Valve disease in cardiac amyloidosis: an echocardiographic score

Cardiac amyloidosis (CA) may affect all cardiac structures, including the valves. From 423 patients undergoing a diagnostic workup for CA we selected 2 samples of 20 patients with amyloid transthyretin (ATTR-) or light-chain (AL-) CA, and age- and sex-matched controls. We chose 31 echocardiographic items related to the mitral, aortic and tricuspid valves, giving a value of 1 to each abnormal item. Patients with ATTR-CA displayed more often a shortened/hidden and restricted posterior mitral valve leaflet (PMVL), thickened mitral chordae tendineae and aortic stenosis than those with AL-CA, and less frequent PMVL calcification than matched controls. Score values were 15.8 (13.6-17.4) in ATTR-CA, 11.0 (9.3-14.9) in AL-CA, 12.8 (11.1-14.4) in ATTR-CA controls, and 11.0 (9.1-13.0) in AL-CA controls (p = 0.004 for ATTR- vs. AL-CA, 0.009 for ATTR-CA vs. their controls, and 0.461 for AL-CA vs. controls). Area under the curve values to diagnose ATTR-CA were 0.782 in patients with ATTR-CA or matched controls, and 0.773 in patients with LV hypertrophy. Patients with ATTR-CA have a prominent impairment of mitral valve structure and function, and higher score values. The valve score may help identify patients with ATTR-CA among patients with CA or unexplained hypertrophy.

N-terminal pro-B-type natriuretic peptide and high-sensitivity troponin T hold diagnostic value in cardiac amyloidosis

AIMS

Cardiac amyloidosis (CA) is associated with an elevation of natriuretic peptides and troponins, predicting outcome. Nevertheless, the diagnostic yield of these biomarkers has not been extensively investigated. This study aimed to evaluate the diagnostic performance for CA of N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity troponin T (hs-TnT).

METHODS AND RESULTS

Patients with suspected CA (n = 1149) underwent a diagnostic work-up in three centres in Italy, France (n = 343, derivation cohort), and United Kingdom (n = 806, validation cohort). Biomarker values with either 100% sensitivity or ≥95% specificity were selected as rule-out/rule-in cut-offs, respectively. In the derivation cohort, 227 patients (66%) had CA, and presented with higher NT-proBNP and hs-TnT. NT-proBNP 180 ng/L and hs-TnT 14 ng/L were selected as rule-out cut-offs, and hs-TnT 86 ng/L as rule-in cut-off. NT-proBNP <180 ng/L or hs-TnT <14 ng/L were found in 7% of patients, and ruled out CA without false negatives. In the validation cohort, 20% of patients (2% false negatives) had NT-proBNP <180 ng/L or hs-TnT <14 ng/L, and 10% showed both biomarkers below cut-offs (0.5% false negatives). These cut-offs refined CA prediction when added to echocardiographic scores in patients with a haematologic disease or an increased wall thickness. In the validation cohort, the 86 ng/L hs-TnT cut-off ruled in 20% of patients (2% false positives). NT-proBNP and hs-TnT cut-offs retained their rule-out and rule-in performance also in cohorts with CA prevalence of 20%, 10%, 5% and 1% derived from the original cohort through bootstrap analysis.

CONCLUSIONS

Cardiac biomarkers can refine the diagnostic algorithm in patients with suspected CA. NT-proBNP <180 ng/L and hs-TnT <14 ng/L reliably exclude the diagnosis, both in the overall population and subgroups referred for either AL-CA or cardiac (pseudo)hypertrophy.

Multi-chamber speckle tracking imaging and diagnostic value of left atrial strain in cardiac amyloidosis

AIMS

Cardiac amyloidosis (CA) affects the four heart chambers, which can all be evaluated through speckle-tracking echocardiography (STE).

METHODS AND RESULTS

We evaluated 423 consecutive patients screened for CA over 5 years at two referral centres. CA was diagnosed in 261 patients (62%) with either amyloid transthyretin (ATTR; n = 144, 34%) or amyloid light-chain (AL; n = 117, 28%) CA. Strain parameters of all chambers were altered in CA patients, particularly those with ATTR-CA. Nonetheless, only peak left atrial longitudinal strain (LA-PALS) displayed an independent association with the diagnosis of CA or ATTR-CA beyond standard echocardiographic variables and cardiac biomarkers (Model 1), or with the diagnosis of ATTR-CA beyond the validated IWT score in patients with unexplained left ventricular (LV) hypertrophy. Patients with the most severe impairment of LA strain were those most likely to have CA or ATTR-CA. Specifically, LA-PALS and/or LA-peak atrial contraction strain (PACS) in the first quartile (i.e. LA-PALS <6.65% and/or LA-PACS <3.62%) had a 3.60-fold higher risk of CA, and a 3.68-fold higher risk of ATTR-CA beyond Model 1. Among patients with unexplained LV hypertrophy, those with LA-PALS or LA-PACS in the first quartile had an 8.76-fold higher risk for CA beyond Model 1, and a 2.04-fold higher risk of ATTR-CA beyond the IWT score.

CONCLUSIONS

Among STE measures of the four chambers, PALS and PACS are the most informative ones to diagnose CA and ATTR-CA. Patients screened for CA and having LA-PALS and/or LA-PACS in the first quartile have a high likelihood of CA and ATTR-CA.

