Risk of Syncope and Sudden Cardiac Death in HCM

Chief Complaint: Syncope

HPI: A 53-year-old man presents with an episode of syncope which occurred once while he was riding his bicycle. The patient was not injured in the incident. He has not experienced chest discomfort on exertion. Since that time the patient has avoided riding and has remained asymptomatic. Prior to this episode the patient denied any dyspnea. There have been no symptoms of orthopnea, lower extremity edema, nor palpitations.

Family History: There are no family members with a diagnosis of hypertrophic cardiomyopathy nor any family members with premature sudden cardiac death.

Social/Occupational History: He is a lifelong smoker and non-alcohol user. He takes frequent 5-mile bicycle rides in his neighborhood without any issues.

Pertinent Physical Exam:
BMI: 31 kg/m2
Blood pressure: 122/80 mm Hg
Pulse: 72/min
Cardiac exam: Discrete and nondisplaced point of maximal impulse, regular rate and rhythm, grade 2/6 late-peaking systolic ejection murmur heard best along the left sternal border without change during Valsalva.

ECG: example provided normal sinus rhythm with T-wave inversions in the precordial leads.

Figure 1

Ambulatory ECG monitoring: 14 days of monitoring demonstrated sinus rhythm with no sustained arrhythmias.

Transthoracic echocardiography:

Figure 2

Cardiac MR:

Figure 3

What is the next step in the management of this patient?

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