Correct!
1. Cardiology consultation
Review of her outside medical records, which were not available at her initial presentation, revealed a history of long-standing obstructive hypertrophic cardiomyopathy (HCM). She has also had a fairly recent cardiac catherization which shows an absence of significant coronary artery disease, marked septal hypertrophy with a gradient across the gradient of < 150 mm and moderately severe mitral valve regurgitation. Mitral valve regurgitation often accompanies severe HCM due to anterior movement of the mitral valve.
The goal of therapy for HCM is to reduce the gradient across the hypertrophied septum (1). This can be done with beta-blockers and calcium channel blockers. Anticoagulants are often added to prevent thromboembolic phenomena. She was on each of these. In HCM the use of inotropic drugs such as digoxin should be avoided since they can make the outflow gradient worse. Similarly, nitrates and sympathomimetic amines should be avoided except in those patients with concomitant coronary artery disease. Diuretics should be used with caution because of their potential adverse effect on the LV outflow gradient and ventricular volume. The BNP is only modestly elevated and consistent with the modest elevation usually seen with HCM.
Which of the following should be considered? (Click on the correct answer to proceed to the fourth of seven pages)