Review

European Journal of Preventive

Cardiology

Keys to early diagnosis of cardiac 2020, Vol. 27(17) 1806–1815

! The European Society of
Cardiology 2019
amyloidosis: red flags from clinical, Article reuse guidelines:
sagepub.com/journals-permissions
laboratory and imaging findings DOI: 10.1177/2047487319877708
journals.sagepub.com/home/cpr

Giuseppe Vergaro1,2, Alberto Aimo1, Andrea Barison1,2,

Dario Genovesi2, Gabriele Buda3, Claudio Passino1,2 and
Michele Emdin1,2

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Abstract
Cardiac involvement in systemic amyloidosis, due either to immunoglobulin light-chain or transthyretin amyloidosis,
influences clinical presentation and is a strong predictor of unfavourable outcome. Until recently considered as a rare,
incurable disease, cardiac amyloidosis, is still mis/underdiagnosed, although treatments effective in improving patient
survival are now available for both subtypes, including chemotherapy regimens for immunoglobulin light-chain amyloid-
osis and tetramer stabiliser for transthyretin amyloidosis. Achieving a timely diagnosis allows initiating life-saving thera-
pies and requires the early recognition of clinical, laboratory and imaging signs of cardiac involvement, some of them may
be apparent well before the disease becomes clinically manifest. Given the systemic nature of amyloidosis, a close
interaction among experts in multiple specialties is also required, including cardiologists, nephrologists, haematologists,
neurologists, radiologists, nuclear medicine specialists and internists. As an increased awareness about disease presen-
tation is required to ameliorate diagnostic performance, we aim to provide the clinician with a guide to the screening and
early diagnosis of cardiac amyloidosis, and to review the clinical, biohumoral and instrumental ‘red flags’ that should raise
the suspicion of cardiac amyloidosis.

Keywords
Cardiac amyloidosis, diagnosis, red flags
Received 13 July 2019; accepted 1 September 2019

