Prevalence of transthyretin amyloid cardiomyopathy in at-risk outpatients: real-world data from a german multicentre ambulatory registry (BNK ATTRact Registry)
S Schwarting, K Luber De Quintana, S Glueck, F GossAbstract
Background
Transthyretin cardiac amyloidosis (ATTR-CM) is an increasingly recognised but still underdiagnosed cause of heart failure. Early diagnosis is essential to enable timely initiation of disease-modifying therapies. In routine care, office-based cardiology practices represent the first point of contact for most patients with heart failure and therefore play a key role in identifying red-flag features, performing a differentiated clinical assessment and initiating further diagnostic evaluation for ATTR-CM. While current ESC guidelines provide a structured diagnostic algorithm, real-world epidemiological data on their implementation and feasibility in ambulatory care remain limited.
Methods
This prospective, multicentre, non-interventional registry was conducted in 46 office-based cardiology practices across Germany. Patients aged >60 years with heart failure, left ventricular wall thickness ≥13 mm and at least two red flags leading to high clinical suspicion of cardiac amyloidosis were enrolled. Diagnostic evaluation followed current ESC guideline recommendations and included bone scintigraphy and exclusion of light-chain amyloidosis (AL) (1). The primary endpoint was the prevalence of confirmed ATTR-CM in an outpatient setting. Demographics and diagnostic work-up as well as clinical characteristics, red-flag features and sex-specific differences were analysed.
Results
Among 504 screened individuals, 499 patients were included in the final analysis (median age 81 [74–85] years; 72% male). Bone scintigraphy was performed in 87.6% of patients, identifying diagnostic myocardial tracer uptake in 123 individuals. After exclusion of AL amyloidosis, 80 patients were diagnosed with ATTR-CM, corresponding to a prevalence of 16% in this at-risk outpatient population. The diagnostic pathway was predominantly non-invasive, with a non-invasive-to-biopsy ratio of 2:1. Patients with ATTR-CM were older, predominantly male and exhibited more advanced heart failure symptoms and significantly greater left ventricular wall thickness at the time of diagnosis. Genetic testing identified hereditary ATTR in five patients. Identified ATTR-CM cases were evenly distributed across the nationwide screening cohort. Typical extracardiac red-flag features were frequent but did not substantially differ between patients with and without confirmed ATTR-CM. Female patients showed higher left ventricular ejection fraction and a higher prevalence of neurological and musculoskeletal manifestations.
Conclusions
In this nationwide ambulatory registry, ATTR-CM was diagnosed in approximately one in six elderly patients with heart failure and increased left ventricular wall thickness. These findings highlight the substantial real-world burden of ATTR-CM and emphasise the pivotal role of office-based cardiology practices in the early detection of ATTR-CM supporting the implementation of structured, risk-based diagnostic strategies in routine ambulatory care.For image description, please refer to the figure legend and surrounding text.