Question of the Week # 204

204) A 16 year old boy presents for pre-participation examination prior to athletic training in his college campus. He denies any history of dizziness or palpitations or shortness of breath upon exertion. He denies any syncopal episodes.  His father died of cardiac arrest during a marathon at the age of 32 years. Physical examination reveals a systolic murmur that increases with valsalva maneuver.  Electrocardiogram reveals changes consistent with left ventricular hypertrophy. An echocardiogram reveals asymmetric septal hypertrophy and Systolic Anterior Motion (SAM) of the Anterior Mitral Leaflet. Which of the following is an indication for Implantable Cardioverter-Defibrillator in this patient?

A) Left Ventricular Thickness of 22mm

B) Increase in blood pressure upon exercise

C) His age

D) Systolic Anterior Motion of Mitral leaflet

E) Decrease in blood pressure during exercise

 

7 Responses

  1. d

  2. An implantable-cardioverter defibrillator (ICD) may be needed to prevent sudden death. ICDs are used in high-risk patients. High risks include:
    • Drop in blood pressure during exercise
    • Family history of cardiac arrest
    • History of cardiac arrest or ventricular tachycardia
    • History of unexplained fainting
    • Life-threatening heart rhythms on a Holter monitor
    • Severe heart muscle thickness(,septum thickness more than 30 mm)
    Ans E.

  3. E

  4. Hypertrophic cardiomyopathy who have 1 or more major risk factors for sudden cardiac death, need ICD. Answer E

    •History of previous cardiac arrest. •In many cases this may be the only symptom a person with HCM may have. Thankfully today AED’s (automated external defibrillators) are becoming more common place and, therefore, more people survive cardiac arrest, SCA.

    •Mass Hypertrophy •Mass Hypertrophy is measured on echocardiogram and/or MRI
    •Septal measurements or left free wall measurement of 3.0 or greater are defined as “Mass Hypertrophy” (in young children this number should be discussed with a knowledgeable HCM expert as “massive hypertrophy” in a young child may be less than 3.0)

    •Hypotensive Blood Pressure response on stress test •If blood pressure drops; fails to rise or is blunted during stress test

    •Family History of Sudden Death •The death of one or more family members from HCM.
    •It may not be possible to know if a family member had HCM due to lack of medical records, lack of autopsy or family dynamics. In these cases, we suggest you discuss any unexpected cardiac related deaths of family members under the age of 50 with your physician.

    •History of Ventricular Arrhythmia •Captured on Holtor monitor or telemetry.

    •A Previous Cardiac Arrest •If you have already survived a cardiac arrest this indicates that it is possible to happen again.

  5. Consider placement of an ICD in patients with HCM at high risk for sudden death, regardless of whether they are symptomatic, including those with:
     Family history of sudden death at a young age
     Young age (<30 years) at diagnosis
     Unexplained syncope
     Resuscitation from cardiac arrest
     Non sustained or sustained VT during Holter monitoring
     Significant LVH (wall thickness 30 mm)
     Abnormal BP response during exercise

    Both options "B" and "E" are correct. Hypotension as well as Age! The more correct and appropriate option here is "B" because it's clear that he is 16 years of at the time of diagnosis.

  6. answer is E

    IF PATIENT IS 16 YO AND ASYMPTOMATIC, ICD IS NOT INDIACTED

  7. E:)

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