Cardiac amyloidosis: why to suspect it
Amyloidosis is a systemic disease characterised by
extracellular deposition of insoluble fibrils, deriving
from proteins encoded by mutated genes or normal,
misfolded proteins. Cardiac involvement in amyloid-
osis is a major determinant of clinical presentation
and outcome, and is common in immunoglobulin
light-chain (AL) amyloidosis and transthyretin amyl-
oidosis (ATTR).
AL amyloidosis is the most common type of sys-
temic amyloidosis, affecting approximately 10 people
per million per year.1 Monoclonal light chains undergo
extracellular misfolding and aggregation into proteo-
toxic soluble oligomers and, finally, into amyloid fibrils.
The outcome of patients with AL amyloidosis is poor,
especially when cardiac involvement is present.2
Nonetheless, given recent advances in haematological
therapy and better support therapy for cardiac amyl-
oidosis (CA), patient survival is improving.3
TTR is a highly conserved protein rich in beta strands
which is synthesised mostly by the liver and involved in
the transportation of thyroxine and retinol-binding pro-
tein. Wild-type (wt) TTR has an intrinsic propensity to
aggregate into insoluble amyloid fibres. The process of
fibrillogenesis requires the dissociation of TTR
1
Institute of Life Sciences, Scuola Superiore Sant’Anna, Italy
2
Fondazione Toscana Gabriele Monasterio, Pisa, Italy
3
Department of Clinical and Experimental Medicine, University of Pisa,
Italy
Corresponding author:
Giuseppe Vergaro, Scuola Superiore Sant’Anna and Fondazione Toscana
Gabriele Monasterio, Via G. Moruzzi 1, 56124 Pisa, Italy.
Email: vergaro@ftgm.it
Vergaro et al.
homotetrameric structure into misfolded monomers
that self-assemble in soluble oligomeric species, protofi-
brils and finally mature amyloid fibres, which deposit
within tissues. ATTR can follow the deposition of
either mutant (variant ATTR, vATTR) or wild-type
TTR (ATTRwt). Single-base substitutions resulting in
missense mutations represent the majority of genetic
alterations in vATTR; the clinical presentation of
vATTR is largely influenced by the underlying muta-
tions, ranging from pure polyneuropathy (as in familial
amyloid polyneuropathy), to the coexistence of neuro-
logical and cardiac disease, to isolated cardiomyopathy.
The most common mutation in vATTR is a point muta-
tion causing the replacement of a valine with a methio-
nine at position 30 (V30M).4 The epidemiology of
vATTR is difficult to define as its prevalence displays
significant regional variations, although in a recent
study 5% of patients initially diagnosed with left ven-
tricular (LV) hypertrophy had TTR gene mutations.5
Previously termed senile CA, as the heart is usually the
most severely affected organ, ATTRwt is a sporadic dis-
order, most often affecting men. Several reports have
challenged the common view of ATTRwt as a rare dis-
ease. Autopsy studies suggest that the prevalence of
ATTRwt may be as high as 25% of individuals older
than 85 years,6 and 13% among patients with heart fail-
ure and preserved ejection fraction (HFpEF).7
Tafamidis, a tetramer stabiliser, has recently been
proven to be the first therapy able to modify the natural
history of ATTR cardiomyopathy, reducing all-cause
mortality and cardiovascular-related hospitalisations,8
and many other molecules are currently being tested.9
As the therapeutic armamentarium for both AL
amyloidosis and ATTR-related cardiomyopathy is
increasing, and the management of CA is substantially
different from other forms of heart failure (HF)10 or
hypertrophic cardiomyopathy (HCM),11 clinicians pos-
sibly dealing with amyloidosis patients (including, but
not limited to, cardiologists, internal and nuclear medi-
cine specialists, nephrologists, neurologists and general
practitioners) should be aware of this condition, which
remains a highly underdiagnosed disorder, with often
long times to diagnosis.12 In the present paper, we sum-
marise the red flags, i.e. those clinical, biohumoral and
imaging findings prompting the diagnosis of a specific
disease, that should raise a suspicion of CA (Figure 1).
Clinical features
AL amyloidosis or ATTR-related CA is typically
identified when signs and symptoms of restrictive
cardiomyopathy and/or HFpEF develop, including
dyspnoea, reduced exercise tolerance, peripheral
oedema, hepatomegaly, ascites and elevated jugular
pressure. Nonetheless, such a presentation is usually
1807
observed in advanced stages of disease, while cardiac
involvement may be more subtle or even asymptomatic
in earlier phases.13
AL amyloidosis is a systemic disease, with half of the
patients having renal involvement, 16% having liver
disease and 10% having neuropathy.14 Information
about the coexistence of such conditions should be
acquired as a part of routine patient interview.
Phenotypic heterogeneity is also significant in the case
of vATTR, following differences in the responsible
mutation, penetrance, ethnicity and geographical area.
Some mutations are associated with combined neuro-
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logical and cardiac manifestations, whereas others have
exclusively either a neurological or, less frequently,
cardiological presentation.15 Especially in endemic
areas, a family history of hereditary amyloidosis or,
more commonly, cardiac hypertrophy presenting in
aged individuals, should prompt the initiation of
screening measures even in asymptomatic individuals.
Extra-cardiac disease is less frequent in ATTRwt,
although clues to systemic amyloid deposition come,
for example, from carpal tunnel syndrome (which is
observed in half of the patients and often precedes car-
diac manifestations by several years),16 or from rupture
of the long head of the biceps tendon, producing the
‘Popeye sign’, both representing clinically relevant red
flags.17 Although generally affecting the elderly male
population, recent reports have shown that women
account for up to 20% of ATTRwt cases.13 In addition,
ATTRwt is increasingly being recognised as a cause of
HFpEF, accounting for a considerable number of cases
in recent series.7 Notably, other possible causes of myo-
cardial hypertrophy do not exclude the diagnosis of CA.
For example, hypertension is present in more than half
of patients with ATTRwt, and significant mitral or
aortic diseases (possibly even requiring transcatheter
aortic valve replacement) may be encountered.13
Electrocardiogram: common and less
common findings
The electrocardiogram (ECG) in CA may show low-vol-
tage QRS complexes. This can be attributed to the accu-
mulation of non-conducting amyloid fibres, and
possibly also to myocardial oedema (which might
explain why the low-voltage pattern is more common
in AL than ATTR amyloidosis despite a greater amyloid
burden in the latter condition).18 A decrease in QRS
voltages is a red flag for the disease, often preceding a
significant increase in LV wall thickness. A characteristic
discrepancy between peripheral and precordial leads is
commonly observed, with peripheral leads showing low
voltages while voltages in precordial leads are normal or
occasionally high. This discrepancy is not observed with
other causes of low-voltage ECG patterns, namely
1808 European Journal of Preventive Cardiology 27(17)

