A 68-year-old man comes to the physician because of lower extremity edema. His edema has been present for the last six months, but it has worsened lately. He denies chest pain or pressure, although he reports some exertional shortness of breath and a dry cough that occurs mostly at night. He denies any recent change in diet or medications. His other medical problems include chronic obstructive pulmonary disease and hyperlipidemia. His current medications include albuterol/ipratropium inhaler, simvastatin, and aspirin. He has smoked 1 pack of cigarettes per day for the last 48 years, but he denies alcohol or illicit drug use.
His blood pressure is 140/75 mm Hg in both arms, pulse is 60/min, and respirations are 14/min. He is in no acute distress. His jugular veins are distended with the peak of the 'a' wave poorly visualized at 90 degrees. There is a sustained parasternal lift best felt at the left lower parasternal border. There is a normal S1 with a loud S2. There is a holosystolic murmur best heard at the left sternal border that increases with inspiration. The lungs are clear bilaterally. The liver is slightly enlarged. There is 2+ pitting edema to the thighs bilaterally.
A 12 lead ECG is shown in this exhibit.
Which of the following will most likely be seen on echocardiography?

Question

A 68-year-old man comes to the physician because of lower extremity edema.  His edema has been present for the last six months, but it has worsened lately.  He denies chest pain or pressure, although he reports some exertional shortness of breath and a dry cough that occurs mostly at night.  He denies any recent change in diet or medications.  His other medical problems include chronic obstructive pulmonary disease and hyperlipidemia.  His current medications include albuterol/ipratropium inhaler, simvastatin, and aspirin.  He has smoked 1 pack of cigarettes per day for the last 48 years, but he denies alcohol or illicit drug use.
His blood pressure is 140/75 mm Hg in both arms, pulse is 60/min, and respirations are 14/min.  He is in no acute distress.  His jugular veins are distended with the peak of the 'a' wave poorly visualized at 90 degrees.  There is a sustained parasternal lift best felt at the left lower parasternal border.  There is a normal S1 with a loud S2.  There is a holosystolic murmur best heard at the left sternal border that increases with inspiration.  The lungs are clear bilaterally.  The liver is slightly enlarged.  There is 2+ pitting edema to the thighs bilaterally.
A 12 lead ECG is shown in this exhibit. 
Which of the following will most likely be seen on echocardiography?

Quizplus · Accepted Answer

11ec193a_9743_727f_853d_9b18ef0f09b4_MD0002_00 11ec193a_9743_7280_853d_19eeefafea77_MD0002_00 This patient's presentation is consistent with cor pulmonale likely secondary to COPD. Cor pulmonale is a chronic and progressively worsening right heart dysfunction usually due to lung or chest wall disease; it is NOT due to congenital heart disease or left-sided heart disorders. Patients typically present with progressive dyspnea on exertion, exertional syncope or angina, and peripheral edema. Physical examination can show elevated jugular venous pressure with a prominent 'a' wave and evidence of right-sided heart disease (e.g., RV heave, loud S2, tricuspid regurgitation, pulsatile liver) associated with pulmonary hypertension. An ECG may show right axis deviation, complete or partial right bundle branch block (RBBB), right ventricular hypertrophy (RVH), right atrial enlargement, and right ventricular strain pattern (S1Q3T3). Echocardiogram usually shows pulmonary hypertension and RVH with paradoxical bulging of the septum into the left ventricle during systole. The dilated RV can eventually lead to tricuspid regurgitation, as seen in this patient. Treatment involves oxygen (improves RV afterload) and diuretics (reduces RV pressure) in patients with significant symptoms. (Choice A) Examination in severe aortic stenosis usually reveals a hypokinetic carotid pulse with delayed upstroke and a late peaking crescendo-decrescendo systolic murmur radiating to the carotids. ECG shows evidence of left ventricular hypertrophy (LVH). (Choice B) Examination in asymmetric septal hypertrophy usually reveals an S4, an LV lift, and a harsh crescendo-decrescendo murmur at the apex radiating to the axilla and base (possible aortic outflow obstruction and mitral regurgitation). ECHO usually shows LVH, mitral regurgitation, and LV outflow obstruction. (Choice C) A left ventricular aneurysm is a fibrotic wall with necrotic muscle that occurs after a healed transmural MI. Examination shows S3 or S4 and a mitral regurgitation murmur. (Choice D) Pericardial effusion causing tamponade leading to right ventricular/atrial collapse usually presents with hypotension, tachycardia, pulsus paradoxus, distant heart sounds, and low voltage QRS on ECG with electrical alternans. Educational objective: Cor pulmonale is right ventricular failure due to pulmonary or chest wall disease and usually presents with lower extremity edema, progressive dyspnea, and findings of right-sided heart disease (e.g., elevated jugular venous pressure, severe tricuspid regurgitation, RV heave, and loud S2). An ECG typically shows right axis deviation, RBBB, RVH, and right atrial enlargement. Echocardiography usually shows pulmonary hypertension and RVH, with paradoxical bulging of the septum into the left ventricle during systole. __________ References: Cor pulmonale: an overview. (http://www.ncbi.nlm.nih.gov/pubmed/16088545)

A 68-Year-Old Man Comes to the Physician Because of Lower