490 NT-PROBNP AND HIGH-SENSITIVITY TROPONIN T HOLD DIAGNOSTIC VALUE IN CARDIAC AMYLOIDOSIS

Background

Cardiac amyloidosis (CA) is associated with an elevation of natriuretic peptides and troponins, predicting outcome. Nevertheless, the diagnostic yield of these biomarkers has not been extensively investigated.

Aim

To evaluate the diagnostic performance for CA of N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity troponin T (hs-TnT).

Methods

Patients with suspected CA (n=1,149) underwent a diagnostic work-up in 3 Centers in Italy, France (n=343, derivation cohort), and United Kingdom (n=806, validation cohort). Biomarker values with either 100% sensitivity or ≥95% specificity were selected as rule-out/rule-in cut-offs, respectively.

Results

In the derivation cohort, 227 patients (66%) had CA, and presented with higher NT-proBNP and hs-TnT. NT-proBNP 180 ng/L and hs-TnT 14 ng/L were selected as rule-out cut-offs, and hs-TnT 86 ng/L as rule-in cut-off. NT-proBNP &lt;180 ng/L or hs-TnT &lt;14 ng/L were found in 7% of patients, ruled out without false negatives. In the validation cohort, 20% of patients (2% false negatives) had NT-proBNP &lt;180 ng/L or hs-TnT &lt;14 ng/L, and 10% showed both biomarkers below cut-offs (0.5% false negatives). These cut-offs refined CA prediction when added to echocardiographic scores in patients with a hematologic disease or an increased wall thickness. In the validation cohort, the 86 ng/L hs-TnT cut-off ruled in 20% of patients (2% false positives).

Conclusions

Cardiac biomarkers can refine the diagnostic algorithm in patients with suspected CA. NT-proBNP &lt;180 ng/L and hs-TnT &lt;14 ng/L reliably exclude the diagnosis (Figure), both in the overall population and subgroups referred for either AL-CA or cardiac (pseudo)hypertrophy.

Prognostic impact of echocardiographic derived precapillary wedge pressure and pulmonary vascular resistances in patients with heart failure

Background

A reliable echocardiographic algorithm for the estimation of precapillary wedge pressure (PCWP) and pulmonary vascular resistances (PVR) has been recently validated by our group in a large cohort of patients undergoing right heart catheterization (RHC) (1). Those metrics may add relevant clinical and prognostic information in patients with heart failure (HF).

Objective

To assess the clinical/prognostic significance of echocardiographic derived PCWP and PVR in a large cohort of chronic HF patients on modern treatments.

Methods

Outpatients with chronic HF with either reduced (≤40%) or mildly reduced LVEF (41–49%) underwent a thorough clinical multiparametric assessment and were followed-up for a composite endpoint of cardiac death, appropriate ICD shock, or first HF hospitalization.

Results

Out of 1,483 patients prospectively enrolled (70±12 years, 73% males, 42% ischemic etiology, LVEF 35±8%), PCWP (16.4±5.8 mmHg) was elevated (&gt;15 mmHg) in 53% of cases, while PVR (1.7±0.7) was elevated (&gt;3 WU) in 6% of cases. Of the latter group, most (92%) had also elevated PCWP. Patients with increased PCWP were older, had a higher heart rate and lower cardiac output, showed a higher degree of left and right chamber remodeling, had a higher neurohormonal activation, worse renal function, worse functional capacity and ventilatory efficiency on effort (all p&lt;0.001). Those patients with high PCWP and PVR showed higher heart rate and pulmonary pressures, lower cardiac output, and right ventricular function, higher neurohormonal activation, lower functional capacity and ventilatory efficiency on effort compared to patients with high PCWP but normal PVR (all p&lt;0.01). The optimal prognostic cut-point was identified for both PCWP (16.2 mmHg) and PVR (2 WU) by log-rank maximal likelihood ratio. Over a median follow-up of 22 (8–37) months, both measures significantly stratified patients for the risk of the primary endpoint at Kaplan-Meier analysis (log-rank 92.9, p&lt;0.001 for PCWP; log-rank 17.3, p&lt;0.001 for PVR). At multivariable Cox regression analysis (adjusted for age, sex, ischemic HF etiology, renal function, LVEF, and NT-proBNP), PCWP (hazard ratio, HR 1.77 [95% CI 1.30–2.40], p&lt;0.001) but not PVR (HR 1.15 [95% CI 0.88–1.51], p=0.31) remained an independent predictor of the primary outcome.

Conclusion

The estimation of PCWP and PVR by echocardiography add relevant clinical and prognostic information and may help in the decision making in patients with HF.

Funding Acknowledgement

Type of funding sources: None.

Valve disease in cardiac amyloidosis: an echocardiographic score

Background

Cardiac amyloidosis (CA) may affect all cardiac structures, including the valves.

Methods

From 423 patients undergoing a diagnostic workup for CA we selected 2 samples of 20 patients with amyloid transthyretin (ATTR-) or light-chain (AL-) CA, and age- and sex-matched controls. We chose 31 echocardiographic items related to the mitral, aortic and tricuspid valves, giving a value of 1 to each abnormal item.

Results

Patients with ATTR-CA displayed more often a shortened/hidden and restricted posterior mitral valve leaflet (PMVL), thickened mitral chordae tendineae and aortic stenosis than those with AL-CA, and less frequent PMVL calcification than matched controls. Score values were 15.8 (13.6–17.4) in ATTR-CA, 11.0 (9.3–14.9) in AL-CA, 12.8 (11.1–14.4) in ATTR-CA controls, and 11.0 (9.1–13.0) in AL-CA controls (p=0.004 for ATTR- vs. AL-CA, 0.009 for ATTR-CA vs. their controls, and 0.461 for AL-CA vs. controls). Area under the curve values to diagnose ATTR-CA were 0.782 in patients with ATTR-CA or matched controls, and 0.773 in patients with LV hypertrophy.

