Our workup started with an ultrasound and EKG. There is a decreased diameter of the left ventricular outflow tract (LVOT) in the setting of obstructive cardiomyopathy pathology and thickened septum.⁴ This is seen in the parasternal long axis image (Image 1). Furthermore, we can see systolic anterior motion or SAM in patients with HOCM.⁵ SAM occurs when the mitral valve is displaced toward the LVOT and causes obstruction causing further dysfunction and limited flow for these patients. EKGs will have abnormalities in about 90 percent, but they are typically nonspecific findings. In addition, we observed in his EKG high-voltage, LVH, left atrial enlargement, tall R-wave in V1, and Q waves that were like needles.⁶

After a diagnosis is made, treatment can start with beta blockers for angina or dyspnea in adults with HCOM, no matter the type of obstruction. Beta-blockers are a class I recommendation per the American College of Cardiology.⁷ However, be cautious in the case of sinus bradycardia. Verapamil is also a reasonable option as it is also a class I recommendation. Class IIa recommendations include disopyramide with beta-blockers or verapamil if not responsive to either alone. Oral diuretics are another option. Avoid nifedipine, other dihydropyridine CCB, digoxin, disopyramide alone, and positive inotropic vasopressors, as these can precipitate harm.⁷ Once the diagnosis is identified, it is imperative to get cardiology consultation and arrange for a further workup, including a formal echocardiogram.

The Value of the Story

This case exemplifies the critical need for health care professionals to approach each patient encounter without bias, especially when dealing with populations of color who have recently suffered disproportionately from mental health disorders.⁸ Diagnostic anchoring when evaluating patients presenting for seemingly mental health issues can prevent the recognition of pertinent physical health issues, leading to misdiagnosis and inadequate treatment. A study done by emergency medicine physicians in Japan identified that a group of experienced physicians they surveyed had up to 22 percent of diagnostic errors due to overconfidence, confirmation, availability, or anchoring biases.⁹ Even for the most experienced, maintaining an open mind to other possibilities can provide our patients with the best care.

Influencing Emergency Medicine Provision

The story demonstrates the necessity of treating each workup as a new investigation, irrespective of the patient’s prior medical history. It serves as a reminder that symptoms can have multiple etiologies, and a thorough examination is essential to uncover the underlying cause. When a patient presents with “anxiety,” is the symptom masquerading as something more sinister? Are we missing a critical differential or not thinking of an organic presentation? This approach is particularly relevant in emergency medicine, where the pressure to make quick decisions can inadvertently lead to reliance on mental shortcuts, or heuristics, that might not serve the patient’s best interest. This mindset shift is crucial for improving outcomes and fostering a more inclusive and equitable health care system.