Diagnostic utility of three clinical scoring systems for transthyretin amyloid cardiomyopathy in elderly Asian patients with heart failure with preserved ejection fraction
M J Chen, Y H Hung, Z W Chen, C E Tsai, P J Liao, C H Tsai, M F Cheng, L Y Lin, A L Yu, C C Chao, C K Wu, Y H LinAbstract
Background
Among elderly patients with heart failure with preserved ejection fraction (HFpEF), transthyretin amyloid cardiomyopathy (ATTR-CM) is an increasingly recognized etiology. Recently, several scoring systems have been proposed to improve the diagnostic likelihood of ATTR-CM, but the validity in the elderly Asian HFpEF population was still unknown.
Purpose
This study aims to investigate the diagnostic validity of the Mayo ATTR-CM score, the Kumamoto criteria, and the simplified T-Amylo score among patients in an independent Asian multi-center HFpEF study (Prevalence of ATTR-CM in Taiwanese Elderly patients with Heart Failure with preserved Ejection Fraction, PATCH-HFpEF).
Methods
We evaluated the diagnostic performance of the Mayo ATTR-CM score, the Kumamoto criteria, and the simplified T-Amylo score using data from the prospectively collected PATCH-HFpEF study, which systematically screened patients ≥ 60 years with HFpEF for ATTR-CM. Analyses were performed in the overall population and in a prespecified subgroup with left ventricular posterior wall thickness (LVPWd) ≥ 12 mm.
Results
The PATCH-HFpEF study comprised 204 patients (49.5% male, 50.5% female) with a mean age of 79.4 ± 8.1 years. The overall prevalence of ATTR-CM in our study was 4.4%, which increased to 10.3% in the subgroup of patients with LVPWd ≥ 12 mm. In the Mayo ATTR-CM score, the optimal diagnostic cutoff by Youden index was score 7, with sensitivity 88.9% and specificity 88.7%. The positive predictive value (PPV) and negative predictive value (NPV) were 26.7% and 98.4% respectively. In the Kumamoto criteria, the optimal diagnostic cutoff by Youden index was score 2, with sensitivity 77.8% and specificity 90.3%. The PPV and NPV were 26.9% and 98.9% respectively. As for the simplified T-Amylo score, the optimal diagnostic cutoff by Youden index was score 5, with sensitivity 62.5% and specificity 92.8%. The PPV and NPV were 26.3% and 98.4% respectively. In the overall HFpEF population, the Mayo ATTR-CM score, the Kumamoto criteria, and the simplified T-Amylo score yielded AUCs of 0.95 (SE: 0.05, 95% CI: 0.86-1.05), 0.92 (SE: 0.06, 95% CI: 0.80-1.05), and 0.91 (SE: 0.07, 95% CI: 0.78-1.05), respectively. When applied to the LVPWd ≥ 12 mm subgroup, these models maintained robust diagnostic performance with AUCs of 0.90 (SE: 0.07, 95% CI: 0.77-1.04), 0.89 (SE: 0.07, 95% CI: 0.75-1.03), and 0.88 (SE: 0.08, 95% CI: 0.72-1.04), respectively. All models demonstrated appropriate calibration. We also compared the AUC in each scoring system with one another by DeLong’s test, which revealed no statistically significant (Mayo ATTR-CM v.s. Kumamoto, p=0.691, Mayo ATTR-CM v.s. T-Amylo, p=0.6516, Kumamoto v.s. T-Amylo, p=0.9433).
Conclusion
The Mayo ATTR-CM score, Kumamoto criteria, and simplified T-Amylo score demonstrated strong discrimination in our overall elderly HFpEF study, with preserved performance among patients with increased wall thickness.Table 1.Clinical Characteristics