Cardiac amyloidosis is a subcategory of amyloidosis where there is depositing of the protein amyloid in the heart muscle and sometimes other organs or structures. Amyloid, a misfolded and insoluble protein, can become a deposit in the heart's atria, valves, or ventricles. These deposits can cause thickening of different sections of the heart, leading to decreased cardiac function and heart failure. The overall decrease in cardiac function leads to a plethora of symptoms. This multisystem disease was often misdiagnosed, with a definitive diagnosis only during autopsy. Advancements of technologies have led to earlier and more accurate diagnosis. However diagnosis may still be delayed as the disease may remain asymptomatic for years as amyloid deposits in the heart and other organs or tissues. Diagnosis may be delayed further as the disease may be misdiagnosed or confused for other more common conditions that cause heart enlargement (such as hypertension or other forms of heart failure).
Cardiac amyloidosis has multiple sub-types including light chain, hereditary transthyretin amyloidosis (due to genetic variants leading to misfolded transthyretin protein depositing in the heart and other tissues), and wild type transthyretin amyloidosis (where misfolded transthyretin builds up in heart muscle and other tissues, but with an absence of any mutations). The genetic variants responsible for hereditary transthyretin amyloidosis are inherited in an autosomal dominant manner, with the penetrance and prevalence in a population being dependent on the specific genetic variant and other factors. Being more common in older adults, the mean age of diagnosis for both the genetic variant and wild-type variant of transthyretin cardiac amyloidosis is between age 74–90.
One of the most studied types is light chain cardiac amyloidosis. Prognosis depends on the extent of the deposits in the body and the type of amyloidosis. New treatment methods are actively being researched in regards to the treatment of heart failure and specifically for cardiac amyloidosis.
Types The multiple subtypes of cardiac amyloidosis have varying epidemiological, diagnostic, and prognostic characteristics. Seventy five percent of transthyretin (TTR) cardiac amyloidosis is the wild-type and 25% if the inherited type.
Light chain (AL-CM) This relatively rare form of cardiac amyloidosis occurs in an estimated six to ten cases per 1,000,000 people. This sub- type usually affects males over the age of 60 and is rapidly progressive. Pathogenesis of this form is due to the aggregation of immunoglobulin lambda light chains. These chains are created by an abnormal expansion of plasma cells. Over time, these light chains deposit into the interstitial tissue within the myocardium. Diagnostic tests includes serum and urine electrophoresis, laboratory testing for the determination of elevated levels of troponin and BNP, and ECGs showing low QRS voltages.
Familial (ATTRm-CM) This type is caused by mutations of genes encoding amino acids of the transthyretin protein (TTR) causing transthyretin misfolding. Due to the multiple number of potential genetic causes (approximately 130 gene variants are known) the incidence of this form is variable in different populations, depending on the genetic variant. The vast majority of familial cardiac amyloidosis still present after the age of 60. A common mutation is the TTR gene mutation Val122Ile. It is estimated that 3.5–4% of African Americans in the United States have the Val 122lle mutation. This type of amyloidosis can be identified by genetic testing for protein mutation. Histological evaluation involves special stains being utilized to visualize the amyloid deposits. One such stain is Congo Red, which binds specifically to the amyloid deposits and can be characterized by various lighting methods. Under polarized light, the amyloid deposits show characteristic apple green birefringence, and under plain light the deposits will appear a light salmon pink color. Familial amyloidosis usually causes a combination of heart failure and peripheral neuropathy or autonomic neuropathy. Whereas wild-type transthyretin amyloidosis usually causes heart failure, with neuropathy being more rare.
Wild-type (ATTRwt-CM) This type has no mutations in the TTR gene but TTR deposits still form in the heart and other tissues. Males are more commonly affected, at ages over 70 years. Carpal tunnel syndrome may form as well as amyloid deposits in the carpal tunnel causing compression of the median nerve. Amyloid deposits in the carpal tunnel or other ligaments (causing tendon rupture) or the spinal canal causing spinal stenosis may precede the development of heart failure by 10-15 years.
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. Amyloid deposition in the heart causes restrictive diastolic heart failure that progresses to systolic heart failure.
Cardiac manifestations include: Dyspnea on exertion Peripheral edema and ascites Pericardial effusion Arrhythmias (secondary to disruption of the normal electrical system of the heart) Atrial arrhythmias (such as atrial fibrillation) First/second degree heart blocks Syncope Elevated neck veins and jugular venous pressure Myocardial ischemia/angina (secondary to amyloid deposition in the coronary arteries of the heart) Myocardial oxygen demand is increased in patients with cardiac amyloidosis, regardless of changes to coronary perfusion.
For patients with light-chain amyloidosis, there can be depositions of amyloid into numerous different organs. Deposition of amyloid into other organs makes the diagnosis of cardiac amyloidosis difficult as these extracardiac manifestations mask the diagnosis. Extracardiac manifestations include: Macroglossia Periorbital bruising Thromboembolisms Symmetric sensory neuropathy (such as bilateral carpal tunnel) 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. Amyloidosis presents with ventricle and valvular thickening, biatrial enlargement, restrictive filling pattern, with normal to mildly reduced systolic function and decreased diastolic filling. An echo can be used to evaluate for prognosis of the disease, measuring the different strains within the heart. Cardiac amyloidosis produces specific alterations to the functionality of the heart. Echocardiography can be utilized to detect this specific pattern (relative preservation of the apical myocardium with decreased longitudinal strain in the mid and basal sections), which is 90–95% sensitive and 80–85% specific for cardiac amyloidosis. Echocardiography can be used to aid with diagnosis, but it is not a definitive test.
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, with poor R-waves of the chest leads. In TTR amyloidosis, there is often a discordance between wall thickness suggested by EKG and actual wall thickness, with lower voltages on EKG underestimating wall thickness.
Holter monitors can be used to identify asymptomatic arrhythmias.
EKG changes may be present, showing low voltage and conduction abnormalities like atrioventricular block or sinus node dysfunction. Atrial fibrillation (AF) is observed in up to 70% of patients at the time of diagnosis, and patients typically have controlled ventricular rates caused by concomitant conduction system disease.
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. In light-chain amyloidosis, a low paraprotein level can be present.
Cardiac biomarkers There are two main cardiac biomarkers used in the assessment of cardiac amyloidosis, troponin and N-terminal proBNP. 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.
Biopsies
Extracardiac biopsies of tissues of the kidney, liver, peripheral nerve, or abdominal fat can be used to confirm the presence of amyloid deposits. Amyloid deposits in biopsy samples are confirmed through the use of Congo red dye, which produces a green birefringence when viewed under polarized light. Sirius red staining or electron microscopy examination can also be done. The determination of the type of amyloid can be done by immunohisto-labeling techniques as well as immunofluorescence staining.
For light-chain amyloidosis patients, bone marrow biopsies could be conducted to determine the baseline percentage of plasma cells and to rule out multiple myeloma.
Catheterization Right heart catheterization is the test used to test for elevated diastolic ventricular pressures. This test is more invasive and would be performed after inconclusive endomyocardial biopsy samples.
Cardiac magnetic resonance imaging