Recognizing Cardiac Amyloidosis Phenotype by Echocardiography Increases Downstream Testing

Q: What are the key findings of this study?

Language suggestive of cardiac amyloidosis in TTE reports increased downstream diagnostic testing within 1 year compared to reports without such language (38% vs 4%, OR 9.6, 95% CI 3.3-28, P<0.001).

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Severely increased left ventricular wall thickness concerning for cardiac amyloidosis (n=271). Intervention: Language suggestive of cardiac amyloidosis in TTE report vs. TTE report without language suggestive of cardiac amyloidosis. Primary outcome: Downstream diagnostic cardiac amyloidosis testing within 1 year of TTE (OR 9.6, 95% CI 3.3-28, p=<0.001).

Q: What question did this study set out to answer?

To evaluate the rate of diagnostic cardiac amyloidosis testing in older adults with severely increased left ventricular wall thickness and determine if suggestive echocardiography report language increases testing rates.

Peter Graeme Miller; Mathew S. Maurer; Andrew Jeffrey Einstein; Pierre Adil Elias; Timothy Joseph Poterucha

doi:10.1016/j.echo.2023.08.018

August 26, 2023Journal of the American Society of EchocardiographyOpen Access

Recognizing Cardiac Amyloidosis Phenotype by Echocardiography Increases Downstream Testing

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Key result

Amyloidosis-suggestive echo reporting is linked to ~9.6-fold higher odds of downstream diagnostic testing.

OR 9.6
95% CI 3.3-28
P<0.001
n=271

Why the study?

Does inclusion of language suggestive of cardiac amyloidosis in transthoracic echocardiography reports increase downstream diagnostic testing for cardiac amyloidosis within 1 year in patients ≥65 years old with severely increased LV wall thickness?

Key Points

To evaluate the rate of diagnostic cardiac amyloidosis testing in older adults with severely increased left ventricular wall thickness and determine if suggestive echocardiography report language increases testing rates.
Retrospective review of 271 patients aged ≥65 years without prior cardiac amyloidosis testing or diagnosis who had transthoracic echocardiography (TTE) demonstrating interventricular septal or posterior wall thickness ≥16 mm between 2017 and 2021.
Tracked downstream cardiac amyloidosis testing within 1 year and categorized TTE reports by the presence of language explicitly suggesting cardiac amyloidosis.
Within 1 year of echocardiography, only 21 of 271 patients (8%) underwent cardiac amyloidosis testing, with amyloidosis confirmed in 11 of those 21 patients (52%; 10 ATTR-CA, 1 light chain CA).
Testing was completed in 10 of 26 patients (38%) whose TTE reports included suggestive language compared to 11 of 245 patients (4%) without suggestive language (P < .001).
Suggestive echocardiography report language was independently associated with downstream testing after adjusting for age, sex, wall thickness, ejection fraction, and hypertension (OR = 9.6; 95% CI, 3.3–28).

Study Design

Type

Cohort (n=271)

Multicenter

No

Structured PICO

Does inclusion of language suggestive of cardiac amyloidosis in transthoracic echocardiography reports increase downstream diagnostic testing for cardiac amyloidosis within 1 year in patients ≥65 years old with severely increased LV wall thickness?

P

Population

271 older adults (≥65 years) without prior cardiac amyloidosis testing or diagnosis who had severely increased LV wall thickness (IVST or LVPWT ≥16 mm) on transthoracic echocardiography, followed for 1 year.

E

Exposure

Inclusion of language suggestive of cardiac amyloidosis phenotype in the transthoracic echocardiography report (n=26).

C

Comparator

Transthoracic echocardiography report without language suggestive of cardiac amyloidosis (n=245).

O

Outcome

Downstream diagnostic cardiac amyloidosis testing performed within 1 year of TTE.surrogate

Main Result

Odds Ratio: 9.6 (95% CI 3.3–28)

Absolute Event Rate: 38% vs 4%

p-value: p=<0.001

Explicitly mentioning the possibility of cardiac amyloidosis in echocardiogram reports for older adults with severe LV wall thickening significantly increases the rate of subsequent diagnostic testing, addressing a major gap in underdiagnosis.

Limitations

Single-center study
Findings may not be generalizable to younger patients at lower cardiac amyloidosis risk
Did not control for symptomatology, heart failure history, or patient-provider decisions regarding testing
Echocardiography lab did not routinely perform strain analysis during the study period
Possible undocumented cardiac amyloidosis testing performed outside the institution
Single-center nature
Findings may not be generalizable to younger patients at lower CA risk
Did not control for factors impacting testing rates such as symptomatology, heart failure history, or patient-provider decisions
Possible undocumented CA testing performed outside the institution

Implication

Report phrasing may influence diagnostic pursuit in suspected amyloidosis; hypothesis-generating for strategies to reduce underdiagnosis pending prospective validation.

Abstract

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Discussion

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Cite This Study

Miller et al. (2023) conducted a cohort in Severely increased left ventricular wall thickness concerning for cardiac amyloidosis (n=271). Language suggestive of cardiac amyloidosis in TTE report vs. TTE report without language suggestive of cardiac amyloidosis was evaluated on Downstream diagnostic cardiac amyloidosis testing within 1 year of TTE (OR 9.6, 95% CI 3.3-28, p=<0.001). Language suggestive of cardiac amyloidosis in TTE reports increased downstream diagnostic testing within 1 year compared to reports without such language (38% vs 4%, OR 9.6, 95% CI 3.3-28, P<0.001).

synapsesocial.com/papers/6ae32fb30168543384384573 https://doi.org/10.1016/j.echo.2023.08.018

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Recognizing Cardiac Amyloidosis Phenotype by Echocardiography Increases Downstream Testing

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

Recognizing Cardiac Amyloidosis Phenotype by Echocardiography Increases Downstream Testing

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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