Falling Out

Falling Out

Joanna Davidson MD 11/19/2014

17 year old M passes out

EMS brings in 17 yo M from nearby high school after he passed out

Patient has no complaints Previously healthy male Vital signs: 120/80, 67, 16, 98.0, 99% on RA

Important HPI questions?

What were you doing when you passed out? Did you have a warning/prodrome? Any family history of SCD?

What do you want to order?

EKG EKG EKG EKG

HOCM

? Hypertrophied, non-dilated LV (normal CXR) ? Thickened, prominent septum ? Only 55% of patients have family history of sudden cardiac death ? Average age of diagnosis is 30-40 years! ? Systolic murmur:

? Increases with valsalva and standing (lowering preload) ? Decreases with trendelenburg and squatting (increased

preload) ? ECG findings ? High left ventricular voltages & Left atrial enlargement (Most

Common) ? Tall R wave in V1 (non-specific, mimics posterior MI)

HOCM ECG findings

Left ventricular hypertrophy results in increased precordial voltages and non-specific ST segment and T-wave abnormalities.

Asymmetrical septal hypertrophy produces deep, narrow ("dagger-like") Q waves in the lateral (V5-6, I, aVL) and inferior (II, III, aVF) leads

Left ventricular diastolic dysfunction may lead to compensatory left atrial hypertrophy, with signs of left atrial enlargement ("P mitrale") on the ECG.

There is an association between HCM and Wolff-Parkinson-White (WPW) syndrome: ECG features of WPW were seen in 33% of patients with HCM in one study. At least one genetic mutation has been identified that is associated with both conditions.

Atrial fibrillation and supraventricular tachycardias are common. Ventricular dysrhythmias (e.g. VT) also occur and may be a cause of sudden death.

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