Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan.
Center of Metabolic Regulation of Healthy Aging, Kumamoto University Faculty of Life Sciences, Kumamoto, Japan.
ESC Heart Fail. 2021 Dec;8(6):5316-5326. doi: 10.1002/ehf2.13621. Epub 2021 Sep 28.
This study was performed to investigate whether left atrial (LA) strain by echocardiography provides prognostic information in patients with wild-type transthyretin amyloid cardiomyopathy (ATTRwt-CM).
Among 129 patients who were diagnosed with ATTRwt-CM at Kumamoto University Hospital from December 2002 to December 2019, 113 patients who had enough information for two-dimensional speckle tracking echocardiography were enrolled in this study. During a median follow-up of 668 days, 28 cardiovascular deaths occurred. Compared with patients in the non-event group, those in the cardiovascular death group were significantly older (81.5 ± 7.4 vs. 78.1 ± 6.1 years, P < 0.01), had a lower incidence of carpal tunnel syndrome (21% vs. 47%, P < 0.05), and had a higher high-sensitivity cardiac troponin T [0.085 (0.063-0.105) vs. 0.049 (0.036-0.079) ng/mL, P < 0.01] and B-type natriuretic peptide concentrations [419 (239-541) vs. 271 (155-462) pg/mL, P < 0.01] and lower estimated glomerular filtration rate (41.8 ± 15.4 vs. 53.4 ± 14.6 mL/min/1.73 m , P < 0.01). Electrocardiography showed higher rate of a V1-V3 QS pattern (52% vs. 24%, P < 0.01) and complete left bundle branch block (27% vs. 6%, P < 0.01), and echocardiography showed a significantly lower peak LA strain rate during the contraction phase (0.16 ± 0.13 vs. 0.28 ± 0.27 S , P < 0.05), LA strain during the reservoir phase (LASr) (5.84 ± 2.41 vs. 8.22 ± 4.05%, P < 0.01), and peak LA strain rate during the reservoir phase (0.26 ± 0.09 vs. 0.33 ± 0.15 S , P < 0.05) in the cardiovascular death group than in non-event group. By contrast, conventional echocardiographic findings were not significantly different between these two groups. After adjusting for conventional predictive factors of ATTRwt-CM (age, high-sensitivity cardiac troponin T and B-type natriuretic peptide concentrations, and estimated glomerular filtration rate), multivariable Cox proportional hazard analyses showed that LASr was significantly and independently associated with cardiovascular death in patients with ATTRwt-CM (odds ratio, 0.84; 95% confidence interval, 0.72-0.98; P < 0.05). After adjusting for age and echocardiographic findings associated with cardiovascular death (LA volume index and peak LA strain rate during the contraction phase), LASr was significantly and independently associated with cardiovascular death in patients with ATTRwt-CM (odds ratio, 0.83; 95% confidence interval, 0.70-0.98; P < 0.05). Receiver operating characteristic curve analysis showed that the area under the curve of LASr for cardiovascular death was 0.686 and that the best cut-off value of LASr was 6.69% (sensitivity, 62.4%; specificity, 64.3%). In the Kaplan-Meier analysis, patients with low LASr (<6.69%) had a significantly higher probability of total cardiovascular death (P < 0.05) and heart failure-related hospitalization (P < 0.05).
Left atrial strain during the reservoir phase provides significant prognostic value in patients with ATTRwt-CM even after adjusting for conventional predictive factors.
本研究旨在探讨左心房应变（LA）通过超声心动图提供预后信息在野生型转甲状腺素蛋白淀粉样心肌病（ATTRwt-CM）患者。
在从 2002 年 12 月至 2019 年 12 月期间在熊本大学医院诊断为 ATTRwt-CM 的 129 名患者中，纳入了 113 名具有足够二维斑点追踪超声心动图信息的患者。在中位随访 668 天期间，发生了 28 例心血管死亡事件。与非事件组相比，心血管死亡组的患者年龄明显更大（81.5±7.4 岁 vs. 78.1±6.1 岁，P<0.01），腕管综合征的发生率更低（21% vs. 47%，P<0.05），高敏心肌肌钙蛋白 T [0.085（0.063-0.105）ng/ml vs. 0.049（0.036-0.079）ng/ml，P<0.01]和 B 型利钠肽浓度[419（239-541）pg/ml vs. 271（155-462）pg/ml，P<0.01]更高，估算肾小球滤过率（eGFR）更低（41.8±15.4 vs. 53.4±14.6 ml/min/1.73 m ，P<0.01）。心电图显示更高的 V1-V3 QS 模式（52% vs. 24%，P<0.01）和完全左束支传导阻滞（27% vs. 6%，P<0.01），超声心动图显示收缩期峰值 LA 应变率明显更低（0.16±0.13 vs. 0.28±0.27 S ，P<0.05），心房储备期 LA 应变（LASr）（5.84±2.41 vs. 8.22±4.05%，P<0.01）和心房储备期峰值 LA 应变率（0.26±0.09 vs. 0.33±0.15 S ，P<0.05）在心血管死亡组比非事件组。相比之下，两组之间的常规超声心动图发现没有显著差异。在调整 ATTRwt-CM 的常规预测因素（年龄、高敏心肌肌钙蛋白 T 和 B 型利钠肽浓度以及 eGFR）后，多变量 Cox 比例风险分析显示，LASr 与 ATTRwt-CM 患者的心血管死亡显著且独立相关（优势比，0.84；95%置信区间，0.72-0.98；P<0.05）。在调整与心血管死亡相关的年龄和超声心动图发现（左心房容积指数和收缩期峰值 LA 应变率）后，LASr 与 ATTRwt-CM 患者的心血管死亡显著且独立相关（优势比，0.83；95%置信区间，0.70-0.98；P<0.05）。接受者操作特征曲线分析显示，LASr 用于心血管死亡的曲线下面积为 0.686，最佳 LASr 截断值为 6.69%（敏感性，62.4%；特异性，64.3%）。在 Kaplan-Meier 分析中，LASr 较低（<6.69%）的患者总心血管死亡的可能性显著更高（P<0.05）和心力衰竭相关住院（P<0.05）。
即使在调整常规预测因素后，心房储备期 LA 应变在 ATTRwt-CM 患者中提供了显著的预后价值。
