PREVALENCE AND CHARACTERISTICS OF TRANSTHYRETIN AMYLOIDOSIS IN PATIENTS WITH LEFT VENTRICULAR HYPERTROPHY OF UNKNOWN ETIOLOGY TTRACK
Conditions: Transthyretin Amyloidosis Cardiomyopathy (ATTR-CM)
Sponsor: Pfizer

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Title 
Prevalence and characteristics of transthyretin amyloidosis in 
patients with left ventricular hypertrophy of unknown etiology 
TTRACK 
Protocol number 
B3461058 
Protocol version 
identifier 
Amendment 2.3 Final protocol version 
Date  
04 NOVEMBER 2021 
Research question and 
objectives 
Primary objective 
• To assess the prevalence of patients with cardiac fixation 
on a radionuclide bone scintigraphy and/or Single Photon 
Emission Computed Tomography (SPECT) performed 
with 99mTc-DPD or 99mTc-PYP or 99mTc-HMDP* among 
patients with (left ventricular hypertrophy) LVH from an 
undiagnosed etiology. 
Secondary objectives 
• To assess the prevalence of AL or ATTR amyloidosis in 
patients with cardiac fixation at the bone scintigraphy 
(visual grade 1 to 3) and/or SPECT; 
• In patients diagnosed with ATTR Amyloidosis to assess 
the prevalence of hereditary (ATTRv) and wild-type 
(ATTRwt) ATTR amyloidosis; 
• To describe TTR genetic mutations** in patients with 
ATTRv amyloidosis; 
• To assess the prevalence of patients with familial history 
of known cardiomyopathy (CM), polyneuropathy (PN), 
sudden cardiac death (SCD) among their relatives (ie, 
parents, siblings and 2nd /3rd degree family members); 
• To assess the prevalence in patients with positive cardiac 
fixation at the bone scintigraphy or SPECT of patients 

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with concomitant signs or symptoms of ATTR 
amyloidosis, ie,: 
• Sensori-motor Polyneuropathy (PN); 
• Carpal Tunnel syndrome (CTS); 
• Autonomic dysfunction; 
• Cardiological manifestations; 
• Laboratory signs; 
• Others. 
• To compare the clinical and biochemical characteristics 
between patients with positive scintigraphy (cardiac 
fixation at the bone scintigraphy grade 1, 2 or 3) and/or 
SPECT. 
• To asses the level of discrepancy in the evaluation of the 
scintigraphy and/or SPECT images by different 
evaluators. 
* Bisphosphonate (99mTc-DPD/99mTc-PYP/99mTc-HMDP) 
Scintigraphy. 
** Variant and pathogenic mutation per sequencing the 
coding parts. 
Author 
MD, MPH, PhD 
This document contains confidential information belonging to Pfizer.  Except as otherwise agreed to in writing, 
by accepting or reviewing this document, you agree to hold this information in confidence and not copy or 
disclose it to others (except where required by applicable law) or use it for unauthorized purposes.  In the event 
of any actual or suspected breach of this obligation, Pfizer must be promptly notified. 
PPD

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1. TABLE OF CONTENTS 
1. TABLE OF CONTENTS .......................................................................................................3 
2. LIST OF ABBREVIATIONS ................................................................................................5 
3. RESPONSIBLE PARTIES ....................................................................................................7 
4. ABSTRACT ...........................................................................................................................9 
5. AMENDMENTS AND UPDATES .....................................................................................16 
6. MILESTONES .....................................................................................................................17 
7. RATIONALE AND BACKGROUND ................................................................................17 
8. RESEARCH QUESTION AND OBJECTIVES .................................................................23 
9. RESEARCH METHODS ....................................................................................................25 
9.1. Study Design ...........................................................................................................26 
9.2. Setting ......................................................................................................................26 
9.2.1. Site Initiation ..............................................................................................26 
9.2.2. Inclusion Criteria ........................................................................................27 
9.2.3. Centralized Review of Bone Scintigraphy (for all patients) .......................28 
9.2.4. Blood Samples Analyses ............................................................................29 
9.2.5. Inclusion/exclusion Criteria ........................................................................29 
9.2.5.1. Follow-up Visit .........................................................................30 
9.3. Variables ..................................................................................................................30 
9.4. Data sources ............................................................................................................32 
9.5. Study Size ................................................................................................................32 
9.6. Data Management ...................................................................................................32 
9.6.1. Case Report forms (CRFs)/Data Collection Tools (DCTs)/Electronic 
Data Record .....................................................................................................33 
9.6.2. Record Retention ........................................................................................33 
9.7. Data analysis ...........................................................................................................34 
9.8. Quality Control ........................................................................................................34 
9.8.1. Investigational Site Set Up .........................................................................34 
9.8.2. Investigational Site Monitoring ..................................................................35 
9.8.3. Study Coordination .....................................................................................35 
9.8.4. Quality and Accuracy of Records ...............................................................35 
9.8.5. Storage of Record .......................................................................................35 

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9.9. Limitations of the Research Methods ......................................................................36 
9.9.1. Investigational Site Selection .....................................................................36 
9.9.2. Patient Selection .........................................................................................36 
9.9.3. Patients Lost to Follow-up ..........................................................................36 
9.9.4. Measurement Biases ...................................................................................36 
9.10. Other Aspects ........................................................................................................36 
10. PROTECTION OF HUMAN SUBJECTS ........................................................................37 
10.1. Patient Information ................................................................................................37 
10.2. Patient Consent ......................................................................................................37 
10.3. Patient Withdrawal ................................................................................................38 
10.4. Institutional Review Board (IRB)/Independent Ethics Committee (IEC) ............38 
10.5. Ethical Conduct of the Study ................................................................................38 
11. MANAGEMENT AND REPORTING OF ADVERSE EVENTS/ADVERSE 
REACTIONS ......................................................................................................................39 
11.1. REQUIREMENTS ................................................................................................39 
11.2. Reporting Period ...................................................................................................40 
11.3. Causality Assessment ............................................................................................41 
11.4. DEFINITIONS OF SAFETY EVENTS ...............................................................41 
11.4.1. Adverse events ..........................................................................................41 
11.4.2. Serious Adverse Events ............................................................................42 
11.4.3. Scenarios Necessitating Reporting to Pfizer Safety Within 24 Hours .....44 
12. PLANS FOR DISSEMINATING AND COMMUNICATING STUDY RESULTS........47 
13. REFERENCES ..................................................................................................................47 
ANNEX 1. LIST OF STAND ALONE DOCUMENTS .........................................................53 
ANNEX 2. BONE SCINTIGRAPHY TECHNOLOGY .........................................................54 
ANNEX 3 – SCINTIGRAPHY EXTERNAL REVIEW.........................................................56 
 

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2. LIST OF ABBREVIATIONS 
Abbreviation 
Definition 
99mTc-DPD 
99mTechnetium-3,3-diphosphono-1,2-propanodi-carboxylic acid 
99mTc-PYP 
99mTechnetium-pyrophosphate 
99mTc-HMDP 
99mTechnetium-hydroxymethylene diphosphonate 
AA 
Serum Amyloid A Protein 
AL 
Light chain amyloidosis 
ATTR 
Transthyretin amyloid 
ATTRm 
Mutant transthyretin related amyloidosis  
ATTRwt 
Wild type transthyretin related amyloidosis 
AVA 
Aortic valve area 
BNP 
Brain natriuretic peptide 
CA 
Cardiac amyloidosis 
CM 
Cardiomyopathy 
CMR 
Cardiac magnetic resonance 
CT 
Computed tomography 
CTS 
Carpal Tunnel syndrome 
EC 
Ethics Committee 
ECG 
Electrocardiogram 
ECHO 
Echocardiography 
e-CRF 
Electronic Case Report Form 
EDP 
Exposure during pregnancy 
EF 
Ejection fraction 
EMB 
Endomyocardial biopsy 
FPFV 
First Patient First Visit 
HCM 
Hypertrophic cardiomyopathy 
hs-cTnT 
High sensitivity cardiac troponin T 
AICD 
Automatic Implantable Cardiac Defibrillator 
ICD 
Inform Consent Document 
IEC 
Independent Ethics Committee 
IRB 
Institutional Review Board 
IFE 
Immunofixation electrophoresis 
LGE 
Late gadolinium enhancement 
LPLV 
Last Patient Last Visit 
LV 
Left ventricular 
LVEF 
Left ventricular ejection fraction 
LVH 
Left ventricular hypertrophy 
LVOTO 
Left ventricular outflow tract obstruction 
MRI 
Magnetic resonance imaging 
MWT 
Maximal wall thickness 
NT-proBNP 
N-terminal pro-brain natriuretic peptide 

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Abbreviation 
Definition 
PET 
Positron emission tomography 
PN 
Polyneuropathy 
SCD 
Sudden cardiac death 
sFLC 
Serum free light chain 
SPECT 
Single Photon Emission Computed Tomography 
TTE 
Transthoracic echocardiography 
TNNI3 
Troponin I, cardiac muscle 
TNNT2 
Troponin T, cardiac muscle 
TPM1 
Tropomyosin alpha-1 chain 
TTR 
Transthyretin 
ATTR-CM 
Transthyretin amyloid cardiomyopathy 
ATTR-FAP 
Transthyretin amyloid polyneuropathy 
TTRv 
Variant transthyretin 
TTRwt 
Wild-type transthyretin 
 

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3. RESPONSIBLE PARTIES 
Scientific Committee Investigators 
Name, degree(s) 
Affiliation 
Address 
MD 
MD 
MD 
MD 
MD 
MD 
 MD 
MD 
 
PPD
PPD
PPD
PPD
PPD
PPD
PPD
PPD
PPD
PPD
PPD
PPD
PPD
PPD
PPD
PPD
PPD
PPD
PPD
PPD
PPD
PPD
PPD
PPD
PPD
PPD

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Pfizer Study Representatives 
Name, degree(s) 
Title 
Affiliatio
n 
Address 
MD, MPH, PhD 
Pfizer  
 
Pfizer 
SAS 
 
PPD
PPD
PPD
PPD
PPD
PPD

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4. ABSTRACT 
Title 
Prevalence and characteristics of transthyretin amyloidosis in patients with left ventricular 
hypertrophy of unknown etiology (TTRACK) 
Rationale and background 
In an adult, hypertrophic cardiomyopathy (HCM) is defined by the presence of a left 
ventricular (LV) wall thickness ≥15 mm in one or more LV myocardial segments that is not 
explained solely by abnormal loading conditions.11  Five to ten percent of adult cases are 
caused by genetic disorders including inherited metabolic and neuromuscular diseases, 
chromosome abnormalities and genetic syndromes.  Some patients have non-genetic 
disorders that present similarly to genetic forms of the disease, for example, wild-type ATTR 
amyloidosis (ATTRwt, formerly known as senile amyloidosis) and light chain amyloidosis 
(AL).45 
The diagnosis of HCM is based on the detection of increased LV wall thickness by any 
imaging modality.11 
The three most frequent and clinically challenging types of systemic amyloidosis are 
acquired monoclonal immunoglobulin light chain amyloidosis (AL), the hereditary mutant 
ATTR (ATTRv), and the non-mutant ATTR, also known as systemic “senile” amyloidosis or 
ATTRwt.42 
AL and ATTR amyloidosis can affect the heart in isolation or with multiorgan involvement. 
Clinical features of transthyretin amyloid cardiomyopathy (ATTR-CM) are varied.  Although 
heart failure symptoms predominate, suspicion of ATTR-CM can also be prompted by 
syncope, arrhythmias, or unexplained LV wall thickening on echocardiography (ECHO).17 
Transthyretin (TTR) amyloidosis (ATTR amyloidosis) is a rare protein misfolding disease.  It 
presents with a wide spectrum of clinical manifestations.8,49  TTR, the protein implicated in 
ATTR amyloidosis, is a tetrameric transport protein.  Misfolded TTR protein forms amyloid 
fibrils causing tissue damage by direct compression and obstruction.49 
The clinical spectrum of ATTR amyloidosis varies widely from an exclusive neurological 
involvement to a predominant cardiac presentation.45  In the first case, the disease is called 
ATTR polyneuropathy (ATTR-PN).  In the second case, the disease is called ATTR 
cardiomyopathy (ATTR-CM). 
ATTR-CM may occur alone or in conjunction with ATTR-PN. ATTR-CM can be  associated 
with genetic variants of TTR and can also occur in the absence of a specific mutation, which 
is known as wild-type TTR (TTRwt).19,47 