Polineuropathy Reduced GFR

CLINICAL Family history of Monoclonal BIOMARKERS

Thrombo/ “hypertrophy” component Proteinuria
embolism

nNT-proBNP
Restrictive Bilateral CTS /BNP
Abnormal
CMP Histology liver
Popeye Sign function
HFmr/pEF
Periorbital purpura
Genetic testing n troponin

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Macroglossia

CARDIAC
AMILOIDOSIS
Mass/
voltage Diffuse
AV
discrepancy subendocardial LGE
conduction
Early darkening Pleural
disorders RV
Low QRS Cardiac uptake effusion
dysfunction
voltages with bone tracers
Apical
LBBB/ sparing
RBBB Increased wall
Pseudonecrosis Pericardial
thickness
ECG Q waves effusion IMAGING
Supraventricular
Atrial dilation/
arrhythmias
dysfunction

Figure 1. Clinical, electrocardiographic, biohumoral and imaging findings raising the suspicion of cardiac amyloidosis. Darker areas
indicate higher diagnostic specificity. AV: atrio-ventricular; BNP: B-type natriuretic peptide; CMP: cardiomyopathy; CTS: carpal tunnel
syndrome; GFR: glomerular filtration rate; HFmr/pEF: heart failure with mid-range/preserved ejection fraction; LGE: late gadolinium
enhancement; NT-proBNP: N-terminal fraction of B-type natriuretic peptide; RV: right ventricular.

