Management of patients with cardiac amyloidosis in ambulatory heart clinic: a single centre experience

Abstract

Cardiac amyloidosis (CA) is a common type of restrictive cardiomyopathy associated with recurrent episodes of decompensated heart failure, fluid overload and hospitalisations (1)(2) which contribute to adverse prognosis. The advent of novel therapies that improves survival in these patients necessitates the need for optimal management. Heart failure decompensation is a potential cause of morbidity and mortality for patients with CA.

Purpose

To explore the applicability of ambulatory heart failure clinic in management of patients with CA presenting with decompensated heart failure and the impact of this intervention on the rate of heart failure (HF) hospitalisation.

Methods

In this retrospective single centred study, we analysed data from patients with CA who were treated in the ambulatory heart failure clinic from January 2020 to February 2025. Outcomes measured included dosage and administration of intravenous diuretic therapy, initiation and up-titration of guideline directed medical therapy (GDMT) in patients with heart failure with reduced ejection fraction(HFrEF), and rate of hospitalisation pre-visit and post-visit.

Results

29 patients with a diagnosis of CA attended heart failure ambulatory clinic, of which 13 and 7 patients had a formal diagnosis of ATTR and AL amyloidosis respectively. The sample population was predominately male (79%) and of a median age of 78 years (52-92 years).The majority of the patients had NYHA class II symptoms (n= 23, 79%) with a median N-terminal pro-B-type natriuretic peptide (NT-proBNP) level of 4568 pg/ml (interquartile range[IQR], 2081-6874pg/ml). A total of 165 visits took place, of which 95% resulted in safe discharge from the hospital. A total of 87 visits (53%) resulted in administration of intravenous diuretics in the form of furosemide infusion with 24% receiving doses above or equal to 300mg of furosemide. There were no adverse features noted following treatment.

In the subgroup of patients with heart failure with reduced ejection fraction (HFrEF), conventional heart failure therapy was initiated and up titrated with 53% patients on at least three agents by the end of study. The rate of hospitalisation reduced from 24 events pre-visit to 14 events post-visit, demonstrating a 42% lower risk of hospitalisation (RR = 0.58, 95% CI: 0.39–0.88, p = 0.013).

Conclusions

While early diagnosis and wider recognition of cardiac amyloidosis is a paramount aspect of improving management as well as morbidity and mortality outcome in this cohort of patients(3), it is equally important to address timely management of decompensated heart failure through novel heart failure services to prevent hospitalisations and adverse outcomes. One such model is an ambulatory heart failure clinic, this treatment option requires further characterisation.Baseline characteristicsFor image description, please refer to the figure legend and surrounding text.Number of hospitalisationsFor image description, please refer to the figure legend and surrounding text.