• echocardiography
• cardiomyopathy
• restrictive
• heart failure
• aortic valve stenosis

In recent years, transthyretin cardiac amyloidosis (ATTR-CA) has transformed from a historically under-recognised disease to a crucial concern in cardiology driven by increased awareness, advent of non-invasive confirmatory algorithms using nuclear scintigraphy and development of effective pharmacological treatments. Approximately 25% of people over 85 years of age have ATTR deposition in the myocardium at autopsy, while severe aortic stenosis (AS) affects >3% of individuals over 75 years. On the background of an ageing population, with both wildtype ATTR-CA and AS highly prevalent in older adults, the coexistence of ATTR-CA with AS (AS-ATTR) is particularly pertinent to cardiologists.

Prior studies have demonstrated that 8%–16% of patients with severe AS have coexistent ATTR (AS-ATTR)1–5 (table 1). Case ascertainment for ATTR-CA in a cohort with AS can be challenging as the two disease entities share common features, including older age, increased left ventricular (LV) wall thickness, diastolic dysfunction and elevated natriuretic peptides. Conceptually, a natural assumption may be that the two pathological processes are summative, specifically that the increased afterload from AS in combination with restrictive filling from infiltration with ATTR would result in more advanced disease and worse outcomes than either entity in isolation.

In the current study, Patel and colleagues6 seek to better characterise the AS-ATTR cohort in comparison with AS alone, ATTR-CA alone, and older age controls without AS or ATTR-CA. A total of 583 patients were recruited from four prospective cohorts: (1) 81 controls from a sample of older adult patients of European origin; (2) 36 patients with AS-ATTR from two prospective observational studies in the UK and Vienna, Austria, in which patients 75 years or older with severe AS referred for a transcatheter aortic valve implantation (TAVI) underwent pre-TAVI nuclear …