Left Ventricular Hypertrophy: Diagnostic Challenge

Initial Presentation

*Chief Complaint: Palpitations
History of Present Illness: A 48-year-old woman presents with increasingly frequent palpitations associated with effort intolerance. She has had episodic spells for several years, including an episode 2 years earlier of acute-onset rapid, irregular palpitations, crushing chest pain, and shortness of breath while at rest. She was found to have atrial fibrillation with sinus rhythm returned within 12 hours. Over the previous year, she has had milder recurrences with increasing frequency.


Other Medical History (include comorbidities, implants, etc.): Chronic watery diarrhea (4 years)
Mild renal impairment, chronic kidney disease, baseline creatinine of 1.7 g/dL
Family History: Mother with "heart block" requiring a pacemaker; died of heart failure at 89 years of age
Sister with atrial fibrillation, onset in her 50s
Brother with renal failure in his 20s leading to renal transplant; died of heart failure at 64
Son developed palpitations in his 20s
Social/Occupational History: Lifelong nonsmoker; does not drink alcohol or caffeine; no illicit drug use
She enjoys the outdoors and recently began participating in triathlons at a recreational level

Physical Findings

*Age: 48 years
*Gender: Female
Race: Caucasian
*Blood Pressure: 135/82 mm Hg
*Pulse: 58 bpm
General Appearance: Comfortable
Skin (as necessary): Small red-purple nonblanching papules scattered on the trunk
Head and Neck: Jugular venous pressure 6 cm H2O, normal carotid impulses
Chest and Lungs: Clear lung fields
*Cardiac Exam: Regular rate and rhythm, normal S1 and S2, no murmurs at rest or with Valsalva maneuver
Extremities (pulse, edema, etc.): Peripheral pulses 2+ throughout
Extremities warm, well perfused, no edema
Additional Information: Blood urea nitrogen of 31 mmol/L, creatinine of 1.7 g/dL
N-terminal pro–brain natriuretic peptide of 1441 pg/mL
Urine microalbumin of 5.1 mg/dL with a microalbumin-to-creatinine ratio of 123.2 mg albumin/g creatinine.

An electrocardiogram (ECG) is notable for sinus rhythm (Figure 1). There is a short P-R interval. There is markedly increased QRS amplitude in the limb and precordial leads with associated repolarization abnormalities.

Figure 1

Figure 1

Transthoracic echocardiography reveals left ventricular hypertrophy (LVH) and normal left ventricular (LV) systolic function with an ejection fraction of 65% (Figure 2).

Figure 2

Figure 2

Which one of the following statements is true?

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