Amyloidosis is an infiltrative disease that may cause cardiomyopathy if the precursor protein that misfolds and forms the amyloid is transthyretic or plasma abnormal light chains. Transthyretin amyloid cardiomyopathy has to be diagnosed timely and accurately since there are specific treatment options to support the patients. Multimodality imaging including electrocardiography, echocardiography with strain imaging and cardiac magnetic resonance applying late gadolinium enhancement imaging, native T1 mapping and extracellular volume, raise a high suspicion of the disease and bone scintigraphy set the diagnosis even without the need of biopsy. However, the morbidity and mortality remain high and the need for risk stratification and assessment of the response to treatment are of paramount importance. Cardiac imaging biomarkers offer a thoughtful insight into the prognosis of these patients at diagnosis and after treatment. The current narrative review aims to enlighten the use of multimodality cardiac imaging in transthyretic amyloid cardiomyopathy throughout the disease pathogenesis and evolution from diagnosis to prognosis and response to treatment in a personalized manner.

Background: Reliable quantification of systemic venous congestion in acute heart failure (HF) has become feasible with the advent of the venous excess ultrasound (VExUS) score, informing therapeutic management. Nevertheless, the determinants of the VExUS score trajectory during hospitalization and the prognostic implications of persistent subclinical congestion at discharge remain poorly defined. Methods: Consecutive patients admitted for acute HF were prospectively enrolled (n = 418, 73.3 ± 11.8 years old, 59.1% male). VExUS scores were assessed at admission and prior to discharge to categorize the patients into three groups: non-congested (persistent score of 0; n = 81), improved (score reduction of ≥1 point; n = 214), and non-improved (persistent congestion without score reduction; n = 123). Baseline clinical data were collected and all the patients had a transthoracic echocardiogram on admission. All patients were followed up post-discharge and the primary endpoint was a composite of all-cause mortality or HF hospitalization. Results: Patients with non-improved VExUS exhibited a higher burden of right-sided remodeling and dysfunction including larger right chambers, lower right ventricle (RV) systolic function indices, higher RV systolic pressures and a higher prevalence of severe tricuspid regurgitation (all p < 0.001). Severe tricuspid regurgitation was the sole independent predictor of VExUS non-improvement (OR 2.86, 95% CI 1.51–5.45, p = 0.001). Non-improved VExUS (HR 1.77; 95% CI 1.17–2.67; p = 0.007), severe tricuspid regurgitation (HR 1.88; 95% CI 1.16–3.02; p = 0.010) and intravenous furosemide dose (HR 1.00; 95% CI 1.00–1.01; p = 0.011) were independent predictors of the composite primary endpoint. Inclusion of non-improved VExUS provided incremental prognostic value over models including clinical, laboratory, and echocardiographic parameters (Δχ²= 9.22; p = 0.007). Conclusions: VExUS non-improvement throughout hospitalization marks patients with worse primary endpoint Severe tricuspid regurgitation emerges as an independent determinant of VExUS non-improvement which is independently associated with poor long-term outcomes.

High bleeding risk (HBR) patients represent a significant proportion of those who undergo percutaneous coronary interventions (PCI). The accurate diagnosis of the HBR population is essential because they suffer significantly higher rates of mortality and bleeding compared with non-HBR patients. Although many bleeding risk scores have been developed, the Academic Research Consortium for HBR (ARC–HBR) criteria have established their superiority over the others. In HBR patients without an indication for oral anticoagulant (OAC), shortening the duration of dual antiplatelet therapy (DAPT) is an effective way to minimize bleeding complications in HBR patients with chronic coronary syndromes (CCS). In cases of an acute coronary syndrome (ACS) however, HBR patients combine increased thrombotic burden with an augmented risk of bleeding. Early antiplatelet interruption could result in stent thrombosis with catastrophic consequences. Therefore, in HBR patients with an ACS choosing the optimal DAPT duration, the right P2Y12 inhibitor and the correct time for de-escalation from a potent P2Y12 inhibitor to clopidogrel are of paramount importance. Similar considerations apply to patients with an OAC indication who, according to the ARC–HBR criteria, are HBR. Although new-generation drug-eluting stents (DES) have been developed to induce faster stent endothelization, only few DES have been examined in a HBR population, and these stents should be preferred. The aim of this review is to present the current knowledge of the HBR population and provide comprehensive algorithms to optimally treat HBR patients who undergo PCI with or without an OAC indication and for both ACS and CCS.

Heart failure (HF) is increasingly recognized as a progressive syndrome that begins long before patients develop clinical signs or symptoms, during which conventional echocardiographic parameters may fail to detect early myocardial impairment. Atrial strain imaging by speckle-tracking echocardiography has emerged as a sensitive, non-invasive tool capable of identifying subtle functional abnormalities before symptoms or structural remodeling occur. Impaired left atrial (LA) reservoir strain (LASr) serves as a sensitive marker of left ventricular (LV) diastolic dysfunction with elevated filling pressures, exercise intolerance, and HF with preserved ejection fraction, with incremental diagnostic or prognostic value reported in selected studies. Reduced LA strain is also strongly associated with atrial fibrillation (AF), valvular heart disease progression, adverse outcomes following myocardial infarction, and pulmonary vascular involvement. Although comparatively less studied, right atrial (RA) reservoir strain (RASr) reflects the haemodynamic burden of the right heart, right ventricular–pulmonary arterial coupling, and early subclinical dysfunction in cardiometabolic disease, pulmonary hypertension, and established HF. Similarly, RA strain has demonstrated potential diagnostic and prognostic value across the HF spectrum. This review summarizes contemporary evidence regarding the pathophysiological, diagnostic, and prognostic significance of LASr and RASr in unveiling subclinical dysfunction in HF. Both LA and RA strain may provide complementary information on atrioventricular coupling and may identify functional impairment and increased haemodynamic burden before overt structural remodeling becomes evident. Atrial strain assessment may therefore complement conventional echocardiography in the early detection, phenotypic characterization, and risk stratification of patients across different stages of HF.