 But I'm gonna do what I do in the clinic, actually, which is to sit there and just ask the question why. Cos I think it's something that actually, as physicians, we don't do very often. That slide that Victoria just showed about that path to the left, which is simple, but wrong. Physicians like things to be simple and we like to be told what to do most of the time, sort I'm not going to get into this, as there are people on this call are far more ex roaming this, ond yn eich cyfnod, mae'n gweithio'r bwysig y gallwch chi'n gweithio'r ffordd, ond gyda'r bwysig o'r bwysig, a'r ffordd gweithio'r bwysig yn y llef, ond y ffordd llef, yn y lleffnid, yn y llefiau'r ffordd llef. Si'n gwahanol cymdeithas, rydyn ni'n bod y ddweud yn ddweud amlododosis rwynt. Yr 1 ymlaenau amlodosis ym hyn, i'r llwylaid yn ychydig, am y bwysig, o'r plasys ym mwynt. Rwy'n credu bod yw'r ystod o'r tyfn yn ymdyn nhw'n mynd i'w ddim yn ymwysigol. Ond rydyn ni'n credu bod yma yn ymwyloedd cyhoedd, sy'n ymwysigol yma yma yma i'w ddweud cyfan amloedd Cymru, byddai'r ddysgu o'r transthyratonau. Mae'r ddysgu o'r ddysgu, mae'n pryddiadau o'r pryddiadau o'r ddysgu. Ieidentrwych yn cael ei ffordd o'r awdraedd a'r gweithio'r awdraedd mewn i'r pethau sydd. Mae'n gweithio'r awdraedd, mae'n fyfyrddio'r caratyristanol yn awdraedd o modd yn cael ei ffordd i benderfynion, donolyddur, hynny, nesl, rhywbodaeth, ond y gallwn ymddiannol yn cael ei ffordr faint o'r weld Lord General. phenotype clusters. So there are particular mutations that seem to manifest almost exclusively with a neurological phenotype, particularly familial amyloid polyneuropathy. We see other mutations that present with a predominant cardiac phenotype and of course there are variants which result in a more mixed phenotype. With regard to these cardiac phenotypes, there's one in particular the V122i mutation or variant, which is probably underestimated in clinical practice. We know that maybe somewhere between three, four, maybe as much as five percent of people of black African ancestry carry this variant. And I'll come back to this variant later because I actually think this could be telling us something very interesting about the mechanism of disease in association with some of the hereditary forms of TTR myloidosis. So the classical paradigm, the thing that we're taught as medical students and as cardiologists is that there are these two basic types. There's the familial form with this variable presentation, male predominance, often neurological manifestations as I've described, dysaltonomia prominent amongst them. And then there's what we used to call senile or appropriately now wild type TTR myloidosis where you get deposition of the native protein within the heart. This seems to be largely a disease of the elderly once again and male predominance and predominantly cardiac with a few exceptions for example deposition within the carpal tunnel ligament. Now the kind of patients that come to us to clinic are those who've already been diagnosed with TTR myloidosis and are referred for investigation of their heart. We have very occasional patients who have a neurological presentation such as polyneuropathy and are referred to us with so-called unexplained cardiac abnormalities but the overwhelming majority are those who present with what appears to be isolated cardiac disease, sometimes with systemic symptoms that have been overlooked. Now again this is a classical thing that all cardiology trainees will know is that myloidosis is associated with a particular phenomenon on the electrocardiogram. We have small electrical voltages. It's a little more nuanced than that, it's when you have small voltages despite the presence of a thick heart on cardiac imaging so it's that disparity which is the if you like the diagnostic red flag to disease. And that is certainly something that we see but we also now recognise that that is actually a relatively late finding and actually in some forms of TTR myloidosis particularly some of the familial forms actually the voltages may be normal or actually increased suggesting that you have an increase in myocytes cell volume of mass. And that's one of those things what I say writing in the margins you know the questions I ask myself in the clinic is why does this person person have evidence for left ventricular hypertrophy so not storage not deposition but big cardiomyocytes. The classic pathology is is marked by this infiltration this deposition of amyloid fibros between cardiomyocytes and this classically gives you concentric thickenings all the segments of the left ventricle the right ventricle it's usually what we call concentric so it involves all of the segments of the left ventricle equally but we do see so called asymmetric patterns where the disease curiously can be very localised within the muscle. The valves again in classical descriptions are thickened although that can be difficult to discern with any level of certainty on ultrasound. Another feature which is in all the textbooks is that this causes a so-called restrictive cardiomyopathy in other words the heart is very poorly distensible and we can assess that using a variety of non-invasive physiological instruments such as echo echo Doppler but once again we know that there is a full spectrum from no apparent abnormality and diastolic function to extreme stiffness of the ventricle. Just as a couple of examples so what you see here is is a transthoracic echocardiogram and you're seeing the left ventricle cutting cross-section so this ventricle is not that happy it's not contracting very well and you see this concentric thickening and another thing that we love to talk about when we're imaging the heart is so-called echo brightness the echo the heart is characteristically hyper reflective although again a dangerous sign and not that