Prognostic Utility of Left Atrial Strain to Predict Thrombotic Events and Mortality in Amyloid Cardiomyopathy

Emmanuel Akintoye; Muhammad Majid; Allan L Klein; Mazen Hanna

doi:10.1016/j.jcmg.2023.01.015

Prognostic Utility of Left Atrial Strain to Predict Thrombotic Events and Mortality in Amyloid Cardiomyopathy

JACC Cardiovasc Imaging. 2023 Nov;16(11):1371-1383. doi: 10.1016/j.jcmg.2023.01.015. Epub 2023 Apr 12.

Authors

Emmanuel Akintoye¹, Muhammad Majid¹, Allan L Klein¹, Mazen Hanna²

Affiliations

¹ Section of Cardiovascular Imaging, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Ohio, USA.
² Section of Heart Failure and Cardiac Transplantation, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Ohio, USA. Electronic address: hannam@ccf.org.

PMID: 37940322
DOI: 10.1016/j.jcmg.2023.01.015

Abstract

Background: There is currently no thromboembolic risk stratification tool for amyloid cardiomyopathy (ACM) and the current survival staging systems for ACM have only modest discriminatory ability.

Objectives: This study aims to evaluate the prognostic value of left atrial (LA) strain to predict incident thrombotic event (TE) and improve survival staging systems in ACM.

Methods: The authors identified patients with light chain (AL) or transthyretin (ATTR) ACM and no history of atrial fibrillation (AF) at diagnosis. Three components of LA strain (reservoir, conduit, and contractile) were measured and their predictive value for TE and mortality was determined. In addition, the authors evaluated the incremental utility of adding LA strain to current prognostic staging systems.

Results: The authors included 448 patients (50.2% AL; 49.8% ATTR) with median follow-up of 3.8 years. There were 64 (14.3%) TE cases, 103 (23%) AF cases, and 234 (52.2%) deaths. Notably, 75% of TEs occurred without preceding AF documented. LA strain reservoir and LA contractile strain significantly predicted both events: HRs for TE were 2.22 (95% CI: 1.27-3.85; P = 0.006) and 2.63 (95% CI: 1.25-5.00; P = 0.01) per SD decrease in LA strain reservoir and LA contractile strain, respectively. The respective HRs for mortality were 1.32 (95% CI: 1.09-1.59; P < 0.001) and 1.49 (95% CI: 1.22-1.75; P < 0.001). Also, LA strain reservoir and LA contractile strain significantly improved the C-statistics of the Mayo AL staging from 0.65 to 0.68 and 0.70, respectively (P ≤ 0.02); Mayo ATTR staging (0.73 to 0.79 and 0.80, respectively; P < 0.001); and Gillmore ATTR staging (0.70 to 0.79 and 0.80, respectively; P < 0.001).

Conclusions: LA strain identifies ACM patients with high thrombotic risk (independent of AF) and improves current ACM-specific survival staging.

Keywords: amyloid; death; embolism; left atrial strain; stroke; thrombosis.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Atrial Fibrillation* / diagnosis
Cardiomyopathies* / diagnostic imaging
Heart Atria / diagnostic imaging
Humans
Predictive Value of Tests
Prognosis