Differential diagnosis of non­obstructive hypertrophic cardiomyopathy and cardiac amyloidosis with atypical delayed enhancement patterns on magnetic resonance imaging: the role of myocardial strain analysis

Aim. To evaluate the diagnostic potential of cardiac magnetic resonance imaging (MRI) using left ventricular (LV) myocardial strain parameters in the differential diagnosis of non-obstructive hypertrophic cardiomyopathy (HCM) and cardiac amyloidosis.

Material and methods. This single-center, retrospective, observational study included 48 patients as follows: 23 with non-obstructive HCM and 25 with cardiac amyloidosis (AL and ATTR types). All patients underwent contrast-enhanced cardiac MRI. Left ventricular morphofunctional parameters, delayed enhancement patterns, and global and regional myocardial strain indices (2D and 3D strain) were assessed. Statistical analysis included group comparisons and ROC analysis to determine the diagnostic significance of strain parameters.

Results. Atypical patterns of delayed enhancement or its absence were detected in 22% of patients, complicating imaging differentiation between HCM and amyloid cardiomyopathy. Among myocardial strain parameters, the most significant differences between groups were found for 3D radial strain of the LV, which was significantly lower in patients with amyloid cardiomyopathy compared to HCM (30,00±17,92 vs 45,98±20,16%; p=0,003). A 3D radial strain cutoff value <29,1% provided a sensitivity of 87% and a specificity of 57% in the differential diagnosis of these diseases. Differences in longitudinal and circumferential strain did not reach statistical significance.

Conclusion. Myocardial strain parameters, particularly LV 3D radial strain, have high diagnostic value in the differential diagnosis of non-obstructive HCM and cardiac amyloidosis, especially in cases of atypical or absent delayed enhancement patterns. Myocardial strain analysis can be considered a promising non-contrast method that expands the diagnostic potential of cardiac MRI and creates the rationale for short MRI screening protocols in patients with myocardial hypertrophy of unknown origin.

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