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Prevalence of ATTR-CA and high-risk features to guide testing in patients referred for TAVR

Bryan Abadie1, Adel Hajj Ali1, Trejeeve Martyn1

  • 1Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA.

European Journal of Nuclear Medicine and Molecular Imaging
|August 22, 2023
PubMed

Insights

The prevalence of transthyretin cardiac amyloidosis (ATTR-CA) in contemporary transcatheter aortic valve replacement (TAVR) patients is lower than previously thought. Elevated NT-pro BNP levels can effectively guide screening for ATTR-CA in this population.

Area of Science:

  • Cardiology
  • Cardiovascular Imaging
  • Medical Diagnostics

Background:

  • Transthyretin cardiac amyloidosis (ATTR-CA) is increasingly recognized in severe aortic stenosis (AS) patients undergoing transcatheter aortic valve replacement (TAVR).
  • Previous studies on ATTR-CA prevalence in TAVR candidates were conducted when TAVR was limited to high-risk, elderly, or inoperable patients.
  • Contemporary TAVR indications have expanded to include lower-risk populations, necessitating a reevaluation of ATTR-CA prevalence.

Purpose of the Study:

  • To determine the prevalence of ATTR-CA in a current cohort of TAVR candidates with severe AS.
  • To identify clinical and echocardiographic features that can effectively guide screening for ATTR-CA using technetium-99 pyrophosphate scans (99mTc-PyP scans).

Main Methods:

  • Patients aged 70 years and older with severe AS referred to a TAVR clinic underwent 99mTc-PyP scanning for ATTR-CA evaluation.
  • The primary outcome was the percentage of patients with a positive 99mTc-PyP scan.
  • The study assessed the discriminatory ability of various risk factors to develop a more targeted screening strategy.

Main Results:

  • Of 380 screened patients, 5.3% had a positive 99mTc-PyP scan, with 4.7% confirmed for ATTR-CA.
  • Elevated NT-pro BNP levels (>1000 ng/L) demonstrated the highest discriminatory power for referral.
  • NT-pro BNP achieved 90% sensitivity and 99% negative predictive value for guiding 99mTc-PyP scan screening.

Conclusions:

  • The prevalence of ATTR-CA appears lower in the contemporary, broader TAVR population compared to earlier studies.
  • NT-pro BNP is a valuable, simple biomarker to optimize screening yield and judiciously select patients for 99mTc-PyP scan evaluation.
  • A refined screening algorithm incorporating NT-pro BNP can improve the efficiency of ATTR-CA detection in severe AS patients undergoing TAVR.
Abstract

Keywords:
Aortic stenosisCardiac amyloidosisCardiac scintigraphyTranscatheter aortic valve replacement

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