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Badwan O, Berglund F, Rosenzveig A, Persits I, Gharaibeh A, Kumar A, Agrawal A, Sul L, Chan N, Wang TKM, Hanna M, Klein AL. Pericardial Disease in Cardiac Amyloidosis: A Comprehensive Review. Am J Cardiol 2024; 223:100-108. [PMID: 38740164 DOI: 10.1016/j.amjcard.2024.05.007] [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: 01/28/2024] [Revised: 05/02/2024] [Accepted: 05/08/2024] [Indexed: 05/16/2024]
Abstract
In patients with cardiac amyloidosis, pericardial involvement is common, with up to half of patients presenting with pericardial effusions. The pathophysiological mechanisms of pericardial pathology in cardiac amyloidosis include chronic elevations in right-sided filling pressures, myocardial and pericardial inflammation due to cytotoxic effects of amyloid deposits, and renal involvement with subsequent uremia and hypoalbuminemia. The pericardial effusions are typically small; however, several cases of life-threatening cardiac tamponade with hemorrhagic effusions have been described as a presenting clinical scenario. Constrictive pericarditis can also occur due to amyloidosis and its identification presents a clinical challenge in patients with cardiac amyloidosis who concurrently manifest signs of restrictive cardiomyopathy. Multimodality imaging, including echocardiography, cardiac computed tomography, and cardiac magnetic resonance imaging, is useful in the evaluation and management of this patient population. The recognition of pericardial effusion is important in the risk stratification of patients with cardiac amyloidosis as its presence confers a poor prognosis. However, specific treatment aimed at the effusions themselves is seldom indicated. Cardiac tamponade and constrictive pericarditis may necessitate pericardiocentesis and pericardiectomy, respectively.
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Affiliation(s)
- Osamah Badwan
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Felix Berglund
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell, and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Akiva Rosenzveig
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ian Persits
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ahmad Gharaibeh
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ashwin Kumar
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell, and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ankit Agrawal
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell, and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lidiya Sul
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Nicholas Chan
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Tom Kai Ming Wang
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell, and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Mazen Hanna
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell, and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Allan L Klein
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell, and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
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Gannon MP, Sison CP, Saba SG. Regional Analysis of Myocardial Strain to Wall Thickness Ratio in Cardiac Amyloidosis and Hypertrophic Cardiomyopathy. J Thorac Imaging 2024; 39:255-264. [PMID: 38193208 DOI: 10.1097/rti.0000000000000772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
BACKGROUND Increased left ventricular wall thickness is a hallmark of cardiac amyloidosis (CA). Several other disease states, including hypertrophic cardiomyopathy (HCM), share this common feature. Myocardial strain has emerged as a diagnostic and prognostic tool to differentiate causes of increased left ventricular wall thickness. We sought to determine if regional strain differences were present in CA when compared with HCM when indexed to wall thickness as well as adjusting for important factors such as ejection fraction (EF), age, sex, and hypertension. METHODS We performed a multicenter, retrospective analysis of 122 patients in 3 groups: CA (n=40), HCM (n=44), and controls (n=38). Using commercially available software, we determined peak systolic strain measurements in the base, mid, and apical segments in all 3 cardinal directions of radial strain, circumferential strain, and longitudinal strain. The regional strain was indexed to wall thickness to create a strain to wall thickness (STT) ratio. Analysis of Variance was performed to examine the association of each strain parameter with the disease group, adjusting for age, sex, hypertension, and EF. Multinomial logistic regression was performed to determine which combination of variables can potentially be used to best model the disease group. RESULTS Ratios of STT at all 3 levels were significantly different with respect to the cardinal directions of radial, circumferential, and longitudinal strain in a multivariable analysis adjusting for age, sex, and hypertension. Specifically, with respect to the basal segments, the STT ratio across CA, HCM, and normal were significantly different in radial (1.13±0.34 vs. 3.79±0.22 vs. 4.12±0.38; P <0.0001), circumferential (-0.79±0.10 vs. -1.62±0.07 vs. -2.25±0.11; P <0.0001), and longitudinal directions (-0.41±0.09 vs. -1.03±0.06 vs. -1.41±0.10; P <0.0001). When adjusting for age, sex, hypertension and EF, only the base was significantly different between the CA and HCM groups in the radial (1.49±0.37 vs. 3.53±0.24; P <0.0001), circumferential -1.04±0.10 vs. -1.44±0.06; P <0.005), and longitudinal (-0.55±0.10 vs -0.94±0.06; P =0.007) directions. Using multinomial logistic regression, the use of age, left ventricular EF, global longitudinal strain, and basal radial strain yielded a diagnostic model with an area under the receiver operating characteristic curve (AUC) of 0.98. A model excluding age, despite being likely an independent predictor in our cohort, yielded an overall AUC of 0.90. When excluding age, the overall AUC was 0.91 and specifically when discriminating CA from HCM was 0.95. CONCLUSIONS Regional myocardial strain indexed to wall thickness with an STT ratio can differentiate between etiologies of increased left ventricular wall thickness. Differences in myocardial deformation may be independent of wall thickness. Differences in basal strain when indexed to wall thickness in all 3 cardinal directions between CA and HCM are independent of EF. Multinomial logistic regression analysis using strain parameters differentiates CA and HCM with excellent diagnostic accuracy.
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Affiliation(s)
- Michael P Gannon
- Lewis Katz School of Medicine, Temple University Hospital, Philadelphia, PA
- National Heart, Lung, and Blood Institute, NIH, Bethesda, MD
| | - Cristina P Sison
- Biostatistics Unit, The Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY
- Department of Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
| | - Shahryar G Saba
- Department of Cardiology, Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
- Department of Radiology, Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
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Morfino P, Aimo A, Franzini M, Vergaro G, Castiglione V, Panichella G, Limongelli G, Emdin M. Pathophysiology of Cardiac Amyloidosis. Heart Fail Clin 2024; 20:261-270. [PMID: 38844297 DOI: 10.1016/j.hfc.2024.02.002] [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] [Indexed: 06/09/2024]
Abstract
Amyloidosis refers to a heterogeneous group of disorders sharing common pathophysiological mechanisms characterized by the extracellular accumulation of fibrillar deposits consisting of the aggregation of misfolded proteins. Cardiac amyloidosis (CA), usually caused by deposition of misfolded transthyretin or immunoglobulin light chains, is an increasingly recognized cause of heart failure burdened by a poor prognosis. CA manifests with a restrictive cardiomyopathy which progressively leads to biventricular thickening, diastolic and then systolic dysfunction, arrhythmias, and valvular disease. The pathophysiology of CA is multifactorial and includes increased oxidative stress, mitochondrial damage, apoptosis, impaired metabolism, and modifications of intracellular calcium balance.
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Affiliation(s)
| | - Alberto Aimo
- Fondazione Toscana Gabriele Monasterio, via G. Moruzzi 1, 56124, Pisa, Italy; Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Maria Franzini
- Department of Translational Research and of New Surgical and Medical Technologies, University of Pisa, Pisa, Italy
| | - Giuseppe Vergaro
- Fondazione Toscana Gabriele Monasterio, via G. Moruzzi 1, 56124, Pisa, Italy; Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Vincenzo Castiglione
- Fondazione Toscana Gabriele Monasterio, via G. Moruzzi 1, 56124, Pisa, Italy; Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Giorgia Panichella
- Department of Clinical and Experimental Medicine, Careggi University Hospital, Florence, Italy
| | - Giuseppe Limongelli
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Michele Emdin
- Scuola Superiore Sant'Anna, Pisa, Italy; Fondazione Toscana Gabriele Monasterio, via G. Moruzzi 1, 56124, Pisa, Italy.
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Usuku H, Yamamoto E, Sueta D, Shinriki R, Oike F, Tabata N, Ishii M, Hanatani S, Hoshiyama T, Kanazawa H, Arima Y, Takashio S, Kawano Y, Oda S, Kawano H, Ueda M, Tsujita K. A new staging system using right atrial strain in patients with immunoglobulin light-chain cardiac amyloidosis. ESC Heart Fail 2024; 11:1612-1624. [PMID: 38400613 PMCID: PMC11098642 DOI: 10.1002/ehf2.14710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 01/09/2024] [Accepted: 01/21/2024] [Indexed: 02/25/2024] Open
Abstract
AIMS There are minimal data on the prognostic impact of right atrial strain during the reservoir phase (RASr) in patients with immunoglobulin light-chain (AL) cardiac amyloidosis. METHODS AND RESULTS Among 78 patients who were diagnosed with AL cardiac amyloidosis at Kumamoto University Hospital from 2007 to 2022, 72 patients with sufficient two-dimensional speckle tracking imaging data without chemotherapy before the diagnosis were retrospectively analysed. During a median follow-up of 403 days, 31 deaths occurred. Age and the rate of male sex were not significantly different between the all-cause death group and the survival group (age, 70.4 ± 8.8 years vs. 67.0 ± 10.0 years, P = 0.14, male sex, 65% vs. 66%, P = 0.91). The estimated glomerular filtration rate (eGFR) was significantly lower, and B-type natriuretic peptide (BNP) and high sensitivity cardiac troponin T (hs-cTnT) were significantly higher, in the all-cause death group versus the survival group (eGFR, 48.2 ± 21.0 mL/min/1.73 m2 vs. 59.4 ± 24.4 mL/min/1.73 m2, P < 0.05, BNP, 725 [360-1312] pg/mL vs. 123 [81-310] pg/mL, P < 0.01, hs-cTnT, 0.12 [0.07-0.18] ng/mL vs. 0.05 [0.03-0.08] ng/mL, P < 0.01). Left ventricular (LV) global longitudinal strain (GLS) (LV-GLS), left atrial strain during the reservoir phase (LASr), right ventricular GLS (RV-GLS), and RASr were significantly lower in the all-cause death group versus the survival group (LV-GLS, 8.5 ± 4.3% vs. 11.8 ± 3.8%, P < 0.01, LASr, 8.8 ± 7.1% vs. 14.3 ± 8.1%, P < 0.01, RV-GLS, 11.6 ± 5.1% vs. 16.4 ± 3.9%, P < 0.01, RASr, 10.2 ± 7.3% vs. 20.7 ± 9.5%, P < 0.01). RASr was significantly associated with all-cause death after adjusting for RV-GLS, LV-GLS and LASr (hazard ratio [HR]: 0.91, 95% confidence interval [95% CI]: 0.83-0.99, P < 0.05). RASr and log-transformed BNP were significantly associated with all-cause death after adjusting for log-transformed troponin T and eGFR (RASr, HR: 0.93, 95% CI: 0.87-1.00, P < 0.05; log-transformed BNP, HR: 2.10, 95% CI: 1.17-3.79, P < 0.05). The optimal cut-off values were RASr: 16.4% (sensitivity: 66%, specificity: 84%, area under curve [AUC]: 0.81) and BNP: 311.2 pg/mL (sensitivity: 83%, specificity: 78%, AUC: 0.82) to predict all-cause mortality using ROC analysis. Kaplan-Meier analysis revealed that patients with low RASr (<16.4%) or high BNP (>311.2 pg/mL) had a significantly high probability of all-cause death (both, P < 0.01). We devised a new staging score by adding 1 point if RASr decreased or BNP levels increased more than each cut-off value. The HR for all-cause death using score 0 as a reference was 5.95 (95% CI: 1.19-29.79; P < 0.05) for score 1 and 23.29 (95% CI: 5.37-100.98; P < 0.01) for score 2. CONCLUSIONS The new staging system using RASr and BNP predicted prognosis in patients with AL cardiac amyloidosis.
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Affiliation(s)
- Hiroki Usuku
- Department of Laboratory MedicineKumamoto University HospitalKumamotoJapan
- Department of Cardiovascular Medicine, Graduate School of Medical SciencesKumamoto UniversityKumamotoJapan
- Center of Metabolic Regulation of Healthy AgingKumamoto University Faculty of Life SciencesKumamotoJapan
| | - Eiichiro Yamamoto
- Department of Cardiovascular Medicine, Graduate School of Medical SciencesKumamoto UniversityKumamotoJapan
- Center of Metabolic Regulation of Healthy AgingKumamoto University Faculty of Life SciencesKumamotoJapan
| | - Daisuke Sueta
- Department of Cardiovascular Medicine, Graduate School of Medical SciencesKumamoto UniversityKumamotoJapan
- Center of Metabolic Regulation of Healthy AgingKumamoto University Faculty of Life SciencesKumamotoJapan
| | - Rumi Shinriki
- Department of Laboratory MedicineKumamoto University HospitalKumamotoJapan
| | - Fumi Oike
- Department of Cardiovascular Medicine, Graduate School of Medical SciencesKumamoto UniversityKumamotoJapan
- Center of Metabolic Regulation of Healthy AgingKumamoto University Faculty of Life SciencesKumamotoJapan
| | - Noriaki Tabata
- Department of Cardiovascular Medicine, Graduate School of Medical SciencesKumamoto UniversityKumamotoJapan
- Center of Metabolic Regulation of Healthy AgingKumamoto University Faculty of Life SciencesKumamotoJapan
| | - Masanobu Ishii
- Department of Cardiovascular Medicine, Graduate School of Medical SciencesKumamoto UniversityKumamotoJapan
- Center of Metabolic Regulation of Healthy AgingKumamoto University Faculty of Life SciencesKumamotoJapan
| | - Shinsuke Hanatani
- Department of Cardiovascular Medicine, Graduate School of Medical SciencesKumamoto UniversityKumamotoJapan
- Center of Metabolic Regulation of Healthy AgingKumamoto University Faculty of Life SciencesKumamotoJapan
| | - Tadashi Hoshiyama
- Department of Cardiovascular Medicine, Graduate School of Medical SciencesKumamoto UniversityKumamotoJapan
- Center of Metabolic Regulation of Healthy AgingKumamoto University Faculty of Life SciencesKumamotoJapan
| | - Hisanori Kanazawa
- Department of Cardiovascular Medicine, Graduate School of Medical SciencesKumamoto UniversityKumamotoJapan
- Center of Metabolic Regulation of Healthy AgingKumamoto University Faculty of Life SciencesKumamotoJapan
| | - Yuichiro Arima
- Department of Cardiovascular Medicine, Graduate School of Medical SciencesKumamoto UniversityKumamotoJapan
- Center of Metabolic Regulation of Healthy AgingKumamoto University Faculty of Life SciencesKumamotoJapan
| | - Seiji Takashio
- Department of Cardiovascular Medicine, Graduate School of Medical SciencesKumamoto UniversityKumamotoJapan
- Center of Metabolic Regulation of Healthy AgingKumamoto University Faculty of Life SciencesKumamotoJapan
| | - Yawara Kawano
- Department of Hematology, Rheumatology, and Infectious Diseases, Graduate School of Medical ScienceKumamoto UniversityKumamotoJapan
| | - Seitaro Oda
- Department of Diagnostic Radiology, Faculty of Life SciencesKumamoto UniversityKumamotoJapan
| | - Hiroaki Kawano
- Department of Cardiovascular Medicine, Graduate School of Medical SciencesKumamoto UniversityKumamotoJapan
- Center of Metabolic Regulation of Healthy AgingKumamoto University Faculty of Life SciencesKumamotoJapan
| | - Mitsuharu Ueda
- Center of Metabolic Regulation of Healthy AgingKumamoto University Faculty of Life SciencesKumamotoJapan
- Department of Neurology, Graduate School of Medical SciencesKumamoto UniversityKumamotoJapan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical SciencesKumamoto UniversityKumamotoJapan
- Center of Metabolic Regulation of Healthy AgingKumamoto University Faculty of Life SciencesKumamotoJapan
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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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Benz DC, Dorbala S. Multimodality imaging of cardiac amyloidosis. Heart 2024; 110:873-882. [PMID: 37586824 PMCID: PMC10869633 DOI: 10.1136/heartjnl-2022-321115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/18/2023] Open
Affiliation(s)
- Dominik C Benz
- Department of Nuclear Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Sharmila Dorbala
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Kang Y, Qu N, Zhang Z, Zhang Q, Chen X, Fu M. Tolerability and effectiveness of beta-blockers in patients with cardiac amyloidosis: A systematic review and meta-analysis. Int J Cardiol 2024; 402:131813. [PMID: 38278490 DOI: 10.1016/j.ijcard.2024.131813] [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: 11/27/2023] [Revised: 01/19/2024] [Accepted: 01/22/2024] [Indexed: 01/28/2024]
Abstract
OBJECTIVE This systematic review aimed to assess the tolerability of patients with cardiac amyloidosis (CA) to beta-blockers (BBs) and evaluate its association with adverse outcomes. METHODS We performed a comprehensive search from January 1, 2000 to October 20, 2023. Studies examining BB use and tolerance or the relationship between BB use and outcomes in patients with CA were included. Pooled adjusted hazard ratios (aHRs) for all-cause mortality were calculated using random- and fixed-effects models. RESULTS Eight observational studies involving 4002 patients with CA (87.5% with transthyretin CA [ATTR-CA] and 12.5% with immunoglobulin light chain CA [AL-CA]) were assessed. BBs were used by 52.5% of the patients. However, 26.3% of the patients discontinued BBs because of hypotension, bradycardia, or fatigue. Regarding the association between BB use and all-cause death, four studies were identified that included 2874 patients with ATTR-CA and 16 patients with AL-CA. The meta-analysis revealed no apparent relationship between BB use and all-cause mortality (pooled aHR = 0.78, 95% confidence interval (CI) = 0.40-1.51). Two studies on patients with ATTR-CA found no impact of BB use on all-cause mortality in the subgroup with left ventricular ejection fraction (LVEF) > 40%, but conflicting results exist for those with LVEF ≤40% (pooled aHR = 0.78, 95% CI = 0.40-1.54). CONCLUSION The limited number of observational studies that predominantly enrolled patients with ATTR-CA showed that BBs were used in almost half of the patients with CA, with varying tolerability. However, no significant association was observed between BB use and all-cause mortality.
