Images in Clinical Medicine
Heart in the Heart
N Engl J Med 1999; 341:1045September 30, 1999
- Article
Figure 1 A 65-year-old man with a five-year history of uncontrolled hypertension was admitted to the emergency department with pulmonary edema. On admission his blood pressure was 180/110 mm Hg. A chest film showed bilateral pleural effusions as well as pulmonary edema. The electrocardiogram demonstrated left bundle-branch block. Hypertension and pulmonary edema resolved rapidly after treatment with nitroglycerin, furosemide, and morphine. During the first 24 hours of treatment, the levels of cardiac enzymes increased (creatine kinase, 370 U per liter; creatine kinase MB, 31 U per liter; and troponin I, 15.6 U per liter). The electrocardiographic findings remained unchanged. The results of coronary angiography were normal, and left ventriculography revealed an ejection fraction of 25 percent. An apical four-chamber view obtained by two-dimensional echocardiography showed a hypokinetic, hypertrophied, and dilated left ventricle with a heart-shaped, mobile thrombus (20 by 15 mm) on a stem in the apex. The patient was treated with enalapril, hydrochlorothiazide, and phenprocoumon, and the thrombus resolved completely within 11 days. The presumptive diagnosis was hypertensive dilated cardiomyopathy.
Jochen Schuler, M.D.
Martin Dissmann, M.D.
Krankenhaus Reinickendorf, 13500 Berlin, Germany
