A 20 Year Old College Student Complains Of Chest Pain And Shortness Of Breath During Exercise

A 20 year old college student comes to his physician concerned about his health because he feels chest pain and gets short of breath during exercise or sports. He also describes having episodes of feeling his heart beat very fast. He wanted to have workup done because his brother died suddenly at an age of 18 years while participating in his school sports event.
On examination the patient is a healthy looking young man and there were no abnormalities detected on his chest examination.
An ECG was done which is shown below:

The above ECG is notable for inverted T waves, and deep narrow dagger like Q waves in the leads V4, V5 and V6

On Echocardiography there is septal hypertrophy with left ventricular outflow tract obstruction.

Based on the ECG and the history of the patient what is the most probable diagnosis?
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Hypertrophic Obsstructive cardiomyopathy


Case Discussion:
Hypertrophic cardiomyopathy is a primary disease of the cardiac muscle in which a portion of the myocardium is thickened causing functional impairment of the cardiac muscle.

Causes:

• The disease can run in families through an autosomal dominant inheritance.
• The condition may be acquired as a part of aging or long standing high blood pressure
• Unknown reasons. 

Clinical Features: Some patients may be asymptomatic while others may present with one or more of the following:

• Rapid heart beat / Palpitations
• Fainting or syncope during or after exercise
• Shortness of breath usually during exertion
• Chest pain on exertion
• Sudden death (rare)

On Examination most patients have no signs but some may have:

• Jerky pulse
• A prominent apical impulse
• A systolic murmur at the left lower sternal edge or the apex. 
• Fourth hearth sound which is easier to feel than hear at the apex

Diagnosis: The following diagnostic tests are recommended:

1. ECG: findings varies from T wave inversion to signs of overt left ventricular hypertrophy.

2. Echocardiography: will classically show asymmetrical septal hypertrophy with systolic anterior motion of mitral leaflet. left ventricular outflow tract obstruction and secondary mitral regurgitation.

3. Ambulatory Monitory: will help in identifying the cause of palpitation and detect arrhythmia

4. Treadmill Stress Test: can help identify changes with exercise which cannot be detected while at rest.

5. Cardiac MRI: Can give a more detailed picture of hypertrophy and obstruction of flow.

Treatment:is aimed at controlling the symptoms and preventing the complications.  Regular follow up visits are needed to identify any risk factors that may lead to worsening of symptoms. 

1. Antibiotic prophylaxis is generally recommended before dental and surgical procedures.

2. Symptoms of chest pain and breathlessness can be controlled with a Beta blocker or calcium antagonist. 

3. In some cases surgical myomectomy may be required to partially excise the hypertrophied septum and help improve the blood flow.