Prevalence and Outcomes of Concomitant Aortic Stenosis and Cardiac Amyloidosis
Why the study?
It was unknown whether concomitant aortic stenosis and cardiac amyloidosis (AS-CA) has worse outcomes or results in futility of TAVR.
Does concomitant cardiac amyloidosis worsen mortality in patients with severe aortic stenosis, and does TAVR improve survival in this population?
Population
407 older patients with severe AS
Comparison
Concomitant AS-CA vs lone AS
Design
Cohort study with blinded heart team decisions
Follow-up
Median of 1.7 years
Authors
Discussion
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Member takes
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“This is quite compelling evidence that we should not withhold ATTR-specific treatment from these patients, as has been done by many centers, [some of which] contributed to this registry.”
“It is really important that our interventional colleagues understand that even though the focus may be sometimes fixing the aortic valve, the patients will not do well unless they get the right diagnosis. I think these two things coexist frequently enough that probably [screening] should become standard for those at risk.”
“Patients with AS plus ATTR-CA experience worse clinical outcomes than patients with AS only. Increased awareness of these coexisting conditions may help facilitate earlier screening and improve prognosis.”
Implication
AS-CA associated with higher mortality than lone AS; leaves open whether routine screening or targeted therapies improve TAVR outcomes.
Key Points
- To assess the prevalence, clinical profile, and mortality outcomes of concomitant severe aortic stenosis and cardiac amyloidosis (AS-CA) compared to lone aortic stenosis.
- Assessed 407 patients (mean age 83.4 ± 6.5 years; 49.8% men) with severe aortic stenosis using technetium-DPD bone scintigraphy and tissue biopsy prior to intervention.
- Treatment strategy—transcatheter aortic valve replacement (81.6%), surgical aortic valve replacement (2.5%), or medical management (15.9%)—was assigned by a heart team blinded to scintigraphy results, with all-cause mortality tracked over a median follow-up of 1.7 years.
- Cardiac amyloidosis was identified in 11.8% of patients (n = 48; grade 1: 3.9%, grade 2/3: 7.9%), and a predictive clinical tool (RAISE score) identified AS-CA with an AUC of 0.86 (95% CI: 0.78 to 0.94; p < 0.001).
- One-year mortality was significantly higher in patients with AS-CA than in those with lone aortic stenosis (24.5% vs. 13.9%; p = 0.05).
- Transcatheter aortic valve replacement improved survival compared with medical therapy, yielding post-procedural survival rates that did not significantly differ between patients with AS-CA and lone aortic stenosis (p = 0.36).
Structured PICO
Does concomitant cardiac amyloidosis worsen mortality in patients with severe aortic stenosis, and does TAVR improve survival in this population?
P
Population
407 older patients with severe aortic stenosis, mean age 83.4 ± 6.5 years, 49.8% men.
I
Intervention
Presence of concomitant cardiac amyloidosis (AS-CA) and treatment with transcatheter aortic valve replacement (TAVR)
C
Comparator
Lone aortic stenosis (lone AS) and medical management
O
Outcome
All-cause mortality captured by national registrieshard clinical
Concomitant cardiac amyloidosis is common in older patients with severe aortic stenosis and is associated with worse prognosis, but TAVR is equally effective in improving survival in these patients as in those with lone AS.
Cite This Study
Nitsche et al. (2020) studied this question.