Diagnosis of Cardiomegaly
Cardiomegaly Diagnosis: Book Excerpts
Diagnostic Tests for Cardiomegaly: Online Medical Books
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CARDIOMEGALY:
Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is there a murmur? Cardiomegaly with cardiac murmurs suggests valvular disease, but it also suggests congestive heart failure and advanced myocardiopathies. One should also be sure that the murmur is not a pericardial friction rub.
- Is there fever? Fever with cardiomegaly should suggest rheumatic heart disease and bacterial endocarditis. However, it may also suggest an acute myocarditis or acute pericarditis.
- Is there chest pain? Cardiomegaly with chest pain would certainly suggest a myocardial infarction, but it also may suggest an acute pericarditis.
- Is there hepatomegaly? Cardiomegaly and hepatomegaly suggest congestive heart failure. Hepatomegaly also may suggest one of the systemic diseases that causes a myocardiopathy such as amyloidosis.
- Is there edema? The presence of peripheral edema would suggest congestive heart failure, and if it is nonpitting, it would suggest myxedema.
- Is there hypertension? Cardiomegaly with hypertension would suggest that the cardiomegaly is due to left ventricular enlargement from the chronic hypertension.
- Is there cyanosis? Cardiomegaly with cyanosis, particularly if there is an associated murmur, suggests congenital heart disease of the cyanotic type.
DIAGNOSTIC WORKUP
A CBC, sedimentation rate, ANA, chemistry panel, VDRL test, thyroid profile, EKG, and chest x-ray should be done on all patients. An echocardiogram will be helpful in diagnosing valvular disease, myocardiopathies, congestive heart failure, and pericardial effusion. If congestive heart failure is suspected, venous pressure and circulation time can be measured, and one should do pulmonary function studies. If there is fever, then one would want to do a streptozyme test, ASO titer, and serial blood cultures. If there is hypertension, a hypertensive workup may be indicated
. Patients with cyanosis need a workup for congenital heart disease, which will probably include cardiac catheterization and angiocardiography.
Most prudent physicians will refer the patient with cardiomegaly to a cardiologist before pursuing this extensive diagnostic workup.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Cardiomegaly:
Differential Diagnosis
(In a Page: Signs and Symptoms)
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Congestive heart failure
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Ischemic heart disease
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Hypertension (with left ventricular hypertrophy)
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Valvular disease (primarily MR, AS, AR)
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Hypertrophic cardiomyopathy
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Congenital heart disorders (e.g., ASD, VSD, PDA, coarctation of the aorta, Ebstein's anomaly, tetralogy of Fallot)
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Idiopathic cardiomyopathy
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Alcoholic cardiomyopathy
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Lung disease (leading to right-sided enlargement)
–Pulmonary embolus
–COPD
–Cor pulmonale
–Primary pulmonary hypertension
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Subacute bacterial endocarditis
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Myocarditis
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Renal failure (risk of pericardial effusion)
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Anemia
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Scleroderma
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Systemic lupus erythematosus
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Sickle cell disease
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Marfan's syndrome
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Pregnancy
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Drugs (numerous drugs are cardiotoxic)
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Postradiation
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Normal, “athletic” heart
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Mediastinal mass
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Kyphoscoliosis
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Rheumatoid arthritis
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Less common etiologies include infiltrative diseases (e.g., amyloidosis, hemochromatosis, atrial myxoma, endocardial fibroelastosis, Fabry's disease, Hurler's syndrome, Pompe's disease), epicardial fat pad, carcinoid, acromegaly, hyper- or hypoparathyroidism, and severe cases of hypocalcemia, hypomagnesemia, and/or hypophosphatemia
Workup and Diagnosis
-
Complete history and physical exam
–Associated symptoms may include fatigue, dyspnea at
rest and/or on exertion, palpitations, dizziness, or syncope
–Note use of alcohol or recreational drugs
–Family history of heart disease or sudden death
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Chest X-ray and ECG
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Echocardiogram is indicated in all patients to evaluate for valvular disease, chamber size, wall motion abnormalities, and ventricular function
-
-
-
Stress testing if coronary artery disease is suspected
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Cardiac catheterization may be indicated to evaluate for coronary artery disease and valvular disease
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Laboratory studies may include CBC, ESR, electrolytes, BUN/creatinine, glucose, TSH, calcium, magnesium, and phosphorus
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-
-
Blood cultures are indicated in some cases
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Consider ANA, rheumatoid factor, and screening for pheochromocytoma (i.e., urinary metanephrines and VMA) and hemochromatosis (i.e., iron studies) in selected patients
» READ BOOK EXCERPT ONLINE »
Source: In a Page: Signs and Symptoms, 2004
CARDIOMEGALY:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The diagnosis of cardiomegaly can be further developed be a good history and the association of other symptoms and signs. Is there a history of hypertension, alcoholism, rheumatic fever or other systemic disease? Has the patient experienced shortness of breath, angina, fever, joint pains, and so forth? Are there findings of pedal edema, hepatomegaly, or jugular venous distention (CHF)? Are there hypertension and proteinuria (renal disease or essential hypertension)? Is there a significant heart murmur (congenital heart disease, rheumatic heart disease)?
