Author + information
- Richard K. Cheng, MD, MSca,∗ (, )@RichardKCheng2,
- Wayne C. Levy, MDa,
- Alexi Vasbinder, RNb,
- Sergio Teruya, MDc,
- Jeffeny De Los Santos, MDc,
- Douglas Leedy, MDa and
- Mathew S. Maurer, MDc
- aDivision of Cardiology, Department of Medicine, University of Washington Medical Center, Seattle, Washington
- bDepartment of Health Informatics, School of Nursing, University of Washington, Seattle, Washington
- cDivision of Cardiology, Columbia University Irving Medical Center, New York, New York
- ↵∗Address for correspondence:
Dr. Richard K. Cheng, Department of Medicine, Division of Cardiology and Department of Radiology, University of Washington Medical Center, Box 356422, Seattle, Washington 98195.
Background With increasing diagnoses and available treatment options for transthyretin amyloidosis cardiomyopathy (ATTR-CM), risk stratification of ATTR-CM patients is imperative.
Objectives We hypothesized that diuretic dose and New York Heart Association (NYHA) functional class are independent predictors of mortality in ATTR-CM and would be incrementally additive to existent risk scores.
Methods Consecutive ATTR-CM patients referred to a single center were identified. Adjusted Cox proportional hazards models determined the association between diuretic dose (furosemide equivalent in mg/kg) at time of diagnosis and the primary outcome of all-cause mortality. The incremental value of adding diuretic dose and NYHA functional class to existing ATTR-CM risk scores was assessed for discrimination and calibration.
Results 309 patients were identified, with mean age 73.2 ± 9.8 years, 84.1% male, and 66% wild type. Daily mean diuretic dose was 0.6 ± 1.0 mg/kg and significantly associated with all-cause mortality (unadjusted hazard ratio: 2.12 per 1-mg/kg increase, [95% confidence interval: 1.71 to 2.61] and fully adjusted hazard ratio: 1.43 [95% confidence interval: 1.06 to 1.93]). Testing previously published ATTR risk scores, adding diuretic dose as categories (0 mg/kg, >0 to 0.5 mg/kg, >0.5 to 1 mg/kg, and >1 to 2 mg/kg) improved the area under the curve of the Mayo risk score from 0.693 to 0.767 and the UK risk score from 0.711 to 0.787 while preserving calibration. Adding NYHA functional class further improved the area under the curve to 0.798 and 0.816, respectively.
Conclusions Diuretic dose and NYHA functional class are independent predictors of mortality in ATTR-CM patients and provide incremental value to existing ATTR-CM risk scores.
UW CoMotion holds the copyright to the Seattle Heart Failure Model. Dr. Levy has received support from National Heart, Lung, and Blood Institute grant R21HL140445-01A1. Dr. Maurer has received support from National Institutes of Health grants R01HL139671, R21AG058348, and K24AG036778. Dr. Levy has served on steering committees for GE Healthcare, Respircardia, and Cardiac Dimensions, Inc.; has served on clinical endpoint committees for EBR Systems and CardioMems (Abbott & Baim Institute); and has consulted for Impulse Dynamics and Medtronic. Dr. Maurer has received consulting income and his institution has received clinical trial funding from Pfizer, Eidos, Prothena, Akcea, and Alnylam. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: CardioOncology author instructions page.
- Received February 23, 2020.
- Revision received June 1, 2020.
- Accepted June 2, 2020.
- 2020 The Authors