A 59-year-old man with a history of coronary artery disease (CAD) and remote coronary bypass surgery presents with progressive dyspnea and vague chest pain. He had a stress echocardiogram for these symptoms that demonstrated normal LV function with no stress-induced wall motion abnormalities. However, he returned to the emergency department a few days later with recurrent symptoms. This time the house officer examining the patient notes 3+ pedal edema. The patient is admitted and started on diuretics. His blood tests are as follows:
Owing to the recurrent symptoms, his cardiologist decides to refer him for a right and left heart catheterization. The coronary grafts are all patent. The tracings from the study are shown in Figure below.
What is the most logical explanation for this patient’s symptoms?
Constrictive pericardial disease. This patient did not have evidence of ischemia on a recent stress test. Furthermore, there is no evidence of obstructive disease in his coronaries or grafts. His tracings mostly support the diagnosis of constriction, given the diastolic equalization of pressures in the cardiac chambers and the typical square root sign. Amyloidosis would typically show signs of restrictive hemodynamics with no respiratory variation. Echocardiography typically shows increased LV wall thickness. Additionally, a diagnosis of tamponade should have been evident by echocardiography, which the patient had before heart catheterization. Otherwise, hemodynamic tracings of cardiac tamponade would look exactly the same as for constriction.
A 73-year-old man with no cardiac history presents with chronic lower extremities edema. His primary care physician attributed his symptoms to old age. He was treated with hydrochlorothiazide. Initially, he reported a good response to the therapy, but, over the past few months, his edema recurred, and doubling the diuretic dose did not alleviate his symptoms. On his initial examination, you notice distended neck veins and a quiet precordium. He has mild hepatomegaly and 4+ pedal edema. A TTE is suboptimal because of the patient’s inability to lie flat and obstructive lung disease. His blood work is as follows:
A cardiac catheterization is performed. He has normal coronary arteries with mild impairment in LV systolic function. The tracings from the study are shown in Figure below.
What is your explanation of his symptoms?
This patient has significant diastolic dysfunction, and his prognosis is guarded. He has evidence of restrictive LV filling (advanced diastolic dysfunction) in the absence of CAD. The differential diagnosis in his age group includes amyloidosis (especially considering concomitant renal dysfunction), hemochromatosis, and other infiltrative processes.
A 56-year-old male smoker with a family history significant for CAD is presenting with dyspnea on exertion and nonexertional vague chest pain. His physical examination and his initial ECG are unremarkable. His CXR demonstrates an increased cardiac silhouette. There is also a small nodule seen in his right upper lobe. The radiologist is not certain about its significance. Given his risk factors and symptoms, he is referred for a perfusion stress test. The images from the stress test are shown in Figure below.
Which of the following does the patient clearly have?
His symptoms are related to impairment of RV filling and pericardial disease. This patient with the main presentation of dyspnea has an increased cardiac silhouette. The nuclear image provided shows a circumferential echolucency surrounding the heart. This is consistent with a large pericardial effusion, and he most likely has RA and RV diastolic compromise. There is no evidence of a perfusion defect to suggest ischemia.
A 58-year-old man, with cardiac risk factors of tobacco use, hypertension, and hypercholesterolemia, presented to the emergency department a few days ago with an acute onset of left-sided chest pain. His evaluation revealed a diaphoretic man in moderate discomfort. An ECG was performed and showed a pattern consistent with an inferior wall acute MI. The patient was treated with thrombolytics. Forty-five minutes after the initial dose of the thrombolytics, he felt better and had complete resolution of his symptoms and normalization of the ECG. On the third day after the event, he reports midsternal chest pain, vague in nature, with mild diaphoresis and shortness of breath. An ECG is performed, as shown in Figure below.
Which of the following should you tell the patient is the next step in managing his condition?
He is showing signs of early postinfarction pericarditis, and a nonsteroidal anti-inflammatory medication should be started. This patient had an MI 72 hours ago that was successfully treated with thrombolytics. The ECG shows diffuse ST elevation with PR depression. These findings support the diagnosis of post-MI pericarditis. The ECG changes are new and nonlocalizing. Most patients improve with nonsteroidal anti-inflammatory medications.
A 19-year-old male college student presents to his local physician for evaluation of a dry cough. His symptoms started 3 days ago but now appear to be resolving. He had planned a trip overseas but was concerned and is now seeking advice. His physical examination is unremarkable. A CXR is performed and is read as showing an enlarged right cardiac silhouette. A TTE is ordered, which is shown in Figure below.
The patient most likely has which of the following conditions?
He has a pericardial cyst that is benign; no further treatment should be offered. The TTE and CXR show a pericardial cyst. Pericardial cysts are usually smooth structures containing transudative fluid. They are frequently only 2 or 3 cm in diameter, often located at the right cardiodiaphragmatic angle, and clinically silent. However, cysts can be associated with chest pain, dyspnea, cough, and arrhythmias likely caused by compression of adjacent tissues. They can also become secondarily infected. In this patient, whose nonspecific symptoms appear to be resolving, no further treatment is needed.
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