Case Study 4: Collette
HCM with LVOTO and Progressive NYHA Decline

Collette is a 57-year-old woman with HCM and LVOTO that was initially diagnosed 10 years prior when she had a screening echocardiogram as a participant in a clinical trial. Her symptoms of exertional dyspnea have been worsening over the past 12 months and are now NYHA class II on a good day and class III on a bad day. A recent stress echo revealed a peak LVOT gradient in excess of 100 mmHg and a hypotensive response to exercise. She denies angina. Her goal is to be able to hike 5 miles.

 

Past Medical History: Polycystic Kidney Disease (baseline Cr ~1.5), hypertension, hyperlipidemia, hyperparathyroidism, Schatzki’s Ring.
Medications: Metoprolol 50mg TID; Valsartan 40 mg QDay; Tolvaptan: 60mg QAM, 30mg QPM; Evolocumab:140 mg q 2 weeks.
Surgical History: Parathyroidectomy.
Allergies: Atorvastatin -> myalgia.
Social History: She is a nurse by training and currently works in the insurance industry. Never smoked. Social, non-daily, alcohol consumption. No drugs of abuse or recreation.

Family History: No history of HCM. Ischemic heart disease in several paternal uncles.

 

Exam: BP 94/56 mmHg, P 54 bpm, R 16, BMI 29.7.
General: Appears normal and no apparent distress.
Neck: No JVD on exam.
Heart: Regular heart rate and rhythm, III/VI systolic crescendo decrescendo murmur that increases following Valsalva.
Resp: Lungs clear to auscultation without adventitious breath sounds bilaterally.
Extremities: No lower extremity edema, palpable pulses bilaterally.

Labs: Na 141, K 4.5, Cl 104, CO2 27, BUN 28, Cr 1.51, Glucose 90; Wbc, 6.2; Hgb 11.4; Hct 35; Plt 211.
LFT’s: all wnl.