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ATTR amyloidosis is likely underdiagnosed, mainly because the disease can mimic other 
causes of left ventricular hypertrophy (LVH), including hypertensive heart disease and 
hypertrophic cardiomyopathy (HCM). 
The diagnosis of ATTR-CM remains challenging. The electrocardiograms (ECGs), 
transthoracic ECHO (TTE) and cardiac magnetic resonance (CMR) of ATTR-CM show 
similar findings to cardiac AL.  The diagnosis strategy for ATTR amyloidosis combines 
pathology and molecular genetic testing.  TTR is a gene of small size (7 kB), including four 
exons, and its screening by full sequencing of the coding parts is now easily accessible.  In 
asymptomatic ATTR carriers, CMR may detect early cardiac involvement by focal 
myocardial late gadolinium enhancement (LGE).32 
Routine laboratory testings are helpful. High levels of brain natriuretic peptide (BNP) 16      
N-terminal pro-brain natriuretic peptide (NT-proBNP)6 and high sensitivity cardiac troponin 
T (hs-cTnT) are associated with cardiovascular events, heart failure and death.  Despite 
comparable values of LV wall thickness, plasma BNP values are three to five fold higher in 
patients with ATTR-CM than in patients with other causes of HCM.  
Non-invasive techniques have been developed in the last few years to assist in the diagnosis 
of ATTR-CM. One of the imaging techniques is bone scintigraphy which has been shown to 
have excellent results in the diagnosis of ATTR-CM.  
Several studies have suggested that ATTR-derived fibrils show avidity for bone tracers, in 
particular, recent systematic evaluation of bone scintigraphy suggests that 99mTc labeled 3,3-
diphosphono-1,2-propanodicarboxylic acid (99mTc-DPD), 99mTc-labeled pyrophosphate 
(99mTc-PYP), and 99mTc-labeled hydroxymethylene diphosphonate (99mTc-HMDP) may be 
remarkably sensitive and specific for diagnosing ATTR-CM and may reliably distinguish 
other causes of CM that mimic amyloid such as HCM.33,41,43,1,38 
For this reason, 99mTc-tracer scintigraphy (99mTc-DPD or 99mTc-PYP or 99mTc-HMDP) should 
be considered in patients in whom ATTR-CM is suspected, supporting the diagnosis when 
histology is not or hardly achievable.12 
Bone scintigraphy enables the reliable diagnosis of ATTR-CM in the absence of histological 
data, in patients who have been evaluated for and do not have a monoclonal gammopathy. 
Non-invasive diagnostic criteria for ATTR-CM are applicable to the majority of patients with 
this disease.17 
Nuclear medicine bone scans differentiate ATTR cardiomyopathy (ATTR-CM) from light 
chain cardiac amyloidosis and other myocardial disorders, helping to make the diagnosis 
without biopsy.  Standard bone scans are not absolutely quantitative, so are assessed by 
comparing the heart to other tissues.40 
The standard visual scoring system compares heart to bone.  This accurately diagnoses 
ATTR-CM and has been validated in a multicenter study, but has limitations.  
Semiquantitative techniques including heart/contralateral thorax (H/CL) and heart/whole 

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body ratio (H/WB) improve on visual scoring but still rely on extracardiac sites as 
comparators.  Absolute quantitation of myocardial uptake using quantitative SPECT should 
help overcome these shortcomings.  In ATTR-CM, this technique is practical, accurately 
makes the diagnosis and provides information that is not identical to visual scores.40 
Additional SPECT/CT significantly improved the diagnostic efficacy of 99mTc-DPD 
scintigraphy.  Uptake grade of involved organs and degree of background activity might help 
to differentiate between AL and ATTR subtypes.26 
Figure 1. Diagnostic Algorithm for Patients with Suspected Amyloid Cardiomyopathy 
(Gillmore 2016)17 
 
Echocardiographic features suggesting/indicating cardiac amyloid include (but are not 
limited to) increased left ventricular wall thickness, restrictive filling pattern, abnormal left 
and right ventricular longitudinal strain, and atrial septal thickening. 
Features suggesting/indicating cardiac amyloid on cardiac magnetic resonance imaging 
(CMR) include (but are not limited to) restrictive morphology, abnormal gadolinium kinetics, 
and extracellular volume expansion based on T1 mapping.  

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AApoA1 indicates apolipoprotein A-I; DPD, 3,3-diphosphono-1,2-propanodicarboxylic acid; 
HDMP, hydroxymethylene diphosphonate; and PYP, pyrophosphate; TTR, transthyretin; 
ATTR, TTR amyloidosis.  
Research question and objectives 
Primary objective 
• To assess the prevalence of patients with cardiac fixation on a radionuclide bone 
scintigraphy and/or Single Photon Emission Computed Tomography (SPECT) 
performed with 99mTc-DPD or 99mTc-PYP or 99mTc-HMDP* among patients with left 
ventricular hypertrophy (LVH) from an undiagnosed etiology; 
Secondary objectives 
• To assess the prevalence of AL or ATTR amyloidosis amyloidosis in patients with 
cardiac fixation at the bone scintigraphy (visual grade 1 to 3) and/or SPECT; 
• In patients diagnosed with ATTR Amyloidosis to assess the prevalence of hereditary 
(ATTRv) and wild-type (ATTRwt) ATTR amyloidosis; 
• To describe TTR genetic mutations** in patients with ATTRv amyloidosis; 
• To assess the prevalence of patients with familial history of known cardiomyopathy 
(CM), polyneuropathy (PN), sudden cardiac death (SCD) among their relatives (ie, 
parents, siblings and 2nd/3rd degree family members); 
• To assess the prevalence in patients with cardiac fixation at the bone 
scintigraphy/SPECT of concomitant signs or symptoms of ATTR amyloidosis, ie,: 
• Sensori-motor Polyneuropathy (PN); 
• Carpal Tunnel syndrome (CTS); 
• Autonomic dysfunction; 
• Cardiological manifestations; 
• Laboratory signs; 
• Others; 
• To compare the clinical and biochemical characteristics between patients with 
positive scintigraphy (cardiac fixation at the bone scintigraphy grade 1, 2 or 3) and/or 
SPECT. 

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• To asses the level of discrepancy in the evaluation of the scintigraphy and/or SPECT 
images by different evaluators 
* Bisphosphonate (99mTc-DPD/99mTc-PYP/99mTc-HMDP) Scintigraphy 
** Variant and pathogenic mutation per sequencing the coding parts 
Study design  
Multi-center and multi-national epidemiological study. 
Principal investigators will be cardiologists experienced in the diagnosis of cardiomyopathies 
or physician specialized in diagnosing patients with LVH. 
Patient population. Inclusion and exclusion criteria: 
1. Inclusion Criteria. 
a. Patient signed inform consent. 
b. Males and Females. 
c. Age ≥50 years. 
d. Left ventricular hypertrophy (LVH) defined as end-diastolic LV maximum wall 
thickness (MWT) ≥15mm in Echocardiogram. 
e. Plan to undergo or recently underwent radionuclide bone scintigraphy and/or 
SPECT with any of the following radio labelled tracers: 99mTc-DPD or 99mTc-PYP 
or 99mTc-HMDP. 
2. Exclusion Criteria: 
a. Etiological diagnosis explaining the LVH prior to patient inclusion (eg, 
Sarcomeric HCM, Myeloma, Fabry disease, Sarcoidosis, any type of amyloidosis 
[AA, AL, TTR])  
b. Severe aortic stenosis defined as aortic valve area (AVA) < 1.0 cm2 
Variables– include exposures, outcomes, and key co-variates 
• Date Informed Consent Document signed.  
• Inclusion and exclusion criteria met. 
• Patient demographic data (Age, Gender, Weight, Height, Race). 

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• Patient family history. 
• Relatives (parents, siblings and 2nd/3rd grade family) with known cardiomyopathy 
(CM), Polyneuropathy (PN), and/or Sudden cardiac death (SCD). 
• Patient medical history. 
• Results of Cardiological assessments, if performed. 
• Blood pressure  
• Bone scintigraphy with radiolabelled Technetium tracer (99mTc-DPD or 99mTc-
PYP or 99mTc-HMDP) visual grading score and/or SPECT 
• ECG (last ECG performed). 
• Echocardiograhy. 
• Magnetic resonance imaging (MRI).  
• Neurological assessments: 
• Symptoms and clinical signs of peripheral neuropathy (small fibres). 
• Autonomic symptoms and clinical signs.  
• Carpal tunnel syndrome (CTS) history and symptoms.  
Additional set of variables from the patient clinical records as available will be included in 
the CRF of those patients with cardiac fixation in bone scintigraphy (Grade 1, 2 or 3) and/or 
SPECT: 
• Results from blood sample testing (Creatinine, Haemoglobin, BNP, NT proBNP, 
Troponin I & T); 
• Results from monoclonal protein studies (in urine and blood); 
• Results from TTR gene sequencing. 

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Data sources 
Data will be collected from medical records completed during routine clinical practice.  As 
an epidemiological study, there are no specific requirements with regard to patient 
procedures to be performed or the treatment regimen.  Data from each patient will be 
reported on an electronic case report form (e-CRF). 
Study size 
The study is designed to enroll approximately 1500 patients. 
Considering a prevalence of ATTR-CM around 10%, the screening of 1.500 patients will 
provide a precision of ±1.5% in the estimation of this prevalence with a 95% two-sided 
confidence interval (primary objective).  In addition, considering such a prevalence, the 
prevalence of the different symptoms or additional signs within the population of ATTR-CM 
(other objectives) will be estimated with a precision of ±7.3 % for any sign/symptom with a 
frequency of 30% or lower. 
Data analysis 
Detailed methodology for statistical analyses of data collected in this study will be 
documented in a Statistical Analysis Plan (SAP), which will be dated, filed and maintained 
by the sponsor.  The SAP may modify the plans outlined in the protocol; any major 
modifications of primary endpoint definitions or their analyses would be reflected in a 
protocol amendment. 
• Descriptive analysis will be performed for all the variables; 
• Analysis will be stratified by age in years (50 to ≤55; 55 to ≤60; 60 to ≤65; 65 to ≤70; 
70 to ≤75; 75 to ≤80; >80 ), gender and cardiac symptomatology at baseline; 
• Patients with a final diagnosis of ATTR-CM will be compared with the other 
“negative” screened patients in order to understand possible diagnostic red flags; 
• Factors associated with ATTR amyloidosis will be identified by univariate and 
multivariate logistic regression.  A significance level of 10% and 5% will be used for 
the univariate and multivariate analyses, respectively. 

