Case report
An unusual ST-segment elevation: Apical hypertrophic cardiomyopathy shows the ace up its sleeve
Elevação do segment St pouco usual: cardiomiopatia hipertrófica apical mostra o às na manga
Francesco de Santis, Amedeo Pergolini, Giordano Zampi
, Gaetano Pero, Paolo Giuseppe Pino, Giovanni Minardi
Corresponding author
Department of Cardiovascular Science, “S. Camillo-Forlanini” Hospital, Rome, Italy
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Camillo-Forlanini” Hospital, Rome, Italy" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Elevação do segment St pouco usual: cardiomiopatia hipertrófica apical mostra o às na manga" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2594 "Ancho" => 3000 "Tamanyo" => 841342 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Rest-stress myocardial perfusion scintigraphy revealing reduced left ventricular chamber volume suggestive of hypertrophic cardiomyopathy without signs of ischemia or previous myocardial necrosis.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Apical hypertrophic cardiomyopathy (AHCM) is part of the broad clinical and morphologic spectrum of hypertrophic cardiomyopathy (HCM).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Cases of AHCM with and without apical aneurysm mimicking myocardial infarction have occasionally been reported.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–4</span></a> We report a patient with abnormalities on the electrocardiogram (ECG) in whom acute coronary syndrome (ACS) was excluded and AHCM was demonstrated by careful differential diagnosis.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 77-year-old Caucasian woman was examined by a primary care physician because of dyspnea and atypical chest pain. The ECG showed atrial fibrillation, mean heart rate of 85 bpm, right bundle branch block and 4-mm convex ST segment elevation in C4-C6 with biphasic T waves (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). Due to this atypical ECG, similar to a previous one performed two years before, rest-stress myocardial perfusion scintigraphy was prescribed. This revealed a reduction of left ventricular chamber volume suggestive of HCM without signs of ischemia or previous myocardial necrosis (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>). The patient was referred to our echo lab in order to complete the diagnostic procedure. Transthoracic echocardiography (TTE) demonstrated AHCM, showing left ventricular (LV) apical hypertrophy with the typical ace of spades shape (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>A1). The ace of spades was therefore studied in depth using color Doppler (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>A2, Video 1), Sonovue contrast TTE (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>A3, Video 2) and real-time three-dimensional echocardiography (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>A4, Video 3). A small area of turbulent flow and a mid-ventricular gradient of about 63<span class="elsevierStyleHsp" style=""></span>mmHg were found (<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>a). In order to evaluate possible modification of the mid-ventricular gradient, an intravenous bolus of atenolol (3<span class="elsevierStyleHsp" style=""></span>mg) was administered. A significant decrease of about 40<span class="elsevierStyleHsp" style=""></span>mmHg was observed while the ECG was unchanged (<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>b). Beta-blocker therapy was prescribed indefinitely. At six-month follow-up, the patient was asymptomatic and in good clinical condition.