Atrial mechanical contraction predicts cerebrovascular risk in patients with transthyretin amyloid cardiomyopathy and sinus rhythm
Porcari, Aldostefano Passo, Beatrice Dal Venneri, Lucia Aimo, Alberto Sezer, Zehra Irem Bandera, Francesco Razvi, Yousuf Sheikh, Awais Mansell, Josephine Rauf, Muhammad Umaid
Porcari, Aldostefano
Passo, Beatrice Dal
Venneri, Lucia
Aimo, Alberto
Sezer, Zehra Irem
Bandera, Francesco
Razvi, Yousuf
Sheikh, Awais
Mansell, Josephine
Rauf, Muhammad Umaid
Abstract
Background
Patients with transthyretin amyloid cardiomyopathy (ATTR-CM) remain at risk of cerebrovascular events even when in sinus rhythm (SR), yet the majority of these patients are unrecognized.
Objectives
This study sought to identify patients in SR at high risk of cerebrovascular events.
Methods
We analyzed patients diagnosed with ATTR-CM between January 2003 and December 2023 at the UK National Amyloidosis Centre. Left atrial (LA) function was assessed using speckle-tracking strain echocardiography. Atrial electromechanical dissociation (AEMD) was defined as SR on electrocardiogram with absent left atrial strain contraction (LASc). Patients in SR were stratified according to LASc tertiles. The primary outcome was a cerebrovascular event defined as stroke or transient ischemic attack (TIA), whichever occurred first. The secondary outcome was development of atrial fibrillation (AF). Death was treated as a competing event.
Results
The study comprised 2,310 patients with ATTR-CM, of which 873 patients were in SR and not receiving anticoagulation (age 77 years, 82% male, 61% wild type, CHADS-VASc 4). AEMD was present in 115 patients (13.2%). Of the patients in SR, over a median of 34 months (Q1-Q3: 18-54 months), 269 patients (30.8%) developed incident AF and 85 (9.7%) experienced stroke/TIA. Patients with baseline AF receiving anticoagulation had a rate of stroke or TIA of 0.7 per 100 person-years. AEMD was associated with a 2.4-fold higher incident AF and 3-fold higher risk of stroke or TIA compared with SR with LA mechanical contraction (8.7 vs 2.5 per 100 person-years, respectively, for stroke or TIA), independent of CHADS-based scores and markers of disease severity. Among 758 patients in SR without AEMD, LASc tertiles (<4%, 4%-7%, >7%) exhibited an independent association with 1-year risk of stroke or TIA, with LASc <4% being associated with 10-fold increased risk compared to LASc >7%. This association was consistent after adjustment for NAC stage and prior cerebrovascular events. Adding LASc tertiles to CHADS-VASc or CHADS-VA significantly improved model fit and risk reclassification at 1 year.
Conclusions
LA dysfunction, particularly AEMD and severely impaired LASc, is associated with increased cerebrovascular events in ATTR-CM. Using LAS analysis may refine risk stratification and help identify patients with ATTR-CM in SR who might potentially benefit from intensified extended rhythm monitoring or prophylactic anticoagulation.
MIDER Authors
Affiliations
Date
2026-02-09
Type
Article
Collections
Citation
Porcari A, Passo BD, Venneri L, Aimo A, Sezer ZI, Bandera F, Razvi Y, Sheikh A, Mansell J, Rauf MU, Zaro E, Giampieri G, Burgel C, De Caterina R, Emdin M, Petrie A, Knight DS, Virsinskaite R, Kotecha T, Wechalekar A, Lachmann H, Whelan C, Moody WE, Martinez-Naharro A, Jering KS, Solomon SD, Hawkins PN, Gillmore JD, Fontana M. Atrial Mechanical Contraction Predicts Cerebrovascular Risk in Patients With Transthyretin Amyloid Cardiomyopathy and Sinus Rhythm. J Am Coll Cardiol. 2026 Feb 9:S0735-1097(25)10564-0. doi: 10.1016/j.jacc.2025.12.033.