Redefining the epidemiology of cardiac amyloidosis. A systematic review and meta-analysis of screening studies.

Abstract

An algorithm for non-invasive diagnosis of amyloid transthyretin cardiac amyloidosis (ATTR-CA) and novel disease-modifying therapies have prompted an active search for CA. We examined the prevalence of CA in different settings based on literature data. We performed a systematic search for screening studies on CA, focusing on the prevalence, sex and age distribution in different clinical settings. The prevalence of CA in different settings was as follows: bone scintigraphy for non-cardiac reasons (n=5 studies), 1% (95% confidence interval [CI] 0%-1%); heart failure with preserved ejection fraction (n=6), 12% (95% CI 6%-20%); heart failure with reduced or mildly reduced ejection fraction (n=2), 10% (95% CI 6%-15%); conduction disorders warranting pacemaker implantation (n=1), 2% (95% CI 0%-4%); surgery for carpal tunnel syndrome (n=3), 7% (95% CI 5%-10%); hypertrophic cardiomyopathy phenotype (n=2), 7% (95% CI 5%-9%); severe aortic stenosis (n=7), 8% (95% CI 5%-13%); autopsy series of 'unselected' elderly individuals (n=4), 21% (95% CI 7%-39%). The average age of CA patients in the different settings ranged from 74 to 90 years, and the percentage of men from 50% to 100%. Many patients had ATTR-CA, but the average percentage of patients with amyloid light-chain (AL) CA was up to 18%. Searching for CA in specific settings allows to identify a relatively high number of cases who may be eligible for treatment if the diagnosis is unequivocal. ATTR-CA accounts for many cases of CA across the different settings, but AL-CA is not infrequent. Median age at diagnosis falls in the eighth or ninth decades, and many patients diagnosed with CA are women.