Sustained tip shock

Specialty: Cardiovascular.

• sustained apical beat
• hyperkinetic and sustained tip shock

Why it occurs

• Severe concentric left ventricular hypertrophy (secondary to aortic stenosis or chronic hypertensive heart disease)
• Hypertrophic cardiomyopathy
• Chronic aortic or mitral valve regurgitation with massive left ventricular overload
• Severe aortic coarctation
• Long-term severe uncontrolled systemic arterial hypertension

Initial workup

12-lead electrocardiogram to quantify the degree of left ventricular hypertrophy using the Sokolow-Lyon index (S wave in V1 + R wave in V5 or V6 >35 mm) or the Cornell index, and assess the presence of asymmetric inverted T waves with a systolic overload pattern; Two-dimensional transthoracic echocardiogram with Doppler to accurately measure the thickness of the interventricular septum and the posterior wall (hypertrophy if thickness >=12 mm), estimate the indexed mass of the left ventricle, evaluate systolic and diastolic function, and rule out obstruction in the ventricular outflow tract; Chest x-ray.

Standard management

• Metoprolol succinate — beta blocker indicated to reduce heart rate, reduce myocardial oxygen consumption and attenuate pathological hypertrophy; 25 to 100 mg once daily orally, titrating to clinical tolerance and target heart rate
• Losartan — ARA-II indicated in hypertensive heart disease to promote the regression of ventricular hypertrophy and control blood pressure levels; 50 to 100 mg once daily orally
• Verapamil — non-dihydropyridine calcium antagonist indicated as an alternative if beta-blockers are contraindicated or in hypertrophic cardiomyopathy; 120 to 240 mg daily in divided doses, monitoring atrioventricular conduction
• Ramipril (ACEI to control hypertension and reduce afterload; 5 to 10 mg per day orally).