Progress in ATTR-CM: A Detailed Exploration of Pathophysiology, Diagnostics, and Treatment Approaches

Transthyretin amyloid cardiomyopathy (ATTR-CM) represents a progressive and underrecognized condition driven by the deposition of misfolded transthyretin (TTR) amyloid fibrils in the heart. Through this review, we aim to explore the complexities of ATTR-CM, including its classification into wild-type (wtATTR), predominantly affecting older males, and hereditary (hATTR), linked to over 120 pathogenic TTR gene variants such as Val30Met and Val122Ile, which is notably common in individuals of African descent. The subtle and often non-specific nature of its symptoms underscores the challenges in timely diagnosis. Advances in diagnostic techniques, including Tc- 99m PYP scintigraphy and PET imaging, have transformed non-invasive detection, facilitating early identification and differentiation from other amyloidosis types. We discuss the impact of therapeutics like tafamidis, a TTR stabilizer, which has improved survival rates and reduced hospitalizations, while emphasizing the urgent need to address healthcare disparities that limit access to these advancements in certain populations. This review delves into the molecular underpinnings of ATTR-CM, highlighting the pathological progression from TTR monomer misfolding to the formation of toxic oligomers and amyloid fibrils that disrupt mitochondrial function and myocardial integrity. We evaluate emerging therapeutic approaches, such as fibril-disrupting agents and gene-editing technologies, and their potential to redefine treatment paradigms. By synthesizing the latest insights, we aim to provide a comprehensive overview of ATTR-CM, emphasizing the integration of advanced diagnostics, personalized therapeutics, and health equity to guide future research and clinical practice.