reproducible. This is when this is what we call an apical four chamber view where you see the two ventricles for some reason in adult cardiology we turn the echo upside down and back to front I don't know why but that's what we do so you see the two ventricles at the top of the screen here the two atria the atria are often enlarged myocardium again is thick and this is something which is very subtle but we can look at the deformation of the myocardium using echo by using a technique we call speckle tracking where you take adjacent speckles and see how they move together and apart and actually what we often see is that in the basal segments defamation is poor but for some reason there's preservation of defamation at the apex and we have other ways of demonstrating this this is what's called the ball's eye image and here this represents the apex where you have this preservation or contractility at the apex is unexplained but a characteristic diagnostic red flag for cardiac amyloidosis the why question regionality of disease now in cardiac amyloidosis um that we're in a sort of a renaissance of this it's always been one of those things you learned about to do exams but didn't worry too much about in the clinic but there are now several important drivers in clinical practice which are making us pay attention to this as a disease and one of those is improved diagnostics one of the tests that's made a huge difference is cardiac magnetic resonance imaging so this demonstrates some of the same structural features i've i've described to you on echo so again you see the two atrium the two ventricles the ventricle is thickened the right ventricle is also somewhat thickened and the heart is very poorly contracting but the major contribution this brings is the opportunity to interrogate the tissue substrate non-invasively using contrast agents in this case gadolinium as a contrast agent a paramagnetic agent and what we see are very characteristic patterns of gadolinium uptake so we see often see this sort of very diffuse pattern and also this curious subendocardial pattern my why question why do you see subendocardial deposition in amyloidosis a test which an old test which has transformed our ability to diagnose amyloidosis in the clinic is bone scintigraphy we've known from incidental findings for for many years that we occasionally encounter patients who are having a bone scan for some other reason metastatic cancer whatever and the heart lights up so this is a calcium avid tracer and the heart is lighting up and what we've learned is that this test seems to be close to 100 percent sensitive and specific for TTR related amyloidosis and indeed it is so sensitive and specific that in the absence of any evidence for a plasma cell dysgrazia in blood or urine with free light chains simply by doing a bone scan if the scan is positive in the appropriate context that's all we now need to do to make the diagnosis of TTR amyloidosis whereas before we had to do a cardiac biopsy another really important changer of course is that this is potentially potentially a treatable disease and there's an enormous amount of activity as vitorio alluded to about treatment options in both al and ttr amyloidosis in al amyloidosis we have highly effective chemotherapy now to suppress the abnormal cell clone and reduce light chain production and if you can treat patients early enough this has a significant impact on their longevity and also on their symptoms because simply removing that light chain clone results in an improvement in cardiac function and a reduction in cardiac biomarkers although the amyloid load may remain the same and that this if you like is a classic example of toxicity in TTR the focus here is on what is thought to be the putative mechanism of TTR related amyloidosis which is dissociation of the TTR tetramer into the oligomers and monomers that were being mentioned at the beginning of this talk and it's felt to be these if you like these non-native TTR species misfolded monomers oligomers which re-accumulate as fibals within the myocardium and when there are a variety of approaches now being developed for silencing or preventing TTR production within the liver or stabilizing the native TTR tetramer and this is where the greatest example has been over the past couple of years is in a drug called tephamidus which sits in the central pocket of the TTR tetramer that same pocket which um in which tharoxin sits for example TTR is a transport protein and it stabilizes the the tetramer prevents dissociation and in a randomized clinical controlled trial reduced mortality by 30 percent now remember this is this is essentially a heart failure trial and any change of that magnitude is now very unusual in the modern era particularly in a population with a rapidly progressive fatal disease with a median age of 75 for me even more important is that it seemed to slow disease progression so if we look at quality of life scores these were relatively stable in those treated but deteriorated inexorably in patients in the placebo arm the same in deterioration in six minute walk so stabilization of disease was again really quite traumatic and this also translated into a reduction in time to first cardiovascular hospitalization with heart failure this is not the only agent which is being investigated as i've said there are now approaches using silencing RNA technologies or anti-sensoric and nucleotines designed to reduce or or knock down completely TTR production within the liver now these are currently undergoing trials in patients with cardiac amyloidosis but have been shown to be effective in the neurological familial forms with polyneuropathy and the final driver is that of course now that we have these tests we go back and we start to find that actually the textbook description of