AVOIDING ANCHORING BIAS: DIAGNOSIS OF AL-AMYLOIDOSIS IN WORSENING HEART FAILURE AFTER CORONARY ARTERY BYPASS GRAFTING

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Amyloidosis is a systemic disease caused by deposition of misfolded protein in various tissues and organs. Early recognition amyloidosis necessary as cardiac dysfunction the major determinant survival(1). The diagnosis often delayed given non-specific symptoms at onset. Prognosis primarily dependent on degree involvement and, AL amyloidosis, circulating light-chain levels(2). CASE PRESENTATION: patient 68-year-old male referred to our institution for assessment worsening heart failure (HF). Four months prior, he began experience exertional dyspnea along with jaw pain. Subsequent evaluation included lab work, chest X-ray electrocardiogram demonstrating troponin elevation, pulmonary edema complete block respectively. An echocardiogram(ECHO) demonstrated severely reduced ejection fraction(EF). Temporary pacemaker was placed subsequent angiogram showed severe multi-vessel coronary artery disease(CAD). He underwent bypass graft surgery. Post-operatively EF improved 45%. Implantable loop recorder due concerns post-operative atrial fibrillation. Three later, experienced syncopal event attributed ventricular tachycardia, CRT-D placed. ECHO revealed reduction his (30%) moderate concentric left hypertrophy(LVH). A repeat patency grafts. After referral institution, findings concerning amyloidosis. Protein electrophoresis monoclonal IgG gammopathy, fat pad aspirate confirmed DISCUSSION: Although CAD most common cause HF EF, other etiologies must be considered when cannot explained solely ischemia. Cardiac suspected based constellation clinical well suggestive findings(Biventricular hypertrophy, restrictive filling pattern, Bull's eye appearance LV strain). should patients who have unexplained LVH no prior history hypertension(3). Patients also present events conduction blocks, bradyarrhythmia, or case patient, tachyarrhythmias. important emerging therapies that can halt damage, potentially reducing risk mortality allowing amyloid clearance function. CONCLUSIONS: Anchoring bias tendency stick initial impressions even new information becomes available. Clinicians avoid this consider alternative diagnoses do not anticipated outcome particular treatment. REFERENCE #1: 1. Fontana M. Banypersad SM. Treibel TA, et al. Differential myocyte responses transthyretin amyloidosis: MR imaging study. Radiology. 2015;277:388–97 #2: 2. Kumar S, Dispenzieri A, Lacy MQ, Revised prognostic staging system light chain incorporating biomarkers serum free measurements. J Clin Oncol 2012;30:989-95 #3: 3. Gertz MA. Comenzo R. Falk RH, Definition organ treatment response immunoglobulin (AL): consensus opinion from 10th International Symposium Amyloid Amyloidosis, Tours, France, 18-22 April 2004. Am Hematol. 2005;79:319–28 DISCLOSURES: disclosure file Brian Hardaway; No relevant relationships Michael Liu, source=Web Response Amith Reddy Seri,