An 85 year old lady with with a central chest ache and an abnormal ECG

Authored by Dr Christine A’Court. GP cardiologist, Oxford.

A sprightly 85 year old lady whose only medical history was of well controlled hypertension had her handbag snatched when in her GP surgery’s waiting room. She was understandably distressed and the following day developed unusual fatigue and then 30 mins central chest ache, without other symptoms. Her GP attended, found her BP lower than usual and arranged an ECG (attached). Her only previous ECG, obtained 14 years earlier, was reportedly normal. When she attended a community cardiology clinic some weeks later she reported mild fatigue and exertional breathlessness. Her examination showed a soft Ejection Systolic Murmur at the left sternal edge and a repeat ECG was the same as the most recent.

 

Current ECG

 

ECG from a month ago

 

 

Discussion

Whilst the age group and chest pain might make ACS seem likely, the distribution of the T wave change and depth is unusual, and the lack of any evolution over some weeks also makes ACS unlikely.​ Similarly, in Takotsubo cardiomyopathy early ECGs would typically show widespread ST elevation in the precordial leads, without reciprocal ST depression. Hypertensive heart disease is also an unlikely cause for these ECG changes given the well controlled hypertension

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An echocardiogram was perfomed and demonstrated the following:

Normal LV cavity and overall systolic function. Mild-moderate concentric LVH. Prominent septal bulge ( 1.8cm) – a sigmoid septum – without outlet obstruction. Normal RV size with preserved contractility. Mildly dilated left atrium. Moderately dilated RA. Mild-moderate MR. Mild TR, AR ad PR. Estimated PASP 24mmHg + RAP/JVP.

Review of the echo by a Cardiologist concluded that the discrete basal septal bulge was attributable to her age and hypertension (and would not be expected to give these ECG changes) but use of parasternal long axis view and an apical 3 chamber view showed extensive apical hypertrophy and cavity obliteration typical of (predominantly apical) HCM.

A 5 day Holter monitoring showed sinus rhythm and occasional SVEs and VEs.

 

Commentary

The ECG’s deep symmetrical anterolateral T wave inversion is typical of HCM. Although usually manifest earlier in life, phenotype expression in a patient’s late 70s or 80s is recognised. Holter monitoring is normally used as part of sudden cardiac death (SCD) risk stratification  in HCM patients. The European Society of Cardiology (ESC) SCD risk calculator for HCM can be used to estimate the risk of sudden cardiac death and the need for consideration of an implantable cardioverter defibrillator (ICD) http://(http://www.doc2do.com/hcm/webHCM.html ). Aspirin would normally be advised with a dilated LA and HCM but based on recent evidence reinforcing the hazards in this age group, the patient’s history of severe bruising on aspirin in the past, and absence of AF on Holter monitoring,  neither aspirin nor anticoagulation were advised. She was already on an angiotensin 2 receptor antagonist, had a low-normal BP and no additional medications were prescribed, although a beta blocker would often be considered in a patient with HCM prophylactically. Gene testing and family screening is planned.

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