Abstract
Wild-type transthyretin cardiac amyloidosis (ATTRwt-CM) is increasingly recognized as an underdiagnosed cause of heart failure with preserved ejection fraction (HFpEF), particularly in older men. Because symptoms overlap with hypertensive heart disease, the diagnosis is often delayed. A 72-year-old man with well-controlled hypertension presented with progressive exertional dyspnea and recurrent hospital admissions for decompensated HFpEF. Electrocardiography demonstrated low QRS voltage despite marked ventricular wall thickening on echocardiography. Recognition of voltage–mass discordance prompted technetium-99m pyrophosphate scintigraphy, which showed grade 3 myocardial uptake. Monoclonal protein testing was negative, confirming wild-type ATTR cardiomyopathy without the need for biopsy. Discordance between QRS voltage and left ventricular wall thickness should prompt evaluation for cardiac amyloidosis. Early recognition of ATTRwt-CM has important therapeutic implications.