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Obstruction and Gradient


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  • Obstruction and Gradient

    [Obstruction and Gradient]

    Author: Craig (---.dsl.sfldmi.ameritech.net)

    Date: 04-25-02 09:41


    I was diagnosed about five years ago and just saw Dr. Lever at Cleveland Hospital this past week. I did all the tests and the conclusion is that I don't have obstructive HCM. However, I still have a mean resting gradient of 7 and a peak exercise mean gradient of about 15. How is it possible to be non-obstructive but still have a gradient? I thought they were related.

    Also, I have been hospitalized twice in the past eight months, both times I had minor chest pain which was diagnosed as minor heart attacks. My troponen levels reached 3.3 at their highest. Despite this, Dr. Lever reports that my tests show no muscle damage anywhere in my heart. Lever says I had an "enzyme leak" and NOT a heart attack. Has anyone ever heard of an "enzyme leak"? Help me out here.

    Finally, Lever seemed very concerned about my exercise regimen. I swim 3 times a week and my pulse only reaches about 120 bpm. Yet, he first wanted to only let my pulse go to 100 bpm. After a little nudging and explaining, he agreed to let me swim up to 120 bpm. I've had several stress tests, and in each one I have reached Stage 5 on the Bruce Protocal with no chest pain or other problems. So, why then should I still be so restricted in my exercise? Also, I have never had an arrythmia or a-fib documented by a holter and don't believe I have ever exhibited this symptom.

    BY the way, I'm a 31 year-old male, and take 100mg Toprol and 5mg Norvasc daily and baby aspirin.

    Any help would be greatly appreciated.


    Craig Regester


    [Re: Obstruction and Gradient]

    Author: Sarah Beckley (---.dialup.mindspring.com)

    Date: 04-25-02 13:47

    Dear Craig

    I, too, have had elevated troponin without having had a heart attack. Dr. Klarich at the Mayo told me that troponin is a fussy enzyme, very tricky and liable to elevated by minor happenings -- and that this alone is not a sign of a heart attack, although many doctors don't know this. The profound lack of damaged heart muscle in yourself would be evidence enough for me to believe Lever and Klarich. I, too, thought I was having a heart attack, but wasn't. It was stress-induced chest pain and tachycardia.

    emedicine.com says this about the gradient:

    "The pressure gradient appears to be related to further narrowing of the outflow tract, already made small by the marked asymmetric septal hypertrophy and the possibly abnormally located mitral valve, by systolic anterior motion of the mitral valve against the hypertrophied septum. Most likely, this is caused by a Venturi effect as a result of increased ejection velocity produced by the abnormal LV outflow tract orientation and geometry. In addition, most patients with HCM have abnormal diastolic function whether or not a pressure gradient exists. This diastolic dysfunction impairs ventricular filling and increases filling pressure despite a normal or small ventricular cavity."

    The last two sentances suggest to me that it is possible to have a problem with your pressure gradient despite no actual obstruction.

    Re: exercise. Got me on that one. I do know that if your blood pressure drops during exercise, that is an indication to not work out, but I think you really need to have another conversation with the doctor here. If his decisions don't make sense to you, then you need to talk to him until they do. That is his purpose!

    Hope this all helps,



    [Re: Obstruction and Gradient]

    Author: Bob (---.dyn.optonline.net)

    Date: 04-25-02 14:35

    Hi Craig,

    From what I have read, a gradient measurement lower than 30 mg is considered insignificant (maybe it's like being 6 ounces overweight - really doesn't matter). Usually they don't even cite the measurement if it's below 30. I wouldn't be concerned.

    I had a gradient well above 100 before getting a DDD pacemaker, which eliminated the problem so far.

    Good Luck,



    [Re: Obstruction and Gradient]

    Author: Lisa Salberg (---.dyn.optonline.net)

    Date: 04-28-02 20:03

    A word of caution regarding obstruction:

    Many people in and out of the medical community are extremely concerned with obstruction in patients with hypertrophic Cardiomyopathy. Sometimes, it appears that there's more attention on obstruction rather than the hypertrophic cardiomyopathy as a whole. Gradients are measurement to help determine how obstructed one's hearts become, interestingly some people with minimal obstruction or none at all have very significant symptoms to the contrary some people with very large gradients appear to have no symptoms at all.

    There have been many people who believe that minimizing were eliminating gradients somehow "cures" or minimizes the disease process and hypertrophic cardiomyopathy. This is very dangerous thinking.

    Craig, in your case you're gradients would be considered minimal, trivial or simply insignificant for the purposes of evaluating pressures. A gradients of under 10mm is very low. You should not confuse obstruction for risk. Just because you do not have a large gradients does not mean there is no risk. You have been evaluated by one of the top centers in the country. You would be well advised to follow their recommendations. I know the two are only 31 years old and are feeling quite well so the restrictions and precautions you have been given seem a bit extreme. I have seen far more cases of HCM than most physicians, I have spoken to hundreds upon hundreds of people just like you. Unfortunately, some of those people are no longer with us because they failed to listen to precautions and restrictions because somehow they thought they knew better than the doctors. There is one thing and life th at is in fact certain, mortality. At the age of 31 is extremely difficult to imagine yourself with a serious medical condition. This adjustment will take time, but it will happen.

    Another difficult topic to understand when dealing with hypertrophic cardiomyopathy is a matter of scar tissue within the heart. This is a topic that has been written about the medical literature but in my opinion requires more review to truly comprehended understand the mechanisms as to the how's and why's. What Dr. Lever explained to you regarding enzymes is accurate yet so complicated to follow. It is believed that the scar tissue created in the heart may be created during episodes of chest pain where there may be insufficient oxygen supply to the heart. A more complicated way of phrasing this would be to saying that the scar tissue may be responsible for impaired coronary vasodilator reserve and bursts of myocardial ischemia leading to myositis gas and repair in the form of patchy or transmural replacement scarring. The disorganized cell structure in the heart may also expand interstitial collagen probably serving as arrythmogenic substrates predisposing one to life-threatening electrical instability.

    Therefore, just because you have not had episodes of arrhythmia yet does not mean you will never have this problem.

    Regarding the concept of DDD pacing, it is rarely used any longer for the purpose of reducing gradients. To multicenter studies have proved that the symptomatic improvements and those with these types of pacemakers are not statistically significant. In the best cases these pacemakers reduced gradients by approximately 50 percent. In some patients who were not having streams symptoms due to their gradients the devices appear to be of no negative consequences. The surgical remedy, myectomy, still views as gold standard for reducing gradients in highly symptomatic patients. Of course alcohol septal ablation is also an option for the reduction of gradients.

    I know this is been a rather long response, but I hope has helped.

    Best wishes,

    Lisa Salberg


    NOTE: This is a post from the previous forum message board.