Conclusions

Patients with ATTR-CA have a prominent impairment of mitral valve structure and function, and higher score values. The valve score is quite effective in identifying patients with ATTR-CA among patients with CA or unexplained hypertrophy.

Funding Acknowledgement

Type of funding sources: None.

Clinical and prognostic significance of left ventricular outflow tract velocity time integral (LVOT-VTI) in patients with chronic heart failure

Background

The echocardiographic evaluation of cardiac output relies on the product of the flow across the left ventricular outflow tract (LVOT), estimated through its velocity time integral (LVOT-VTI), and its cross-sectional area, estimated through the formula πr2. Considering the geometrical assumption behind such formula, LVOT-VTI has been proposed as a more reproducible surrogate of cardiac systolic function and showed prognostic value in the critical care setting. However, the role of such measure in patients with chronic heart failure (HF) remains unexplored.

Objective

To assess the clinical and prognostic significance of LVOT-VTI in a contemporary cohort of patients with chronic HF.

Methods

Outpatients with chronic HF with a LV ejection fraction &lt;50% were prospectively enrolled to undergo a clinical, echocardiographic, and biohumoral assessment, and were followed-up for the endpoint of all-cause death.

Results

Finally, 971 patients were enrolled (71±12 years, 72% men, 50% ischemic etiology, LVEF 35±9%). Most patients showed a NYHA class I-II (74%) and were treated with ACE-inhibitors/ARBs or ARNI (81%), beta-blockers (95%), and mineralocorticoid receptor antagonists (71%). Patients were distinguished in three subgroups according to LVOT-VTI tertiles &lt;19 (n=324), 19–24 (n=324), or ≥24 (n=323). Compared with the other two subgroups, patients with LVOT-VTI &lt;19 showed worse NYHA class, lower LVEF and tricuspid annular plane systolic excursion (TAPSE), and higher E/e', left atrial volume index (LAVi), estimated systolic pulmonary arterial pressure (sPAP), and NT-proBNP concentration (all p&lt;0.001). No differences were observed as for patients' age, HF etiology, and therapies (all p&gt;0.05). Over a median follow-up of 22 (9–34) months, 103 (11%) patients met the primary endpoint. LVOT-VTI significantly stratified the risk of death, observing 65 (20%), 21 (7%), and 17 (5%) events across the subgroups with values &lt;19, 19–24, or ≥24 (log-rank 33, p&lt;0.001). At multivariable regression analysis, LVOT-VTI &lt;19 (HR 2.06 [95% 1.21–3.49], p=0.008), but not LVEF &lt;30% (p=0.614) was an independent predictor of all-cause death in a model adjusted for age, sex, ischemic etiology, renal function, hemoglobin, E/e', LAVi, TAPSE, sPAP, and NT-proBNP.

Conclusion

LVOT-VTI is associated with disease severity and is a strong predictor of all-cause death in patients with chronic HF.

Funding Acknowledgement

Type of funding sources: None.

Haemodynamic forces as predictors of cardiac remodelling and outcome in heart failure with reduced ejection fraction treated with sacubitril/valsartan

Background

Angiotensin receptor-neprilysin inhibitor (ARNI) is a cornerstone of treatment in heart failure (HF) with reduced ejection fraction (HFrEF), but its effectiveness shows interindividual differences.

Objectives

To evaluate the predictive value of echo-derived hemodynamic forces (HDF), together with other echocardiographic, biohumoral and cardiopulmonary parameters on a) response to ARNI after 6 months; b) adverse cardiovascular events at follow-up.

Methods

Eighty-nine consecutive HFrEF patients from two HF centers performed clinical evaluation, laboratory analyses, rest echocardiography and cardiopulmonary exercise testing. Response to ARNI at 6 months was considered in patients without HF admissions, death, or urgent heart transplant and with a ≥50% reduction in NT-proBNP levels and/or ≥10% increase in left ventricle ejection fraction. After 6 months, patients were followed up for a composite endpoint of cardiovascular death, HF-related hospitalization and new-onset atrial fibrillation.

Results

Response to ARNI was documented in 45/89 (51%) of patients. At baseline, responders and non-responders were paired in clinical assessment, conventional echocardiography, functional status and therapy. At multivariate logistic regression analysis, HDF-derived whole cardiac cycle left ventricle strength (wLVS) was the only independent predictor of ARNI response at 6 months (odds ratio 1.36, 95% confidence interval 1.10–1.67; p=0.004). A wLVS ≥3.7% showed a good accuracy in predicting ARNI response (AUC = 0.736, 0.607–0.840; p&lt;0.0001). During a median of 33 (IQR 23–41) months, wLVS increase from baseline to 6-month (ΔwLVS) showed a high discrimination ability at time-dependent ROC analysis (optimal cut-off: ≤0.5%; AUC=0.811, 0.69–0.90; p&lt;0.0001), stratified prognosis at Kaplan-Meier analysis (log-rank p&lt;0.0001), and remained an independent prognostic predictor of the composite endpoint (hazard ratio 0.76, 0.61–0.95; p&lt;0.01) even after adjusting for clinical, functional and conventional echocardiographic parameters.

