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Recurrent Syncope: An Unusual Complication of Hypertensive Heart Disease

https://doi.org/10.1016/j.amjmed.2016.07.003Get rights and content

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Case Report

A 62-year-old hypertensive woman presented with a syncopal episode of 15 minutes duration after voiding on the toilet. The patient denied any presyncopal symptoms, postictal confusion, urinary, or bowel incontinence but reported several previous episodes of syncope. On examination, she had a grade III/VI systolic murmur and appeared hypovolemic with flat neck veins and orthostatic hypotension. Relevant laboratory results revealed hyponatremia, acute kidney injury, hypomagnesemia, elevated

Discussion

Syncope accompanied by a systolic murmur generally suggests a fixed mechanical obstruction. However, outflow tract obstruction may be dynamic, for example, after exercise or during Valsalva maneuvers.6 Predictors of hemodynamically significant outflow tract obstruction include chordal systolic anterior motion at peak, small hyperdynamic left ventricles, increased septal wall thickness, and younger age.7

Conclusions

This case is notable because hypertensive heart disease rarely is implicated as the sole cause of left ventricular outflow tract obstruction. Our case also highlights 2 therapeutic challenges in managing outflow tract obstruction: (1) maintaining adequate preload while also (2) decreasing afterload with antihypertensive therapy targeted toward reverse ventricular remodeling.8

Cited by (1)

Funding: None.

Conflict of Interest: None.

Authorship: Both authors had access to the data and played a role in writing this manuscript.

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