JAMA Clinical Reviews Heart Failure Due to Transthyretin Protein Amyloidosis
Mar 5, 2024
Frederick L. Ruberg, cardiologist and Thomas J. Ryan Professor at Boston University, explains transthyretin (ATTR) cardiac amyloidosis. He outlines how ATTR presents in older adults, when to suspect it, and advances in noninvasive diagnosis. He discusses standard heart-failure care, arrhythmia surveillance and anticoagulation, and new disease-modifying therapies that stabilize or reduce transthyretin production.
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Consider ATTR In Older Patients With HF
- Suspect ATTR in older patients with progressive congestive heart failure symptoms like dyspnea, fatigue, hypotension, and edema.
- Consider ATTR when symptoms appear late in life or overlap with other conditions such as hypertension or aortic stenosis.
Noninvasive Diagnosis Is Now Standard
- Use noninvasive imaging plus blood tests to diagnose ATTR and often avoid endomyocardial biopsy.
- Combine CMR or sensitive echo with bone-seeking nuclear tracers (eg, technetium pyrophosphate) and exclude AL amyloidosis by blood testing.
Look For Extracardiac Clues
- Suspect amyloid when older patients have heart failure plus bilateral carpal tunnel or spinal stenosis.
- Refer for amyloid testing when these extracardiac clues or unexplained increased wall thickness are present.