A 45-year-old man comes to the emergency department due to a 4-week history of progressively worsening shortness of breath. The patient has no history of cardiopulmonary disease, although his wife, who accompanies him, states that he snores heavily at night. In addition, over the last 6 months his hands and feet have become enlarged; he is unable to take off his wedding ring and his shoes no longer fit. The patient has no significant medical history and takes no medications. He does not use tobacco or alcohol. On examination, he has coarse facial features with prominent frontal bones and jaw and crowding of the pharyngeal space. The extremities show enlarged, swollen hands and feet. There are fine crackles at the lung bases. Which of the following is most likely to be found on echocardiogram?

Question

A 45-year-old man comes to the emergency department due to a 4-week history of progressively worsening shortness of breath.  The patient has no history of cardiopulmonary disease, although his wife, who accompanies him, states that he snores heavily at night.  In addition, over the last 6 months his hands and feet have become enlarged; he is unable to take off his wedding ring and his shoes no longer fit.  The patient has no significant medical history and takes no medications.  He does not use tobacco or alcohol.  On examination, he has coarse facial features with prominent frontal bones and jaw and crowding of the pharyngeal space.  The extremities show enlarged, swollen hands and feet.  There are fine crackles at the lung bases.  Which of the following is most likely to be found on echocardiogram?

Quizplus · Accepted Answer

11ec25c8_d39a_d804_bc81_3384d54b3e5e_MD0003_00 This patient has characteristic manifestations of acromegaly, including coarsening of facial features, pharyngeal crowding, and enlargement of hands and feet. Acromegaly is caused by excessive secretion of growth hormone, usually from a pituitary somatotroph adenoma. Growth hormone increases hepatic production of insulin-like growth factor-1 (IGF-1), which causes excessive growth of bone and soft tissues, leading to the clinical manifestations of the disease. In the heart, acromegaly causes concentric myocardial hypertrophy leading to diastolic dysfunction; eventually this may also lead to left ventricular dilation and systolic dysfunction with global hypokinesis. The cardiomyopathy is worsened by concurrent hypertension, obstructive sleep apnea (likely present in this patient), and valvular heart disease, which are common in acromegaly. Complications include heart failure (eg, dyspnea, crackles at bases) and arrhythmias. Cardiovascular disease is the leading cause of death in patients with acromegaly, but normalization of growth hormone levels following successful treatment markedly reduces cardiovascular mortality. (Choice A) Left ventricular aneurysm is not a common complication of acromegalic cardiomyopathy. It usually occurs as a result of Q-wave myocardial infarction in the territory of the left anterior descending artery; less common causes include hypertrophic cardiomyopathy and Chagas disease. (Choice B) Hypertrophic cardiomyopathy, a congenital cardiomyopathy that should be distinguished from myocardial hypertrophy caused by other cardiovascular diseases (eg, hypertensive, valvular, ischemic), is characterized by asymmetric thickening of the interventricular septum, leading to left ventricular outflow tract obstruction, diastolic dysfunction, and mitral regurgitation. It would not explain the features of acromegaly seen in this patient. Hypertrophic cardiomyopathy (Choice D) Flail mitral valve leaflet is caused by rupture of the chordae tendineae (due to mitral valve prolapse, endocarditis, or myxomatous degeneration) or by rupture of the papillary muscles in acute myocardial infarction. Acute mitral regurgitation due to a flail leaflet is characterized by severe pulmonary edema and hypotension with a hyperdynamic precordium. (Choice E) A mild-to-moderate pericardial effusion may not by itself produce any specific symptoms or signs unless cardiac tamponade occurs. Signs of tamponade include tachycardia, elevated jugular pressure, pulsus paradoxus, and edema. Educational objective: Acromegaly causes concentric myocardial hypertrophy and diastolic dysfunction; this may eventually lead to left ventricular dilation and global hypokinesis. This cardiomyopathy is often worsened by concurrent hypertension, obstructive sleep apnea, and valvular heart disease. Complications include heart failure and arrhythmias. References: Congestive heart failure in acromegaly: a review of 6 cases. (http://www.ncbi.nlm.nih.gov/pubmed/23226648)

A 45-Year-Old Man Comes to the Emergency Department Due to a 4-Week