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Circulation. 2016 Jun 14;133(24):2404-12. doi: 10.1161/CIRCULATIONAHA.116.021612. Epub 2016 Apr 22.

Nonbiopsy Diagnosis of Cardiac Transthyretin Amyloidosis.

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1
From National Amyloidosis Centre, Division of Medicine (J.D.G., A.D.W., C.C.Q., H.J.L., T.R., M.F., K.F., T.L., F.W.V., C.J.W., D.F.H., P.N.H.) and Barts Heart Centre, Institute of Cardiovascular Science (J.C.M.), University College London, UK; Clinical Cardiovascular Research Laboratory for the Elderly, Columbia University Medical Center, New York (M.S.M., S.B., A.C.); Department of Cardiology and Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (R.H.F., S.D.); Amyloidosis Research and Treatment Center, Foundation Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, and Department of Molecular Medicine, University of Pavia, Italy (G.M., G.P., P.M.); Department of Cardiology, University Hospital Henri Mondor, Amyloidosis Mondor Network, Creteil, France (T.D.); Division of Hematology, Division of Cardiovascular Diseases, and Department of Radiology, Division of Nuclear Medicine, Department of Medicine, Mayo Clinic, Rochester, MN (A.D., M.G., G.B.J.); Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, MA (J.L.B., F.L.R.); Departments of Nuclear Medicine and Molecular Imaging (A.W.J.M.G.) and Rheumatology and Clinical Immunology (B.P.H.), University of Groningen, University Medical Center Groningen, The Netherlands; Department of Nuclear Medicine, S. Orsola-Malpighi Hospital, and Cardiology Unit, Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater-University of Bologna, Italy (P.L.G., C.R.); and Yale University School of Medicine, Section of Cardiovascular Medicine, New Haven, CT (E.J.M.).

Abstract

BACKGROUND:

Cardiac transthyretin (ATTR) amyloidosis is a progressive and fatal cardiomyopathy for which several promising therapies are in development. The diagnosis is frequently delayed or missed because of the limited specificity of echocardiography and the traditional requirement for histological confirmation. It has long been recognized that technetium-labeled bone scintigraphy tracers can localize to myocardial amyloid deposits, and use of this imaging modality for the diagnosis of cardiac ATTR amyloidosis has lately been revisited. We conducted a multicenter study to ascertain the diagnostic value of bone scintigraphy in this disease.

METHODS AND RESULTS:

Results of bone scintigraphy and biochemical investigations were analyzed from 1217 patients with suspected cardiac amyloidosis referred for evaluation in specialist centers. Of 857 patients with histologically proven amyloid (374 with endomyocardial biopsies) and 360 patients subsequently confirmed to have nonamyloid cardiomyopathies, myocardial radiotracer uptake on bone scintigraphy was >99% sensitive and 86% specific for cardiac ATTR amyloid, with false positives almost exclusively from uptake in patients with cardiac AL amyloidosis. Importantly, the combined findings of grade 2 or 3 myocardial radiotracer uptake on bone scintigraphy and the absence of a monoclonal protein in serum or urine had a specificity and positive predictive value for cardiac ATTR amyloidosis of 100% (positive predictive value confidence interval, 98.0-100).

CONCLUSIONS:

Bone scintigraphy enables the diagnosis of cardiac ATTR amyloidosis to be made reliably without the need for histology in patients who do not have a monoclonal gammopathy. We propose noninvasive diagnostic criteria for cardiac ATTR amyloidosis that are applicable to the majority of patients with this disease.

KEYWORDS:

amyloid; cardiomyopathies; genetics; hypertrophy; radionuclide imaging

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