How can my father manage hypertrophic cardiomyopathy at 62?

Question

Hello doctor,

My father is 62 years old. He has never had high blood pressure, diabetes, or any other chronic illness, and there is no family history of these conditions.

A few months ago, he began experiencing brief episodes of dizziness. Initially, we assumed this was age-related. However, when these episodes became more frequent, occurring once every two to three weeks, he was first treated as a case of acute coronary syndrome.

Later, a more detailed evaluation was carried out, including echocardiography, coronary angiography, which showed mild coronary artery disease, and a 96-hour Holter study. Based on these findings, he was diagnosed with nonobstructive hypertrophic cardiomyopathy, and implantation of an ICD was advised. The hospital reports are attached.

For a second opinion, we consulted the hospital. After reviewing the reports, they advised continuation of beta blockers and Cardarone and recommended proceeding with ICD implantation when the family felt ready. Their summary is attached.

As per our family's decision, we also consulted a hospital. There, some investigations were repeated, including ECG, echocardiography, and blood tests. The blood test reports are attached, including hemoglobin 11 g/dL, creatinine 0.6 mg/dL, and LDL cholesterol 103 mg/dL; however, we do not have copies of the ECG and echo reports. At the hospital, we were again advised to proceed with ICD implantation for now.

However, they also mentioned that they were not certain whether the symptoms were truly due to hypertrophic cardiomyopathy. They stated that if the same symptoms persisted even after ICD implantation, the device could be removed later. As a family, we are not comfortable with this trial-and-error approach.

Subsequently, we sought another opinion last month. There, my father underwent a cardiac MRI and a tilt table test. The reports are attached. The advice given there was to continue medical management and that no surgical intervention was required at present. They suggested that if he experiences another episode, an ECG should be done immediately.

As a family, we are confused by the differing medical opinions and anxious to make the decision that is genuinely best for him. Our main questions are as follows:

What is the most likely or actual diagnosis in his case?
Can his condition be safely managed with medications alone at this stage?
Is an ICD truly mandatory at present, based on the current findings?
If an ICD is implanted and later found to be unnecessary, is it practical and safe to remove it after a short period, such as two months?
What type of follow-up and monitoring would you recommend for him, considering that he lives in our native place and I work in another city?
Does he need very close daily supervision, or are routine follow-ups and symptom-based evaluation sufficient?

We would be very grateful for your clear guidance, as we wish to take an informed and balanced decision for his health and quality of life.

Please help.

Thank you.

Answer 1

Hello,

Welcome to icliniq.com.

I have gone through your query and understand your concern.

Your father has nonobstructive hypertrophic cardiomyopathy (a genetic heart condition where the heart muscle thickens, but not in a way that blocks blood flow out of the heart).

Based on the cardiac MRI (magnetic resonance imaging) findings, the maximum wall thickness is not in the high-risk range, and there is only minimal fibrosis or scarring within the heart, which is reassuring. In addition, there has been no evidence of arrhythmia (an abnormal heart rhythm) on any of the Holter monitoring performed so far.

Current clinical guidelines strongly recommend ICD (implantable cardioverter-defibrillator) implantation in high-risk patients, but they do not strongly advocate it in the absence of high-risk features. Moreover, ICD implantation may not provide benefit if the symptoms are not related to arrhythmia.

Ideally, Holter monitoring should be performed when the patient is not taking beta blockers or Amiodarone, as these medications can suppress potential arrhythmias. In your father's case, he experienced syncope during the tilt table test without any documented tachyarrhythmia, which suggests that hypertrophic cardiomyopathy is unlikely to be the primary cause of his symptoms.

The following steps should be considered. First, extended ECG (electrocardiogram) monitoring using a loop recorder to capture any intermittent rhythm abnormalities. Second, a detailed evaluation by an electrophysiologist to rule out other causes, such as autonomic dysfunction (a disorder where the autonomic nervous system malfunctions), vasovagal syncope (the most common type of fainting), or orthostatic hypotension (a form of low blood pressure).

His condition can be managed medically at this stage. A trial of medical management focusing on reasonable heart rate control, adequate hydration, and symptom monitoring should be attempted first. Based on current evidence, ICD implantation is not mandatory at this time.

Regarding your question about ICD removal, it is generally safe and feasible in most cases, particularly when performed early. For follow-up and monitoring, closer observation is recommended for now, as he is still experiencing symptoms. Someone must be available to assist him, as syncopal episodes can increase the risk of falls and related injuries.

I hope I have answered your question.

Let me know if I can assist you further.

Thank you.