pericardial or pleural effusion, obesity, emphysema,
pneumothorax, or myxoedema.19,20 Among 337
consecutive treatment-naive AL amyloidosis patients
(233 with cardiomyopathy and 104 without), the esti-
mated prevalence of low-voltage patterns in AL amyl-
oidosis ranged from 84% when the Sokolow–Lyon
index of 15 mm or less was used as a cut-off, to 27%
when low voltages were defined as QRS amplitude of
5 mm or less in each peripheral and 10 mm or less in
each precordial lead.21 In other cohort studies on AL
amyloidosis, using different diagnostic criteria, the
prevalence of low QRS voltages ranged from 42% to
71%.18–21 Finally, among patients with biopsy-con-
firmed CA, only 60% (AL) and 35% (ATTR) displayed
low peripheral voltages (<5 mV in all peripheral
leads).18 Overall, despite the multiplicity of diagnostic
criteria, the absence of a low-voltage ECG pattern
does not rule out AL or ATTR-type CA and the discrep-
ancy between QRS voltages and LV mass as measured
by echocardiography could be even more relevant than
QRS voltages per se.
Conduction disturbances are also common in
patients with CA. Among 344 patients diagnosed with
AL amyloidosis, those with cardiac involvement
(n ¼ 240) displayed prolonged PQ, QRS, QT and QTc
intervals (all P < 0.05) and a higher prevalence of intra-
ventricular blocks (28% vs. 17%, P < 0.05).22 Other
ECG features described in patients with AL-type CA
are a pseudo-infarction pattern with QS complexes in
the anterior leads, an unusual axis of the QRS complex
(particularly extreme right axis deviation),19 abnormal
P wave morphology and duration (reflecting slow atrial
conduction). In AL-type CA, a fragmentation of QRS
complexes has been reported, consisting of abnormal-
ities such as notches and a RsR0 pattern in the absence
of QRS prolongation, reasonably due to areas of
myocardial necrosis and fibrosis.23 Atrial fibrillation
is also rather frequent in patients with amyloidosis.
Vergaro et al.
For example, more than half of patients with ATTRwt
had any form of atrial fibrillation in a recently pub-
lished series.13
Laboratory findings
Sensitive biomarkers are required to identify cardiac
damage at an early, asymptomatic stage. Such markers
might be particularly useful in patients considered at
higher risk for the development of amyloidosis, such
as those with monoclonal gammopathy of unknown
significance (MGUS), at risk of AL CA especially
when an abnormal free light chain j/k ratio is pre-
sent,24 and carriers of TTR gene mutations, searchable
by genetic screening when needed to differentiate
vATTR and ATTwt amyloidosis.
With regard to the confirmation of the suspicion of
AL CA the search for the j/k monoclonal protein
either in serum or urine, although not detectable
in 50% of patients, is necessary, while the increase
in free light chain blood concentration is essential to
diagnosis, useful for risk stratification and evaluation
of treatment efficacy.14
Natriuretic peptides and troponins are invariably
elevated in patients with CA, following interstitial
amyloid deposition or direct toxic effects of light
chains on cardiomyocytes.25 In patients with AL-type
CA, B-type natriuretic peptide (BNP) and N-terminal
proBNP (NT-proBNP) are produced and released into
the bloodstream following volume overload and direct
toxicity by immunoglobulin light chains. Among
152 subjects with AL amyloidosis, those with cardiac
disease never had NT-proBNP levels lower than the
97.5 percentile for normal individuals, indicating
100% sensitivity; furthermore, a 1285 ng/L
NT-proBNP cut-off had 92% accuracy for the
detection of cardiac involvement.26 As NT-proBNP
increase predicts HF development in AL amyloidosis,27
routine NT-proBNP testing is recommended during the
follow-up of patients with MGUS and an abnormal j/k
ratio.24
Unexplained or disproportionate circulating levels of
natriuretic peptides may also support the clinical and
instrumental suspicion of ATTR cardiomyopathy,
in particular in high-risk populations, such as carriers
of TTR mutations (either asymptomatic or with only
neuropathic symptoms),5 or in patients with conditions
mimicking or associated with ATTR, such as aortic
stenosis or HFpEF.7 Natriuretic peptides also reflect
the severity of cardiac amyloid burden,28 and patients
with elevated BNP and NT-proBNP at diagnosis are at
higher risk of mortality.29
Cardiac troponins (cTn) are specific markers of myo-
cardial injury. Newer, high-sensitivity assays allow us
to detect much lower concentrations, thus refining
1809
diagnosis and risk stratification in both acute and
chronic settings, as in HF and cardiomyopathies. The
elevation of plasma highly sensitive troponin T (hs-
TnT) is observed in the vast majority of patients with
AL amyloidosis, including those free from overt cardiac
involvement, and represents a red flag for the disease.
Moreover, hs-TnT is associated with clinical indices of
HF severity, LV systolic dysfunction, and wall thick-
ness in patients with AL-type CA.30 The exact mechan-
ism of cTn release in patients with amyloidosis has to
be elucidated, but the proinflammatory or toxic effects
of the amyloid fibres or their precursors and/or micro-
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vascular ischaemia may lead to cardiomyocyte damage
and troponin release. cTn is commonly elevated in
patients with ATTR cardiomyopathy, although to a
lesser extent than in AL-type CA, despite a more
severe increase in wall thickness and worse LV systolic
function.31 Nonetheless, evidence on the diagnostic
properties of circulating biomarkers in CA is still lim-
ited.32,33 Notably, natriuretic peptide and cTn levels
must be interpreted based on renal function and/or
atrial fibrillation, which are commonly encountered in
these patients and affect circulating levels of these
biomarkers.
Confirmation and refinement of the diagnosis may
include the search for amyloid deposits either at the
periumbilical fat level, or in selected cases with the sus-
picion of AL CA, by endomyocardial biopsy.24
Echocardiography
Echocardiography is the most widely used non-invasive