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Affiliation(s)
- Yu Kang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Nan Qu
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zhongyin Zhang
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Qing Zhang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xiaojing Chen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Michael Fu
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Martini N, Sinigiani G, De Michieli L, Mussinelli R, Perazzolo Marra M, Iliceto S, Zorzi A, Perlini S, Corrado D, Cipriani A. Electrocardiographic features and rhythm disorders in cardiac amyloidosis. Trends Cardiovasc Med 2024; 34:257-264. [PMID: 36841466 DOI: 10.1016/j.tcm.2023.02.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 02/16/2023] [Accepted: 02/18/2023] [Indexed: 02/27/2023]
Abstract
Cardiac amyloidosis (CA) is an infiltrative cardiomyopathy caused by extracellular deposition of amyloid fibrils, mainly derived from transthyretin, either wild-type or hereditary variants, or immunoglobulin light chains misfolding. It is characterized by an increased left ventricular (LV) mass and diastolic dysfunction, which can lead to heart failure with preserved ejection fraction and/or conduction disturbances. The diagnosis is based on invasive pathology demonstration of amyloid deposits, or non-invasive criteria using advanced cardiovascular imaging techniques. Nevertheless, 12-lead electrocardiogram (ECG) remains of crucial importance in the assessment of patients with CA, since they can manifest peculiar features such as low QRS voltages, in discordance with the LV hypertrophy, but also pseudo-infarction patterns, sinus node dysfunction, atrioventricular blocks, premature supraventricular and ventricular beats, which support the presence of a myocardial disease. Great awareness of these common ECG characteristics of CA is needed to increase diagnostic performance and improve patient's outcome. In the present review, we discuss the current role of the ECG in the diagnosis and management of CA, focusing on the most common ECG abnormalities and rhythm disorders.
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Affiliation(s)
- Nicolò Martini
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, Padua 35128, Italy
| | - Giulio Sinigiani
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, Padua 35128, Italy
| | - Laura De Michieli
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, Padua 35128, Italy
| | - Roberta Mussinelli
- Amyloidosis Research and Treatment Center, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Martina Perazzolo Marra
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, Padua 35128, Italy
| | - Sabino Iliceto
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, Padua 35128, Italy
| | - Alessandro Zorzi
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, Padua 35128, Italy
| | - Stefano Perlini
- Amyloidosis Research and Treatment Center, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy; Emergency Medicine, Vascular and Metabolic Disease Unit, Department of Internal Medicine, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Domenico Corrado
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, Padua 35128, Italy
| | - Alberto Cipriani
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, Padua 35128, Italy.
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Kamel MA, Abbas MT, Kanaan CN, Awad KA, Baba Ali N, Scalia IG, Farina JM, Pereyra M, Mahmoud AK, Steidley DE, Rosenthal JL, Ayoub C, Arsanjani R. How Artificial Intelligence Can Enhance the Diagnosis of Cardiac Amyloidosis: A Review of Recent Advances and Challenges. J Cardiovasc Dev Dis 2024; 11:118. [PMID: 38667736 PMCID: PMC11050851 DOI: 10.3390/jcdd11040118] [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: 02/29/2024] [Revised: 04/09/2024] [Accepted: 04/11/2024] [Indexed: 04/28/2024] Open
Abstract
Cardiac amyloidosis (CA) is an underdiagnosed form of infiltrative cardiomyopathy caused by abnormal amyloid fibrils deposited extracellularly in the myocardium and cardiac structures. There can be high variability in its clinical manifestations, and diagnosing CA requires expertise and often thorough evaluation; as such, the diagnosis of CA can be challenging and is often delayed. The application of artificial intelligence (AI) to different diagnostic modalities is rapidly expanding and transforming cardiovascular medicine. Advanced AI methods such as deep-learning convolutional neural networks (CNNs) may enhance the diagnostic process for CA by identifying patients at higher risk and potentially expediting the diagnosis of CA. In this review, we summarize the current state of AI applications to different diagnostic modalities used for the evaluation of CA, including their diagnostic and prognostic potential, and current challenges and limitations.
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Affiliation(s)
- Moaz A. Kamel
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
| | | | | | - Kamal A. Awad
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Nima Baba Ali
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Isabel G. Scalia
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Juan M. Farina
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Milagros Pereyra
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Ahmed K. Mahmoud
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
| | - D. Eric Steidley
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Julie L. Rosenthal
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Chadi Ayoub
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
- Division of Cardiovascular Imaging, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Reza Arsanjani
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
- Division of Cardiovascular Imaging, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
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10
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Shibata A, Izumiya Y, Yoshida T, Tanihata A, Yamaguchi Y, Kitada R, Fukuda D. Elevation of end-tidal CO 2 during exercise is attenuated in patients with cardiac amyloidosis. Heart Vessels 2024; 39:340-348. [PMID: 38105354 DOI: 10.1007/s00380-023-02342-w] [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: 08/07/2023] [Accepted: 11/16/2023] [Indexed: 12/19/2023]
Abstract
Reduced exercise tolerance is one of the hallmarks of patients with cardiac amyloidosis (CA), but detailed biological responses during exercise were not investigated. The purpose of this study was to compare the cardiopulmonary exercise test (CPX) parameters between CA patients and propensity-matched heart failure patients. This was a single-center, retrospective, observational study of patients diagnosed with CA. The control group was extracted by propensity score matching from patients who underwent CPX for chronic heart failure during the same period. Clinical data including assessment of biological responses during CPX were compared between the patients with CA (CA group, n = 16) and the control group (non-CA group, n = 16). Echocardiography suggested more impaired diastolic function in the CA group than in the non-CA group. There was no significant difference between groups in the fraction of end-tidal carbon dioxide (FETCO2) at rest. However, the difference between the FETCO2 at rest and the FETCO2 at the respiratory compensation point (ΔFETCO2) was significantly smaller in the CA group than in the non-CA group (0.40% ± 0.37% vs. 0.82% ± 0.33%; p = 0.002). Only in the CA group, there was a significant negative correlation between the ΔFETCO2 and the E/e' ratio on echocardiography (r = - 0.521; p = 0.039) and the serum high-sensitivity troponin T concentration (r = - 0.501; p = 0.048). In conclusion, patients with CA may find it difficult to increase cardiac output during exercise due to severe diastolic dysfunction.
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Affiliation(s)
- Atsushi Shibata
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Yasuhiro Izumiya
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan.
| | - Toshitake Yoshida
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Akiko Tanihata
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Yumi Yamaguchi
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Ryoko Kitada
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Daiju Fukuda
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
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11
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Bart NK, Fatkin D, Gunton J, Hare JL, Korczyk D, Kwok F, Lam K, Russell D, Sidiqi H, Sutton T, Gibbs SDJ, Mollee P, Thomas L. 2024 Australia-New Zealand Expert Consensus Statement on Cardiac Amyloidosis. Heart Lung Circ 2024; 33:420-442. [PMID: 38570258 DOI: 10.1016/j.hlc.2023.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 11/17/2023] [Indexed: 04/05/2024]
Abstract
Over the past 5 years, early diagnosis of and new treatments for cardiac amyloidosis (CA) have emerged that hold promise for early intervention. These include non-invasive diagnostic tests and disease modifying therapies. Recently, CA has been one of the first types of cardiomyopathy to be treated with gene editing techniques. Although these therapies are not yet widely available to patients in Australia and New Zealand, this may change in the near future. Given the rapid pace with which this field is evolving, it is important to view these advances within the Australian and New Zealand context. This Consensus Statement aims to update the Australian and New Zealand general physician and cardiologist with regards to the diagnosis, investigations, and management of CA.
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Affiliation(s)
- Nicole K Bart
- Department of Cardiology, St Vincent's Hospital, Sydney; School of Clinical Medicine, Faculty of Health and Medicine, The University of New South Wales, Sydney, and The Victor Chang Cardiac Research Institute, Sydney, NSW, Australia. http://www.twitter.com/drnikkibart
| | - Diane Fatkin
- Department of Cardiology, St Vincent's Hospital, Sydney; School of Clinical Medicine, Faculty of Health and Medicine, The University of New South Wales, Sydney, and The Victor Chang Cardiac Research Institute, Sydney, NSW, Australia
| | - James Gunton
- Department of Cardiology, Flinders Medical Centre, Adelaide, SA, Australia
| | - James L Hare
- Department of Cardiology, Alfred Health, Melbourne, and Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Vic, Australia
| | - Dariusz Korczyk
- Department of Cardiology, The Princess Alexandra Hospital, Brisbane, Qld, Australia
| | - Fiona Kwok
- Department of Haematology, Westmead Hospital, Sydney, NSW, Australia
| | - Kaitlyn Lam
- Department of Cardiology, Western Australia Advanced Heart Failure and Cardiac Transplant Service, Perth, WA, Australia
| | - David Russell
- Department of Cardiology, Royal Hobart Hospital, Hobart, Tas, Australia
| | - Hasib Sidiqi
- Department of Haematology, Fiona Stanley Hospital, Perth, WA, Australia
| | - Tim Sutton
- Te Whatu Ora Counties Manukau, Auckland; and Department of Cardiology, Auckland, Aotearoa, New Zealand
| | - Simon D J Gibbs
- Department of Haematology, Eastern Health; Epworth Freemasons; and Monash University, Melbourne, Vic, Australia
| | - Peter Mollee
- Queensland Amyloidosis Centre, The Princess Alexandra Hospital, Brisbane; and, School of Medicine, University of Queensland, Brisbane, Qld, Australia
| | - Liza Thomas
- Department of Cardiology, Westmead Hospital, Sydney; Westmead Clinical School, University of Sydney, Sydney; and, South West Clinical School, University of New South Wales, Sydney, NSW, Australia.
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12
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Citro R, Silverio A, Bellino M. Echocardiographic tools for prognostic stratification in transthyretin cardiac amyloidosis: a new arrow in the quiver. Eur Heart J Cardiovasc Imaging 2024; 25:480-481. [PMID: 38279943 DOI: 10.1093/ehjci/jeae028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 01/18/2024] [Accepted: 01/20/2024] [Indexed: 01/29/2024] Open
Affiliation(s)
- Rodolfo Citro
- Division of Cardiology, Cardiovascular and Thoracic Department, San Giovanni di Dio e Ruggi d' Aragona University Hospital, Largo Città d'Ippocrate, 84131 Salerno, Italy
- Vascular Physiopathology Unit, IRCCS Neuromed, Pozzilli, Italy
| | - Angelo Silverio
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno, Italy
| | - Michele Bellino
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno, Italy
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13
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De Lillo A, Pathak GA, Low A, De Angelis F, Abou Alaiwi S, Miller EJ, Fuciarelli M, Polimanti R. Clinical spectrum of Transthyretin amyloidogenic mutations among diverse population origins. Hum Genomics 2024; 18:31. [PMID: 38523305 PMCID: PMC10962184 DOI: 10.1186/s40246-024-00596-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 03/08/2024] [Indexed: 03/26/2024] Open
Abstract
PURPOSE Coding mutations in the Transthyretin (TTR) gene cause a hereditary form of amyloidosis characterized by a complex genotype-phenotype correlation with limited information regarding differences among worldwide populations. METHODS We compared 676 diverse individuals carrying TTR amyloidogenic mutations (rs138065384, Phe44Leu; rs730881165, Ala81Thr; rs121918074, His90Asn; rs76992529, Val122Ile) to 12,430 non-carriers matched by age, sex, and genetically-inferred ancestry to assess their clinical presentations across 1,693 outcomes derived from electronic health records in UK biobank. RESULTS In individuals of African descent (AFR), Val122Ile mutation was linked to multiple outcomes related to the circulatory system (fold-enrichment = 2.96, p = 0.002) with the strongest associations being cardiac congenital anomalies (phecode 747.1, p = 0.003), endocarditis (phecode 420.3, p = 0.006), and cardiomyopathy (phecode 425, p = 0.007). In individuals of Central-South Asian descent (CSA), His90Asn mutation was associated with dermatologic outcomes (fold-enrichment = 28, p = 0.001). The same TTR mutation was linked to neoplasms in European-descent individuals (EUR, fold-enrichment = 3.09, p = 0.003). In EUR, Ala81Thr showed multiple associations with respiratory outcomes related (fold-enrichment = 3.61, p = 0.002), but the strongest association was with atrioventricular block (phecode 426.2, p = 2.81 × 10- 4). Additionally, the same mutation in East Asians (EAS) showed associations with endocrine-metabolic traits (fold-enrichment = 4.47, p = 0.003). In the cross-ancestry meta-analysis, Val122Ile mutation was associated with peripheral nerve disorders (phecode 351, p = 0.004) in addition to cardiac congenital anomalies (fold-enrichment = 6.94, p = 0.003). CONCLUSIONS Overall, these findings highlight that TTR amyloidogenic mutations present ancestry-specific and ancestry-convergent associations related to a range of health domains. This supports the need to increase awareness regarding the range of outcomes associated with TTR mutations across worldwide populations to reduce misdiagnosis and delayed diagnosis of TTR-related amyloidosis.
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Affiliation(s)
- Antonella De Lillo
- Department of Psychiatry, Yale University School of Medicine, 60 Temple, Suite 7A, New Haven, CT, 06510, USA
- Department of Biology, University of Rome "Tor Vergata", Rome, Italy
| | - Gita A Pathak
- Department of Psychiatry, Yale University School of Medicine, 60 Temple, Suite 7A, New Haven, CT, 06510, USA
- VA CT Healthcare Center, West Haven, CT, USA
| | - Aislinn Low
- Department of Psychiatry, Yale University School of Medicine, 60 Temple, Suite 7A, New Haven, CT, 06510, USA
- VA CT Healthcare Center, West Haven, CT, USA
| | - Flavio De Angelis
- Department of Psychiatry, Yale University School of Medicine, 60 Temple, Suite 7A, New Haven, CT, 06510, USA
- Department of Physical and Mental Health, and Preventive Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Sarah Abou Alaiwi
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Edward J Miller
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Maria Fuciarelli
- Department of Biology, University of Rome "Tor Vergata", Rome, Italy
| | - Renato Polimanti
- Department of Psychiatry, Yale University School of Medicine, 60 Temple, Suite 7A, New Haven, CT, 06510, USA.
- VA CT Healthcare Center, West Haven, CT, USA.
- Wu Tsai Institute, Yale University, New Haven, CT, USA.
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14
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Ruberg FL, Maurer MS. Cardiac Amyloidosis Due to Transthyretin Protein: A Review. JAMA 2024; 331:778-791. [PMID: 38441582 PMCID: PMC11167454 DOI: 10.1001/jama.2024.0442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
Importance Systemic amyloidosis from transthyretin (ATTR) protein is the most common type of amyloidosis that causes cardiomyopathy. Observations Transthyretin (TTR) protein transports thyroxine (thyroid hormone) and retinol (vitamin A) and is synthesized predominantly by the liver. When the TTR protein misfolds, it can form amyloid fibrils that deposit in the heart causing heart failure, heart conduction block, or arrhythmia such as atrial fibrillation. The biological processes by which amyloid fibrils form are incompletely understood but are associated with aging and, in some patients, affected by inherited variants in the TTR genetic sequence. ATTR amyloidosis results from misfolded TTR protein deposition. ATTR can occur in association with normal TTR genetic sequence (wild-type ATTR) or with abnormal TTR genetic sequence (variant ATTR). Wild-type ATTR primarily manifests as cardiomyopathy while ATTR due to a genetic variant manifests as cardiomyopathy and/or polyneuropathy. Approximately 50 000 to 150 000 people in the US have heart failure due to ATTR amyloidosis. Without treatment, heart failure due to ATTR amyloidosis is associated with a median survival of approximately 5 years. More than 130 different inherited genetic variants in TTR exist. The most common genetic variant is Val122Ile (pV142I), an allele with an origin in West African countries, that is present in 3.4% of African American individuals in the US or approximately 1.5 million persons. The diagnosis can be made using serum free light chain assay and immunofixation electrophoresis to exclude light chain amyloidosis combined with cardiac nuclear scintigraphy to detect radiotracer uptake in a pattern consistent with amyloidosis. Loop diuretics, such as furosemide, torsemide, and bumetanide, are the primary treatment for fluid overload and symptomatic relief of patients with ATTR heart failure. An ATTR-directed therapy that inhibited misfolding of the TTR protein (tafamidis, a protein stabilizer), compared with placebo, reduced mortality from 42.9% to 29.5%, reduced hospitalizations from 0.7/year to 0.48/year, and was most effective when administered early in disease course. Conclusions and Relevance ATTR amyloidosis causes cardiomyopathy in up to approximately 150 000 people in the US and tafamidis is the only currently approved therapy. Tafamidis slowed progression of ATTR amyloidosis and improved survival and prevented hospitalization, compared with placebo, in people with ATTR-associated cardiomyopathy.