the classical cardiac amyloid patient is maybe not quite so classical we see other manifestations so this is in a term which i really hate which is heart failure with preserved ejection fraction so patients who present with signs and symptoms of heart failure but the ejection fraction is normal now this can occur in hypertension obesity but in this study from spain they took patients with so-called HEFPEF performed dpd scanning and found that 13 13% had cardiac amyloidosis which if translated into the pop general population would be an enormous number of people we've also learned to say that the echo patterns are not necessarily classical they can be very localised thickening the low voltage gcg and so on patients may present with actually without heart failure but actually with a stroke with heart block um with valve disease and indeed this this population of patients with valve disease eltic stenosis in particular we're now starting to see very high rates of patients with cardiac amyloid 16% in this series six percent in a surgical series the why question here is is this coincidence is it simply because it's an elderly population or is there a connection between the fact that the patient has significant valve disease and the fact that they also have my cardio deposition of ttr and the final thing this is this is something that is very topical for me today because i've been trying to defend parameters at a nice hearing but if you look at incidental findings in people having bone scan and you can see in this recent australian study maybe as much as four to five percent of individuals above the age of 85 with a positive scan is that disease well they certainly have thicker heart so it probably is so already i hope you've seen that there are many answer questions but there are others some of which are perhaps more relevant clinically others which i think are very relevant to the people on the call here scientists should we be screening for ttr how do we screen who do we screen the purpose of screening is that the evidence from the to families trial of course is that the earlier you treat the better is the effect but how do we do that well there's some suggestion that if we see patients who present with some of their their non-cardiac manifestations which should be screening and the classic one here is carpal tunnel syndrome or spinal canal stenosis which can predate presentation with the cardiac abnormality by five maybe as much as 10 years so perhaps we should be screening that population another why question is why is it affecting the carpal tunnel ligament 10 years before they present with cardiac disease we could screen them with dpd scanning to answer the how question but of course this is not a very expensive test but it is there is some expensive and of course it does involve exposure to radiation another why question for you is is why is the scan positive i asked my my amyloid colleagues about this all the time and they say oh well it binds to the amyloid fibros what does it do we know that and why do we see some exceptions of course the more we do this i said it was 100 percent sensitive and specific well if you look at the v30 met neuropathy early onset presentation actually we're starting to see people who have abnormal echoes but have a normal dpd scan here's another example of a genetic subgroup who have thickening they have an abnormal MRI so they seem to have deposition of amyloid but the dpd scans are negative there must be a biological signal here which is telling us something about the biology of tt and amyloidosis another way of screening is to do genetic testing and this is something we we have a large population of patients who present with thick hearts for other reasons and we've recently done a genetic screen in these patients we found perhaps as you'd expect a number that had the v122i but if you look at the ages here none of these patients had evidence clinically for cardiac amyloid except this individual who was homozygous for the variant she was afro-caribbean and female but we really need a serum markers because that's the really only way in which you're going to do large-scale screening of high-risk populations and we don't have any serum markers yet which are specific to ttr amyloidosis this is an interesting approach using a combination of of known biomarkers so actually measuring serum concentrations of ttr itself which appear to be reduced i'll be um i'll be um retinal binding protein which is also reduced um troponins which are elevated and bmp's which are elevated and in this population of patients with v122i the combination of these things was very predictive of those who actually had cardiac amyloidosis so maybe we're going to be looking at combinations of if you like surrogate biomarkers why do we see this variable disease penetrance and why is it a disease of predominantly elderly men what is it different about the the ttr pathophysiology or the hearts of elderly men compared to women i've asked for why just the heart and the carpal tunnel ligment and this issue toxicity versus storage this is something if i suggest this to some of my clinical amyloid colleagues they tell me to you know they're they're calm down you're just a cardiologist this is not a toxic disease well okay but i'll come back to that in a second with regard to the variability this is what we see in all monogenic diseases and it's going to relate to genetic modifiers epigenetic modifiers and we have some evidence for sort of epigenetic effects with these geographic clusters some evidence for genetic anticipation within some family pedigrees this business about the the importance of what happens to the cardiomyocyte in ttr and this is this is looking at using MRI to assess the extracellular space and cardiomyocyte volume and we see differences