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Chapters

  • 00:00:14
    Primary care doctors are really the gatekeepers to this puzzle,
  • 00:00:18
    because they’re looking at the whole patient.
  • 00:00:20
    A primary care doctor should start thinking about cardiac amyloidosis,
  • 00:00:25
    AL amyloidosis, when they see signs of worsening heart failure,
  • 00:00:30
    worsening dyspnea on exertion,
  • 00:00:32
    worsening ascites and pedal edema,
  • 00:00:35
    along with signs of other organ involvement.
  • 00:00:38
    So, they will commonly see nephrotic syndrome— a lot of protein in the urine.
  • 00:00:43
    They will commonly see acquired Factor X deficiency.
  • 00:00:46
    They will see patients developing bruising under their eyes, so-called "raccoon eyes".
  • 00:00:51
    They will start noticing that a patient is getting light-headed when they stand up.
  • 00:00:55
    And then, they will start thinking about where to send the patient
  • 00:00:59
    and a lot of times they’ll refer the patient to a cardiologist or a nephrologist.
  • 00:01:04
    So, I think the primary care doctor actually is key to
  • 00:01:07
    an early diagnosis of cardiac amyloidosis
  • 00:01:10
    because they will be the first person to see this disease.
  • 00:01:13
    The other test that they might start doing is, you know,
  • 00:01:15
    looking for a plasma cell dyscrasia with serum-free light chains
  • 00:01:18
    and urine-free light chains, and things of that nature.
  • 00:01:21
    And, all of this can also be done in consultation with a haematologist.
  • 00:01:26
    But, the most important test, I think, for a primary care doctor to order
  • 00:01:30
    when somebody has worsening heart failure symptoms,
  • 00:01:33
    is an echocardiogram and an electrocardiogram, an ECG.
  • 00:01:37
    So, it is crucial that the primary care doctor considers
  • 00:01:42
    this diagnosis as an emergency
  • 00:01:46
    before organ dysfunction progresses and the organs fail.
  • 00:01:59
    The 75-year-old lady
  • 00:02:02
    who presented to primary care doctor with symptoms of
  • 00:02:05
    congestive heart failure with reduced exercise tolerance,
  • 00:02:10
    shortness of breath with exertion, and swelling of her legs.
  • 00:02:15
    The primary care doctor called me personally,
  • 00:02:19
    and asked what workup should be done, and I suggested her to get the
  • 00:02:24
    plasma cell dyscrasia markers done
  • 00:02:27
    and I would see her in my clinic.
  • 00:02:29
    The plasma cell dyscrasia markers were already obtained before
  • 00:02:33
    the patient came to my clinic,
  • 00:02:35
    and they were significantly abnormal; with elevated serum-free light chain levels,
  • 00:02:42
    as well as immunofixation, which was positive.
  • 00:02:46
    So, by the time the patient arrived in my clinic, which was three weeks later,
  • 00:02:51
    the patient already had the diagnosis of plasma cell dyscrasia
  • 00:02:56
    with infiltrative cardiomyopathy,
  • 00:02:59
    and I just needed to do an abdominal fat pad aspiration in my clinic
  • 00:03:04
    and subject it to Congo red staining, which came back as positive.
  • 00:03:09
    And, she has already begun treatment for her AL amyloidosis
  • 00:03:15
    within three weeks from her initial presentation.
  • 00:03:19
    So, this again speaks very highly of the primary care doctor,
  • 00:03:24
    who did not wait for the consult to go through electronic medical records,
  • 00:03:30
    to be seen by a doctor in cardiology, seen by a doctor in haematology,
  • 00:03:35
    seen by a doctor in echocardiography.
  • 00:03:38
    But, she took it upon herself to make the phone calls so that
  • 00:03:43
    her diagnosis was obtained in a timely fashion to
  • 00:03:47
    prevent further deterioration of her congestive heart failure and cardiac involvement.