How nuclear cardiology has transformed care for cardiac amyloidosis
Nuclear cardiology has transformed the landscape of cardiac amyloidosis. Once considered untreatable and difficult to diagnose, cardiac amyloidosis has emerged as a condition where early detection and new therapies are changing patient outcomes.
These advances will be highlighted at the annual American Society of Nuclear Cardiology (ASNC) 2025 meeting during the keynote Mario Verani Memorial Lecture, presented by former ASNC president Prem Soman, MD, PhD, the Richard S. Caligiuri Endowed Chair in Amyloidosis and Heart Failure, director of the Cardiac Amyloidosis Center and nuclear cardiology and a professor of medicine at the University of Pittsburgh Medical Center (UPMC) Heart and Vascular Institute.
“Even a decade ago, cardiac amyloidosis was a medical curiosity,” Soman explained in an interview with Cardiovascular Business. “Diagnosis required invasive biopsy, and there were no treatments. Today, we have noninvasive nuclear imaging to screen and diagnose patients, and multiple FDA-approved therapies that are extending lives.”
Amyloid moves from obscure disease into mainstream diagnosis
The majority of cases involve transthyretin (TTR) amyloidosis, where unstable proteins misfold and deposit in the heart muscle. For years, the only way to confirm the disease was through cardiac biopsy. That changed with the repurposing of bone scintigraphy tracers, which can now definitively identify TTR amyloidosis noninvasively using SPECT nuclear imaging.
“This test is simple, widely available, and essentially without contraindications,” Soman explained. “Unlike biopsy, it can be used for screening, which has revealed that amyloidosis is far more common than we once thought.”
Echocardiography remains the frontline tool, raising suspicion when thickened heart walls are detected. But when more precision is needed, nuclear scintigraphy or cardiac MRI can distinguish amyloidosis from other causes of hypertrophy. Importantly, diagnosis must be paired with blood testing to rule out light-chain (AL) amyloidosis, a hematologic disorder that requires an entirely different treatment.
Explosion of cardiac amyloidosis awareness and treatment
The past decade has also brought a revolution in therapy. Before 2018, no treatments were available for cardiac TTR amyloidosis. Today, three therapies are approved by the U.S. Food and Drug Administration (FDA), with several more in clinical trials. Current drugs cannot cure or reverse the disease, but they can halt or significantly slow the progression, Soman said.
“Previously, three to five years after the diagnosis, patients would become quite ill and many of them would die. Now, we haven't had very long-term follow-up on therapy because these drugs haven't existed for that long. But today, at the end of three to five years, most patients are alive. So it is been a transformation," Soman said.
The dual advance of diagnosis and treatment has led to a surge in awareness. Nuclear cardiology labs that once saw amyloidosis as a rarity now find it routine. At UPMC, Soman said he diagnoses three to five new patients with TTR amyloidosis each week, and cardiac amyloidosis imaging now makes up about 10% of his nuclear lab volume.
The role of ASNC and future directions in amyloidosis
ASNC has played a central role in raising awareness and providing education for nuclear cardiologists and technologists. Training requirements for performing amyloid scans are relatively modest, making it feasible for community nuclear labs across the country to adopt the technology.
"We once thought it was a very rare disease, but it is not that rare, and a lot of patients who we thought had hypertensive heart disease, we now know have amyloid," Soman said. He pointed out that education efforts the last few years has made cardiologists consider amyloidosis as a possibility when looking at these patients, which testing can now easily confirm. "Once you think of the diagnosis, it is easy to make the diagnosis and therapies available," he added.
Certain demographics of the population, such as Black patients, have a striking prevalence of a gene mutation that predisposes patients to amyloid, Soman explained. For this reason, it is very important to keep this in mind when patients present with heart failure symptoms or have thick ventricles that are otherwise explained.
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: [email protected]