Diagnosis and supportive therapeutic management of cardiac light chain amyloidosis—a cardiologist’s perspective

Signs and symptoms of heart failure (HF) should be assessed, including severity of dyspnea and the presence of peripheral edema, ascites or pulmonary effusion. It is crucial to check for family history of heart failure and sudden cardiac death, as this may suggest hereditary forms of CA (especially in ATTR), in which case genetic testing and counselling can be offered. Oftentimes patients with CA report poor tolerance to beta-blockers, as these patients require higher heart rates to compensate for low stroke volume due to reduced diastolic filling [10]. Patients with CA are usually normo- or hypotensive, which also makes the differential diagnosis of hypertensive heart disease rather unlikely in these patients.

Additionally, it is important to assess symptoms of other organ manifestation such as peripheral polyneuropathy, signs of renal failure and gastrointestinal symptoms, which in combination with signs and symptoms of HF could be indicative of systemic amyloidosis.

Signs and symptoms of HF should prompt laboratory assessment of cardiac biomarkers including NT-pro BNP. While NT-pro BNP is not an exceptionally specific parameter to diagnose CA as it is elevated in most forms of HF, it is a sensitive test, which is also useful to evaluate disease progression [11, 12]. Even though there seems to be no correlation between NT-pro BNP and amyloid load [13], it does correlate well with symptoms and is a powerful predictor of outcome in patients with CA [14]. However, is must be considered that worsening renal function may also impact NT-pro BNP levels [15]. This is especially relevant in patients with AL amyloidosis as progression of disease is likely to also cause worsening of renal function [16].

Cardiac troponins are elevated in most patients with CA and serve as multipurpose markers [7, 17].

In the absence of coronary artery disease, cardiac troponins (cTnt) can be a diagnostic tool to identify patients with CA. In contrast to acute coronary syndrome (ACS), cTnt does not show a crescendo dynamic. However, it must be stressed that if the clinical suspicion of ACS prevails, coronary obstruction should be excluded by angiography even when CA is present. Additionally, cTnt represent a prognostic marker for poor survival in patients with AL as well as ATTR [18, 19].

Typical features of CA in electrocardiogram (ECG) include low voltage in the setting of myocardial hypertrophy and pseudoinfarct pattern, which can be seen as extensive pathological Q waves in limb and/or precordial leads [20]. Especially in the absence of echocardiographic evidence of past myocardial infarction (myocardial scar or regional wall motion abnormalities), this finding is indicative of CA (Fig. 2).

A multitude of benign as well as potentially malignant cardiac arrhythmias can be found in CA. Findings are very heterogeneous and include conduction disorders, tachycardias, as well as bradycardias [21]. Atrial fibrillation is common in CA and can be found in about 44–70% of patients with CA [22, 23].

Transthoracic echocardiography (TTE) may not only be the most important method for generating the first suspicion of CA, but is also an optimal tool for screening and follow-up. However, knowledge of echocardiographic features of CA is essential for early and accurate identification of patients with CA, since the differential diagnosis of left ventricular (LV) hypertrophy can be challenging. The following red flags should be considered when performing TTE in patients with LV hypertrophy, as well as when evaluating cardiac involvement in patients with verified amyloid deposits in other organs:

Cardiac magnetic resonance imaging (CMR) is ideal for diagnosing CA, as well as for quantifying myocardial amyloid load. It is a radiation-free method; however there are several relative contraindications which commonly apply to patients with amyloidosis, such as impaired renal function. Even though CMR imaging is possible in patients with modern cardiac devices, they significantly reduce image quality and impede interpretation [32]. CMR is the gold standard for quantification of chamber volume and ventricular function [33]. However, it is especially useful in detecting extracellular amyloid deposits using gadolinium, a contrast agent, which shortens the spin-lattice relaxation time (T1) of voxels in which they are present [34]. Gadolinium accumulates in the extracellular matrix, but cannot penetrate healthy cells [35]. Late gadolinium enhancement (LGE) is found in almost all patients with ATTR amyloidosis [36]. However, in AL amyloidosis, even though frequently present, LGE might not be observed at all [37]. Differences in LGE patterns between patients with AL and ATTR have been described [38]. Typical LGE distributions are subendocardial; however, atypical, patchy patterns have also been reported. Since LGE cannot distinguish between amyloid deposition and fibrosis, it is possible that a patchy amyloid infiltration can look similar to diffuse fibrosis [39]. Another indicative finding of CA are ghosting artefacts which are commonly found and caused by effusions [40, 41]. Perhaps one of the biggest advantages of CMR is the exclusion of differential diagnoses which also cause LV hypertrophy, such as hypertrophic cardiomyopathy, Fabry’s disease and hemochromatosis [42].

T1 mapping, a technique used for tissue characterization, is particularly useful for detecting fibrosis and identifying cardiac amyloid deposits. Longitudinal relaxation time (T1) is influenced by the proportion of water content of specific tissues. Mapping techniques have been developed to overcome limitations of LGE, which can only visualize focal areas of increased extracellular matrix. In CA, myocardial T1 times are significantly elevated. Furthermore, extracellular volume (ECV) can be calculated using T1, which correlates well with the amount of myocardial amyloid deposits [43]. Fig. 4 shows positive LGE as well as T1 mapping using the modified look locker inversion sequence (MOLLI) in a patient with ATTR.

