Redefining optimal medical therapy for heart failure in amyloid transthyretin cardiomyopathy.

Abstract

Amyloid transthyretin cardiomyopathy (ATTR-CM) is an infiltrative cardiomyopathy and an underdiagnosed cause of heart failure (HF) across the left ventricular ejection fraction spectrum. As disease-modifying therapies prolong survival, outcomes are increasingly shaped by non-amyloid-specific HF care. Restrictive physiology and frequent autonomic dysfunction create a narrow therapeutic window in which small changes in preload or afterload may precipitate hypotension, renal injury, and low-output symptoms. Loop diuretics remain foundational, requiring individualized dosing, preference for agents with predictable bioavailability when absorption is uncertain, and early, closely monitored combination therapy for refractory congestion. Natriuresis-guided titration, outpatient intravenous diuresis programs, and hemodynamic monitoring may reduce recurrent admissions; however, evidence is largely extrapolated from non-amyloid HF populations and consensus practice, with limited ATTR-specific outcomes data, and these strategies should be viewed as pragmatic options for selected patients rather than standards of care. Randomized outcomes evidence for beta-blockers, renin-angiotensin system inhibitors, and mineralocorticoid receptor antagonists (MRAs) is lacking. Observational data suggest frequent intolerance of beta-blockers and renin-angiotensin system inhibitors, whereas MRAs appear better tolerated with more consistent favorable associations; emerging real-world studies suggest good tolerability of sodium-glucose cotransporter-2 inhibitors with hypothesis-generating signals toward fewer HF events. Accordingly, therapy should be individualized and framed as provisional, prioritizing sustainability and net hemodynamic benefit. Advanced HF care favors transplantation in selected patients and generally discourages durable LV assist devices in restrictive/biventricular phenotypes. Longer survivorship increases the relevance of frailty, nutrition, mobility, caregiver burden, and early palliative integration, alongside multidisciplinary management of extracardiac disease.