Conclusions

HDF analysis may help predict ARNI response and optimize follow-up and medical/device strategies in patients with HfrEF.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Fondazione Toscana Gabriele Monasterio, Pisa, Italy

C42 MULTI–CHAMBER SPECKLE TRACKING IMAGING AND DIAGNOSTIC VALUE OF LEFT ATRIAL STRAIN IN CARDIAC AMYLOIDOSIS

Background

Amyloid deposits in all cardiac chambers, impairing their function. We investigated for the first time if a speckle–tracking echocardiography (STE) analysis extended to all 4 chambers might hold additive diagnostic value for CA and its subtypes (amyloid transthyretin [ATTR–] and light–chain [AL]–CA).

Methods

We evaluated 423 consecutive patients undergoing a diagnostic workup for CA in 2 referral centres from 2015 to 2020.

Results

CA was diagnosed in 261 patients (62%; ATTR–CA, n = 144, 34%; AL–CA, n = 117, 28%). Patients with CA had an impaired function of all cardiac chambers, particularly those with ATTR–CA. Peak left atrial longitudinal strain (LA–PALS) was the only STE parameter that predicted CA and ATTR–CA independent of laboratory and standard echocardiographic variables (Model 1). It also predicted ATTR–CA among patients with unexplained hypertrophy regardless of a diagnostic score (IWT score). Patients with either LA–PALS or LA–peak atrial contraction strain (PACS) in the first quartile (LA–PALS &lt;6.65% or LA–PACS &lt;3.62%) had an almost 4–fold higher likelihood of CA and ATTR–CA regardless of Model 1. Among patients with unexplained hypertrophy, those with LA–PALS or LA–PACS in the first quartile had an almost 9–fold higher likelihood of ATTR–CA irrespective of Model 1, and a 2–fold higher likelihood of ATTR–CA beyond the IWT score.

Conclusions

STE measures of all 4 chambers are abnormal in patients with CA, particularly in those with ATTR–CA. LA strain holds independent diagnostic significance. Among patients screened for CA, those with LA–PALS &lt;6.65% and/or LA–PACS &lt;3.62% have a high likelihood of CA and ATTR–CA.

P294 AN ECHOCARDIOGRAPHIC SCORE OF VALVE DISEASE IN PATIENTS WITH CARDIAC AMYLOIDOSIS

Background

Cardiac amyloidosis (CA) affects all cardiac structures, including the valves. We summarized the echocardiographic features of valve disease in a score.

Methods

From 423 patients undergoing a diagnostic workup for CA we selected 2 samples of 20 patients with amyloid transthyretin (ATTR–) or light–chain (AL–) CA, and selected age– and sex–matched controls. The Amyloid VAlve (AVA) score included 31 items related to the mitral, aortic and tricuspid valves (which can be properly assessed in standard echocardiograms), with a value of 1 for each abnormal item.

Results

Patients with ATTR–CA displayed more often a shortened/hidden and retracted posterior mitral valve leaflet (PMVL), thickened mitral chordae tendineae and aortic stenosis than those with AL–CA, and less frequent PMVL calcification than matched controls. Score values were 15.8 (interquartile interval 13.6–17.4) in ATTR–CA, 11.0 (9.3–14.9) in AL–CA, 12.8 (11.1–14.4) in ATTR–CA controls, and 11.0 (9.1–13.0) in AL–CA controls (p = 0.004 for ATTR– vs. AL–CA, 0.009 for ATTR–CA vs. their controls, and 0.461 for AL–CA vs. controls). We compared the AVA and two validated diagnostic scores (IWT and AMYLI). AUC values for the diagnosis of ATTR–CA were 0.782, 0.846 and 0.902, respectively, in patients with ATTR–CA or matched controls, and 0.773, 0.706 and 0.679 in patients with LV hypertrophy (n = 67, 84%) (all non–significant p values).

Conclusions

Patients with ATTR–CA have a prominent impairment of mitral valve structure and function, and higher score values. The AVA score is quite effective in identifying patients with ATTR–CA among patients with CA or with unexplained hypertrophy.

297 Echocardiographic biventricular coupling index to predict pre-capillary pulmonary hypertension

Aims

Pulmonary hypertension (PH) affects millions of people worldwide. Right heart catheterization (RHC) is the gold standard to correctly classify the subtype of PH. Biventricular coupling index (BCI) is a new echocardiographic index defined as the ratio between non-invasive right ventricular stroke work index (RVSWI) and E/E′ ratio. Due to his comprehensive functional characterization of the right heart physiology, we hypothesized it might correctly identify pre-capillary PH.

Methods and results

BCI was derived in a cohort of 334 patients from the University Hospital of Trieste (Italy) and Karolinska University Hospital (Sweden) who underwent transthoracic echocardiography and RHC for all indications (&lt;6 h between the exams). The accuracy of BCI to identify pre-capillary PH was high in the derivation cohort (AUC: 0.82, P &lt; 0.001, CI: 0.78–0.88). Subsequently BCI was tested in a large validation cohort of 1349 patients with available transthoracic echocardiography and RHC from the Fondazione Toscana G. Monasterio of Pisa (Italy). Among patients with PH, BCI showed a high accuracy to correctly identify pre-capillary PH (AUC = 0.91, 95% CI: 0.89–0.93, P &lt; 0.001), with an optimal cut-off of 1.9 providing a sensitivity of 82% and a specificity of 89%, PPV 77%, and a NPV 92%. BCI outperformed previous indexes, such as the D’Alto score (Z coefficient 3.56, difference between areas 0.05 95% CI: 0.02–0.07, P &lt; 0.001) and the echocardiographic Pulmonary to Left Atrial Ratio (ePLAR) index (Z coefficient 2.88, difference between areas 0.02 95% CI: 0.01–0.04, P &lt; 0.004).

