Anticoagulation in Atrial Fibrillation Associated With Cardiac Amyloidosis: A Narrative Review

Abstract

Cardiac amyloidosis (CA) involves the abnormal deposition and accumulation of amyloid proteins in the heart muscle. A hallmark of disease progression is declining heart function, which can lead to structural irregularities, arrhythmias, and ultimately heart failure. Atrial fibrillation (AF) is the most common arrhythmia that presents in CA patients, and this arrhythmia is significant because it can moderately increase the risk of patients developing intracardiac thrombi, thereby putting them at risk for thromboembolic events. The management of this complication entails the use of anticoagulants like vitamin K antagonists and direct oral anticoagulants to reduce the risk of thrombus formation. This article seeks to review AF in CA and the use of anticoagulation therapy for the management and reduction of thromboembolic risk. The major conclusions of this review are centered around the need for safe administration of anticoagulant therapy to CA patients, regardless of their CHA2DS2-VASc risk score. This review highlights the importance of taking a multidisciplinary or collaborative approach to CA treatment to ensure that all aspects of this multifaceted disease can be properly managed while minimizing adverse events like bleeding risk and drug-drug interactions.

Keywords: amyloidosis al; anticoagul; atrial fibrillation (af); atrial fibrillation cardiac amyloidosis; attr amyloidosis.

Figure 1. Illustration of the evaluation of CA in suspected patients

ATTR, transthyretin amyloidosis; CA, cardiac amyloidosis; LGE, late gadolinium enhancement; LV, left ventricular; NT-proBNP, N-terminal pro-B-type natriuretic peptide; sFLC, serum free light-chain Image credits: Tejbir S. Monga and Mfonido Ekong