Extensive Subepicardial Fibrosis in a Patient With Apical Hypertrophic Cardiomyopathy With Persistent ST-Segment Elevation Simulating Acute Myocardial Infarction

Abstract

HomeCirculationVol. 112, No. 3Extensive Subepicardial Fibrosis in a Patient With Apical Hypertrophic Cardiomyopathy With Persistent ST-Segment Elevation Simulating Acute Myocardial Infarction Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessReview ArticlePDF/EPUBExtensive Subepicardial Fibrosis in a Patient With Apical Hypertrophic Cardiomyopathy With Persistent ST-Segment Elevation Simulating Acute Myocardial Infarction Jong-Won Ha, Byoung-Wook Choi, Se-Joong Rim, Seok-Min Kang, Yangsoo Jang, Namsik Chung, Won-Heum Shim and Seung-Yun Cho Jong-Won HaJong-Won Ha From Cardiology Division, Yonsei University College of Medicine, Yonsei Cardiovascular Center, Seoul, Korea. Search for more papers by this author , Byoung-Wook ChoiByoung-Wook Choi From Cardiology Division, Yonsei University College of Medicine, Yonsei Cardiovascular Center, Seoul, Korea. Search for more papers by this author , Se-Joong RimSe-Joong Rim From Cardiology Division, Yonsei University College of Medicine, Yonsei Cardiovascular Center, Seoul, Korea. Search for more papers by this author , Seok-Min KangSeok-Min Kang From Cardiology Division, Yonsei University College of Medicine, Yonsei Cardiovascular Center, Seoul, Korea. Search for more papers by this author , Yangsoo JangYangsoo Jang From Cardiology Division, Yonsei University College of Medicine, Yonsei Cardiovascular Center, Seoul, Korea. Search for more papers by this author , Namsik ChungNamsik Chung From Cardiology Division, Yonsei University College of Medicine, Yonsei Cardiovascular Center, Seoul, Korea. Search for more papers by this author , Won-Heum ShimWon-Heum Shim From Cardiology Division, Yonsei University College of Medicine, Yonsei Cardiovascular Center, Seoul, Korea. Search for more papers by this author and Seung-Yun ChoSeung-Yun Cho From Cardiology Division, Yonsei University College of Medicine, Yonsei Cardiovascular Center, Seoul, Korea. Search for more papers by this author Originally published19 Jul 2005https://doi.org/10.1161/CIRCULATIONAHA.104.479386Circulation. 2005;112:e49–e50Apical hypertrophic cardiomyopathy is a unique form of hypertrophic cardiomyopathy (HCM), in which the hypertrophy of myocardium predominantly involves the apex of the left ventricle. The ECG in apical HCM typically shows repolarization changes in the anterolateral leads and sometimes giant negative T waves. Previous reports have shown that apical HCM may mimic myocardial infarction, although its underlying mechanism is unclear. This case report demonstrates typical echocardiographic and MRI features of apical HCM, but with unusual electrocardiographic features characterized by chronic ST-segment elevation in the precordial leads. Contrast-enhanced MRI showed unusual extensive subepicardial delayed hyperenhancement at the left ventricular apex, suggesting that subepicardial fibrosis may be a possible cause for this unusual ECG abnormality in patients with apical HCM. Because this condition can be misdiagnosed as acute infarction, resulting in unwarranted thrombolytic therapy or emergency angiography, we believe this case is important as a reminder that acute infarction is not the only cause of ST-segment elevation.In March 2003, a 44-year-old man presented with exertional dyspnea. He was normotensive and had never experienced chest pain or other symptoms suggestive of heart disease. A routine 12-lead ECG (Figure 1) revealed an ST-segment elevation in V3 to V6 precordial leads, which made us suspect possible acute myocardial infarction. Physical examination revealed no abnormal findings, and cardiac biomarkers were negative. Echocardiography and MRI (Figure 2 and Movies) revealed a severe hypertrophy confined to the left ventricular apex, suggesting apical HCM. Coronary angiography by MRI showed no significant luminal narrowing (Figure 3). A contrast-enhanced image obtained by MRI showed prominent delayed hyperenhancement localized at the subepicardial area of the left ventricular apex (Figure 4). Follow-up ECG obtained 1 year later showed persistent ST elevation in precordial leads without interval change (Figure 5). Download figureDownload PowerPointFigure 1. Initial ECG showing ST-segment elevation in V3 to V6 precordial leads, indicative of possible acute myocardial infarction.Download figureDownload PowerPointFigure 2. MRI revealed severe hypertrophy confined to left ventricular apex, suggesting apical HCM.Download figureDownload PowerPointFigure 3. Coronary angiography by MRI showed no significant luminal narrowing.Download figureDownload PowerPointFigure 4. Contrast-enhanced image obtained by MRI of 4-chamber view (left) and 2-chamber view (right) showed prominent delayed hyperenhancement localized at subepicardial area of left ventricular apex.Download figureDownload PowerPointFigure 5. Follow-up ECG 1 y later showed persistent ST elevation in precordial leads without interval change.The Data Supplement is available at http://www.circ.ahajournals.org/cgi/content/full/112/3/e49/DC1.FootnotesCorrespondence to Jong-Won Ha, MD, PhD, Cardiology Division, Yonsei University College of Medicine, Yonsei Cardiovascular Center, CPO Box 8044, Seoul, Korea. E-mail [email protected] Previous Back to top Next FiguresReferencesRelatedDetailsCited By Wu H, Cao Y and Liang L (2021) Persistent ST-Segment Elevation in a Young Man, JAMA Internal Medicine, 10.1001/jamainternmed.2021.4432, 181:11, (1514), Online publication date: 1-Nov-2021. Ozeke O, Ertan C, Keskin G, Deveci B, Cay S, Ozcan F, Topaloglu S, Aras D, Demir A and Aydogdu S (2015) Association of ST elevation with apical aneurysm in hypertrophic cardiomyopathy, Indian Heart Journal, 10.1016/j.ihj.2015.05.019, 67:5, (434-439), Online publication date: 1-Sep-2015. July 19, 2005Vol 112, Issue 3 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCULATIONAHA.104.479386PMID: 16027264 Originally publishedJuly 19, 2005 PDF download Advertisement SubjectsCardiomyopathyComputerized Tomography (CT)