Conclusions

BCI is a new non-invasive index based on standard echocardiographic parameters that allows, with high accuracy, the identification of patients with pre-capillary PH, outperforming previously proposed indexes. Routine use of BCI index could be implemented in the screening work-up of pre-capillary PH.

417 Multi-chamber speckle tracking imaging and diagnostic value of left atrial strain in cardiac amyloidosis

Aims

Amyloid deposits in all cardiac chambers, impairing their function. We investigated for the first time if a speckle-tracking echocardiography (STE) analysis extended to all four chambers might hold additive diagnostic value for CA and its subtypes [amyloid transthyretin (ATTR-) and light-chain (AL)-CA].

Methods and results

We evaluated 423 consecutive patients undergoing a diagnostic workup for CA in two referral centres from 2015 to 2020. CA was diagnosed in 261 patients (62%; ATTR-CA, n = 144, 34%; AL-CA, n = 117, 28%). Patients with CA had an impaired function of all cardiac chambers, particularly those with ATTR-CA. Peak left atrial longitudinal strain (LA-PALS) was the only STE parameter that predicted CA and ATTR-CA independent of laboratory and standard echocardiographic variables (Model 1). It also predicted ATTR-CA among patients with unexplained hypertrophy regardless of a diagnostic score (IWT score). Patients with either LA-PALS or LA-peak atrial contraction strain (PACS) in the first quartile (LA-PALS &lt;6.65% or LA-PACS &lt;3.62%) had an almost 4-fold higher likelihood of CA and ATTR-CA regardless of Model 1. Among patients with unexplained hypertrophy, those with LA-PALS or LA-PACS in the first quartile had an almost 9-fold higher likelihood of ATTR-CA irrespective of Model 1, and a 2-fold higher likelihood of ATTR-CA beyond the IWT score.

Conclusions

STE measures of all two chambers are abnormal in patients with CA, particularly in those with ATTR-CA. LA strain holds independent diagnostic significance. Among patients screened for CA, those with LA-PALS &lt;6.65% and/or LA-PACS &lt;3.62% have a high likelihood of CA and ATTR-CA.

Left atrial strain in cardiac amyloidosis

Background

Patients with cardiac amyloidosis (CA) display an enlarged and dysfunctional left atrium (LA), because of the effects of left ventricular (LV) diastolic and then systolic dysfunction, as well as the amyloid infiltration of LA wall. A single study reported impaired LA strain in CA, but differences among amyloid light-chain (AL) and transthyretin (ATTR) CA and the correlates of reduced LA strain have not been characterized.

Methods

We evaluated 426 consecutive patients undergoing a screening for suspected CA in 2 tertiary referral centres. Among them, 262 (61%) were diagnosed with CA (n=117 AL-CA, n=145 ATTR-CA). We measured peak atrial longitudinal strain (PALS) and peak atrial contraction strain (PACS) from 4- and 2-chamber (4C, 2C) views, and correlated them with maximum and minimum LA volumes, E/e' ratio, and LV global longitudinal strain (GLS).

Results

LA strain was much more severely impaired in patients with ATTR-CA than those without CA, and to a lesser extent than those with AL-CA (Figure). LA volumes were larger in patients with ATTR-CA than those without CA (maximal LA volume, p=0.042; minimal LA volume, p&lt;0.001), and those with AL-CA (both volumes, p&lt;0.001). LA strain values were more closely correlated with minimal than maximal LA volumes, and patients with AL-CA displayed stronger correlations than those with ATTR-CA or without CA; for example, Spearman's rho values for 4C-PALS vs. minimal LA volume were 0.595, 0.481, and 0.462, respectively (all p&lt;0.001). Furthermore, LA strain correlated with E/e' in patients with AL-CA, but not in those with ATTR-CA: 4C-PALS vs. E/e', rho 0.406, p=0.001 (AL-CA), p=0.401 (ATTR-CA), and p=0.097 (no CA). Finally, LA strain correlated most closely with LV GLS in patients with AL-CA: 4C-PALS vs. LV GLS, rho 0.431, p&lt;0.001 (AL-CA), rho 0.401, p&lt;0.001 (ATTR-CA), rho 0.219, p=0.042 (no CA).

Conclusions

LA volume increase and reduced LA strain is particularly prominent in patients with ATTR-CA. Patients with AL-CA seem to display closer relationships between LA strain, size and haemodynamic load, possibly reflecting the most acute disease course, and lower time for amyloid deposition in the LA wall.

Funding Acknowledgement

Type of funding sources: None.

Reverse remodelling criteria to predict cardiovascular death in heart failure with reduced or mid-range ejection fraction

Aims

Reverse remodelling (RR) is the recovery from left ventricle (LV) dilatation and dysfunction. There are no established definitions of RR. We sought to identify RR criteria that better predicted cardiovascular death.

