Quick answer: Cardiac amyloidosis was once considered rare and untreatable — it’s now detected far more often, and for the first time we have licensed treatments that can slow it. Atrial fibrillation ablation has also moved on hugely with newer, safer pulsed-field techniques, and wearable devices are transforming how early rhythm problems get picked up.
Today’s post is the last in my series on the biggest breakthroughs in heart health over the past decade.
So far, we’ve talked about cholesterol, heart scans, heart failure, and new structural procedures. To finish, I want to cover something that’s gone from being considered rare to surprisingly common — a condition called cardiac amyloidosis, or “amyloid in the heart.”
If you’d asked a cardiologist ten years ago how often they saw amyloid, the answer would probably have been “not very.” Ask a GP, and they might have said “incredibly rare.” But that’s all changed. We’re now detecting it far more often, partly because more people are having advanced heart scans, and partly because our understanding of the condition has improved dramatically.
What actually is amyloid?
So what actually is amyloid?
Amyloid is a type of protein that, in some people, folds the wrong way and builds up in different parts of the body — including the heart. It can also affect the carpal tunnel (causing wrist or hand symptoms), the gut (causing digestive problems), and the nerves (leading to tingling or numbness in the feet).
When amyloid builds up in the heart, it can interfere with the electrical system, slowing the heart down and sometimes causing rhythm problems that require a pacemaker. It can also stiffen the heart muscle, leading to heart failure.
How is it diagnosed and treated now?
The good news is that modern scanning technology has completely changed how we spot amyloid. Advanced ultrasound (echo) can suggest it; MRI is even more accurate, showing a distinctive pattern; and sometimes bone scans done for other reasons (like prostate cancer) reveal it by chance.
Until recently, there were no approved treatments — only clinical trials. But that’s no longer the case. We now have a licensed medication that can slow the disease, and another promising drug expected soon. One treatment stops the protein from misfolding; the other works at the genetic level to stop the liver from producing the harmful protein in the first place.
These are extraordinary advances — the kind that only a decade ago would have sounded like science fiction. Amyloid is no longer “rare,” and for the first time, we have genuine treatment options that can make a real difference.
Atrial fibrillation: what’s changed
The last innovation of the decade I want to write about is atrial fibrillation, or AF for short. AF is an abnormal heart rhythm. The commonest symptom a patient would experience is an irregular heart beat, often too fast, but it may also be too slow. Other common symptoms are breathlessness, chest pain (especially if the heart is going too fast) and fatigue. However, very often patients have no symptoms whatsoever, and it is only discovered by accident.
I see many patients in clinic who for example had a routine pulse check in their GP surgery, or were alerted to the problem by a smart watch or home blood pressure machine with an AF detection function. Unfortunately it can be very difficult to differentiate symptoms of AF from those of other heart rhythm abnormalities, yet the risk to the patient, and the treatment recommended, can vary enormously. It is therefore of the utmost importance to get symptom-ECG correlation, often by wearing a heart ECG monitor.
AF can be termed paroxysmal (which means it comes and goes), persistent (episodes >1 week) or permanent. Often there are triggers, such as viruses or other infections, excess alcohol, smoking, exercise, stress but equally it may simply happen without any obvious trigger.
At the heart level, it usually occurs because the veins connecting the lungs to the heart which bring with them oxygenated blood to be pumped around the body, become electrically excitable. This ‘takes over’ the normal electrical system in the atria (the top chambers in the heart), and so the normal checks and balances we have cease to function, and the irregularity ensues.
One of the main issues with AF is that the irregularity of the heart beat can give time for blood clots to form in an area of the heart called the left atrial appendage. If the clot should then detach and go to the brain, the patient will have a stroke. Much focus therefore is on working out which patients are at risk of a stroke with AF, as the risk can be brought to nearly nothing with blood thinners.
Treatment of patients with AF and symptoms depends on a host of factors: how bad their symptoms are, how frequently they get them, reversible factors, their body weight (AF is much more common in overweight people, and weight loss in itself can treat AF). Medications are often tried first, but other options include ablation and in some cases pacemakers.
Ablation has moved on a lot in 10 years, hence including it in my list of major improvements. New technology is making atrial fibrillation (AF) ablation quicker, safer, and more precise. Instead of using heat to burn small areas of heart tissue, a newer method called ‘pulsed-field ablation (PFA)’ uses very short bursts of electricity to target the problem areas without damaging nearby structures like the food pipe or nerves. This means shorter procedures, fewer risks, and faster recovery. At the same time, new 3D mapping tools and even artificial intelligence are helping doctors see exactly where the abnormal signals are coming from, allowing them to treat AF more accurately and effectively than ever before.
I wrote above that many patients with AF do not have symptoms and only get discovered by accident, which neatly segues into my last big change of the last decade:
Wearables
Wearables
So many devices now exist for people to self-monitor it is unbelievable. I’ll say at the outset that I am a big fan. I know some doctors get annoyed with patients bringing their own data to consultations, and I do have some sympathy with that point of view. However I personally feel firstly that a well-informed patient who collects their own data is likely to be more invested in their own health which should be a good thing, and secondly it makes my job easier.
Watches can record ECGs of more than adequate quality for me to make a diagnosis and treatment plan for my patients. I would far far rather see my patient’s diligent blood pressure diary recordings from home than my in-office measurement when they are potentially worried (or couldn’t find a car parking spot!). Devices that alert patients to AF are fantastic innovations, and I can only wonder how many people have been saved the tragedy of a stroke as a result of being advised to take a blood thinner of the back of one of these notifications.
In addition to pulse, blood pressure and ECG capabilities, many devices record other biometrics such as heart rate variability (HRV) and even VO2 (although in my view there are some inaccuracies with current versions) which can give clues as to fitness, general health, recovery and more.
The wearable landscape has really changed, I love it, and can’t wait to see what the next decade of technology brings!