An electrocardiogram (ECG) taken during a routine preoperative examination of a 79-year-old black woman who was scheduled for hemorrhoid surgery is shown (Figure 1). Physical examination (including blood pressure) was normal; no murmurs or abnormal heart sounds were found.
Quiz Answer
Apical hypertrophic cardiomyopathy —The ECG shows marked voltage of left ventricular (LV) hypertrophy, with deeply inverted T waves in leads V2 through V4, characteristic of apical hypertrophic cardiomyopathy. The echocardiogram confirmed the diagnosis of apical hypertrophic cardiomyopathy, demonstrating that the apical myocardium is markedly thickened, as seen in Figure 2.
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| Figure 2—Echocardiogram showing apical hypertrophic cardiomyopathy, with markedly thickened myocardium (arrow). The broken lines outline the location of the myocardium. |
This form of hypertrophic cardiomyopathy is relatively common in Japan and is increasingly being recognized in Europe and in the United States. Although this condition is considered benign, some patients may be at risk for ventricular arrhythmias.1
The ECG findings in this case—combined with a lack of clinical symptoms—suggest the diagnosis of apical hypertrophic cardiomyopathy, which was confirmed by the echocardiogram. Our patient was approved for hemorrhoidectomy.
LV hypertrophy with anterior ischemia, or ischemic heart disease, would be unusual in the absence of symptoms, including normal blood pressure. Aortic stenosis is unlikely in the absence of a murmur. The ECG findings are too severe to be considered normal variant.
Reference
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Halkin A, Keren G. Apical hypertrophic cardiomyopathy: truly a benign entity or not benignly a true entity? Isr Med Assoc J. 2002;4:203-204.
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