Hidden Underneath: AL Amyloid Unmasked by an Inferior STEMI

Document Type

Conference Proceeding

Publication Date

4-2025

Publication Title

Journal of the American College of Cardiology

Abstract

Background: This is the case of a patient with cardiac amyloidosis due to AL amyloid presenting as an inferior STEMI.

Case: A 62 year old female with a past medical history of dyspnea and recurrent pleural effusions over the last 6 months presented to an outside hospital with chest pain. She was found to have an inferior STEMI, low voltage, and junctional bradycardia on ECG. LHC revealed a distal right coronary occlusion with the appearance of thrombus. TTE showed mildly reduced ejection fraction with concentric hypertrophy and a speckle pattern concerning for an infiltrative cardiomyopathy. Amyloid workup was pursued, including blood work and imaging. Her kappa and lambda ratio came back elevated at 30. Bone marrow biopsy revealed 15% plasma cells. Cardiac MRI showed diffuse late gadolinium enhancement in the left ventricle as well as a left atrial appendage thrombus (see image). Cardiac biopsy confirmed the diagnosis of AL amyloid. The patient was discharged and began chemotherapy as an outpatient.

Decision-making: Urgent inpatient diagnostic evaluation led to expediated treatment of AL amyloid. Although the patient eventually needed a CRT-D due to a VT arrest, she has since responded to chemotherapy and had no further hospitalizations.

Conclusion: Patients with AL cardiac amyloid may present with cardio-embolic phenomena. Care must be taken to make an early diagnosis, and aggressive treatment is necessary to ensure long-term survival upon initial presentation.

Volume

85

Issue

12 Suppl

First Page

3360

Comments

American College of Cardiology (ACC) Meeting, March 29-31, 2025, Chicago, IL

Last Page

3360

DOI

doi:10.1016/S0735-1097(25)03844-6

ISSN

1558-3597

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