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.

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<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<0.0001), stratified prognosis at Kaplan-Meier analysis (log-rank p<0.0001), and remained an independent prognostic predictor of the composite endpoint (hazard ratio 0.76, 0.61–0.95; p<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

Prevalence of amyloid transthyretin cardiomyopathy in elderly subjects from the general population: first results from the CATCH study

Background

Amyloid transthyretin cardiomyopathy (ATTR-CM) has become treatable. Wild-type ATTR-CM is an age-related disorder. Establishing the exact prevalence of ATTR-CM in elderly subjects from the general population may be useful for healthcare providers and policy makers alike.

Methods

The Characterizing the burden of Amyloid Transthyretin CardiomyopatHy in the elderly (CATCH) study is a population screening on all subjects aged ≥65 years followed by general practitioners working in a part of Tuscany (Italy) where there is no cluster of variant ATTR. The study started on March 12, 2021 and is ongoing. The first step of the evaluation includes clinical history and physical examination, electrocardiogram, transthoracic echocardiogram, and blood sampling with measurement of N-terminal pro-B-type natriuretic peptide and high-sensitivity (hs) troponin T. The following elements are searched: 1) any clinical red flag of amyloidosis (history of carpal tunnel syndrome, lumbar spine stenosis, etc.), 2) interventricular septal thickness ≥12 mm or other echocardiographic red flags, 3) hs-troponin T higher than the upper reference limit (14 ng/L). Patients with any of these elements are referred to a second step including diphosphonate scintigraphy and the search for a monoclonal protein in the serum and urine. The standard diagnostic workup for CA is then followed until the diagnosis is confirmed or discarded.

Results

As of October 13, 2021, 514 subjects ≥65 years have been evaluated for possible participation. Among them, 135 (26%) could not be contacted, were reluctant to enter the study, died before being contacted, or were bedridden. Out of the other 379 subjects, 329 (87%) have already undergone the first step. Forty percent of individuals (n=132) have been referred to the second step. Thirteen subjects have declined (10%); 69 patients have undergone diphosphonate scintigraphy and the search for a monoclonal protein (while the other 50 are awaiting these exams). Two subjects showed an intense myocardial uptake of the diphosphonate tracer (Perugini score 2–3) and no monoclonal protein, and were then diagnosed with ATTR-CM. They were both women, aged 83 and 78 years, both mildly symptomatic for dyspnea (New York Heart Association II) and with unexplained hypertrophy. The search for TTR gene mutation was negative in the first case and is still ongoing in the second. Based on these preliminary data, the prevalence of ATTR-CM in the elderly population can be calculated as 2/266=0.8% (Figure 1).

Conclusions

The CATCH study is expected to enroll at least 1,000 subjects and will provide the first data on the epidemiology of ATTR-CM in elderly subjects. Based on an interim analysis, almost 1 in 100 individuals ≥65 years has ATTR-CM.

Funding Acknowledgement

Type of funding sources: None.

Comparison of the efficacy and safety between different oral P2Y12 receptor inhibitors in patients with acute coronary syndrome: a systematic review and meta-analysis

Introduction

Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor for at least 1 month is the mainstay of therapy after an acute coronary syndrome (ACS). Despite several randomized controlled trials (RCTs) having compared different DAPT regimens after an ACS, the choice of the optimal P2Y12 receptor inhibitor is still debated.

Purpose

We aimed to compare the efficacy and safety profiles of the new P2Y12 receptor inhibitors (prasugrel and ticagrelor) versus clopidogrel in patients with ACS through a meta-analysis of RCTs.

Methods

We performed an extensive literature search, from January 1970 to December 2021 using PubMed database. Studies were eligible if they were RCTs directly comparing different oral P2Y12 receptor inhibitors in patients with ACS. Data on study methods, patient characteristics, and outcomes of interest (all-cause and cardiovascular death, recurrent myocardial infarction, stroke, major and non-major bleeding) were extracted from the original publications. We performed a meta-analysis using a random-effects model with the Mantel–Haenszel method. The effect measures of each study included were calculated and reported as odds ratio (OR) with 95% confidence interval (CI), visually presented in forest plots. A two-sided p-value <0.05 was considered statistically significant. Heterogeneity was tested using the I2-statistic.

