Recurrent Chest Pain as Initial Manifestation of Rapidly Progressing AL-CA with Microvascular Infiltration Case Report: a Novel Red Flag Associated with Poor Outcomes

Background Angina due to microvascular amyloid infiltration is an under-recognized early red flag of infiltrative disease and should be investigated as a predictor of poor outcomes. Case Summary A 73-year-old man with cardiovascular risk factors and a history of treated obstructive coronary artery disease presented 10 months later with recurrent angina. His condition progressively worsened, with the development of severe dyspnoea. Within six months, he succumbed to cardiogenic shock in the presence of severe biventricular dysfunction and unobstructed coronary arteries. Post-mortem diagnosis revealed AL cardiac amyloidosis with massive myocardial infiltration and extensive microvascular amyloid deposits. Discussion This case underscores chest pain as a critical clinical marker, potentially indicating microvascular amyloid infiltration in patients with AL-CA, particularly those with unobstructed coronary arteries. Its assessment may also have implications for future therapies.