test in patients with HF or abnormal cardiac findings
on examination. The most common two-dimensional
(2D) echocardiographic findings observed in CA are
biatrial dilation, increased LV and right ventricular
(RV) wall thickening, and normal or small LV cavity
size; occasionally, a pericardial effusion can be found.34
Concentric LV pseudohypertrophy is seen in over 90%
of cases of CA, although asymmetric septal hypertro-
phy, LV outflow tract obstruction, or even normal wall
thickness, non-dilated or minimally dilated LV, and
reduced ejection fraction may be encountered. The
myocardium can acquire a granular sparkling appear-
ance, which is attributed to the increased echogenicity
of the amyloid protein.34 In addition, amyloid depos-
ition accounts for the mismatch between QRS voltages
and the degree of LV hypertrophy, as described above.
Doppler imaging usually reveals only mild valvular
dysfunction, while diastolic function is often signifi-
cantly impaired.34 At the initial stages, an abnormal
relaxation pattern is observed, possibly progressing to
a restrictive pattern. Peak early diastolic velocity (E0 )
assessed by tissue Doppler imaging is decreased in the
earliest stages of the disease, and further decreases with
1810
the disease progression, which helps differentiate CA
from disorders such as constrictive pericarditis or
HCM, in which E0 is normal or mildly reduced.34
Strain imaging demonstrates an impairment of lon-
gitudinal ventricular contraction before the decline of
ejection fraction and HF development. In a study of
40 patients with biopsy-confirmed CA and 60 patients
with HCM or hypertensive heart disease, LV global
longitudinal strain (GLS) showed the best performance
to discriminate CA, both in the whole population and
in the subgroups with maximum wall thickness of
16 mm or less or left ventricular ejection fraction
(LVEF) greater than 55%.35 As GLS is impaired
much earlier than LVEF, the LVEF strain ratio
(LVEF/absolute value of global longitudinal strain –
GLS) was proposed, and found to be significantly
higher among CA patients than other individuals with
myocardial hypertrophy, with a cut-off value of
4.1 being associated with an area under the curve of
0.91 for the differentiation of CA from HCM or healthy
controls.36 Together with GLS, circumferential and
radial deformations were reported to be significantly
decreased in patients with CA.37 A severe impairment
of basal longitudinal strain with relative preservation of
apical strain is typically observed. This ‘apical sparing’
is found in both AL and ATTR cardiomyopathy, and is
both sensitive and specific for the diagnosis of CA.38
RV dilation may occur in late disease stages, prob-
ably because of a combination of pulmonary hyperten-
sion and RV systolic dysfunction due to infiltration. LA
function is very often impaired in CA, as assessed
through conventional and strain-derived parameters
of LA function, reflecting reservoir, conduit and con-
tractile LA functions.39 The prevalence of LA thrombi
is remarkably high, even among patients in sinus
rhythm.40 Peak LA longitudinal strain and active LA
emptying fraction were reported to be more altered in
patients with ATTRwt than AL and vATTR.39
Cardiac magnetic resonance
Cardiac magnetic resonance (CMR) allows us to evalu-
ate biventricular morphology and size, functional
parameters (particularly systolic function) and myocar-
dial tissue composition. CMR may reveal almost
pathognomonic findings in advanced amyloidosis, and
may lead to a non-invasive diagnosis of ATTR cardio-
myopathy when combined with clinical and electrocar-
diographic data, diphosphonate scintigraphy and the
exclusion of a monoclonal protein.41
CA is frequently associated with extra-cardiac
abnormalities, most notably pleural effusion (possibly
accompanied by pericardial effusion) and ascites.42
Asymmetrical hypertrophy has been traditionally asso-
ciated with HCM, but emerged as the commonest
European Journal of Preventive Cardiology 27(17)
pattern of ventricular remodelling in ATTR-type CA
(79%), followed by symmetrical concentric hypertro-
phy (18%) and the absence of LV hypertrophy (3%).
Asymmetrical hypertrophy was much less frequent in
AL amyloidosis (14%), while concentric hypertrophy
was found in 68%, and no hypertrophy in 18%.43
Hypertrophy is typically more pronounced than in
hypertensive or valvular heart disease, and is more
prominent in ATTR than AL amyloidosis.42 Contrary
to HCM or other forms of secondary hypertrophy,
changes over months in wall thickness and function
are quite typical of AL amyloidosis.42 The LVEF may
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be normal even into the late phase of disease, while
indexed stroke volume is usually severely reduced.42
Atrial wall thickening, dilation and thrombosis in the
LA appendage can be observed. Finally, an increase in
right ventricular mass is quite common.42
At myocardial tissue characterisation, the typical
amyloid pattern consists of global subendocardial late
gadolinium enhancement (LGE), which may be com-
bined (particularly in AL amyloidosis) with blood pool
early darkening due to the rapid contrast washout from
the blood pool into the systemic interstitial space,
which is extremely enlarged by amyloid deposition.
The typical LGE pattern is virtually pathognomonic
and significantly more specific and sensitive than echo
or CMR functional assessment, and may be an early
finding, i.e. presenting before a significant increase in
mass develops.42 In a meta-analysis of seven studies, the
diagnostic accuracy of LGE CMR, partially deriving
from the detection of this typical LGE pattern, was
reported as high (sensitivity 85%, specificity 92%).44
Notably, different LGE patterns can be encountered,
such as localised enhancement or diffuse transmural
or patchy LGE.45 Overall, non-typical LGE patterns
do not allow us to exclude CA. Furthermore, as LGE
is typically more prominent in ATTR compared with
AL amyloidosis, LGE analysis has been proposed as a
tool to differentiate ATTR from AL cardiomyopathy.
An LGE scoring system taking into account the pres-