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Milestones 
The study will enroll approximately 1500 patients. 
Milestone 
Planned date 
Start of data collection  
September 2017 
End of data collection  
June 2022 or as soon as 1000 patient 
will be screened in the study 
5. AMENDMENTS AND UPDATES 
Amendment 
number 
Date 
Protocol 
section(s) 
changed  
Summary of amendment(s) 
Reason 
N°1 
14 JUN 2018 
 
 
New European legislation 
N°2 
11 
FEBRUARY 
2020 
Inclusion/
Exclusion 
criteria 
Variables 
CRF 
ICD 
Milestone 
Clarification of the protocol 
process to be in line with the 
requirement of a NIS 
protocol 
Addition of the SPECT in 
the inclusion criteria 
Inclusion period extension 
Protocol clarification and 
deletion of the biological 
sample collection 
N°2.1 
22 OCTOBER 
2020 
Milestone 
Extension for the data 
collection 
Due to the international 
pandemy and to allow to reach 
the goal of the number of 
patient screened, it was 
decided to extend the 
inclusion period 
N°2.2 
21 MAY 2021 
Milestone 
Extension for the inclusion 
period and data collection 
Due to the international 
pandemy and to allow to reach 
the goal of a minimum of one 
thousand patient screened, it 
was decided to extend the 
inclusion period. 
Participating country list 
updates 
N°2.3 
04 
NOVEMBER 
2021 
Milestone 
Extension for the inclusion 
period and data collection 
Due to the international 
pandemy and to allow to reach 
the goal of a minimum of one 
thousand patient screened, it 
was decided to extend the 
inclusion period. 
 

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6. MILESTONES 
Milestone 
Planned date 
Feasibility meeting 
06 – 07 October 2017 
Start of data collection  
May 2018 
End of data collection  
June 2022 
Final study report 
December 2022 
 
7. RATIONALE AND BACKGROUND 
Transthyretin (TTR) amyloidosis (ATTR amyloidosis) is a rare protein misfolding disease, 
(Conceicao 2016; Sekijima 2015).8,49  The protein implicated in ATTR amyloidosis, is a 
tetrameric transport protein for thyroxine and the retinol-binding protein–retinol (vitamin A) 
complex (Monaco 1995).31  Destabilisation and dissociation of the native TTR tetramer can 
result in misfolding and the formation of amyloid fibrils and progressive amyloid deposition 
in tissues (Connelly 2010, Klabunde 2000, Johnson 2005, Sekijima 2008).9,22,20,48 
Misfolded TTR protein forms amyloid fibrils causing tissue damage by direct compression 
and obstruction (Sekijima 2015).49  The resulting tissue damage is largely irreversible 
(Coelho 2013; Plante-Bordeneuve 2014).5,37  
The clinical spectrum of ATTR amyloidosis varies widely from an exclusively neurological 
involvement to a predominantly cardiac presentation.  This heterogeneity is linked to several 
factors including specific TTR mutations, patient and transmitting parent gender, 
geographical distribution, and endemic/non-endemic aggregation.  (Rapezzi 2013).45 
When the peripheral nerves are affected predominantly, the disease is termed transthyretin 
amyloid polyneuropathy (ATTR-PN).  When the heart is primarily affected, the disease is 
called transthyretin amyloid cardiomyopathy (ATTR-CM). 
ATTR-PN is a fatal illness resulting from autosomal dominantly inherited single-point 
mutations on the TTR gene.  This disease may strikes people from their 30s.  A person 
affected by this disease will develop a slow, steady, and devastating neurologic decline 
leading ultimately to death with a mean survival of 10 to 15 years.  Symptoms in the early 
stage of disease are not always easy to recognize and are difficult to interpret on clinical 
grounds due to their subjective nature (Conceicao 2008).7  By the time clear symptoms are 
present, the loss of function has already been achieved (Leufacheur 2013; Kodaira 2011).27,23  
Early intervention is therefore critical to stabilize the disease (Coelho 2013; Plante-
Bordeneuve 2014).5,37 
ATTR-CM may occur in isolation or may occur in conjunction with ATTR-PN.  ATTR-CM 
may be associated with genetic variants of TTR but can also occur in the absence of a specific 
mutation, which is known as wild-type TTR (TTRwt) (Jacobson 1997, Saraiva 1995).19,47 

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More than 100 amyloidogenic TTR point mutations have been identified in patients with 
ATTR-PN.  The most common genetic variant associated with polyneuropathy is Val30Met 
(valine replaced by methionine at position 30 of the amino acid chain), which accounts for 
≈85%of ATTR-PN cases worldwide.  Generally, non-Val30Met mutations are associated 
with greater cardiac involvement than Val30Met mutations, and patients with non-Val30Met 
mutations and a cardiac phenotype tend to be older men and have lower survival rates 
(Merlini 2013).28  
Median survival from diagnosis for patients with ATTR-CM was reported as 41 months for 
patients with a Val122Ile mutation (valine replaced by isoleucine at position 122 of the 
amino acid chain) and 46 months for patients with wild-type ATTR-CM (Connors 2011),10 
with most patients dying from cardiac causes, including sudden death, congestive heart 
failure, and myocardial infarction (Kyle 1996, Smith 1984).25,51 
ATTR amyloidosis is likely underdiagnosed, mainly because the disease can mimic other 
causes of left ventricular (LV) hypertrophy (LVH), including hypertensive heart disease and 
HCM. 
In the majority of cases, hypertrophic cardiomyopathy (HCM) is inherited as an autosomal 
dominant genetic trait with a 50% risk of transmission to offspring (Richard 2003).46  In 
patients fulfilling HCM diagnostic criteria, sequencing of sarcomere protein genes identifies 
a disease-causing mutation in up to 60% of cases (Richard 2003, Van Driest 2003).46,52  The 
likelihood of finding a causal mutation is highest in patients with familial disease and lowest 
in older patients and individuals with non-classical features. 
In an adult, hypertrophic cardiomyopathy (HCM) is defined by the presence of a LV wall 
thickness ≥15 mm in one or more LV myocardial segments—as measured by any imaging 
technique (echocardiography (ECHO), cardiac magnetic resonance imaging (CMR) or 
computed tomography (CT))—that is not explained solely by abnormal loading conditions 
(Elliott 2014).11  In up to 60% of adolescents and adults with HCM, the disease is an 
autosomal dominant trait caused by mutations in cardiac sarcomere protein genes (Brito 
2012),3 but five to ten percent of adult cases are caused by other genetic disorders including 
inherited metabolic and neuromuscular diseases, chromosome abnormalities and genetic 
syndromes).  Some patients have non-genetic disorders that present similarly to genetic 
forms of the disease, for example, wild-type ATTR amyloidosis (ATTRwt, formerly known 
as senile amyloidosis) and light chain amyloidosis (AL).  (Rapezzi 2013).45  
AL and hereditary ATTR amyloidosis can affect the heart in isolation or with multiorgan 
involvement, whereas wild-type ATTR amyloidosis predominantly affects the heart. 
The diagnosis of HCM rests on the detection of increased LV wall thickness by any imaging 
modality.  Due to the diverse etiology of the disease, detection of increased LV wall 
thickness that is unexplained by loading conditions should prompt a systematic search for its 
underlying cause.  In many patients, this work-up should include specialized laboratory 
testing and, in some circumstances as ATTR amyloidosis, genetic analysis.  (Elliott 2014).11 

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The common feature of the amyloidosis is the extracellular accumulation of fibrillary 
proteins, leading to loss of normal tissue architecture and myocardial involvement with 
clinical implications (Rapezzi 2009).42 
Clinical features are varied, and although heart failure symptoms predominate, suspicion of 
cardiac amyloidosis can also be prompted by syncope, arrhythmias, or unexplained LV wall 
thickening on ECHO (Gillmore 2016).17 
Amyloidosis may be systemic or localized and is currently classified according to the type of 
precursor protein.  The most frequent types of systemic amyloidosis associated with 
clinically relevant cardiac involvement are: AL, AA and ATTR amyloidosis (Rapezzi 
2009).42  
ATTRm is transmitted as an autosomal dominant trait with variable penetrance (Mohty 
2013).32  Clinical manifestations and age of onset vary depending on the TTR mutation, sex, 
parental gene transmission and geographical area (Plante-Bordeneuve 2011).36  The 
Val30Met ATTR amyloidosis in Portuguese patients occurs in their second or third decade, 
with peripheral neuropathy and cardiac conductive disorders.  In other geographical areas, 
the same Val30met mutation presents as late onset ATTR amyloidosis (at age 50—70years) 
and the clinical manifestations combine peripheral neuropathy, cardiac conductive disorders 
and heart failure (Plante-Bordeneuve 1998).35  In other TTR mutations (Thr60Ala and 
Val122Ile), cardiac involvement is predominant (Mohty 2013).32 
The diagnosis of ATTR-CM remains challenging.  However, because of the overlapping 
symptoms, sole reliance on clinical manifestations for diagnosis is imprudent (Kapoor 
2011).21  The electrocardiograms (ECGs), transthoracic echocardiography (TTE) and CMR 
of ATTR-CM show similar findings to cardiac AL.  The diagnosis strategy for ATTR 
amyloidosis combines pathology and molecular genetic testing.  TTR is a gene of small size 
(7 kB), including four exons, and its screening by full sequencing of the coding parts is now 
easily accessible.  In asymptomatic ATTR amyloidosis carriers, CMR may detect early 
cardiac involvement by focal myocardial late gadolinium enhancement (LGE) (Mohty 
2013).32 
Routine laboratory testing aids. High levels of brain natriuretic peptide (BNP) (Geske 
2013),16 N-terminal pro-brain natriuretic peptide (NT-proBNP) (Coats, 2013)6 and high 
sensitivity cardiac troponin T (hs-cTnT) are associated with cardiovascular events, heart 
failure and death.  Despite comparable values of ventricular wall thickness, plasma BNP 
values are three to five times higher in patients with cardiac amyloidosis than in those with 
other causes of HCM.  
The diagnosis of amyloidosis is also obtained through biopsy of a clinically affected organ, 
with Congo red histology demonstrating pathognomonic green birefringence.  However, 
when amyloidosis is suspected clinically, biopsy of subcutaneous fat, salivary gland, or 
rectum yields the diagnosis in 50% to 80% of patients with AL amyloidosis (Ansari-Lari 
2004, Gillmore 2016).1,17  A much lower yield in patients with ATTR amyloidosis frequently 
results in a requirement for endomyocardial biopsy (EMB) to confirm the diagnosis (Fine 

