Detection of multiple exercise-induced pathophysiological processes in concomitant coronary artery disease and hypertrophic cardiomyopathy by stress echocardiography

摘要

A 51-year-old man presented with intermittent chest pain and fatigueon a background history of percutaneous coronary intervention tothe left main stem (LMS) and left anterior descending artery 1 yearearlier. He also had a recent diagnosis of hypertrophic cardiomyopathywith asymmetric proximal septal hypertrophy measuring 17 mm(Supplementary material online, Figure S1). He was referred for stress echocardiography for assessment of myocardial ischaemia and leftventricular outflow tract (LVOT) obstruction. He performed 7:00min of Bruce protocol treadmill exercise achieving a workload of 10METs with an age-predicted target heart rate of 84% and a bluntedblood pressure response. Immediate post-exercise imaging revealedan increase in the LVOT gradient from 17 mmHg at rest to132 mmHg with exercise (Supplementary material online, Figure S2).Left ventricular images showed hypokinesia of the mid-septum, midanterolateralwall, mid-anterior wall and apex (Figure 1,Supplementary material online, Video S1). Colour flow imaging of themitral valve showed worsening mitral regurgitation (Figure 2,Supplementary material online, Video S2). Subsequent coronary angiographyrevealed some attenuation of the LMS with diffuse threevesseldisease (Supplementary material online, Videos S3 and S4). Hewas managed conservatively, but after approximately 3 years hissymptoms became refractory to drug therapy and he underwent coronaryartery bypass grafting, septal myectomy, and mitral valverepair.