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Abstract: A 68-year-old elderly patient, Uncle Liu, came to the clinic because he felt chest tightness and breathlessness whenever he was active. After consultation, he was diagnosed with non-obstructive hypertrophic cardiomyopathy after cardiac ultrasound examination, and the patient’s current status of cardiac insufficiency was verified by the N-terminal index of brain natriuretic peptide precursors. The patient was then given the appropriate medication for treatment, and finally the patient’s symptoms such as chest tightness and wheezing improved significantly.
Basic information】Male, 68 years old
Disease Type】Non-obstructive hypertrophic cardiomyopathy
Hospital】Wuhan University People’s Hospital
Date of Consultation】April 2022
Treatment plan】Medication (aspirin enteric dissolved tablets+resvastatin calcium tablets+metoprolol succinate extended-release tablets+diltiazem hydrochloride extended-release capsules+sacubitril valsartan sodium tablets)
[Treatment Period] 7 days of inpatient treatment, 2 months of outpatient follow up
Treatment effect】Significant improvement of chest tightness and wheezing
I. Initial consultation
In the past year, 68-year-old Uncle Liu felt tightness in his chest and could not catch his breath whenever he was active, which seriously affected his normal life. When it comes to his condition, he had stent surgery for coronary heart disease many years ago, and the symptoms at that time were mainly angina pectoris, which has not recurred after treatment. These new discomforts that appeared in the last year worried him. After the consultation, his current situation was analyzed, and considering that there were no angina symptoms, it should not be a blockage of the coronary artery again, but most likely a problem with cardiac function. So a cardiac ultrasound was suggested and the results showed: non-obstructive hypertrophic cardiomyopathy with a septal thickness of 26mm, while the normal septal thickness should not exceed 10mm, which fortunately did not lead to obstruction of the left ventricular outflow tract, otherwise it would have been more troublesome. So Uncle Liu was suggested to be hospitalized urgently for detailed examination and treatment plan.
II. Treatment process
After admission, the patient was given a comprehensive evaluation of blood routine, blood biochemistry, brain natriuretic peptide precursor N-terminal and other indicators. Among them, the blood routine, liver and kidney function, and electrolytes were normal, while the brain natriuretic peptide precursor N-terminal was 435 pg/ml, which exceeded the normal value and verified the patient’s cardiac insufficiency. Since the patient had a history of coronary artery disease and had not been reviewed for many years, he was subsequently scheduled for a coronary CTA to assess the vascular condition, which showed a patent stent and no significant stenosis in the remaining vessels, further ruling out the possibility that the symptoms were caused by coronary artery disease. Genetic testing was recommended to the patient and family, but the patient did not undergo it due to financial reasons. Combined with the above, the patient was given a selected treatment plan to maintain secondary prevention of coronary artery disease by continuing to use aspirin enteric-coated tablets and resulvastatin calcium tablets for anti-platelet aggregation and lipid regulation. At the same time, a beta-blocker, metoprolol succinate extended-release tablets were given to improve cardiac diastolic function, and a non-dihydropyridine calcium antagonist, diltiazem hydrochloride extended-release capsules, was used in combination. Because the patient had symptoms of cardiac insufficiency and the N-terminal end of brain natriuretic peptide precursor was also exceeded, sacubitril valsartan sodium tablets were also added for anti-myocardial remodeling and improvement of cardiac function.
III. Treatment effect
During the 7-day hospitalization period, the patient said that he was not as strained to go up two flights of stairs as before, and the feeling of having a stone in his chest was basically gone. Two months after discharge, the patient said he was able to lead a normal life, doing housework, taking a walk, playing tai chi without any problems, and as long as he did not engage in particularly strenuous activities, he would not experience any significant discomfort. The N-terminal brain natriuretic peptide precursor was rechecked and the result showed that it had dropped to 156 pg/ml, which was close to the normal range.
IV. Precautions
Although the current cardiac function status of Uncle Liu has improved well and I am happy for him, I still need to remind the patient that the disease of non-obstructive hypertrophic cardiomyopathy cannot be cured, so he must insist on taking several drugs prescribed by the doctor to inhibit cardiac remodeling, improve ventricular diastole, and maintain cardiac function, and also the secondary prevention drugs for coronary heart disease should not be left behind. In terms of life, although normal activity is restored, do not engage in overly strenuous activities, such as ball games and long-distance running, to avoid the occurrence of malignant arrhythmias or the induction of acute heart failure. In terms of diet, pay attention to a low-salt and low-fat diet, stay away from smoking and alcohol and other health hazards, work and rest regularly, and do not let your emotions get too excited. In addition, pay attention to regular review of cardiac ultrasound condition, monitor ventricular wall thickness, cardiac function and other indicators.
V. Personal insight
Non-obstructive hypertrophic cardiomyopathy is an autosomal dominant disease with some family aggregation, so it is recommended that patients and their immediate family members undergo genetic testing. The clinical manifestations of patients are relatively mild compared to obstructive hypertrophic cardiomyopathy, and some patients may have no obvious symptoms, which may be detected incidentally during electrocardiogram or cardiac ultrasound examination. The diagnosis mainly relies on cardiac ultrasound, which shows hypertrophy of the middle or distal segment of the ventricular septum, and may also be combined with hypertrophy of the free wall of the left ventricle, but not with left ventricular outflow tract obstruction. The treatment mainly uses β-blockers, non-dihydropyridine calcium antagonists and other drugs to improve the diastolic function of the heart, and those with cardiac insufficiency can use RAAS inhibitors to improve cardiac remodeling and cardiac function, and if necessary, diuretics and other symptomatic treatment.