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Bonvicini E, Preda A, Tognola C, Falco R, Gidiucci R, Leo G, Vargiu S, Varrenti M, Gigli L, Baroni M, Carbonaro M, Colombo G, Maloberti A, Giannattasio C, Mazzone P, Guarracini F. Arrhythmic Risk Stratification in Cardiac Amyloidosis: A Review of the Current Literature. J Cardiovasc Dev Dis 2024; 11:222. [PMID: 39057642 PMCID: PMC11277134 DOI: 10.3390/jcdd11070222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 07/10/2024] [Accepted: 07/12/2024] [Indexed: 07/28/2024] Open
Abstract
Cardiac amyloidosis is the most frequent infiltrative disease caused by the deposition of misfolded proteins in the cardiac tissue, leading to heart failure, brady- and tachyarrhythmia and death. Conduction disorders, atrial fibrillation (AF) and ventricular arrhythmia (VA) significantly impact patient outcomes and demand recognition. However, several issues remain unresolved regarding early diagnosis and optimal management. Extreme bradycardia is the most common cause of arrhythmic death, while fast and sustained VAs can be found even in the early phases of the disease. Risk stratification and the prevention of sudden cardiac death are therefore to be considered in these patients, although the time for defibrillator implantation is still a subject of debate. Moreover, atrial impairment due to amyloid fibrils is associated with an increased risk of AF resistant to antiarrhythmic therapy, as well as recurrent thromboembolic events despite adequate anticoagulation. In the last few years, the aging of the population and progressive improvements in imaging methods have led to increases in the diagnosis of cardiac amyloidosis. Novel therapies have been developed to improve patients' functional status, quality of life and mortality, without data regarding their effect on arrhythmia prevention. In this review, we consider the latest evidence regarding the arrhythmic risk stratification of cardiac amyloidosis, as well as the available therapeutic strategies.
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Affiliation(s)
| | - Alberto Preda
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy (S.V.)
| | - Chiara Tognola
- Clinical Cardiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy; (C.T.); (A.M.)
| | - Raffaele Falco
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy (S.V.)
| | - Roberto Gidiucci
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy (S.V.)
| | - Giulio Leo
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy (S.V.)
| | - Sara Vargiu
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy (S.V.)
| | - Marisa Varrenti
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy (S.V.)
| | - Lorenzo Gigli
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy (S.V.)
| | - Matteo Baroni
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy (S.V.)
| | - Marco Carbonaro
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy (S.V.)
| | - Giulia Colombo
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy (S.V.)
| | - Alessandro Maloberti
- Clinical Cardiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy; (C.T.); (A.M.)
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy
| | - Cristina Giannattasio
- Clinical Cardiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy; (C.T.); (A.M.)
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy
| | - Patrizio Mazzone
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy (S.V.)
| | - Fabrizio Guarracini
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy (S.V.)
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Cotella J, Randazzo M, Maurer MS, Helmke S, Scherrer-Crosbie M, Soltani M, Goyal A, Zareba K, Cheng R, Kirkpatrick JN, Yogeswaran V, Kitano T, Takeuchi M, Fernandes F, Hotta VT, Campos Vieira ML, Elissamburu P, Ronderos R, Prado A, Koutroumpakis E, Deswal A, Pursnani A, Sarswat N, Addetia K, Mor-Avi V, Asch FM, Slivnick JA, Lang RM. Limitations of apical sparing pattern in cardiac amyloidosis: a multicentre echocardiographic study. Eur Heart J Cardiovasc Imaging 2024; 25:754-761. [PMID: 38243591 DOI: 10.1093/ehjci/jeae021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 01/05/2024] [Accepted: 01/09/2024] [Indexed: 01/21/2024] Open
Abstract
AIMS Although impaired left ventricular (LV) global longitudinal strain (GLS) with apical sparing is a feature of cardiac amyloidosis (CA), its diagnostic accuracy has varied across studies. We aimed to determine the ability of apical sparing ratio (ASR) and most common echocardiographic parameters to differentiate patients with confirmed CA from those with clinical and/or echocardiographic suspicion of CA but with this diagnosis ruled out. METHODS AND RESULTS We identified 544 patients with confirmed CA and 200 controls (CTRLs) as defined above (CTRL patients). Measurements from transthoracic echocardiograms were performed using artificial intelligence software (Us2.AI, Singapore) and audited by an experienced echocardiographer. Receiver operating characteristic curve analysis was used to evaluate the diagnostic performance and optimal cut-offs for the differentiation of CA patients from CTRL patients. Additionally, a group of 174 healthy subjects (healthy CTRL) was included to provide insight on how patients and healthy CTRLs differed echocardiographically. LV GLS was more impaired (-13.9 ± 4.6% vs. -15.9 ± 2.7%, P < 0.0005), and ASR was higher (2.4 ± 1.2 vs. 1.7 ± 0.9, P < 0.0005) in the CA group vs. CTRL patients. Relative wall thickness and ASR were the most accurate parameters for differentiating CA from CTRL patients [area under the curve (AUC): 0.77 and 0.74, respectively]. However, even with the optimal cut-off of 1.67, ASR was only 72% sensitive and 66% specific for CA, indicating the presence of apical sparing in 32% of CTRL patients and even in 6% healthy subjects. CONCLUSION Apical sparing did not prove to be a CA-specific biomarker for accurate identification of CA, when compared with clinically similar CTRLs with no CA.
