Echocardiography
M-mode and 2D imaging echocardiography are used to detect significant thickening of the myocardium. Left ventricular hypertrophy is generally concentric and linked to right ventricular hypertrophy. Amyloid deposits can cause valves to thicken. As a result, the myocardium has a ‘granular sparkling’ appearance in echocardiograms. However, this is not specific to amyloidosis and can be seen in other cardiac pathologies. Pericardial effusion is present less than 30% of the time. The combination of three hypertrophies (in the left and right ventricles and the pericardial effusion) is very suggestive of amyloidosis but when it is late-onset, the transmitral velocity (measured by pulsed Doppler) usually shows a restrictive pattern (E/A>2), in contrast to its early-onset presentation which is either normal or <1. Myocardial velocities are reduced in tissue doppler imaging. The ejection fraction only alters in the later stages, which explains why diagnosis is often late. Close analysis of contractility using deformation indices (2D-strain) is more precise than that of left ventricle ejection fraction. In amyloidosis, the global 2D strain of the left ventricle is reduced and shows apical sparing pattern.