Medical Resident Ascension Saint Agnes Internal Medicine Residency Program
Description of Clinical Presentation: We present the case of a 42-year-old male with past medical history of hypertension, currently treated however with patient not adequate compliance , who presented to the ED with progressive shortness of breath, triggrered by exertion for the past 3 month worsening over the past 3 months.. Initial evaluation revealed severe hypertension (170/80 mmHg), with the remainder of the examination unremarkably. An electrocardiogram (EKG) demonstrated normal sinus rhythm, severe left ventricular hypertrophy (LVH). Laboratory findings were significant for an elevated brain natriuretic peptide (BNP) at 243, otherwise normal laboratory data. A chest CT angiogram in the ED ruled out pulmonary embolism but revealed a pattern consistent with LVH.
Diagnostic Techniques and Their Most Important Findings: Echocardiography demonstrated a normal eft ventricular ejection fraction (LVEF) of 65% , with asymetric left ventriclular hypertrophy, at the Inter Ventricular Septum assymetric (IVS) measuring in 1.5 cm in short and short axis and 4 chambers views and LVOT gradient at rest of 15mmHg using pase contrast images with upon Valsva maneuver, the gradient increased to 25 mmHg and in addition presence of systolic anterior motion of the mitral valve (SAM) all compatible with the presence of Hypertrophic Obstructive Cardiomyopathy (HOCM) , based on established echocardiographic criteria. To confirm the diagnosis and risk stratification based on the 2024 ACC clinical guidelines, cardiac magnetic resonance imaging (MRI) was performed using our 1.5-tesla MRI scanner. The Cardiac MRI criteria were met, with the thye IVS diameter of 1.53 cm, with SAM and with the LVOT the same as the echordiography at rest. In adition Late Gadolinnium Enhancement shows at the level of the RV insertion in shorst axis images of less than 5% of involvement of the miocardium (fibrosis) as well as on T1 weighted images views obtained which does not portend a high risk strata ( > 15% of the myocardium entails high risk).
Learning Points from this Case: This case underscores the pivotal role of cardiac MRI in confirming Hypertrophic Obstructive Cardiomyopathy (HOCM) in a patient with a complex medical history of hypertension, poor compliance and risk stratification using LGE and T1 weighted images plus phase contrast protocol . Cardiac MRI provided detailed morphological and functional insights, aiding in the precise RISK stratification using LGE, T weighted images and phase contrast techniques. Accurate identification of this condition is crucial for appropriate management and intervention, particularly in patients with diverse clinical presentations and complex medical backgrounds.