The diagnostic workup will include a CBC, urinalysis, chemistry panel, sedimentation rate, a chest x-ray, and ECG. At this point, it is wise to consult a cardiologist. Echocardiography will be helpful in diagnosing valvular heart disease, myocardiopathy, and pericardial effusion. If CHF is suspected, a venous pressure and circulation time as will as spirometry will support the diagnosis. Echocardiography can diagnose congestive heart failure by determining the left ventricular ejection fraction (LVEF). If there is unexplained fever, an ASO titer or streptozyme test should be ordered to rule out rheumatic fever and perhaps serial blood cultures need to be done to exclude subacute bacterial endocarditis. If there is hypertension the patient may need a hypertensive workup (see page 299).
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
Cardiomegaly:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Presenting symptoms. As congestive heart failure (CHF) and cardiomegaly represent the final common path for many patients with these common conditions, the typical symptoms are exertional dyspnea, syncope, fatigue, and angina. Many patients are asymptomatic at the time of diagnosis and sudden death can be the presenting event (2) (Chapter 7.5).
B. Etiology. The most common conditions that result in cardiomegaly include hypertension, coronary artery disease, rheumatic and degenerative valvular heart disease, anemia, alcoholism, endocrinopathies, and infectious and inflammatory conditions.
C. Family history. Premature atherosclerosis and ischemic cardiomyopathy can be caused by familial dyslipidemia. A family history of early CHF may indicate familial dilated cardiomyopathy and premature sudden death may indicate familial hypertrophic obstructive cardiomyopathy.
Physical examination
The typical signs of CHF are usually noted on examination. A decreased arterial pulse with narrowed pulse pressure is common. Cyanosis is rare. Significant cardiac enlargement should be evident on physical examination. Examples of these finding include the following:
A. Lung sounds. Rales or pleural effusion with dullness to percussion and decreased breath sounds may be indicative of left ventricular failure.
B. Heart sounds. Gallops, soft heart sounds, and regurgitant heart murmurs are nonspecific findings of advanced CHF. Alterations in S1 or S2, specific murmurs, (e.g., a Valsalva-enhanced systolic murmur in hypertrophic obstructive cardiomyopathy), and muffled sounds with pericardial effusion, all indicate specific underlying pathology.
C. Cardiac pulsations or point of maximal impulse (PMI). Visible pulsations seen lateral to the midclavicular line signify cardiac enlargement unless is found a thoracic deformity or congenital absence of the pericardium.
D. Apical beat or PMI. The apical beat, or PMI, which is typically palpable in only 40% of cases, is highly dependent on body habitus. Use the flat of the hand to palpate the PMI. Time the pulsations using the carotid pulse or auscultated heart sounds. The left lateral decubitus position increases the palpability of both normal and pathologic apical beats.
A PMI within or superior to the fifth intercostal space is normal. Left ventricular enlargement displaces the PMI laterally and downward. A PMI lateral to the midclavicular line or more than 10 cm lateral to the midsternal line is a sensitive but nonspecific indicator of left ventricular enlargement. An apical impulse of more than 3 cm diameter is an accurate sign of left ventricular enlargement.
With moderate or severe left ventricular hypertrophy, the outward systolic thrust persists throughout ejection, often lasting up to the second heart sound. In patients with volume overload or sympathetic stimulation, the left ventricular impulse is brisker and larger than normal but is hypokinetic in patients with reduced stroke volume (e.g., acute myocardial infarction or dilated cardiomyopathy). Large left ventricular aneurysms are palpable above and medial to the apex beat. Thoracic deformities—particularly scoliosis and pectus excavatum—can laterally displace a normal heart.
E. Percussion. In the absence of an apical beat, as in patients with pericardial effusion or with dilated cardiomyopathy and a markedly displaced, hypokinetic apical beat, the left border of the heart can be outlined by means of percussion. Percussed dullness in the left fifth intercostal space more than 10.5 cm from the midsternal line is sensitive and specific for cardiomegaly (3).
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Cardiomegaly/Congestive Heart Failure:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Congestive heart failure
❑ Hypertensive left ventricular hypertrophy
❑ Anterior myocardial ischemia
❑ Athlete’s heart
❑ Mitral regurgitation
❑ Aortic stenosis
❑ High output
❑ Hypertrophic obstructive cardiomyopathy
❑ Pulmonary hypertension
❑ Cor pulmonale
❑ Dilated cardiomyopathy
❑ Endocarditis
❑ Pericardial effusion
❑ Left ventricular aneurysm
❑ Mitral stenosis
❑ Amyloidosis
Diagnostic Approach
The Framingham criteria for congestive heart failure are a good reference point. Major criteria include paroxysmal nocturnal dyspnea, rales, cardiomegaly, acute pulmonary edema, third heart sound, jugular pressure greater than 16 cm, and positive abdominojugular reflex. Minor criteria include edema, night cough, dyspnea on exertion, hepatomegaly, pleural effusion, and pulse rate slower than 120. Functional limitation is most often classified using the New York Heart Association (NYHA) system: Class I—symptoms of heart failure only at levels of exertion that would limit normal individuals; Class II—symptoms of heart failure with ordinary exertion; Class III—symptoms of heart failure with less than ordinary exertion; Class IV—symptoms of heart failure at rest.
