Transthyretin Amyloid Cardiomyopathy-Current and Future Therapies.

OBJECTIVE: To describe the clinical presentation of transthyretin amyloid cardiomyopathy (ATTR-CM) and discuss current treatments and investigational products and their effect on patient outcomes. DATA SOURCES: A literature search was performed in PubMed (September 2018 to December 2020) using the following keywords: transthyretin amyloidosis, cardiomyopathy, polyneuropathy and transthyretin amyloid cardiomyopathy, monoclonal light-chain, tafamidis, cardiac amyloidosis, ATTR cardiomyopathy, green tea and inhibition of cardiac amyloidosis, AG10, tolcapone, tolcapone and leptomeningeal ATTR, PRX004, NI006, patisiran, inotersen, vutrisiran, AKCEA-TTR-LRx, and NTLA-2001. STUDY SELECTION AND DATA EXTRACTION: Clinical trials were evaluated for evidence supporting pharmacology, safety, efficacy, and measured outcomes. DATA SYNTHESIS: Until 2019, there were no approved treatments for ATTR-CM. Treatment consisted of symptom management and organ transplant. Nonpharmacological and pharmacological treatments focused on the symptoms of heart failure (HF) associated with ATTR-CM. However, there are several emerging therapies recently approved or in development to address the underlying pathophysiology. Treatment classes for ATTR-CM include transthyretin stabilizers, human monoclonal antibodies, gene silencers, and CRISPR/Cas9 gene editing. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE: ATTR-CM is a complex disease in which amyloidosis causes cardiomyopathy. Underdiagnosis is attributed to the clinical presentation being heterogeneous, indistinguishable from HF caused by other etiologies, and the need for invasive testing modalities, including endomyocardial biopsy. Improved diagnostic approaches along with targeted therapies can slow disease progression and enhance patient quality of life. CONCLUSION: Diagnostic modalities along with biomarker and genetic testing could detect disease earlier and target therapy more accurately. Novel therapies demonstrate potential treatment benefits and can help shape the standard of care for these patients.

A new, bioactive structural motif: Visible light induced DNA photobinding and oxygen independent photocleavage by RuII, RhIII bimetallics.

The Ru,Rh bimetallic complexes, [(bpy)(2)Ru(dpp)RhCl(2)(phen)](3+) and [(bpy)(2)Ru(bpm)RhCl(2)(phen)](3+) (bpy=2,2'-bipyridine, dpp=2,3-bis(2-pyridyl)pyrazine, phen=1,10-phenanthroline, and bpm=2,2'-bipyrimidine), couple one ruthenium polyazine light absorber to a cis-Rh(III)Cl(2) center through a dpp or bpm bridging ligand in contrast to the previously studied Ru,Rh,Ru trimetallics. This motif provides a sterically accessible Rh reactive site. These bimetallics are efficient visible light absorbers possessing many advantages compared to the previously reported trimetallics: lower cationic charges, reduced stereoisomerization, and independent variation of terminal ligands at each metal center to modulate properties. The bimetallic systems display efficient visible light induced bioreactivities with DNA. In addition to the known DNA photocleavage in related Ru,Rh,Ru trimetallics, these Ru,Rh bimetallic systems display visible light induced DNA binding. Low lying triplet metal to metal charge transfer ((3)MMCT) excited states provide oxygen independent photoreactivity. This previously unexplored structural motif for DNA modification holds promises in photodynamic therapy and DNA modification schemes.