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Affiliation(s)
- Juan Cotella
- University of Chicago, 5758 S. Maryland Avenue, MC 9067, DCAM 5509, Chicago, IL 60637, USA
| | - Michael Randazzo
- University of Chicago, 5758 S. Maryland Avenue, MC 9067, DCAM 5509, Chicago, IL 60637, USA
| | | | | | | | | | | | | | | | | | | | - Tetsuji Kitano
- University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Masaaki Takeuchi
- University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Fábio Fernandes
- Heart Institute (InCor), São Paulo University Medical School, São Paulo, Brazil
| | - Viviane Tiemi Hotta
- Heart Institute (InCor), São Paulo University Medical School, São Paulo, Brazil
| | | | | | | | - Aldo Prado
- Centro Privado de Cardiología, Tucuman, Argentina
| | | | - Anita Deswal
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amit Pursnani
- NorthShore University Health System, Evanston, IL, USA
| | | | - Karima Addetia
- University of Chicago, 5758 S. Maryland Avenue, MC 9067, DCAM 5509, Chicago, IL 60637, USA
| | - Victor Mor-Avi
- University of Chicago, 5758 S. Maryland Avenue, MC 9067, DCAM 5509, Chicago, IL 60637, USA
| | | | - Jeremy A Slivnick
- University of Chicago, 5758 S. Maryland Avenue, MC 9067, DCAM 5509, Chicago, IL 60637, USA
| | - Roberto M Lang
- University of Chicago, 5758 S. Maryland Avenue, MC 9067, DCAM 5509, Chicago, IL 60637, USA
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Vogel J, Carpinteiro A, Luedike P, Buehning F, Wernhart S, Rassaf T, Michel L. Current Therapies and Future Horizons in Cardiac Amyloidosis Treatment. Curr Heart Fail Rep 2024:10.1007/s11897-024-00669-7. [PMID: 38809394 DOI: 10.1007/s11897-024-00669-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/20/2024] [Indexed: 05/30/2024]
Abstract
PURPOSE OF REVIEW Cardiac amyloidosis (CA) is a condition characterized by misfolding and extracellular deposition of proteins, leading to organ dysfunction. While numerous forms of CA exist, two subtypes dominate clinical prevalence: Transthyretin amyloid (ATTR) and immunoglobulin light chain amyloid. RECENT FINDINGS The current scientific landscape reflects the urgency to advance therapeutic interventions with over 100 ongoing clinical trials. Heart failure treatment is affected by CA phenotype with poor tolerance of otherwise frequently used medications. Treating comorbidities including atrial fibrillation and valvular disease remains a challenge in CA, driven by technical difficulties and uncertain outcomes. Tafamidis is the first ATTR-stabilizer approved with a rapidly growing rate of clinical use. In parallel, various new therapeutic classes are in late-stage clinical trials including silencers, antibodies and genetic therapy. Managing CA is a critical challenge for future heart failure care. This review delineates the current standard-of-care and scientific landscape of CA therapy.
