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Liang S, Liu Z, Li Q, He W, Huang H. Advance of echocardiography in cardiac amyloidosis. Heart Fail Rev 2023; 28:1345-1356. [PMID: 37558934 PMCID: PMC10575814 DOI: 10.1007/s10741-023-10332-3] [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] [Accepted: 07/04/2023] [Indexed: 08/11/2023]
Abstract
Cardiac amyloidosis (CA) occurs when the insoluble fibrils formed by misfolded precursor proteins deposit in cardiac tissues. The early clinical manifestations of CA are not evident, but it is easy to progress to refractory heart failure with an inferior prognosis. Echocardiography is the most commonly adopted non-invasive modality of imaging to visualize cardiac structures and functions, and the preferred modality in the evaluation of patients with cardiac symptoms and suspected CA, which plays a vital role in the diagnosis, prognosis, and long-term management of CA. The present review summarizes the echocardiographic manifestations of CA, new echocardiographic techniques, and the application of multi-parametric echocardiographic models in CA diagnosis.
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Affiliation(s)
- Shichu Liang
- Department of Cardiology, West China Hospital, Sichuan University, No. 37 GuoXue Alley, Chengdu, 610041, China
| | - Zhiyue Liu
- Department of Cardiology, West China Hospital, Sichuan University, No. 37 GuoXue Alley, Chengdu, 610041, China
| | - Qian Li
- Department of Cardiology, West China Hospital, Sichuan University, No. 37 GuoXue Alley, Chengdu, 610041, China
| | - Wenfeng He
- Department of Cardiology, West China Hospital, Sichuan University, No. 37 GuoXue Alley, Chengdu, 610041, China
| | - He Huang
- Department of Cardiology, West China Hospital, Sichuan University, No. 37 GuoXue Alley, Chengdu, 610041, China.
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Wali E, Gruca M, Singulane C, Cotella J, Guile B, Johnson R, Mor-Avi V, Addetia K, Lang RM. How Often Does Apical Sparing of Longitudinal Strain Indicate the Presence of Cardiac Amyloidosis? Am J Cardiol 2023; 202:12-16. [PMID: 37413701 DOI: 10.1016/j.amjcard.2023.06.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 06/02/2023] [Accepted: 06/06/2023] [Indexed: 07/08/2023]
Abstract
Echocardiographic diagnosis of cardiac amyloidosis (CA) is frequently suggested by the presence of a left ventricular (LV) apical sparing pattern (ASP) on longitudinal strain (LS) assessment, the so-called "cherry on top" pattern, defined by strain magnitude preserved exclusively at the apex. However, it is unclear how frequently this strain pattern truly represents CA. This study aimed to evaluate the predictive value of ASP in the diagnosis of CA. We retrospectively identified consecutive adult patients who had the following studies performed within an 18-month period: (1) transthoracic echocardiogram and (2) either (a) cardiac magnetic resonance imaging, (b) Technetium-Pyrophosphate (PYP) imaging, or (c) endomyocardial biopsy. LS was retrospectively measured in the apical 4-, 3-, and 2-chamber views in patients who had adequate noncontrast images (n = 466). An apical sparing ratio (ASR) was calculated as (average apical strain)/[(average basal strain) + (average midventricular strain)]. Patients with ASR ≥1 were evaluated for the presence/absence of CA, using established criteria. Basic LV parameters were also measured. A total of 33 patients (7.1%) had ASP. Nine of these patients (27%) had "confirmed" CA, 2 (6.1%) "highly probable" CA, 1 (3.0%) "possible" CA, and 21 (64%) no evidence of CA. When comparing patients with and without confirmed CA, there were no significant differences in ASR, average global LS, ejection fraction, or LV mass. Patients with confirmed CA were older (76 ± 9 vs 59 ± 18 years, p = 0.01) and had thicker posterior wall (15 ± 3 vs 11 ± 3 mm, p = 0.004) with a trend toward thicker septal wall (15 ± 2 vs 12 ± 4 mm, p = 0.05). In conclusion, the presence of ASP on LS represents confirmed or highly probable CA in only 1/3 of patients and is more likely to indicate true CA in older patients with increased LV wall thickness. Although a larger, prospective study is needed to confirm these findings, 1/3 should be considered as a large diagnostic yield that justifies further testing, given the poor outcomes associated with CA diagnosis.
