Ecase #12-B

Victoria Allen, M.D.

September 4-7, 2001

A 30 year old man presents with complaint of "red eyes" of two days duration.  The patient works in a rock quarry doing extremely heavy lifting and manual labor and noticed at the end of his shift that his left eye had turned "blood red".  He went home, ate dinner and went to bed.  He woke up the next morning and both eyes were "blood red".  He denied change in vision, headache, pain or sensation of foreign body in either eye.

• PMHx: negative

• PSHx: negative

• Meds: none

• FamHx: Father with CAD, s/p CABG age 54, Uncle with CAD, Aunt died of "stiff heart"

• SocHx: Married, two young daughters, works in rock quarry, no ETOH, cigarettes, alcohol, drugs.

• ROS: fatigue, sleep disturbance, sensation of "heart pounding" while lying in bed at night otherwise negative.

• PEx:  Alert, healthy cooperative young man BP 146/96 P86 WT 164 lbs

• HEENT: obvious bilateral conjunctival hemmorhage otherwise normal

• CV: regular rhythm nl S1 S2 PMI prominent and slight lateral displacement systolic murmur heard at left mid sternal border non-radiating

• ABD: normal

• EXT: normal with minor bruises and abrasions

An optometrist examination followed which confirmed bilateral conjunctival hemmorhage, no retinal hemmorhage otherwise normal examination except blood pressure was elevated at 160/90 and it was felt that hemmorhages were due to heavy lifting and hypertension.

The patient returned to clinic and was started on a low dose of atenolol 25mg a day and home blood pressure monitoring.  He returned with persistently elevated home readings in the range of 160-170/80-90 and the complaint of continued nightly palpitations and an episode of near syncope while trying to lift a heavy rock at work. Atenolol was increased to 50mg a day and a 24 holter monitor and echocardiogram were ordered.

The echocardiogram revealed severe septal hypertrophic cardiomyopathy with an outflow tract of only 9.2 mm.  The holter monitor revealed short runs of ventricular tachycardia in the evenings coinciding with patient's symptoms of palpitations.

Hypertrophic cardiomyopathy is an autosomal dominant disorder characterized by myocardial hypertrophy of a nondilated (often relatively small) left ventricle.  The abnormal increase in LV wall thickness often involves the ventricular septum in particular.  This causes dynamic outflow-tract obstruction and frequent spontaneous ventricular arrhythmias.

The cornerstone of medical therapy is the use of beta-blockers to increase diastolic filling, increase outflow tract, and decrease catecholamine stimulation.  The calcium-channel blockers are also used due to their wide spectrum of action on the heart and peripheral vascular system. 

The risk of lethal arrthymias/sudden death warrants consideration of anti-arrhythmic medical therapy.  In this case given the extent of septal hypertrophy, cardiac consultation was obtained regarding medical therapy vs. AICD placement and possible surgical consultation regarding need for myomyectomy.