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Home / For clinicians / Diagnosis guides / Transthyretin (ATTR) amyloidosis / Checklist

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Suspect-and-test checklist

Transthyretin (ATTR) amyloidosis

Hereditary (variant) or wild-type. A bone scan diagnoses ATTR-CM only alongside negative light chain tests, since AL can also show uptake.

ICD-10-CME85.0, E85.1, E85.2, E85.82, I43Trial Friend for Clinicians

1Red flags present

Heart

Orthopedic

Nerves and other organs

Ancestry and family

2Already labeled as

3Family to test

4Testing, in the order the sources describe

  1. Serum free light chains plus serum and urine immunofixationFirst step in typing. All negative: AL ruled out. Not electrophoresis alone.
    Result
  2. Echocardiography and ECGNot diagnostic alone. Wall thickness over 12mm, apical sparing, voltage discordance.
    Result
  3. Technetium PYP, DPD or HMDP scintigraphy with SPECTGrade 2 or 3, no monoclonal protein and typical echo or CMR features: nonbiopsy ATTR-CM diagnosis. SPECT on every positive scan.
    Result
  4. Biopsy with amyloid typingPositive scan with any abnormal light chain test or MGUS; grade 1 or equivocal scans; negative scan with high suspicion.
    Result
  5. Cardiac MRINot diagnostic of ATTR-CM alone. Useful when ATTR is less likely.
    Result
  6. TTR gene sequencingEveryone with ATTR-CM, at any age. Age does not separate wild-type from variant.
    Result

5Results the sources say do not rule it out

  • A positive bone scan without light chain tests. AL can also show uptake.
  • Planar-only uptake. Blood pool, rib fractures or recent infarction can mimic it; SPECT is needed.
  • A negative scan. Phe84Leu, Ser97Tyr and young p.Val50Met carriers can scan negative.
  • A negative fat pad biopsy, or no low ECG voltage. Neither rules out ATTR.

6Specialists the sources name

Diagnosis codes: E85.0 Non-neuropathic heredofamilial amyloidosis; E85.1 Neuropathic heredofamilial amyloidosis; E85.2 Heredofamilial amyloidosis, unspecified; E85.82 Wild-type transthyretin-related (ATTR) amyloidosis; I43 Cardiomyopathy in diseases classified elsewhereCodes patients often carry before diagnosis are listed in the online guide.
Full guide and sourcesEvery point here is sourced in the online guide, which also has a patient note to print.
Trial Friend, trialfriend.com/for-clinicians. Key sources: GeneReviews (2024); 2020 AHA scientific statement; ACC summary of the 2023 decision pathway; ESC position statement (2021); 2021 multisociety imaging consensus; Gillmore 2016 nonbiopsy diagnosis study; all 14 with links in the online guide. Checked November 9, 2026. A reference checklist for licensed clinicians that summarizes published sources. It is not a diagnostic tool, a score or a protocol, and it does not replace clinical judgment, local practice or the prescribing information. Not coding advice. Trial Friend never receives anything written or typed on this sheet.