An 80 year old male presented following an episode of loss of
consciousness which occurred during the night whilst passing urine.
He was brought to the emergency department by which time he had
made a full recovery. Physical examination was unremarkable,
however, on palpation of the carotid pulses he developed a
short episode of asystole which led to further brief loss of
consciousness. 12 lead ECG was grossly abnormal with
widespread T wave inversion and voltage criteria for left
This gentleman had been seen ten years earlier for investigation
of atypical chest pain with normal coronaries on angiography. His
ECG was abnormal at that stage but had been attributed to a
previous heart attack despite no clear wall motion abnormality on
echo. There was no family history of cardiac disease.
An echocardiogram was repeated on this admission and was
technically difficult with poor visualisation of the apex (image
There was, however, a suggestion of localised hypertrophy in the
apical lateral segments. The image quality was greatly enhanced
using Sonovue contrast (images 3-5).
This confirmed the clinical diagnosis of apical hypertrophic
cardiomyopathy. He was assessed by the electrophysiololgists with
a view to pacing and offered screening for his first degree
It is always important to integrate all of the available
clinical information. In this case the gross ECG abnormalities were
difficult to explain by coronary artery disease and therefore
detailed analysis of cardiac structure was particularly important.
Transpulmonary contrast can be very helpful at improving
endocardial definition in such a case.
Last Updated (Tue 28 May 2013)