ence of circumferential and/or transmural LGE in
basal, mid-wall and apical slices, as well as the presence
of RV LGE, was proposed. A score of 13 or greater
differentiated ATTR from AL type with 82% sensitiv-
ity and 76% specificity.45
LGE quantification and assessment of LGE changes
over time may still prove challenging. The use of
contrast medium is also limited in patients with an
estimated glomerular filtration rate less than
30 mL/min/1.73 m2, which is quite common in systemic
AL amyloidosis. Native (i.e. pre-contrast) T1 mapping
may help overcome these limitations. Myocardial
native T1 values increase progressively from diffuse
fibrosis to scar tissue and finally to amyloid
and oedema (the latter being an important element of
Vergaro et al.
AL-type CA), and allow us to differentiate with high
accuracy AL and ATTR cardiomyopathy from
HCM.42 An increase in native T1 may represent a red
flag for the disease, as it is observed before the onset of
LV pseudohypertrophy, LGE development or elevation
in blood biomarkers, and is also able to track cardiac
amyloid burden with the potential to become a useful
tool to quantify cardiac amyloid and track changes
over time.42 At 1.5 T, specific native myocardial T1
cut-off values have been found (<1036 ms to exclude
CA with 98% negative predictive value; T1 > 1164 ms
to confirm CA with 98% positive predictive value), and
a diagnostic algorithm reserving gadolinium adminis-
tration only for patients with intermediate values
(native T1 between 1036 and 1164 ms, representing
58% of patients in the study population) has been
proposed.46
Interstitial expansion due to amyloid infiltration
manifests as extracellular volume increase, which can
be calculated at CMR from postcontrast T1 mapping,
after correction for native T1 and haematocrit.47
Extracellular volume has been demonstrated to be not
only an important early diagnostic tool, being generally
higher in TTR than AL amyloidosis,48 but also a prog-
nostic marker in both AL49 and TTR amyloidosis,43
and a potential tool to monitor response to treatment.
Diphosphonate scintigraphy
Radiolabelled phosphate derivatives, initially devel-
oped as bone tracers, were first noted to localise to
amyloid deposits in 1977 in two patients receiving
99m
Tc-diphosphonate.50 This finding led to the devel-
opment of several tracers, including 99mTc-3,
3-diphosphono-1,2-propanodicarboxylic acid (DPD),
99m
Tc-pyrophosphate (PYP), 99mTc-methylene dipho-
sphonate (MDP) and 99mTc-hydroxymethylene dipho-
sphonate (HMDP).51 In 2005, Perugini et al.52
performed 99mTc-DPD imaging on 25 patients with
CA (10 vATTR, five wtATTR, 10 AL). All 15 ATTR
patients displayed a strong myocardial uptake of
99m
Tc-DPD while no uptake was observed in AL
patients. Therefore, the sensitivity and specificity of
99m
Tc-DPD scintigraphy to diagnose ATTR cardiomy-
opathy were both 100%.52 Several other studies
confirmed these findings, allowing us to conclude
that, in patients with CA, intense 99mTc-DPD retention
is basically pathognomonic of ATTR cardiomyopathy,
while absent uptake tends to exclude this diagnosis.
Moderate 99mTc-DPD myocardial uptake was reported
to be of indeterminate significance, with a prevalence in
AL and ATTR cardiomyopathy of 18% and 36%,
respectively.52–54
The correlation between the intensity of tracer
uptake and cardiac disease severity, evaluated in
1811
terms of septal thickness or impaired longitudinal func-
tion, provides the conceptual framework for the visual
Perugini scoring system: grade 0, no cardiac uptake;
grade 1, cardiac uptake present but less intense than
the bone signal; grade 2, cardiac uptake with intensity
similar to or greater than bone signal; grade 3, cardiac
uptake with much attenuated or absent bone signal.52
This system has been incorporated in the algorithm for
the non-biopsy diagnosis of ATTR-type CA, in which
diphosphonate scintigraphy is advised when CA is sus-
pected based on a combination of clinical, biohumoral
and/or imaging data. When the Perugini grade is 2 or 3,
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and no monoclonal protein is found, ATTR cardiomy-
opathy can be diagnosed without the need for histo-
logical confirmation. By contrast, when a monoclonal
protein is found or Perugini grade is 1, histological con-
firmation and typing of amyloid (preferably through an
endomyocardial biopsy) is suggested. Finally, when
Perugini grade is 0, CMR should be performed or
reviewed when a monoclonal protein is found, while
CA is unlikely if no monoclonal protein is detected
(Figure 2).41
In addition to the semiquantitative Perugini score, a
quantitative analysis can be performed by drawing a
region of interest over the heart corrected for contra-
lateral counts and calculating a heart-to-contralateral
ratio (H/CL). The degree of tracer uptake in the heart
was reported to correlate with LV wall thickness and
mass, and patients with ATTR-type CA displayed a
higher quantitative score than those with AL-type
CA. A H/CL ratio greater than 1.5 had a 97% sensi-
tivity and 100% specificity for identifying ATTR car-
diac amyloidosis.54
There are a few reports of the use of single-photon
emission computed tomography (SPECT) in patients
with ATTR-type CA.55,56 Compared with planar ima-
ging, tomographic acquisitions could allow us to diag-
nose cardiac involvement at an earlier stage, to quantify
the global and regional amyloid burden, and to provide
insight into disease progression and the response to
treatment.
The detection of cardiac uptake during a bone scan
performed for other reasons has been reported.57 We
are not aware of studies assessing the frequency of this
incidental finding, which should prompt a diagnostic
work-up for CA.
Gatekeepers in cardiac amyloidosis
Amyloidosis is a systemic disease and, although cardiac
involvement is one of the major determinants of out-
come, the disease may present with a functional impair-
ment of other organs. Moreover, some non-cardiac
conditions define populations at risk of the develop-
ment of CA. Consequently, there is a need for
1812 European Journal of Preventive Cardiology 27(17)