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Affiliation(s)
- Frederick L Ruberg
- Section of Cardiovascular Medicine, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston, Massachusetts
- Amyloidosis Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Mathew S Maurer
- Cardiac Amyloidosis Program, Seymour, Paul, and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, and NewYork-Presbyterian Hospital, New York
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15
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De Carli G, Mandoli GE, Salvatici C, Biagioni G, Marallo C, Turchini F, Ghionzoli N, Melani A, Pastore MC, Gozzetti A, D'Ascenzi F, Cavigli L, Giacomin E, Cameli M, Focardi M. Speckle tracking echocardiography in plasma cell disorders: The role of advanced imaging in the early diagnosis of AL systemic cardiac amyloidosis. Int J Cardiol 2024; 398:131599. [PMID: 37979786 DOI: 10.1016/j.ijcard.2023.131599] [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: 08/04/2023] [Revised: 10/26/2023] [Accepted: 11/14/2023] [Indexed: 11/20/2023]
Abstract
INTRODUCTION Amyloid light-chain amyloidosis is a rare condition characterized by the abnormal production of immunoglobulin light chain that misshape and form amyloid fibrils. Over time, these amyloid deposits can accumulate slowly, causing dysfunction in organs and tissues. Early identification is crucial to ensure optimal treatment. We aim to identify a better marker of cardiac amyloidosis, using advanced echocardiography, to improve diagnosis and the timing of available treatments. MATERIALS AND METHODS 108 consecutive hematological patients (32, 30% female and 76, 70% male) with a plasma cell disorder referred to our Cardiological center underwent ECG, first and second-level echocardiography (Speckle Tracking) and complete biochemical profile. The best predictors of ALCA (AUC ≥ 0.8) were included in a further analysis stratified by AL score. RESULTS At ROC analysis, the best bio-humoral predictors for the diagnosis of ALCA were Nt-pro-BNP (AUC: 0.97; p < 0.01) and Hs-Tn (AUC: 0.87; p < 0.01). Regarding echocardiography, the best diagnostic predictors were left atrial stiffness (LAS) (AUC: 0.83; p < 0.01) for the left atrium; free wall thickness for the right ventricle (AUC: 0.82; <0.01); left ventricular global longitudinal strain (LVGLS) (AUC: 0.92; p < 0.01) and LVMi (AUC 0.80; p < 0.001) for the left ventricle; and AL-score (AUC 0.83 p < 0.01). In patients with AL-SCORE < 1, LAS (AUC 0.86 vs AUC 0.79), LVGLS (AUC 0.92 vs AUC 0.86) and LV mass (AUC 0.91 vs AUC 0.72) had better diagnostic accuracy than patients with higher AL-score (AL SCORE ≥ 1). CONCLUSION Multi-parametric imaging approach with LVGLS and LAS may be helpful for detecting early cardiac involvement in AL amyloidosis.
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Affiliation(s)
- G De Carli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy.
| | - G E Mandoli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - C Salvatici
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - G Biagioni
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - C Marallo
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - F Turchini
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - N Ghionzoli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - A Melani
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - M C Pastore
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - A Gozzetti
- Department of Hematology, Siena University, Siena, Italy
| | - F D'Ascenzi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - L Cavigli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - E Giacomin
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - M Cameli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - M Focardi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
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16
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Alwan L, Benz DC, Cuddy SAM, Dobner S, Shiri I, Caobelli F, Bernhard B, Stämpfli SF, Eberli F, Reyes M, Kwong RY, Falk RH, Dorbala S, Gräni C. Current and Evolving Multimodality Cardiac Imaging in Managing Transthyretin Amyloid Cardiomyopathy. JACC Cardiovasc Imaging 2024; 17:195-211. [PMID: 38099914 DOI: 10.1016/j.jcmg.2023.10.010] [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: 08/29/2023] [Revised: 10/06/2023] [Accepted: 10/18/2023] [Indexed: 01/29/2024]
Abstract
Amyloid transthyretin (ATTR) amyloidosis is a protein-misfolding disease characterized by fibril accumulation in the extracellular space that can result in local tissue disruption and organ dysfunction. Cardiac involvement drives morbidity and mortality, and the heart is the major organ affected by ATTR amyloidosis. Multimodality cardiac imaging (ie, echocardiography, scintigraphy, and cardiac magnetic resonance) allows accurate diagnosis of ATTR cardiomyopathy (ATTR-CM), and this is of particular importance because ATTR-targeting therapies have become available and probably exert their greatest benefit at earlier disease stages. Apart from establishing the diagnosis, multimodality cardiac imaging may help to better understand pathogenesis, predict prognosis, and monitor treatment response. The aim of this review is to give an update on contemporary and evolving cardiac imaging methods and their role in diagnosing and managing ATTR-CM. Further, an outlook is presented on how artificial intelligence in cardiac imaging may improve future clinical decision making and patient management in the setting of ATTR-CM.
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Affiliation(s)
- Louhai Alwan
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Dominik C Benz
- Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; CV Imaging Program, Cardiovascular Division, Department of Medicine and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; Cardiac Imaging, Department of Cardiology and Nuclear Medicine, Zurich University Hospital, Zurich, Switzerland
| | - Sarah A M Cuddy
- Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; CV Imaging Program, Cardiovascular Division, Department of Medicine and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Stephan Dobner
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Isaac Shiri
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Federico Caobelli
- University Clinic of Nuclear Medicine, Inselspital, Bern University Hospital, Switzerland
| | - Benedikt Bernhard
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; CV Imaging Program, Cardiovascular Division, Department of Medicine and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Simon F Stämpfli
- Department of Cardiology, Heart Centre Lucerne, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Franz Eberli
- Department of Cardiology, Triemli Hospital (Triemlispital), Zurich, Switzerland
| | - Mauricio Reyes
- Insel Data Science Center, Inselspital, Bern University Hospital, Bern, Switzerland; Artificial Intelligence in Medical Imaging, ARTORG Center for Biomedical Research, University of Bern, Bern, Switzerland
| | - Raymond Y Kwong
- CV Imaging Program, Cardiovascular Division, Department of Medicine and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Rodney H Falk
- Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Sharmila Dorbala
- Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; CV Imaging Program, Cardiovascular Division, Department of Medicine and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Christoph Gräni
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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17
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Starr N, Ioannou A, Martinez-Naharro A. Monitoring cardiac amyloidosis with multimodality imaging. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:79-87. [PMID: 37696332 DOI: 10.1016/j.rec.2023.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 06/30/2023] [Indexed: 09/13/2023]
Abstract
Cardiac amyloidosis (CA) refers to an infiltrative process involving amyloid fibril deposition in the myocardium causing restrictive cardiomyopathy. While various types can affect the heart, the predominant forms are immunoglobulin light-chain (AL) amyloidosis and transthyretin (ATTR) amyloidosis. This review article explores the expanding field of imaging techniques used to diagnose AL-CA and ATTR-CA, highlighting their usefulness in prognostication and disease surveillance. Echocardiography is often the initial imaging modality to suspect CA and, since the incorporation of nonbiopsy criteria using bone scintigraphy, diagnosing ATTR-CA has become more attainable following exclusion of plasma cell dyscrasia. Cardiac magnetic resonance is progressively emerging as a vital tool for imaging CA, and is used in diagnosis, prognostication, and disease surveillance. The use of cardiac magnetic resonance in AL-CA is discussed, as it has been shown to accurately evaluate organ response to chemotherapy. As novel drug treatments emerge in the realm of ATTR-CA, the use of cardiovascular imaging surveillance to monitor disease progression is discussed, as it is gaining prominence as a critical consideration. The ongoing phase III trials investigating treatments for patients with ATTR-CA, will undoubtedly enhance our understanding of cardiac imaging surveillance.
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Affiliation(s)
- Neasa Starr
- National Amyloidosis Centre, Royal Free Hospital NHS Foundation Trust, London, United Kingdom
| | - Adam Ioannou
- National Amyloidosis Centre, Royal Free Hospital NHS Foundation Trust, London, United Kingdom
| | - Ana Martinez-Naharro
- National Amyloidosis Centre, Royal Free Hospital NHS Foundation Trust, London, United Kingdom.
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Shah SJ, Fine N, Garcia-Pavia P, Klein AL, Fernandes F, Weissman NJ, Maurer MS, Boman K, Gundapaneni B, Sultan MB, Elliott P. Effect of Tafamidis on Cardiac Function in Patients With Transthyretin Amyloid Cardiomyopathy: A Post Hoc Analysis of the ATTR-ACT Randomized Clinical Trial. JAMA Cardiol 2024; 9:25-34. [PMID: 37966817 PMCID: PMC10652219 DOI: 10.1001/jamacardio.2023.4147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 09/11/2023] [Indexed: 11/16/2023]
Abstract
Importance Tafamidis has been shown to improve survival in patients with transthyretin amyloid cardiomyopathy (ATTR-CM) compared with placebo. However, its effect on cardiac function has not been fully characterized. Objective To examine the effect of tafamidis on cardiac function in patients with ATTR-CM. Design, Setting, and Participants This was an exploratory, post hoc analysis of the Tafamidis in Transthyretin Cardiomyopathy Clinical Trial (ATTR-ACT), a multicenter, international, double-blind, placebo-controlled phase 3 randomized clinical trial conducted from December 2013 to February 2018. The ATTR-ACT included 48 sites in 13 counties and enrolled patients aged 18 to 90 years with ATTR-CM. Data were analyzed from July 2018 to September 2023. Intervention Patients were randomized to tafamidis meglumine, 80 mg or 20 mg, or placebo for 30 months. Main Outcomes and Measures Patients were categorized based on left ventricular (LV) ejection fraction at enrollment as having heart failure with preserved ejection fraction (≥50%), mildly reduced ejection fraction (41% to 49%), or reduced ejection fraction (≤40%). Changes from baseline to month 30 in LV ejection fraction, LV stroke volume, LV global longitudinal strain, and the ratio of early mitral inflow velocity to septal and lateral early diastolic mitral annular velocity (E/e') were compared in patients receiving tafamidis, 80 mg, vs placebo. Results A total of 441 patients were randomized in ATTR-ACT, and 436 patients had available echocardiographic data. Of 436 included patients, 393 (90.1%) were male, and the mean (SD) age was 74 (7) years. A total of 220 (50.5%), 119 (27.3%), and 97 (22.2%) had heart failure with preserved, mildly reduced, and reduced LV ejection fraction, respectively. Over 30 months, there was less pronounced worsening in 4 of the echocardiographic measures in patients receiving tafamidis, 80 mg (n = 176), vs placebo (n = 177) (least squares mean difference: LV stroke volume, 7.02 mL; 95% CI, 2.55-11.49; P = .002; LV global longitudinal strain, -1.02%; 95% CI, -1.73 to -0.31; P = .005; septal E/e', -3.11; 95% CI, -5.50 to -0.72; P = .01; lateral E/e', -2.35; 95% CI, -4.01 to -0.69; P = .006). Conclusions and Relevance Compared with placebo, tafamidis, 80 mg, attenuated the decline of LV systolic and diastolic function over 30 months in patients with ATTR-CM. Approximately half of patients had mildly reduced or reduced LV ejection fraction at enrollment, suggesting that ATTR-CM should be considered as a possible diagnosis in patients with heart failure regardless of underlying LV ejection fraction. Trial Registration ClinicalTrials.gov Identifier: NCT01994889.
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Affiliation(s)
- Sanjiv J. Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Nowell Fine
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Pablo Garcia-Pavia
- Hospital Universitario Puerta de Hierro Majadahonda, CIBERCV and Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | | | | | - Neil J. Weissman
- Medstar Health Research Institute, Georgetown University, Washington, DC
| | - Mathew S. Maurer
- Columbia University College of Physicians and Surgeons, New York City, New York
| | - Kurt Boman
- Research Unit, Skellefteå County Hospital, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
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19
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Ota S, Izumiya Y, Kitada R, Nishi T, Taruya A, Wada T, Takahata M, Ozaki Y, Kashiwagi M, Shiono Y, Kuroi A, Takemoto K, Tanimoto T, Kitabata H, Fukuda D, Tanaka A. Diagnostic significance of paradoxical left ventricular hypertrophy in detecting cardiac amyloidosis. IJC HEART & VASCULATURE 2023; 49:101279. [PMID: 37859641 PMCID: PMC10582063 DOI: 10.1016/j.ijcha.2023.101279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 10/06/2023] [Accepted: 10/09/2023] [Indexed: 10/21/2023]
Abstract
Background Cardiac amyloidosis (CA) progresses rapidly with a poor prognosis. Therefore, methods for early diagnosis that are easily accessible in any hospital, are required. We hypothesized that based on the pathology of CA, morphological left ventricular hypertrophy (LVH) without electrical augmentation, namely paradoxical LVH, could be used to diagnose CA. This study aimed to investigate whether paradoxical LVH has diagnostic significance in identifying CA in patients with LVH. Methods Patients who presented with left ventricular (LV) wall thickness ≥ 12 mm on cardiac magnetic resonance (CMR) were enrolled from a multicentre CMR registry. Paradoxical LVH was defined as a LV wall thickness ≥ 12 mm on CMR, SV1 + RV5 < 3.5 mV, and a lack of secondary ST-T abnormalities. The diagnostic significance of paradoxical LVH in identifying CA was assessed. Results Of the 110 patients enrolled, 30 (27 %) were diagnosed with CA and 80 (73 %) with a non-CA aetiology. The CA group demonstrated paradoxical LVH more frequently than the non-CA group (80 % vs. 16 %, P < 0.001). It was an independent predictor for detecting CA in patients with LVH (odds ratio: 33.44, 95 % confidence interval: 8.325-134.3, P < 0.001). The sensitivity, specificity, positive predict value, negative predict value and accuracy of paradoxical LVH for CA detection were 80 %, 84 %, 65 %, 92 % and 83 %, respectively. Conclusions Paradoxical LVH can be used for identifying CA in patients with LVH. Our findings could contribute to the early diagnosis of CA, even in non-specialized hospitals.
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Affiliation(s)
- Shingo Ota
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Yasuhiro Izumiya
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Ryoko Kitada
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Takahiro Nishi
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Akira Taruya
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Teruaki Wada
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Masahiro Takahata
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Yuichi Ozaki
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Manabu Kashiwagi
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Yasutsugu Shiono
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Akio Kuroi
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Kazushi Takemoto
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Takashi Tanimoto
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Hironori Kitabata
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Daiju Fukuda
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Atsushi Tanaka
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
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20
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Zhang X, Zhao R, Deng W, Li Y, An S, Qian Y, Liu B, Yu Y, Li X. Left Atrial and Ventricular Strain Differentiates Cardiac Amyloidosis and Hypertensive Heart Disease: A Cardiac MR Feature Tracking Study. Acad Radiol 2023; 30:2521-2532. [PMID: 36925334 DOI: 10.1016/j.acra.2023.02.003] [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: 12/06/2022] [Revised: 01/30/2023] [Accepted: 02/01/2023] [Indexed: 03/17/2023]
Abstract
RATIONALE AND OBJECTIVES Strain measured by feature tracking technique represents the degree of deformation and reflects the systolic and diastolic function of the heart. Our purpose was to evaluate the differential diagnostic value and correlations of left atrial (LA) strain (LAS) and left ventricular (LV) strain (LVS) in cardiac amyloidosis (CA) and hypertensive heart disease (HHD) patients. MATERIALS AND METHODS We recruited 25 CA patients, 30 sex- and age-matched HHD patients and 20 healthy subjects totally. LAS and LVS were analyzed by CVI42 post-processing software. The efficiency of LAS and LVS in differentiating CA from HHD was compared by receiver operating characteristic curves analysis. Pearson or Spearman's analysis were used to assess the correlation between LAS and LV parameters. RESULTS Both HHD and CA patients had impaired LVS, the gradient of increasing absolute values of longitudinal strain (LS) and radial strain (RS) from the basal to the apical myocardium was most pronounced in the CA group, its relative apical sparing of LS (RASLS) ratio reached 0.91 ± 0.02, significantly higher than other two groups (HHD: 0.72 ± 0.02; controls: 0.56 ± 0.01, all p <0.001). Additionally, except for the booster strain in the HHD group was preserved, all other LAS were reduced in patients' groups. The RASLS had the best differential diagnostic efficacy with an area under the curve (AUC) of 0.930 (p <0.001); The AUCs of LAS all greater than 0.850, above global LS (GLS) (AUC = 0.770, p = 0.001). LAS was notably correlated with LV ejection fraction (LVEF) and GLS, with reservoir strain having the greatest correlation with GLS (r = -0.828, p <0.001). CONCLUSION The RASLS has high efficiency in guiding the differential diagnosis of CA and HHD with similar degree and presentation of LVH. Moreover, LAS values can also provide some useful information and they are closely linked with LV function, CMR feature tracking may provide assistance in the evaluation of LA-LV coupling.