Methods and results

Forty-two studies used 25 criteria to define RR, most commonly (n=12) as LV end-systolic volume (LVESV) reduction ≥15%. We evaluated 927 patients with LV ejection fraction (LVEF) &lt;50% undergoing 2 echocardiograms within 12±2 months. Over a median 2.8-year follow-up after the second echocardiogram (1.3–4.9), 123 cardiovascular deaths occurred (13%). Model 1 included age, LVEF, N-terminal pro-B-type natriuretic peptide (NT-proBNP), ischaemic aetiology, cardiac resynchronization therapy (CRT), estimated glomerular filtration rate (eGFR), New York Heart Association (NYHA), and LVESV index (LVESVi), and Model 2 the validated 3C-HF score. Two RR criteria proved particularly effective in risk reclassification over Model 1 and Model 2: LVEF increase ≥1 category (severe [LVEF ≤30%], moderate [LVEF 31–40%], mild LV dysfunction [LVEF 41–55%] and normal LV function [LVEF ≥56%]), and LVEF increase &gt;10 U. The same 2 criteria yielded independent prognostic significance and improved reclassification also in patients with LVEF &lt;40% or LVEF ≤35%. LVEF increase ≥1 category and LVEF increase &gt;10 U displayed a stronger prognostic value than LVESV reduction ≥15%, both in the whole population and the subsets with LVEF &lt;40% or ≤35%.

Funding Acknowledgement

Type of funding sources: None.

Prognostic value of reverse remodelling criteria in heart failure with reduced or mid-range ejection fraction

Aims

Reverse remodelling (RR) is the recovery from left ventricular (LV) dilatation and dysfunction. Many arbitrary criteria for RR have been proposed. We searched the criteria with the strongest prognostic yield for the hard endpoint of cardiovascular death.

Methods and results

We performed a systematic literature search of diagnostic criteria for RR. We evaluated their prognostic significance in a cohort of 927 patients with LV ejection fraction (LVEF) < 50% undergoing two echocardiograms within 12 ± 2 months. These patients were followed for a median of 2.8 years (interquartile interval 1.3–4.9) after the second echocardiogram, recording 123 cardiovascular deaths. Two prognostic models were defined. Model 1 included age, LVEF, N‐terminal pro‐B‐type natriuretic peptide, ischaemic aetiology, cardiac resynchronization therapy, estimated glomerular filtration rate, New York Heart Association, and LV end‐systolic volume (LVESV) index, and Model 2 the validated Cardiac and Comorbid Conditions Heart Failure score. We identified 25 criteria for RR, the most used being LVESV reduction ≥15% (12 studies out of 42). In the whole cohort, two criteria proved particularly effective in risk reclassification over Model 1 and Model 2. These criteria were (i) LVEF increase >10 U and (ii) LVEF increase ≥1 category [severe (LVEF ≤ 30%), moderate (LVEF 31–40%), mild LV dysfunction (LVEF 41–55%), and normal LV function (LVEF ≥ 56%)]. The same two criteria yielded independent prognostic significance and improved risk reclassification even in patients with more severe systolic dysfunction, namely, those with LVEF < 40% or LVEF ≤ 35%. Furthermore, LVEF increase >10 U and LVEF increase ≥1 category displayed a greater prognostic value than LVESV reduction ≥15%, both in the whole cohort and in the subgroups with LVEF < 40% or LVEF ≤ 35%. For example, LVEF increase >10 U independently predicted cardiovascular death over Model 1 and LVESV reduction ≥15% (hazard ratio 0.40, 95% confidence interval 0.18–0.90, P = 0.026), while LVESV reduction ≥15% did not independently predict cardiovascular death (P = 0.112).

Conclusions

Left ventricular ejection fraction increase >10 U and LVEF increase ≥1 category are stronger predictors of cardiovascular death than the most commonly used criterion for RR, namely, LVESV reduction ≥15%.

A simple echocardiographic score to rule out cardiac amyloidosis

BACKGROUND

Early diagnosis of cardiac amyloidosis (CA) is warranted to initiate specific treatment and improve outcome. The amyloid light chain (AL) and inferior wall thickness (IWT) scores have been proposed to assess patients referred by haematologists or with unexplained left ventricular (LV) hypertrophy, respectively. These scores are composed of 4 or 5 variables, respectively, including strain data.

METHODS

Based on 2 variables common to the AL and IWT scores, we defined a simple score named AMYLoidosis Index (AMYLI) as the product of relative wall thickness (RWT) and E/e' ratio, and assessed its diagnostic performance.

RESULTS

In the original cohort (n = 251), CA was ultimately diagnosed in 111 patients (44%). The 2.22 value was selected as rule-out cut-off (negative likelihood ratio [LR-] 0.0). In the haematology subset, AL CA was diagnosed in 32 patients (48%), with 2.36 as rule-out cut-off (LR- 0.0). In the hypertrophy subset, ATTR CA was diagnosed in 79 patients (43%), with 2.22 as the best rule-out cut-off (LR- 0.0). In the validation cohort (n = 691), the same cut-offs proved effective: indeed, there were no patients with CA in the whole population or in the haematology or hypertrophy subsets scoring < 2.22, <2.36 or < 2.22, respectively.

CONCLUSIONS

The AMYLI score (RWT*E/e') may have a role as an initial screening tool for CA. A < 2.22 value excludes the diagnosis in patients undergoing a diagnostic screening for CA, while a < 2.36 and a < 2.22 value may be better considered in the subsets with suspected cardiac AL amyloidosis or unexplained hypertrophy, respectively.

High-sensitivity cardiac troponin T and NT-proBNP for ruling-in and ruling-out of cardiac amyloidosis

Background

Cardiac amyloidosis (CA) is caused by the extracellular deposition of misfolded proteins into insoluble amyloid fibrils, the 2 most common forms being transthyretin (ATTR) and immunoglobulin light chain (AL) amyloidosis. Chronic elevation of cardiac troponins and natriuretic peptides is common in CA and predicts worse outcome. The diagnostic yield of biomarkers of cardiac damage for CA has been less investigated.

