CHAD-STOP for cardiac amyloidosis

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CHAD-STOP for cardiac amyloidosis

CHAD-STOP is the mnemonic for the initial steps in the management of cardiac amyloidosis:

C: Conduction and rhythm disorder prevention

H: High heart rate maintenance

A: Anticoagulation

D: Diuretics

STOP: STOP beta receptor and calcium channel blockers, digoxin and renin-angiotensin-aldosterone inhibitors

Preload reserve is limited in cardiac amyloidosis due to severe diastolic dysfunction. Hence the only way to increase the cardiac output is by the heart rate reserve and hence it should not be cut down by beta blockade or calcium channel blockade.

Renin-angiotensin-aldosterone inhibitors carry the risk of severe hypotension, especially in the presence of autonomic nervous system involvement.

Cautious use of diuretics is useful to reduce the congestion of heart failure, but excessive diuretic usage can lead to low cardiac output.

Amiodarone can be used as an antiarrhythmic agent if needed. Anticoagulation may be needed in case of supraventricular arrhythmia, previous history of systemic embolism or intracardiac thrombi. There is a higher chance of thromboembolism in cardiac amyloidosis even in sinus rhythm. Pacemaker implantation may be needed in some cases.

Reference

  1. Ternacle J, Krapf L, Mohty D, Magne J, Nguyen A, Galat A, Gallet R, Teiger E, Cote N, Clavel MA, Tournoux F, Pibarot P, Damy T. Aortic Stenosis and Cardiac Amyloidosis: JACC Review Topic of the Week. J Am Coll Cardiol. 2019 Nov 26;74(21):2638-2651.