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Affiliation(s)
- Julia Vogel
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Alexander Carpinteiro
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Peter Luedike
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Florian Buehning
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Simon Wernhart
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Lars Michel
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany.
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Vereckei A, Katona G, Szénási G, Vidács LD, Földeák D, Takács H, Nagy V, Sepp R. Novel electrocardiographic criteria may render possible the more accurate recognition of cardiac amyloidosis. ESC Heart Fail 2024; 11:1030-1038. [PMID: 38243379 DOI: 10.1002/ehf2.14655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 10/04/2023] [Accepted: 12/12/2023] [Indexed: 01/21/2024] Open
Abstract
AIMS The early diagnosis of cardiac amyloidosis (CA) is paramount, since there are effective therapies that improve patient survival. The diagnostic accuracy of classical electrocardiographic (ECG) signs, such as low voltage, pseudoinfarct pattern, and conduction disturbances in the diagnosis of CA, is inferior to that of the echocardiographic myocardial deformation criteria; therefore, our aim was to find more accurate novel ECG criteria for this purpose. METHODS We tested the diagnostic value of five novel ECG criteria, two of them devised by us, in 34 patients with confirmed CA (20 transthyretin amyloidosis and 14 AL amyloidosis) and 45 control patients with left ventricular hypertrophy on echocardiography due to hypertension, valvular aortic stenosis and hypertrophic cardiomyopathy. The following novel ECG criteria, that suggested CA, were tested: QRS amplitude in lead I < 0.55 mV (I < 0.55); QRS amplitude in lead aVR < 0.5 mV (aVR < 0.5); average QRS amplitude of leads I + aVR < 0.575 mV [(I + aVR) < 0.575]; average QRS amplitude of leads I + aVR/average QRS amplitude of leads V1-4 < 0.375 [(I + aVR)/(V1-4) < 0.375]; average QRS amplitude of leads I + aVR/longest intrinsicoid deflection in leads I,aVL,V1-6 < 0.0115 [(I + aVR)/I,aVL,V1-6ID < 0.0115]. RESULTS The I < 0.55, aVR < 0.5, (I + aVR) < 0.575, (I + aVR)/(V1-4) < 0.375, (I + aVR)/I,aVL,V1-6ID < 0.0115 test accuracy (TA) were 81%, 84.8%, 82.3%, 84.8%, and 83.3%, respectively; the sensitivity (SE): 76.5%, 82.4%, 85.3%, 82.4%, and 76.9%; specificity (SP): 84.4%, 86.7%, 80%, 86.7%, and 87.5%; positive predictive values (PPV): 78.8%, 82.4%, 76.3%, 82.4%, and 80%; negative predictive values (NPV): 82.6%, 86.7%, 87.8%, 86.7%, and 85.4%; area under curve (AUC) values: 0.8922, 0.8794, 09016, 0.8824, and 0.8462 were respectively. These parameters of the novel ECG criteria were at least as good as those reported by other authors in the literature of the qualitative (TA: 67%, SE: 80%, SP: 34%, PPV: 75%, NPV: 42%, AUC: 0.57) and quantitative apical sparing (TA: 64-80%, SE: 66-81.3%, SP: 55-78.3%, PPV: 33-83.9%, NPV: 41-75%, AUC: 0.62-0.68) and left ventricular ejection fraction/global longitudinal strain >4.1 (TA: 77%, SE: 93%, SP: 38%, PPV: 79%, NPV: 69%, AUC: 0.65) echocardiographic criteria. Among the classical criteria, the low voltage in limb leads criterion was present most frequently (in 73.5%) in patients with CA, with slightly worse diagnostic value than the novel ECG criteria (TA: 78.5%, SE: 73.5%, SP: 82.2%, PPV: 75.8%, NPV: 80.4%). CONCLUSIONS The novel ECG criteria [mostly the aVR < 0.5, (I + aVR)/(V1-4) < 0.375] seem at least as reliable in the diagnosis of CA as the best echocardiographic myocardial deformation criteria and might be used either together with the echocardiographic criteria or as stand-alone criteria to diagnose CA in the future.
