# ATTR Cardiac Amyloidosis: Use the Diagnostic Gate

Therapeutic approvals and trial results evolve. Verify the actual article, studied population, and current indication before teaching a treatment as established.

![Infographic: ATTR Cardiac Amyloidosis: Use the Diagnostic Gate](https://urinenephrology.org/visual-reference/images/mastery-attr.png?v=20261003c)

## A protein-folding disease

Transthyretin deposition can produce a restrictive cardiomyopathy and extracardiac clues. Wild-type and hereditary disease require different family and genetic considerations.

## Look beyond ejection fraction

Wall thickening, diastolic dysfunction, conduction disease, neuropathy, and carpal tunnel history can raise suspicion. Preserved ejection fraction does not imply a normal heart.

## Apply the nonbiopsy gate

In the appropriate cardiac phenotype, grade 2–3 myocardial uptake on bone-tracer scintigraphy supports a nonbiopsy ATTR diagnosis only after AL has been excluded with serum free light chains and serum/urine immunofixation. Confirm myocardial uptake, rather than relying on blood-pool activity.

## Handle a positive monoclonal screen

A monoclonal protein makes the scan alone insufficient to establish ATTR. Arrange specialist evaluation and tissue typing as indicated. Once ATTR is established, genetic testing distinguishes hereditary from wild-type disease and determines whether family counseling is needed.

## Individualize management

Coordinate specialist assessment for disease-specific therapy and cautious congestion management. Autonomic dysfunction and fixed stroke volume can limit tolerance of routine cardiac drugs.

## Keep evidence current

Therapeutic approvals and trial results evolve. Verify the actual article, studied population, and current indication before teaching a treatment as established.

## Supporting evidence

- [Supporting guideline or source](https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2023/01/19/14/49/2023-acc-consensus-on-cardiac-amyloidosis)
- [Supporting guideline or source](https://www.acc.org/Education-and-Meetings/Patient-Case-Quizzes/2023/01/05/18/10/Diagnosis-of-ATTR-Cardiac-Amyloidosis)

## Source lessons

- [attr cardiac](https://urinenephrology.org/mastery/amyloid-series/attr-cardiac.html)
- [cardiac amyloidosis](https://urinenephrology.org/mastery/rhc/cardiac-amyloidosis.html)

Read alongside the full lessons; the findings and decisions shown here require the stated clinical context.