Paradoxical association: normal nocturnal blood pressure pattern predicts higher event rate in transthyretin amyloid cardiomyopathy

Introduction

Transthyretin amyloidosis (ATTR) involves autonomic dysfunction that may alter circadian blood pressure rhythms. While abnormal nocturnal patterns are expected to confer worse prognosis, their actual impact remains unclear.

Objectives

To evaluate the prognostic value of nocturnal blood pressure patterns in ATTR cardiomyopathy.

Methods

Observational study of 99 ATTR patients classified by 24-hour ABPM into: dipper (n=25), non-dipper (n=39), riser (n=29), and extreme dipper (n=6). Primary endpoint: composite of heart failure hospitalization or all-cause mortality.

Results

Mean age was 83.6±6.1 years, 72% male, 94% wild-type ATTR.

Contrary to expectations, dippers exhibited the highest event rate (52.0%, 13/25), while abnormal patterns showed lower rates: non-dipper 25.6% (10/39), riser 17.2% (5/29), extreme dipper 16.7% (1/6). Overall event rate was 29.3% (29/99) over 256-day median follow-up. (Figure 1)

Kaplan-Meier analysis showed no significant survival differences between patterns (log-rank p=0.277). (Figure 2)

Conclusions

In ATTR cardiomyopathy, preserved nocturnal blood pressure dipping paradoxically associates with higher event rates, while abnormal patterns (non-dipper, riser, extreme dipper) show better short-term outcomes. This unexpected finding suggests that in advanced ATTR, maintained autonomic function may not confer prognostic benefit, potentially reflecting different disease phenotypes or compensatory mechanisms. Further investigation is needed to understand this counterintuitive observation.Figure 1For image description, please refer to the figure legend and surrounding text.For image description, please refer to the figure legend and surrounding text.