A small clinical-ECG/VCG detail is the diagnostic clue… Did you get it?

Dr. Andrés R. Pérez Riera
Brazil

Case presentation

73-year-old male, Caucasian, lawyer, referred by a neurologist, with whom he was being studied due to cognitive deficit, for cardiac evaluation. He refers to be a long-standing hypertension and concomitantly carrier of familial hypertrophic cardiomyopathy (first-degree relatives – 2 siblings – are carriers of both hypertension and hypertrophic cardiomyopathy). He also refers three episodes of rapid and irregular palpitations, reversed spontaneously, and the last one was recorded, where atrial fibrillation is shown.

He is in regular use of the beta-blocker atenolol 50 mg/day + olmesartan medoxomil 40 mg/day + chlortalidone 12.5 mg/day + spironolactone 25 mg/day + rusovastatin 5 mg/day.
We performed ECG and VCG, as well as echocardiogram and nuclear magnetic resonance of the heart. The last two exams confirmed subaortic hypertrophic cardiomyopathy (high septal thickness 24 mm) and free wall 14 mm. Significant obstruction in the left ventricular outflow tract, and characteristic systolic anterior movement of the mitral valve anterior leaflet. Moderate enlargement of the left atrium, and mild to moderate mitral reflux.

Physical examination: lucid, stained, blood pressure 170/95 mmHg, regular and slow pulses (HR 52 bpm), absence of venous congestion in the neck, ictus cordis located in the 6th left intercostal space, at 1.5 cm outside the hemiclavicular line, intense, and approximately 2 cm in diameter. In the auscultation, 4th pre-systolic sound and regurgitant systolic murmur ++/4 mitral focus, irradiated to axilla. Lungs: clean, Presence of vesicular murmur, without adventitious noises. The rest is not relevant to be noted.

Questions

Which is the ECG diagnosis of ECG-1? Which is the ECG diagnosis of ECG-2? Which is the clinical diagnosis?

Apresentação do caso

Paciente masculino, branco, 73 anos, advogado, encaminhado por neurologista, com quem estava sendo estudado devido a déficit cognitivo, para avaliação cardiológica. Refere ser hipertenso de longa data e concomitantemente ser portador de cardiomiopatia hipertrófica familiar (familiares de primeiro grau – 2 irmãos – são portadores tanto de hipertensão quanto de cardiomiopatia hipertrófica). Refere também três episódios de palpitações rápidas e irregulares, revertidas espontaneamente, tendo sido registrada a última, onde se demonstra fibrilação atrial.

Em uso regular do betabloqueador atenolol 50 mg/dia + olmesartana medoxomila 40 mg/dia + clortalidona 12,5 mg/dia + espironolactona 25 mg/dia + rusovastatina 5 mg/dia.
Realizamos ECG e VCG, assim como ecocardiograma e ressonância nuclear magnética do coração. Os dois últimos exames confirmaram a cardiomiopatia hipertrófica subaórtica (espessura septal alta de 24 mm) e de parede livre 14 mm. Importante obstrução na via de saída do ventrículo esquerdo, e característico movimento anterior sistólico do folheto anterior da válvula mitral. Moderado aumento do átrio esquerdo, e refluxo mitral leve a moderado.

Exame físico: lúcido, corado, pressão arterial 170/95 mmHg, pulsos regulares e lentos (FC 52 bpm), ausência de congestão venosa no pescoço, ictus cordis localizado no sexto espaço intercostal esquerdo, a 1,5 cm por fora da linha hemiclavicular, intenso, e aproximadamente com 2 cm de diâmetro. Na ausculta, quarta bulha pré-sistólica e sopro sistólico regurgitante ++/4 foco mitral. Pulmões: limpos, murmúrio vesicular presente e sem ruídos adventícios. O restante nada digno de nota.