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Endgames Case Report

A patient with hypertrophic cardiomyopathy undergoing non-cardiac surgery

BMJ 2013; 347 doi: (Published 25 November 2013) Cite this as: BMJ 2013;347:f6910
  1. Tania C N Elias, specialist registrar, geriatric medicine1,
  2. Judith S L Partridge, clinical research fellow, proactive care of older people undergoing surgery (POPS)1,
  3. Stuart A McCorkell, consultant anaesthetist2,
  4. Jugdeep K Dhesi, consultant physician, proactive care of older people undergoing surgery (POPS)1
  1. 1Department of Ageing and Health, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 7EH, UK
  2. 2Anaesthetic Department, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
  1. Correspondence to: T C N Elias taniacnelias{at}

A 73 year old woman with hypertension who presented with exertional chest pain was found to have a harsh ejection systolic murmur, with features of left ventricular hypertrophy on electrocardiography. Coronary angiography showed normal coronary arteries and transthoracic echocardiography detected concentric thickening of the left ventricular wall, with hyperdynamic systolic function. These findings were thought to be secondary to hypertension, which was managed with ramipril 10 mg and amlodipine 5 mg.

Three years later she returned with breathlessness, and further transthoracic echocardiography suggested severe obstruction of the left ventricular outflow tract owing to systolic anterior motion of the anterior mitral leaflet, with an outflow gradient of up to 160 mm Hg. She was diagnosed with hypertrophic cardiomyopathy and was managed with bisoprolol 5 mg. Her symptoms improved and no arrhythmias were found on 24 hour electrocardiography (figure).

Two years later she developed painful abdominal distension with anaemia. Computed tomography demonstrated bilateral ovarian masses. She was listed for a total abdominal hysterectomy and bilateral salpingo-oophorectomy. The indication for surgery was symptom relief and suspected cancer.

Electrocardiogram with some typical features of hypertrophic cardiomyopathy


  • 1 What are the pathophysiological changes of hypertrophic cardiomyopathy?

  • 2 What are the clinical features of hypertrophic cardiomyopathy?

  • 3 On the basis of this patient’s clinical history, is her hypertrophic cardiomyopathy likely to be of high or low risk?

  • 4 What risks might hypertrophic cardiomyopathy pose for a patient undergoing non-cardiac surgery?

  • 5 How can these risks be minimised?


1 What are the pathophysiological changes of hypertrophic cardiomyopathy?

Short answer

Hypertrophic cardiomyopathy is an autosomal dominant genetic disorder characterised by left ventricular hypertrophy, impaired diastolic filling, and abnormalities of the mitral valve. These features can cause dynamic obstruction of the left ventricular outflow tract, diastolic dysfunction, myocardial ischaemia, and an increased risk of supraventricular and ventricular tachyarrhythmias.

Long answer

It is thought that a genetic mutation in one of …

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