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Affiliation(s)
- Eisha Wali
- Department of Medicine, Section of Cardiology, The University of Chicago Medical Center, Chicago, Illinois
| | - Martin Gruca
- Department of Medicine, Section of Cardiology, The University of Chicago Medical Center, Chicago, Illinois
| | - Cristiane Singulane
- Department of Medicine, Section of Cardiology, The University of Chicago Medical Center, Chicago, Illinois
| | - Juan Cotella
- Department of Medicine, Section of Cardiology, The University of Chicago Medical Center, Chicago, Illinois
| | - Brittney Guile
- Department of Medicine, Section of Cardiology, The University of Chicago Medical Center, Chicago, Illinois
| | - Roydell Johnson
- Department of Medicine, Section of Cardiology, The University of Chicago Medical Center, Chicago, Illinois
| | - Victor Mor-Avi
- Department of Medicine, Section of Cardiology, The University of Chicago Medical Center, Chicago, Illinois
| | - Karima Addetia
- Department of Medicine, Section of Cardiology, The University of Chicago Medical Center, Chicago, Illinois
| | - Roberto M Lang
- Department of Medicine, Section of Cardiology, The University of Chicago Medical Center, Chicago, Illinois.
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Ferkh A, Tjahjadi C, Stefani L, Geenty P, Byth K, De Silva K, Boyd AC, Richards D, Mollee P, Korczyk D, Taylor MS, Kwok F, Kizana E, Ng ACT, Thomas L. Cardiac "hypertrophy" phenotyping: differentiating aetiologies with increased left ventricular wall thickness on echocardiography. Front Cardiovasc Med 2023; 10:1183485. [PMID: 37465456 PMCID: PMC10351962 DOI: 10.3389/fcvm.2023.1183485] [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: 03/10/2023] [Accepted: 06/15/2023] [Indexed: 07/20/2023] Open
Abstract
Aims Differentiating phenotypes of cardiac "hypertrophy" characterised by increased wall thickness on echocardiography is essential for management and prognostication. Transthoracic echocardiography is the most commonly used screening test for this purpose. We sought to identify echocardiographic markers that distinguish infiltrative and storage disorders that present with increased left ventricular (LV) wall thickness, namely, cardiac amyloidosis (CA) and Anderson-Fabry disease (AFD), from hypertensive heart disease (HHT). Methods Patients were retrospectively recruited from Westmead Hospital, Sydney, and Princess Alexandra Hospital, Brisbane. LV structural, systolic, and diastolic function parameters, as well as global (LVGLS) and segmental longitudinal strains, were assessed. Previously reported echocardiographic parameters including relative apical sparing ratio (RAS), LV ejection fraction-to-strain ratio (EFSR), mass-to-strain ratio (MSR) and amyloidosis index (AMYLI) score (relative wall thickness × E/e') were evaluated. Results A total of 209 patients {120 CA [58 transthyretin amyloidosis (ATTR) and 62 light-chain (AL) amyloidosis], 31 AFD and 58 HHT patients; mean age 64.1 ± 13.7 years, 75% male} comprised the study cohort. Echocardiographic measurements differed across the three groups, The LV mass index was higher in both CA {median 126.6 [interquartile range (IQR) 106.4-157.9 g/m2]} and AFD [median 134 (IQR 108.8-152.2 g/m2)] vs. HHT [median 92.7 (IQR 79.6-102.3 g/m2), p < 0.05]. LVGLS was lowest in CA [median 12.29 (IQR 10.33-15.56%)] followed by AFD [median 16.92 (IQR 14.14-18.78%)] then HHT [median 18.56 (IQR 17.51-19.97%), p < 0.05]. Diastolic function measurements including average e' and E/e' were most impaired in CA and least impaired in AFD. Indexed left atrial volume was highest in CA. EFSR and MSR differentiated secondary (CA + AFD) from HHT [receiver operating curve-area under the curve (ROC-AUC) of 0.80 and 0.91, respectively]. RAS and AMYLI score differentiated CA from AFD (ROC-AUC of 0.79 and 0.80, respectively). A linear discriminant analysis with stepwise variable selection using linear combinations of LV mass index, average e', LVGLS and basal strain correctly classified 79% of all cases. Conclusion Simple echocardiographic parameters differentiate between different "hypertrophic" cardiac phenotypes. These have potential utility as a screening tool to guide further confirmatory testing.
