A 72-year-old veteran is admitted to the hospital due to worsening abdominal pain and distension for the past 4 weeks. He recently moved back to his home town to be close to his family. The patient was admitted to the hospital approximately 6 months ago with leg swelling and "fluid in his belly," and a large-volume paracentesis was performed for symptomatic relief.
The patient has a history of hypertension, hyperlipidemia, atrial fibrillation, myocardial infarction, and coronary artery bypass grafting 5 years ago. He also has a history of Hodgkin lymphoma treated with chemotherapy and radiation therapy 20 years ago. He quit smoking 30 years ago but drinks 1 or 2 glasses of wine almost every day and hard liquor occasionally. Medications include aspirin, atenolol, pravastatin, valsartan, warfarin, and over-the-counter vitamin supplements.
The patient's temperature is 37.2 C (99 F) , blood pressure is 110/60 mm Hg, pulse is 88/min, and respirations are 22/min. Pulse oximetry is 92% on room air. Two spider angiomata are seen on the upper chest. Jugular venous pressure is elevated at 16 cm H₂O. The lungs are clear to auscultation. Cardiac examination reveals irregular heart sounds with no significant murmur or rub. His abdomen is soft with ascites on palpation. There is 2+ pitting lower-extremity edema bilaterally up to the mid-thighs.
Laboratory results are as follows:

ECG shows atrial fibrillation and low-voltage QRS complexes in the precordial leads.
Which of the following would help most in establishing this patient's diagnosis?

Question

A 72-year-old veteran is admitted to the hospital due to worsening abdominal pain and distension for the past 4 weeks. He recently moved back to his home town to be close to his family. The patient was admitted to the hospital approximately 6 months ago with leg swelling and "fluid in his belly," and a large-volume paracentesis was performed for symptomatic relief.
The patient has a history of hypertension, hyperlipidemia, atrial fibrillation, myocardial infarction, and coronary artery bypass grafting 5 years ago. He also has a history of Hodgkin lymphoma treated with chemotherapy and radiation therapy 20 years ago. He quit smoking 30 years ago but drinks 1 or 2 glasses of wine almost every day and hard liquor occasionally. Medications include aspirin, atenolol, pravastatin, valsartan, warfarin, and over-the-counter vitamin supplements.
The patient's temperature is 37.2 C (99 F) , blood pressure is 110/60 mm Hg, pulse is 88/min, and respirations are 22/min. Pulse oximetry is 92% on room air. Two spider angiomata are seen on the upper chest. Jugular venous pressure is elevated at 16 cm H₂O. The lungs are clear to auscultation. Cardiac examination reveals irregular heart sounds with no significant murmur or rub. His abdomen is soft with ascites on palpation. There is 2+ pitting lower-extremity edema bilaterally up to the mid-thighs.
Laboratory results are as follows:

ECG shows atrial fibrillation and low-voltage QRS complexes in the precordial leads.
Which of the following would help most in establishing this patient's diagnosis?

Quizplus · Accepted Answer

11ec193a_96b8_beff_853d_65e9a9dd0939_MD0002_00 The differential diagnosis of this patient's peripheral edema and ascites includes chronic right-sided heart failure (congestive hepatopathy), cirrhosis, primary renal disorders, and nephrotic syndrome. The elevated jugular venous pressure (JVP), low-voltage QRS complexes on ECG, and history of chest radiation for Hodgkin lymphoma suggest chronic right heart failure due to constrictive pericarditis (CP). Long-standing right-sided heart failure can eventually cause cardiac cirrhosis and hemodynamically mediated proteinuria. Current guidelines recommend an initial transthoracic echocardiogram in patients with suspected CP; this reveals pericardial thickening with or without calcification, abnormal septal motion, and characteristic respiratory changes in ventricular inflow. Pericardial thickness >4 mm is highly suggestive of CP. CT and/or cardiac MRI can be used to assess the extent of pericardial thickening and plan surgical resection (pericardiectomy) in appropriately selected patients. Those with suboptimal and inconclusive echocardiographic findings and strong clinical suspicion may require invasive hemodynamic evaluation with right heart catheterization. (Choice A) Abdominal ultrasound can confirm the presence of ascites but would not be helpful in establishing the cause of this patient's right heart failure. (Choice C) Patients with primary renal disorders may have intravascular volume expansion, which causes both pulmonary and peripheral edema with elevated JVP. However, this patient does not have pulmonary edema or significant proteinuria and would likely not benefit from a renal biopsy. (Choice D) Patients with constrictive pericarditis are often misdiagnosed with cirrhosis due to similar presentation (ascites and lower-extremity edema). However, JVP is markedly elevated in constrictive pericarditis and is usually normal or only mildly elevated in patients with tense ascites and cirrhosis. JVP in cirrhosis typically normalizes with removal of ascitic fluid. (Choice E) A V/Q scan of the lungs is helpful in patients with suspected acute pulmonary embolism. It would not be helpful in differentiating the cause of this patient's symptoms. Educational objective: Constrictive pericarditis is an important cause of right heart failure following viral pericarditis, cardiac surgery, or radiation therapy. Diagnosis is made with chest radiograph (pericardial calcification), ECG (low-voltage QRS), echocardiogram (pericardial thickening, abnormal septal motion, biatrial enlargement) and sometimes right heart catheterization. __________ References: Constrictive pericarditis: clinical and pathophysiologic characteristics. (http://www.ncbi.nlm.nih.gov/pubmed/10426832) Constrictive pericarditis in the modern era: novel criteria for diagnosis in the cardiac catheterization laboratory. (http://www.ncbi.nlm.nih.gov/pubmed/18206742) Constrictive pericarditis in a young patient with very thick pericardium initially diagnosed as cirrhosis. (http://www.ncbi.nlm.nih.gov/pubmed/24327731)

A 72-Year-Old Veteran Is Admitted to the Hospital Due to Worsening