Left ventricular hypertrophy diagnosed after a stroke: a case report

Abstract

Background: Stroke is a recognized clinical course of hypertrophic cardiomyopathy. This interesting case showed notable difference on the electrocardiogram of a patient 4 months prior to suffering a stroke and 10 days after suffering a stroke. The pre-stroke electrocardiogram showed atrial fibrillation with a narrow QRS complex, while the post-stroke electrocardiogram showed marked left ventricular hypertrophy. Left ventricular hypertrophy was diagnosed using the Sokolow-Lyon indices. The development of left ventricular hypertrophy a few days after suffering a stroke has not previously been reported.

Case presentation: An 83-year-old white British woman with a background history of permanent atrial fibrillation, hypertension, and previous stroke attended the emergency department with a 2-day history of exertional dyspnea, and chest tightness. On examination, she had bibasal crepitations with a systolic murmur loudest at the apex. In-patient investigations include an electrocardiogram, blood tests, chest X-ray, contrast echocardiogram, coronary angiogram, and cardiovascular magnetic resonance imaging. An electrocardiogram showed atrial fibrillation, with inferolateral T wave inversion, and left ventricular hypertrophy. A chest X-ray showed features consistent with pulmonary edema. A contrast echocardiogram showed marked hypertrophy of the mid to apical left ventricle, appearance consistent with apical hypertrophic cardiomyopathy. Coronary angiography showed eccentric shelf-type plaque with non-flow-limiting stenosis in the left coronary artery main stem. Cardiovascular magnetic resonance imaging reported findings highly suggestive of apical hypertrophic cardiomyopathy. Our patient was treated and discharged on rivaroxaban, bisoprolol, and atorvastatin with a follow-up in the cardiomyopathy outpatient clinic.

Conclusions: Electrocardiogram diagnosis of left ventricular hypertrophy led to the diagnosis of apical hypertrophic cardiomyopathy in this patient. Left ventricular hypertrophy was only evident a few days after our patient suffered a stroke. The underlying mechanisms responsible for this remain unclear. Furthermore, differential diagnosis of hypertrophic cardiomyopathy should be considered in people with electrocardiogram criteria for left ventricular hypertrophy. Cardiovascular magnetic resonance imaging is an important diagnostic tool in identifying causes of left ventricular hypertrophy. Family screening should be recommended in patients with new diagnosis of hypertrophic cardiomyopathy.

Keywords: Electrocardiogram; Left ventricular hypertrophy; Stroke.

Fig. 1

Patient’s electrocardiogram before suffering a stroke

Fig. 2

Patient’s electrocardiogram after suffering a stroke showing marked left ventricular hypertrophy

Fig. 3

Patient’s chest X-ray on admission showing features consistent with interstitial edema

Fig. 4

Apical four-chamber contrast echocardiography showing apical left ventricular hypertrophy

Fig. 5

Apical four-chamber echocardiography showing apical left ventricular hypertrophy

Fig. 6

A different view of apical four-chamber echocardiography showing apical left ventricular hypertrophy

Fig. 7

A coronary angiography showing the left main stem has eccentric shelf-type plaque with non-flow-limiting stenosis

Fig. 8

Cardiovascular magnetic resonance imaging showing apical left ventricular hypertrophy

Fig. 9

Cardiovascular magnetic resonance imaging showing apical left ventricular hypertrophy