Highlights
- •ACEi/ARB and MRA can be safely used in cardiac amyloidosis
- •Treatment must be started at a low dose and slowly up-titrated
- •Patients must be monitored quite closely
- •Beta-blockers are less tolerated in AL amyloidosis and/or worse haemodynamic function
Abstract
Background
Drugs for neurohormonal antagonism are usually denied to patients with cardiac amyloidosis
(CA) because of safety concerns.
Methods
Patients diagnosed with CA at a tertiary referral centre from 2009 to 2019 were enrolled.
In the absence of contraindications, beta-blockers, angiotensin converting enzyme
inhibitors or angiotensin receptor blockers (ACEi/ARB), and mineralocorticoid receptor
antagonists (MRA) were started or up-titrated.
Results
99 patients were evaluated (72% men, age 80 years [72,83], 33% light-chain and 67%
transthyretin amyloidosis); 56% were started on or underwent up-titration of a beta-blocker,
25% of ACEi/ARB, and 39% of MRA; beta-blockers were then prescribed to 87% of patients,
ACEi/ARB to 75%, and MRA to 63%, with median bisoprolol, ramipril, valsartan, and
spironolactone daily equivalent doses of 2.5 mg, 5 mg, 80 mg, and 25 mg, respectively.
Patients starting or starting/up-titrating a beta-blocker did not show a higher frequency
of hypotension, fatigue, syncope, symptomatic bradycardia, need for pacemaker implantation,
or HF hospitalization. Lower stroke volume and cardiac output (CO) predicted HF hospitalization
regardless of amyloidosis type; lower left ventricular ejection fraction predicted
hypotension, and lower CO and diastolic blood pressure predicted syncope. Patients
who had an ACEi/ARB or MRA being started or up-titrated did not experience more adverse
events than other patients.
Conclusions
ACEi/ARB and MRA can be safely used in CA, provided that no contraindications are
present, treatment is started at a low dose and slowly up-titrated, and patients are
monitored quite closely. Beta-blocker therapy is less tolerated in patients with AL
amyloidosis and/or worse haemodynamic function.
Keywords
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Article info
Publication history
Published online: May 28, 2020
Accepted:
May 11,
2020
Received in revised form:
May 6,
2020
Received:
March 20,
2020
Identification
Copyright
© 2020 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
