Heart Failure Readmissions? Suspect Senile Amyloidosis

Even when a patient is repeatedly admitted to the hospital for heart failure exacerbations, the underlying cause may be missed, say clinicians from Albert Einstein Medical Center in Philadelphia, Pennsylvania. One of those causes could be senile amyloidosis. The researchers reported on their own patient, an African American man aged 71 years whose nonischemic cardiomyopathy was presumed secondary to hypertensive heart disease. He had been hospitalized repeatedly in the previous 2 years for heart failure exacerbations.

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When he again presented with heart failure symptoms, the patient was taking an angiotensin-converting enzyme inhibitor, a beta-blocker, and a thiazide diuretic. Electrocardiography (ECG) showed low-voltage QRS complexes in all leads. The brain natriuretic peptide was elevated. Echocardiography showed marked biventricular hypertrophy, global hypokinesis, severe diastolic dysfunction, and dilated atria suggestive of infiltrative cardiomyopathy. Echocardiography from 6 months earlier showed the same findings.

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However, the ECG and echocardiographic findings, the clinicians say, were key to the correct diagnosis that had previously been missed. The combination of low-voltage limb leads with biventricular hypertrophy and the other findings should “raise clinical suspicion,” they note, of amyloidosis, which is the most common prototype of infiltrative heart disease with increased wall thickness. And in fact, the endomyocardial biopsy showed amyloid deposition.

Amyloidosis is a multisystem disease; the severity of organic involvement depends on the precursor protein, the clinicians say. Their patient had senile cardiac amyloidosis, which is a slow progressive disease with only cardiac involvement. It’s often underdiagnosed as a cause of heart failure, they say, because it tends to appear with more common comorbidities, such as long-standing systemic hypertension. The first signs of senile cardiac amyloidosis are usually leg swelling and shortness of breath, both due to congestive heart failure, the clinicians add.

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These patients usually progress to complete heart block and require permanent pacing. Thus, promptly referring them to advanced heart failure specialists could help improve their quality of life and reduce readmission rates.

Source
Alvarez de Venecia TA, Blumhof T, Ukpong D, Lu M, Nieves C, Figueredo V. Am J. Med. 2015;128(5):e15-e16.
doi: 10.1016/j.amjmed.2014.11.019.