Imaging the invisible: comparative diagnostic accuracy of cardiac imaging techniques for amyloidosis
K Singhal, V Patel, N Doobay, M Rahimi, B Darboe, A Balaji, A Gorantla, A Kahn, H ChadowAbstract
Background
Cardiac amyloidosis (CA) is an infiltrative cardiomyopathy that is underdiagnosed until advanced stages. Non-invasive imaging modalities, including echocardiography, cardiovascular magnetic resonance (CMR), bone scintigraphy, positron emission tomography (PET), and computed tomography (CT), have transformed diagnosis, but their relative accuracy remains unclear.
Objectives
To compare the diagnostic performance of major cardiac imaging modalities for CA, stratified by amyloid subtype and disease stage.
Methods
Systematic review and meta-analysis per PRISMA-DTA guidelines. PubMed, Embase, Web of Science, Cochrane CENTRAL, and Scopus were searched through April 30, 2025. Studies evaluating echocardiography, CMR, bone scintigraphy (99mTc-PYP/DPD/HMDP), PET, or CT against histology or validated non-biopsy criteria were included. Bivariate random-effects models estimated pooled sensitivity and specificity; HSROC curves were generated.
Results
Fifty-one studies (n=5,987) included; 64% ATTR, 28% AL. CMR had the highest sensitivity (0.91 [0.86–0.94]), while scintigraphy had the highest specificity for ATTR (0.97 [0.95–0.99]). PET (0.88/0.85), echocardiography (0.81/0.83), and CT (0.82/0.85) were intermediate. Comparative ranking: CMR > Scintigraphy > PET > Echocardiography > CT. Subgroup analyses: scintigraphy best for ATTR, CMR best for AL, and early disease.
Conclusions
CMR provides superior sensitivity; scintigraphy is most specific for ATTR. PET and CT are promising adjuncts. A tiered multimodal imaging approach optimizes diagnosis and early detection.Data TablePrisma