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Affiliation(s)
- Aaisha Ferkh
- Westmead Clinical School, University of Sydney, Westmead, NSW, Australia
- Cardiology Department, Westmead Hospital, Westmead, NSW, Australia
| | - Catherina Tjahjadi
- Cardiology Department, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Luke Stefani
- Westmead Clinical School, University of Sydney, Westmead, NSW, Australia
- Cardiology Department, Westmead Hospital, Westmead, NSW, Australia
| | - Paul Geenty
- Westmead Clinical School, University of Sydney, Westmead, NSW, Australia
- Cardiology Department, Westmead Hospital, Westmead, NSW, Australia
| | - Karen Byth
- WSLHD Research and Education Network, Westmead Hospital, Westmead, NSW, Australia
| | - Kasun De Silva
- Westmead Clinical School, University of Sydney, Westmead, NSW, Australia
- Cardiology Department, Westmead Hospital, Westmead, NSW, Australia
| | - Anita C. Boyd
- Westmead Private Cardiology, Westmead, NSW, Australia
| | | | - Peter Mollee
- Haematology Department, Princess Alexandra Hospital, Brisbane, QLD, Australia
- School of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Dariusz Korczyk
- Cardiology Department, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Mark S. Taylor
- Department of Clinical Immunology and Allergy, Westmead Hospital, Westmead, NSW, Australia
| | - Fiona Kwok
- Haematology Department, Westmead Hospital, Westmead, NSW, Australia
| | - Eddy Kizana
- Westmead Clinical School, University of Sydney, Westmead, NSW, Australia
- Cardiology Department, Westmead Hospital, Westmead, NSW, Australia
- Centre for Heart Research, The Westmead Institute for Medical Research, Westmead, NSW, Australia
| | - Arnold C. T. Ng
- Cardiology Department, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Liza Thomas
- Westmead Clinical School, University of Sydney, Westmead, NSW, Australia
- Cardiology Department, Westmead Hospital, Westmead, NSW, Australia
- South-West Clinical School, University of New South Wales, Liverpool, NSW, Australia
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Kis M, Dogan Y, Yildirim A, Güzel T, Bekar L, Akhan O, Dogdus M, Harbalıoğlu H, Karabulut D, Soydan E, Zoghi M, Ergene O. Evaluation of demographic, clinical, and aetiological data of patients admitted to cardiology clinics and diagnosed with left ventricular hypertrophy in Turkish population (LVH-TR). Acta Cardiol 2022; 77:836-845. [PMID: 36222672 DOI: 10.1080/00015385.2022.2119670] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Left ventricular hypertrophy (LVH) is potentially modifiable cardiovascular risk factor often overlooked in clinical practice. For this reason, we planned to LVH-TR (Left Ventricular Hypertrophy in Turkish Population) trial to determine the aetiological causes and demographic characteristics of LVH patients. METHODS Our study was a multicentre, national, observational study and included 886 patients who applied to the cardiology clinics in 22 centres between February 2020 and August 2021. In the initial evaluation, the Fabry disease (FD) and cardiac amyloidosis (CA) algorithm was followed in patients whose definitive etiologic cause(s) could not be identified. RESULTS The most common aetiological causes of LVH in our study were hypertension with a rate of 56.6%, heart valve disease with 8.2%, and hypertrophic cardiomyopathy with 7.5%. Athlete's heart was detected in eight patients, LV non-compaction was detected in four patients. The rate of LVH of unknown cause was 18.8%. FD was suspected in 143 patients, and CA was suspected in 16 patients. There were 43 (4.85%) patients with low α-galactosidase A enzyme levels. GLA gene mutation analysis was positive in 1.58% of all patients, and these patients were diagnosed with FD, and 15 (1.69%) patients were diagnosed with CA by endomyocardial biopsy method. CONCLUSION In the aetiology of LVH, the rate of LVH of unknown cause was high. FD and CA should be considered primarily in this patient group. Early diagnosis of the disease by following the schemes leading to FD and CA was essential in starting treatment before the progression of the disease.
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Affiliation(s)
- Mehmet Kis
- Department of Cardiology, Dokuz Eylul University, Izmir, Turkey
| | - Yasemin Dogan
- Department of Cardiology, Kayseri City Hospital, Kayseri, Turkey
| | - Abdullah Yildirim
- Department of Cardiology, Adana City Training and Research Hospital, Adana, Turkey
| | - Tuncay Güzel
- Department of Cardiology, Akhisar State Hospital, Manisa, Turkey
| | - Lutfu Bekar
- Department of Cardiology, Hitit University Faculty of Medicine, Corum, Turkey
| | - Onur Akhan
- Department of Cardiology, Bilecik State Hospital, Bilecik, Turkey
| | - Mustafa Dogdus
- Department of Cardiology, Usak University Training and Research Hospital, Usak, Turkey
| | - Hazar Harbalıoğlu
- Department of Cardiology, Düzce Atatürk State Hospital, Duzce, Turkey
| | - Dilay Karabulut
- Department of Cardiology, Bakırkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Elton Soydan
- Department of Cardiology, EGE University, Izmir, Turkey
| | - Mehdi Zoghi
- Department of Cardiology, EGE University, Izmir, Turkey
| | - Oktay Ergene
- Department of Cardiology, Dokuz Eylul University, Izmir, Turkey
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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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