RED FLAGS
>LV wall thickness + low QRS voltage, +/– HF symptoms,
<troponin/B-type natriuretic peptides, peripheral/autonomic neuropathy,
family history, multi-organ involvement

Diphosphonate scintigraphy (Perugini score)

Grade 0 Grade 1 Grade 2–3

Serum and urine immunofixation, serum free light chain assay.

Monoclonal protein present?

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No Yes Yes No Yes No

Review/ Cardiac ATTR

request amyloidosis
CMR Histological confirmation and
typing of amyloid
TTR
genotyping

Cardiac Other Cardiac

AL/ATTR cardiomyopathies amyloidosis
amyloidosis (AL, ATTR,
unlikely other forms) ATTRv ATTRwt

Figure 2. Diagnostic algorithm for cardiac amyloidosis. A schematic representation of the diagnostic algorithm for cardiac amyl-
oidosis, revised from that proposed by Gillmore et al.,41 is proposed. Consultation with a haematologist is warranted when a
monoclonal component is detected. AL: immunoglobulin light-chain amyloidosis; ATTR: transthyretin amyloidosis (ATTRv): variant
transthyretin amyloidosis; ATTRwt: wild-type transthyretin amyloidosis; CMR: cardiac magnetic resonance; HF: heart failure. Modified
from Emdin et al.9

collaboration among neurology, nephrology, haematol- immunofixation electrophoresis to search for j or k