Results

A total of 117 studies were available for the analysis; after full reading 11 studies were eligible to be analyzed. The 11 studies reported data on 50,722 patients: 25,424 [50.1%] taking a new oral P2Y12 receptor inhibitor and 25,298 [49.9%] taking clopidogrel. Patients receiving ticagrelor or prasugrel showed a lower risk of all-cause mortality (OR 0.88, 95% confidence interval [CI] 0.80–0.97, I2=8%), cardiovascular mortality (OR 0.88, 95% CI 0.81–0.95, I2=0%), and recurrent myocardial infarction (OR 0.86, 95% CI 0.76–0.97, I2=43%) compared to those receiving clopidogrel. The two groups did not differ significantly concerning the risk of stroke (OR 0.98, 95% CI 0.82–1.17, I2=0%), major bleeding (OR 1.05, 95% CI 0.97–1.15, I2=0%), or non-major bleeding (OR 1.36, 95% CI 0.85–2.20, I2=67%). By restricting the analysis to the studies comparing ticagrelor versus clopidogrel, the ticagrelor group showed a lower risk of all-cause mortality (OR 0.79, 95% CI 0.70–0.90, I2=0%), but a higher risk of non-major bleeding (OR 1.67, 95% CI 1.05–2.66, I2=30%). There was no significant difference between ticagrelor and clopidogrel in terms of cardiovascular death (OR 0.87, 95% CI 0.73–1.05, I2=0%), stroke (OR 1.06, 95% CI 0.85–1.13, I2=0%), or major bleeding (OR 1.02, 95% CI 0.93–1.12, I2=0%).

Conclusions

In patients with an ACS, a DAPT strategy with aspirin plus either prasugrel or ticagrelor is associated with a reduced risk of all-cause and cardiovascular mortality as well as of recurrent myocardial infarction compared to aspirin plus clopidogrel, without an increased risk of bleeding.

Funding Acknowledgement

Type of funding sources: None.

P288 PREVALENCE OF AMYLOID TRANSTHYRETIN CARDIOMYOPATHY IN ELDERLY SUBJECTS FROM THE GENERAL POPULATION: FIRST RESULTS FROM THE CATCH STUDY

Background

Amyloid transthyretin cardiomyopathy (ATTR–CM) has become treatable. Wild–type ATTR–CM is an age–related disorder. Establishing the exact prevalence of ATTR–CM in elderly subjects from the general population may be useful for healthcare providers and policy makers.

Methods

The Characterizing the burden of Amyloid Transthyretin CardiomyopatHy in the elderly (CATCH) study is a population screening on all subjects aged ≥65 years followed by general practitioners in a part of Tuscany (Italy) where there is no cluster of variant ATTR. The study started on March 12, 2021 and is ongoing. Patients with 1) any clinical red flag of amyloidosis, 2) interventricular septal thickness ≥12 mm or other echocardiographic red flags, and/or 3) hs–troponin T > 14 ng/L are referred to diphosphonate scintigraphy and search for a monoclonal protein.

Results

As of October 13, 2021, 514 subjects ≥65 years have been evaluated for possible participation. Among them, 135 (26%) could not be contacted, were reluctant to enter the study, died before being contacted, or were bedridden. Out of the other 379 subjects, 329 (87%) have already undergone the first step. Forty percent of individuals (n = 132) have been referred to the second step. Thirteen subjects have declined (10%); 69 patients have undergone diphosphonate scintigraphy and the search for a monoclonal protein (while the other 50 are awaiting these exams). Two subjects showed an intense myocardial uptake of the diphosphonate tracer (Perugini score 2–3) and no monoclonal protein, and were then diagnosed with ATTR–CM. They were both women, aged 83 and 78 years, both mildly symptomatic for dyspnea (New York Heart Association II) and with unexplained hypertrophy. The search for TTR gene mutation was negative in the first case and is still ongoing in the second. Based on these preliminary data, the prevalence of ATTR–CM in the elderly population can be calculated as 2/266=0.8%.

Conclusions

The CATCH study is expected to enroll at least 1,000 subjects and will provide the first data on the epidemiology of ATTR–CM in elderly subjects. Based on an interim analysis, almost 1 in 100 individuals ≥65 years has ATTR–CM.

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 <6.65% or LA–PACS <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 <6.65% and/or LA–PACS <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.

Prognostic value of sST2 in heart failure patients with diabetes

Background

Soluble suppression of tumorigenesis-2 (sST2) is released in response to inflammation and vascular injury, and holds prognostic value in heart failure (HF). Type 2 diabetes (T2D) is characterized by a pro-inflammatory status and is highly prevalent among HF patients, with adverse impact on outcomes. The clinical value of sST2 in HF patients with T2D has never been characterized.

