Cardiac amyloidosis: what every interventional cardiologist should know

Cardiac amyloidosis (CA) is increasingly encountered by interventional cardiologists during the evaluation of chest pain, myocardial injury, coronary artery disease, atrial arrhythmias, and aortic stenosis. Its recognition can be challenging because amyloid cardiomyopathy often coexists with common coronary, valvular, and arrhythmic conditions. A key diagnostic clue is discordance: the apparent coronary, valvular, or hemodynamic abnormality does not fully explain the patient’s symptoms, myocardial phenotype, low-flow physiology, or persistent high-sensitivity cardiac troponin elevation. This review focuses on clinical situations in which interventional cardiologists should suspect CA. We discuss myocardial ischemia and coronary microvascular dysfunction caused by intramural vascular amyloid deposition, extravascular compression, and impaired vasodilator reserve; atrial arrhythmias and catheter ablation; the frequent coexistence of transthyretin cardiac amyloidosis (ATTR-CM) with aortic stenosis in patients undergoing transcatheter aortic valve implantation; and the complementary roles of echocardiography, cardiac computed tomography, cardiovascular magnetic resonance, bone-avid tracer scintigraphy, and invasive hemodynamic assessment. We also propose a practical cath-lab approach that integrates readily available clinical information, recognizes persistent or disproportionate myocardial injury as a diagnostic red flag, promptly distinguishes light-chain from ATTR amyloidosis, and preserves appropriate treatment of coexisting coronary or valvular disease. For the interventional cardiologist, the central principle is simple: when the lesion does not fully explain the patient, look beyond the lesion.