Apical Sparing and Granular Sparkling: Not Everything that Glitters Is Cardiac Amyloidosis

Introduction

With recent advances in the diagnosis and treatment of cardiac amyloidosis (CA), the role of complementary cardiac imaging methods for the early recognition of this disease has been widely discussed. In this context, myocardial hyperrefringence and preservation of left ventricular apex contractility (apical sparing; AS), evidenced by transthoracic echocardiography (TTE) with myocardial strain analysis (STE), are findings that frequently raise suspicion of CA.

However, despite this association, the heterogeneity of this finding in CA, depending on the population studied, in addition to its presentation in other conditions, leads to questions regarding the real accuracy of AS for the diagnosis of this disease. Through the report of three clinical cases of patients with different clinical conditions – hypertrophic cardiomyopathy (HCM), chronic kidney disease (CKD), and use of anabolic steroids – in which myocardial hyperrefringence and AS were described on echocardiography, a brief discussion is proposed regarding the pathophysiology of these findings and their limitations for the diagnosis of CA.

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