Vanderbilt Internal Medicine Residency Podcast · Jared Freitas and Terra Swanson

S6: E5 Cardiac Amyloidosis

·36 min·2 clips

Carpal tunnel, spinal stenosis, and a biceps tendon rupture can point to ATTR cardiac amyloidosis.

1. Vanderbilt Internal Medicine Residency Podcast’s "S6: E5 Cardiac Amyloidosis" focuses on cardiac amyloidosis in a resident-led cardiology case discussion. 2. Leonard Chu, a second-year Vanderbilt internal medicine resident applying for cardiology fellowship, presents the case and thanks Dr. Deepak Gupta, Dr. Lynn Panus, and Dr. Rebecca Hung for teaching him about amyloidosis. 3. The episode asks what cardiac amyloidosis is, how often it appears, how to recognize it clinically, and how to treat AL and ATTR disease earlier. 4. A 65-year-old man with lumbar spinal stenosis, paroxysmal atrial fibrillation, HFpEF with EF 60% to 65%, dyspnea, edema, and a BNP of 600 anchors the discussion. 5. His exam includes a JVP of 14 cm, crackles, abdominal distension, and lower-extremity edema, while his ECG shows poor R-wave progression with normal voltage. 6. Echocardiography shows increased wall thickness and small ventricular chambers relative to the atria, which Leonard says suggests an infiltrative process. 7. The workup then finds free light chains in the 600s with a kappa-lambda ratio of 0.001 and an endomyocardial biopsy that stains amyloid with Congo red and apple-green birefringence. 8. Leonard defines the two main forms as AL amyloidosis from overproduced light chains and ATTR amyloidosis from transthyretin made in the liver. 9. He distinguishes ATTR variant, including the Val122Ile mutation, from ATTR wild-type, which develops in older adults without a specific mutation. 10. He says cardiac amyloidosis is more common than many clinicians think, citing half a dozen Vanderbilt patients, 25,000 to 120,000 U.S. ATTR variant cases, and over 200,000 U.S. ATTR wild-type cases. 11. Leonard highlights that 3.5% of self-identified African Americans are carriers of Val122Ile and says healthcare inequities likely lead to underdiagnosis and mislabeling as hypertensive heart disease. 12. He notes that 1 in 10 older adults undergoing carpal tunnel release at Cleveland Clinic had amyloid in tenosynovial tissue, and that bilateral carpal tunnel syndrome can point toward ATTR. 13. He adds that lumbar spinal stenosis, a tendon rupture with the "Popeye sign," and hip or knee problems can cluster with heart failure symptoms and raise suspicion for ATTR. 14. On ECG, he says low voltage is the textbook clue but has low sensitivity, so a normal-voltage tracing does not rule out amyloidosis. 15. For imaging, he reviews echo, cardiac MRI, and pyrophosphate scanning, emphasizing the "cherry on top" strain pattern and that PYP grades 2 or 3 support ATTR. 16. He then explains a three-step diagnostic pathway using serum and urine monoclonal studies, free light chains, PYP scanning when light chains are negative, and ATTR genetic testing after confirmation. 17. For treatment, Leonard says patients often need spironolactone and bioavailable loop diuretics such as torsemide or bumetanide, while ACE inhibitors, ARBs, ARNIs, and beta blockers lack guideline-based recommendations. 18. He warns that verapamil, diltiazem, and digoxin can bind amyloid fibrils and that all amyloid patients with atrial fibrillation should be anticoagulated regardless of CHA2DS2-VASc. 19. The tone is teaching-focused and case-based, with a resident-to-resident conversation, frequent physiology explanations, and specific trial names such as Andromeda and ATTR-ACT. 20. Listeners who manage HFpEF, arrhythmias, or unexplained LV wall thickening will benefit most, while people wanting a general cardiology overview may skip the medication and trial details.

As heard by us

A practical, case-led look at the clues that make cardiac amyloidosis easy to miss.

This episode walks cardiac amyloidosis through a real case and a clear line of reasoning. It starts with the usual heart failure frame, then picks up the quieter clues: carpal tunnel, spinal stenosis, hip and knee problems, and tendon rupture. The ECG point lands well too.

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Why you'd press play

You want the clues that turn vague heart failure symptoms into a cardiac amyloid workup.

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