Transthyretin Cardiac Amyloidosis in Older Adults: Optimizing Cardiac Imaging to the Corresponding Diagnostic and Management Goal

Abstract

Purpose of review Transthyretin cardiac amyloidosis is increasingly recognized as an important cause of heart failure in older adults. Many cardiac imaging modalities have evolved to evaluate transthyretin cardiac amyloidosis and include 2D echocardiography with tissue Doppler and speckle-strain imaging, nuclear scintigraphy, cardiac magnetic resonance imaging, and positron emission tomography. The purpose of this review is to highlight the optimal selection of advanced cardiac imaging techniques with corresponding diagnostic goals including raising suspicion, making an early diagnosis, and subtyping transthyretin cardiac amyloid, as well as management goals including assessment of ventricular impairment, prognosticating, and monitoring disease progression. Potential benefits of optimizing cardiac imaging in the elderly patient with transthyretin cardiac amyloidosis may include enhanced and earlier diagnosis and refined long-term management. Recent findings Advances in cardiac imaging techniques are changing diagnostic and management algorithms for transthyretin cardiac amyloidosis. Summary With a new era of novel therapeutics, enhanced recognition, and earlier diagnosis approaching, selecting the appropriate non-invasive cardiac imaging modality will be essential for optimal care in the elderly patient with transthyretin cardiac amyloidosis.

Heart Failure Association of the ESC, Heart Failure Society of America and Japanese Heart Failure Society Position statement on endomyocardial biopsy

“…These imaging techniques allow identification of cardiac structural and functional alterations, tissue characterisation, exclusion of significant coronary artery disease or pericardial involvement, and the assessment of myocardial perfusion and metabolism (Table 5). [85][86][87][88][89][90][91] In most instances, modern imaging techniques in combination with laboratory analyses, biomarkers, genetic testing and/or biopsy of non-cardiac tissues can provide the diagnosis without a requirement for EMB, thus narrowing the scope of clinical situations in which EMB may be necessary. Nevertheless, EMB cannot be fully substituted by cardiac imaging.…”

The quintessential form of diastolic heart failure in older adults: Wild type transthyretin cardiac amyloidosis

“…This test is noninvasive and readily obtainable in the older adult patient. Echocardiographic findings in support of the diagnosis are well described and include biventricular wall thickening, biatrial enlargement, thickening of the interatrial septum, and the presence of a pericardial effusion . Other echocardiographic features are diastolic dysfunction and/or a “speckled” appearance of the myocardium.…”

“…Echocardiographic findings in support of the diagnosis are well described and include biventricular wall thickening, biatrial enlargement, thickening of the interatrial septum, and the presence of a pericardial effusion. 30 Other echocardiographic features are diastolic dysfunction and/or a "speckled" appearance of the myocardium. However, it is important to note these findings are neither sensitive nor specific for cardiac amyloidosis.…”

Evolución a mediano plazo de pacientes con diagnóstico de cardiopatía amiloidótica por transtiretina

“…La amiloidosis por transtiretina de tipo salvaje es una enfermedad de inicio tardío, que por lo general se asocia con afectación principalmente cardíaca. (16)(17)(18)(19)(20) En contraste, la amiloidosis por transtiretina hereditaria es una enfermedad autosómica dominante de penetrancia incompleta, con un inicio de la sintomatología más temprano y una presentación variable, que depende de la mutación específica de transtiretina, entre otros, y puede originar fenotipos cardíacos, neurológicos o mixtos. Ante el diagnóstico de amiloidosis cardíaca por transtiretina hereditaria, el estudio genético y el cribado clínico de los familiares de primer grado debe ser considerado.…”