# Trends in Conventional Heart Failure Therapy in a Real-World Multinational ATTR-CA Cohort

## TL;DR

This study examines heart failure treatment patterns in a multinational cohort of patients with transthyretin cardiac amyloidosis and finds that beta-blockers and ACEi/ARBs are increasingly used but do not significantly affect survival.

## Contribution

The study provides real-world evidence on HF therapy trends and outcomes in ATTR-CA patients, where clinical trial data is lacking.

## Key findings

- Beta-blockers and ACEi/ARBs were more frequently prescribed in advanced-stage ATTR-CA patients.
- Neither beta-blocker nor ACEi/ARB use significantly impacted mortality in multivariate analysis.
- Prescription rates of beta-blockers and combination therapy with ACEi/ARBs increased over time.

## Abstract

Background: Conventional HF treatment in transthyretin cardiac amyloidosis (ATTR-CA) resulting in restrictive cardiomyopathy is debated due to absent trial evidence in this specific sub-population of heart failure (HF) patients. Current European Society of Cardiology guidelines recommend the use of diuretics and mineralocorticoid receptor antagonists (MRAs). However, beta-blockers (BBs) and angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEi/ARBs) are often discontinued due to hypotension or bradycardia. This study assesses real-world HF treatment patterns and their impact on survival in a multinational ATTR-CA cohort. Methods: A retrospective analysis of 794 ATTR-CA patients examined baseline BB, ACEi/ARB, and MRA prescriptions. The cohort was divided based on guideline publication dates. Results: Patients were predominantly male (73.2%) with a median age of 78 years. Prescription of diuretics (52.8%) and disease-modifying therapy (44.9%), mostly tafamidis, was common. BBs (43.7%) and ACEi/ARBs (41.2%) were prescribed more often in patients with higher NYHA class, elevated NT-proBNP, and more comorbidities. Blood pressure and heart rate were similar regardless of BB or ACEi/ARB use. BB prescription and combination therapy with BB and ACEi/ARB increased over time. Neither BB nor ACEi/ARB use significantly impacted mortality when analyzed in a multivariate Cox proportional hazard regression. Conclusions: Use of BBs and ACEi/ARBs has increased over time, particularly in advanced-stage ATTR-CA patients, and although these therapies appear to be reasonably tolerated, survival was not significantly altered.