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Affiliation(s)
- Xinna Zhang
- Department of Radiology, The First Affiliated Hospital of Anhui Medical University, No. 218 Jixi Road, Hefei 230032, Anhui Province, China; Research Center of Clinical Medical Imaging, Anhui Province Clinical Image Quality Control Center, No. 218 Jixi Road, Hefei 230032, Anhui Province, China
| | - Ren Zhao
- Department of Cardiology, The First Affiliated Hospital of Anhui Medical University, No. 218 Jixi Road, Hefei 230032, Anhui Province, China
| | - Wei Deng
- Department of Radiology, The First Affiliated Hospital of Anhui Medical University, No. 218 Jixi Road, Hefei 230032, Anhui Province, China; Research Center of Clinical Medical Imaging, Anhui Province Clinical Image Quality Control Center, No. 218 Jixi Road, Hefei 230032, Anhui Province, China
| | - Yuguo Li
- Department of Radiology, The First Affiliated Hospital of Anhui Medical University, No. 218 Jixi Road, Hefei 230032, Anhui Province, China; Research Center of Clinical Medical Imaging, Anhui Province Clinical Image Quality Control Center, No. 218 Jixi Road, Hefei 230032, Anhui Province, China
| | - Shutian An
- Department of Radiology, The First Affiliated Hospital of Anhui Medical University, No. 218 Jixi Road, Hefei 230032, Anhui Province, China; Research Center of Clinical Medical Imaging, Anhui Province Clinical Image Quality Control Center, No. 218 Jixi Road, Hefei 230032, Anhui Province, China
| | - Yinfeng Qian
- Department of Radiology, The First Affiliated Hospital of Anhui Medical University, No. 218 Jixi Road, Hefei 230032, Anhui Province, China; Research Center of Clinical Medical Imaging, Anhui Province Clinical Image Quality Control Center, No. 218 Jixi Road, Hefei 230032, Anhui Province, China
| | - Bin Liu
- Department of Radiology, The First Affiliated Hospital of Anhui Medical University, No. 218 Jixi Road, Hefei 230032, Anhui Province, China; Research Center of Clinical Medical Imaging, Anhui Province Clinical Image Quality Control Center, No. 218 Jixi Road, Hefei 230032, Anhui Province, China
| | - Yongqiang Yu
- Department of Radiology, The First Affiliated Hospital of Anhui Medical University, No. 218 Jixi Road, Hefei 230032, Anhui Province, China; Research Center of Clinical Medical Imaging, Anhui Province Clinical Image Quality Control Center, No. 218 Jixi Road, Hefei 230032, Anhui Province, China
| | - Xiaohu Li
- Department of Radiology, The First Affiliated Hospital of Anhui Medical University, No. 218 Jixi Road, Hefei 230032, Anhui Province, China; Research Center of Clinical Medical Imaging, Anhui Province Clinical Image Quality Control Center, No. 218 Jixi Road, Hefei 230032, Anhui Province, China.
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21
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Samuel TJ, Oneglia AP, Cipher DJ, Ezekowitz JA, Dyck JRB, Anderson T, Howlett JG, Paterson DI, Thompson RB, Nelson MD. Integration of longitudinal and circumferential strain predicts volumetric change across the cardiac cycle and differentiates patients along the heart failure continuum. J Cardiovasc Magn Reson 2023; 25:55. [PMID: 37779191 PMCID: PMC10544545 DOI: 10.1186/s12968-023-00969-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 09/21/2023] [Indexed: 10/03/2023] Open
Abstract
BACKGROUND Left ventricular (LV) circumferential and longitudinal strain provide important insight into LV mechanics and function, each contributing to volumetric changes throughout the cardiac cycle. We sought to explore this strain-volume relationship in more detail, by mathematically integrating circumferential and longitudinal strain and strain rate to predict LV volume and volumetric rates of change. METHODS Cardiac magnetic resonance (CMR) imaging from 229 participants from the Alberta HEART Study (46 healthy controls, 77 individuals at risk for developing heart failure [HF], 70 patients with diagnosed HF with preserved ejection fraction [HFpEF], and 36 patients with diagnosed HF with reduced ejection fraction [HFrEF]) were evaluated. LV volume was assessed by the method of disks and strain/strain rate were assessed by CMR feature tracking. RESULTS Integrating endocardial circumferential and longitudinal strain provided a close approximation of LV ejection fraction (EFStrain), when compared to gold-standard volumetric assessment (EFVolume: r = 0.94, P < 0.0001). Likewise, integrating circumferential and longitudinal strain rate provided a close approximation of peak ejection and peak filling rates (PERStrain and PFRStrain, respectively) compared to their gold-standard volume-time equivalents (PERVolume, r = 0.73, P < 0.0001 and PFRVolume, r = 0.78, P < 0.0001, respectively). Moreover, each integrated strain measure differentiated patients across the HF continuum (all P < 0.01), with the HFrEF group having worse EFStrain, PERStrain, and PFRStrain compared to all other groups, and HFpEF having less favorable EFStrain and PFRStrain compared to both at-risk and control groups. CONCLUSIONS The data herein establish the theoretical framework for integrating discrete strain components into volumetric measurements across the cardiac cycle, and highlight the potential benefit of this approach for differentiating patients along the heart failure continuum.
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Affiliation(s)
- T Jake Samuel
- College of Nursing and Health Innovation, University of Texas at Arlington, Arlington, TX, USA
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Andrew P Oneglia
- College of Nursing and Health Innovation, University of Texas at Arlington, Arlington, TX, USA
| | - Daisha J Cipher
- College of Nursing and Health Innovation, University of Texas at Arlington, Arlington, TX, USA
| | - Justin A Ezekowitz
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, AB, Canada
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Jason R B Dyck
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, AB, Canada
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Todd Anderson
- Libin Cardiovascular Institute of Alberta, Calgary, AB, Canada
- Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada
| | | | - D Ian Paterson
- University of Ottawa Heart Institute, University of Ottawa, Ottawa, ON, Canada
| | - Richard B Thompson
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, AB, Canada
- Department of Biomedical Engineering, University of Alberta, Edmonton, AB, Canada
| | - Michael D Nelson
- College of Nursing and Health Innovation, University of Texas at Arlington, Arlington, TX, USA.
- Applied Physiology and Advanced Imaging Laboratory, Department of Kinesiology, University of Texas at Arlington, 676 W. Nedderman Dr., Arlington, TX, 76019, USA.
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22
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Appunni S, Rubens M, Ramamoorthy V, Saxena A, Doke M, Roy M, Ruiz-Pelaez JG, Zhang Y, Ahmed A, Zhang Z, McGranaghan P, Chaparro S, Jimenez J. Adverse Outcomes in Hospitalizations for Amyloid-Related Heart Failure. Am J Cardiol 2023; 203:169-174. [PMID: 37499596 DOI: 10.1016/j.amjcard.2023.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 06/30/2023] [Accepted: 07/06/2023] [Indexed: 07/29/2023]
Abstract
Transthyretin amyloid cardiomyopathy is being increasingly recognized as an important cause of heart failure (HF). In this study, we looked at adverse outcomes in hospitalizations with amyloid-related HF. This study was a retrospective analysis of the National Inpatient Sample data, collected from 2016 to 2019. Patients ≥41 years of age and admitted for HF were included in the study. In these hospitalizations, amyloid-related HF was identified through the International Classification of Diseases, Tenth Revision, Clinical Modification codes for amyloidosis. The primary outcome of the study was in-hospital mortality, whereas secondary outcomes were prolonged length of stay, mechanical ventilation, mechanical circulatory support, vasopressors use, and dispositions other than home. From 2016 to 2019, there were 4,705,274 HF hospitalizations, of which 16,955 (0.4%) had amyloid cardiomyopathy. In all HF hospitalizations, amyloid-related increased from 0.26% in 2016 to 0.46% in 2019 (relative increase, 76.9%, P for trend <0.001). Amyloid-related HF hospitalizations were more common in older, male, and Black patients. The odds of in-hospital mortality (odds ratio [OR], 1.29; 95% confidence interval [CI]: 1.11 to 1.38), prolonged hospital length (OR, 1.61; 95% CI: 1.49 to 1.73) and vasopressors use (OR, 1.59; 95% CI: 1.23 to 2.05) were significantly higher for amyloid-related hospitalizations. Amyloid-related HF hospitalizations are increasing substantially and are associated with adverse hospital outcomes. These hospitalizations were disproportionately higher for older, male, and Black patients. Amyloid-related HF is rare and underdiagnosed yet has several adverse outcomes. Hence, healthcare providers should be watchful of this condition for early identification and prompt management.
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Affiliation(s)
| | - Muni Rubens
- Office of Clinical Research, Baptist Health South Florida, Miami, Florida; Department of Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida; Department of Health Science, Universidad Espíritu Santo, Ecuador
| | | | - Anshul Saxena
- Department of Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida; Center for Advanced Analytics, Baptist Health South Florida, Miami, Florida
| | - Mayur Doke
- Diabetic Research Institute, Miller School of Medicine, University of Miami, Miami, Florida
| | - Mukesh Roy
- Office of Clinical Research, Baptist Health South Florida, Miami, Florida
| | - Juan Gabriel Ruiz-Pelaez
- Department of Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
| | - Yanjia Zhang
- Center for Advanced Analytics, Baptist Health South Florida, Miami, Florida
| | - Ashfaq Ahmed
- Center for Advanced Analytics, Baptist Health South Florida, Miami, Florida
| | - Zhenwei Zhang
- Center for Advanced Analytics, Baptist Health South Florida, Miami, Florida
| | - Peter McGranaghan
- Office of Clinical Research, Baptist Health South Florida, Miami, Florida; Department of Internal Medicine and Cardiology, Charité Campus Virchow-Klinikum, Berlin, Germany
| | - Sandra Chaparro
- Department of Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida; Department of Medicine, Miami Cardiac & Vascular Institute, Baptist Health South Florida, Miami, Florida
| | - Javier Jimenez
- Department of Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida; Department of Medicine, Miami Cardiac & Vascular Institute, Baptist Health South Florida, Miami, Florida.
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23
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Moura B, Aimo A, Al-Mohammad A, Keramida K, Ben Gal T, Dorbala S, Todiere G, Cameli M, Barison A, Bayes-Genis A, von Bardeleben RS, Bucciarelli-Ducci C, Delgado V, Mordi IR, Seferovic P, Savarese G, Čelutkienė J, Rapezzi C, Emdin M, Coats A, Metra M, Rosano G. Diagnosis and management of patients with left ventricular hypertrophy: Role of multimodality cardiac imaging. A scientific statement of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2023; 25:1493-1506. [PMID: 37581253 DOI: 10.1002/ejhf.2997] [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: 03/22/2023] [Revised: 07/28/2023] [Accepted: 08/09/2023] [Indexed: 08/16/2023] Open
Abstract
Left ventricular (LV) hypertrophy consists in an increased LV wall thickness. LV hypertrophy can be either secondary, in response to pressure or volume overload, or primary, i.e. not explained solely by abnormal loading conditions. Primary LV hypertrophy may be due to gene mutations or to the deposition or storage of abnormal substances in the extracellular spaces or within the cardiomyocytes (more appropriately defined as pseudohypertrophy). LV hypertrophy is often a precursor to subsequent development of heart failure. Cardiovascular imaging plays a key role in the assessment of LV hypertrophy. Echocardiography, the first-line imaging technique, allows a comprehensive assessment of LV systolic and diastolic function. Cardiovascular magnetic resonance provides added value as it measures accurately LV and right ventricular volumes and mass and characterizes myocardial tissue properties, which may provide important clues to the final diagnosis. Additionally, scintigraphy with bone tracers is included in the diagnostic algorithm of cardiac amyloidosis. Once the diagnosis is established, imaging findings may help predict future disease evolution and inform therapy and follow-up. This consensus document by the Heart Failure Association of the European Society of Cardiology provides an overview of the role of different cardiac imaging techniques for the differential diagnosis and management of patients with LV hypertrophy.
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Affiliation(s)
- Brenda Moura
- Faculty of Medicine, University of Porto, Porto, Portugal
- Cardiology Department, Porto Armed Forces Hospital, Porto, Portugal
| | - Alberto Aimo
- Scuola Superiore Sant'Anna, Pisa, Italy
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Abdallah Al-Mohammad
- South Yorkshire Cardiothoracic Centre (Northern General Hospital), Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Kalliopi Keramida
- Cardiology Department, General Anti-Cancer, Oncological Hospital Agios Savvas, Athens, Greece
| | - Tuvia Ben Gal
- Rabin Medical Center, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sharmila Dorbala
- Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA
| | - Giancarlo Todiere
- Scuola Superiore Sant'Anna, Pisa, Italy
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Matteo Cameli
- Cardiology Division, University Hospital of Siena, Siena, Italy
| | | | - Antoni Bayes-Genis
- Institut del Cor, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
- CIBERCV, Carlos III Institute of Health, Madrid, Spain
| | | | | | - Victoria Delgado
- Institut del Cor, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain
| | - Ify R Mordi
- Division of Molecular and Clinical Medicine, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Petar Seferovic
- Serbian Academy of Sciences and Arts, Belgrade, Serbia
- University of Belgrade Faculty of Medicine, Belgrade, Serbia
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiology, Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Jelena Čelutkienė
- Vilnius University, Faculty of Medicine, Vilnius, Lithuania
- State Research Institute Centre for Innovative Medicine, Vilnius, Lithuania
| | - Claudio Rapezzi
- Cardiology Centre, University of Ferrara, Ferrara, Italy
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Michele Emdin
- Faculty of Medicine, University of Porto, Porto, Portugal
- Cardiology Department, Porto Armed Forces Hospital, Porto, Portugal
| | | | - Marco Metra
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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24
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Moody WE, Turvey-Haigh L, Knight D, Coats CJ, Cooper RM, Schofield R, Robinson S, Harkness A, Oxborough DL, Gillmore JD, Whelan C, Augustine DX, Fontana M, Steeds RP. British Society of Echocardiography guideline for the transthoracic echocardiographic assessment of cardiac amyloidosis. Echo Res Pract 2023; 10:13. [PMID: 37653443 PMCID: PMC10468878 DOI: 10.1186/s44156-023-00028-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 08/07/2023] [Indexed: 09/02/2023] Open
Abstract
These guidelines form an update of the BSE guideline protocol for the assessment of restrictive cardiomyopathy (Knight et al. in Echo Res Prac, 2013). Since the original recommendations were conceived in 2013, there has been an exponential rise in the diagnosis of cardiac amyloidosis fuelled by increased clinician awareness, improvements in cardiovascular imaging as well as the availability of new and effective disease modifying therapies. The initial diagnosis of cardiac amyloidosis can be challenging and is often not clear-cut on the basis of echocardiography, which for most patients presenting with heart failure symptoms remains the first-line imaging test. The role of a specialist echocardiographer will be to raise the suspicion of cardiac amyloidosis when appropriate, but the formal diagnosis of amyloid sub-type invariably requires further downstream testing. This document seeks to provide a focused review of the literature on echocardiography in cardiac amyloidosis highlighting its important role in the diagnosis, prognosis and screening of at risk individuals, before concluding with a suggested minimum data set, for use as an aide memoire when reporting.
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Affiliation(s)
- William E Moody
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Edgbaston, Birmingham, B15 2TH, UK.
- Institute of Cardiovascular Science, College of Medical and Dental Science, University of Birmingham, Birmingham, UK.
| | - Lauren Turvey-Haigh
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Edgbaston, Birmingham, B15 2TH, UK
| | - Daniel Knight
- Division of Medicine, National Amyloidosis Centre, University College London, London, UK
| | | | - Robert M Cooper
- Liverpool Heart and Chest Hospital, Liverpool, UK
- Liverpool John Moores University, Liverpool, UK
| | | | | | - Allan Harkness
- East Suffolk and North Essex NHS Foundation Trust, Essex, UK
| | - David L Oxborough
- Sports and Exercise Sciences, Liverpool John Moores University, Liverpool, UK
| | - Julian D Gillmore
- Division of Medicine, National Amyloidosis Centre, University College London, London, UK
| | - Carol Whelan
- Division of Medicine, National Amyloidosis Centre, University College London, London, UK
| | - Daniel X Augustine
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
- Department For Health, University of Bath, Bath, UK
| | - Marianna Fontana
- Division of Medicine, National Amyloidosis Centre, University College London, London, UK
| | - Richard P Steeds
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Edgbaston, Birmingham, B15 2TH, UK
- Institute of Cardiovascular Science, College of Medical and Dental Science, University of Birmingham, Birmingham, UK
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25
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Usuku H, Yamamoto E, Sueta D, Imamura K, Oike F, Marume K, Ishii M, Hanatani S, Arima Y, Takashio S, Oda S, Kawano H, Ueda M, Matsui H, Tsujita K. Usefulness of automatic assessment for longitudinal strain to diagnose wild-type transthyretin amyloid cardiomyopathy. IJC HEART & VASCULATURE 2023; 47:101227. [PMID: 37416484 PMCID: PMC10320495 DOI: 10.1016/j.ijcha.2023.101227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/16/2023] [Accepted: 05/18/2023] [Indexed: 07/08/2023]
Abstract
Background Left ventricular (LV) apical sparing by transthoracic echocardiography (TTE) has not been widely accepted to diagnose transthyretin amyloid cardiomyopathy (ATTR-CM), because it is time consuming and requires a level of expertise. We hypothesized that automatic assessment may be the solution for these problems. Methods-and-Results We enrolled 63 patients aged ≥70 years who underwent 99mTc-labeled pyrophosphate (99mTc-PYP) scintigraphy on suspicion of ATTR-CM and performed TTE by EPIQ7G, and had enough information for two-dimensional speckle tracking echocardiography at Kumamoto University Hospital from January 2016 to December 2019. LV apical sparing was described as a high relative apical longitudinal strain (LS) index (RapLSI). Measurement of LS was repeated using the same apical images with three different measurement packages as follows: (1) full-automatic assessment, (2) semi-automatic assessment, and (3) manual assessment. The calculation time for full-automatic assessment (14.7 ± 1.4 sec/patient) and semi-automatic assessment (66.7 ± 14.4 sec/patient) were significantly shorter than that for manual assessment (171.2 ± 59.7 sec/patient) (p < 0.01 for both). Receiver operating characteristic curve analysis showed that the area under curve of the RapLSI evaluated by full-automatic assessment for predicting ATTR-CM was 0.70 (best cut-off point; 1.14 [sensitivity 63%, specificity 81%]), by semi-automatic assessment was 0.85 (best cut-off point; 1.00 [sensitivity, 66%; specificity, 100%]) and by manual assessment was 0.83 (best cut-off point; 0.97 [sensitivity, 72%; specificity, 97%]). Conclusion There was no significant difference between the diagnostic accuracy of RapLSI estimated by semi-automatic assessment and that estimated by manual assessment. Semi-automatically assessed RapLSI is useful to diagnose ATTR-CM in terms of rapidity and diagnostic accuracy.
