Left atrial strain imaging differentiates cardiac amyloidosis and hypertensive heart disease

Abstract

Echocardiographic diagnosis of cardiac amyloidosis (CA) can be difficult to differentiate from increased left ventricular (LV) wall thickness from hypertensive heart disease. The aim of this study was to evaluate left atrial (LA) function and deformation using strain and strain rate (SR) imaging in cardiac amyloidosis. We reviewed 44 cases of CA confirmed by tissue biopsy or a combination of clinical and cardiac imaging data. Cases were classified according two subgroups: amyloid light chain (AL) or amyloid transthyretin (ATTR). These subjects underwent 2D-Speckle tracking echocardiographic derived (STE) LA strain analysis. These were compared to 25 hypertensive (HT) patients with increased LV wall thickness. The three phases of LA function were evaluated using strain and strain rate parameters. Despite a similar increase in LV wall thickness, all LA strain parameters were significantly reduced in the AL cohort compared to the HT cohort (reservoir strain/LAs: 11.0 vs. 24.8%, p < 0.05). The ATTR cohort had significantly thicker LV walls and higher atrial fibrillation burden compared to AL and HT patients but similar reduction in LA strain values compared to AL group. A reservoir strain (S-LAs) cut off value of 20% was 86.4% sensitive and 88.6% specific for detecting CA compared to HT heart disease in this cohort. LA strain parameters were able to identify LA dysfunction in all types of CA. LA function in CA is significantly worse compared with hypertensive patients despite similar increase in LV wall thickness. In combination with other clinical and imaging features, LA strain may provide incremental value in differentiating cardiac amyloidosis from increased wall thickness secondary to hypertension.

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Authors

Contributions

KR—concept and design, data collection, primary author of manuscript. GMS—concept and design, critical revision of article. KS—interobserver variability data collection. NE—data collection, critical revision of article. AL—concept and design, drafting article, critical revision of article. DGP—concept and design, critical revision of article. JC—concept and design, oversight of data collection, statistical analysis, drafting article, critical revision of article.

Corresponding author

Correspondence to Jonathan Chan.

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Appendices

Appendix

Data including study vendor, year of study and strain values for the amyloid and hypertensive cohorts

Disease state Vendor Year of study Reservoir strain (S-LAs Conduit strain (S-LAe) Contractile strain (S-LAa)
AL GE 2017 11.87   
AL Phillips 2018 7.94 4.895 3.045
AL Phillips 2016 8.77 5.85 2.92
AL Phillips 2010 22.955 7.75 15.205
AL Phillips 2015 6.795 3.11 3.685
AL Phillips 2015 9.09 4.87 4.22
AL Phillips 2011 7.44 4.455 2.985
AL GE 2017 2.245 1.385 0.86
AL Phillips 2017 27.655 16.285 11.37
AL GE 2015 12.64 4.805 7.835
AL GE 2017 3.65   
ATTR GE 2015 12.64 4.805 7.835
ATTR GE 2017 3.65   
ATTR GE 2018 6.245 3.995 2.25
ATTR Phillips 2016 3.27 2.73 0.535
ATTR GE 2016 5.46 3.58 1.88
ATTR GE 2017 10.21   
ATTR Phillips 2019 5.00   
ATTR GE 2018 4.13   
ATTR GE 2017 5.57   
ATTR GE 2017 15.84 5.40 10.45
ATTR GE 2017 15.87 6.53 9.34
ATTR GE 2018 6.10   
ATTR Phillips 2014 19.51   
ATTR Phillips 2018 10.78 8.18 2.60
ATTR GE 2017 6.60   
ATTR Phillips 2018 7.71   
ATTR Phillips 2017 3.73   
ATTR GE 2019 6.22   
ATTR Phillips 2015 10.08   
ATTR Phillips 2015 25.70 15.47 10.24
ATTR GE 2015 9.95 3.41 6.54
ATTR GE 2016 5.70 4.63 1.07
ATTR GE 2015 7.30   
ATTR GE 2014 5.21   
ATTR GE 2015 6.10   
ATTR GE 2017 4.82   
ATTR GE 2013 7.34   
ATTR Phillips 2010 20.71 6.92 13.79
ATTR HP7500 2004 2.49   
ATTR Phillips 2017 6.30 4.61 1.69
ATTR Phillips 2018 28.70 4.94 15.77
ATTR Phillips 2016 9.18   
ATTR Siemens 2016 2.37   
ATTR Phillips 2017 8.34 5.48 2.86
ATTR GE 2015 32.64 15.91 13.65

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Rausch, K., Scalia, G.M., Sato, K. et al. Left atrial strain imaging differentiates cardiac amyloidosis and hypertensive heart disease. Int J Cardiovasc Imaging 37, 81–90 (2021). https://doi.org/10.1007/s10554-020-01948-9

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Keywords

  • Cardiac amyloidosis
  • Left atrial strain
  • Atrial deformation
  • Hypertension