A 78-year-old man comes to the office due to lower extremity swelling. He has had progressive exertional dyspnea over the past 2 years. Over the past 2 months, the patient has noticed lower extremity swelling, decreased appetite, and increased abdominal girth. He has a history of poorly controlled hypertension but no known coronary artery disease. The patient is a lifetime nonsmoker. He has no history of prior surgeries. Blood pressure is 165/88 mm Hg and pulse is 72/min and regular. He is afebrile. On physical examination, the jugular veins are distended and there are prominent V waves. A holosystolic murmur is heard at the lower sternal border, and there is 3+ pitting edema of the lower extremities bilaterally. Which of the following best explains the physical examination findings in this patient?

Question

A 78-year-old man comes to the office due to lower extremity swelling.  He has had progressive exertional dyspnea over the past 2 years.  Over the past 2 months, the patient has noticed lower extremity swelling, decreased appetite, and increased abdominal girth.  He has a history of poorly controlled hypertension but no known coronary artery disease.  The patient is a lifetime nonsmoker.  He has no history of prior surgeries.  Blood pressure is 165/88 mm Hg and pulse is 72/min and regular.  He is afebrile.  On physical examination, the jugular veins are distended and there are prominent V waves.  A holosystolic murmur is heard at the lower sternal border, and there is 3+ pitting edema of the lower extremities bilaterally.  Which of the following best explains the physical examination findings in this patient?

Quizplus · Accepted Answer

11ec25c8_d815_63f0_bc81_1753989eb8ca_MD0003_00 This patient with prolonged uncontrolled hypertension and progressive dyspnea, lower extremity swelling, and jugular venous distension likely has decompensated left-sided heart failure due to hypertensive heart disease. The holosystolic murmur at the left lower sternal border is consistent with tricuspid regurgitation (TR). An estimated 90% of TR is secondary (functional), defined as that occurring with an anatomically normal tricuspid valve. Secondary TR usually results from right ventricular (RV) cavity enlargement in the setting of chronic right-sided volume or pressure overload (eg, right-sided heart failure). Left-sided heart failure (as in this patient) is a common cause of RV overload. Similar to left ventricular enlargement in secondary mitral regurgitation, RV enlargement causes tricuspid annular dilation as well as tethering (increased tension) of the chordae tendineae, both of which restrict adequate closure of normal tricuspid valve leaflets. secondary mitral regurgitation On the jugular venous pulsation (JVP) waveform, prominent V waves are highly specific for TR. The C wave of the JVP waveform occurs at the start of RV contraction and is followed by the x descent as right atrial (RA) pressure decreases. The V wave then follows as RA pressure increases with atrial refilling. Because incompetent tricuspid valve closure leads to a sustained elevation in RA pressure during RV systole, TR causes an absent x descent and prominent V wave. (Choice A) Pulmonary artery dilation may be present with pulmonary hypertension due to decompensated heart failure, but it does not cause a prominent V wave or holosystolic murmur. (Choice C) Flailing of a tricuspid valve leaflet can occur due to chordae tendineae rupture in the setting of tricuspid valve myxomatous degeneration. This is an example of primary TR, which is far less common than secondary TR. In addition, it typically causes acute TR with rapid onset of right-sided heart failure and is less likely in this patient with progressive symptoms. (Choice D) Fusion of the tricuspid valve commissures can occur with rheumatic heart disease and results in tricuspid stenosis. A rumbling diastolic murmur is expected, and the JVP demonstrates a flattened y descent and prominent A wave due to obstructed RV filling. prominent A wave (Choice E) Increased intrapericardial pressure occurs in cardiac tamponade. Muffled heart sounds are expected, and the JVP demonstrates a flattened y descent due to restriction of passive RV filling. flattened y descent Educational objective: Tricuspid regurgitation is usually secondary (functional), resulting from right ventricular cavity enlargement in the setting of chronic right-sided volume or pressure overload. A prominent V wave in jugular venous pulsation is highly specific for tricuspid regurgitation. References: Secondary tricuspid valve regurgitation: a forgotten entity. (http://www.ncbi.nlm.nih.gov/pubmed/26503944) Images in clinical medicine. Lancisi's sign. (http://www.ncbi.nlm.nih.gov/pubmed/26760104)

A 78-Year-Old Man Comes to the Office Due to Lower