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2014, Gillmore 2016).13,17  EMB is associated with a risk of complications, including 
myocardial perforation and tamponade that may be fatal and requires expertise that can 
introduce diagnostic delay (Maurer 2015, Gillmore 2016).30,17  ECGs are abnormal in 90% of 
cases with cardiac involvement (Mohty 2013).  The low precordial and limb lead voltage is 
primarily due to the destruction and replacement of myocytes by the electrically inert 
amyloid.  Although this pattern is exhibited by approximately 70% of AL-associated cardiac 
amyloidosis, only one third of patients with hereditary amyloidosis and wild-type 
amyloidosis show low voltage.  The pseudoinfarction pattern as evidenced by QS waves in 
2 consecutive leads is another common finding (Kapoor 2011).21  Differential diagnosis 
between HCM and cardiac amyloidosis is aided by measuring the ratio between QRS 
voltages and LV wall thickness (Elliott 2014).11 
ECHO, although a valuable and widely accessible tool for investigating heart failure, is 
neither sensitive nor specific for cardiac amyloidosis.  Typical findings on ECHO include 
thickening of ventricular walls, restrictive filling, abnormal left and right ventricular 
longitudinal strain, and atrial septal thickening (Falk 2014).12  In hereditary amyloidosis, 
marked LVH may be seen on echocardiogram even in the absence of significant heart failure 
(Kapoor 2011).21  Low voltage on ECHO and interventricular septal thickness of >19.8 mm 
on ECHO together have a sensitivity of 72% and specificity of 91% for cardiac amyloidosis 
(Rahman 2004).39  Cardiac magnetic resonance imaging (CMR) has much greater diagnostic 
value in cardiac amyloidosis, but false-positive and false-negative CMRs are not infrequent 
(Maceira 2005).  Typical findings include restrictive morphology, abnormal gadolinium 
kinetics, and extracellular volume expansion on T1 mapping.  Furthermore, CMR is costly, is 
available only in specialist centers, is contraindicated in a substantial proportion of patients, 
and cannot reliably distinguish different types of amyloid (Gillmore 2016).17 
The ventricular myocytes of the “amyloid heart” have shown augmentation of both atrial and 
brain natriuretic peptide gene expression.  Although nonspecific from a diagnostic utility 
standpoint in cardiac amyloidosis, NT-proBNP is a sensitive (93%) prognostic biomarker 
(Kapoor 2011).21  Regarding nuclear imaging, the major clinical contribution is the detection 
of ATTR-CM. TTR is a tetrameric plasma transport protein synthesized in the liver and is the 
precursor protein in wild-type and familial TTR-related amyloidosis.  Several studies have 
suggested that TTR-derived fibrils show avidity for bone tracers, in particular 99mTechnetium 
labeled tracers, whereas there is no uptake of tracer in the hearts of patients with HCM 
caused by sarcomeric protein gene mutations.  
Recent systematic evaluation of bone scintigraphy suggests that 99mTc-labeled 3,3-
diphosphono-1,2-propanodicarboxylic acid (DPD), 99mTc-labeled pyrophosphate (PYP), and 
99mTc-labeled hydroxymethylene diphosphonate (HMDP) may be remarkably sensitive and 
specific for imaging cardiac TTR amyloid and may reliably distinguish other causes of 
cardiomyopathy that mimic amyloid such as HCM (Perugini 2005, Rapezzi 2008, Rapezzi 
2011, Bokhari 2013, Quarta 2012).33,41,43,1,38  Indeed, radionuclide bone scintigraphy may 
identify cardiac ATTR deposits early in the course of the disease, sometimes before the 
development of abnormalities on ECHO or CMR (Glaudemans 2014, Fontana 2014),15,14 
and has been used to diagnose ATTR amyloidosis among patients with heart failure and 

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preserved ejection fraction (Castaño 2015).4  Cardiac localization of radiotracer occurs in a 
small proportion of patients with AL amyloidosis, and although usually low grade, it can 
confound distinguishing between cardiac ATTR and AL types of amyloid (Bokhari 2013).1 
For this reason, bone scintigraphy (99mTc-DPD or 99mTc-PYP or 99mTc-HMDP) should be 
considered in patients in whom ATTR amyloidosis is a possibility (age >65 years, history of 
bilateral carpal tunnel syndrome (CTS), absent family history of HCM, and features 
consistent with cardiac amyloidosis on ECG and cardiac imaging) (Rapezzi 2011, Elliott 
2014),43,11 supporting the diagnosis (Falk 2014).12  
Gillmore analyses of 374 patients with EMBs, corroborated in the whole cohort of 
1.217 patients, indicate that cardiac uptake (grade 1, 2, or 3) on a radionuclide bone scan is 
>99% sensitive but not completely specific for cardiac ATTR (68% specificity compared 
with EMB histology); the low specificity results largely from low-grade uptake in patients 
with cardiac AL or cardiac apolipoprotein A-I amyloidosis (Hutt 2014).18  The specificity for 
cardiac ATTR of grade 2 or 3 cardiac uptake on radionuclide imaging increases to ≈87%, but 
the sensitivity falls to 91%.  Because it is absolutely essential to avoid misdiagnosis of 
cardiac ATTR  in a patient who actually has cardiac AL requiring chemotherapy, the primary 
aim of the proposed diagnostic criteria was to achieve very high diagnostic specificity.  The 
specificity and positive predictive value for ATTR-CM of the combination of grade 2 or 
3 cardiac uptake on a radionuclide scan and the absence of a detectable monoclonal protein 
despite serum immunofixation electrophoresis (IFE), urine IFE, and serum free light chain 
(sFLC) assay were 100% (positive predictive value confidence interval, 99.0–100%) in this 
cohort of 1.217 patients and were also 100% among each of the 3 different radiotracer 
cohorts.  Although we acknowledge that further validation of 99mTc-HMDP scintigraphy 
against EMB histology is required, the presented preliminary data for 99mTc-HMDP indicate 
that it behaves identically to 99mTc-DPD and 99mTc-PYP. 
The diagnosis of ATTR-CM is often delayed or missed as a result of the poor sensitivity and 
specificity of ECHO (Kristen 2010),24 coupled with the current requirement for histological 
confirmation of amyloid in a tissue biopsy.  The diagnosis of ATTRwt is particularly 
challenging because it presents in older age (when confounding comorbidities such as 
coronary heart disease, hypertension, and aortic stenosis frequently coexist) (Pinney 2013, 
Gillmore 2016).34,17 
Bone scintigraphy enables the diagnosis of ATTR-CM to be made reliably without the need 
for histology in patients who do not have a monoclonal gammopathy.  Non-invasive 
diagnostic criteria for ATTR-CM are applicable to the majority of patients with this disease 
(Gillmore 2016).17 

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Nuclear medicine bone scans differentiate ATTR cardiomyopathy (ATTR-CM) from light 
chain cardiac amyloidosis and other myocardial disorders, helping to make the diagnosis 
without biopsy.  Standard bone scans are not absolutely quantitative, so are assessed by 
comparing the heart to other tissues.  (Ramsay et al. 2019).40 
The standard visual scoring system compares heart to bone.  This accurately diagnoses 
ATTR-CM and has been validated in a multicenter study, but has limitations. 
Semiquantitative techniques including heart/contralateral thorax (H/CL) and heart/whole 
body ratio (H/WB) improve on visual scoring but still rely on extracardiac sites as 
comparators.  Absolute quantitation of myocardial uptake using quantitative SPECT should 
help overcome these shortcomings.  In ATTR-CM, this technique is practical, accurately 
makes the diagnosis and provides information that is not identical to visual scores.  (Ramsay 
et al. 2019).40 
Additional SPECT/CT significantly improved the diagnostic efficacy of 99mTc-DPD 
scintigraphy.  Uptake grade of involved organs and degree of background activity might help 
to differentiate between AL and ATTR subtypes.  (Lee J, 2020).26 
Figure 1. Diagnostic Algorithm for Patients with Suspected Amyloid Cardiomyopathy 
(Gillmore 2016)17 
 

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Echocardiographic features suggesting/indicating cardiac amyloid include (but are not 
limited to) increased left ventricular wall thickness, restrictive filling pattern, abnormal left 
and right ventricular longitudinal strain, and atrial septal thickening. 
Features suggesting/indicating cardiac amyloid on cardiac magnetic resonance imaging 
(CMR) include (but are not limited to) restrictive morphology, abnormal gadolinium kinetics, 
and extracellular volume expansion based on T1 mapping.  
AApoA1 indicates apolipoprotein A-I; DPD, 3,3-diphosphono-1,2-propanodicarboxylic acid; 
HDMP, hydroxymethylene diphosphonate; and PYP, pyrophosphate.  
Moreover, the data clearly indicate that the combined finding of grade 2 or 3 cardiac uptake 
on radionuclide scintigraphy and the absence of a monoclonal protein by serum 
immunofixation electrophoresis (IFE), urine IFE, and sFLC (Freelite) assay was 
100% specific for presence of ATTR-CM (Gillmore 2016).17  
A diagnosis of ATTR-CM should be followed by TTR genotyping in all patients to 
differentiate between wild-type and variant ATTR-CM. 
The main purpose of this study is to determine the prevalence of ATTR-CM among patients 
admitted due to LVH of unknown etiology when radionuclide bone scintigraphy or SPECT is 
used. 
8. RESEARCH QUESTION AND OBJECTIVES 
Primary objective 
• To assess the prevalence of patients with cardiac fixation on a radionuclide bone 
scintigraphy and/or Single Photon Emission Computed Tomography (SPECT) 
performed with 99mTc-DPD or 99mTc-PYP or 99mTc-HMDP* among patients with 
(left ventricular hypertrophy) LVH from an undiagnosed etiology. 
Secondary objectives 
• To assess the prevalence of AL or ATTR amyloidosis amyloidosis in patients with 
cardiac fixation at the bone scintigraphy (visual grade 1 to 3) and/or SPECT; 
• In patients diagnosed with ATTR Amyloidosis to assess the prevalence of hereditary 
(ATTRv) and wild-type (ATTRwt) ATTR amyloidosis; 
• To describe TTR genetic mutations** in patients with ATTRv amyloidosis; 
• To assess the prevalence of patients with familial history of known cardiomyopathy 
(CM), polyneuropathy (PN), sudden cardiac death (SCD) among their relatives (ie, 
parents, siblings and 2nd /3rd degree family members). 

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• To assess the prevalence in patients with positive cardiac fixation at the bone 
scintigraphy and/or SPECT of patients with concomitant signs or symptoms of ATTR 
amyloidosis, ie,: 
• Sensori-motor Polyneuropathy (PN); 
• Carpal Tunnel syndrome (CTS); 
• Autonomic dysfunction; 
• Cardiological manifestations; 
• Laboratory signs; 
• Others. 
• To compare the clinical and biochemical characteristics between patients with 
positive scintigraphy (cardiac fixation at the bone scintigraphy grade 1, 2 or 3) and/or 
SPECT. 
• To asses the level of discrepancy in the evaluation of the scintigraphy and/or SPECT 
images by different evaluators 
* Bisphosphonate (99mTc-DPD/99mTc-PYP/99mTc-HMDP) Scintigraphy. 
** Variant and pathogenic mutation per sequencing the coding parts. 

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Figure 2. Study Flow Chart 
 
 
 
9. RESEARCH METHODS  

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9.1. Study Design  
TTRACK is an epidemiological multicenter and multinational study. 
Patients can be enrolled from several countries listed in Appendix 5.  This list is non-
exhaustive and additional countries may be added to this list. 
The management of this protocol will be aligned with country legislation and regulatory 
procedures. 
Investigators will be cardiologists experienced in diagnosis of cardiomyopathies or 
physicians specialized in diagnosing patients with LVH. The sites involved (at least when 
performing feasibility) will be representative of their respective country in terms of practice.  
Participating physicians will not be influenced in their decision making and routine 
proceedings in any way. 
The study will include approximately 1500 patients.  
All assessments described in this protocol are performed as part of routine clinical practice or 
standard practice guidelines for the patient population and healthcare provider specialty in 
the countries where this non-interventional study is being conducted.  Data, including 
individual study results, will be collected from these assessments, if performed. 
9.2. Setting 
9.2.1. Site Initiation 
The cardiologists who agreed to participate in the study will receive a letter containing: 
• A cover letter with a reply slip to be returned to Pfizer's logistics center; 
• A study synopsis; 
• The participating physicians' contracts, one copy of which should be returned to 
Pfizer's logistics center; 
• A pre-paid envelope. 
Once the contract has been signed and returned to Pfizer's logistics center, it will be validated 
by Pfizer. 
A site initiation visit will be organized to present the protocol and its documentation. 
This documentation will be sent by mail few days before initiation visit and it will be 
composed with: 
• All study documents in the paper version (protocol, regulatory agreements, etc ...);  

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• Briefings and patient consent;  
• Monitoring documentation (Screening and enrollment log, Subject identification code 
list, Site visit log, etc).  
To initiate the site, Pfizer will have to receive some mandatory documents such as: 
• Protocol Acceptance Form signed by the physician; 
• The certificate of safety training; 
• The signature sheet and delegations of duties log; 
• The Curriculum Vitae of the physician and all the people involved in the project. 
After reception of these documents, the physician and all the people involved in the study 
will receive the study website address and his/her own access code.  They will find the 
following documents on the website: 
• Regulatory authorities opinion; 
• Ethics committee (EC) opinion; 
• The study protocol and protocol amendment; 
• The serious adverse events (SAE) declaration form. 
In addition, data relating to the physician (year of registration, year of doctoral thesis, town 
where practicing etc.) can be uploaded to the website as well as the anonymized data 
regarding the patients. 
Each physician investigator will be a single number (0001 to 00XX). 
Each patient screened in the study will be assigned a number by order of inclusion in the 
study. 
Therefore, each patient will be identified in the study by the center number and patient 
number (for example 0002-05 is the 5th patient included by the second site) 
The physicians will be provided with a hotline number as well as an email address where 
they can ask questions about the conduct of the study. 
9.2.2. Inclusion Criteria 
The study will enroll patients according to the eligibility criteria in participating countries. 
The recruiting centers will be representative of each country involved in terms of care 
management systems, of size and of practices (at least when performing feasibility).  

