Key result
Novel ECG-echo algorithm achieves ~86% accuracy for cardiac amyloidosis, outperforming visual apical sparing.
Why the study?
Early diagnosis of cardiac amyloidosis is paramount given effective survival-improving therapies, and while novel ECG criteria previously showed similar diagnostic value to literature-based myocardial deformation criteria, a direct comparison with directly measured myocardial deformation criteria was needed.
Do novel electrocardiographic criteria and a combined 4-step algorithm improve the diagnostic accuracy for cardiac amyloidosis compared to myocardial deformation criteria in patients with verified cardiac amyloidosis and left ventricular hypertrophy controls?
Case-Control (n=103)
Do novel electrocardiographic criteria and a combined 4-step algorithm improve the diagnostic accuracy for cardiac amyloidosis compared to myocardial deformation criteria in patients with verified cardiac amyloidosis and left ventricular hypertrophy controls?
Combining novel ECG criteria and posterior wall thickness-to-aVR ratio with myocardial deformation parameters into a 4-step algorithm improves the diagnostic accuracy for presumptive cardiac amyloidosis over visual apical sparing alone.
May support noninvasive diagnosis of cardiac amyloidosis in LVH; leaves open prospective validation before clinical adoption.
Background The early diagnosis of cardiac amyloidosis (CA) is paramount, since there are effective therapies that improve patient survival. In a previous study our novel electrocardiographic (ECG) criteria for cardiac amyloidosis (CA) were much more accurate than the classical ECG criteria, such as low voltage and pseudoinfarct pattern, and had the same diagnostic value as that of the myocardial deformation criteria based on literature data. Purpose In this study we compared the diagnostic value of the myocardial deformation criteria measured by ourselves with that of the novel ECG criteria. Methods 53 verified CA patients (41 transthyretin and 12 AL CA) and 50 control patients with left ventricular hypertrophy on echocardiography due to other underlying cause were studied. The following were the best tested criteria suggesting CA. 1. QRS amplitude in lead aVR <0.4 mV (aVR<0.4); 2. average QRS amplitude of leads I+aVR/average QRS amplitude of leads V1-4 <0.375 [(I+aVR)/(V1-4)<0.375]; 3. left ventricular posterior wall thickness/QRS amplitude in lead aVR >3.059 (PWT/aVR >3.059); 4. qualitative visual apical sparing (ApS); 5. quantitative average apical strain/average basal strain+average middle wall strain >1 [avApicS/(avBasS+avMidS) >1]. Results The sensitivity, specificity, positive and negative predictive, test accuracy and area under curve values were the following. (aVR<0.4): 70%, 90%, 88%, 74%, 80%, 0.8711; [(I+aVR)/(V1-4)<0.375]: 60%, 92%, 89%, 69%, 76%, 0.7687; (PWT/aVR >3.059): 74%, 88%, 87%, 76%, 81%, 0.834; ApS: 86%, 70%, 75%, 83%, 78%, 0.7895; [avApicS/(avBasS+avMidS) >1]: 76.5%, 92%, 91%, 79%, 84%, 0.9073. These values of a 4-step algorithm with the greatest diagnostic accuracy composed of the 1., 3., 4., 5. criteria were: 91%, 82%, 84%, 89%, 86%, 0.8558, each of them was better than that of the ApS criterion. These values of the novel ECG and (PWT/aVR >3.059) criteria were approximately as accurate as those of the myocardial deformation criteria. Conclusions Based on our results, to establish a more probable presumptive CA diagnosis, in addition to the most commonly applied ApS criterion in clinical practice, it is recommended to use either the novel ECG and/or the (PWT/aVR >3.059) and/or the quantitative myocardial deformation criteria.
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Vereckei et al. (2026) conducted a case-control in Cardiac amyloidosis (n=103). Novel ECG criteria, PWT/aVR >3.059, and a 4-step diagnostic algorithm vs. Myocardial deformation criteria including qualitative visual apical sparing (ApS) and quantitative strain ratios was evaluated on Diagnostic accuracy for cardiac amyloidosis (AUC 0.8558 (4-step algorithm) vs 0.7895 (ApS)). A 4-step ECG and echocardiographic algorithm achieved 86% diagnostic accuracy (sensitivity 91%, specificity 82%, AUC 0.8558) for cardiac amyloidosis, outperforming visual apical sparing (78% accuracy).
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