Purpose

We aimed to assess sST2 clinical correlates and prognostic value in HF patients with T2D.

Methods

Individual data of 3476 patients with stable chronic HF from 5 cohorts from the BIOS (Biomarkers In Heart Failure Outpatient Study) dataset were analysed, with available N-terminal fraction of pro-B-type natriuretic peptide (NT-proBNP), high-sensitivity troponin T (hs-TnT), and sST2 levels.

Results

Mean age was 65±12 years (75% males). T2D was present in 1386 patients (40%), who had higher body mass index (BMI, 27 [24–30] vs. 26 [23–29] kg/m2, p<0.001), lower estimated glomerular filtration rate (eGFR, 56±22 vs. 60±19 mL/min/1,73 m2, p<0.001), higher sST2 (33 [24–47] vs. 27 [20–40] ng/mL, p<0.001), NT-proBNP (1735 [742–3963] vs. 1450 [514–3299] ng/L, p<0.001), hs-TnT (28 [16.2–51.5] vs. 17 [9–31] ng/L, p<0.001) and high-sensitivity C-reactive protein (hs-CRP, 6 [2–11] vs. 4. [2–9] mg/L, p=0.003) (Figure). Differences between sST2 levels in patients with or without T2D were influenced by hs-CRP (p for interaction=0.010) and hs-TnT (p=0.031), but not by NT-proBNP and eGFR. At multivariate linear regression analysis, NT-proBNP, hs-TnT and hs-CRP were independently associated with sST2 levels in both T2D and non-T2D patients. Compared with patients without T2D, those with T2D showed higher 1-year all-cause mortality (12% vs. 10%, p=0.034), cardiovascular mortality (9% vs. 7%, p=0.011), and HF hospitalization rate (22% vs. 12%, p<0.001). In a prognostic model including age, sex, eGFR, ischemic vs- non-ischemic aetiology, left ventricular ejection fraction class, New York Heart Association class, NT-proBNP, hs-TnT, and hs-CRP, sST2 retained independent prognostic value in both patients with or without T2D for 1-year all-cause and cardiovascular mortality, and 1-year HF hospitalization, with higher optimal cut-offs for mortality prediction in T2D vs. non-T2D (39 and 45 vs. 29 and 29 ng/mL respectively for 1-year all-cause and cardiovascular mortality).

Conclusions

sST2 is higher in HF patients with T2D and likely linked to a pro-inflammatory status. sST2 maintains its prognostic value both in diabetic and non-diabetic HF patients, independently of NT-proBNP, hs-TnT and hs-CRP.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Heterogeneity of right ventricular refractory period: a novel prognostic predictor in type-1 Brugada

Funding Acknowledgements

Type of funding sources: None.

Risk stratification in Brugada syndrome (BrS) is needed especially for the choice of an Implantable Cardiac Defibrillator (ICD). To date the predictive value of either clinical or conventional electrophysiological indexes in type 1 electrocardiographic pattern BrS is rather low.

We aimed to evaluate the eventual prognostic significance of refractoriness heterogeneity of right ventricular outflow tract, an emergent relevant pathophysiological substrate, at electrophysiological study (EPS) in patients with BrS.

From 5 centers 348 patients were retrospectively selected (age 44 ± 15 years, males 68%). Eighty-five (24%) patients had an ICD. EPS was proposed in patients with spontaneous type-1 ECG pattern regardless of symptoms, or in patients with drug-induced type-1 ECG pattern with symptoms (n = 174). The difference in the refractory period between the right ventricular outflow tract and the apex (ΔRPRVOT-apex) at EPS was evaluated as a prognostic factor. The optimal ΔRPRVOT-apex cutpoint for prognosis prediction was calculated through a P-spline hazard ratio analysis. Thus, ΔRPRVOT-apex  was compared through different statistical analyses to other other clinical or conventional electrophysiological prognostic indexes previosly described in literature. 

