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655 irregular heart rate of 175 bpm and a blood pres‐ sure of 110/80 mm Hg. Baseline laboratory tests indicated normal red and white blood cell count, electrolyte, and creatinine levels, as well as ele‐ vated lipid and cardiac troponin T levels (maxi‐ mum value, 1242 ng/ml; upper limit of normal, 14 ng/ml). Atrial fibrillation was converted to si‐ nus rhythm after an intravenous administration of metoprolol and amiodaron. Coronary angiog‐ raphy revealed no abnormalities in coronary ar‐ teries. The patient was treated with a β ‐blocker, angiotensin ‐converting enzyme inhibitor, statin, and vitamin K antagonist. On electrocardiogra‐ phy during sinus rhythm, left ventricular hyper‐ trophy was present. Resting echocardiography revealed significant left ventricular hypertrophy (interventricular septum, 21 mm; posterior wall, 14 mm), without LVOT obstruction at rest and after the Valsalva maneuver (FIGURE 1A and 1B), left ventricular ejection fraction of 65%, diastolic dysfunction (grade I), slight left atrial enlarge‐ ment, mild mitral and tricuspid insufficiency, and normal right ventricular systolic function. No pathology on chest X ‐ray was present. During in ‐hospital cardiac rehabilitation, an episode of syncope occurred, following which the patient was referred for exercise stress echocardiogra‐ phy to assess LVOT obstruction during exercise. Exercise stress echocardiography was per‐ formed on a semi ‐supine cycle ergometer, us‐ ing the ramp protocol (25 wats / 2 minutes). The exercise was terminated after 5 minutes and 57 seconds because of excessive fatigue (8 points on the 10‐point Borg scale) without In patients with hypertrophic cardiomyopathy (HCM), identification of left ventricular out‐ flow tract (LVOT) obstruction is important in the management of symptoms and assessment of the risk of sudden cardiac death. In symptom‐ atic patients with HCM without a significant LVOT obstruction at rest, and if bedside ma‐ neuvers fail to induce a LVOT pressure gradient of 50 mm Hg or higher, exercise stress echocar‐ diography is recommended to assess LVOT ob‐ struction during exercise (Class I, Level B).1 Until now, there have been 3 types of protocols used for stress echocardiography to assess LVOT pres‐ sure gradient in patients with HCM: fully phys‐ iological (an upright position during exercise and recovery), nonphysiological (a supine po‐ sition at both stages), and semi ‐physiological (an upright position during exercise and a su‐ pine position at recovery).2 We suggest using, in some cases, the fourth type, namely, reverse semi ‐physiological (a supine or semi ‐supine po‐ sition during exercise and an upright position during recovery). A 65‐year ‐old obese woman (body mass index, 34 kg/m2) was admitted to our department be‐ cause of type 2 myocardial infarction secondary to the episode of paroxysmal atrial fibrillation with fast ventricular rhythm. She had a histo‐ ry of recurrent syncope, arterial hypertension, hyperlipidemia, type 2 diabetes, obesity, and smoking, as well as a family history of sudden cardiac death. On admission, the patient was in poor clinical condition (sweating, weakness), with a resting Correspondence to: Krzysztof Smarż, MD, PhD, Department of Cardiology, Postgraduate Medical School, Grochowski Hospital, ul. Grenadierów 51/59, 04-073 Warszawa, Poland, phone: +48 22 810 17 38, email: krzysztofsmarz@hotmail.com Received: April 30, 2019. Revision accepted: June 4, 2019. Published online: June 6, 2019. Kardiol Pol. 2019; 77 (6): 655-656 doi:10.33963/KP.14860 Copyright by Polskie Towarzystwo Kardiologiczne, Warszawa 2019 C L I N I C A L V I G N E T T E

kardiologia polska

Significant left ventricular outflow tract obstruction observed during postexercise verticalization in a symptomatic patient with hypertrophic cardiomyopathy