54-Year-Old Woman With Progressive Dyspnea on Exertion and Syncopal Episodes

1.Which one of the following is the most likely etiology of this patient's symptoms? a. Acute pulmonary embolism (PE) b. Myocardial infarction c. Brugada syndrome d. Vasovagal syncope e. Hypertrophic cardiomyopathy (HCM) This patient presented with shortness of breath and chest discomfort, which is common in PE. Brugada syndrome should be suspected in patients with syncope, incomplete right bundle branch block, and ST-segment elevations in the anterior precordial leads. Patients with HCM have LV wall thickness greater than 15 mm in females and 16 mm in males and nondilated ventricular chambers.2 Approximately 70% have LVOT obstruction and may also experience diastolic dysfunction, mitral regurgitation, myocardial ischemia from demandsupply mismatch, and atrial and ventricular arrhythmias.3 Syncope can be precipitated by arrhythmias and exercise-induced LVOT obstruction leading to hypotension and cerebral hypoperfusion. Catheterization of the left side of the heart revealed 10% to 20% nonobstructive coronary artery disease. 2.Based on the patient's initial presentation, which one of the following represents the need for placement of an automatic implantable cardioverter-defibrillator device (AICD)? a. Family history of sudden death and 2 unexplained syncopal episodes b. Chest pain c. Progressive dyspnea on exertion d. Nonobstructive coronary artery disease e. Orthopnea A family history of sudden death and unexplained syncopal episodes are indications to consider AICD placement. The American College of Cardiology Foundation/American Heart Association guideline recommends an AICD for primary prevention if SCD occurred presumably from HCM in one or more first-degree relatives, if maximum LV thickness is 30 mm or more, in the setting...