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">AHCM is characterized by segmental hypertrophy confined to the distal portion of the LV chamber. The prevalence of AHCM among HCM patients is 15% in Japan, whereas in the USA it is only 3%. Among AHCM patients 54% are symptomatic, the most common symptoms being chest pain, palpitations, dyspnea and syncope. This condition may cause various complications including atrial fibrillation, acute myocardial infarction, embolic events, ventricular fibrillation, congestive heart failure, apical aneurysm and cardiac arrest. Moreover, it may mimic other conditions, such as cardiac tumors, LV apical thrombus, isolated ventricular non-compaction, endomyocardial fibrosis and coronary artery disease. The most common ECG findings, seen in about 93% of patients, are negative T waves in the precordial leads (>10<span class="elsevierStyleHsp" style=""></span>mm deep in 47%), followed by signs of LV hypertrophy in 63% of cases. TTE usually shows LV apical hypertrophy and is thus usually the standard diagnostic tool for AHCM. Symptomatic patients may be treated with verapamil, beta-blockers and antiarrhythmic drugs, all of which may improve the signs and symptoms of this condition.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In conclusion, AHCM is a clinical condition that can cause various complications and simulate ACS. Its diagnosis enables ACS to be excluded in patients with atypical ST-segment elevation. TTE is usually sufficient to make the diagnosis, enabling appropriate medical treatment.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Protection of human and animal subjects</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Confidentiality of data</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Right to privacy and informed consent</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres286550" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec269733" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres286549" "titulo" => "Resumo" ] 3 => array:2 [ "identificador" => "xpalclavsec269734" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Right to privacy and informed consent" ] ] ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-09-26" "fechaAceptado" => "2012-11-01" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec269733" "palabras" => array:3 [ 0 => "Electrocardiogram" 1 => "Hypertrophic cardiomyopathy" 2 => "Congenital heart disease" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec269734" "palabras" => array:3 [ 0 => "Eletrocardiograma" 1 => "Miocardiopatia hipertrófica" 2 => "Cardiopatias congénitas" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Apical hypertrophic cardiomyopathy is part of the broad clinical and morphologic spectrum of hypertrophic cardiomyopathy. We report a patient with electrocardiographic abnormalities in whom acute coronary syndrome was excluded and apical hypertrophic cardiomyopathy was demonstrated by careful differential diagnosis.</p>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A miocardiopatia hipertrófica apical faz parte do amplo espectro clínico e morfológico da miocardiopatia hipertrófica. Nós reportamos um doente com alterações electrocardiográficas no qual foi excluída uma síndrome coronária aguda e foi demonstrada uma miocardiopatia hipertrófica apical usando um processo correto de diagnóstico diferencial.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1494 "Ancho" => 2500 "Tamanyo" => 409301 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">The ECG shows an unusual 4-mm convex ST segment elevation in C4–C6 with biphasic T waves.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2594 "Ancho" => 3000 "Tamanyo" => 841342 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Rest-stress myocardial perfusion scintigraphy revealing reduced left ventricular chamber volume suggestive of hypertrophic cardiomyopathy without signs of ischemia or previous myocardial necrosis.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2564 "Ancho" => 1669 "Tamanyo" => 300132 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Apical hypertrophic cardiomyopathy shows the ace up its sleeve. A1: two-dimensional transthoracic echocardiography; A2: color Doppler transthoracic echocardiography; A3: contrast-enhanced transthoracic echocardiography; A4: real-time three-dimensional reconstruction.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 2240 "Ancho" => 1667 "Tamanyo" => 287952 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Transthoracic echocardiography, apical 4-chamber view showing (a) a mid-ventricular gradient of about 63 mmHg and (b) a significant decrease in the gradient after administration of an intravenous bolus of atenolol.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hypertrophic cardiomyopathy with ventricular septal hypertrophy localized to the apical region of the left ventricle (apical hypertrophic cardiomyopathy)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "B.J. 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| 2023 October | 54 | 13 | 67 |
