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JAMA Cardiology Clinical Challenge
May 13, 2020

A 32-Year-Old Man With Chronic Left Ventricular Dysfunction

Author Affiliations
  • 1Warren Alpert School of Medicine, Department of Medicine, Brown University, Providence, Rhode Island
JAMA Cardiol. Published online May 13, 2020. doi:10.1001/jamacardio.2020.0295

A 32-year-old man with a diagnosis of dilated cardiomyopathy sought care for angina and dyspnea with exertion. His chest pain and dyspnea were chronic and had recently increased in frequency. His cardiomyopathy followed a diagnosis of myocarditis after repeated putative chest colds and chest pain at age 14 years, at which time the ejection fraction was reported to be 30%. The results of a graded exercise stress test at 22 years were unremarkable.

On examination, he was afebrile. His heart rate was 68 beats per minute, his blood pressure was 114/77 mm Hg, and his examination was notable for an absence of jugular venous distension, peripheral edema, and murmurs or extra heart sounds. His electrocardiogram, shown in Figure 1, was notable for right bundle branch block and left anterior fascicular block, unchanged from his electrocardiogram at age 14 years. Transthoracic echocardiography revealed an ejection fraction of 40%. An exercise nuclear stress test revealed a fixed, severe apical defect, a partially reversible severe anterior wall defect, moderate global hypokinesis, and severe hypokinesis of the distal anterior wall and apex. His ejection fraction was estimated to be 32%. Given these findings, left-sided heart catheterization was performed.

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