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Affiliation(s)
- Hiroki Usuku
- Department of Laboratory Medicine, Kumamoto University Hospital, Kumamoto, Japan
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
- Center of Metabolic Regulation of Healthy Aging, Kumamoto University, Faculty of Life Sciences, Kumamoto, Japan
| | - Eiichiro Yamamoto
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
- Center of Metabolic Regulation of Healthy Aging, Kumamoto University, Faculty of Life Sciences, Kumamoto, Japan
| | - Daisuke Sueta
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
- Center of Metabolic Regulation of Healthy Aging, Kumamoto University, Faculty of Life Sciences, Kumamoto, Japan
| | - Kanako Imamura
- Department of Laboratory Medicine, Kumamoto University Hospital, Kumamoto, Japan
| | - Fumi Oike
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
- Center of Metabolic Regulation of Healthy Aging, Kumamoto University, Faculty of Life Sciences, Kumamoto, Japan
| | - Kyohei Marume
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
- Center of Metabolic Regulation of Healthy Aging, Kumamoto University, Faculty of Life Sciences, Kumamoto, Japan
| | - Masanobu Ishii
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
- Center of Metabolic Regulation of Healthy Aging, Kumamoto University, Faculty of Life Sciences, Kumamoto, Japan
| | - Shinsuke Hanatani
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
- Center of Metabolic Regulation of Healthy Aging, Kumamoto University, Faculty of Life Sciences, Kumamoto, Japan
| | - Yuichiro Arima
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
- Center of Metabolic Regulation of Healthy Aging, Kumamoto University, Faculty of Life Sciences, Kumamoto, Japan
| | - Seiji Takashio
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
- Center of Metabolic Regulation of Healthy Aging, Kumamoto University, Faculty of Life Sciences, Kumamoto, Japan
| | - Seitaro Oda
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Hiroaki Kawano
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
- Center of Metabolic Regulation of Healthy Aging, Kumamoto University, Faculty of Life Sciences, Kumamoto, Japan
| | - Mitsuharu Ueda
- Center of Metabolic Regulation of Healthy Aging, Kumamoto University, Faculty of Life Sciences, Kumamoto, Japan
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto
| | - Hirotaka Matsui
- Department of Molecular Laboratory Medicine, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
- Center of Metabolic Regulation of Healthy Aging, Kumamoto University, Faculty of Life Sciences, Kumamoto, Japan
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Rashdan L, Hodovan J, Masri A. Imaging cardiac hypertrophy in hypertrophic cardiomyopathy and its differential diagnosis. Curr Opin Cardiol 2023:00001573-990000000-00084. [PMID: 37421401 DOI: 10.1097/hco.0000000000001070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/10/2023]
Abstract
PURPOSE OF REVIEW The aim of this study was to review imaging of myocardial hypertrophy in hypertrophic cardiomyopathy (HCM) and its phenocopies. The introduction of cardiac myosin inhibitors in HCM has emphasized the need for careful evaluation of the underlying cause of myocardial hypertrophy. RECENT FINDINGS Advances in imaging of myocardial hypertrophy have focused on improving precision, diagnosis, and predicting prognosis. From improved assessment of myocardial mass and function, to assessing myocardial fibrosis without the use of gadolinium, imaging continues to be the primary tool in understanding myocardial hypertrophy and its downstream effects. Advances in differentiating athlete's heart from HCM are noted, and the increasing rate of diagnosis in cardiac amyloidosis using noninvasive approaches is especially highlighted due to the implications on treatment approach. Finally, recent data on Fabry disease are shared as well as differentiating other phenocopies from HCM. SUMMARY Imaging hypertrophy in HCM and ruling out other phenocopies is central to the care of patients with HCM. This space will continue to rapidly evolve, as disease-modifying therapies are under investigation and being advanced to the clinic.
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Affiliation(s)
- Lana Rashdan
- Hypertrophic Cardiomyopathy Center, Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
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Briasoulis A, Bampatsias D, Papamichail A, Kuno T, Skoularigis J, Xanthopoulos A, Triposkiadis F. Invasive and Non-Invasive Diagnostic Pathways in the Diagnosis of Cardiac Amyloidosis. J Cardiovasc Dev Dis 2023; 10:256. [PMID: 37367421 DOI: 10.3390/jcdd10060256] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/07/2023] [Accepted: 06/08/2023] [Indexed: 06/28/2023] Open
Abstract
The appropriate diagnosis and subtyping of cardiac amyloidosis (CA) is frequently missed or delayed due to its vague presentation, clinical overlapping, and diagnostic pitfalls. Recent developments in both invasive and non-invasive diagnostic techniques have significantly changed the diagnostic approach of CA. With the present review, we aim to summarize the current diagnostic approach of CA and to underline the indications of tissue biopsy, either surrogate site or myocardial. The most important factor for timely diagnosis is increased clinical suspicion, especially in certain clinical scenarios. Appropriate imaging with echocardiography or cardiac magnetic resonance (CMR) can provide significant evidence for the diagnosis of CA. Importantly, all patients should undergo monoclonal proteins assessment, with these results significantly determining the steps to follow. A negative monoclonal protein assessment will lead to a non-invasive algorithm which, in combination with positive cardiac scintigraphy, can establish the diagnosis of ATTR-CA. The latter is the only clinical scenario in which the diagnosis can be established without the need of biopsy. However, if the imaging results are negative but the clinical suspicion remains high, a myocardial biopsy should be performed. In the case of the presence of monoclonal protein, an invasive algorithm follows, first by surrogate site sampling and then by myocardial biopsy if the results are inconclusive or prompt diagnosis is needed. The role of endomyocardial biopsy, even though limited by current advances in other techniques, is highly valuable in selected patients and is the only method to reliably establish a diagnosis in challenging cases.
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Affiliation(s)
- Alexandros Briasoulis
- Amyloidosis Center, Department of Clinical Therapeutics, Faculty of Medicine, Alexandra Hospital, National and Kapodistrian University of Athens, 80 Vasilissis Sophias Avenue, 11528 Athens, Greece
| | - Dimitrios Bampatsias
- Amyloidosis Center, Department of Clinical Therapeutics, Faculty of Medicine, Alexandra Hospital, National and Kapodistrian University of Athens, 80 Vasilissis Sophias Avenue, 11528 Athens, Greece
| | - Adamantia Papamichail
- Amyloidosis Center, Department of Clinical Therapeutics, Faculty of Medicine, Alexandra Hospital, National and Kapodistrian University of Athens, 80 Vasilissis Sophias Avenue, 11528 Athens, Greece
| | | | - John Skoularigis
- Department of Cardiology, University Hospital of Larissa, 41110 Larissa, Greece
| | - Andrew Xanthopoulos
- Department of Cardiology, University Hospital of Larissa, 41110 Larissa, Greece
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Benjamin MM, Arora P, Munir MS, Darki A, Liebo M, Yu M, Syed MA, Kinno M. Association of Left Atrial Hemodynamics by Magnetic Resonance Imaging With Long-Term Outcomes in Patients With Cardiac Amyloidosis. J Magn Reson Imaging 2023; 57:1275-1284. [PMID: 35801623 DOI: 10.1002/jmri.28320] [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: 03/18/2022] [Revised: 06/10/2022] [Accepted: 06/10/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Left atrial (LA) function and strain patterns by magnetic resonance imaging (MRI) have been investigated as markers of several cardiovascular pathologies, including cardiac amyloidosis (CA). However, associations with clinical outcomes have not been investigated. PURPOSE To compare LA function and strain by MRI in CA patients to a matched cohort of patients without cardiovascular disease (CVD) and evaluate the association with long-term clinical outcomes in CA patients. STUDY TYPE Retrospective case control. POPULATION A total of 51 patients with CA and 51 age-, gender-, and race-matched controls without CVD who underwent MRI in sinus rhythm. FIELD STRENGTH/SEQUENCE ECG-gated balanced steady-state free precession sequence at 1.5 T. ASSESSMENT All measurements were completed by one investigator (M.M.B.). LA function and strain parameters were measured including LA indexed minimum and maximum volumes, LA reservoir (R), contractile (CT), and conduit (CD) strain. We compared groups after adjusting for age, hypertension, New York Heart Association class, modified staging system (troponin-I, BNP, estimated GFR) and left ventricular ejection fraction (LVEF) for an endpoint of all-cause mortality and a composite endpoint of heart failure hospitalization (HFH) or death. STATISTICAL TESTS Differences between groups were evaluated with t tests for continuous variables or χ2 tests for categorical variables. A multivariable regression model was used to assess the associations of the P values-two-sided tests-<0.05 were considered statistically significant. RESULTS CA patients with median follow up of 4.9 (8.5) months had significantly lower LA strain and higher LA volumes in comparison to the matched cohort. In the multivariable analysis, only LVEF was significantly associated with death while ƐCT (OR 0.6, CI: 0.41-0.89), indexed minimum LA volume (OR 1.06, CI: 1.02-1.13) and indexed maximum LA volume (OR 1.08, CI: 1.01-1.15) were significantly associated with the composite outcome of death or HFH. CONCLUSION In this retrospective study of CA patients, ƐCT and indexed minimum and maximum LA volumes were significantly associated with the composite outcome of death or HFH. EVIDENCE LEVEL 3 TECHNICAL EFFICACY: Stage 3.
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Affiliation(s)
- Mina M Benjamin
- Division of Cardiovascular Medicine, Loyola University Medical Center, Maywood, Illinois
| | - Punit Arora
- Department of Internal Medicine, Loyola University Medical Center, Maywood, Illinois, USA
| | - Muhammad S Munir
- Department of Internal Medicine, Loyola University Medical Center, Maywood, Illinois, USA
| | - Amir Darki
- Division of Cardiovascular Medicine, Loyola University Medical Center, Maywood, Illinois
| | - Max Liebo
- Department of Cardiology, Loyola University Chicago, Stritch School of Medicine, Loyola University Medical Center, Maywood, Illinois, USA
| | - Mingxi Yu
- Department of Cardiology, Loyola University Chicago, Stritch School of Medicine, Loyola University Medical Center, Maywood, Illinois, USA
| | - Mushabbar A Syed
- Division of Cardiovascular Medicine, Loyola University Medical Center, Maywood, Illinois
| | - Menhel Kinno
- Division of Cardiovascular Medicine, Loyola University Medical Center, Maywood, Illinois
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Khedraki R, Robinson AA, Jordan T, Grodin JL, Mohan RC. A Review of Current and Evolving Imaging Techniques in Cardiac Amyloidosis. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2023; 25:43-63. [PMID: 38239280 PMCID: PMC10795761 DOI: 10.1007/s11936-023-00976-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/30/2022] [Indexed: 03/07/2023]
Abstract
Purpose of review Establishing an early, efficient diagnosis for cardiac amyloid (CA) is critical to avoiding adverse outcomes. We review current imaging tools that can aid early diagnosis, offer prognostic information, and possibly track treatment response in CA. Recent findings There are several current conventional imaging modalities that aid in the diagnosis of CA including electrocardiography, echocardiography, bone scintigraphy, cardiac computed tomography (CT), and cardiac magnetic resonance (CMR) imaging. Advanced imaging techniques including left atrial and right ventricular strain, and CMR T1 and T2 mapping as well as ECV quantification may provide alternative non-invasive means for diagnosis, more granular prognostication, and the ability to track treatment response. Summary Leveraging a multimodal imaging toolbox is integral to the early diagnosis of CA; however, it is important to understand the unique role and limitations posed by each modality. Ongoing studies are needed to help identify imaging markers that will lead to an enhanced ability to diagnose, subtype and manage this condition.
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Affiliation(s)
- Rola Khedraki
- Section of Advanced Heart Failure, Division of Cardiovascular Medicine, Scripps Clinic, Prebys Cardiovascular Institute, 9898 Genesee Ave., AMP-300, La Jolla, San Diego, CA 92037, USA
| | - Austin A. Robinson
- Section of Advanced Heart Failure, Division of Cardiovascular Medicine, Scripps Clinic, Prebys Cardiovascular Institute, 9898 Genesee Ave., AMP-300, La Jolla, San Diego, CA 92037, USA
| | - Timothy Jordan
- Section of Advanced Heart Failure, Division of Cardiovascular Medicine, Scripps Clinic, Prebys Cardiovascular Institute, 9898 Genesee Ave., AMP-300, La Jolla, San Diego, CA 92037, USA
| | - Justin L. Grodin
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, USA
| | - Rajeev C. Mohan
- Section of Advanced Heart Failure, Division of Cardiovascular Medicine, Scripps Clinic, Prebys Cardiovascular Institute, 9898 Genesee Ave., AMP-300, La Jolla, San Diego, CA 92037, USA
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30
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Cotella JI, Slivnick JA, Sanderson E, Singulane C, O'Driscoll J, Asch FM, Addetia K, Woodward G, Lang RM. Artificial intelligence based left ventricular ejection fraction and global longitudinal strain in cardiac amyloidosis. Echocardiography 2023; 40:188-195. [PMID: 36621915 DOI: 10.1111/echo.15516] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 11/15/2022] [Accepted: 12/10/2022] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Assessment of left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) plays a key role in the diagnosis of cardiac amyloidosis (CA). However, manual measurements are time consuming and prone to variability. We aimed to assess whether fully automated artificial intelligence (AI) calculation of LVEF and GLS provide similar estimates and can identify abnormalities in agreement with conventional manual methods, in patients with pre-clinical and clinical CA. METHODS We identified 51 patients (age 80 ± 10 years, 53% male) with confirmed CA according to guidelines, who underwent echocardiography before and/or at the time of CA diagnosis (median (IQR) time between observations 3.87 (1.93, 5.44 years). LVEF and GLS were quantified from the apical 2- and 4-chamber views using both manual and fully automated methods (EchoGo Core 2.0, Ultromics). Inter-technique agreement was assessed using linear regression and Bland-Altman analyses and two-way ANOVA. The diagnostic accuracy and time for detecting abnormalities (defined as LVEF ≤ 50% and GLS ≥ -15.1%, respectively) using AI was assessed by comparisons to manual measurements as a reference. RESULTS There were no significant differences in manual and automated LVEF and GLS values in either pre-CA (p = .791 and p = .105, respectively) or at diagnosis (p = .463 and p = .722). The two methods showed strong correlation on both the pre-CA (r = .78 and r = .83) and CA echoes (r = .74 and r = .80) for LVEF and GLS, respectively. The sensitivity and specificity of AI-derived indices for detecting abnormal LVEF were 83% and 86%, respectively, in the pre-CA echo and 70% and 79% at CA diagnosis. The sensitivity and specificity of AI-derived indices for detecting abnormal GLS was 82% and 86% in the pre-CA echo and 100% and 67% at the time of CA diagnosis. There was no significant difference in the relationship between LVEF (p = .99) and GLS (p = .19) and time to abnormality between the two methods. CONCLUSION Fully automated AI-calculated LVEF and GLS are comparable to manual measurements in patients pre-CA and at the time of CA diagnosis. The widespread implementation of automated LVEF and GLS may allow for more rapid assessment in different disease states with comparable accuracy and reproducibility to manual methods.
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Affiliation(s)
- Juan I Cotella
- University of Chicago Medical Center, Chicago, Illinois, USA
| | | | - Emily Sanderson
- Ultromics Ltd, 4630 Kingsgate, Cascade Way, Oxford Business Park South, Oxford, OX4 2SU, Oxford, UK
| | | | - Jamie O'Driscoll
- Ultromics Ltd, 4630 Kingsgate, Cascade Way, Oxford Business Park South, Oxford, OX4 2SU, Oxford, UK.,Canterbury Christ Church University School of Psychology, Politics and Sociology, Canterbury, UK.,Department of Cardiology, St George's University Hospitals NHS Foundation Trust, Tooting, London, UK
| | - Federico M Asch
- Cardiovascular Core Labs, MedStar Health Research Institute, Washington DC, Washington, USA
| | - Karima Addetia
- University of Chicago Medical Center, Chicago, Illinois, USA
| | - Gary Woodward
- Ultromics Ltd, 4630 Kingsgate, Cascade Way, Oxford Business Park South, Oxford, OX4 2SU, Oxford, UK
| | - Roberto M Lang
- University of Chicago Medical Center, Chicago, Illinois, USA
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31
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Pudis M, Bastarrika Alemañ G. [Current role of imaging techniques in cardiac amyloidosis]. Med Clin (Barc) 2023; 160:121-128. [PMID: 36543710 DOI: 10.1016/j.medcli.2022.09.010] [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: 07/13/2022] [Revised: 09/19/2022] [Accepted: 09/21/2022] [Indexed: 12/23/2022]
Abstract
Cardiac amyloidosis (CA) is an underdiagnosed disease and, if left untreated, rapidly fatal. Emerging therapies for CA increase the urgency of developing non-invasive diagnostic methods for its early detection and for monitoring therapeutic response. Classic imaging features on echocardiography and cardiac magnetic resonance, although typical for cardiac amyloidosis, are not specific enough to distinguish light chain amyloidosis from transthyretin. Myocardial bone-avid radiotracer uptake is highly specific for transthyretin cardiac amyloidosis when plasma cell dyscrasia has been excluded; it is now replacing the need for biopsy in many patients. Detection of early cardiac amyloidosis, quantitation of its burden, and assessment of response to therapy are important next steps for imaging to advance the evaluation and management of cardiac amyloidosis.
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Affiliation(s)
- Michal Pudis
- Servicio de Medicina Nuclear-PET (IDI), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España.
