'Cardiomyopathy mindset' applied to Dynamic Stress Computed Tomography Perfusion: Cardiac Amyloidosis behind myocardial perfusion defects

A 72-year-old male known for arterial hypertension presented with exertional dyspnoea and chest discomfort. Electrocardiogram revealed sinus rhythm, grade first degree atrioventricular block, left posterior fascicular block, and non-specific repolarization abnormalities (Figure A). According to the physician’s intention to rule out coronary artery disease, the patient underwent coronary computed tomography angiography (CCTA) with regadenoson-induced stress dynamic CT perfusion. CT exam excluded any relevant epicardial stenoses (Figure B–D) but revealed diffuse subendocardial perfusion defects (nearly transmural at basal inferoseptal and inferolateral level) with no clear coronary distribution (Figure E–H). Coupling such peculiar myocardial tissue abnormalities with left ventricle (LV) hypertrophic appearance, suspicion of cardiac amyloidosis arose. Consequently, the patient was referred to cardiac magnetic resonance (Figure I–K), showing moderate LV concentric hypertrophy and diffuse subendocardial late gadolinium enhancement (nearly transmural at basal inferoseptal and inferolateral level) coupled with abnormal gadolinium kinetics, thus in line with the diagnosis of cardiac amyloidosis. Subsequent diagnostic workup, according to current guidelines, confirmed the diagnosis of wild-type transthyretin cardiac amyloidosis.