From the Guidelines
Managing preload in cardiac amyloidosis requires careful volume control through diuretics, dietary sodium restriction, and close monitoring, with loop diuretics like furosemide (20-80mg daily) or torsemide (10-40mg daily) as first-line treatments. The goal is to maintain optimal preload that balances symptom relief with adequate cardiac output, typically requiring more frequent clinical assessment than in other heart failure syndromes 1.
Key Considerations
- Patients should restrict sodium intake to 2-3g daily and limit fluid intake to 1.5-2L per day.
- Regular weight monitoring (daily) helps track fluid status, with weight gains of >2kg in 3 days suggesting fluid retention requiring diuretic adjustment.
- Careful monitoring of renal function and electrolytes is essential, as amyloidosis patients are sensitive to volume depletion.
- Excessive diuresis can worsen cardiac output due to the restrictive physiology of amyloid hearts, which depend on adequate filling pressures.
- Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers should be avoided or used cautiously as they may cause hypotension in amyloidosis patients, as noted in previous guidelines 1.
Treatment Approach
- Loop diuretics are the mainstay of treatment, with thiazides such as metolazone (2.5-5mg) added for resistant cases.
- The use of other medications such as β-blockers and calcium channel blockers should be cautious due to their potential negative effects on cardiac output in the setting of restrictive physiology 1.
- Tafamidis, a US Food and Drug Administration–approved therapy for transthyretin cardiac amyloidosis, may be considered, but its benefit is attenuated with advanced amyloidosis and its high cost should be weighed against its potential benefits 1.
From the Research
Managing Preload in Cardiac Amyloidosis
To manage preload in cardiac amyloidosis, several strategies can be employed:
- Ambulatory diuresis: This approach has been shown to be effective in managing congestion related to cardiac amyloidosis, as demonstrated in a study published in the American Heart Journal 2. The study found that ambulatory intravenous diuresis was safe and reduced healthcare utilization in patients with cardiac amyloidosis.
- Neurohormonal antagonism: The use of beta-blockers, angiotensin-converting enzyme inhibitors (ACEi), and mineralocorticoid receptor antagonists (MRA) can be beneficial in patients with cardiac amyloidosis, as long as there are no contraindications 3. These medications can help reduce symptoms and improve outcomes.
- Monitoring and adjustment of medications: Close monitoring of patients with cardiac amyloidosis is crucial to adjust medications and prevent adverse events such as hypotension, fatigue, and syncope 3.
- Early recognition and diagnosis: Early diagnosis of cardiac amyloidosis is essential to initiate appropriate treatment and improve outcomes 4, 5, 6. Newer imaging modalities and biomarkers can aid in the timely diagnosis of cardiac amyloidosis.
Key Considerations
When managing preload in cardiac amyloidosis, it is essential to consider the following:
- Individualized treatment approach: Each patient with cardiac amyloidosis requires an individualized treatment approach, taking into account their specific symptoms, disease severity, and comorbidities.
- Multidisciplinary care: A multidisciplinary team, including cardiologists, hematologists, and other specialists, is necessary to provide comprehensive care for patients with cardiac amyloidosis.
- Ongoing research and updates: Staying up-to-date with the latest research and advancements in the diagnosis and treatment of cardiac amyloidosis is crucial to provide optimal care for patients with this condition 5, 6.