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Diagnosis and treatment of cardiac amyloidosis in heart failure patients

Cardiac amyloidosis suspected HF and LV wall thickness ≥12 mm AND age ≥65 or at least 1 red flaga

Serum free light-chain assay Serum and urine protein electrophoresis with immunofixation 99mTc-PYP, DPD or HMDP scintigraphy with SPECT

Histological confirmation to subtype (usually cardiac)b Amyloidosis

unlikely Histological confirmation

of diagnosis (cardiac/ extracardiac)c Tafamidis

(Class I)

Amyloidosis

unlikely

Both abnormal Abnormal haematology

No myocardial uptake Normal haematology

Grade 1 uptake Normal haematology

Grade 2–3 uptake All normal

ATTR

Genetic counselling

Cardiac amyloidosis

on CMR imaging

Positive or inconclusive Negative

Consider patisiran or inotersen if hereditaryATTR and polyneuropathy

Figure 21 Diagnosis and treatment of cardiac amyloidosis in heart failure patients. Based on.973 ATTR = transthyretin amyloidosis; CMR = cardiac magnetic resonance; DPD = 3,3-diphosphono1,2-propanodicarboxylic acid; HF = heart failure; HMDP = hydroxymethylene diphosphonate; LV = left ventricular; SPECT = single-photon emission computed tomography; 99mTc-PYP = technetium-labelled 99mTc-pyrophosphate. aRed flags are listed in Table 35. bGenerally requires endomyocardial biopsy for a diagnosis of the cardiac subtype. cRequires biopsy that may be cardiac or abdominal. Downloaded from academic.oup.com/eurheartj/article/42/36/3599/6358045 by guest on 07 October 2026