Management of rhythm and conduction disorders in cardiac amyloidosis: a French nationwide Delphi study

Abstract Background Cardiac amyloidosis (CA) is an increasingly recognized cardiomyopathy characterized by the deposition of amyloid fibrils in the myocardial extracellular matrix, leading to restrictive cardiomyopathy, heart failure, arrhythmias and conduction disorders. Despite the development of new therapies to prevent CA progression to heart failure, managing arrhythmias and conductive disorders remains largely undefined. While managing these abnormalities is crucial, specific guidelines are lacking, and physicians often rely on broader international recommendations that may not fully address the complexities of real-world CA management in clinical practice. Purpose This study aimed to gather French expert experience on current practices and treatment strategies for managing arrhythmias and conduction disorders in CA. Main topics included atrial fibrillation (AF) management, anticoagulation therapy, and criteria for implanting cardiac rhythm devices. Methods A modified Delphi method was used, involving a panel of 71 cardiologists and electrophysiologists specializing in CA. The panel evaluated 248 statements over two rounds. Consensus was defined as agreement from at least 66.7% of the panel (responses of 'agree' or 'completely agree'), with a strong consensus requiring over 50% complete agreement. Results In this study, 80% of experts completed Round 1, and approximately 90% of those continued to complete Round 2. Consensus was achieved on 177 out of 248 statements across two rounds (71%). Key agreements included the necessity for regular Holter monitoring and anticoagulation therapy in specific high-risk scenarios. The panel agreed to consider rhythm control strategies, including the use of amiodarone and AF ablation, particularly in the early stages of the disease. The use of cardiac devices was supported for advanced conduction disorders, with decisions influenced by disease staging and left ventricular ejection fraction. Conclusions This study highlighted the need for personalized, multidisciplinary management of arrhythmias and conduction disorders in CA. It emphasized the importance of proactive monitoring and management and calls for future research to develop evidence-based guidelines.