Circulation Cardiovascular Case Series Still a Kid at Heart Hypertrophic Cardiomyopathy in the Elderly

76-year-old man with a history of hypertrophic obstructive cardiomyopathy (HOCM), hypertension, dyslipidemia, and obstructive sleep apnea presents with dyspnea on exertion. This symptom has progressed slowly over the past year, to the point that he now has dyspnea on climbing 1 flight of stairs. The patient denies orthopnea, paroxysmal nocturnal dyspnea, edema, chest discomfort, palpitations, lightheadedness, and syncope. His medications are metoprolol, verapamil, disopyramide, rosuvastatin, and omeprazole. He is a retired electrician, is married with 3 adult children, and lives in Florida and Massachusetts, each for half the year. He has a history of heavy tobacco use but quit smoking more than 30 years ago. His family history is notable only for diabetes mellitus and stroke in his father; there are no family members with heart failure, hypertrophic cardiomyopathy (HCM), or sudden cardiac death (SCD). Dr Michael A. Fifer: This patient’s presenting complaint is progressive dyspnea on exertion, for which he has possibly contributory comorbidities, namely, obstructive sleep apnea and hypertension. The history of HCM is particularly relevant because dyspnea is a common initial manifestation of the disease. 1 Dyspnea may occur in HCM as a result of a variety of mechanisms, including diastolic heart failure due to myocardial hypertrophy and fibrosis, left ventricular outflow tract (LVOT) obstruction, and associated mitral regurgitation (MR). Although the correlation between symptoms and the magnitude of the LVOT gradient is weak,2 dyspnea is usually relieved by septal reduction therapy. In this patient, any or all of these factors might contribute to progressive dyspnea on exertion. More information regarding how the diagnosis of HOCM was made and how the condition has been managed since it was diagnosed would help determine whether it is primarily responsible for the worsening dyspnea. The diagnosis of HOCM was made 10 years before the current presentation. He presented then with exertional chest pain and dyspnea. An echocardiogram showed asymmetrical septal hypertrophy and a resting LVOT gradient. The diagnosis was confirmed by left-sided heart catheterization, which revealed an LVOT gradient that increased to 90 mm Hg with the Valsalva maneuver. Holter monitoring did not demonstrate ventricular tachycardia. The patient had substantial improvement in symptoms after undergoing medical therapy, which consisted of sustained-release metoprolol titrated up to 200 mg daily and sustained-release verapamil 120 mg daily. With the reappearance of dyspnea 1 year before the current presentation, disopyramide was added to the medical regimen, again with an initially favorable response.