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32
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Krittanawong C, Rodriguez M, Lui M, Misra A, Tang WHW, Bozkurt B, Yancy CW. Misconceptions and Facts about Heart Failure with Reduced Ejection Fraction. Am J Med 2023; 136:422-431. [PMID: 36740210 DOI: 10.1016/j.amjmed.2023.01.024] [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] [Received: 12/27/2022] [Revised: 01/11/2023] [Accepted: 01/11/2023] [Indexed: 02/05/2023]
Abstract
Heart failure with reduced ejection fraction is a significant driver of morbidity and mortality. There are common misconceptions regarding the disease processes underlying heart failure and best practices for therapy. The terms heart failure with reduced ejection fraction and left ventricular systolic dysfunction are not interchangeable terms. Key therapies for heart failure with reduced ejection fraction target the underlying disease processes, not the left ventricular ejection fraction alone. The absence of congestion does not rule out heart failure. Patients with cardiac amyloidosis can also present with heart failure with reduced ejection fraction. A rise in serum creatinine in acute heart failure exacerbation is not associated with tubular injury. Guideline directed medical therapy should be continued during acute exacerbations of heart failure with reduced ejection fraction and should be started in the same hospitalization in new diagnoses. Marginal blood pressure is not a relative contraindication to optimal guideline directed medical therapy. Guideline directed medical therapy should be continued even if ejection fraction improves. There are other therapies that provide significant benefit besides the four key medications in guideline directed medical therapy.
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Affiliation(s)
| | - Mario Rodriguez
- John T Milliken Department of Medicine, Division of Cardiovascular Disease, Section of Advanced Heart Failure and Transplant, Barnes-Jewish Hospital/Washington University in St. Louis School of Medicine, Mo
| | - Matthew Lui
- John T Milliken Department of Medicine, Division of Cardiovascular Disease, Section of Advanced Heart Failure and Transplant, Barnes-Jewish Hospital/Washington University in St. Louis School of Medicine, Mo
| | - Arunima Misra
- Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Ohio
| | - Biykem Bozkurt
- Winters Center for Heart Failure Research, Cardiovascular Research Institute, Baylor College of Medicine, DeBakey VA Medical Center, Houston, Texas
| | - Clyde W Yancy
- Chief, Division of Cardiology, Northwestern University, Feinberg School of Medicine, Chicago, Ill
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Deep Learning to Classify AL versus ATTR Cardiac Amyloidosis MR Images. Biomedicines 2023; 11:biomedicines11010193. [PMID: 36672702 PMCID: PMC9855341 DOI: 10.3390/biomedicines11010193] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 12/18/2022] [Accepted: 01/11/2023] [Indexed: 01/13/2023] Open
Abstract
The aim of this work was to compare the classification of cardiac MR-images of AL versus ATTR amyloidosis by neural networks and by experienced human readers. Cine-MR images and late gadolinium enhancement (LGE) images of 120 patients were studied (70 AL and 50 TTR). A VGG16 convolutional neural network (CNN) was trained with a 5-fold cross validation process, taking care to strictly distribute images of a given patient in either the training group or the test group. The analysis was performed at the patient level by averaging the predictions obtained for each image. The classification accuracy obtained between AL and ATTR amyloidosis was 0.750 for cine-CNN, 0.611 for Gado-CNN and between 0.617 and 0.675 for human readers. The corresponding AUC of the ROC curve was 0.839 for cine-CNN, 0.679 for gado-CNN (p < 0.004 vs. cine) and 0.714 for the best human reader (p < 0.007 vs. cine). Logistic regression with cine-CNN and gado-CNN, as well as analysis focused on the specific orientation plane, did not change the overall results. We conclude that cine-CNN leads to significantly better discrimination between AL and ATTR amyloidosis as compared to gado-CNN or human readers, but with lower performance than reported in studies where visual diagnosis is easy, and is currently suboptimal for clinical practice.
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Shen CP, Vanichsarn CT, Pandey AC, Billick K, Rubenson DS, Mohan RC, Heywood JT, Srivastava AV. Wild type cardiac amyloidosis: is it time to order a nuclear technetium pyrophosphate SPECT imaging study? Int J Cardiovasc Imaging 2023; 39:201-208. [PMID: 36598681 PMCID: PMC9813141 DOI: 10.1007/s10554-022-02692-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 07/01/2022] [Indexed: 01/09/2023]
Abstract
Transthyretin (ATTR) amyloidosis is a debilitating systemic disease often associated with symptomatic cardiac involvement. Diagnosis has dramatically changed with the advent of Technetium-99 m pyrophosphate (Tc-PYP) single-photon emission computed tomography (SPECT). With the ability to diagnose ATTR amyloidosis noninvasively and offer newer therapies, it is increasingly important to identify which patients should be referred for this testing. Relative apical sparing of longitudinal strain on echocardiogram can be potentially used to screen such patients. We sought to describe electrocardiogram (ECG) and echocardiogram (TTE) findings, including relative apical sparing of longitudinal strain, in ATTR amyloidosis patients diagnosed non-invasively with 99mTc-PYP imaging. This was a single-center, retrospective study with 64 patients who underwent 99mTc-PYP imaging between June 2016 and February 2019. Relative apical longitudinal strain was calculated from left ventricular longitudinal strain (LV LS) values. No ECG parameters were meaningfully associated with of 99 m Tc-PYP positive patients. LV mass index (p = 0.001), IVSd (p < 0.001), and LVPWd (< 0.001) demonstrated a highly significant difference between positive and negative 99mTc-PYP groups. 99mTc-PYP positive patients had a higher relative apical sparing of LV LS (p < 0.001), and notably, no 99mTc-PYP negative patient had a ratio > 1.0. The finding of relative apical sparing of longitudinal strain can reliably guide clinicians in triaging which patients to consider ordering 99mTc-PYP imaging for the noninvasive diagnosis of wild type cardiac amyloidosis. A patient with clinically suggestive features and an LV LS relative apical sparing ratio > 0.8 can be considered for 99mTc-PYP imaging to evaluate for ATTR cardiac amyloidosis.
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Affiliation(s)
- Christine P Shen
- Division of Cardiology, Scripps Clinic, 9898 Genesee Ave, AMP-300, La Jolla, CA, USA
| | | | - Amitabh C Pandey
- Division of Cardiology, Scripps Clinic, 9898 Genesee Ave, AMP-300, La Jolla, CA, USA
- Scripps Research Translational Institute, Scripps Research, La Jolla, CA, USA
| | - Kristen Billick
- Division of Cardiology, Scripps Clinic, 9898 Genesee Ave, AMP-300, La Jolla, CA, USA
| | - David S Rubenson
- Division of Cardiology, Scripps Clinic, 9898 Genesee Ave, AMP-300, La Jolla, CA, USA
| | - Rajeev C Mohan
- Division of Cardiology, Scripps Clinic, 9898 Genesee Ave, AMP-300, La Jolla, CA, USA
| | - James Thomas Heywood
- Division of Cardiology, Scripps Clinic, 9898 Genesee Ave, AMP-300, La Jolla, CA, USA
| | - Ajay V Srivastava
- Division of Cardiology, Scripps Clinic, 9898 Genesee Ave, AMP-300, La Jolla, CA, USA.
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Merlo M, Gagno G, Baritussio A, Bauce B, Biagini E, Canepa M, Cipriani A, Castelletti S, Dellegrottaglie S, Guaricci AI, Imazio M, Limongelli G, Musumeci MB, Parisi V, Pica S, Pontone G, Todiere G, Torlasco C, Basso C, Sinagra G, Filardi PP, Indolfi C, Autore C, Barison A. Clinical application of CMR in cardiomyopathies: evolving concepts and techniques : A position paper of myocardial and pericardial diseases and cardiac magnetic resonance working groups of Italian society of cardiology. Heart Fail Rev 2023; 28:77-95. [PMID: 35536402 PMCID: PMC9902331 DOI: 10.1007/s10741-022-10235-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/22/2022] [Indexed: 02/07/2023]
Abstract
Cardiac magnetic resonance (CMR) has become an essential tool for the evaluation of patients affected or at risk of developing cardiomyopathies (CMPs). In fact, CMR not only provides precise data on cardiac volumes, wall thickness, mass and systolic function but it also a non-invasive characterization of myocardial tissue, thus helping the early diagnosis and the precise phenotyping of the different CMPs, which is essential for early and individualized treatment of patients. Furthermore, several CMR characteristics, such as the presence of extensive LGE or abnormal mapping values, are emerging as prognostic markers, therefore helping to define patients' risk. Lastly new experimental CMR techniques are under investigation and might contribute to widen our knowledge in the field of CMPs. In this perspective, CMR appears an essential tool to be systematically applied in the diagnostic and prognostic work-up of CMPs in clinical practice. This review provides a deep overview of clinical applicability of standard and emerging CMR techniques in the management of CMPs.
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Affiliation(s)
- Marco Merlo
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy.
| | - Giulia Gagno
- grid.5133.40000 0001 1941 4308Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Anna Baritussio
- grid.5608.b0000 0004 1757 3470Cardiology, Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Barbara Bauce
- grid.5608.b0000 0004 1757 3470Cardiology, Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Elena Biagini
- grid.412311.4Cardiology Unit, St. Orsola Hospital, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
| | - Marco Canepa
- grid.410345.70000 0004 1756 7871Cardiologia, IRCCS Ospedale Policlinico San Martino, Genova, Italy ,grid.5606.50000 0001 2151 3065Dipartimento di Medicina Interna e Specialità Mediche, Università degli Studi di Genova, Genova, Italy
| | - Alberto Cipriani
- grid.5608.b0000 0004 1757 3470Cardiology, Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Silvia Castelletti
- grid.418224.90000 0004 1757 9530Department of Cardiology, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Santo Dellegrottaglie
- Division of Cardiology, Ospedale Accreditato Villa dei Fiori, 80011 Acerra, Naples, Italy
| | - Andrea Igoren Guaricci
- grid.7644.10000 0001 0120 3326University Cardiology Unit, Department of Emergency and Organ Transplantation, University of Bari, 70124 Bari, Italy
| | - Massimo Imazio
- grid.411492.bCardiothoracic Department, University Hospital “Santa Maria Della Misericordia”, Udine, Italy
| | - Giuseppe Limongelli
- grid.416052.40000 0004 1755 4122Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, AORN Dei Colli, Monaldi Hospital, Naples, Italy
| | - Maria Beatrice Musumeci
- grid.7841.aCardiology, Clinical and Molecular Medicine Department, Faculty of Medicine and Psychology, Sapienza University of Rome, 00189 Rome, Italy
| | - Vanda Parisi
- grid.412311.4Cardiology Unit, St. Orsola Hospital, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
| | - Silvia Pica
- grid.419557.b0000 0004 1766 7370Multimodality Cardiac Imaging Section, IRCCS Policlinico San Donato, Milan, Italy
| | - Gianluca Pontone
- grid.418230.c0000 0004 1760 1750Dipartimento di Cardiologia Perioperatoria e Imaging Cardiovascolare, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Giancarlo Todiere
- grid.452599.60000 0004 1781 8976Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Camilla Torlasco
- grid.418224.90000 0004 1757 9530Department of Cardiology, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Cristina Basso
- grid.5608.b0000 0004 1757 3470Cardiology, Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Gianfranco Sinagra
- grid.5133.40000 0001 1941 4308Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Pasquale Perrone Filardi
- grid.4691.a0000 0001 0790 385XDipartimento Scienze Biomediche Avanzate, Università degli Studi Federico II, Mediterranea CardioCentro, Naples, Italy
| | - Ciro Indolfi
- grid.477084.80000 0004 1787 3414Dipartimento di Scienze Mediche e Chirurgiche, Cattedra di Cardiologia, Università Magna Graecia, Catanzaro, Mediterranea Cardiocentro, Napoli, Italy
| | - Camillo Autore
- grid.7841.aCardiology, Clinical and Molecular Medicine Department, Faculty of Medicine and Psychology, Sapienza University of Rome, 00189 Rome, Italy
| | - Andrea Barison
- grid.452599.60000 0004 1781 8976Fondazione Toscana Gabriele Monasterio, Pisa, Italy
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Zegkos T, Gossios T, Ntelios D, Parcharidou D, Karvounis H, Efthimiadis G. Wild-Type Transthyretin Amyloid Cardiomyopathy: The Gordian-Knot of Novel Therapeutic Regimens. Cardiol Rev 2023; 31:36-41. [PMID: 36469360 DOI: 10.1097/crd.0000000000000427] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Wild-type TTR amyloidosis (wtATTR) represents a disease difficult to diagnose with poor prognosis. Increased clinical suspicion is key, allowing for timely diagnosis. Until recently, only off-label therapies were available but recent introduction of disease specific therapy has shown potential to alter the natural history of the disease. Tafamidis, the only currently approved drug for the therapy of wtATTR, provided significantly better survival and quality of life. However, not all subgroups of patients derived equal benefit. This, along with the increased cost of treatment raised question on whether treatment should be invariably administered through the wtATTR population. This review aims to summarize current evidence on the natural history and staging systems for wtATTR, as well as available treatment options. Special consideration is given to the selection process of patients who would be expected to gain maximum benefit from tafamidis treatment, based on an ethical and cost-effective point of view.
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Affiliation(s)
- Thomas Zegkos
- From the 1st Cardiology Department, Center of Cardiomyopathies and Inherited Cardiac Diseases, AHEPA University Hospital, Thessaloniki, Greece
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Eckstein J, Körperich H, Weise Valdés E, Sciacca V, Paluszkiewicz L, Burchert W, Farr M, Sommer P, Sohns C, Piran M. CMR-based right ventricular strain analysis in cardiac amyloidosis and its potential as a supportive diagnostic feature. IJC HEART & VASCULATURE 2022; 44:101167. [PMID: 36632287 PMCID: PMC9827025 DOI: 10.1016/j.ijcha.2022.101167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 10/11/2022] [Accepted: 12/23/2022] [Indexed: 12/29/2022]
Abstract
Background Right ventricular (RV) strain has provided valuable prognostic information for patients with cardiac amyloidosis (CA). However, the extent to which RV strain and strain rate can differentiate CA is not yet clinically established. CA underdiagnosis delays treatment strategies and exacerbates patient prognosis. Aims Evaluation of cardiac magnetic resonance (CMR) quantified RV global and regional strain of CA and HCM patients along with CA subtypes. Methods CMR feature tracking attained longitudinal, radial and circumferential global and regional strain in 47 control subjects (CTRL), 43 CA-, 20 hypertrophic cardiomyopathy- (HCM) patients. CA patients were subdivided in 21 transthyretin-related amyloidosis (ATTR) and 20 acquired immunoglobulin light chain (AL) patients. Strain data and baseline clinical parameters were statistically analysed with respect to diagnostic performance and discriminatory power between the different clinical entities. Results Effective differentiation of CA from HCM patients was achieved utilizing global longitudinal (GLS: 16.5 ± 3.9% vs. -21.3 ± 6.7%, p = 0.032), radial (GRS: 11.7 ± 5.3% vs. 16.5 ± 7.1%, p < 0.001) and circumferential (GCS: -7.6 ± 4.0% vs. -9.4 ± 4.4%, p = 0.015) right ventricular strain. Highest strain-based hypertrophic phenotype differentiation was attained using GRS (AUC = 0.86). Binomial regression found right ventricular ejection fraction (RV-EF) (p = 0.017) to be a significant predictor of CA-HCM differentiation. CA subtypes had comparable cardiac strains. Conclusion CMR-derived RV global strains and various regional longitudinal strains provide discriminative radiological features for CA-HCM differentiation. However, in terms of feasibility, cine-derived RV-EF quantification may suffice for efficient differential diagnostic support.
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Affiliation(s)
- Jan Eckstein
- Institute for Radiology, Nuclear Medicine and Molecular Imaging, Heart and Diabetes Center North Rhine Westphalia, Bad Oeynhausen, University of Bochum, Germany
| | - Hermann Körperich
- Institute for Radiology, Nuclear Medicine and Molecular Imaging, Heart and Diabetes Center North Rhine Westphalia, Bad Oeynhausen, University of Bochum, Germany,Corresponding author at: Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Institut für Radiologie, Nuklearmedizin und Molekulare Bildgebung, Georgstr. 11, 32545 Bad Oeynhausen, Germany.
| | - Elena Weise Valdés
- Institute for Radiology, Nuclear Medicine and Molecular Imaging, Heart and Diabetes Center North Rhine Westphalia, Bad Oeynhausen, University of Bochum, Germany
| | - Vanessa Sciacca
- Clinic for Electrophysiology, Heart and Diabetes Center North Rhine Westphalia, Bad Oeynhausen, University of Bochum, Germany
| | - Lech Paluszkiewicz
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center North-Rhine Westphalia, Ruhr-University of Bochum, Bad Oeynhausen, Germany
| | - Wolfgang Burchert
- Institute for Radiology, Nuclear Medicine and Molecular Imaging, Heart and Diabetes Center North Rhine Westphalia, Bad Oeynhausen, University of Bochum, Germany
| | - Martin Farr
- Cardiogenetic Laboratory, Heart and Diabetes Center North-Rhine Westphalia, Ruhr-University of Bochum, Bad Oeynhausen, Germany
| | - Philipp Sommer
- Clinic for Electrophysiology, Heart and Diabetes Center North Rhine Westphalia, Bad Oeynhausen, University of Bochum, Germany
| | - Christian Sohns
- Clinic for Electrophysiology, Heart and Diabetes Center North Rhine Westphalia, Bad Oeynhausen, University of Bochum, Germany
| | - Misagh Piran
- Institute for Radiology, Nuclear Medicine and Molecular Imaging, Heart and Diabetes Center North Rhine Westphalia, Bad Oeynhausen, University of Bochum, Germany
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Arshad S, Goldberg YH, Bhopalwala H, Dewaswala N, Miceli NS, Birks EJ, Vaidya GN. High Prevalence of Cardiac Amyloidosis in Clinically Significant Aortic Stenosis: A Meta-Analysis. Cardiol Res 2022; 13:357-371. [PMID: 36660066 PMCID: PMC9822671 DOI: 10.14740/cr1436] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 10/28/2022] [Indexed: 12/23/2022] Open
Abstract
Background There is growing evidence of coexistence of aortic stenosis (AS) and transthyretin cardiac amyloidosis (CA). Not screening AS patients at the time of hospital/clinic visit for CA represents a lost opportunity. Methods We surveyed studies that reported the prevalence of CA among AS patients. Studies that compared patients with aortic stenosis with cardiac amyloidosis (AS-CA) and AS alone were further analyzed, and meta-regression was performed. Results We identified nine studies with 1,321 patients of AS, of which 131 patients had concomitant CA, with a prevalence of 11%. When compared to AS-alone, the patients with AS-CA were older, more likely to be males, had higher prevalence of carpal tunnel syndrome, right bundle branch block. On echocardiogram, patients with AS-CA had thicker interventricular septum, higher left ventricular mass index (LVMI), lower myocardial contraction fraction, and lower stroke volume index. Classical low-flow low-gradient (LFLG) physiology was more common among patients with AS-CA. Patients with AS-CA had higher all-cause mortality than patients with AS alone (33% vs. 22%, P = 0.02) in a follow-up period of at least 1 year. Conclusions CA has a high prevalence in patients with AS and is associated with worse clinical, imaging, and biochemical parameters than patients with AS alone.