between al amyloidosis and ttr amyloidosis first of all ttr amyloidosis the hearts tend to be thicker and if you look at the the left ventricular mass is independent from the extracell volume so the amount or the size of the cardiomyocytes they're bigger in ttr than they are in al amyloidosis this is straying into to your territory we've yeah we've got experimental evidence that if you expose cardiomyocytes to ttr and in particular modified forms of ttr such as oxidised forms then you see a toxic effect you also see changes in cardiomyocyte biology so you have abnormalities of mitochondrial function you have the generation of oxidative stress within the cell you have dysregulation of intracellular calcium so this is a toxic effect this has got nothing to do with the storage and this this interesting idea that what we're actually seeing is a complex interplay between the ttr itself whether it be its abnormal structure whether it be secondary modification of the structure through oxidation or by changing side chains on the molecule as well as changes in cell membranes and in this instance particularly the cardiomyocyte cell membrane with changes in cholesterol content and also as has already been alluded to ganglion cell content and this was a diagram I never actually finished but I like this idea that what we're seeing is yes we see dissociation yes we see this generation of non-native species oligomers etc and these can accumulate as fibrils but there's some evidence that they may be internalised into the cell and that they also have this interaction with the cell membrane resulting in the changes that I just described on the previous slide now is there a clinical signal for toxicity well I genuinely believe that there is if you look at this subgroup analysis of the Apollo B study so this was using patizaran so this is knocking down ttr production in the liver what you see is in the treatment arm not only stabilisation of this biomarker internal pro BMP it basically tells you that the cardiomyocyte is under stress but you start to see a reduction and that reduction begins almost as soon as you start giving the drug so you're taking away some form of stress on the cell I don't I cannot believe this is clearance of amyloid from the heart and it's the same picture as you see with AL amyloidosis and this is a completely wild idea but if you look at biobank registries and you look at africarabians with this familiar variant and look at the prevalence of heart failure with aging in individuals with this variant it is dramatic and this signal keeps coming back if we look at heart failure studies heart failure trials 10% of africarabians in those studies carry this variant now do they all have amyloidosis do they all have deposition or do they have some toxic effect some pre deposition phenotype I don't know you tell me just five minutes okay so these last points on this like I last largely clinical but how do we stratify risk how do we monitor there are a variety of clinical stratification tools built around measurement of biomarkers such as BMP renal function and n-terminal pro BMP this is looking again at those non-native species which seem to be elevating in patients with pulmonary neuropathy but interestingly also seem to respond to therapy and interest if you if you're a non-responder you don't see such a knockdown in these non-native species these oligomers which may give us a way of monitoring therapy and identifying people who are best or who are most likely to respond to treatment and this final point again is something that we're going to be moving into the future who should receive therapy what kind of therapy should you receive what is the role of conventional therapy and this point is what are we actually trying to achieve are we trying to achieve stabilization or reversal or prevention and the strategy will depend on what it is that we're actually trying to do clinically in the interest of time I think I'll probably stop there thank you very much I think thanks a lot uh do we have questions yeah so there's a question from Alexander on why is the heart so much more often affected by amyloidosis than other organs I I just don't know so I mean it's um I think it has to have something to do with the tissue susceptibility and that's why I showed that slide about changes in the cardiomyoside membrane which we know changes with aging we know the lipid content for example of the cardiomyoside membrane changes so there may be a susceptibility effect um but that there are others on the school who may have other ideas um but I think another question which I didn't pose was about the circulating oligomers are they there all the time yeah is this a failure to to clear those toxic oligomers um or are we producing them all the time if we're not producing them all the time is it something that happens with aging as maybe cell mechan interest cell in the mechanisms for dealing with misfolded proteins deteriorate I don't know the answer to those questions um but but clearly there's something which changes in the in organs susceptibility with age and heart changes more than other organs or more than other organs but how do I connect the cognitive ligament I really don't know I accept you know it's interesting that the I see a lot of people with other rare diseases and the other group of patients that I see a lot of carpal tunnel syndrome and are patients with mucopolysaccharidosis so where the carpal tunnel again seems to be particularly susceptible as does the heart and as does valve tissue so is there some commonality there in tissue susceptibility I don't know it's it's not one of those questions why I always ask myself why why why are my little patients with NPS getting a cardiac phenotype which if you squint a little bit looks a little bit like amyloidosis