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Office of Education
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Joe Sims: DiscussionShortness of breath can result from dysfunction of almost any organ system. However, most commonly dyspnea results from a cardiac or respiratory disorder. In Joe’s case the physical examination reveals cardiomegaly and clear lungs, both of which are confirmed on chest x-ray. Cardiomegaly can result from disorders affecting any of the cardiac structures, namely valves, myocardium, pericardium, or coronary vessels. Statistically, the commonest causes of cardiomegaly are coronary artery disease and hypertension. Joe is unlikely to have either of these since his blood pressure is well within normal and he has never had chest pain. Valvular disease is unlikely given the absence of murmurs. Pericardial effusion can cause cardiac enlargement but this would be expected to conceal the PMI and soften the heart sounds, neither of which has occurred. By exclusion, a primary myocardial disorder or cardiomyopathy is the most likely diagnosis. The EKG shows low voltage and T wave abnormalities consistent with (but not diagnostic of) cardiomyopathy. Individuals with unexplained cardiac enlargement benefit from referral to a cardiologist and initial evaluation with an echocardiogram to delineate ventricular function and differentiate among occult valvular disease, pericardial effusion, and cardiomyopathy. If Joe does have heart muscle disease it will most likely be idiopathic dilated cardiomyopathy, a disorder of unknown cause with a variable prognosis. Treatments for that disorder include ACEs, beta blockers, agents used to treat CHF, and implantable defibrillators. Unfortunately, idiopathic dilated cardiomyopathy is often progressive, requiring cardiac transplantation for survival. Next: References for this case  |
