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. 2022 Aug;24(8):1387-1396.
doi: 10.1002/ejhf.2566. Epub 2022 Jul 11.

Systemic embolism in amyloid transthyretin cardiomyopathy

Silvia Vilches  1 , Marianna Fontana  2 , Esther Gonzalez-Lopez  1 , Lindsey Mitrani  3 , Giulia Saturi  4 , Mary Renju  2 , Jan M Griffin  3 , Angelo Caponetti  4 , Sahana Gnanasampanthan  2 , Jeffeny De Los Santos  3 , Christian Gagliardi  4 , Adrian Rivas  1 , Fernando Dominguez  1 , Simone Longhi  4 , Claudio Rapezzi  5   6 , Mathew S Maurer  3 , Julian Gillmore  2 , Pablo Garcia-Pavia  1   7   8   9
Affiliations

Systemic embolism in amyloid transthyretin cardiomyopathy

Silvia Vilches et al. Eur J Heart Fail. 2022 Aug.

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 CHA2 DS2 -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. CHA2 DS2 -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 CHA2 DS2 -VASc score did not correlate well with clinical outcome in ATTR-CM and should not be used to assess thromboembolic risk in this population.

Keywords: Anticoagulation; Atrial fibrillation; CHA2DS2-VASc; Cardiac amyloidosis; Embolism; Transthyretin.

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Figures

Figure 1
Figure 1
Atrial fibrillation (AF) and embolic events. Flowchart diagram showing the distribution of patients in our cohort according of the presence of AF and embolic events. ATTR‐CM, amyloid transthyretin cardiomyopathy; ATTRv, hereditary transthyretin amyloidosis; ATTRwt, wild‐type transthyretin amyloidosis.
Figure 2
Figure 2
Prevalence of embolic events during follow‐up in non‐anticoagulated patients with atrial fibrillation (AF) and non‐anticoagulated patients in sinus rhythm according to the CHA2DS2‐VASc score. OAC, oral anticoagulation.
Figure 3
Figure 3
Prevalence of embolic events during follow‐up in patients with atrial fibrillation (AF) according to the CHA2DS2‐VASc score.
Figure 4
Figure 4
Embolic events during follow‐up in amyloid transthyretin cardiomyopathy patients with atrial fibrillation according to the type of oral anticoagulation (vitamin K antagonist [VKA] vs. direct oral anticoagulant [DOAC]) (hazard ratio 0.79, 95% confidence interval 0.3–2.3, p = 0.66).
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References

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