INTRODUCTION: A left ventricular outflow tract (LVOT) obstruction assessment with a provoking test should be a routine part of the evaluation of patients with hypertrophic cardiomyopathy (HCM). The aim of this study was to compare the utility of the Valsalva maneuver (VM) and sublingual spray application of isosorbide dinitrate (ISDN) for detection of an obstruction. MATERIAL AND METHODS: We prospectively evaluated 81 consecutive HCM patients without severe rest LVOT obstruction (defined as peak rest pressure gradient (PG) ≥ 50 mm Hg). We measured PG at rest, during the VM, after sublingual ISDN spray, and during the VM after ISDN. An obstruction was defined as a PG ≥ 30 mm Hg. RESULTS: An obstruction was present in 15 patients (19%) at rest (median and interquartile range of PG 16 (7-26) mm Hg), in 38 patients (47%) during the VM (PG 28 (12-49) mm Hg), in 50 (62%) patients after ISDN (PG 50 (12-79) mm Hg), and in 55 patients (68%) during the VM after ISDN (PG 59 (20-87) mm Hg). The difference in occurrence of obstruction among different provoking tests was statistically significant for all comparisons (p < 0.001, except for the comparison of the ISDN test with the VM during ISDN, p = 0.025). CONCLUSIONS: The ISDN test and the VM are useful screening methods for the detection of an HCM obstruction. Although ISDN appears to be more precise than the VM, the best option is a combination of both methods, which maximizes inducement of LVOT obstruction in patients with HCM.

Department of Cardiology 2 Medical School of Charles University and University Hospital Motol Prague Czech Republic

Department of Cardiology 2 Medical School of Charles University and University Hospital Motol Prague Czech Republic ; International Clinical Research Center Brno Brno Czech Republic

International Clinical Research Center Brno Brno Czech Republic

See more in PubMed

Houshmand M, Montazeri M, Kuchekian N, Noohi F, Nozar G, Zamani A. Is 8860 variation a rare polymorphism or associated as a secondary effect in HCM disease? Arch Med Sci. 2011;7:242–6. PubMed PMC

Veselka J, Duchonová R, Pálenícková J, et al. Age-related hemodynamic and morphologic differences in patients undergoing alcohol septal ablation for hypertrophic obstructive cardiomyopathy. Circ J. 2006;70:880–4. PubMed

Zemánek D, Tomašov P, Přchystalová P, Linhartová K, Veselka J. Evaluation of the right ventricular function in hypertrophic obstructive cardiomyopathy: a strain and tissue Doppler study. Physiol Res. 2010;59:697–702. PubMed

Zemánek D, Veselka J, Adla T, Šetina M, Ferda J. Uncommon cause of obstruction in the left ventricular outflow tract by a metastasis of adenocarcinoma. Arch Med Sci. 2010;6:981–3. PubMed PMC

Maron MS, Olivotto I, Zenovich AG, et al. Hypertrophic cardiomyopathy is predominantly a disease of left ventricular outflow tract obstruction. Circulation. 2006;114:2232–9. PubMed

Maron MS, Olivotto I, Betocchi S, et al. Effect of left ventricular outflow tract obstruction on clinical outcome in hypertrophic cardiomyopathy. N Engl J Med. 2003;348:295–303. PubMed

Veselka J. Alcohol septal ablation for hypertrophic obstructive cardiomyopathy: is it safe? Catheter Cardiovasc Interv. 2009;74:520–1. PubMed

Malek LA, Chojnowska L, Klopotowski M, et al. Long term exercise capacity in patients with hypertrophic cardiomyopathy treated with percutaneous transluminal septal myocardial ablation. Eur J Heart Fail. 2008;10:1123–6. PubMed

Shah JS, Esteban MT, Thaman R, et al. Prevalence of exercise-induced left ventricular outflow tract obstruction in symptomatic patients with non-obstructive hypertrophic cardiomyopathy. Heart. 2008;94:1288–94. PubMed

Lang RM, Bierig M, Devereux RB, et al. American Society of Echocardiography's Nomenclature and Standards Committee; Task Force on Chamber Quantification; American College of Cardiology Echocardiography Committee; American Heart Association; European Association of Echocardiography, European Society of Cardiology. Recommendations for chamber quantification. Eur J Echocardiogr. 2006;7:79–108. PubMed

Olaf S, Debora B, Ricarda B, et al. Exercise tolerance in asymptomatic patients with moderate-severe valvular heart disease and preserved ejection fraction. Arch Med Sci. 2012;8:1018–26. PubMed PMC

Vukajlovic D, Milasinovic G, Angelkov L, et al. Contractile reserve assessed by dobutamine test identifies super-responders to cardiacresynchronization therapy. Arch Med Sci. 2014;10:684–91. PubMed PMC

Faber L, Heemann A, Surig M, Michalowski Z, Gleichmann U, Klempt HW. Outflow acceleration assessed by continuous-wave doppler echocardiography in left ventricular hypertrophy: an analysis of 103 consecutive cases. Cardiology. 1998;90:220–6. PubMed

Dimitrow PP, Bober M, Michalowska J, Sorysz D. Left ventricular outflow tract gradient provoked by upright position or exercise in treated patients with hypertrophic cardiomyopathy without obstruction at rest. Echocardiography. 2009;26:513–20. PubMed

Marwick TH, Nakatani S, Haluska B, Thomas JD, Lever HM. Provocation of latent left ventricular outflow tract gradients with amyl nitrite and exercise in hypertrophic cardiomyopathy. Am J Cardiol. 1995;75:805–9. PubMed

Gersh BJ, Maron BJ, Bonow RO, et al. American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines; American Association for Thoracic Surgery; American Society of Echocardiography; American Society of Nuclear Cardiology; Heart Failure Society of America; Heart Rhythm Society; Society for Cardiovascular Angiography and Interventions; Society of Thoracic Surgeons. 2011 ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy. Circulation. 2011;124:e783–831. PubMed

Zemánek D, Tomasov P, Homolová S, Linhartová K, Veselka J. Sublingual isosorbide dinitrate for the detection of obstruction in hypertrophic cardiomyopathy. Eur J Echocardiogr. 2011;12:684–7. PubMed

Jensen MK, Havndrup O, Pecini R, et al. Comparison of Valsalva manoeuvre and exercise in echocardiographic evaluation of left ventricular outflow tract obstruction in hypertrophic cardiomyopathy. Eur J Echocardiogr. 2010;11:763–9. PubMed