Spontaneous myocardial injury in hypertrophic cardiomyopathy: Coexistence of microvascular dysfunction and microvascular obstruction

Hypertrophic cardiomyopathy (HCM) is a genetic disorder characterized by left ventricular hypertrophy without abnormal loading conditions, often complicated by microvascular dysfunction (MVD), which leads to myocardial ischemia. While MVD in HCM has been extensively described, reports of concomitant microvascular obstruction (MVO) as a feature of spontaneous myocardial injury are scarce. We present a 58-year-old man with genetically confirmed HCM who experienced recurrent chest discomfort attributed to spontaneous myocardial injury. This was evidenced by markedly elevated biomarkers and cardiac magnetic resonance imaging (CMR) findings, including severe inducible myocardial ischemia on stress perfusion, myocardial edema, and MVO. This case highlights the potential coexistence of MVD and MVO in severe HCM, suggesting a complex interplay that may contribute to disease progression. Advanced imaging techniques, particularly CMR, are crucial in detecting myocardial damage and guiding management. Future research should explore the clinical significance of MVO in HCM and its potential as a therapeutic target.