An 87-year-old male had been under cardiology follow-up since 2013 due to ischaemic heart disease with New York Heart Association (NYHA) functional class II/IV. His medical history included hypercholesterolaemia as a cardiovascular risk factor, osteoarthritis, polymyalgia rheumatica, knee prosthesis, benign prostatic hyperplasia, and a transient ischaemic attack in 2010. He was also under assessment for cognitive decline.
Initial cardiac diagnosis revealed single-vessel coronary artery disease affecting the proximal left anterior descending artery, revascularised with a drug-eluting stent. Left ventricular ejection fraction (LVEF) was preserved with no valvular disease.
Medical therapy included acetylsalicylic acid (100 mg/day), bisoprolol (2.5 mg/day), nitrates, and atorvastatin (20 mg/day). Later, congestive heart failure was attributed to bradycardia, which improved upon beta-blocker withdrawal.
Over time, the patient’s functional class deteriorated. Stress echocardiography ruled out ischaemia but showed concentric left ventricular hypertrophy, mildly reduced LVEF, increased filling pressures, biatrial dilation, and reduced basal longitudinal strain with apical sparing. These findings raised suspicion of cardiac amyloidosis.
Technetium-99m diphosphonate scintigraphy confirmed transthyretin (ATTR) amyloidosis with grade 3 cardiac uptake. A haematological study was not repeated due to a recent negative result during an internal medicine admission for urinary tract infection, ruling out monoclonal gammopathy.
At diagnosis, the patient had mildly depressed LVEF and NYHA class III symptoms, not meeting criteria for Tafamidis initiation per current guidelines.
This case underscores the importance of broadening differential diagnoses in patients with prior ischaemic heart disease, especially when symptoms persist despite adequate treatment. Cardiac amyloidosis may also present with angina and can be misattributed to coronary disease. Diagnostic red flags – such as electrocardiographic changes, intolerance to standard medications, and specific echocardiographic features – should prompt further investigation. Early recognition allows for timely initiation of treatments like Tafamidis, which improve prognosis in transthyretin cardiac amyloidosis.