Purpose

We aimed to evaluate the ruling-in/out values for the diagnosis of CA of high-sensitivity cardiac troponin T (hs-cTnT) and of N-terminal fraction of pro-B-type natriuretic peptide (NT-proBNP).

Methods

We studied 275 consecutive patients referred to two tertiary Centers in Italy (n=184) and France (n=91) with the clinical suspicion of CA due to the presence of a plasma cell dyscrasia or an unexplained left ventricular (pseudo)hypertrophy. CA was confirmed by the combination of suggestive features on imaging techniques (echocardiography, cardiac magnetic resonance, diphosphonate scintigraphy) and biopsy examination. All patients underwent a full baseline characterization including hs-cTnT and NT-proBNP. Biomarkers values corresponding to a negative likelihood ratio &lt;0.1 or a positive likelihood ratio &gt;10 were respectively chosen as rule-out and rule-in cut-offs for CA.

Results

CA was confirmed in 161 (59%) patients, who had either AL amyloidosis (n=96, 60%) or ATTR amyloidosis (n=65, 40%). At time of evaluation, 97 (35%) patients (34 CA vs. 63 controls, p=0.112) were hospitalized for decompensated heart failure. Patients with CA showed higher hs-cTnT (65 ng/L [44–122] vs. 31 [18–42], p&lt;0.001) and NT-proBNP (4260 ng/L [2006–8911] vs. 1199 [468–3357], p&lt;0.001) than those without CA. The area under the curve (AUC) values for hs-cTnT and NT-proBNP were 0.832 and 0.744 respectively (p=0.002 for the difference). The combination of the two biomarkers (AUC=0.836) improved discrimination over NT-proBNP (p=0.004), but not over hs-cTnT (p=0.423). A hs-cTnT value &lt;15 ng/L (sensitivity=100%, negative predictive value=100%, true negatives=13, false negatives=0) and a NT-proBNP &lt;550 ng/L (sensitivity=98%, negative predictive value=89%, true negatives=33, false negatives=4) were selected as rule-out cut-offs. A hs-cTnT level ≥80 ng/L (specificity=96%, positive predictive value=93%, true positives=71, false positives=5) was optimal for ruling in amyloidosis, while no rule-in cut-off could be selected for NT-proBNP. hs-cTnT values of either ≥80 or &lt;15 ng/dL could effectively rule-in/out 89 (32%) patients.

Conclusions

Plasma hs-cTnT and NT-proBNP have diagnostic value in patients with suspected CA. Stand-alone hs-cTnT levels &lt;15 or ≥80 ng/L may help to exclude or confirm the diagnosis of CA in up to one third of patients undergoing a diagnostic screening for the disease.

Figure 1

Funding Acknowledgement

Type of funding source: None

Reverse remodelling, changes in diastolic function and their prognostic value compared to natriuretic peptides

Background

Reverse remodelling (RR) is the recovery from left ventricular (LV) dilation and dysfunction in response to treatment for heart failure (HF). RR is usually associated with improved prognosis. The impact of RR on indices of diastolic function, and the relative prognostic value of RR, changes in diastolic function and natriuretic peptide levels are currently unknown.

Methods

We analysed data from patients with stable systolic HF (LV ejection fraction [LVEF] &lt;50%) undergoing 2 transthoracic echocardiograms (TTE) within 12±2 months. RR was defined as a ≥15% reduction in LV end-systolic volume index (LVESVi). The follow-up started after the second TTE.

Results

927 patients were evaluated (68±12 years; median LVEF 35% [interquartile interval 30–43%]; 27% women; 52% ischaemic aetiology). Patients experiencing RR (n=286, 31%) displayed more prominent positive changes in several parameters reflecting diastolic dysfunction, namely E/e' ratio, left atrial volume index (LAVi), and systolic pulmonary artery pressure (sPAP), as well as N-terminal fraction of pro-B-type natriuretic peptide (NT-proBNP; Figure). In the whole population, percent changes (Δ%) LVESVi displayed weak but significant correlations with Δ% E/e' (r=0.237, p&lt;0.001), LAVi (r=0.316, p&lt;0.001), and sPAP (r=0.158, p&lt;0.001), and also with Δ% NT-proBNP (r=0.279, p&lt;0.001). There were 123 cardiovascular deaths and 4 heart transplantations over 2.8 years (1.3–4.9). Δ% LVESVi, RR, Δ% sPAP and Δ% NT-proBNP were univariate predictors of this endpoint. In 2 multivariable models including Δ% sPAP and Δ% NT-proBNP and either RR or Δ% LVESVi, only Δ% NT-proBNP emerged as independent predictor of outcome (hazard ratio 1.01, 95% confidence interval 1.01–1.02; p&lt;0.001).

Conclusions

A recovery of LV geometry is accompanied by positive modifications in several indices related to diastolic function, as well as a decrease in NT-proBNP levels. Percent changes in NT-proBNP over 12 months are stronger predictors of outcome than variations in LV geometry or sPAP.

Funding Acknowledgement

Type of funding source: None

Two common echocardiographic variables to diagnose cardiac amyloidosis: the AMYLoidosis Index (AMYLI) score

Background

Early diagnosis of cardiac amyloidosis (CA) is warranted to initiate specific treatment and improve outcome. The amyloid light chain (AL) and inferior wall thickness (IWT) scores have been proposed to assess patients referred by hematologists or with unexplained left ventricular (LV) hypertrophy, respectively. These scores are composed of 4 or 5 variables, respectively, including strain data, and no decisional cut-offs were introduced.

