How Often Does Apical Sparing of Longitudinal Strain Indicate the Presence of Cardiac Amyloidosis?

Wali, Eisha; Gruca, Martin; Singulane, Cristiane Carvalho; Cotella, Juan I; Guile, Brittney; Johnson, Roydell; Mor‐Avi, Victor; Addetia, Karima; Lang, Roberto M.

doi:10.1016/j.amjcard.2023.06.022

Cited by 15 publications

(4 citation statements)

References 14 publications

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“… 8 Bavishi et al 14 reported a PPV of 38.6% of relative apical sparing of longitudinal strain with a strain ratio ≥2.0 (although they did not define it accurately, it was probably a ratio of average apical strain/average basal strain) for patients with confirmed or suspicious CA. Wali et al 15 reported very similar results, among patients with the relative apical sparing (average apical strain/average basal strain + average mid strain >1.0) criterion only 33% of patients had confirmed or highly probable CA; thus, the PPV of this criterion was only 33%. These data support our statement that the diagnostic value of the novel ECG criteria is at least as good as that of the best myocardial deformation criteria, which are most commonly used to establish the non‐invasive, presumptive diagnosis of CA.…”

Section: Discussionmentioning

confidence: 72%

“…18 In another study the relative apical sparing criterion was present in much more (88%) patients with severe aortic valve stenosis before transcatheter aortic valve implantation (TAVI) and after TAVI it was found in only 77% of the patients. 15 The latter two studies 18,19 showed that the presence of relative apical sparing was associated with more severe aortic valve disease, left ventricular dysfunction and hypertrophy, which was in some or most cases reversible after aortic valve replacement.…”

Section: The Diagnostic Value Of the Echocardiographic Myocardial Def...mentioning

confidence: 99%

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Novel electrocardiographic criteria may render possible the more accurate recognition of cardiac amyloidosis

Vereckei,

Katona,

Szénási

et al. 2024

ESC Heart Failure

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AimsThe early diagnosis of cardiac amyloidosis (CA) is paramount, since there are effective therapies that improve patient survival. The diagnostic accuracy of classical electrocardiographic (ECG) signs, such as low voltage, pseudoinfarct pattern, and conduction disturbances in the diagnosis of CA, is inferior to that of the echocardiographic myocardial deformation criteria; therefore, our aim was to find more accurate novel ECG criteria for this purpose.MethodsWe tested the diagnostic value of five novel ECG criteria, two of them devised by us, in 34 patients with confirmed CA (20 transthyretin amyloidosis and 14 AL amyloidosis) and 45 control patients with left ventricular hypertrophy on echocardiography due to hypertension, valvular aortic stenosis and hypertrophic cardiomyopathy. The following novel ECG criteria, that suggested CA, were tested: QRS amplitude in lead I < 0.55 mV (I < 0.55); QRS amplitude in lead aVR < 0.5 mV (aVR < 0.5); average QRS amplitude of leads I + aVR < 0.575 mV [(I + aVR) < 0.575]; average QRS amplitude of leads I + aVR/average QRS amplitude of leads V1–4 < 0.375 [(I + aVR)/(V1–4) < 0.375]; average QRS amplitude of leads I + aVR/longest intrinsicoid deflection in leads I,aVL,V1–6 < 0.0115 [(I + aVR)/I,aVL,V1–6ID < 0.0115].ResultsThe I < 0.55, aVR < 0.5, (I + aVR) < 0.575, (I + aVR)/(V1–4) < 0.375, (I + aVR)/I,aVL,V1–6ID < 0.0115 test accuracy (TA) were 81%, 84.8%, 82.3%, 84.8%, and 83.3%, respectively; the sensitivity (SE): 76.5%, 82.4%, 85.3%, 82.4%, and 76.9%; specificity (SP): 84.4%, 86.7%, 80%, 86.7%, and 87.5%; positive predictive values (PPV): 78.8%, 82.4%, 76.3%, 82.4%, and 80%; negative predictive values (NPV): 82.6%, 86.7%, 87.8%, 86.7%, and 85.4%; area under curve (AUC) values: 0.8922, 0.8794, 09016, 0.8824, and 0.8462 were respectively. These parameters of the novel ECG criteria were at least as good as those reported by other authors in the literature of the qualitative (TA: 67%, SE: 80%, SP: 34%, PPV: 75%, NPV: 42%, AUC: 0.57) and quantitative apical sparing (TA: 64–80%, SE: 66–81.3%, SP: 55–78.3%, PPV: 33–83.9%, NPV: 41–75%, AUC: 0.62–0.68) and left ventricular ejection fraction/global longitudinal strain >4.1 (TA: 77%, SE: 93%, SP: 38%, PPV: 79%, NPV: 69%, AUC: 0.65) echocardiographic criteria. Among the classical criteria, the low voltage in limb leads criterion was present most frequently (in 73.5%) in patients with CA, with slightly worse diagnostic value than the novel ECG criteria (TA: 78.5%, SE: 73.5%, SP: 82.2%, PPV: 75.8%, NPV: 80.4%).ConclusionsThe novel ECG criteria [mostly the aVR < 0.5, (I + aVR)/(V1–4) < 0.375] seem at least as reliable in the diagnosis of CA as the best echocardiographic myocardial deformation criteria and might be used either together with the echocardiographic criteria or as stand‐alone criteria to diagnose CA in the future.

