Methods and results Clinical characteristics, history of atrial fibrillation (AF) and embolic events were retrospectively collected from ATTR‐CM patients evaluated at four international amyloid centres. Overall, 1191 ATTR‐CM patients (87% men, median age 77.1 years [interquartile range‐IQR 71.4–82], 83% ATTRwt) were studied. A total of 162 (13.6%) have had an embolic event before initial evaluation. Over a median follow‐up of 19.9 months (IQR 9.9–35.5), 41 additional patients (3.44%) had an embolic event. Incidence rate (per 100 patient‐years) was 0 among patients in sinus rhythm with OAC, 1.3 in sinus rhythm without OAC, 1.7 in AF with OAC, and 4.8 in AF without OAC. CHA2DS2‐VASc did not predict embolic events in patients in sinus rhythm whereas in patients with AF without OAC, only those with a score ≥4 had embolic events. There was no difference in the incidence rate of embolism between patients with AF treated with vitamin K antagonists (VKAs) (n = 322) and those treated with direct oral anticoagulants (DOACs) (n = 239) (p = 0.66). Conclusions Embolic events were a frequent complication in ATTR‐CM. OAC reduced the risk of systemic embolism. Embolic rates did not differ with VKAs and DOACs. The CHA2DS2‐VASc score did not correlate well with clinical outcome in ATTR‐CM and should not be used to assess thromboembolic risk in this population.

August 2022 at a glance: focus on heart failure with preserved ejection fraction and cardiac amyloidosis

“…Embolic events occurred also in patients in sinus rhythm who were not treated with anticoagulation and in those with atrial fibrillation on oral anticoagulation (incidence rate of 1.3 and 1.7 per 100 patient‐years, respectively). Furthermore, the CHA 2 ‐DS 2 ‐VASc score had a poor correlation with the embolic risk 30 …”

Time to reconsider thromboembolic risk and anticoagulation in transthyretin cardiac amyloidosis?

“…Whilst the CHA 2 DS 2 ‐VASc score has some limitations, it includes factors known to be associated with global cardiovascular risk that, with different extent, promote the development of HF and AF. The low absolute number of embolic events did not allow Vilches et al 12 . to perform a comprehensive multivariable analysis.…”

“…Whilst the CHA 12 to perform a comprehensive multivariable analysis. Notably, the parameters included in the score (except diabetes) were associated with systemic embolism at univariable analysis and those tested in the multivariable model (age and peripheral vascular disease) resulted independent prognostic predictors.…”

“…In the last issue of the Journal, we read with interest the study by Vilches et al 12 . that tries to shed light upon the current knowledge gap on systemic embolism in ATTR‐CA.…”

Systemic embolism in transthyretin amyloid cardiomyopathy: how to look into the future

“…In this issue of the Journal, the study by Vilches and colleagues aspires to fill some of the gaps in the existing knowledge within the field of SE in ATTR patients. 11 The authors should be congratulated with this large multicentre study comprising a total of 1191 ATTR patients. The majority of these were wild-type ATTR (83%) and, importantly, no patients with light-chain amyloidosis were included.…”