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Atrial and Ventricular Strain Among Patients With Cardiac Amyloidosis
Quick Takes
- Decreased LV global longitudinal strain (GLS) previously has been associated with an adverse prognosis among patients with cardiac amyloidosis.
- Strain values from all four chambers were significantly associated with survival.
- Peak LA strain had the strongest association with survival; LA strain combined with LV GLS and RV free wall strain had the highest prognostic value.
Study Questions:
What is the prognostic value of atrial and ventricular strain imaging among patients with biopsy-proven cardiac amyloidosis? In addition to left ventricular (LV) global longitudinal strain (GLS), is there prognostic value associated with left (LA) or right atrial (RA) and right ventricular (RV) strain among patients with biopsy-proven cardiac amyloidosis?
Methods:
A cohort of 136 patients with cardiac amyloidosis and available follow-up data were studied by endomyocardial biopsy, noncardiac biopsy with supportive cardiac imaging, or autopsy confirmation. Of those, 109 patients (80%) had light-chain, 23 (17%) had transthyretin, and 4 (3%) had amyloid A type cardiac amyloidosis. GLS, RV free wall strain, peak longitudinal LA strain, and peak longitudinal RA strain were measured from apical views. Clinical and routine echocardiographic data were compared. All-cause mortality was assessed (median follow-up 5 years, range 1.5-12 years).
Results:
Strain data were feasible for GLS in 127 (93%), LA strain in 119 (88%), RA strain in 117 (86%), and RV strain in 102 (75%). Strain values from all four chambers were significantly associated with survival. Hazard ratio (HR) and 95% confidence interval (CI) for low median strain values were as follows: GLS HR 2.3, 95% CI 1.3-3.8 (p < 0.01); LA strain HR 7.5, 95% CI 3.8-14.7 (p < 0.001); RA strain HR 3.5, 95% CI 2.0-6.2 (p < 0.001); and RV free wall strain HR 2.8, 95% CI 1.5-5.1 (p < 0.001). Peak longitudinal LA strain and RV strain remained independently associated with survival in multivariable analysis. Peak LA strain had the strongest association with survival (p < 0.001), and LA strain combined with LV GLS and RV free wall strain had the highest prognostic value (p < 0.001).
Conclusions:
Strain data from all four chambers had important prognostic associations with survival among patients with biopsy-confirmed cardiac amyloidosis. Peak longitudinal LA strain was particularly associated with prognosis. The authors concluded that atrial and ventricular strain have promise for clinical utility among patients with cardiac amyloidosis.
Perspective:
Echocardiography in patients with amyloidosis can reveal evidence of increased wall thickness, atrial enlargement, diastolic dysfunction, and abnormal LV GLS with characteristic apical sparing. Decreased LV GLS previously has been associated with an adverse prognosis in cardiac amyloidosis. However, amyloidosis is a diffuse disease, potentially affecting all cardiac chambers. This study demonstrated prognostic importance associated with strain data from all four cardiac chambers, with a strong association between peak longitudinal LA strain and increased mortality risk at a median 5-year follow-up. This study helps support the role of strain imaging in a variety of clinical scenarios, including among patients with heart valve disease and in monitoring LV function among patients receiving potentially cardiotoxic chemotherapy. Future research can help address whether strain data can be useful in treatment decisions among patients with cardiac amyloidosis.
Clinical Topics: Heart Failure and Cardiomyopathies, Noninvasive Imaging, Valvular Heart Disease, Acute Heart Failure, Echocardiography/Ultrasound
Keywords: Amyloidosis, Autopsy, Biopsy, Diagnostic Imaging, Echocardiography, Heart Failure, Heart Valve Diseases, Prealbumin, Survival, Ventricular Dysfunction, Left
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