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Published on: March 26, 2018
Cardiac transthyretin amyloidosis in aortic valve replacement: RAISE score performance in the postoperative setting
Richard J Nies1, Svenja Ney2, Jasper F Nies3
1University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Kerpener Str. 62, 50937, Cologne, Germany. richard.nies@uk-koeln.de.
Insights
The RAISE Score shows lower sensitivity for transthyretin amyloid cardiomyopathy (ATTR-CM) screening after aortic valve replacement (AVR). Simpler factors like age, carpal tunnel syndrome, and NT-proBNP levels are more effective for identifying patients needing further bone scintigraphy.
Area of Science:
- Cardiology
- Medical Diagnostics
- Nuclear Medicine
Background:
- Transthyretin amyloid cardiomyopathy (ATTR-CM) screening is crucial in patients with aortic stenosis (AS).
- The RAISE Score was developed to aid ATTR-CM screening but is not routinely implemented.
- Evaluating the RAISE Score's utility post-aortic valve replacement (AVR) is important for clinical practice.
Purpose of the Study:
- To assess the performance of the RAISE Score in screening for ATTR-CM after AVR.
- To compare the RAISE Score's diagnostic accuracy with simpler clinical parameters.
- To investigate the association of ATTR-CM indicators with mortality and heart failure hospitalization.
Main Methods:
- A prospective, observational study included 131 patients (≥60 years) with specific interventricular septum thickness post-AVR.
- Patients underwent hydroxydiphosphonate (HDP) bone scintigraphy.
- The diagnostic performance of the RAISE Score and simpler parameters (age, carpal tunnel syndrome, NT-proBNP) were analyzed.
Main Results:
- Pathological HDP uptake was observed in 16% of patients, with 8.4% diagnosed with ATTR-CM.
- The RAISE Score demonstrated moderate sensitivity and specificity, with scores ≥2 and ≥3 yielding different performance metrics.
- Simpler parameters, including advanced age (≥83 years) and the presence of carpal tunnel syndrome and/or elevated NT-proBNP (≥1,400 pg/mL), showed comparable predictive value to the RAISE Score.
Conclusions:
- The RAISE Score exhibits reduced sensitivity for ATTR-CM screening post-AVR compared to prior reports.
- Simpler clinical factors, such as advanced age, carpal tunnel syndrome history, and elevated NT-proBNP, are valuable for identifying patients who may benefit from bone scintigraphy.
- These simpler parameters, particularly the combination of CTS and/or NT-proBNP, were significantly associated with all-cause mortality.
Aims:
The RAISE Score, encompassing five domains (Remodeling, Age, Injury, Systemic, Electrical), was proposed to screen for transthyretin amyloid cardiomyopathy (ATTR-CM) in patients with aortic stenosis (AS), but is not routinely used. This study evaluated its performance following aortic valve replacement (AVR).
Methods:
This single-center, prospective, observational study included patients aged ≥ 60 years with end-diastolic interventricular septum thickness (IVSd) ≥ 12 mm, who underwent hydroxydiphosphonate (HDP) bone scintigraphy after AVR between March 2021 and July 2024. The diagnostic performance of the RAISE Score assessed at 30-day follow-up and of simpler screening parameters for pathological HDP uptake (Perugini 1-3) were analyzed, along with their association with all-cause mortality and heart failure (HF) hospitalization.
Results:
Among 131 included patients (median age 81 years; 64% male) pathological HDP uptake was found in 21 (16%), and 11 (8.4%) were diagnosed with ATTR-CM. A RAISE Score ≥ 2 demonstrated 76% sensitivity and 56% specificity for pathological bone scintigraphy, while a Score ≥ 3 showed 62% sensitivity and 78% specificity. The parameters age ≥ 83 years and the combination of carpal tunnel syndrome (CTS) and/or N-terminal pro-B-type natriuretic peptide (NT-proBNP) ≥ 1,400 pg/mL performed similarly to the RAISE Score. Cardiac HDP uptake showed a strong trend toward HF hospitalization (HR [95%-CI]: 5.81 [0.93-36.20]; p = 0.060) and all-cause mortality (HR [95%-CI]: 3.27 [0.95-11.24]; p = 0.060). CTS and/or NT-proBNP ≥ 1,400 pg/mL was significantly associated with higher all-cause mortality (HR [95%-CI]: 3.92 [1.04-14.84]; p = 0.044), whereas the RAISE Score was not.
Conclusion:
After AVR, the complex RAISE Score showed lower sensitivity than originally reported, while simpler parameters demonstrated comparable predictive value for ATTR-CM screening. Advanced age, CTS history and elevated NT-proBNP levels seem most valuable for identifying candidates for bone scintigraphy.
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