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Clinical case scenario
An 18-year-old man, African-American college basketball player is seen for pre-participation cardiovascular screening. He reports no cardiovascular symptoms and has no family history of juvenile sudden cardiac death or heritable cardiac disease. A screening ECG shows T wave inversion preceded by ST segment elevation in V3-V4 and abnormal T wave inversion in the lateral leads V5-V6, I and aVL (figure 1). An echocardiogram is performed showing concentric left ventricular hypertrophy with prominent apical thickening with a maximal septal measurement of 24 mm, posterior wall thickness of 12–13 mm, left ventricular internal diameter in diastole of 4.8 cm, and normal left ventricular systolic and diastolic function without outflow tract obstruction. Cardiac MRI demonstrates asymmetric thickening of the mid and apical septum with a maximal measurement of 31 mm, as well as several adjacent dense foci of delayed gadolinium enhancement in the mid inferior septum; findings consistent with a diagnosis of hypertrophic cardiomyopathy (HCM). Subsequent exercise treadmill testing and ambulatory ECG monitoring show no abnormalities. The patient receives an implantable cardioverter defibrillator (ICD) for primary prevention of sudden death because his maximal wall thickness is >30 mm (class IIa). Should he be allowed to return to competitive sports?
ICDs have demonstrated a mortality benefit in many cardiac conditions by reducing sudden death from ventricular arrhythmias. ICDs are indicated for high-risk patients with cardiomyopathies and channelopathies where the potential benefit outweighs the risk of complications. High-risk patients are typically defined as having a prior cardiac arrest, ventricular tachycardia, left …
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