ogy and cardiology specialists in order to achieve a
timely diagnosis and improve prognosis (Figure 3).
Haematologists following patients with plasma cell
disorders should raise the suspicion of CA when
nephrotic range proteinuria, HFpEF, non-diabetic per-
ipheral neuropathy, unexplained hepatomegaly or diar-
rhoea develop. Physical signs of amyloidosis, such as
macroglossia or periorbital purpura, are highly specific
but poorly sensitive, and should never be used to rule
out the disease.58 Patients with MGUS or smouldering
myeloma should also be monitored to check for the
development of AL amyloidosis, which is 8.8-fold
more likely than in the general population.59
Although patients with MGUS or multiple myeloma
typically have a monoclonal peak on serum protein
electrophoresis, patients with AL amyloidosis often
have little intact monoclonal Ig; furthermore, most of
them have only light chains, and about half the patients
are missed if only serum protein electrophoresis is used
for screening, which underlies the importance of
light chains.60 The latest recommendations suggest
that cardiac involvement should be diagnosed when
mean wall thickness is greater than 12 mm at echocar-
diography (in the absence of other causes of hypertro-
phy), and/or NT-proBNP greater than 332 ng/L when
renal failure or atrial fibrillation are not present.61
On the other hand, lower circulating concentrations
do not allow us to rule out CA, especially when clinical
suspicion is high and other causes of natriuretic peptide
elevation are excluded.
Kidney involvement is found in two-thirds of
patients with AL amyloidosis at the time of diagnosis,
and may present with proteinuria in the nephrotic
range (composed mainly of albumin, often with detect-
able urine monoclonal light chains) and, in some cases,
decreased glomerular filtration rate.62 A relevant
number of cases is then diagnosed by nephrologists.
Although the screening for cardiac involvement is man-
datory once the diagnosis has been clarified, most early
signs of cardiac disease are to be considered with
Vergaro et al.
CARDIOLOGIST NEPHROLOGIST
HFpEF (HFrEF) Proteinuria
↑ LV mass ↓ GFR
↑ cTn/B-type NPs
NEUROLOGIST INTERNIST
CARDIAC
Peripheral Multi-organ
AMYLOIDOSIS involvement
and/or autonomic
neuropathy
HAEMATOLOGIST
Plasma cell
dyscrasia
Figure 3. A multidisciplinary approach as a key to the early
diagnosis of cardiac involvement in amyloidosis. GFR: glomerular
filtration rate; HFpEF: heart failure with preserved ejection
fraction; HFrEF: heart failure with reduced ejection fraction; NPs:
natriuretic peptides; LV: left ventricular.
caution; for example, circulating concentrations of
markers of myocardial damage are influenced by
renal function,63 and long-term reduction in the glom-
erular filtration rate can lead to LV hypertrophy by
itself.
Autonomic neuropathy, either alone or associated
with peripheral neuropathy, is observed in both AL
and ATTR amyloidosis. Such symptoms, when not
explained by concomitant disorders, should prompt a
screening for amyloidosis and for cardiac involvement,
particularly in high-risk subsets, e.g. carriers of TTR
gene mutations,5 those with a family history of ‘hyper-
trophic’ cardiomyopathy, or signs of systemic disease.
Conclusions and future directions
The diagnosis of CA is challenging because of its
phenotypic heterogeneity, multi-organ involvement
often requiring the interaction among experts in differ-
ent specialties and subspecialties, lack of a single non-
invasive diagnostic tool, and limited awareness in the
medical community. Recent studies have challenged the
dogma of CA as a rare, incurable disease, and have
redefined the epidemiology and therapeutic options of
this condition. Missing or delaying the diagnosis of CA
may have a profound impact on patient outcome, as
potentially life-saving treatments (in particular chemo-
therapy in the case of AL amyloidosis) may be omitted
or delayed. To obtain a timely identification, physicians
potentially encountering CA must be able to recognise
1813
the ‘red flags’ prompting a dedicated diagnostic
work-up.
Clinical signs of CA often appear in late-stage dis-
ease, thus effort is required to identify novel tools for an
early diagnosis. Biohumoral markers of cardiac
involvement will be likely to be of help, although
there is currently scarce evidence on their use for
screening purposes in at-risk individuals. Future
research should also be directed at identifying imaging
features holding high specificity for the differential
diagnosis of subtypes of CA. In this view, the use of
[18F]-Florbetaben positron emission tomography/com-
Downloaded from https://academic.oup.com/eurjpc/article/27/17/1806/6125508 by guest on 21 March 2023
puted tomography seems promising in the non-invasive
diagnosis of AL CA.64
Author contribution
GV, CP and ME contributed to the conception and design of
the work. GV, AA, AB, DG and GB contributed to the lit-
erature review and to the drafting of the manuscript. ME and
CP critically revised the manuscript. All authors gave final
approval and agree to be accountable for all aspects of the
work ensuring integrity and accuracy.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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