| 2023 September | 53 | 19 | 72 |
| 2023 August | 30 | 49 | 79 |
| 2023 July | 49 | 12 | 61 |
| 2023 June | 56 | 15 | 71 |
| 2023 May | 58 | 25 | 83 |
| 2023 April | 45 | 4 | 49 |
| 2023 March | 41 | 24 | 65 |
| 2023 February | 37 | 25 | 62 |
| 2023 January | 47 | 11 | 58 |
| 2022 December | 57 | 20 | 77 |
| 2022 November | 50 | 36 | 86 |
| 2022 October | 52 | 13 | 65 |
| 2022 September | 31 | 26 | 57 |
| 2022 August | 46 | 34 | 80 |
| 2022 July | 47 | 27 | 74 |
| 2022 June | 42 | 20 | 62 |
| 2022 May | 39 | 37 | 76 |
| 2022 April | 47 | 21 | 68 |
| 2022 March | 72 | 27 | 99 |
| 2022 February | 66 | 24 | 90 |
| 2022 January | 76 | 21 | 97 |
| 2021 December | 49 | 27 | 76 |
| 2021 November | 59 | 37 | 96 |
| 2021 October | 78 | 34 | 112 |
| 2021 September | 60 | 32 | 92 |
| 2021 August | 68 | 36 | 104 |
| 2021 July | 63 | 26 | 89 |
| 2021 June | 46 | 17 | 63 |
| 2021 May | 55 | 39 | 94 |
| 2021 April | 90 | 40 | 130 |
| 2021 March | 52 | 18 | 70 |
| 2021 February | 73 | 18 | 91 |
| 2021 January | 50 | 10 | 60 |
| 2020 December | 51 | 12 | 63 |
| 2020 November | 58 | 18 | 76 |
| 2020 October | 72 | 7 | 79 |
| 2020 September | 73 | 18 | 91 |
| 2020 August | 55 | 8 | 63 |
| 2020 July | 70 | 7 | 77 |
| 2020 June | 48 | 9 | 57 |
| 2020 May | 71 | 9 | 80 |
| 2020 April | 47 | 13 | 60 |
| 2020 March | 66 | 13 | 79 |
| 2020 February | 103 | 12 | 115 |
| 2020 January | 54 | 6 | 60 |
| 2019 December | 45 | 6 | 51 |
| 2019 November | 30 | 6 | 36 |
| 2019 October | 47 | 6 | 53 |
| 2019 September | 63 | 8 | 71 |
| 2019 August | 35 | 4 | 39 |
| 2019 July | 28 | 11 | 39 |
| 2019 June | 23 | 10 | 33 |
| 2019 May | 44 | 7 | 51 |
| 2019 April | 36 | 14 | 50 |
| 2019 March | 116 | 11 | 127 |
| 2019 February | 84 | 11 | 95 |
| 2019 January | 60 | 7 | 67 |
| 2018 December | 56 | 10 | 66 |
| 2018 November | 100 | 11 | 111 |
| 2018 October | 190 | 14 | 204 |
| 2018 September | 38 | 9 | 47 |
| 2018 August | 48 | 8 | 56 |
| 2018 July | 31 | 5 | 36 |
| 2018 June | 45 | 7 | 52 |
| 2018 May | 50 | 8 | 58 |
| 2018 April | 48 | 1 | 49 |
| 2018 March | 51 | 8 | 59 |
| 2018 February | 31 | 0 | 31 |
| 2018 January | 33 | 5 | 38 |
| 2017 December | 48 | 9 | 57 |
| 2017 November | 34 | 7 | 41 |
| 2017 October | 26 | 13 | 39 |
| 2017 September | 38 | 6 | 44 |
| 2017 August | 27 | 9 | 36 |
| 2017 July | 28 | 11 | 39 |
| 2017 June | 44 | 8 | 52 |
| 2017 May | 32 | 5 | 37 |
| 2017 April | 25 | 4 | 29 |
| 2017 March | 32 | 6 | 38 |
| 2017 February | 44 | 1 | 45 |
| 2017 January | 41 | 2 | 43 |
| 2016 December | 52 | 6 | 58 |
| 2016 November | 39 | 5 | 44 |
| 2016 October | 44 | 1 | 45 |
| 2016 September | 45 | 3 | 48 |
| 2016 August | 18 | 2 | 20 |
| 2016 July | 14 | 3 | 17 |
| 2016 June | 18 | 4 | 22 |
| 2016 May | 20 | 2 | 22 |
| 2016 April | 20 | 3 | 23 |
| 2016 March | 31 | 7 | 38 |
| 2016 February | 48 | 9 | 57 |
| 2016 January | 41 | 9 | 50 |
| 2015 December | 30 | 8 | 38 |
| 2015 November | 38 | 6 | 44 |
| 2015 October | 32 | 6 | 38 |
| 2015 September | 41 | 8 | 49 |
| 2015 August | 24 | 3 | 27 |
| 2015 July | 20 | 4 | 24 |
| 2015 June | 21 | 1 | 22 |
| 2015 May | 20 | 2 | 22 |
| 2015 April | 22 | 6 | 28 |
| 2015 March | 23 | 0 | 23 |
| 2015 February | 11 | 3 | 14 |
| 2015 January | 35 | 4 | 39 |
| 2014 December | 37 | 8 | 45 |
| 2014 November | 17 | 5 | 22 |
| 2014 October | 37 | 3 | 40 |
| 2014 September | 34 | 4 | 38 |
| 2014 August | 41 | 2 | 43 |
| 2014 July | 45 | 14 | 59 |
| 2014 June | 26 | 3 | 29 |
| 2014 May | 43 | 5 | 48 |
| 2014 April | 28 | 1 | 29 |
| 2014 March | 60 | 14 | 74 |
| 2014 February | 57 | 9 | 66 |
| 2014 January | 57 | 14 | 71 |
| 2013 December | 69 | 12 | 81 |
| 2013 November | 65 | 11 | 76 |
| 2013 October | 4 | 2 | 6 |
Show all
