Triple Ripple Hocm

1. With which abnormality do you often find a mid-systolic dip in the presence of LVH?

ANS: Hypertrophic obstructive cardiomyopathy (HOCM).

2. What kind of impulse may be imparted to the apex beat of a patient with severe HOCM if an A wave is also present?

ANS: A triple outward movement (known by some as a "triple ripple"). This is almost pathognomonic of HOCM).

3. Which valvular abnormality may have a mid-systolic dip without LVH?

ANS: A prolapsed mitral valve. An S4 or a click and murmur quickly differentiates the cause of the dip.

Apex Cardiogram
This apex impulse tracing (apex cardiogram) is from a 45-year-old man with HOCM. The atrial hump and the midsystolic dip give an impression of a triple outward movement.

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