Relative apical sparing pattern was significantly higher in cardiac amyloidosis than in non-amyloid cardiac diseases with a moderate effect size (SMD 0.676, 95% CI 0.493–0.860, p < 0.001).
Systematic Review
Yes
Does the relative apical sparing pattern (RASP) differentiate cardiac amyloidosis from non-amyloid conditions?
Relative apical sparing is most pronounced in cardiac amyloidosis compared to phenocopies, but its diagnostic magnitude varies by imaging modality, supporting a modality-specific interpretation.
Effect estimate: SMD 0.676 (95% CI 0.493–0.860)
p-value: p=<0.001
Background: Relative apical sparing of longitudinal strain is widely used as a diagnostic marker of cardiac amyloidosis. However, similar deformation patterns have been reported in other cardiac diseases, raising concerns regarding disease specificity. A comprehensive multimodality synthesis of the relative apical sparing pattern (RASP) across disease entities is lacking. Methods: A systematic review and meta-analysis were conducted according to PRISMA guidelines. PubMed, Scopus, and EMBASE were searched through December 2025 for studies reporting RASP or regional longitudinal strain values allowing standardized RASP calculation. Cardiac amyloidosis and major phenocopies—including aortic stenosis, hypertrophic cardiomyopathy, hypertensive heart disease, Fabry disease, mitral valve prolapse, and other cardiomyopathies—were included. Random-effects models were used to compare cardiac amyloidosis with non-amyloid conditions using standardized mean differences (SMDs), with subgroup analyses according to imaging modality (two-dimensional speckle-tracking echocardiography 2D-STE versus cardiac magnetic resonance feature tracking CMR-FT). Results: Fourteen studies (nine 2D-STE and five CMR-FT) were included in the quantitative synthesis. Overall, cardiac amyloidosis was associated with significantly higher RASP compared with non-amyloid conditions (SMD 0.676, 95% CI 0.493–0.860; p < 0.001), with substantial heterogeneity (I2 = 96.9%). Modality-stratified analyses showed a very large pooled effect for 2D-STE (SMD 2.152, 95% CI 1.354–2.950; I2 = 97.6%) and a moderate, homogeneous effect for CMR-FT (SMD 0.594, 95% CI 0.405–0.782; I2 = 0%). Sensitivity analyses confirmed robustness. No significant publication bias was detected by Egger’s test. Conclusions: Relative apical sparing is not specific to cardiac amyloidosis but is most pronounced in this condition. Its diagnostic magnitude varies across modalities and clinical contexts, supporting a multiparametric, modality-specific interpretation.
Sonaglioni et al. (Tue,) conducted a systematic review in Cardiac amyloidosis and other cardiac diseases including aortic stenosis, hypertrophic cardiomyopathy, hypertensive heart disease, Fabry disease, mitral valve prolapse, and other cardiomyopathies. Relative apical sparing pattern (RASP) assessment by 2D speckle-tracking echocardiography (2D-STE) or cardiac magnetic resonance feature tracking (CMR-FT) vs. Non-amyloid cardiac diseases and healthy controls was evaluated on Standardized mean difference (SMD) in relative apical sparing pattern (RASP) values comparing cardiac amyloidosis to non-amyloid conditions (SMD 0.676, 95% CI 0.493–0.860, p=<0.001). Relative apical sparing pattern was significantly higher in cardiac amyloidosis than in non-amyloid cardiac diseases with a moderate effect size (SMD 0.676, 95% CI 0.493–0.860, p < 0.001).