First systematic screening of cardiac amyloidosis in the elderly: findings and cost-effectiveness profile

Wild-type transthyretin cardiac amyloidosis (ATTRwt-CA) is increasingly recognized in older adults. Nonetheless, its true prevalence in unselected subjects is unclear. We performed a systematic screening in 1000 individuals aged 65-90 years to identify CA and assess the clinical and economic impact of diagnosing both CA and incidental findings.

All participants underwent a cardiology visit, electrocardiogram, echocardiogram, and measurement of cardiac biomarkers. Patients with any red flag proceeded to bone scintigraphy and monoclonal protein testing. We catalogued incidental cardiac or renal abnormalities, referred individuals for further evaluation, and estimated total screening costs. We then incorporated tafamidis therapy for the newly diagnosed patients with CA and conducted two cost-effectiveness analyses: one excluding quality-adjusted life years (QALYs) from incidental diagnoses and another one including them. Four new cases of ATTRwt-CA were diagnosed (0.46%). Additional findings included moderate-to-severe valvular disease, conduction abnormalities requiring device implantation, and previously unknown Stage 3-5 chronic kidney disease in 15.6% of participants. The total non-drug screening cost was around €252 000, while tafamidis (5 years, four patients) added €1 080 000. Excluding incidental benefits, the incremental cost-effectiveness ratio (ICER) was around €94 000 per QALY. With an estimated 15-20 extra QALYs from incidental findings, the ICER fell to €39 000-€46 000 per QALY.

A structured screening programme for CA in elderly subjects can uncover important comorbidities but remains expensive, with an incremental cost of approximately €39 000-€94 000 per QALY; the overall value of such a strategy will therefore depend on tafamidis pricing and the willingness-to-pay threshold adopted by individual health systems.