What Is Really a Nonobstructive Hypertrophic Cardiomyopathy? The Importance of Orthostatic Factor in Exercise Echocardiography

The authors report the case of a 23-year-old girl with nonobstructive hypertrophic cardiomyopathy evaluated by resting echocardiography. The patient complained of syncope after playing basketball. The patient was submitted to treadmill exercise echocardiogram, and she exercised for 9 minutes in standard Bruce protocol. The left ventricular outflow gradient did not occur at peak workload; however she developed intraventricular gradient greater than 100 mmHg after exercise in orthostatic position. There was fall in arterial pressure, and the patient was then put in supine position. The authors suggest the possible role of exercise stress echo in symptomatic patients with no significant gradient at baseline, as well as maintenance in orthostatic position after exercise, as an important stress factor. This can disclose the occurrence of left ventricular outflow tract obstruction that should not be detected in other way and has potential relevance in the patient's symptoms understanding.