Hypertrophic cardiomyopathy case study one

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Case #1

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Soroush Seifirad, M.D.[2]

Management of HCM in presence of Hypotension and Cardiovascular Collapse

The first patient I (C. Michael Gibson, M.D.) treated as a medical student was an 18 year old woman who had HOCM. She had just entered college and had partied throughout the night. She was vomiting, developed new atrial fibrillation at a rate of 180 beats per minute. She had a syncopal episode and had a systolic blood pressure of 60 mm Hg. This young lady had sustained hemodynamic collapse as a result of volume depletion and tachycardia.

Precipitants of Hemodynamic Collapse

  • Volume depletion or dehydration which can be due to:
  • Vomiting
  • Diuretics
  • Hemorrhage
  • Reduced pre-load which can be due to:
  • Sepsis
  • Venodilators such as nitrates
  • Following epidural blockade
  • Vasodilator therapy
  • Sepsis

Physical examination Findings in Hemodynamic Collapse

A rapid, weak pulse is present in the patient who is hypotensive. The JVP is flat. A systolic murmur is present.

Echocardiographic Findings in Hemodynamic Collapse

  • A small hypercontractile left ventricle is present
  • Prolonged systolic anterior motion of the mitral valve is present
  • Mitral regurgitation with a posterior directed jet

Treatment of Hemodynamic Collapse

Initial treatment includes the following:

  • Avoid nitrates even though it appears the patient is in heart failure!
  • Avoid vasodilators again even though it appears the patient is in heart failure! Both these agents could cause further hemodynamic compromise.
  • Administer beta-blockers to slow the heart rate and fluids to raise the left ventricular filling pressures.
  • Elevate the legs to increase venous return and raise the preload

If the patient does not respond to these measures, then the following can also be administered:

  • Intravenous phenylephrine at a rate of 100 to 180 µg/min, which is then reduced to 2 to 3 mL/min (40 to 60 drops/min).
  • How to mix the phenylephrine: Make a solution that contains 10 mg (1 mL of 1 percent phenylephrine) of phenylephrine diluted in 500 mL of D5W. Administer at a rate of 5 to 9 mL/min (i.e. 100 to 180 drops/min assuming there are 20 drops/mL). This solution provides a phenylephrine drip of 100 to 180 µg/min.
  • Outside of the US, intravenous disopyramide at a dose of 50 mg over one to five minutes can be administered.