A Man in His 80s With Hypertension, Left Ventricular Hypertrophy, and Enlarged Biceps

What implication would the physical findings of hypertension, left ventricular hypertrophy, and enlarged biceps have in the setting of an elderly patient with a diagnosis of hypertensive heart disease? A man in his 80s with a history of long-standing arterial hypertension who was receiving multiple antihypertensive medications was referred for a cardiology consultation because of worsening dyspnea. Echocardiographic testing showed findings of mild concentric left ventricular hypertrophy (interventricular septum, 14 mm; posterior wall, 13 mm), preserved ejection fraction (56%), and impaired diastolic relaxation, which were consistent with hypertensive heart disease.¹ The finding of bilateral spontaneous rupture of the biceps tendon (Figure) raised suspicion of amyloid cardiomyopathy, despite the lack of conventional echocardiographic and extracardiac red flags.² A subsequent workup, which included tissue-Doppler echocardiography (revealing mitral annulus velocities: lateral S', 4 cm/s; E', 6 cm/s; A', 2 cm/s; medial: S', 4 cm/s; E', 5 cm/s; A’, 2 cm/s) and speckle-tracking echocardiography (global longitudinal strain, −9.5%), technetium-99m hydroxymethylene diphosphonate scintigraphy,³ testing for monoclonal gammopathy, and genetic testing, allowed a noninvasive⁴ diagnosis of wild-type transthyretin-associated amyloid cardiomyopathy.⁵