Management of Rhythm and Conduction Disorders in Cardiac Amyloidosis

Charles Guénancia; Benoît Lequeux; W. Amara; Otilia Buiciuc; Thibaud Damy; Pascal Defaye; Alexandre Duparc; Jean-Christophe Eicher; Rodrigue Garcia; Vincent Galand; Olivier Lairez; Nicolas Lellouche; Silvia Oghina

doi:10.1016/j.jacadv.2025.101604

February 15, 2025JACC AdvancesOpen Access

Management of Rhythm and Conduction Disorders in Cardiac Amyloidosis

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Why the study?

Cardiac amyloidosis carries an associated risk of arrhythmias and conduction disorders, but their management remains largely undefined.

Key Points

To establish expert consensus and identify current clinical strategies for managing cardiac arrhythmias, conduction disorders, anticoagulation, and device implantation in cardiac amyloidosis.
Convened an expert panel of 56 French cardiologists and electrophysiologists specializing in cardiac amyloidosis using a modified Delphi method.
Evaluated 248 clinical statements over 2 survey rounds, defining consensus as ≥66.7% agreement and strong consensus as >50% complete agreement.
Achieved consensus on 177 of 248 statements (71%) across both rounds.
Reached agreement on regular Holter monitoring, anticoagulation in high-risk scenarios, and early rhythm control using amiodarone and atrial fibrillation ablation.
Supported implantable cardiac rhythm devices for advanced conduction disorders, with indications guided by disease stage and left ventricular ejection fraction.

Structured PICO

P

Population

Patients with cardiac amyloidosis and associated arrhythmias or conduction disorders (evaluated by a panel of 56 French cardiologists and electrophysiologists)

I

Intervention

Expert consensus recommendations on atrial fibrillation management, anticoagulation therapy, and criteria for implanting cardiac rhythm devices

O

Outcome

Consensus agreement on 248 proposed statements (defined as ≥66.7% agreement)

A French expert consensus provides guidance on managing arrhythmias and conduction disorders in cardiac amyloidosis, emphasizing regular monitoring, anticoagulation, rhythm control, and appropriate device implantation.

Implication

Supports consensus-based arrhythmia care in cardiac amyloidosis; cautions amiodarone use given low-certainty evidence against benefit.

Abstract

BACKGROUND: Cardiac amyloidosis (CA) is an increasingly recognized cardiomyopathy with an associated risk of arrhythmias and conduction disorders; however, managing arrhythmias and conductive disorders remains largely undefined. OBJECTIVES: This study aims to gather French expert experience on current practices and treatment strategies for managing arrhythmias and conduction disorders in CA. The main areas of interest included atrial fibrillation (AF) management, anticoagulation therapy, and criteria for implanting cardiac rhythm devices. METHODS: A modified Delphi method was employed, involving a panel of 56 cardiologists and electrophysiologists specializing in CA. The panel evaluated 248 statements over 2 rounds. Consensus was defined as agreement from at least 66.7% of the panel, with strong consensus requiring more than 50% complete agreement. RESULTS: Consensus was achieved on 177 out of 248 statements across 2 rounds (71%). Key agreements included 1) the necessity for regular Holter monitoring and anticoagulation therapy in high-risk scenarios; 2) a rhythm control management strategy, including the use of amiodarone and AF ablation, particularly in the early stages of the disease; and 3) the use of cardiac devices for advanced conduction disorders, with decisions influenced by disease staging and left ventricular ejection fraction. CONCLUSIONS: Approximately 70% of the proposed statements achieved agreement among the experts, reflecting reasonable alignment on anticoagulation therapy, AF management, and implantable cardiac devices. However, the study also highlights the need for personalized, multidisciplinary management of arrhythmias and conduction disorders in CA and emphasizes the need for future research to develop evidence-based guidelines.