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Section: Discussionmentioning

confidence: 72%

Section: The Diagnostic Value Of the Echocardiographic Myocardial Def...mentioning

confidence: 99%

Novel electrocardiographic criteria may render possible the more accurate recognition of cardiac amyloidosis

Vereckei,

Katona,

Szénási

et al. 2024

ESC Heart Failure

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Section: Segmental Longitudinal Strainmentioning

confidence: 99%

“…Apical sparing defined as preserved LS in the apical segments despite impaired strain in the basal and mid segments demonstrated high accuracy in differentiating cardiac amyloidosis from other causes of cardiac hypertrophy [3,30,31] and infiltrative disease [32]. While a RASP above 1 was shown to accurately identify cardiac amyloidosis [3], several studies suggested that the pattern may not be entirely specific for cardiac amyloidosis [31,33]. Of note, in 10% of the subjects, the endocardial RASP was above 1, implying once again that further studies are warranted to validate the clinical utility of the parameter in the screening and diagnosis of cardiac amyloidosis.…”

Section: Segmental Longitudinal Strainmentioning

confidence: 99%

Lower Limit of Normality of Segmental Multilayer Longitudinal Strain in Healthy Adult Subjects

Moraru,

Mirea,

Toader

et al. 2024

JCDD

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Speckle tracking echocardiography is an advanced imaging technique that allows for a more detailed assessment of cardiac global and regional function. Reference values for segmental longitudinal layered strain (subendocardial, mid-myocardial, and subepicardial) are scarce, limiting the clinical use of these measurements in clinical practice. Two hundred consecutive Caucasian healthy subjects (mean age = 37 ± 11 years) were enrolled in the study. The mean values of global longitudinal strain (GLS) for endocardial (Endo), mid-myocardial (Myo) and epicardial (Epi) layers were −22.9 ± 2.7, −20.0 ± 2.4 and −17.5 ± 2.1, respectively. The GLSEndo/GLSMyo ratio was 1.1 ± 0.05, while the GLSEndo/GLSEpi ratio was 1.3 ± 0.05. The apical strain-sparing ratio was >1 in 10% of the subjects (endocardium) and 7% (mid-myocardium). The lower limits for segmental LS were as follows: for endocardial LS, −10% (basal), −12% (mid), −14% (apical); for mid-myocardial LS, −10% −10% (basal), −10% (mid), −10% (apical); and for epicardial LS, −7% (basal), −8% (mid), −8% (apical). The findings of this study provide data regarding the lower limit of normality of LS for each LV segment and suggest, for practical considerations, that an LS value below 10% should be considered abnormal in any segment. Further larger studies are warranted to confirm these findings.

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Current Therapies and Future Horizons in Cardiac Amyloidosis Treatment

Vogel,

Carpinteiro,

Luedike

et al. 2024

Curr Heart Fail Rep

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Purpose of Review Cardiac amyloidosis (CA) is a condition characterized by misfolding and extracellular deposition of proteins, leading to organ dysfunction. While numerous forms of CA exist, two subtypes dominate clinical prevalence: Transthyretin amyloid (ATTR) and immunoglobulin light chain amyloid. Recent Findings The current scientific landscape reflects the urgency to advance therapeutic interventions with over 100 ongoing clinical trials. Heart failure treatment is affected by CA phenotype with poor tolerance of otherwise frequently used medications. Treating comorbidities including atrial fibrillation and valvular disease remains a challenge in CA, driven by technical difficulties and uncertain outcomes. Tafamidis is the first ATTR-stabilizer approved with a rapidly growing rate of clinical use. In parallel, various new therapeutic classes are in late-stage clinical trials including silencers, antibodies and genetic therapy. Summary Managing CA is a critical challenge for future heart failure care. This review delineates the current standard-of-care and scientific landscape of CA therapy.

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How Often Does Apical Sparing of Longitudinal Strain Indicate the Presence of Cardiac Amyloidosis?

Cited by 15 publications

References 14 publications

Novel electrocardiographic criteria may render possible the more accurate recognition of cardiac amyloidosis

Novel electrocardiographic criteria may render possible the more accurate recognition of cardiac amyloidosis

Lower Limit of Normality of Segmental Multilayer Longitudinal Strain in Healthy Adult Subjects

Current Therapies and Future Horizons in Cardiac Amyloidosis Treatment

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