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Review
. 2024 Sep 20;13(18):5588.
doi: 10.3390/jcm13185588.

Electrocardiographic Patterns and Arrhythmias in Cardiac Amyloidosis: From Diagnosis to Therapeutic Management-A Narrative Review

Lucio Teresi  1   2 , Giancarlo Trimarchi  1   3 , Paolo Liotta  1 , Davide Restelli  1 , Roberto Licordari  1 , Gabriele Carciotto  1 , Costa Francesco  1   4 , Pasquale Crea  1 , Giuseppe Dattilo  1 , Antonio Micari  5 , Michele Emdin  3   6 , Antonio Berruezo  2 , Gianluca Di Bella  1
Affiliations
Review

Electrocardiographic Patterns and Arrhythmias in Cardiac Amyloidosis: From Diagnosis to Therapeutic Management-A Narrative Review

Lucio Teresi et al. J Clin Med. .

Abstract

Electrophysiological aspects of cardiac amyloidosis (CA) are still poorly explored compared to other aspects of the disease. However, electrocardiogram (ECG) abnormalities play an important role in CA diagnosis and prognosis and the management of arrhythmias is a crucial part of CA treatment. Low voltages and a pseudonecrosis pattern with poor R-wave progression in precordial leads are especially common findings. These are useful for CA diagnosis and risk stratification, especially when combined with clinical or echocardiographic findings. Both ventricular and supraventricular arrhythmias are common in CA, especially in transthyretin amyloidosis (ATTR), and their prevalence is related to disease progression. Sustained and non-sustained ventricular tachycardias' prognostic role is still debated, and, to date, there is a lack of specific indications for implantable cardiac defibrillator (ICD). On the other hand, atrial fibrillation (AF) is the most common supraventricular arrhythmia with a prevalence of up to 88% of ATTR patients. Anticoagulation should be considered irrespective of CHADsVA score. Furthermore, even if AF seems to not be an independent prognostic factor in CA, its treatment for symptom control is still crucial. Finally, conduction disturbances and bradyarrhythmias are also common, requiring pacemaker implantation in up to 40% of patients.

Keywords: arrhythmias; cardiac amyloidosis; electrocardiogram.

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Conflict of interest statement

The authors declare no conflicts of interest.

Figures

Figure 1
Figure 1
Anterior pseudonecrosis. Electrocardiogram of a 54-year-old male with variant transthyretin amyloidosis (Glu89Gln mutation) reveals left bundle branch block and anterior pseudonecrosis characterized by Q waves in leads V1–V4 measuring at least 1 mV. The patient has no history of ischemic heart disease and no kinetic abnormalities on echocardiography.
Figure 2
Figure 2
Low voltages in the peripheral leads. Electrocardiogram of a 72-year-old man with wild-type transthyretin cardiac amyloidosis and low voltages in the peripheral leads (≤5 mV in all peripheral leads) but relatively preserved voltages in the precordial leads.
Figure 3
Figure 3
Arrhythmia pathophysiology in cardiac amyloidosis. Brady- and tachyarrhythmias are common in cardiac amyloidosis for many specific pathophysiological reasons. The main ones are summarized in the figure. AF: atrial fibrillation; AL: light chain amyloidosis; ATTRv: variant transthyretin amyloidosis; PVC: premature ventricular complex; nsVT: non-sustained ventricular tachycardia; sVT: sustained ventricular tachycardia.
Figure 4
Figure 4
Mechanical impairment on sinus rhythm. Electrocardiogram and echocardiographic mitral pattern of an 82-year-old man with wild-type transthyretin amyloidosis (ATTR−wt). Absence of a clear A wave despite sinus rhythm being observed.
See this image and copyright information in PMC

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