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.