左心房应变预测淀粉样心肌病血栓事件和死亡的预后价值。

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

机构信息

Section of Cardiovascular Imaging, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Ohio, USA.

Section of Heart Failure and Cardiac Transplantation, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Ohio, USA.

出版信息

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

DOI:10.1016/j.jcmg.2023.01.015

PMID:37940322

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.

摘要

背景

目前尚无针对淀粉样变心肌病（ACM）的血栓栓塞风险分层工具，而 ACM 的现行生存分期系统的区分能力也较为有限。

目的

本研究旨在评估左心房（LA）应变预测血栓事件（TE）的预后价值，并改善 ACM 的生存分期系统。

方法

作者鉴定了诊断时无房颤（AF）病史的轻链（AL）或转甲状腺素蛋白（ATTR）ACM 患者。测量 LA 应变的三个组成部分（储器、导管和收缩），并确定其对 TE 和死亡率的预测价值。此外，作者还评估了将 LA 应变添加到现行预后分期系统中的增量效用。

结果

作者纳入了 448 例患者（50.2%为 AL；49.8%为 ATTR），中位随访时间为 3.8 年。共有 64 例（14.3%）发生 TE，103 例（23%）发生 AF，234 例（52.2%）死亡。值得注意的是，75%的 TE 发生时并无先前记录的 AF。LA 应变储器和 LA 收缩应变均显著预测了这两种事件：TE 的 HR 分别为 2.22（95%CI：1.27-3.85；P = 0.006）和 2.63（95%CI：1.25-5.00；P = 0.01），每降低 LA 应变储器和 LA 收缩应变 1 个标准差。相应的死亡率 HR 分别为 1.32（95%CI：1.09-1.59；P < 0.001）和 1.49（95%CI：1.22-1.75；P < 0.001）。此外，LA 应变储器和 LA 收缩应变分别显著提高了 Mayo AL 分期的 C 统计量，从 0.65 提高到 0.68 和 0.70（P ≤ 0.02）；Mayo ATTR 分期（从 0.73 提高到 0.79 和 0.80，P < 0.001）；以及 Gillmore ATTR 分期（从 0.70 提高到 0.79 和 0.80，P < 0.001）。