Case for UK CPN R.A. NHS Lothian

65 year-old man PMH of sleep apnoea 2017 – investigated for possible TIA; no significant carotid stenosis but diagnosed with hypertension ECHO at this stage also showed ‘marked left ventricular apical hypertrophy, moderate septal and anteroseptal hypertrophy, and mild hypertrophy in other regions’

No specific recent illnesses or complaints Was reportedly well when he went to bed but found dead there the following morning (due to sleep apnoea, wife slept separately so no witness to actual circumstances surrounding death)

PM BMI of 23 (190cm, 83kg) 670g heart; concentric LVH 22mm (RV 6mm); patchy left ventricular fibrosis in all regions; severe atheroma proximal LAD, otherwise patchy mild-to-moderate atheroma; valves no significant disease Kidneys (R200g, L210g) granular cortices Lungs (each 900g) widely oedematous Other main organs showed no specific abnormalities

Histo Mid-ventricular slice plus conduction system sampled Areas of established fibrosis and myocyte misalignment in all blocks from the left ventricle (including away from the septum), with single focus of similar in one right ventricular section Mild thickening of some intramyocardial arterioles

Question Are the changes consistent with HCM, or could such changes be attributable to his diagnosed hypertension (including the extensive disarray)? My view is that his cardiac enlargement may be due to both! Many thanks!

1. Free anterior LV sections

2. Lateral left ventricle sections

3. Free posterior LV section

4. Anterior and posterior septal sections

5. Right ventricle section