The role of retinol-binding protein 4 (RBP4), a natural binding partner of plasma circulating transthyretin (TTR), in TTR-associated cardiomyopathies is unknown. RBP4 is a small (21 kDa) protein that normally functions as a transporter for all-trans retinol (Vitamin A) and travels in the bloodstream as a ternary complex bound to TTR. Previous in vitro studies have demonstrated that RBP4 stabilizes native (tetrameric) TTR and prevents its disassembly into monomers, the key step in TTR amyloid fibril formation. Though increased serum concentrations of RBP4 have been reported in non-amyloidotic cardiomyopathies, there is little information about circulating levels in the inherited (ATTRm) and acquired (ATTRwt) forms of TTR-associated cardiac amyloid disease. Our study objectives were to investigate TTR amyloid-infiltrated cardiac tissue for the presence of RBP4 and to compare serum levels of the protein in ATTRm, ATTRwt and controls. We hypothesized that there would be histological and serological differences in RBP4 between ATTR patient and control samples. In the present study, we demonstrate that RBP4 is highly abundant in ATTRm cardiac tissue surrounding amyloid-infiltrated regions and, to a lesser extent, in ATTRwt specimens. Serum levels of RBP4 are significantly lower in ATTRm compared to ATTRwt (p < 0.0001) and healthy controls (p < 0.0011), with significant correlation between circulating RBP4 concentration and cardiac troponin-I (c-TnI) in our ATTRwt cohort. These data suggest, for the first time, that the pathobiologies of ATTRm and ATTRwt are dissimilar, and provide support for RBP4 as a serum biomarker of amyloid cardiomyopathy in ATTRm.