Reversible Pseudo-Amyloid Strain Pattern in Acute Hypertensive Cardiomyopathy

BACKGROUND: Acute hypertensive cardiomyopathy can transiently reproduce imaging features typically associated with infiltrative cardiomyopathies, including an apical-sparing strain pattern. CASE SUMMARY: A middle-aged patient presented with severe hypertension, pulmonary edema, concentric left ventricular wall thickening, and an apical-sparing global longitudinal strain pattern suggestive of cardiac amyloidosis. Cardiac magnetic resonance imaging demonstrated normal native T1 values, preserved extracellular volume, and only minimal nonspecific late gadolinium enhancement, findings incompatible with amyloid light-chain or transthyretin amyloidosis. With rapid afterload reduction, wall thickness, global longitudinal strain, and the strain distribution normalized, confirming load-dependent dysfunction. DISCUSSION: Acute elevations in afterload can disproportionately impair basal longitudinal fibers, producing a reversible pseudo-amyloid strain pattern that may resemble infiltrative disease on initial assessment. TAKE-HOME MESSAGES: Apical sparing can occur in acute hypertensive cardiomyopathy. Load-dependent basal dysfunction may mimic amyloid patterns. Rapid reversibility aids diagnostic distinction.