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Affiliation(s)
- András Vereckei
- Department of Medicine and Hematology, Semmelweis University, Budapest, Hungary
| | - Gábor Katona
- Department of Medicine and Hematology, Semmelweis University, Budapest, Hungary
| | - Gábor Szénási
- Institute of Translational Medicine, Semmelweis University, Budapest, Hungary
| | - László Dániel Vidács
- Department of Internal Medicine, Division of Non-Invasive Cardiology, University of Szeged, Szeged, Hungary
| | - Dóra Földeák
- Department of Internal Medicine, Division of Non-Invasive Cardiology, University of Szeged, Szeged, Hungary
| | - Hedvig Takács
- Department of Internal Medicine, Division of Non-Invasive Cardiology, University of Szeged, Szeged, Hungary
| | - Viktória Nagy
- Department of Internal Medicine, Division of Non-Invasive Cardiology, University of Szeged, Szeged, Hungary
| | - Róbert Sepp
- Department of Internal Medicine, Division of Non-Invasive Cardiology, University of Szeged, Szeged, Hungary
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Moraru L, Mirea O, Toader D, Berceanu M, Soldea S, Munteanu A, Donoiu I, Raicea V. Lower Limit of Normality of Segmental Multilayer Longitudinal Strain in Healthy Adult Subjects. J Cardiovasc Dev Dis 2024; 11:102. [PMID: 38667720 PMCID: PMC11050488 DOI: 10.3390/jcdd11040102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 03/25/2024] [Accepted: 03/26/2024] [Indexed: 04/28/2024] Open
Abstract
Speckle tracking echocardiography is an advanced imaging technique that allows for a more detailed assessment of cardiac global and regional function. Reference values for segmental longitudinal layered strain (subendocardial, mid-myocardial, and subepicardial) are scarce, limiting the clinical use of these measurements in clinical practice. Two hundred consecutive Caucasian healthy subjects (mean age = 37 ± 11 years) were enrolled in the study. The mean values of global longitudinal strain (GLS) for endocardial (Endo), mid-myocardial (Myo) and epicardial (Epi) layers were -22.9 ± 2.7, -20.0 ± 2.4 and -17.5 ± 2.1, respectively. The GLSEndo/GLSMyo ratio was 1.1 ± 0.05, while the GLSEndo/GLSEpi ratio was 1.3 ± 0.05. The apical strain-sparing ratio was >1 in 10% of the subjects (endocardium) and 7% (mid-myocardium). The lower limits for segmental LS were as follows: for endocardial LS, -10% (basal), -12% (mid), -14% (apical); for mid-myocardial LS, -10% -10% (basal), -10% (mid), -10% (apical); and for epicardial LS, -7% (basal), -8% (mid), -8% (apical). The findings of this study provide data regarding the lower limit of normality of LS for each LV segment and suggest, for practical considerations, that an LS value below 10% should be considered abnormal in any segment. Further larger studies are warranted to confirm these findings.
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Affiliation(s)
- Liviu Moraru
- Department of Anatomy, UMFST, 540142 Targu-Mures, Romania;
- Department of CardioVascular Surgery, IUBCVT, 540142 Targu-Mures, Romania
| | - Oana Mirea
- Department of Cardiology, Emergency County Hospital Craiova, 200638 Craiova, Romania; (D.T.); (S.S.); (I.D.)
| | - Despina Toader
- Department of Cardiology, Emergency County Hospital Craiova, 200638 Craiova, Romania; (D.T.); (S.S.); (I.D.)
| | - Mihaela Berceanu
- Department of CardioVascular Surgery, Emergency County Hospital Craiova, 200638 Craiova, Romania; (M.B.); (V.R.)
| | - Sorina Soldea
- Department of Cardiology, Emergency County Hospital Craiova, 200638 Craiova, Romania; (D.T.); (S.S.); (I.D.)
| | - Alexandru Munteanu
- Department of General Surgery, Emergency County Hospital Craiova, 200638 Craiova, Romania;
| | - Ionuț Donoiu
- Department of Cardiology, Emergency County Hospital Craiova, 200638 Craiova, Romania; (D.T.); (S.S.); (I.D.)
| | - Victor Raicea
- Department of CardioVascular Surgery, Emergency County Hospital Craiova, 200638 Craiova, Romania; (M.B.); (V.R.)
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