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Affiliation(s)
- Samiullah Arshad
- Department of Medicine, University of Kentucky, Lexington, KY, USA,Corresponding Author: Samiullah Arshad, Department of Medicine, University of Kentucky, Lexington, KY, USA.
| | | | - Huzefa Bhopalwala
- Department of Medicine, Appalachian Regional Healthcare, Whitesburg, KY, USA
| | - Nakeya Dewaswala
- Division of Cardiology (Advanced Heart Failure and Transplantation), Gill Heart and Vascular Institute, University of Kentucky, Lexington KY, USA
| | - Nicholas S. Miceli
- College of Management, School of Business, Park University, Parkville, MO, USA
| | - Emma J. Birks
- Division of Cardiology (Advanced Heart Failure and Transplantation), Gill Heart and Vascular Institute, University of Kentucky, Lexington KY, USA
| | - Gaurang N. Vaidya
- Division of Cardiology (Advanced Heart Failure and Transplantation), Gill Heart and Vascular Institute, University of Kentucky, Lexington KY, USA
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Cardiovascular Magnetic Resonance Imaging-Based Right Atrial Strain Analysis of Cardiac Amyloidosis. Biomedicines 2022; 10:biomedicines10123004. [PMID: 36551760 PMCID: PMC9775378 DOI: 10.3390/biomedicines10123004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 10/19/2022] [Accepted: 11/14/2022] [Indexed: 11/24/2022] Open
Abstract
Background: Cardiac amyloidosis (CA) manifests in a hypertrophic phenotype with a poor prognosis, making differentiation from hypertrophic cardiomyopathy (HCM) challenging and delaying early treatment. The extent to which magnetic resonance imaging (MRI) quantifies the right atrial strain (RAS) and strain rate (RASR), providing valuable diagnostic information, is not yet clinically established. Aims: This study assesses diagnostic differences in the longitudinal RAS and RASR between CA and HCM patients, control subjects (CTRL) and CA subtypes in addition to the impact of atrial fibrillation (AF) on the right atrial function in CA patients. The RAS and RASR of tricuspid regurgitation (TR) patients are used to assess the potential for diagnostic overlap. Methods: RAS and RASR quantification was conducted via MRI feature-tracking for biopsy-confirmed CA patients with subtypes identified. Strain parameters were compared for CTRL, HCM and TR patients. Post hoc testing identified intergroup differences. Results: In total, 41 CA patients were compared to 47 CTRL, 20 HCM and 31 TR patients. Reservoir (R), conduit and booster RAS and RASRs allow for significant differentiation (p < 0.001) between CA and HCM patients (R: 10.6 ± 14.3% vs. R: 33.5 ± 16.3%) and CTRL (R: 44.6 ± 15.7%). Booster and reservoir RAS and RASRs qualified as reliable diagnostic tests (AUC > 0.8). CA patients with AF, in contrast to sinus rhythm, demonstrated a significantly impaired reservoir RAS and RASR and booster RASR. The discriminative power of RAS for CA vs. TR was insufficient (R: 10.6% ± 14.3% vs. 7.0% ± 6.0%, p = 0.069). Differentiation between 21 transthyretin and 20 light-chain amyloidosis subtypes was not achievable (R: 0.7% ± 1.0% vs. 0.7% ± 1.0%, p = 0.827). Conclusion: The MRI-derived RAS and RASR are impaired in CA patients and may support noninvasive differentiation between CA, HCM and CTRL.
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Eckstein J, Moghadasi N, Körperich H, Weise Valdés E, Sciacca V, Paluszkiewicz L, Burchert W, Piran M. A Machine Learning Challenge: Detection of Cardiac Amyloidosis Based on Bi-Atrial and Right Ventricular Strain and Cardiac Function. Diagnostics (Basel) 2022; 12:2693. [PMID: 36359536 PMCID: PMC9689404 DOI: 10.3390/diagnostics12112693] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 10/23/2022] [Accepted: 11/01/2022] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND This study challenges state-of-the-art cardiac amyloidosis (CA) diagnostics by feeding multi-chamber strain and cardiac function into supervised machine (SVM) learning algorithms. METHODS Forty-three CA (32 males; 79 years (IQR 71; 85)), 20 patients with hypertrophic cardiomyopathy (HCM, 10 males; 63.9 years (±7.4)) and 44 healthy controls (CTRL, 23 males; 56.3 years (IQR 52.5; 62.9)) received cardiovascular magnetic resonance imaging. Left atrial, right atrial and right ventricular strain parameters and cardiac function generated a 41-feature matrix for decision tree (DT), k-nearest neighbor (KNN), SVM linear and SVM radial basis function (RBF) kernel algorithm processing. A 10-feature principal component analysis (PCA) was conducted using SVM linear and RBF. RESULTS Forty-one features resulted in diagnostic accuracies of 87.9% (AUC = 0.960) for SVM linear, 90.9% (0.996; Precision = 94%; Sensitivity = 100%; F1-Score = 97%) using RBF kernel, 84.9% (0.970) for KNN, and 78.8% (0.787) for DT. The 10-feature PCA achieved 78.9% (0.962) via linear SVM and 81.8% (0.996) via RBF SVM. Explained variance presented bi-atrial longitudinal strain and left and right atrial ejection fraction as valuable CA predictors. CONCLUSION SVM RBF kernel achieved competitive diagnostic accuracies under supervised conditions. Machine learning of multi-chamber cardiac strain and function may offer novel perspectives for non-contrast clinical decision-support systems in CA diagnostics.
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Affiliation(s)
- Jan Eckstein
- Institute for Radiology, Nuclear Medicine and Molecular Imaging, Heart and Diabetes Center North-Rhine Westphalia, Ruhr-University of Bochum, 32545 Bad Oeynhausen, Germany
| | - Negin Moghadasi
- Department of Engineering Systems & Environment, University of Virginia, Charlottesville, VA 22904, USA
| | - Hermann Körperich
- Institute for Radiology, Nuclear Medicine and Molecular Imaging, Heart and Diabetes Center North-Rhine Westphalia, Ruhr-University of Bochum, 32545 Bad Oeynhausen, Germany
| | - Elena Weise Valdés
- Institute for Radiology, Nuclear Medicine and Molecular Imaging, Heart and Diabetes Center North-Rhine Westphalia, Ruhr-University of Bochum, 32545 Bad Oeynhausen, Germany
| | - Vanessa Sciacca
- Clinic for Electrophysiology, Heart and Diabetes Center North-Rhine Westphalia, Ruhr-University of Bochum, 32545 Bad Oeynhausen, Germany
| | - Lech Paluszkiewicz
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center North-Rhine Westphalia, Ruhr-University of Bochum, 32545 Bad Oeynhausen, Germany
| | - Wolfgang Burchert
- Institute for Radiology, Nuclear Medicine and Molecular Imaging, Heart and Diabetes Center North-Rhine Westphalia, Ruhr-University of Bochum, 32545 Bad Oeynhausen, Germany
| | - Misagh Piran
- Institute for Radiology, Nuclear Medicine and Molecular Imaging, Heart and Diabetes Center North-Rhine Westphalia, Ruhr-University of Bochum, 32545 Bad Oeynhausen, Germany
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Beyond Sarcomeric Hypertrophic Cardiomyopathy: How to Diagnose and Manage Phenocopies. Curr Cardiol Rep 2022; 24:1567-1585. [PMID: 36053410 DOI: 10.1007/s11886-022-01778-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/20/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE OF REVIEW We describe the most common phenocopies of hypertrophic cardiomyopathy, their pathogenesis, and clinical presentation highlighting similarities and differences. We also suggest a step-by-step diagnostic work-up that can guide in differential diagnosis and management. RECENT FINDINGS In the last years, a wider application of genetic testing and the advances in cardiac imaging have significantly changed the diagnostic approach to HCM phenocopies. Different prognosis and management, with an increasing availability of disease-specific therapies, make differential diagnosis mandatory. The HCM phenotype can be the cardiac manifestation of different inherited and acquired disorders presenting different etiology, prognosis, and treatment. Differential diagnosis requires a cardiomyopathic mindset allowing to recognize red flags throughout the diagnostic work-up starting from clinical and family history and ending with advanced imaging and genetic testing. Different prognosis and management, with an increasing availability of disease-specific therapies make differential diagnosis mandatory.
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Rapezzi C, Aimo A, Barison A, Emdin M, Porcari A, Linhart A, Keren A, Merlo M, Sinagra G. Restrictive cardiomyopathy: definition and diagnosis. Eur Heart J 2022; 43:4679-4693. [PMID: 36269634 PMCID: PMC9712030 DOI: 10.1093/eurheartj/ehac543] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 08/23/2022] [Accepted: 09/16/2022] [Indexed: 01/05/2023] Open
Abstract
Restrictive cardiomyopathy (RCM) is a heterogeneous group of diseases characterized by restrictive left ventricular pathophysiology, i.e. a rapid rise in ventricular pressure with only small increases in filling volume due to increased myocardial stiffness. More precisely, the defining feature of RCM is the coexistence of persistent restrictive pathophysiology, diastolic dysfunction, non-dilated ventricles, and atrial dilatation, regardless of ventricular wall thickness and systolic function. Beyond this shared haemodynamic hallmark, the phenotypic spectrum of RCM is wide. The disorders manifesting as RCM may be classified according to four main disease mechanisms: (i) interstitial fibrosis and intrinsic myocardial dysfunction, (ii) infiltration of extracellular spaces, (iii) accumulation of storage material within cardiomyocytes, or (iv) endomyocardial fibrosis. Many disorders do not show restrictive pathophysiology throughout their natural history, but only at an initial stage (with an evolution towards a hypokinetic and dilated phenotype) or at a terminal stage (often progressing from a hypertrophic phenotype). Furthermore, elements of both hypertrophic and restrictive phenotypes may coexist in some patients, making the classification challenge. Restrictive pathophysiology can be demonstrated by cardiac catheterization or Doppler echocardiography. The specific conditions may usually be diagnosed based on clinical data, 12-lead electrocardiogram, echocardiography, nuclear medicine, or cardiovascular magnetic resonance, but further investigations may be needed, up to endomyocardial biopsy and genetic evaluation. The spectrum of therapies is also wide and heterogeneous, but disease-modifying treatments are available only for cardiac amyloidosis and, partially, for iron overload cardiomyopathy.
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Affiliation(s)
- Claudio Rapezzi
- Corresponding author. Tel: +39 0532239882, Fax: +39 0532 293031,
| | - Alberto Aimo
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, piazza Martiri della Libertà 33, 56127 Pisa, Italy,Cardiology Division, Fondazione Toscana Gabriele Monasterio, via Moruzzi 1, 56124 Pisa, Italy
| | - Andrea Barison
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, piazza Martiri della Libertà 33, 56127 Pisa, Italy,Cardiology Division, Fondazione Toscana Gabriele Monasterio, via Moruzzi 1, 56124 Pisa, Italy
| | - Michele Emdin
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, piazza Martiri della Libertà 33, 56127 Pisa, Italy,Cardiology Division, Fondazione Toscana Gabriele Monasterio, via Moruzzi 1, 56124 Pisa, Italy
| | - Aldostefano Porcari
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Via Giacomo Puccini, 50, 34148 Trieste, Italy
| | - Ales Linhart
- General University Hospital and Charles University, Opletalova 38, 110 00 Staré Město, Czech Republic
| | - Andre Keren
- Cardiology Division, Hadassah Hebrew University Hospital, Sderot Churchill 8, Jerusalem, Israel,Heart Failure Center, Clalit Health Services, Bnei Brit St 22, Jerusalem, Israel
| | - Marco Merlo
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Via Giacomo Puccini, 50, 34148 Trieste, Italy
| | - Gianfranco Sinagra
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Via Giacomo Puccini, 50, 34148 Trieste, Italy
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Cipriani A, De Michieli L, Porcari A, Licchelli L, Sinigiani G, Tini G, Zampieri M, Sessarego E, Argirò A, Fumagalli C, De Gaspari M, Licordari R, Russo D, Di Bella G, Perfetto F, Autore C, Musumeci B, Canepa M, Merlo M, Sinagra G, Gregori D, Iliceto S, Perazzolo Marra M, Cappelli F, Rapezzi C. Low QRS Voltages in Cardiac Amyloidosis. JACC CardioOncol 2022; 4:458-470. [DOI: 10.1016/j.jaccao.2022.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 08/27/2022] [Accepted: 08/28/2022] [Indexed: 02/08/2023] Open
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Argiro' A, Zampieri M, Mazzoni C, Catalucci T, Biondo B, Tomberli A, Gabriele M, Di Mario C, Perfetto F, Cappelli F. Red flags for the diagnosis of cardiac amyloidosis: simple suggestions to raise suspicion and achieve earlier diagnosis. J Cardiovasc Med (Hagerstown) 2022; 23:493-504. [PMID: 35904994 DOI: 10.2459/jcm.0000000000001337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Cardiac amyloidosis is an infiltrative disease characterized by extracellular deposition of insoluble amyloid fibrils in the heart leading to organ dysfunction. Despite recent diagnostic advances, the diagnosis of cardiac amyloidosis is often delayed or even missed. Furthermore, a long diagnostic delay is associated with adverse outcomes, with the early diagnosed patients showing the longest survival. In this narrative review we aimed to summarize the 'red flags' that may facilitate the correct diagnosis. The red flags may be classified as clinical, biohumoral, electrocardiographic, echocardiographic, and cardiac magnetic resonance features and should promptly raise the suspicion of cardiac amyloidosis in order to start a correct diagnostic pathway and targeted treatment strategies that may improve patients' outcomes.
