55-year-old male with known apical HCM and new symptoms

David Niederseer, Sports Cardiology Quiz Section Co-Editor

12 Sep 2025

Dr. Emmanuel Androulakis , FESC

Dr. Szymon Musiol

Prof. Michael Papadakis , FESC

Dr. Maria Teresa Tome Esteban

Topic(s):

Rehabilitation and Sports Cardiology

The case

55-year-old veteran marathon runner was under the surveillance of the Inherited Cardiac Conditions clinic due to a diagnosis of likely apical hypertrophic cardiomyopathy diagnosed initially due to an incidental abnormal ECG, and a subsequent mild echocardiographic phenotype (11.5 mm septal diastolic diameter, and mild hypertrophy in apical anterior and inferior segments).

After years of uneventful follow-up, he presented worsening athletic performance and exertional breathlessness over 1 year. As the symptoms were out of keeping with his relatively mild phenotype, extended investigations were carried out:

His interval cardiac MRI scan showed extensive subendocardial myocardial enhancement more evident in the mid-to-apical segments (Figure 1, panel B4) and diffuse myocardial enhancement of mid-to-apical septum and anterior walls, elevated T1 mapping values and extracellular volume as well as a circumferential pericardial effusion with a maximum diameter of 13 mm.
He was found to have a monoclonal IgA paraproteinaemia with a kappa-to-lambda ratio of 0.08.
A definitive diagnosis of multiple myeloma and AL cardiac amyloid was made with interdisciplinary collaboration with the haematology team.

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Case report

Read the corresponding case report:

Cardiac AL amyloidosis in a veteran endurance athlete with pre-existing apical hypertrophic cardiomyopathy: A Case Report

Emmanuel Androulakis, Szymon Musiol, Michael Papadakis, Maria Teresa Tome Esteban; European Heart Journal - Case Reports, ytaf443, https://doi.org/10.1093/ehjcr/ytaf443

References

Question 1:

1. Sharma S, Drezner JA, Baggish A, et al. International recommendations for electrocardiographic interpretation in athletes. Eur Heart J 2018; 39: 1466–1480.
2. Malhotra A, Dhutia H, Gati S, et al. Anterior T-Wave Inversion in Young White Athletes and Nonathletes: Prevalence and Significance. J Am Coll Cardiol. 2017;69(1):1-9.

Question 2:

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Question 3:

1. National Institute for Health and Care Excellence (NICE). Myeloma: diagnosis and management (NICE guideline NG35). Published 10 Feb 2016. Last updated 25 Oct 2018. Available at: https://www.nice.org.uk/guidance/ng35/.
2. Rajkumar SV. Updated Diagnostic Criteria and Staging System for Multiple Myeloma. Am Soc Clin Oncol Educ B 2016; e418–e423.
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6. Phull P, Sanchorawala V, Connors LH, et al. Monoclonal gammopathy of undetermined significance in systemic transthyretin amyloidosis (ATTR). Amyloid 2018; 25: 62.

Notes to editor

Authors information:

Dr Emmanouil Androulakis,
Dr Szymon Musiol, Royal United Hospitals Bath NHS Foundation Trust
Dr Michael Papadakis, St George’s University Hospitals NHS Foundation Trust
Dr Maria Teresa Tome Esteban, St George’s University Hospitals NHS Foundation Trust

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