Question

A 35 year old farmer consulted a local medical practitioner for recurrent attacks of chest pain. His elder brother had similar complaints and had died suddenly at the age of 40 years. The farmer was advised to take nitroglycerine sublingually at the time of pain. However, the patient finds that the intensity of pain is increased by nitroglycerine. Most probably he is suffering from:

• A. Subacute bacterial endocarditis involving the aortic valve
• B. Hypertrophic obstructive cardiomyopathy
• C. Degenerative mitral regurgitation
• D. Chronic type A dissection of the aorta

Hint:

Chest pain that worsens, not improves, with nitroglycerine plus a family history of sudden death points to hypertrophic obstructive cardiomyopathy.

Answer 1

The Correct Option is B

Step 1: Focus on the one unusual detail.
In ordinary angina, nitroglycerine relieves the chest pain because it widens the veins, lowers the blood returning to the heart, and eases the heart's workload. Here the pain gets worse with nitroglycerine, which is the opposite of what typical angina does, so this points away from simple coronary artery disease.

Step 2: Work out why nitroglycerine can worsen pain in this condition.
In hypertrophic obstructive cardiomyopathy, the wall between the ventricles is abnormally thick and narrows the outflow path that blood takes out of the left ventricle. Nitroglycerine lowers the blood coming back to the heart and lowers the resistance the heart pumps against. Both of these effects make the ventricle chamber smaller and the outflow narrowing tighter, so the obstruction and the pain actually get worse instead of better.

Step 3: Match the family history.
Hypertrophic cardiomyopathy is passed down in families in an autosomal dominant pattern and is a well known cause of sudden death in young and middle aged people, exactly like the brother who died suddenly at age 40. This strengthens the case for this diagnosis.

Step 4: Rule out subacute bacterial endocarditis.
This condition presents with fever, weight loss, and signs of infection along with a new or changing heart murmur, not with chest pain that specifically worsens with nitroglycerine.

Step 5: Rule out degenerative mitral regurgitation.
This usually presents with breathlessness and a murmur of regurgitation rather than nitroglycerine sensitive chest pain, and it does not explain the strong family pattern of sudden death seen here.

Step 6: Rule out chronic aortic dissection.
Dissection classically causes sudden, severe, tearing pain that often radiates to the back, and it is not a condition where nitroglycerine has this characteristic worsening effect described here.

Step 7: Final answer.
The combination of pain worsened by nitroglycerine and a family history of sudden death fits hypertrophic obstructive cardiomyopathy.
\[ \boxed{\text{Hypertrophic obstructive cardiomyopathy}} \]