Scintigraphy should be included in the diagnostic algorithm of CA, as it has a high sensitivity and specificity for detecting cardiac ATTR [44]. Multiple nuclear tracers such as Tc-diphosphono‑1,2‑propandicarbonsäure (Tc-DPD) and Tc-pyrosphosphate (Tc-PYP) can be used for this purpose [45]. The Perugini grading system has been implemented to describe the intensity of myocardial tracer uptake [46]. Fig. 5 shows strong cardiac tracer (Perugini grade 3) uptake in a patient with ATTR. In ATTR amyloidosis myocardial tracer uptake is present in almost 100% of the cases and usually very strong (Perugini grade 2 or 3). On the contrary, only a minority of AL amyloidosis patients show myocardial tracer uptake and if so, rather subtle (Perugini grade 1) [44].

Furthermore, two nuclear positron emission tomography tracers, 11C-Pittsburg B compound and 18F-florbetapir have been described to bind to AL and ATTR amyloid fibrils alike, thus, providing a promising tool for imaging CA [47, 48].

Even though there has been a tremendous advancement of noninvasive diagnostic tools for CA, endomyocardial biopsy (EMB) remains the gold standard for definite diagnosis. However, due to its potential risks especially in this patient population, noninvasive strategies for diagnosing CA in ATTR are acceptable and should be preferred when cardiac imaging results are unambiguous [44]. When AL has been definitely diagnosed by other organ biopsy (typically bone marrow), cardiac involvement can also be determined by imaging in most cases. In patients with less obvious imaging results, EMB may be the only way to conclusively determine cardiac involvement. Histological analysis shows positive Congo red staining, and green birefringence under cross-polarized light. Immunohistochemistry is performed for amyloid subclassification [49]. However, acquisition of representative myocardial biopsy samples in CA patients can be challenging due to the patchy distribution of amyloid in the heart. Therefore, a negative biopsy sample cannot rule out CA. Furthermore, staining and interpretation of the results should be done only in experienced centers [42].

The primary goal in AL amyloidosis is to halt disease progression by stopping the production of light chains. This can be achieved with drugs, successfully used in treatment regimens of multiple myeloma. Those include steroids (dexamethasone, prednisolone), alkylators (melphalan, cyclophosphamide), proteasome inhibitors (bortezomib, carfilzomib, ixazomib), immunomodulators (lenalidomide, pomalidomide), an anti-CD38 antibody (daratumumab), and an anti-SLAMF7 antibody (elotuzumab) [51]. However, potential side effects such as cardiac decompensation (steroids, carfilzomib) or thrombotic events (lenalidomide and pomalidomide) should be taken into account [51].

Of note, even though commonly used, none of these agents has been approved for the treatment of AL amyloidosis.

Another cornerstone of supportive therapy in AL CA is sufficient diuresis. From our clinical experience most patients need a combination of loop-diuretics with a mineralocorticoid receptor antagonist. However, over-diuresis has to be avoided, as CA patients, due to their stiffened myocardium, are dependent on a certain preload in order to achieve adequate ventricular filling.

Irrespective of left ventricular ejection fraction no evidence for the use of standard heart failure medication, such as beta-blockers, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, or angiotensin receptor neprilysin inhibitors exists. These agents are usually poorly tolerated, as CA patients are prone to develop hypertension [1]. Furthermore, beta-blockers can lead to significant hemodynamic deterioration as CA patients can increase their cardiac output only via heart rate [52]. Therefore, these agents can be stopped, unless well-tolerated and needed due to other indications (e.g., arterial hypertension, heart rate control in atrial fibrillation).

Many CA patients develop atrial fibrillation/flutter (AF), which often makes heart rate control necessary. When rate control strategy is desired, beta-blockers and amiodarone are preferred over digitalis derivatives and calcium channel blockers. Digitalis derivatives bind to amyloid fibers and cause locally toxic levels [53]. However, when the administration of digitalis derivatives is needed, close monitoring of serum levels and side effects are of utmost importance [54, 55]. In order to maintain adequate cardiac output in a rate control setting, target heart rate at our center for AF is ≥ 70 bpm.

Due to amyloid infiltration of the cardiac conduction system arrhythmias are common. Therefore, thorough and frequent diagnostic work-up is necessary to evaluate the need for pacemaker or implantable cardioverter defibrillator implantation. Generally, the decision for device implantation should made in accordance with current guidelines and recommendations. However, the level of evidence is low and studies show conflicting results [56‐58]. Thus decisions, should be tailored to the individual patient.

In patients with severe AL CA, cardiac transplantation can be a valuable therapeutic option that should be discussed and evaluated early to avoid unnecessary delays [59]. However, a complete hematological response is needed in order to avoid recurrence of AL CA in the transplanted organ [59]. General contraindications for heart transplantation apply.