Familial Hyperlipidemia and Exertional Chest Pain
A 52-year-old woman with familial hyperlipidemia complains of exertional chest pain but walks 2 to 5 miles daily without difficulty. She is feeling depressed and has had weight gain.
She has a 12-lead electrocardiogram (ECG) as depicted in Figure 33-1 and undergoes a supine bicycle stress echocardiogram with imaging at rest (heart rate [HR] 52 beats per minute; Videos 33-1 and 33-2), at intermediate exercise (HR 90 beats per minute; Videos 33-3 and 33-4), and during peak stress (HR 131 beats per minute = 78% maximum predicted HR; Videos 33-5 and 33-6), end-systolic frames depicted. Left ventricular ejection fraction is normal at rest without wall motion abnormalities (Fig. 33-2).
 Figure 33-1. Resting 12-lead ECG. |
 Figure 33-2A,B. |
QUESTION 1. Which statement is true?
A. The left ventricle (LV) is smallest at the intermediate stage exercise, suggesting a hibernating myocardium at rest
B. The LV cavity dilates at peak stress in a uniform pattern, suggesting a nonischemic cardiomyopathy
C. The LV cavity dilates in a regional pattern during peak stress, suggesting an ischemic response to stress
View Answer
ANSWER 1: C. It is correct that the LV is smallest during intermediate stage exercise. This is a normal response to exercise, and in a patient with normal LV systolic function to start does not imply a hibernating myocardium. Our patient has regional variation in myocardial contractility during peak stress (Fig. 33-4), consistent with obstructive coronary artery disease. A patient with global LV dilatation at stress may have a nonischemic cardiomyopathy, significant valvular disease, or may have ischemic disease due to left main or triple vessel disease.
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