(Case and images courtesy of Jay Perera, text Jay Perera and Genevieve Carbonatto)

Triage: 30F presents with 2/7 of worsening palpitations, worse post Salbutamol. She has a history  of PTSD and anxiety. HR 78 regular.

Further history:

  • 3 years of fatigue and lethargy
  • Complains of intermittent palpitations and dyspnoea. Trialled on Salbutamol by her GP with minimal relief. No lung function testing
  • Diagnosed with OSA on CPAP.
  • Referred to a psychiatrist for anxiety. Her psychiatrist did an ECG which showed ? LVH prompting a referral to a  cardiologist.
  • Presented to ED due to escalating dyspnoea and palpitations, frustrated as feels no clear cause of symptoms found and gaining weight due to inability to exercise

ECG showing LAD.

Decision made to perform bedside FELS to further evaluate.

This is her PLAX view

How would you describe the heart in this view?

  • Normal LV function
  • Small LV cavity size due to severely hypertrophied interventricular septum. LV cavity is obliterated in systole.
  • Normal RV function. Unable to comment on RV cavity size (not fully visualized)

 

This is her PSAX view

How would you describe her LV and RV size and function?

What is the most likely diagnosis?

  • Normal LV function
  • LV cavity size small. Asymmetric hypertrophy well appreciated in this view
  • RV cavity size and function normal
  • Hypertrophic cardiomyopathy is the most likely diagnosis

HYPERTROPHIC CARDIOMYOPATHY (HCM)

  • Is a genetic disease – disorganised myocytes
  • 2/3 have an obstructive form
  • Prevalence 1:200
  • Most common form of cardiac death in athletes

Types of HCM

  • Obstructive:  LVOT obstruction of midventricular obstruction
  • Non obstructive: apical, asymmetric

ECG

  • LV hypertrophy with associated ST segment / T-wave abnormalities
  • Deep, narrow (“dagger-like”) Q waves in the lateral > inferior leads
  • Giant precordial T-wave inversions in apical HCM

ECHO findings

  • Thickened, speckled appearance of LV wall
  • Asymmetric hypertrophy
  • Small LV
  • Turbulent flow in LVOT consistent with dynamic left ventricular outflow tract narrowing from systolic anterior motion of the mitral valve
  • Mild mitral regurgitation.

 

These are her 4CV and 5CV

Both these views again show normal LV function, normal RV function and localized IVS LV hypertrophy.

Progress:

  • Echo findings relayed to cardiology and images viewed remotely. Agreement  that the patient was likely to have HCM
  • Formal echo done next day and a cardiac MRI confirming the diagnosis
  • Discharged on beta blockers with outpatient cardiology follow up

Impact of point of care echo on patient care:

  • Immediate bedside diagnosis.
  • Cardiology able to confirm findings remotely and organise appropriate ongoing care, including disposition(admission and monitored bed) prior to seeing patient in ED
  • Patient relieved and very grateful that cause of symptoms(other than anxiety!) found

Take home points:
A bedside echo is often helpful in patients with a history of change in exercise tolerance, signs of failure or shock.

For any questions about the RPA ED COM or if you have any suitable cases please email Jay at jayashanki.perera@health.nsw.gov.au or Genevieve at genevieve.carbonatto@health.nsw.gov.au