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To ensure equitable recruitment, each site will be limited to a 100 screened patient 
maximum. 
All patients who met the inclusion and exclusion criteria will be invited to participate in the 
study. 
An informed consent document, will be signed by each patient before any data collection 
(Appendix 1). 
If a patient isn’t included in the study for any reason, the non-inclusion register has to be 
completed (Appendix 2). 
The enrollment visit will be performed at the time of inclusion, after the patients’ acceptance 
of enrollment in the study and Informed Consent Document signature.  
Data will come from medical records and will be collected in routine clinical practice.  The 
enrollment visit will comprise a first section on patients’ eligibility for every patient and a 
second section on the patient information, family history and clinical evaluation at the 
inclusion.  
After the patient undergoes a Bone Scintigraphy and/or SPECT as part of standard of care 
(Annex 3) the images will be evaluated by the nuclear medicine specialist of the 
investigational center. 
Scans will be defined at each site according to the internationally accepted grading:   
Grade 0 = absent cardiac uptake 
Grade 1=mild uptake less than bone 
Grade 2=moderate uptake equal to bone  
Grade 3=high uptake greater than bone 
For all patients with cardiac fixation at scintigraphy and/or SPECT the following data will be 
collected and incorporated in the CRF if available: 
• Answers from questions regarding ATTR amyloidosis red flags 
• Results from clinical laboratory tests and genotyping.  
The patient will finish the study after this visit.  
9.2.3. Centralized Review of Bone Scintigraphy (for all patients) 
In this study, all the scintigraphy/SPECT tests will be additionally reviewed by two external 
evaluators. 

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The objective of this evaluation will be to asses the level of discrepancy in the evaluation of 
the scintigraphy/SPECT images by different evaluators 
All the scintigraphy/SPECT tests will be uploaded in a dedicated database via the study web 
site. 
Two experts from the scientific committee members will connect to the study web site with 
personalized connection access.  They’ll review the scintigraphies/SPECT and enter their 
evaluation. 
9.2.4. Blood Samples Analyses 
Following the standard practice guidelines for the patient population with positive 
scintigraphy, blood and urine analyses are usually done to rule out AL amyloidosis.  If 
performed, results of these tests will be collected.  
Moreover, to differentiate between wild-type and variant ATTR-CM, genotyping are usually 
completed.  If performed, results will be collected. 
9.2.5. Inclusion/exclusion Criteria 
Patients with LVH from undiagnosed etiology and the following inclusion/exclusion criteria: 
1. Inclusion Criteria. 
a. Patient signed inform consent 
b. Males and Females 
c. Age ≥50 years 
d. Left ventricular hypertrophy (LVH) defined as end-diastolic LV maximum wall 
thickness (MWT) ≥15mm in Echocardiogram. 
e. Plan to undergo or recently underwent radionuclide bone scintigraphy and/or 
SPECT with any of the following radio labelled tracers: 99mTc-DPD or 99mTc-PYP 
or 99mTc-HMDP*. 
* Scintigraphy will be defined at each site according to the standard 
grading:   
Grade 0 = absent cardiac uptake 
Grade 1=mild uptake less than bone 
Grade 2=moderate uptake equal to bone  
Grade 3=high uptake greater than bone 

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2. Exclusion Criteria: 
a. Etiological diagnosis explaining the LVH prior to patient inclusion (eg, 
Sarcomeric HCM, Myeloma, Fabry disease, Sarcoidosis, any type of amyloidosis 
[AA, AL, TTR**]).  
b. Severe aortic stenosis defined as aortic valve area (AVA) <1.0 cm2. 
** TTR diagnosis at exclusion criteria: Direct relative (siblings or parents) 
of a carrier with a known hereditary mutation in the TTR gene or any 
patient already diagnosed by any of the following: cardiac fixation at the 
bone scintigraphy, TR mutation at the genetic testing, biopsy with 
amyloidosis (positive red congo) and positive TTR staining. 
9.2.5.1. Follow-up Visit 
Patients will undergo follow-up to collect results of biological and genetic tests if there is 
cardiac fixation on a radionuclide bone scintigraphy and/or SPECT. 
9.3. Variables 
Variable 
Data source(s) 
Patient informed consent date 
PATIENT INCLUSION 
Patient visit date 
PATIENT INCLUSION 
Age ≥50 years 
PATIENT INCLUSION 
LVH 
Echo demonstrated end-diastolic LV MWT ≥15mm 
PATIENT INCLUSION 
Maximal end diastolic wall thickness 
PATIENT INCLUSION 
Sarcomeric HCM (Genetic testing) 
PATIENT INCLUSION 
Plasma cell dyscrasia  
PATIENT INCLUSION 
Fabry disease  
PATIENT INCLUSION 
AL, AA or any other amyloidosis 
PATIENT INCLUSION 
Severe aortic stenosis (defined as) Maximal aortic velocity >4 
m/s or Mean gradient >40 mmHg 
PATIENT INCLUSION 
Birth date (mm-yyyy) 
PATIENT INFORMATION 
Gender 
PATIENT INFORMATION 
Weight 
PATIENT INFORMATION 
Height 
PATIENT INFORMATION 
Ethnic Origin 
PATIENT INFORMATION 
Date 
CLINICAL EVALUATION 
Diastolic blood pressure 
CLINICAL EVALUATION 
Systolic blood pressure 
CLINICAL EVALUATION 
Diagnosed hypertension 
CLINICAL EVALUATION 
Antihypertensive medication 
CLINICAL EVALUATION 
Coronary artery disease 
CLINICAL EVALUATION 
Renal insufficiency 
CLINICAL EVALUATION 
Diabetes Mellitus 
CLINICAL EVALUATION 
Lumbar spinal stenosis 1  
CLINICAL EVALUATION 
CTS – surgery history 2 
CLINICAL EVALUATION 
New York heart Association (NYHA) class 
CLINICAL EVALUATION 
Atrial Fibrillation (AF) 
CLINICAL EVALUATION 

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Variable 
Data source(s) 
Pacemaker  
CLINICAL EVALUATION 
AICD (Automatic Implantable Cardiac Defibrillator) 
CLINICAL EVALUATION 
LGE (Late Gadolinium Enhancement) 
CLINICAL EVALUATION 
Heart rate 
CLINICAL EVALUATION 
Sinus rhythm 
CLINICAL EVALUATION 
PR Interval 
CLINICAL EVALUATION 
QRS interval 
CLINICAL EVALUATION 
Sokolow index 
CLINICAL EVALUATION 
Pseudo-MI pattern 
CLINICAL EVALUATION 
Poor precordial R wave progression 
CLINICAL EVALUATION 
LBBB RBBB Paced Intraventricular conduct delay 
CLINICAL EVALUATION 
Left Ventricular Ejection Fraction (LVEF) 
CLINICAL EVALUATION 
Left Ventricular Obstruction Tract (LVOT) 
CLINICAL EVALUATION 
Longitudinal strain done? 
CLINICAL EVALUATION 
LV end-diastolic diameter 
CLINICAL EVALUATION 
MWT 
CLINICAL EVALUATION 
MWT at septum 
CLINICAL EVALUATION 
MWT posterior wall 
CLINICAL EVALUATION 
Hypertrophic pattern 
Apical, Concentric, Asymmetric, Mix 
CLINICAL EVALUATION 
LV mass index 
CLINICAL EVALUATION 
Aortic valvular stenosis 
CLINICAL EVALUATION 
Pericardial effusion 
CLINICAL EVALUATION 
Patient scintigraphy date 
SCINTIGRAPHY 
99mTc-DPD, 99mTc-PYP, 99mTc-HMDP 
SCINTIGRAPHY 
Grade 0=absent cardiac uptake 
Grade 1=mild uptake less than bone 
Grade 2=moderate uptake equal to bone 
Grade 3=high uptake greater than bone 
SCINTIGRAPHY 
Walking ability: No Impairment, Impaired but ability to walk 
without a stick or crutches, Walking only with the help of one 
stick or crutch, Walking with the help of two sticks or 
crutches, Confined to a wheelchair or bedridden 
ATTR RED FLAGS 
SPECT date 
SPECT 
SPECT Result 
SPECT 
Paresthesia / Numbness / Sensory loss * 
ATTR RED FLAGS 
Pain* 
ATTR RED FLAGS 
Temperature sensory loss* 
ATTR RED FLAGS 
Muscle weakness* 
ATTR RED FLAGS 
Carpal tunnel syndrome symptoms 
ATTR RED FLAGS 
Erectile dysfunction / Vaginal dryness 
ATTR RED FLAGS 
Orthostatic / postural hypotension (dizziness, syncope) 
ATTR RED FLAGS 
Urinary difficulties (i.e. dysuria, incontinence…) 
ATTR RED FLAGS 
Sweating abnormalities 
ATTR RED FLAGS 
Digestive dysautonomia: Constipation, alternating 
constipation and diarrhoea, nausea, vomiting… 
ATTR RED FLAGS 
Early satiety / Gastro paresis 
ATTR RED FLAGS 
Unintentional weight loss 
ATTR RED FLAGS 
Visual disturbances: Dry eye / Glaucoma 
ATTR RED FLAGS 
Creatinine  
CLINICAL LABORATORIES 
Haemoglobin 
CLINICAL LABORATORIES 

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Variable 
Data source(s) 
BNP 
CLINICAL LABORATORIES 
NTproBNP 
CLINICAL LABORATORIES 
Troponin I 
CLINICAL LABORATORIES 
Troponin  T  
CLINICAL LABORATORIES 
IFE of serum 
CLINICAL LABORATORIES 
IFE of urine 
CLINICAL LABORATORIES 
*sFLC assay 
CLINICAL LABORATORIES 
Electrophoresis performed?  
CLINICAL LABORATORIES 
Date 
TTR gene sequencing 
Result 
TTR gene sequencing 
 