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Affiliation(s)
| | | | | | | | | | | | | | - Carlo Di Mario
- Tuscan Regional Amyloidosis Centre
- Division of Interventional Structural Cardiology, Cardiothoracovascular Department
| | - Federico Perfetto
- Tuscan Regional Amyloidosis Centre
- IV Internal Medicine Division, Careggi University Hospital, Florence, Italy
| | - Francesco Cappelli
- Tuscan Regional Amyloidosis Centre
- Division of Interventional Structural Cardiology, Cardiothoracovascular Department
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Chacko L, Karia N, Venneri L, Bandera F, Dal Passo B, Buonamici L, Lazari J, Ioannou A, Porcari A, Patel R, Razvi Y, Brown J, Knight D, Martinez-Naharro A, Whelan C, Quarta CC, Manisty C, Moon J, Rowczenio D, Gilbertson JA, Lachmann H, Wechelakar A, Petrie A, Moody WE, Steeds RP, Potena L, Riefolo M, Leone O, Rapezzi C, Hawkins PN, Gillmore JD, Fontana M. Progression of echocardiographic parameters and prognosis in ATTR cardiac amyloidosis. Eur J Heart Fail 2022; 24:1700-1712. [PMID: 35779241 PMCID: PMC10108569 DOI: 10.1002/ejhf.2606] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 06/30/2022] [Accepted: 07/01/2022] [Indexed: 11/08/2022] Open
Abstract
AIMS Transthyretin amyloid cardiomyopathy (ATTR-CM) is an increasingly diagnosed disease. Echocardiography is widely utilized, but studies to confirm the value of echocardiography for tracking changes over time are not available. We sought to describe: (1) changes in multiple echocardiographic parameters; (2) differences in rate of progression of three predominant genotypes; and (3) the ability of changes in echocardiographic parameters to predict prognosis. METHODS AND RESULTS We prospectively studied 877 ATTR-CM patients attending our centre between 2000 and 2020. Serial echocardiography findings at baseline, 12-months and 24-months were compared with survival. Five-hundred-and-sixty-five patients had wild-type ATTR-CM and 312 hereditary ATTR-CM (201 with V122I; 90 with T60A).There was progressive worsening of structural and functional parameters over time, patients with V122I ATTR-CM showing more rapid worsening of left and right ventricular structural and functional parameters compared to both wild-type and T60A ATTR-CM. Among a wide range of echocardiographic analyses, including deformation-based parameters, only worsening in the degree of mitral and tricuspid regurgitation (MR and TR) at 12-and 24 month assessments was associated with worse prognosis (change at 12-months: MR, hazard ratio 1.43 (1.14-1.80,p=0.002); TR, hazard ratio 1.38 (1.10-1.75,p=0.006). Worsening in MR remained independently associated with poor prognosis after adjusting for known predictors. CONCLUSION In ATTR-CM, echocardiographic parameters progressively worsen over time. Patients with V122I ATTR-CM demonstrate the most rapid deterioration. Worsening of MR and TR were the only parameters associated with mortality, MR remaining independent after adjusting for known predictors. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Liza Chacko
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Nina Karia
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Lucia Venneri
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Francesco Bandera
- Heart Failure Unit, Cardiology University Department, IRCCS Policlinico San Donato, Piazza Malan, 1, San Donato Milanese, Milan, 20097, Italy.,Department for Biomedical Sciences for Health, University of Milano, Via Luigi, Mangiagalli, 31, Milan, 20133, Italy
| | - Beatrice Dal Passo
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Lodovico Buonamici
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Jonathan Lazari
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Adam Ioannou
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Aldostefano Porcari
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Rishi Patel
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Yousuf Razvi
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - James Brown
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Daniel Knight
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Ana Martinez-Naharro
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Carol Whelan
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Candida C Quarta
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Charlotte Manisty
- Barts Heart Centre, The Cardiovascular Magnetic Resonance Imaging Unit, and the Inherited Cardiovascular Diseases Unit, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK
| | - James Moon
- Barts Heart Centre, The Cardiovascular Magnetic Resonance Imaging Unit, and the Inherited Cardiovascular Diseases Unit, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK
| | - Dorota Rowczenio
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Janet A Gilbertson
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Helen Lachmann
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Ashutosh Wechelakar
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Aviva Petrie
- Eastman Dental Institute, University College London, Grays Inn Road, London, WC1X 8LD, UK
| | - William E Moody
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, B15 2TH, UK
| | - Richard P Steeds
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, B15 2TH, UK
| | - Luciano Potena
- Division of Cardiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Mattia Riefolo
- Division of Pathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Ornella Leone
- Division of Pathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Claudio Rapezzi
- Cardiologic Center, University of Ferrara, Italy.,Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Philip N Hawkins
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Julian D Gillmore
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Marianna Fontana
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
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Antonopoulos AS, Panagiotopoulos I, Kouroutzoglou A, Koutsis G, Toskas P, Lazaros G, Toutouzas K, Tousoulis D, Tsioufis K, Vlachopoulos C. Prevalence and Clinical Outcomes of Transthyretin Amyloidosis: A Systematic Review and Meta-analysis. Eur J Heart Fail 2022; 24:1677-1696. [PMID: 35730461 DOI: 10.1002/ejhf.2589] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 06/10/2022] [Accepted: 06/18/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Systematic evidence on the prevalence and clinical outcome of transthyretin amyloidosis (ATTR) is missing. We explored: a) the prevalence of cardiac amyloidosis in various patient subgroups, b) survival estimates for ATTR subtypes and c) the effects of novel therapeutics on the natural course of disease. METHODS A systematic review of literature published in Medline before 31/12/2021 was performed for the prevalence of cardiac amyloidosis & all-cause mortality of ATTR patients. Extracted data included sample size, age, sex, and all-cause mortality at 1, 2 and 5-years. Subgroup analyses were performed for ATTR subtype i.e., wild type ATTR (wtATTR) vs. hereditary ATTR (htATTR), htATTR genotypes and treatment subgroups. RESULTS We identified a total of 62 studies (n=277,882 individuals) reporting the prevalence of cardiac amyloidosis, which was high among patients with a hypertrophic cardiomyopathy phenotype, HFpEF, and elderly with aortic stenosis. Data on ATTR mortality were extracted from 95 studies (n=18,238 ATTR patients). Patients with wtATTR were older (p=7x10-10 ) and more frequently male (p=5x10-20 ) vs. htATTR. The 2-year survival of ATTR was 73.3% (95%CI 71.6-76.2); for non-subtyped ATTR 70.4% (95%CI 66.9-73.9), for wtATTR (76.0%, 95%CI: 73.0-78.9) and for htATTR (77.2%, 95%CI: 74.0-80.4); in meta-regression analysis wtATTR was associated with higher survival after adjusting for confounders. There was an interaction between survival and htATTR genotypes (p=10-15 , Val30Met having the lowest and Val122Ile/Thr60Ala the highest mortality). ATTR 2-year survival was higher on tafamidis/patisiran compared to natural disease course (79.9%, 95%CI: 74.4-85.3 vs. 72.4%, 95%CI 69.8-74.9, p<0.05). CONCLUSIONS We report the prevalence of ATTR in various population subgroups and provide survival estimates for the natural course of disease and the effects of novel therapeutics. Important gaps in worldwide epidemiology research in ATTR were identified. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Alexios S Antonopoulos
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Ioannis Panagiotopoulos
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Alexandrina Kouroutzoglou
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Georgios Koutsis
- Neurogenetics Unit, 1st Department of Neurology, National and Kapodistrian University of Athens, Eginition University Hospital, Athens, Greece
| | - Pantelis Toskas
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Georgios Lazaros
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Konstantinos Toutouzas
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Dimitris Tousoulis
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Konstantinos Tsioufis
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Charalambos Vlachopoulos
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
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Dohy Z, Szabo L, Pozsonyi Z, Csecs I, Toth A, Suhai FI, Czimbalmos C, Szucs A, Kiss AR, Becker D, Merkely B, Vago H. Potential clinical relevance of cardiac magnetic resonance to diagnose cardiac light chain amyloidosis. PLoS One 2022; 17:e0269807. [PMID: 35696411 PMCID: PMC9191721 DOI: 10.1371/journal.pone.0269807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 05/28/2022] [Indexed: 11/19/2022] Open
Abstract
Background
While patients with cardiac transthyretin amyloidosis are easily diagnosed with bone scintigraphy, the detection of cardiac light chain (AL) amyloidosis is challenging. Cardiac magnetic resonance (CMR) analyses play an essential role in the differential diagnosis of cardiomyopathies; however, limited data are available from cardiac AL-Amyloidosis. Hence, the purpose of the present study was to analyze the potential role of CMR in the detection of cardiac AL-amyloidosis.
Methods
We included 35 patients with proved cardiac AL-amyloidosis and two control groups constituted by 330 patients with hypertrophic cardiomyopathy (HCM) and 70 patients with arterial hypertension (HT), who underwent CMR examination. The phenotype and degree of left ventricular (LV) hypertrophy and the amount and pattern of late gadolinium enhancement (LGE) were evaluated. In addition, global and regional LV strain parameters were also analyzed using feature-tracking techniques. Sensitivity and specificity of several CMR parameters were analyzed in diagnosing cardiac AL-amyloidosis.
Results
The sensitivity and specificity of diffuse septal subendocardial LGE in diagnosing cardiac AL-amyloidosis was 88% and 100%, respectively. Likewise, the sensitivity and specificity of septal myocardial nulling prior to blood pool was 71% and 100%, respectively. In addition, a LV end-diastolic septal wall thickness ≥ 15 mm had an optimal diagnostic performance to differentiate cardiac AL-amyloidosis from HT (sensitivity 91%, specificity 89%). On the other hand, a reduced global LV longitudinal strain (< 15%) plus apical sparing (apex-to-base longitudinal strain > 2) had a very low sensitivity (6%) in detecting AL-Amyloidosis, but with very high specificity (100%).
Conclusions
The findings from this study suggest that CMR could have an optimal diagnostic performance in the diagnosis of cardiac AL-amyloidosis. Hence, further larger studies are warranted to validate the findings from this study.
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Affiliation(s)
- Zsofia Dohy
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Liliana Szabo
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Zoltan Pozsonyi
- Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | - Ibolya Csecs
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Attila Toth
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | | | | | - Andrea Szucs
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Anna Reka Kiss
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - David Becker
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Bela Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Hajnalka Vago
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
- * E-mail:
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48
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Bay K, Gustafsson F, Maiborg M, Bagger‐Bahnsen A, Strand AM, Pilgaard T, Poulsen SH. Suspicion, screening, and diagnosis of wild-type transthyretin amyloid cardiomyopathy: a systematic literature review. ESC Heart Fail 2022; 9:1524-1541. [PMID: 35343098 PMCID: PMC9065854 DOI: 10.1002/ehf2.13884] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 02/11/2022] [Accepted: 02/25/2022] [Indexed: 01/15/2023] Open
Abstract
Wild-type transthyretin amyloid cardiomyopathy (ATTRwt CM) is a more common disease than previously thought. Awareness of ATTRwt CM and its diagnosis has been challenged by its unspecific and widely distributed clinical manifestations and traditionally invasive diagnostic tools. Recent advances in echocardiography and cardiac magnetic resonance (CMR), non-invasive diagnosis by bone scintigraphy, and the development of disease-modifying treatments have resulted in an increased interest, reflected in multiple publications especially during the last decade. To get an overview of the scientific knowledge and gaps related to patient entry, suspicion, diagnosis, and systematic screening of ATTRwt CM, we developed a framework to systematically map the available evidence of (i) when to suspect ATTRwt CM in a patient, (ii) how to diagnose the disease, and (iii) which at-risk populations to screen for ATTRwt CM. Articles published between 2010 and August 2021 containing part of or a full diagnostic pathway for ATTRwt CM were included. From these articles, data for patient entry, suspicion, diagnosis, and screening were extracted, as were key study design and results from the original studies referred to. A total of 50 articles met the inclusion criteria. Of these, five were position statements from academic societies, while one was a clinical guideline. Three articles discussed the importance of primary care providers in terms of patient entry, while the remaining articles had the cardiovascular setting as point of departure. The most frequently mentioned suspicion criteria were ventricular wall thickening (44/50), carpal tunnel syndrome (42/50), and late gadolinium enhancement on CMR (43/50). Diagnostic pathways varied slightly, but most included bone scintigraphy, exclusion of light-chain amyloidosis, and the possibility of doing a biopsy. Systematic screening was mentioned in 16 articles, 10 of which suggested specific at-risk populations for screening. The European Society of Cardiology recommends to screen patients with a wall thickness ≥12 mm and heart failure, aortic stenosis, or red flag symptoms, especially if they are >65 years. The underlying evidence was generally good for diagnosis, while significant gaps were identified for the relevance and mutual ranking of the different suspicion criteria and for systematic screening. Conclusively, patient entry was neglected in the reviewed literature. While multiple red flags were described, high-quality prospective studies designed to evaluate their suitability as suspicion criteria were lacking. An upcoming task lies in defining and evaluating at-risk populations for screening. All are steps needed to promote early detection and diagnosis of ATTRwt CM, a prerequisite for timely treatment.
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Affiliation(s)
- Katrine Bay
- Bay WritingCopenhagenDenmark
- Pfizer DenmarkBallerupDenmark
| | - Finn Gustafsson
- The Heart CenterCopenhagen University Hospital, RigshospitaletCopenhagenDenmark
| | - Michael Maiborg
- Odense Amyloidosis Center & Department of CardiologyOdense University HospitalOdenseDenmark
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Sciacca V, Eckstein J, Körperich H, Fink T, Bergau L, El Hamriti M, Imnadze G, Guckel D, Fox H, Gerçek M, Farr M, Burchert W, Sommer P, Sohns C, Piran M. Magnetic-Resonance-Imaging-Based Left Atrial Strain and Left Atrial Strain Rate as Diagnostic Parameters in Cardiac Amyloidosis. J Clin Med 2022; 11:jcm11113150. [PMID: 35683537 PMCID: PMC9181318 DOI: 10.3390/jcm11113150] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 05/14/2022] [Accepted: 05/29/2022] [Indexed: 01/15/2023] Open
Abstract
Aims: The present study aims to evaluate magnetic-resonance-imaging (MRI)-assessed left atrial strain (LAS) and left atrial strain rate (LASR) as potential parameters for the diagnosis of cardiac amyloidosis (CA), the distinction of clinical subtypes and differentiation from other cardiomyopathies. Methods and results: LAS and LASR were assessed by MRI feature tracking in patients with biopsy-proven CA. LAS and LASR of patients with CA were compared to healthy subjects and patients with hypertrophic cardiomyopathy. LAS and LASR were also analyzed concerning differences between patients with transthyretin (ATTR) and light chain amyloidosis (AL). A total of 44 patients with biopsy-proven CA, 19 patients with hypertrophic cardiomyopathy and 24 healthy subjects were included. In 22 CA patients (50%), histological examination identified ATTR as CA subtype and AL in the remaining patients. No significant difference was observed for reservoir, conduit or booster LAS in patients with AL or ATTR. Reservoir LAS, conduit LAS and booster LAS were significantly reduced in patients with CA and HCM as compared to healthy subjects (p < 0.001). Reservoir LAS and booster LAS were significantly reduced in CA as compared to HCM patients (p < 0.001). A linear correlation was observed between LA global reservoir strain and LA-EF (p < 0.001, r = 0.5), conduit strain and global longitudinal LV strain (p < 0.001, r = 0.5), global booster strain rate and LA-EF (p < 0.001, r = 0.6) and between global booster strain rate and LA area at LVED (p < 0.0001, 0.5). Conclusions: LAS and LASR are severely impaired in patients with CA. The MRI-based assessment of LAS and LASR might allow non-invasive diagnosis and categorization of CA and its distinct differentiation from other hypertrophic phenotypes.
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Affiliation(s)
- Vanessa Sciacca
- Clinic for Electrophysiology, Herz-und Diabeteszentrum NRW, Ruhr-Universität Bochum, 32545 Bad Oeynhausen, Germany; (T.F.); (L.B.); (M.E.H.); (G.I.); (D.G.); (P.S.)
- Correspondence: (V.S.); (C.S.)
| | - Jan Eckstein
- Institute for Radiology, Nuclear Medicine and Molecular Imaging, Herz-und Diabeteszentrum NRW, Ruhr-Universität Bochum, 32545 Bad Oeynhausen, Germany; (J.E.); (H.K.); (W.B.); (M.P.)
| | - Hermann Körperich
- Institute for Radiology, Nuclear Medicine and Molecular Imaging, Herz-und Diabeteszentrum NRW, Ruhr-Universität Bochum, 32545 Bad Oeynhausen, Germany; (J.E.); (H.K.); (W.B.); (M.P.)
| | - Thomas Fink
- Clinic for Electrophysiology, Herz-und Diabeteszentrum NRW, Ruhr-Universität Bochum, 32545 Bad Oeynhausen, Germany; (T.F.); (L.B.); (M.E.H.); (G.I.); (D.G.); (P.S.)
| | - Leonard Bergau
- Clinic for Electrophysiology, Herz-und Diabeteszentrum NRW, Ruhr-Universität Bochum, 32545 Bad Oeynhausen, Germany; (T.F.); (L.B.); (M.E.H.); (G.I.); (D.G.); (P.S.)
| | - Mustapha El Hamriti
- Clinic for Electrophysiology, Herz-und Diabeteszentrum NRW, Ruhr-Universität Bochum, 32545 Bad Oeynhausen, Germany; (T.F.); (L.B.); (M.E.H.); (G.I.); (D.G.); (P.S.)
| | - Guram Imnadze
- Clinic for Electrophysiology, Herz-und Diabeteszentrum NRW, Ruhr-Universität Bochum, 32545 Bad Oeynhausen, Germany; (T.F.); (L.B.); (M.E.H.); (G.I.); (D.G.); (P.S.)
| | - Denise Guckel
- Clinic for Electrophysiology, Herz-und Diabeteszentrum NRW, Ruhr-Universität Bochum, 32545 Bad Oeynhausen, Germany; (T.F.); (L.B.); (M.E.H.); (G.I.); (D.G.); (P.S.)
| | - Henrik Fox
- Clinic for Thoracic and Cardiovascular Surgery, Herz-und Diabeteszentrum NRW, Ruhr-Universität Bochum, 32545 Bad Oeynhausen, Germany;
- Heart Failure Department, Herz-und Diabeteszentrum NRW, Ruhr-Universität Bochum, 32545 Bad Oeynhausen, Germany
| | - Muhammed Gerçek
- Clinic for General and Interventional Cardiology/Angiology, Herz-und Diabeteszentrum, 32545 Bad Oeynhausen, Germany; (M.G.); (M.F.)
| | - Martin Farr
- Clinic for General and Interventional Cardiology/Angiology, Herz-und Diabeteszentrum, 32545 Bad Oeynhausen, Germany; (M.G.); (M.F.)
| | - Wolfgang Burchert
- Institute for Radiology, Nuclear Medicine and Molecular Imaging, Herz-und Diabeteszentrum NRW, Ruhr-Universität Bochum, 32545 Bad Oeynhausen, Germany; (J.E.); (H.K.); (W.B.); (M.P.)
| | - Philipp Sommer
- Clinic for Electrophysiology, Herz-und Diabeteszentrum NRW, Ruhr-Universität Bochum, 32545 Bad Oeynhausen, Germany; (T.F.); (L.B.); (M.E.H.); (G.I.); (D.G.); (P.S.)
| | - Christian Sohns
- Clinic for Electrophysiology, Herz-und Diabeteszentrum NRW, Ruhr-Universität Bochum, 32545 Bad Oeynhausen, Germany; (T.F.); (L.B.); (M.E.H.); (G.I.); (D.G.); (P.S.)
- Correspondence: (V.S.); (C.S.)
| | - Misagh Piran
- Institute for Radiology, Nuclear Medicine and Molecular Imaging, Herz-und Diabeteszentrum NRW, Ruhr-Universität Bochum, 32545 Bad Oeynhausen, Germany; (J.E.); (H.K.); (W.B.); (M.P.)
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50
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Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2022; 145:e895-e1032. [PMID: 35363499 DOI: 10.1161/cir.0000000000001063] [Citation(s) in RCA: 635] [Impact Index Per Article: 317.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
AIM The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure. METHODS A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines Liaison
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