Amyloid red flags

ESC 2026 Table 20: extracardiac and cardiac red flags for transthyretin and light-chain cardiac amyloidosis. Relevant at any EF; kidney insufficiency and proteinuria are on the list.

Kidney disease is one of the red flags

Cardiac amyloidosis should be suspected with HF, increased LV wall thickness and the red flags below, particularly over 65. Kidney insufficiency and proteinuria are red flags for both TTR and AL amyloidosis, so a CKD patient with thick walls deserves the question. Suspicion triggers immunofixation, free light chains and bone scintigraphy (Class I, B).

Increased LV wall thickness on imaging

ESC's trigger pairs wall thickness with the red flags, particularly in patients over 65.

Extracardiac red flags

TTR = transthyretin, AL = light chain (ESC Table 20)

PolyneuropathyTTRAL
DysautonomiaTTRAL
Skin bruisingAL
MacroglossiaAL
DeafnessTTR
Bilateral carpal tunnel syndromeTTR
Ruptured biceps tendonTTR
Lumbar spinal stenosisTTR
Vitreous deposits (hereditary TTR)TTR
Family history (hereditary TTR)TTR
Kidney insufficiencyTTRAL
ProteinuriaTTRAL

Cardiac red flags (both types)

clinical

Hypotension or normotension if previously hypertensive

ECG

Pseudo-infarct ECG pattern
Low or decreased QRS voltage relative to LV thickness
AV conduction disease

laboratory

Disproportionately elevated NT-proBNP relative to HF severity
Persistently elevated cardiac troponin

echocardiography

Granular sparkling of myocardium
Increased right ventricular wall thickness
Increased valve thickness
Increased interatrial septum thickness
Pericardial effusion
Reduced longitudinal strain with apical sparing

CMR

Global subendocardial or transmural LGE
Elevated native T1 values
Increased extracellular volume
Abnormal gadolinium kinetics

Result

Select the findings present to check the amyloid red flags.

For educational use by clinicians. This tool summarizes published guidelines, drug labels and trials; it is not medical advice and does not replace clinical judgement or the full source documents. Verify every recommendation against the cited source and the patient in front of you.