9.4. Data sources  
Data will be collected from medical records and routine clinical practice.  As an 
epidemiological study, there are no specific requirements with regard to patient procedures to 
be performed or the treatment regimen.  Data from each patient will be reported on an 
electronic case report form (e-CRF). 
An electronic Case Report Form (e-CRF – Appendix 3) will be used for data recording.  In 
this protocol, the term e-CRF should be understood to refer to medical records in electronic 
data form.  The data collection method used will be an e-CRF for physicians in English.  
The visit after scintigraphy/SPECT should be documented only when the bone scintigraphy 
is positive with tracer uptake (Grade 1, 2 or 3) or SPECT shows cardiac fixation. 
It is the investigator's responsibility to ensure completion and to review and approve all 
e-CRFs. E-CRFs must be signed by the investigator or by an authorized staff member   These 
signatures serve to attest that the information contained on the e-CRFs is true. Anytime, the 
investigator has the final personal responsibility for the accuracy and authenticity of all 
clinical and laboratory data entered into the e-CRF. 
9.5. Study Size 
Considering a prevalence of ATTR-CM around 10%, the screening of N =1500 patients will 
provide a precision of ±1.5% in the estimation of this prevalence with a 95% two-sided 
confidence interval (first objective).  In addition, considering such a prevalence, the precision 
of the estimation of the different symptoms or additional signs within the population of 
ATTR-CM (other objectives) will be estimated with a precision of ± 7.3% for any 
sign/symptom with a frequency of 30% or lower. 
9.6. Data Management  
The database and data management plan will be generated to include the following as a 
minimum: 
• Data Flow Plan; 

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• Case Report Form Completion Guidelines; 
• Data Entry Methods and Guidelines; 
• Data Validation Document; 
• Data Handling Conventions. 
A Data Clarification Form (DCF) process will be used for handling data discrepancies. 
Data management and statistical analysis will be performed with SAS software.  
9.6.1. Case Report forms (CRFs)/Data Collection Tools (DCTs)/Electronic Data Record 
As used in this protocol, the term CRF should be understood to refer to either a paper form or 
an electronic data record or both, depending on the data collection method used in this study. 
A CRF is required and should be completed for each included patient.  The completed 
original CRF are the sole property of Pfizer and should not be made available in any form to 
third parties, except for authorized representatives of Pfizer or appropriate regulatory 
authorities, without written permission from Pfizer.  The investigator shall ensure that the 
CRFs are securely stored at the study site in encrypted electronic form and will be password 
protected to prevent access by unauthorized third parties. 
The investigator has ultimate responsibility for the collection and reporting of all clinical, 
safety, and laboratory data entered on the CRFs and any other data collection forms (source 
documents) and ensuring that they are accurate, authentic/original, attributable, complete, 
consistent, legible, timely (contemporaneous), enduring, and available when required.  The 
CRFs must be signed by the investigator or by an authorized staff member to attest that the 
data contained on the CRFs are true.  Any corrections to entries made in the CRFs or source 
documents must be dated, initialed, and explained (if necessary) and should not obscure the 
original entry. 
In most cases the source documents are the hospital or the physician's chart. In these cases, 
data collected on the CRFs must match those charts.  
In some cases, the CRF may also serve as the source document.  In these cases, a document 
should be available at the investigator site and at Pfizer that clearly identifies those data that 
will be recorded on the CRF, and for which the CRF will stand as the source document. 
9.6.2. Record Retention 
To enable evaluations and/or inspections/audits from regulatory authorities or Pfizer, the 
investigator agrees to keep records, including the identity of all participating patients 
(sufficient information to link records, eg, CRFs and hospital records), all original signed 
informed consent documents, copies of all CRFs, safety reporting forms, source documents, 
detailed records of treatment disposition, and adequate documentation of relevant 

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correspondence (eg, letters, meeting minutes, and telephone call reports).  The records should 
be retained by the investigator according to local regulations or as specified in the clinical 
study agreement (CSA), whichever is longer.  The investigator must ensure that the records 
continue to be stored securely for so long as they are retained. 
If the investigator becomes unable for any reason to continue to retain study records for the 
required period (eg, retirement, relocation), Pfizer should be prospectively notified.  The 
study records must be transferred to a designee acceptable to Pfizer, such as another 
investigator, another institution, or to an independent third party arranged by Pfizer.  
Investigator records must be kept for a minimum of 15 years after completion or 
discontinuation of the study or for longer if required by applicable local regulations.  
The investigator must obtain Pfizer's written permission before disposing of any records, 
even if retention requirements have been met. 
9.7. Data analysis  
Detailed methodology for summary and statistical analyses of data collected in this study will 
be documented in a Statistical Analysis Plan (SAP), which will be dated, filed and 
maintained by the sponsor.  The SAP may modify the plans outlined in the protocol; any 
major modifications of primary endpoint definitions or their analyses would be reflected in a 
protocol amendment. 
• Descriptive analysis will be performed for all the variables;  
• Analysis will be stratified by age [50 to ≤55 ; 55 to ≤60; 60 to ≤65; 65 to ≤70; 70 to 
≤75; 75 to ≤80; >80 years old], gender and cardiac symptomatology at entry; 
• Patients with a final diagnosis of ATTR-CM will be compared with the patients who 
do not have a final diagnosis of ATTR-CM in order to highlight possible diagnostic 
red flags; 
• Factors associated to ATTR amyloidosis will be identified by univariate and 
multivariate logistic regression. A significance level of 10% and 5% will be used for 
the univariate and multivariate analyses, respectively. 
An interim analysis of the data collected will be performed for all the variables as soon as 
75 patients will be selected with a scintigraphy grade 1, 2 or 3 and with completed e-CRF. 
9.8. Quality Control 
9.8.1. Investigational Site Set Up 
Appropriate training relevant to the study will be given to investigational staff.  Any new 
information relevant to the performance of this Study will be forwarded to the staff during 
the study. 

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9.8.2. Investigational Site Monitoring 
Regular contacts with the sites will be planned to provide information and support to the 
investigator(s) and verify that study sites procedures are compliant with the protocol and that 
data are being accurately recorded in the CRFs.  
Additional monitoring tasks will be described in a monitoring plan according to Pfizer SOP; 
monitoring visit at investigators sites will ensure that: 
• information letters have been given to the patients and consents have been signed;  
• study is conducted according to the protocol; 
• data reported on case report forms is compliant with source documents; 
• study documents are correctly archived in accordance with the investigator’s study 
file.  
9.8.3. Study Coordination 
Regular progress reports presenting key indicators at a National and International level will 
be regularly prepared and forwarded to the study coordinating team.  Based on these status 
reports, different actions will be decided by the study coordinating team to ensure a 
satisfactory progress and an appropriate quality of data.  
Different signals (Protocol deviations as identified by monitoring) will be used as potential 
identification of low protocol compliance by investigators.  
9.8.4. Quality and Accuracy of Records 
The investigator will have the responsibility for collecting and reporting of all clinical, safety 
and laboratory data entered in the e-CRFs and/or any other data collection forms (source 
documents) and ensuring that they are accurate, authentic/original, attributable, complete, 
consistent, legible, timely (contemporaneous), enduring and available when required.  
To enable evaluations and/or audits from regulatory authorities or Pfizer, the investigator 
agrees to keep records, including the identity of all participating subjects (sufficient 
information to link records, eg, CRFs and hospital records), all original signed informed 
consent forms, copies of all CRFs, serious adverse event forms, source documents, and 
detailed records of treatment disposition, and adequate documentation of relevant 
correspondence (eg, letters, meeting minutes, telephone call reports).  
9.8.5. Storage of Record 
The records should be retained by the investigator according to local regulations, and/ or as 
specified in the Clinical Study Agreement. 

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9.9. Limitations of the Research Methods 
9.9.1. Investigational Site Selection 
The voluntary participation of physicians constitutes a selection bias observed for this type of 
study.  Investigational sites will be recruited within a list of the country’s centers, 
representative in terms of size, care management system and practices. 
9.9.2. Patient Selection  
This constitutes another potential selection bias classically associated with studies.  
Voluntary or involuntary selection of patients in a study by investigators is inevitable, but 
this bias can be limited by systematic attempts to enroll patients in the study. 
9.9.3. Patients Lost to Follow-up 
The pragmatic nature of this study (which involves non-intervention on usual patient 
management practices) may increase the number of patients lost to follow-up after the 
scintigraphy results reported.  
Monitoring on site, remote monitoring and warnings implemented in the e-CRF should 
minimize this. 
9.9.4. Measurement Biases 
The assessment of the primary endpoint is based on the bone scintigraphy reading, which 
implies an evaluator-dependent variability and may create a bias.  
In order to measure this bias scintigraphy reviews by external evaluators have been planned.  
Digitalized images will be reviewed by two external evaluators to analize level of 
concordance/discrepancies among different specialists as part of a secondary objective for 
the study. 
Secondary endpoints are based on laboratory analyses and may constitute a bias as each site 
has their own process, units and norms.  They are also based on symptom assessment that may 
differ from an investigator to another and may constitute a bias. 
9.10. Other Aspects 
If a physician agrees to participate in this study, a written agreement will be concluded with 
this physician containing the amount of allowance paid for the documentation of one subject.  
The agreed allowance is paid for the workload involved in the documentation of the 
treatment on the specific e-CRF. 
Since no other examinations will be performed than the usual clinical examinations and 
laboratory tests, the medical services provided and the drugs will be reimbursed by the health 
insurer.  

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10. PROTECTION OF HUMAN SUBJECTS 
10.1. Patient Information  
All parties will comply with all applicable laws, including laws regarding the implementation 
of organizational and technical measures to ensure protection of patient personal data.  Such 
measures will include omitting patient names or other directly identifiable data in any 
reports, publications, or other disclosures, except where required by applicable laws.  
The personal data will be stored at the study site in encrypted electronic form and will be 
password protected to ensure that only authorized study staffs have access.  The study site 
will implement appropriate technical and organizational measures to ensure that the personal 
data can be recovered in the event of disaster.  In the event of a potential personal data 
breach, the study site shall be responsible for determining whether a personal data breach has 
in fact occurred and, if so, providing breach notifications as required by law. 
To protect the rights and freedoms of natural persons with regard to the processing of 
personal data, when study data are compiled for transfer to Pfizer and other authorized 
parties, patient names will be removed and will be replaced by a single, specific, numerical 
code, based on a numbering system defined by Pfizer.  All other identifiable data transferred 
to Pfizer or other authorized parties will be identified by this single, patient-specific code.  
The investigator site will maintain a confidential list of patients who participated in the study, 
linking each patient’s numerical code to his or her actual identity.  In case of data transfer, 
Pfizer will maintain high standards of confidentiality and protection of patients’ personal data 
consistent with the Clinical Study Agreement and applicable privacy laws. 
10.2. Patient Consent 
The informed consent documents and any patient recruitment materials must be in 
compliance with local regulatory requirements and legal requirements, including applicable 
privacy laws. 
The informed consent documents used during the informed consent process and any patient 
recruitment materials must be reviewed and approved by Pfizer, approved by the institutional 
review board (IRB)/independent ethics committee (IEC) before use, and available for 
inspection. 
The investigator must ensure that each study patient or his or her legally acceptable 
representative fully informed about the nature and objectives of the study, the sharing of data 
relating to the study and possible risks associated with participation, including the risks 
associated with the processing of the patient’s personal data.  The investigator further must 
ensure that each study patient or his or her legally acceptable representative is fully informed 
about his or her right to access and correct his or her personal data and to withdraw consent 
for the processing of his or her personal data. 
Whenever consent is obtained from a patient’s legally acceptable representative/parent(s) or 
legal guardian, the patient’s assent (affirmative agreement) must subsequently be obtained 

