To the Editor:—
The Clinical Concepts and Commentary titled “Hypertrophic Cardiomyopathy” (HCM) by Poliac et al. 1provides a detailed update on the disease, its clinical significance, and its anesthetic management. Recognition that HCM is not so “rare” and that most patients are undiagnosed significantly expands our understanding of the perianesthetic implications of HCM. However, there are two aspects of perianesthetic management upon which I wish the authors had expanded. First, despite an excellent discussion of the choice of volatile agent and avoidance of histamine releasing or vagolytic relaxants, no mention is made of induction techniques. Should the vasodilating myocardial depressant propofol be avoided in favor of etomidate? Is catecholamine-releasing ketamine contraindicated? Second, the authors are concerned “that a not inconsequential subset of HCM patients will present for surgery and anesthesia without an established diagnosis.” However, only limited diagnostic clues are provided. I suspect that I am not the only anesthetist whose preoperative cardiac examination does not include having the patient stand or Valsalva in an effort to produce a systolic ejection murmur. If 75% or more have an abnormal 12-lead electrocardiogram, what findings on an intraoperative 3-lead or 5-lead electrocardiographic monitor might cause me to delay induction until a more formal 12-lead electrocardiogram or echocardiogram is obtained? Dr. Maron is certainly aware that HCM is the most common cause of sudden death in young American athletes.2Corrado et al. 3have shown that identification of young athletes with HCM can reduce their incidence of sudden death. The opportunity for anesthetists to make a potentially lifesaving diagnosis should not be missed.
Dartmouth Medical School, Hanover, New Hampshire. john.d.gallagher@hitchcock.org
