The diagnosis of Amyloidosis is often delayed or missed. Routine heart failure assessments such as echo and electrocardiogram (ECG), along with advanced imaging techniques, can help identify clues on the diagnostic pathway. By increasing your suspicion of Amyloidosis, you can identify patients who may require further testing to make a diagnosis.
Some familiar signs/symptoms that could be clues for cardiac amyloidosis, which include:
- Strain imaging showing apical sparing or apical preservation
- Longitudinal strain seen on echocardiography is reduced in the basal and midwall area; however, the apical strain is spared or preserved
- A history of bicep tendon rupture
- A diagnosis of hypertrophic cardiomyopathy
- Arrhythmias such as atrial fibrillation (most common) and conduction abnormalities, which may require a pacemaker
- Aortic stenosis (AS) and ATTR-CM may occur in elderly patients, notably those with a low-flow, low-gradient AS pattern
- Hip and knee arthroplasty
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Furthermore, here are a few things we don't hear much about, but definitely need to be apart of the conversation before ruling out or ruling in amyloidosis:
1. Heart failure with preserved ejection fraction in patients typically over 60
- In ATTR-CM, diastolic function is impaired due to amyloid fibril deposition in the myocardium, resulting in thicker and inelastic ventricles, thereby decreasing stroke volume. It is not until the later stages of ATTR-CM disease that ejection fraction drops
- Imaging clues, such as reduced longitudinal strain with apical sparing, may help increase suspicion
2. Intolerance to standard heart failure therapies, ie, ACEi/ARBs and beta blockers
- Patients can develop a decrease in stroke volume, which can lead to low blood pressure. As a result they can develop an intolerance to blood pressure–lowering therapies
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3. Diagnosis of carpal tunnel syndrome or lumbar spinal stenosis
- Bilateral carpal tunnel syndrome and lumbar stenosis are often seen in ATTR-CM due to amyloid deposition in these areas
- Bilateral carpal tunnel syndrome in ATTR-CM often precedes cardiac manifestations by several years
These hidden warning signs could be hidden in plain sight. Be sure to stay abreast of new findings, clinicial research and treatment breakthroughs with www.BlackDoctor.org