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when the patient has the capacity to provide assent, as determined by the IRB/IEC.  If the 
investigator determines that a patient’s decisional capacity is so limited that he or she cannot 
reasonably be consulted, then, as permitted by the IRB/IEC and consistent with local 
regulatory and legal requirements, the patient’s assent may be waived with source 
documentation of the reason assent was not obtained.  If the study patient does not provide 
his or her own consent, the source documents must record why the patient did not provide 
consent (eg, minor, decisionally impaired adult), how the investigator determined that the 
person signing the consent was the patient’s legally acceptable representative, the consent 
signer’s relationship to the study patient (eg, parent, spouse), and that the patient’s assent was 
obtained or waived.  If assent is obtained verbally, it must be documented in the source 
documents. 
The investigator, or a person designated by the investigator, will obtain written informed 
consent from each patient or the patient’s legally acceptable representative, parent(s), or legal 
guardian and the patient’s assent before any study-specific activity is performed. The 
investigator will retain the original of each patient's signed consent document. 
10.3. Patient Withdrawal 
Patients may withdraw from the study at any time at their own request, or they may be 
withdrawn at any time at the discretion of the investigator or sponsor for safety, behavioral, 
or administrative reasons.  In any circumstance, every effort should be made to document 
patient outcome, if applicable.  The investigator would inquire about the reason for 
withdrawal and follow-up with the patient regarding any unresolved adverse events.   
If the patient withdraws from the study, and also withdraws consent for disclosure of future 
information, no further evaluations should be performed, and no additional data should be 
collected.  The sponsor may retain and continue to use any data collected before such 
withdrawal of consent. 
10.4. Institutional Review Board (IRB)/Independent Ethics Committee (IEC) 
According to the involved country legislation, It is the responsibility of PFIZER or the 
investigator to have prospective approval of the study protocol, protocol amendments, and 
informed consent forms, and other relevant documents, (eg, recruitment advertisements), if 
applicable, from the IRB/IEC.  All correspondence with the IRB/IEC should be retained by 
PFIZER or the investigator.  Copies of IRB/IEC approvals should be forwarded to Pfizer or 
the investigator. 
10.5. Ethical Conduct of the Study 
The study will be conducted in accordance with legal and regulatory requirements, as well as 
with scientific purpose, value and rigor and follow generally accepted research practices 
described in Guidelines for Good Pharmacoepidemiology Practices (GPP) issued by the 
International Society for Pharmacoepidemiology (ISPE), Good Epidemiological Practice 
(GEP) guidelines issued by the International Epidemiological Association (IEA), Good 
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and Outcomes Research (ISPOR), International Ethical Guidelines for Epidemiological 
Research issued by the Council for International Organizations of Medical Sciences 
(CIOMS), European Medicines Agency (EMA) European Network of Centres for 
Pharmacoepidemiology and Pharmacovigilance (ENCePP) Guide on Methodological 
Standards in Pharmacoepidemiology, and Food and Drug Administration (FDA) Guidance 
for Industry: Good Pharmacovigilance and Pharmacoepidemiologic Assessment, FDA 
Guidance for Industry and FDA Staff: Best Practices for Conducting and Reporting of 
Pharmacoepidemiologic Safety Studies Using Electronic Healthcare Data Sets, Guidance for 
Industry: Patient-Reported Outcome Measures: Use in Medical Product Development to 
Support Labeling Claims and/or equivalent. 
11. MANAGEMENT AND REPORTING OF ADVERSE EVENTS/ADVERSE 
REACTIONS  
11.1. REQUIREMENTS 
The table below summarizes the requirements for recording safety events on the case report 
form and for reporting safety events on the non-interventional study (NIS) adverse event 
monitoring (AEM) Report Form to Pfizer Safety.  These requirements are delineated for 
three types of events: (1) serious adverse events (SAEs); (2) non-serious AEs (as applicable); 
and (3) scenarios involving exposure to a Pfizer product, including exposure during 
pregnancy, exposure during breast feeding, medication error, overdose, misuse, 
extravasation, and occupational exposure. These events are defined in the section 
DEFINITIONS OF SAFETY EVENTS”.  
Safety event 
Recorded on the case report 
form 
Reported on the NIS AEM 
Report Form to Pfizer 
Safety within 24 hours of 
awareness 
SAE 
All (regardless of whether the 
event is determined by the 
investigator to be related to 
any Pfizer product) 
Only events determined by 
the investigator to be related 
to a Pfizer product 
Non-serious AE 
All (regardless of whether the 
event is determined by the 
investigator to be related to 
any Pfizer product) 
Only events determined by 
the investigator to be related 
to a Pfizer product 

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Safety event 
Recorded on the case report 
form 
Reported on the NIS AEM 
Report Form to Pfizer 
Safety within 24 hours of 
awareness 
Scenarios involving exposure 
to a Pfizer product, including 
exposure during pregnancy, 
exposure during breast 
feeding, medication error, 
overdose, misuse, 
extravasation; lack of efficacy; 
and occupational exposure 
All (regardless of whether 
associated with an AE), 
except occupational 
exposure  
All (regardless of whether 
associated with an AE) 
involving exposure to a 
Pfizer product 
 
For each AE, the investigator must pursue and obtain information adequate both to determine 
the outcome of the adverse event and to assess whether it meets the criteria for classification 
as a SAE (see section "Serious Adverse Events” below). 
Safety events must be reported to Pfizer within 24 hours of awareness of the event by the 
investigator as described in the table above.  In particular, if the SAE is fatal or life-
threatening, notification to Pfizer must be made immediately, irrespective of the extent of 
available event information.  This timeframe also applies to additional new (follow-up) 
information on previously forwarded safety event reports. In the rare situation that the 
investigator does not become immediately aware of the occurrence of a safety event, the 
investigator must report the event within 24 hours after learning of it and document the time 
of his/her first awareness of the events. 
For those safety events that are considered serious or that are identified in the far right 
column of the table above that are reportable to Pfizer within 24 hours of awareness, the 
investigator is obligated to pursue and to provide any additional information to Pfizer in 
accordance with this 24-hour timeframe.  In addition, an investigator may be requested by 
Pfizer to obtain specific follow-up information in an expedited fashion. This information is 
more detailed than that recorded on the case report form. In general, this will include a 
description of the adverse event in sufficient detail to allow for a complete medical 
assessment of the case and independent determination of possible causality. Information 
relevant to the event, such as concomitant medications and illnesses must be provided. In the 
case of a patient death, a summary of available autopsy findings must be submitted as soon 
as possible to Pfizer or its designated representative.  
11.2. Reporting Period  
For each patient, the safety event reporting period begins at the time of the patient’s informed 
consent, which is obtained prior to the patient’s enrollment in the study, and lasts through the 
end of the observation period of the study; a report must be submitted to Pfizer Safety (or its 

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designated representative) for any of the types of safety events listed in the table above 
occurring during this period.  If the investigator becomes aware of a SAE occurring at any 
time after completion of the study and s/he considers the serious AE to be related to a Pfizer 
product, the SAE also must be reported to Pfizer Safety.  
11.3. Causality Assessment 
The investigator is required to assess and record the causal relationship.  For all AEs, 
sufficient information should be obtained by the investigator to determine the causality of 
each adverse event.  For AEs with a causal relationship to a Pfizer product, follow-up by the 
investigator is required until the event and/or its sequelae resolve or stabilize at a level 
acceptable to the investigator, and Pfizer concurs with that assessment.  
An investigator’s causality assessment is the determination of whether there exists a 
reasonable possibility that a Pfizer product caused or contributed to an adverse event.  If the 
investigator’s final determination of causality is “unknown” and s/he cannot determine 
whether a Pfizer product caused the event, the safety event must be reported within 24 hours. 
If the investigator cannot determine the etiology of the event but s/he determines that a Pfizer 
product did not cause the event, this should be clearly documented on the case report form 
and the NIS AEM Report Form.  
11.4. DEFINITIONS OF SAFETY EVENTS 
11.4.1. Adverse events 
An AE is any untoward medical occurrence in a patient administered a medicinal product. 
The event need not necessarily have a causal relationship with the product treatment or 
usage.  Examples of adverse events include but are not limited to:  
• Abnormal test findings (see below for circumstances in which an abnormal test 
finding constitutes an adverse event); 
• Clinically significant symptoms and signs; 
• Changes in physical examination findings; 
• Hypersensitivity; 
• Progression/worsening of underlying disease;  
• Lack of efficacy;  
• Drug abuse;  
• Drug dependency. 
Additionally, for medicinal products, they may include the signs or symptoms resulting from: 

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• Drug overdose; 
• Drug withdrawal; 
• Drug misuse;  
• Off-label use;  
• Drug interactions; 
• Extravasation; 
• Exposure during pregnancy; 
• Exposure during breast feeding; 
• Medication error; 
• Occupational exposure. 
Abnormal test findings 
The criteria for determining whether an abnormal objective test finding should be reported as 
an adverse event are as follows:  
• Test result is associated with accompanying symptoms, and/or 
• Test result requires additional diagnostic testing or medical/surgical intervention, 
and/or 
• Test result leads to a change in study dosing or discontinuation from the study, 
significant additional concomitant drug treatment, or other therapy, and/or 
• Test result is considered to be an adverse event by the investigator or sponsor. 
Merely repeating an abnormal test, in the absence of any of the above conditions, does not 
constitute an adverse event.  Any abnormal test result that is determined to be an error does 
not require reporting as an adverse event. 
11.4.2. Serious Adverse Events 
A serious adverse event is any untoward medical occurrence in a patient administered a 
medicinal or nutritional product (including pediatric formulas) at any dose that: 
• Results in death; 
• Is life-threatening; 

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• Requires inpatient hospitalization or prolongation of hospitalization (see below for 
circumstances that do not constitute adverse events); 
• Results in persistent or significant disability/incapacity (substantial disruption of the 
ability to conduct normal life functions); 
• Results in congenital anomaly/birth defect. 
Medical and scientific judgment is exercised in determining whether an event is an important 
medical event.  An important medical event may not be immediately life-threatening and/or 
result in death or hospitalization.  However, if it is determined that the event may jeopardize 
the patient or may require intervention to prevent one of the other outcomes listed in the 
definition above, the important medical event should be reported as serious. 
Examples of such events are intensive treatment in an emergency room or at home for 
allergic bronchospasm; blood dyscrasias or convulsions that do not result in hospitalization; 
or development of drug dependency or drug abuse. 
Additionally, any suspected transmission via a Pfizer product of an infectious agent, 
pathogenic or non-pathogenic, is considered serious.  The event may be suspected from 
clinical symptoms or laboratory findings indicating an infection in a patient exposed to a 
Pfizer product.  The terms “suspected transmission” and “transmission” are considered 
synonymous.  These cases are considered unexpected and handled as serious expedited cases 
by PV personnel.  Such cases are also considered for reporting as product defects, if 
appropriate. 
Hospitalization 
Hospitalization is defined as any initial admission (even if less than 24 hours) to a hospital or 
equivalent healthcare facility or any prolongation to an existing admission.  Admission also 
includes transfer within the hospital to an acute/intensive care unit (eg, from the psychiatric 
wing to a medical floor, medical floor to a coronary care unit, neurological floor to a 
tuberculosis unit).  An emergency room visit does not necessarily constitute a hospitalization; 
however, an event leading to an emergency room visit should be assessed for medical 
importance.  
Hospitalization in the absence of a medical AE is not in itself an AE and is not reportable. 
For example, the following reports of hospitalization without a medical AE are not to be 
reported.  
• Social admission (eg, patient has no place to sleep); 
• Administrative admission (eg, for yearly exam); 
• Optional admission not associated with a precipitating medical AE (eg, for elective 
cosmetic surgery); 

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• Hospitalization for observation without a medical AE; 
• Admission for treatment of a pre-existing condition not associated with the 
development of a new AE or with a worsening of the pre-existing condition (eg, for 
work-up of persistent pre-treatment lab abnormality); 
• Protocol-specified admission during clinical study (eg, for a procedure required by 
the study protocol). 
11.4.3. Scenarios Necessitating Reporting to Pfizer Safety Within 24 Hours  
Scenarios involving exposure during pregnancy, exposure during breastfeeding, medication 
error, overdose, misuse, extravasation, lack of efficacy, and occupational exposure are 
described below. 
Exposure during pregnancy 
An exposure during pregnancy (EDP) occurs if: 
1. A female becomes, or is found to be, pregnant either while receiving or having been 
exposed to (eg, environmental) a Pfizer product, or the female becomes, or is found to 
be, pregnant after discontinuing and/or being exposed to a Pfizer product (maternal 
exposure). 
An example of environmental exposure would be a case involving direct contact with 
a Pfizer product in a pregnant woman (eg, a nurse reports that she is pregnant and has 
been exposed to chemotherapeutic products). 
2. A male has been exposed, either due to treatment or environmental exposure to a 
Pfizer product prior to or around the time of conception and/or is exposed during the 
partner pregnancy (paternal exposure). 
As a general rule, prospective and retrospective exposure during pregnancy reports from any 
source are reportable irrespective of the presence of an associated AE and the procedures for 
SAE reporting should be followed.  
If a study participant or study participant’s partner becomes, or is found to be, pregnant 
during the study participant’s treatment with a Pfizer product, this information must be 
submitted to Pfizer, irrespective of whether an adverse event has occurred, must be submitted 
using the NIS AEM Report Form and the EDP Supplemental Form.  
In addition, the information regarding environmental exposure to a Pfizer product, in a 
pregnant woman (e.g., a subject reports that she is pregnant and has been exposed to a 
cytotoxic product by inhalation or spillage) must be submitted using the NIS AEM Report 
Form and the EDP supplemental form. This must be done irrespective of whether an AE has 
occurred.  