Methods

Based on 2 variables common to the AL and IWT scores, we defined a simple score named AMYLoidosis Index (AMYLI) as the product of relative wall thickness (RWT) and E/e' ratio, and assessed its diagnostic performance. Optimal rule-out cut-offs were searched as those with negative likelihood ratio (LR−) &lt;0.1.

Results

In the derivation cohort (n=251), CA was ultimately diagnosed in 111 patients (44%). The 2.22 score value was selected as rule-out cut-off (LR- 0.0). In the hematology subset, AL CA was finally diagnosed in 32 patients (48%), with 2.36 as rule-out cut-off (LR− 0.0). In the hypertrophy subset, ATTR CA was diagnosed in 79 patients (43%), with 2.22 as best rule-out cut-off (LR− 0.0). In the validation cohort (n=691), where more patients were diagnosed with CA (94% and 68% in the hematology and in the hypertrophy subsets, respectively), the 2.22 rule-out cut-off had a LR− = ∞ (as no patient scoring &lt;2.22 had CA). In the hematology and hypertrophy subsets, the 2.36 and 2.22 cut-offs were effective for ruling-out CA, with both LR− = ∞ (as no patient scoring &lt;2.36 or 2.22, respectively, had CA).

Conclusions

The AMYLI score (RWT* E/e') is simpler than those proposed and similarly accurate. A 2.22 cut-off value excludes CA diagnosis in patients undergoing a diagnostic screening for CA, while a &lt;2.36 and a &lt;2.22 value may be better considered in the subsets with either blood dyscrasia or unexplained hypertrophy, respectively.

Funding Acknowledgement

Type of funding source: None

Effect of Sex on Reverse Remodeling in Chronic Systolic Heart Failure

OBJECTIVES

This study sought to investigate sex-related differences in reverse remodeling (RR).

BACKGROUND

RR, that is, the recovery from left ventricular (LV) dilation and dysfunction in response to treatment for heart failure (HF), is associated with improved prognosis.

METHODS

Data from patients with stable systolic HF (LV ejection fraction [LVEF] of <50%) undergoing 2 transthoracic echocardiograms within 12 ± 2 months were analyzed. Reverse remodeling was defined as a ≥15% reduction in LV end-systolic volume index.

RESULTS

A total of 927 patients were evaluated (68 ± 12 years; median LVEF = 35% [interquartile range: 30% to 43%]; 27% women). Ischemic HF was less often encountered in women (33% vs. 60%, respectively; p < 0.001), whereas most characteristics did not differ with regard to sex. Women showed a higher incidence of RR (41% vs. 27%, respectively; p < 0.001), despite similar baseline LV volume and function. RR was more frequent among women in the subgroups with either ischemic or nonischemic HF, as well as in all categories of systolic dysfunction (LVEF ≤35% or >35%, according to current indication for device implantation, and LVEF <40% or 40% to 50% according to the definition of HF with reduced or mid-range EF). In the whole population, female sex was an independent predictor of RR (hazard ratio: 1.54; 95% confidence interval: 1.11 to 2.14; p = 0.011), together with cause of HF, disease duration, and left bundle branch block. Female sex was again an independent predictor of RR in all LVEF categories.

CONCLUSIONS

Reverse remodeling is more frequent among women, regardless of cause and severity of LV dysfunction. Female sex is an independent predictor of RR in all categories of LV systolic dysfunction.

Similar patterns of myocardial metabolism and perfusion in patients with type 2 diabetes and heart disease of ischaemic and non-ischaemic origin

AIMS/HYPOTHESIS

Type 2 diabetes and insulin resistance are often associated with the co-occurrence of coronary atherosclerosis and cardiac dysfunction. The aim of this study was to define the independent relationships between left ventricular dysfunction or ischaemia and patterns of myocardial perfusion and metabolism in type 2 diabetes.

METHODS

Twenty-four type 2 diabetic patients--12 with coronary artery disease (CAD) and preserved left ventricular function and 12 with non-ischaemic heart failure (HF)--were enrolled in a cross-sectional study. Positron emission tomography (PET) was used to assess myocardial blood flow (MBF) at rest, after pharmacological stress and under euglycaemic hyperinsulinaemia. Insulin-mediated myocardial glucose disposal was determined with 2-deoxy-2-[(18)F]fluoroglucose PET.

RESULTS

There was no difference in myocardial glucose uptake (MGU) between the healthy myocardium of CAD patients and the dysfunctional myocardium of HF patients. MGU was strongly influenced by levels of systemic insulin resistance in both groups (CAD, r = 0.85, p = 0.005; HF, r = 0.77, p = 0.01). In HF patients, there was an inverse association between MGU and the coronary flow reserve (r = -0.434, p = 0.0115). A similar relationship was observed in non-ischaemic segments of CAD patients. Hyperinsulinaemia increased MBF to a similar extent in the non-ischaemic myocardial of CAD and HF patients.

CONCLUSIONS/INTERPRETATION

In type 2 diabetes, similar metabolic and perfusion patterns can be detected in the non-ischaemic regions of CAD patients with normal cardiac function and in the dysfunctional non-ischaemic myocardium of HF patients. This suggests that insulin resistance, rather than diagnosis of ischaemia or left ventricular dysfunction, affects the metabolism and perfusion features of patients with type 2 diabetes.