Bilateral subclavian artery occlusion masking severe systemic hypertension as cause for heart failure: the role of multi-modality cardiovascular imaging in guiding diagnosis and management.

A 62-year-old female smoker presented with gradually worsening exertional breathlessness over 1 year, despite initiation of treatment for chronic obstructive pulmonary disease. She gave a history of transient ischaemic attack and possible subclavian artery stenosis diagnosed at a different institution. Physical examination revealed blood pressure (BP) readings of 80/50 mmHg in both arms. Electrocardiogram showed sinus rhythm with left bundle branch block (QRS duration 147 ms, Panel A). Echocardiography identified severe left ventricular (LV) systolic dysfunction (ejection fraction 29%) and suspected apical thrombus (Panel B, Supplementary data online, Video S1). She was initiated on ivabradine and considered for cardiac resynchronization therapy due to hypotension which limited the introduction of additional heart failure (HF) pharmacotherapy. Cardiovascular magnetic resonance confirmed LV dysfunction (supplementary data online, Video S2) and mild LV hypertrophy. There was septal fibrosis but no myocardial infarction or LV thrombus (Panel C & D), suggestive of non-ischaemic dilated cardiomyopathy phenotype. Computed tomography coronary angiography showed unobstructed coronary arteries but revealed bilateral subclavian artery occlusion (Panels E–G).