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AMY DA site - i can identify - Video 5
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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.