A 71 year old woman was referred for assessment of a severe form of hypertrophic obstructive cardiomyopathy. She complained of chest pain and shortness of breath on exertion. She had an uncertain family history of heart disease, but there was no family history of sudden death. Her history included hypothyroidism, hypertension, and cerebrovascular accidents with minimal sequelae. She had moderate stenosis of the right internal carotid artery. The patient was taking verapamil (240 mg/day) and atenolol (50 mg/day).

Physical examination revealed a 3/6 systolic ejection murmur radiating towards the neck; there was no ejection click. Blood pressure was 180/100 mm Hg and she was in sinus rhythm (heart rate 57 beats/min).

Electrocardiography showed left ventricular hypertrophy with giant T wave inversion and ST segment depression in the anterior and lateral leads. Chest radiography showed an increased cardiothoracic ratio of 16:27. Cross sectional …