AMY DA site - i can identify - Video 5

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.