? Cardiac amyloid

56-year-old man for a Radical prostatectomy for prostate cancer


  • Asthma – well-controlled
  • Lifelong smoker – 30 pack years
  • Active, goes to the gym daily >4METS


  • Inferior TWI noted on perioperative ECG
  • No history of symptoms
  • Echocardiogram showed ‘moderately hypertrophic LV with marginally reduced systolic function, Grade 1 diastolic dysfunction, infiltrative process cannot be excluded, and ASD with small left>right shunt.’


  • Discussed at cardiology meeting regarding need for further investigations preoperatively. Cardiologist recommended that surgery proceeds, cancer surgery.
  • Differential diagnosis:
  • Ischaemic Heart disease – relatively normal LV systolic function is reassuring.
  • Infiltrative process – E.G. Amyloidosis, unlikely but at present it is not significant. Not obvious on echo and voltages preserved on ECG. Recommends post-op outpatient cardiology review and cardiac MRI
  • AHA guidelines would support proceeding without further cardiac investigations
  • Normal sestamibi would be reassuring but abnormal result would likely cause delay and not change intraoperative management


  • Proceed with planned procedure
  • Refer to GP for postoperative cardiology referral and consideration of cardiac MRI and stress test.