Cardiac amyloidosis

The multiple subtypes of cardiac amyloidosis have varying epidemiological, diagnostic, and prognostic characteristics. One such stain is Congo Red, which binds specifically to the amyloid deposits and can be characterized by various lighting methods. Wild type ATTR cardiac amyloidosis (and the genetic variant) can be diagnosed with cardiac nuclear scintigraphy to visualize amyloid deposits in the heart walls. Serum free light chains, serum and urine electrophoresis with immunofixation can rule out AL amyloidosis. If the diagnosis is unclear, a biopsy may be obtained. Biopsy with histological evaluation can rule out light chain and genetic testing can rule out familial subtypes. This type is often misdiagnosed. However, greater use of cardiac magnetic resonance has increased the rate of diagnosis. The severity of the disease tends to be less than the light chain and familial variants. This is due to the amount of time that it takes to accumulate the amyloid depositions being longer in the wild-type variant. == Symptoms and signs==

Symptoms of cardiac amyloidosis are a combination of heart failure and amyloid deposition in various other organs. Cardiac manifestations include: • Dyspnea on exertion For patients with light-chain amyloidosis, there can be depositions of amyloid into numerous different organs. • Postural hypotension (secondary to autonomic neuropathy) • Nephrotic syndrome (secondary to free light chain damage to the kidneys/deposition of amyloid in the kidneys) == Cause ==

The general cause of cardiac amyloidosis is the misfolding of a specific protein precursor depending on the amyloidosis type. Protein precursors include immunoglobulin-derived light chains and transthyretin. The misfolding of the protein causes it to have insoluble beta-pleated sheets, creating an amyloid. Amyloid, the aggregation, or clumping, of proteins, is resistant to degradation by the body. Amyloids are mostly fibrils, while also containing a P component, apolipoprotein, collagen, fibronectin, and laminin. The P component, a pentameric protein, stabilizes the fibrils of the amyloid, which reduces their clearance from the body. Deposits of amyloid can occur throughout the body, including the heart, liver, kidneys, spleen, adrenal glands, and bones. Deposits in the extracellular cardiac space can stiffen the heart, resulting in restriction of the ventricles. This restriction in ventricular motion results in a decreased ability for the heart to pump efficiently, leading to the various symptoms associated with cardiac amyloidosis. Impaired protein processing (proteostasis) and reduced endoplasmic reticulum degradation of TTR with advancing age are thought to potentially contribute to the delayed presentation of both wild-type and genetic TTR amyloidosis. Both diseases usually presenting after age 60. == Diagnosis ==

Echocardiography Echocardiography is a safe and non-invasive method that can be used to assess structural and functional disease of the heart. ECG/EKG ECGs of patients with cardiac amyloidosis usually show a low voltage in the limb leads, with an unusual extreme right axis. There is usually a normal P-wave, however, it can be slightly prolonged. For patients with light-chain amyloidosis, the QRS complex pattern is skewed, Laboratory tests Laboratory tests including urea and creatinine levels, liver enzymes, glucose, thyroid function, full blood count, and clotting tests. The analysis of serum and urine for presence of monoclonal immunoglobulin is also done through immunofixation for detection of the monoclonal band. Presence of the monoclonal band would be consistent with light chain amyloidosis. For light chain amyloidosis, serum immunoglobulin free light chain assay can be used for diagnosis and following of the amyloidosis. As expected, with cardiac damage and dysfunction, there can be an elevation of these markers in patients with cardiac amyloidosis. These markers have been incorporated into the various staging/scoring systems used by physicians to determine severity of the disease and prognosis. Scintigraphy/radionuclide imaging Scintigraphy can be used to measure the extent and distribution of the amyloid throughout the body, including the liver, kidney, spleen, and heart. In this method of imaging, radiolabeled technetium is injected into the body where it binds to cardiac amyloid deposits. == Treatments ==

Treatments differ according to the type of amyloidosis present. For light-chain amyloidosis, the use of FLC assays and NT-proBNP levels can be used to monitor the progression of amyloidosis and any response to treatments. For familial amyloidosis, ACE-inhibitors and beta-blockers can be prescribed if there is no autonomic neuropathy. Liver transplantation does not always halt the disease, and in some cases disease progression continues. Medications such as patisiran and inotersen can also decreases the activity of the transthyretin genes. In a 30-month trial, tafamidis showed reduced mortality, reduced hospitalizations compared to placebo. Outside of standard indications for implantable cardioverter defibrillators for those with heart failure, specific benefits in those with cardiac amyloidosis are not well established. Two to 5% of people with ATTR amyloidosis experience sudden cardiac death. == Prognosis ==

Overall prognosis is dependent on the extent of cardiac dysfunction. Worse outcomes have been seen when echocardiography shows left ventricular wall thickness, poor systolic function and severe diastolic dysfunction. Light chain (AL-CM) Prognosis: For light-chain amyloidosis early detection leads to best possibility of therapies prolonging the period of remission. Well treated light chain cardiac amyloidosis has a 4-year survival rate of around 90%. In patients that undergo stem cell transplant the average survival time increases to 10 years. Staging systems have been developed to stratify severity of the disease, including the Mayo Biomarker Stage, which utilizes various biomarkers such as troponin I, troponin T, BNP, and NT-proBNP, and Free light chain concentrations. Familial (ATTRm-CM) Prognosis: Due to the extensive number of variables involved in this subtype, prognosis varies depending on the specific type of familial cardiac amyloidosis. Variables involve mutant vs wild type transthyretin mutation and age of onset of symptoms. In comparison to light chain amyloidosis, the familial subtype is slower to progress and has a more favorable prognosis. However, the Val 122lle mutation (most common cause of familial cardiac amyloidosis) has a 4-year survival rate of 16% with an average length of 26 months and is associated with a worse prognosis than wild type ATTR. A delay in recognition plays a major factor in this reduced survival rate. ==References==