Trends in Conventional Heart Failure Therapy in a Real-World Multinational ATTR-CA Cohort

Background: Transthyretin cardiac amyloidosis (ATTR-CA) results from misfolded transthyretin protein deposition in the myocardium, causing restrictive cardiomyopathy, heart failure (HF), and conduction disorders. Conventional HF treatment in ATTR-CA is debated due to absent trial evidence. Current European Society of Cardiology guidelines recommend the use of diuretics and mineralocorticoid receptor antagonists (MRAs). However, beta-blockers (BBs) and angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEi/ARBs) are often discontinued due to hypotension or bradycardia. This study assesses real-world HF treatment patterns and their impact on survival in a multinational ATTR-CA cohort. Methods: A retrospective analysis of 794 ATTR-CA patients examined baseline BB, ACEi/ARB, and MRA prescriptions. The cohort was divided based on guideline publication dates. Results: Patients were predominantly male (73.2%) with a median age of 78 years old. Prescription of diuretics (52.8%) and disease-modifying therapy (44.9%), mostly tafamidis, were common. BBs (43.7%) and ACEi/ARBs (41.2%) were prescribed more often in patients with higher NYHA class, elevated NT-proBNP, and more comorbidities. Blood pressure and heart rate were similar regardless of BB or ACEi/ARB use. BB prescription and combination therapy with BB and ACEi/ARB increased over time. Neither BB nor ACEi/ARB use significantly impacted mortality when analyzed in a multivariate Cox proportional hazard regression. Conclusions: BBs and ACEi/ARBs are more frequently used over time in particular in advanced-stage ATTR-CA patients and although BB and ACEi/ARB appear to be reasonably tolerated in the ones that were prescribed these drugs, survival was not significantly altered.