During a 36-month median follow-up (range 6-228) 3 SCD and 10 appropriate ICD shocks (aborted SCD, aSCD) occurred. Fifty patients (29%) had a positive EPS (induction of sustained ventricular tachycardia, VT, or ventricular fibrillation, VF, during the procedure). At multivariable logistic analysis, only ΔRPRVOT-apex  and late potentials remained independent predictors of a positive EPS. At Cox Proportional Hazard analysis, family history of SCD, history of syncope, VT/VF inducibility and a ΔRPRVOT-apex >60 ms were all univariate predictors of SCD/aSCD. At bivariate analysis, a ΔRPRVOT-apex >60 ms remained an independent predictor of SCD/aSCD even when adjusted the other univariate predictors. At C-Statistic analysis, the strongest predictive model was the one using ΔRPRVOT-apex >60 ms as covariate with a C-statistics (95% CI) of 0.72 (0.51-0.93). At Kaplan-Meyer curves, ΔRPRVOT-apex >60 ms was confirmed a strong predictor of SCD/aSCD and another very interesting observation was possible: patients with positive EPS, but a ΔRPRVOT-apex < 60 ms, had a similar risk to SCD/aSCD compared to patients with a negative EPS, while those with a positive EPS and a ΔRPRVOT-apex > 60 ms were found to be at a higher risk of events.

Refractory period heterogeneity of the right ventricle defined as ΔRPRVOT-apex > 60 ms at EPS is a strong and independent predictor of SCD/aSCD in patients with BrS, beyond VT/VF inducibility at EPS and common clinical predictors. Abstract Figure.

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 <0.1 or a positive likelihood ratio >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<0.001) and NT-proBNP (4260 ng/L [2006–8911] vs. 1199 [468–3357], p<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 <15 ng/L (sensitivity=100%, negative predictive value=100%, true negatives=13, false negatives=0) and a NT-proBNP <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 <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 <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

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−) <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 <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 <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 <2.36 and a <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

P995The extent of late gadolinium enhancement predicts defibrillator shocks in patients with non-ischaemic heart failure

Background

Implantable cardioverter defibrillator (ICD) is recommended for patients with non-ischaemic heart failure (HF) and left ventricular ejection fraction (LVEF) ≤35%, although most patients will not experience any appropriate ICD intervention. We assessed if cardiovascular magnetic resonance (CMR) findings may predict benefit from ICD implantation.

Methods and results

We retrieved the data of all patients (n=183) with non-ischaemic HF receiving an ICD for primary prevention at our Institution, and undergoing CMR within 1 month before implantation. 183 patients were evaluated (men 73%, median age 66 years, LVEF 24%, N-terminal fraction of pro-B-type natriuretic peptide 1217 ng/L, atrial fibrillation, flutter or atrial ectopic rhythm 21%). They received single-chamber (n=21, 12%), dual-chamber (n=34, 19%), or cardiac resynchronization therapy devices (n=127, 69%); 1 patient (1%) received a subcutaneous defibrillator. Twenty patients (11%) experienced a shock for ventricular tachycardia or fibrillation (VT/VF) over 2.5 years (0.8–5.4), and 13 (7%) had an inappropriate shock over 2.7 years (0.9–5.4). Late gadolinium enhancement (LGE) was present in 146 patients (80%), but on average accounted for limited percentage of LV mass (4% [2–11%]). LGE mass independently predicted shocks for VT/VF (HR 2.13, 95% CI 1.02–4.47; p=0.045). LGE mass ≥14% (the best cut-off at receiver operating characteristics analysis) independently predicted shocks for VT/VF (HR 3.82, 95% CI 1.51–9.68; p=0.005). LGE mass <4% was the only univariate predictor of inappropriate shocks (HR 4.82, 95% CI 1.07–21.76; p=0.041).

Conclusions

Patients with non-ischaemic HF and LGE mass ≥14% benefit most from ICD, while those with LGE mass <4% display mainly inappropriate shocks.

P2729NT-proBNP and high-sensitivity cardiac troponin T to diagnose cardiac amyloidosis

Background

Cardiac amyloidosis (CA) is characterized by the accumulation of misfolded proteins into amyloid fibrils, leading to cardiomyocyte toxicity, extracellular volume expansion and ventricular pseudohypertrophy. As a consequence of such processes, natriuretic peptides and cardiac troponins are chronically elevated in CA and hold significant prognostic value. The diagnostic yield of these biomarkers for CA has never been explored so far.

Methods

Plasma levels of N-terminal fraction of pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin T (hs-cTnT) were measured in 230 patients referred to a tertiary centre with the clinical suspicion of cardiac amyloidosis. The final diagnosis was established according to current protocols, which include clinical, electrocardiographic, biohumoral, instrumental (echocardiography, cardiac magnetic resonance, diphosphonate scintigraphy), and biopsy examinations.

