(Kiosk 1) Balancing the Multisystem Complications of Cardiac Amyloidosis in a Patient with Bilateral Subdural Hematomas in Acute Inpatient Rehabilitation

Case Diagnosis: Bilateral subdural hematomas complicated by recurrent pleural effusions secondary to wild-type cardiac amyloidosis (ATTRwt).

Case Description or Program Description: An 88-year-old man with atrial fibrillation (rivaroxaban held), ATTRwt, ventricular tachycardia and type 2 diabetes was admitted to acute rehabilitation after multiple falls resulting in punctate subarachnoid hemorrhages and bilateral subdural hemorrhages. His cardiac amyloidosis caused reduced ejection fraction on echocardiogram and a left pleural effusion, which was found to be transudative with no malignancy on thoracentesis cytology. Upon presentation, the patient was hypotensive but his cardiologist recommended keeping his beta-blocker for rate control, so midodrine was started. His pleural effusion reaccumulated, which was only evident on physical exam and chest x-rays as he was rarely symptomatic. Following a second thoracentesis, the fluid reaccumulated and torsemide was started. Ultimately he required a Pleurx catheter.

Setting: Acute Inpatient Rehabilitation Hospital

Assessment/Results: N/A

Discussion (relevance): Amyloids are malformed proteins that accumulate in various tissues and organs. Cardiac amyloidosis causes restrictive cardiomyopathy, resulting in symptoms associated with right heart failure and decreased cardiac output including: dyspnea, lower extremity edema, elevated jugular venous pressure, hepatic congestion, and ascites. Treatment is dependent on the presentation and extent of cardiac infiltration. Most treatments incorporate the use of loop diuretics for typical heart failure symptoms, beta blockers and anticoagulants if atrial fibrillation is present, tafamidis to reduce amyloid production, and cardiac transplantation.

Conclusions: Complications from ATTRwt require close surveillance of multiple organ systems, including cardiac function, blood pressure and respiratory function in order to maximize patients’ rehab potential. Our patient’s participation was limited by his hypotension and desaturation. A challenging aspect of management was balancing metoprolol, midodrine and torsemide in conjunction with elastic bandages and abdominal binders to maintain a stable blood pressure while slowing the reaccumulation of his pleural effusion. Therefore, a multidisciplinary coordination of medication, physical interventions, nutrition and physical exams is essential in allowing the patient to participate in rehabilitation.