Case presentation
A 65-year-old male patient was admitted with a chief complaint of
recurrent chest distress that had been ongoing for over 10 years, but
became aggravated in the past month. The patient’s medical history
revealed a previous diagnosis of Hypertrophic Cardiomyopathy (HCM) based
on findings from a transthoracic echocardiogram (TTE). However, the
patient did not receive regular treatment for this condition. In the
past month, the patient experienced more frequent and severe symptoms
during physical activity, specifically while walking. These episodes
lasted between 10 minutes to half an hour and were relieved after rest.
Concerned about his cardiovascular health, he measured his systolic
blood pressure at 152mmHg. Further investigations through an
Electrocardiogram (ECG) revealed sinus bradycardia, first-degree
atrioventricular block, left ventricle hypertrophy, and ST-T changes.
Additionally, a thoracic CT scan showed cardiac enlargement and nodules
present on both adrenal glands.
Past History: The patient has a 30-year history of
hypertension, with the highest recorded blood pressure reaching
190/110mmHg. They have been on regular treatment consisting of
amlodipine, metoprolol, irbesartan, and hydrochlorothiazide to manage
their blood pressure. Recent monitoring shows readings ranging between
140-150/80-90mmHg. The patient also presents with hyperuricacidemia and
hyperlipidemia. There is a family history of hypertension. During the
physical examination, the patient’s blood pressure was measured at
153/88mmHg. No jugular vein distension or rales were observed in the
lungs. The heart rhythm was regular, but an enlargement of the heart
border was noted along with an ejective murmur detected in both first
and second aortic valve regions as well as the apex region. No edema was
present. Laboratory tests revealed hypokalemia (potassium levels ranging
from 3.01-3.52mmol/L; normal range: 3.3-5.3mmol/L). Aldosterone (ALD)
levels ranged from 456.21-762.179pg/mL, plasma renin activity (PRA)
ranged from 0.154-166ng/mL/hour, and aldosterone-to-renin ratio (ARR)
ranged from 69.12-141.126.
A computed tomography scan showed nodules on both adrenal glands
measuring between 10mm to 17mm in diameter. Transthoracic echocardiogram
(TTE) indicated hypertrophic left ventricle (LV wall thickness measuring
l5mm; basal segment of ventricular septum measuring 22mm), positive SAM
sign (Fig1. Systolic Anterior Motion), Vmax (left ventricular outflow
tract velocity measurement ) of LVOT measured2.47m/s and Peak Pressure
Gradient of LVOT was 24mmHg, and an ejection fraction (EF) of 68%.
Cardiac magnetic resonance imaging (MRI) revealed a left atrium
measurement of 47mm, right atrium measurement of 45mm, left ventricular
end-diastolic diameter (LVED) measuring 91mm, right ventricular
end-diastolic diameter(RVED)measuring77 mm. The thicknesses of the LV
walls ranged from 11-23mm with improper movement noted (Fig 2.). Cardiac
output(CO) was calculated as 130.52 L/min. Coronary artery computed
tomography scan and Holter monitoring both yielded negative results. A
comprehensive timeline summarizing the patient’s historical information
and treatment course is provided in Table 1.