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The Heart in Portuguese Amyloidosis

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The Heart in Portuguese Amyloidosis Postgraduate Medical Journal (1986) 62, 601-605 Postgrad Med J: first published as 10.1136/pgmj.62.728.601 on 1 June 1986. Downloaded from The heart in Portuguese amyloidosis A. Falcao de Freitas School ofMedicine, Oporto University, 4200 Porto, Portugal. Summary: A systematic investigation was performed in patients with familial amyloidotic poly- neuropathy, Portuguese type (AFp) to assess the pattern and incidence of cardiac involvement. Of 327 patients investigated, ECG abnormalities were present in 285 (87.2%). Low voltage and QS pattern in V1, V2, V3 were found in 51.3% and 35.7% patients respectively. Conduction disturbances were present in 211 (64.5%). Sinus node disease, 1st degree and Wenckebach interventricular blocks were frequent. Complete atrioventricular block was observed in only 2 patients (0.6%). Left anterior hemi-block was present in 30.8%, left bundle branch block in 3.9%, left posterior hemi-block in 2.4% and right bundle branch block in 2.1%. Holter monitoring showed a much higher incidence of conduction disturbances, most of these occurring at night. The mean values of septum and posterior wall thickness and mass evaluated by echocardiography in 72 patients were normal. The systolic and diastolic global and regional functions, determined in 12 patients, analysing the echo by a digitization computer technique, were normal. In 7% a trivial pericardial effusion was observed. In 16 patients with ECG changes and normal echocardiograms the technetium 99m pyrophosphate scanning was negative. We conclude that the ECG is the most precise, sensitive and clinically useful method for detecting cardiac amyloidosis in patients with AFp. In spite of the rarity of congestive and restrictive patterns, the incidence and severity of conduction disturbances does not allow us to consider heart disease in AFp as a benign entity. copyright. Heart involvement is a common feature in all forms of Methods systemic amyloidosis, including the heredofamilial syndromes. The heterogeneity of the amyloid protein A nerve or skin biopsy, positive for amyloid, was the precursors, the genetic or acquired nature of these required criterion for patient selection. All the patients diseases, the different ages at which symptoms appear showed the typical neurological picture and the and their duration, make it difficult to establish a hereditary pattern (Andrade, 1952). A standard ECG http://pmj.bmj.com/ common pattern of heart manifestations in was recorded in 327 consecutive patients. We perfor- amyloidosis. There are generally five clinical presenta- med 24 hour Holter monitoring using 2 leads in 100 tions for amyloid heart disease: dilated (congestive) consecutive patients aged 40.5 ± 10.2 (range 24-74) cardiomyopathy, arrhythmia and conduction distur- years with a mean time ofsymptom duration 6.7 ± 5.5 bances, hypertrophic and restrictive cardiomyopath- years. Semiautomatic analysis oftracings was made by ies and the 'stiff heart syndrome'. Familial a cardiologist who recorded representative parts. amyloidotic polyneuropathy, Portuguese type (AFp), M-mode echocardiograms were performed in 72 on September 24, 2021 by guest. Protected involves motor, sensory and autonomic nerves and is patients (40 men), with mean age 37.3 ± 9.13 years, transmitted by a dominant autosomal gene. All these and in 20 normals age and sex matched. Parameter patients have the same protein amyloid precursor - a determinations were performed according to Craw- variant of prealbumin - and an incidence of 100% of ford et al. (1980) using the mean of3 measurements. In cardiac amyloidosis at necropsy. In the course of a 12 patients and 10 normals, age and sex matched, left systematic approach to AFp, clinical, electrocar- ventricular global and regional diastolic function were diographic (ECG), Holter monitoring, echocardiogra- assessed by digitized analysis of the left ventricle phic and technetium 99m scanning studies were per- echocardiogram. Three cycles in each recording were formed and their utility assessed. Data from these digitized and for each cardiac cycle we acquired the studies are reported here to establish the general continuous left ventricular dimension and its rate of pattern and incidence of cardiac involvement in AFp. change (Figure 1). Its most positive value is the filling rate. We determined the isovolumic relaxation and the rapid filling rate periods (Figure 1) (Sutton et al., Correspondence: A.F. de Freitas, M.D., Ph.D. 1982). For the septum and posterior wall, we obtained ) The Fellowship of Postgraduate Medicine, 1986 Postgrad Med J: first published as 10.1136/pgmj.62.728.601 on 1 June 1986. Downloaded from 602 A.F. de FREITAS T7 TP T7 TP TZ TP TZ TP TM TQ TM TQ TM TQ TM TQ T2 TR T2 TR T2 TR T2 R 0 Normal 0Patient I 0 EE I~~~~ N >N 0,00~~~~~~~~ TZ TP TZ TP TZ TP TZ TP) TM TQ TM TQ TM TQ TM TQ T2 TR T2 TR T2 TR T2 TR 200 1 2 1 NomlzNoml> EJ 0EPatient>z E00E -J o~~~~~~E -I 0 10 1 0 10 1 -200~ 1 -200, -10Ot copyright. Figure 1 DLV - left ventricle dimension during the cycle. DDLV - rate of change of LV dimension. DDLVN - plots ofnormalized rate ofchange of LV dimension. TZ - minimum diameter; TM - opening ofmitral valve; T2 - end of the rapid filling period; TP - start of the P wave; TQ - start of QRS. (Note: all X axes are time axes in seconds). the thickness variation during the digitized cardiac the most frequent finding - were present in 64.5% cycle and the rate of change normalized by the patients. Sinoatrial block was found in 8.5%. At atrio- http://pmj.bmj.com/ instantaneous thickness. The most negative value ventricular level, partial blocks of 1st degree and corresponds to the normalized peak rate of diastolic Wenckebach type were commonly found. Complete thinning ofthe wall (Figure 2). In 16 patients, 9 women heart block was found in only 2 patients. The interven- and 7 men, mean age 40.5 (range 28-55) years, tricular conduction disturbances were characterized technetium 99m pyrophosphate scintigraphy was per- by a marked difference between left and right bundle formed. Three hours after 925 MBq ofthe isotope was branch involvement. Left bundle branch disease was injected intravenously, 2,500,000 counts were collec- present in 122 patients (36.1%) with a high incidence ted from antero-posterior, 45° left anterior and 90° left of left anterior fascicular block (30.8%). Complete on September 24, 2021 by guest. Protected lateral views. All these patients had electrocardiogra- right bundle branch block was present in 7 patients phic changes and normal echocardiograms. (2.1%), less than those with left posterior fascicular block (2.4%). Associate blocks, at different levels, were present in 111 patients. The comparison in the Results same patient between standard ECG and Holter monitoring findings showed a higher incidence of In 327 patients observed in the last 25 years, cardiac conduction disturbances in the latter, especially sino- failure was very rarely seen (0.1%). Syncopal attacks atrial block (22:9%) and the Wenckebach type of were a frequent complaint, mostly due to hypoadren- atrioventricular block (26:7%). In all Holter record- ergic postural hypotension and to conduction distur- ings the higher degree of these disturbances occurred bances. Electrocardiographic changes were present in at night. This method enabled us to detect arrhythmias 285 (87.2%) patients (Table I). Low voltage and a QS rarely found on standard ECG with special reference pattern in VI to V3 were found in 51.3% and 35.7% to ventricular tachycardia runs (6%). Thirty patients of patients respectively. Conduction disturbances - had conduction disturbances or arrhythmia only in Postgrad Med J: first published as 10.1136/pgmj.62.728.601 on 1 June 1986. Downloaded from AMYLOID HEART DISEASE 603 TZ TP TZ TP TZ TP TZ TP TM TQ TM TQ TM TQ TM TQ T2 TR T2 TR T2 TR T2 TR Normal Patient E E E E 0~~~~~0 0 TZ TP TZ TP 1 TZ TP1 TZ TP1 TM TQ TM TQ TM TQ TM TQ 10 T2 TR T2 TR T2 TR i T2' TR z z z Normal Patient z A Wi 0V 1 0 v1 0 0 -10 -10 -10 -10 copyright. Figure 2 DSEP - septal thickness; DPW - posterior wall thickness; DDSEPN - normalized rate of change of septal thickness; DDPWN - normalized rate ofchange ofposterior wall thickness'. (Note: all X axes are time axes in seconds). Holter monitoring. Mean values of septal diastolic Table H Ambulatory ECG compared to routine ECG in thickness, posterior wall diastolic thickness, the ratio 100 patients with AFp of septum/left posterior wall thickness and cross-sec- tional area of the left ventricle were identical in both Routine Ambulatory http://pmj.bmj.com/ groups. Nevertheless, increases of septal diastolic and ECG ECG Sinoatrial block 9 22 Table I Electrocardiographic findings in 327 patients with APBs (<30/h) 3 21 Portuguese amyloidosis Frequent APBs (>30/h) - 30 Ectopic supraventricular rhythm 0 8 N(%) Supraventricular tachycardia 0 6 on September 24, 2021 by guest. Protected Atrial flutter 1 2 Sinoatrial block 28 8.5 Frequent VPBs (>30/h) - 5 A-V block 1st degree 121 37.0 Multifocal VPBs 0 6 A-V block 2nd degree type I 36 11.0 Paired VPBs 1 19 A-V block 3rd degree 2 0.6 Ventricular tachycardia 0 6 Right bundle branch block 7 2.1 1st degree A-V block 29 36 Left anterior hemiblock 101 30.8 2nd degree A-V block (type I) 7 26 Left posterior hemiblock 8 2.4 2nd degree A-V block (type II) 0 1 Left bundle branch block 13 3.9 3rd degree A-V block 2 3 Low voltage 168 51.3 No rhythm disturbances 45 1 QS pattern on V1-V3 117 35.7 Normal ECG pattern 42 12.8 APB = atrial premature beat; VPB = ventricular premature beat.
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