From the Guidelines
This patient requires urgent follow-up with a cardiologist due to the risks associated with borderline Concentric Left Ventricular (LV) Hypertrophy and Mild Systolic Anterior Motion (SAM). The presence of borderline concentric left ventricular hypertrophy and mild systolic anterior motion (SAM) of the mitral valve are findings that warrant further evaluation, as they may indicate an underlying cardiac condition that requires monitoring or treatment 1. The main risks include potential progression of left ventricular hypertrophy which can lead to heart failure, and the SAM could potentially worsen and cause more significant mitral regurgitation or left ventricular outflow tract obstruction. While anxiety and stress can cause temporary cardiovascular changes like increased heart rate or blood pressure, they do not typically cause structural heart abnormalities like those seen on this echocardiogram 1. These findings represent actual physical changes to the heart that should not be neglected. The patient should not ignore these findings as they may indicate an underlying cardiac condition that requires monitoring or treatment. Some key points to consider in the follow-up care include:
- Comprehensive 2D echocardiography to establish the diagnosis of HCM, determine hypertrophy pattern, presence of LV apical aneurysms, LV systolic and diastolic function, mitral valve function, and presence and severity of LVOTO 1
- Routine follow-up of patients with HCM is an important part of optimal care, with serial TTE performed every 1 to 2 years to assess for changes in LV systolic and diastolic function, wall thickness, chamber size, LVOTO, and concomitant valvular disease 1
- Changes in signs or symptoms in patients with HCM are often attributable to progression of the hemodynamics of HCM, or the development of new concomitant cardiovascular abnormalities, such as valvular heart disease, and echocardiography is the primary imaging modality to assess these changes in patients with new or worsening symptoms 1.
From the Research
Concentric Left Ventricular Hypertrophy and Systolic Anterior Motion
- Concentric Left Ventricular (LV) Hypertrophy is associated with increased cardiovascular events 2
- Systolic Anterior Motion (SAM) of the mitral valve can result in severe left ventricular outflow tract obstruction and/or mitral regurgitation, and is associated with a risk of sudden death 3
- The mechanisms of SAM are complex and depend on the functional status of the ventricle, and can occur in patients with hypertrophic cardiomyopathy (HCM) or following mitral valve repair 3
Risk of Progression to Left Ventricular Dysfunction
- 13% of patients with concentric LV hypertrophy and a normal ejection fraction progress to systolic dysfunction during approximately 3 years of follow-up 2
- The risk factors for loss of function include interval myocardial infarction, prolonged QRS, and chronically elevated arterial impedance 2
- In patients with concentric LVH, the transition from a normal LVEF to a low LVEF was relatively infrequent (20%) after long-term follow-up in the absence of interval MI 4
Management of Systolic Anterior Motion
- A stepwise approach is advocated for the management of SAM, consisting of medical therapy, followed by aggressive volume loading and beta-adrenoceptor blockade, with surgery as the final option 3
- Disopyramide can be used to successfully treat postoperative SAM refractory to beta blockade 5
- Angiotensin II antagonists could be considered as the treatment of choice for patients with mild LV hypertrophy and LV outflow tract obstruction 6
Attribution to Anxiety and Stress
- There is no direct evidence in the provided studies to suggest that borderline concentric LV hypertrophy and mild SAM can be attributed to anxiety and stress alone
- However, it is possible that anxiety and stress may contribute to the progression of LV hypertrophy and SAM, and further evaluation is needed to determine the relationship between these factors 2, 3