Chest Pain, Palpitations and Heart Murmur In A Basketball Player

Abstract

HISTORY: A 16 year old male competitive basketball player referred for a 3 month history of intermittent palpitations associated with chest pain at rest. Initially the symptoms were occurring once or twice a week, then once every 2 days, then occurring almost daily. The episodes are characterized by irregular heartbeat, followed by chest pain, with occasional shortness of breath. There is also chest pain associated with exercise. Characterized as burning which lasts 15-20 seconds. It does not change with activity level. He can usually play through the pain. He denies dizziness, presyncope or syncope. Also denies effort intolerance. PHYSICAL EXAMINATION: Well developed in no distress. No thyromegaly. No pallor. Lungs clear. Regular rate and rhythm. Normal S1 and S2. I-II/VI nonspecific SEM heard at LUSB and RUSB in the supine position. Pulses 2+ and equal. Abdomen soft and non-tender. DIFFERENTIAL DIAGNOSIS: 1. Musculoskeletal chest pain Palpitations-probably benign 2. Innocent murmur TESTS AND RESULTS: ECG: sinus bradycardia, LVH, ST elevation right precordial leads, T wave inversion inferior leads ECHOCARDIOGRAM: LVH with notable hypertrophy of left posterior wall (14 mm). Borderline LAE. HOLTER MONITOR: rare PVC’s and PAC’s. One polymorphic couplet CARDIAC MRI: borderline concentric LVH (max 12.8 mm: Z score 2.2), borderline LV wall mass. Borderline LAE. No regional wall motion abnormalities or delayed gadolinium enhancement METABOLIC STRESS: peak VO2 93% predicted. Ventricular ectopy at rest, with exercise and in recovery: suppressed at max HR. PFT (post exercise): FVC decreased 15%; FEV1 decreased 14%; FEF 25-75% decreased 39% CARDIAC CATHETERIZATION: normal LV end diastolic pressures. No myocardial bridge GENE DX: negative FINAL/WORKING DIAGNOSIS: 1. Left Ventricular Hypertrophy 2. Premature Ventricular Contractions 3. Exercise Induced Bronchospasm TREATMENT AND OUTCOMES: 1. Implantable loop recorder 2. Allowed to return to play with AED on site 3. Albuterol MDI prior to exercise 4. Repeat Metabolic Stress in 6 months