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Information submitted should include the anticipated date of delivery (see below for 
information related to termination of pregnancy). 
Follow-up is conducted to obtain general information on the pregnancy, in addition, follow-
up is conducted to obtain information on EDP outcome for all EDP reports with pregnancy 
outcome unknown. outcome.  A pregnancy is followed until completion or until pregnancy 
termination (eg, induced abortion) and Pfizer is notified of the outcome.  This information is 
provided as a follow up to the initial EDP report.  In the case of a live birth, the structural 
integrity of the neonate can be assessed at the time of birth.  In the event of a termination, the 
reason(s) for termination should be specified and, if clinically possible, the structural 
integrity of the terminated fetus should be assessed by gross visual inspection (unless pre-
procedure test findings are conclusive for a congenital anomaly and the findings are 
reported). 
If the outcome of the pregnancy meets the criteria for an SAE (eg, ectopic pregnancy, 
spontaneous abortion, intrauterine fetal demise, neonatal death, or congenital anomaly [in a 
live born, a terminated fetus, an intrauterine fetal demise, or a neonatal death]), the 
procedures for reporting SAEs should be followed. 
Additional information about pregnancy outcomes that are reported as SAEs follows:  
• Spontaneous abortion includes miscarriage and missed abortion; 
• Neonatal deaths that occur within 1 month of birth should be reported, without regard 
to causality, as SAEs.  In addition, infant deaths after 1 month should be reported as 
SAEs when the investigator assesses the infant death as related or possibly related to 
exposure to investigational product. 
Additional information regarding the exposure during pregnancy may be requested. Further 
follow-up of birth outcomes will be handled on a case-by-case basis (eg, follow-up on 
preterm infants to identify developmental delays).  
In the case of paternal exposure, the study participant will be provided with the Pregnant 
Partner Release of Information Form to deliver to his partner. It must be documented that the 
study participant was given this letter to provide to his partner. 
Exposure during breastfeeding 
Scenarios of exposure during breastfeeding must be reported, irrespective of the presence of 
an associated AE.  An exposure during breastfeeding report is not created when a Pfizer drug 
specifically approved for use in breastfeeding women (eg, vitamins) is administered in 
accord with authorized use.  However, if the infant experiences an AE associated with such a 
drug’s administration, the AE is reported together with the exposure during breastfeeding. 
Medication error 

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A medication error is any unintentional error in the prescribing, dispensing or administration 
of a medicinal product that may cause or lead to inappropriate medication use or patient harm 
while in the control of the health care professional, patient, or consumer.  Such events may 
be related to professional practice, health care products, procedures, and systems including: 
prescribing; order communication; product labeling, packaging, and nomenclature; 
compounding; dispensing; distribution; administration; education; monitoring; and use.  
Medication errors include: 
• Near misses, involving or not involving a patient directly (eg, inadvertent/erroneous 
administration, which is the accidental use of a product outside of labeling or 
prescription on the part of the healthcare provider or the patient/consumer); 
• Confusion with regard to invented name (eg, trade name, brand name). 
The investigator must submit the following medication errors to Pfizer, irrespective of the 
presence of an associated AE/SAE: 
• Medication errors involving patient exposure to the product, whether or not the 
medication error is accompanied by an AE. 
• Medication errors that do not involve a patient directly (eg, potential medication 
errors or near misses).  When a medication error does not involve patient exposure to 
the product the following minimum criteria constitute a medication error report: 
• An identifiable reporter; 
• A suspect product; 
• The event medication error. 
Overdose, Misuse, Extravasation 
Reports of overdose, misuse, and extravasation associated with the use of a Pfizer product are 
reported to Pfizer by the investigator, irrespective of the presence of an associated AE/SAE.  
Lack of Efficacy 
Reports of lack of efficacy to a Pfizer product are reported to Pfizer by the investigator, 
irrespective of the presence of an associated AE/SAE or the indication for use of the Pfizer 
product. 
Occupational Exposure 
Reports of occupational exposure to a Pfizer product are reported to Pfizer by the 
investigator, irrespective of the presence of an associated AE/SAE. 

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12. PLANS FOR DISSEMINATING AND COMMUNICATING STUDY RESULTS 
A final report will present the results of analyses concerning follow-up of the patient cohort 
and will address the study objectives.  
Abstracts will be submitted to scientific society congresses where posters or oral 
communications will be presented.  Study results will be presented in publications submitted 
to peer-reviewed European and international journals. 
COMMUNICATION OF ISSUES 
In the event of any prohibition or restriction imposed (eg, clinical hold) by an applicable 
Competent Authority in any area of the world, or if the investigator is aware of any new 
information which might influence the evaluation of the benefits and risks of a Pfizer 
product, Pfizer should be informed immediately.  
In addition, the investigator will inform Pfizer immediately of any urgent safety 
measures taken by the investigator to protect the study patients against any immediate 
hazard, and of any serious breaches of this NI study protocol that the investigator 
becomes aware of. 
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28. Merlini G, Planté-Bordeneuve V, Judge DP, Schmidt H, Obici L, Perlini S, Packman J, 
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30. Maurer MS. Noninvasive identification of ATTRwt cardiac amyloid: the re-emergence 
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47. Saraiva MJ. Transthyretin mutations in health and disease. Hum Mutat 1995;5(3):191-6.   
48. Sekijima Y, Kelly JW, Ikeda S. Pathogenesis and therapeutic strategies to ameliorate 
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50. Shin S, Robinson-Papp J. Amyloid neuropathies. Mt Sinai J Med 2012; 79(6): 733-48.   
51. Smith TJ, Kyle RA, Lie JT. Clinical significance of histopathologic patterns of cardiac 
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52. Van Driest SL, Ellsworth EG, Ommen SR, Tajik AJ, Gersh BJ, Ackerman MJ. 
Prevalence and spectrum of thin filament mutations in an outpatient referral population 
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ANNEX 1. LIST OF STAND ALONE DOCUMENTS 
 
Number 
Document Reference 
Number 
Date 
Title 
Appendix 1 
CT24-WI-GL07-RF02 1.0 
19-November 
2019 
B3461058_TTRACK 
Study_ICD_15112019 
Appendix 2 
Non-Inclusion Register 
19-November 
2019 
B3461058_TTRACK_Non-inclusion 
Register_15112019 
Appendix 3 
Case Report Form 
28 Jue 2021 
B3461058_TTRACK_Case Report 
Form_28062021 
Appendix 4 
Safety Report Form 
August 2016 
Non-interventional Study Adverse Even 
Report Form For protocols without 
Stipulated Actvive Collection of Adverse 
Events 
Appendix 5 
Coutries list 
21 May 2021 
B3461058_TTRACK_Countries List 

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ANNEX 2. BONE SCINTIGRAPHY TECHNOLOGY 
 
99m Tc-DPD Bone Scintigraphy Methodology 
The patient receives 740MBq (+/- 10%) of 99m Tc-DPD intravenously. 
A gamma camera (single- or double-headed gamma camera) is used equipped with low-energy, 
high resolution collimator (LEHR collimator). 
Whole body scan is obtained 5 min (early) and 3 h (late after injection. The acquisition 
parameters used for planar imaging are: matrix 1024x512 and velocity 10 cm/min.  anterior 
(ANT) and left anterior oblique (LAO) planar views, with the heart centered in the field of 
view, are obtained for a totoal of 750-1000 Kc. The acquisition parameters used forWhole 
body scan are 256x256 matrix with 1.46 zoom factor. 
In patients showing cardiac uptake, a myocardial single-photon emission computer 
tomography (SPECT) is acquired after the late whole-body scan. Acquisition parameters  for 
SPECT imaging are LEHR collimators, matrix 64x64 with 1.46 zoom. In the reconstruction, a 
Butterworth filter is used with a cut-off of 0.50 and order 5.00. 
Visual scoring of cardiac retention is obtained according to the classification of Perugini: 
 Score 0, absent cardiac uptake and normal bone uptake 
 Score 1, mild cardiac uptake, inferior to bone uptake 
 Score 2, moderate cardiac uptake accompanied by attenuated bone uptake 
 Score 3, strong cardiac uptake with attenuated bone uptake. 
Scintigraphy grading (0 to 3) 
 Grade 0 = absent cardiac uptake 
 Grade 1 = mild uptake less than bone 
 Grade 2 = moderate uptake equal to bone  
 Grade 3 = high uptake greater than bone 
For a semi-quantitative primary analysis, a circular ROI is drawn over the heart, copied and 
mirrored over the contralateral chest for normalize for the spillover from the ribs. Mean total 
absolute counts are measure correcting for background counts, and the fraction of mean counts 
in the heart ROI-to-contralateral chest ROI are calculated as the heart-to contralateral (H/CL) 
ratio. 

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Semi-quantitative analysis of heart retention (HR), whole body retention (WBR) and heart to 
whole-body retention ration (H/WB) is evaluated from region of interest (ROI) drawing in the 
standard manner. 
On anterior images rectangular ROIs are drawn over the heart, and irregular ROIs over the 
kidneys and bladder.  These ROIs are copied and mirrored on posterior images, and for each 
ROI geometric means of the two projections are calculated.  All ROIs are corrected for 
background counts.  Total counts in the images are considered as whole-body counts.  Early 
whole-body is used to represented the injected activity.  Whole-body retention (WBR) is 
evaluated by comparing counts in the late images (corrected for decay and subtracting the 
activity in the urinary tract and bladder) with the counts in the early whole-body images. 
Heart retention (HR is evaluated by comparing decay-corrected counts of the heart in late 
images with counts in early whole-body images. 
Heart to whole-body retention ration (H/WB) values are calculated by dividing counts in the 
heart by counts in late whole-body images. 
 
 

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ANNEX 3 – SCINTIGRAPHY EXTERNAL REVIEW 
In this study, all the scintigraphy tests will be additionally reviewed by two external 
evaluators. 
The objective of this evaluation will be to asses the level of discrepancy in the evaluation of 
the scintigraphy or SPECT images by different evaluators 
All the scintigraphy tests will be uploaded in a dedicated database via the study web site. 
Two experts from the scientific committee members will connect to the study web site with 
personalized connection access.  They’ll review the scintigraphies and enter their grading 
evaluation.