Results

Patients were aged 79 (interquartile interval 73–83) years and were predominantly males (n=147, 64%). Mean left ventricular (LV) ejection fraction was 55% (48–62%), and mean LV mass indexed was 150 (120–178) g/m2. CA was confirmed in 86 patients (37%), who had either light chain (AL) amyloidosis (n=25, 29%) or transthyretin (ATTR) amyloidosis (n=61, 71%). Alternative diagnoses were hypertensive cardiopathy (n=69, 48%), valvular disease (n=27, 19%), hypertrophic cardiomyopathy (n=18, 13%), or left ventricular hypertrophy with unknown or multifactorial mechanisms. Patients with CA showed higher NT-proBNP (5507 ng/L [2348–10326] vs. 1332 [392–3752], p<0.001) and hs-cTnT (65 ng/L [48–114] vs. 35 [21–52], p<0.001) than those without CA. The area under the curve (AUC) values for NT-proBNP and hs-cTnT were 0.712 and 0.775 respectively (p=0.062 for the difference). The combination of the two biomarkers improved discrimination over NT-proBNP alone (p=0.011), but not over hs-cTnT (p=0.470) (Figure). A NT-proBNP level <600 ng/L or a hs-cTnT level <17 ng/L were optimal for ruling out amyloidosis, with a negative predictive value of 95% in both cases.

Patients with AL amyloidosis had higher NT-proBNP and hs-cTnT than those with ATTR (10809 ng/L [6292–17483] vs. 3084 [1841–7624], p=0.014; 130 ng/L [64–211] vs. 61 [48–95], p=0.006). The difference was even more prominent when biomarker levels were normalized for LV mass (NT-proBNP/LV mass, 33.9 ng/L/g [20.4–53.8] vs. 10.0 [5.8–23.5], p=0.002; hs-cTnT/LV mass, 0.48 ng/L/g [0.25–0.71] vs. 0.19 [0.14–0.26], p=0.001). NT-proBNP and hs-cTnT could effectively discriminate patients with AL amyloidosis among subjects with clinical suspicion of CA (AUC values of 0.787 and 0.805 respectively) (Figure).

Figure 1

Conclusions

Plasma NT-proBNP and hs-cTnT have diagnostic value in patients with suspected CA. In the subgroup with CA, both biomarkers are higher in patients with AL amyloidosis even when normalizing for LV mass, possibly because of a greater cardiotoxic effect of light-chain fibrils.

Diagnostic Accuracy of Xeromammography

The analytical study of the case material has allowed a precise evaluation of the distribution by age groups of the different pathologic processes of the breast, of the localization and dimensions of malignant tumors, as well as the diagnostic accuracy for those cases histologically ascertained and those with a follow-up. The diagnostic accuracy and the consequent reliability of the xeroradiographic method for the diagnosis of breast cancer is distinctly superior to that reported in the literature for traditional mammography, whereas for the differential diagnosis between circumscribed dysplastic manifestations and benign tumors xeromammography is not sufficiently reliable. The authors critically discuss the results and in particular the problem of false positives, which also include diagnostic errors that cannot be avoided in that they directly derive from the pathologic morphology of the disease process (plasma cell mastitis and sclerosing adenosis). As regards the problem of false negatives, they can be reduced within certain limits by resorting to other instrumental investigations. However, there are cases (1% of the malignant neoplasias histologically ascertained) that present a completely negative xeroradiographic finding. These are the limits of the radiologic investigation which cannot in any way be surmounted.

[The value of xeroradiographic patterns in the diagnosis of breast diseases (author's transl)]

The purpose of this study was to establish the value of xeroradiographic patterns and their applicability in the automatic diagnosis of breast diseases. Such an evaluation is based on the comparison with the histologic examination, irrespective of the overall diagnostic judgement previously formulated. From an analysis of the material examined it was possible to ascertain the distribution frequency, the sensitivity, the specificity, the discriminating capacity, and finally the weight of each radiologic sign considered. There are xeroradiographic signs that are apparent almost exclusively in the malignant pathology and therefore can be considered as positive indices of the malignancy of the alteration. The specificity of the radiologic signs considered is very high, whereas the same cannot be said for the sensitivity. Moreover, a linear discriminating analysis made it possible to identify those semiologic elements which, with a minor probability of error, would attribute the pathologic process to the class verified histologically, for malignant neoplasms as well as benign tumors and dysplastic processes.