Treatment of ATTR Amyloidosis

A 76-year-old man with a medical history of hypertension, hyperlipidemia, type 2 diabetes mellitus, carpal tunnel syndrome, and benign prostatic hypertrophy was recently diagnosed with wildtype transthyretin (ATTR) cardiac amyloidosis with preserved left ventricular ejection fraction of 51% on echocardiography. He does not have a known history of atrial fibrillation or coronary artery disease. He presents due to worsening dyspnea on exertion and to establish care.

Although he was playing tennis on weekends several months prior, over the previous month he has been getting short of breath completing chores around the house and when he bends over. In addition, he has noted some swelling around his ankles and his abdomen has felt bloated. He denies any chest pain, palpitations, or syncope. He has woken up several times overnight feeling short of breath. When he tries to do activities quickly, he becomes short of breath, his legs fatigue, he has to rest, and he cannot keep up with his spouse or his friends.

On examination, his blood pressure is 100/65 mm Hg, heart rate is 68 bpm and regular, and respiratory rate is unremarkable. He is well appearing and in no distress at rest. His jugular venous pressure is elevated to 10-12 cm H2O, heart is regularly in rate and rhythm with a soft grade 2/6 holosystolic murmur at the left lower sternal border, and there is no S3. His lungs show scattered rales at the bases. His abdomen is full without obvious ascites. His extremities show 1+ pitting edema.

His current medications include amlodipine 10 mg daily, metoprolol succinate 50 mg daily, furosemide 20 mg daily, empagliflozin 10 mg daily, metformin 1000 mg BID, spironolactone 25 mg daily, rosuvastatin 10 mg daily, and finasteride 5 mg daily.

Based on this clinical presentation, which one of the following medications could be considered for decreasing or stopping?

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