History is key in CHF. Findings due to excess fluid accumulation include dyspnea, edema, hepatic congestion, and ascites. Findings due to reduced cardiac output include weakness and fatigue, more pronounced with exertion. Acute and subacute CHF produce primarily shortness of breath with exertion or at rest. Other common symptoms include orthopnea, paroxysmal nocturnal dyspnea, and right upper quadrant discomfort due to hepatic congestion in right heart failure.
Decreased cardiac output is counterbalanced by increased sympathetic activity, manifest as sinus tachycardia, diaphoresis, and peripheral vasoconstriction (cool and cyanotic extremities due to decreased perfusion and increased oxygen extraction). A prominent dicrotic notch may be felt in severe left ventricular dysfunction, as the compensitory increase in total peripheral resistence and corresponding reduced aortic compliance accentuate the aortic valve closure. Pulsus alternans (alternating strong and weak pulse beats) is uncommon but pathognomonic of advanced heart failure. Volume overload is manifest as pulmonary congestion (rales), peripheral edema, and elevated jugular venous pressure. The medulla controls the respiratory rate based on pCO 2. The length of the Cheyne-Stokes cycle is proportional to the circulatory delay from the alveoli to the arterioles (r = 0.80).
Systolic heart failure is marked by decreased cardiac output, with manifestations such as weakness, fatigue, and decreased exercise tolerance. Mitral regurgitation, especially when acute, augments early diastolic inflow and may produce an S3 with normal systolic function. Diastolic heart failure is associated with reduced ventricular compliance and increased filling pressures with manifestations of dyspnea and rales.
Findings suggesting left ventricular hypertrophy include a sustained forceful apical thrust, a double apical impulse, an apical impulse larger than 3 cm, and a fourth heart sound on auscultation. Left ventricular enlargement will cause the apical impulse (PMI) to be displaced downward and to the left. Right ventricular hypertrophy will cause a sustained right parasternal lift. It is seen with pulmonary hypertension, pulmonic stenosis, and volume overload with tricuspid regurgitation or atrial septal defect. Right ventricular failure is recognized by edema, jugular venous distension, and abdominojugular reflex.
Key findings on physical examination:
Rales Increased interstitial fluid/pressure causes alveoli to pop open. Pulmonary venous capacitance increases in chronic heart failure, and rales may be absent.
Third heart sound (S3) Ventricular vibration occurs during rapid inflow of blood in early diastole when the long-axis expansion limit is reached, due to reduced LV compliance or increased filling pressure. S3 is a low-pitched sound over the apex, and yield is doubled in the 45 degree left lateral decubitus position. JVD and S3 are independent on multivariate analysis.
JVD The IJ is a right atrial manometer. High JVD (present .45 deg) has a LR 4.1 that CVP is .10 cm. Low JVD (present ,30 deg) has a LR 3.4 that CVP is ,5 cm.
Abdominojugular reflux Apply abdominal pressure for 10 sec. A positive AJR is a 4 cm or greater drop in JVP after release, due to decreased RV compliance or increased LVEDP.
Edema With renin-angiotensin-aldosterone activation, pulmonary and peripheral fluid accumulates. After the extracellular fluid is in excess of about five liters, symmetric, dependent, and pitting peripheral edema develops.
Valsava response The normal response is for BP to rise .15 mm Hg during valsalva, but to fall before 10 seconds passes. When valsalva is released, the BP rises again .15 mm over the resting threshold. In CHF, an abnormal response can consist of absent phase 4 overshoot or a square wave in phase 2.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
CARDIOMEGALY:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The diagnosis of cardiomegaly can be further developed by a good
history and the association of other symptoms and signs. Is there a history
of hypertension, alcoholism, rheumatic fever, or other systemic disease? Has
the patient experienced shortness of breath, angina, fever, joint pains, and
so forth? Are there findings of pedal edema, hepatomegaly, or jugular venous
distention (CHF)? Are there hypertension and proteinuria (renal disease or
essential hypertension)? Is there a significant heart murmur (congenital
heart disease, rheumatic heart disease)?
The diagnostic workup will include a CBC, urinalysis, chemistry panel,
sedimentation rate, chest x-ray, and ECG. At this point, it is wise to
consult a cardiologist. Echocardiography will be helpful in diagnosing
valvular heart disease, myocardiopathy, and pericardial effusion. If CHF is
suspected, a venous pressure and circulation time as well as spirometry will
support the diagnosis. Echocardiography can diagnose CHF by determining the
left ventricular ejection fraction (LVEF). If there is unexplained fever, an
antistreptolysin O (ASO) titer or streptozyme test should be ordered to rule
out rheumatic fever, and perhaps serial blood cultures should be done to
exclude subacute bacterial endocarditis. If there is hypertension, the
patient may need a hypertensive workup .
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
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