Ebook Tips and tricks of bedside cardiology (first edition): Part 1

(BQ) Part 1 book Tips and tricks of bedside cardiology presents the following contents: Systemic hypertension, headache and dizziness; exertional angina and fainting episodes, young hypertensive, exertional fatigue; thin and tall male and early diastolic murmur; severe chest pain, cold and blue hand;...

TIPS AND TRICKS OF

T IPS AND T RICKS OF

Atul LuthraMBBS MD DNB

Diplomate National Board of Medicine Consultant Physician and Cardiologist New Delhi, India

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Tips and Tricks of Bedside Cardiology

© 2010, Jaypee Brothers Medical Publishers (P) Ltd.

All rights reserved No part of this publication and CD-ROM should be reproduced, stored in

a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher.

This book has been published in good faith that the material provided by author is original Every effort is made to ensure accuracy of material, but the publisher, printer and author will not be held responsible for any inadvertent error(s) In case of any dispute, all legal matters are to be settled under Delhi jurisdiction only.

First Edition: 2010

ISBN 978-93-80704-99-9

Typeset at JPBMP typesetting unit

Printed at

My Father

Mr PP Luthrawho made me

&

to

My Mother

Ms Prem Luthrawhose fond memoriesalways guide me

The electrocardiogram (ECG), chest skiagram (X-Ray) andechocardiogram (ECHO) are simple yet informative diagnostic modalitiesthat have withstood the test of time They elegantly complement theinformation gathered from medical history and physical examination andthey are cost-effective investigations in resource sensitive settings Moreover,since the equipment for these tests are portable, the tests can be convenientlyperformed at the patient’s bedside and the results interpreted in the light ofclinical data.

I must compliment Dr Luthra for this brilliant and unique title Tips and

Tricks of Bedside Cardiology. He has elegantly compiled a wide variety ofreal-world clinical situations encountered during the course of cardiologypractice The discussion and clinical pearls after each case description arereally worth appreciating Cardiology students preparing for theirexaminations, resident doctors and paramedical staff working in cardiac-care units as well as non-cardiologist physicians dealing with heart patientsare most likely to benefit from this book

I wish Atul and his excellent book all success

There was a time when heart disease was diagnosed at the bedside of thepatient Clinicians were like detectives who would skillfully gather vitaldiagnostic clues from a thoughtfully taken medical history and ameticulously performed clinical examination Present-day cardiology isreplete with a wide variety of high-tech diagnostic tools that seem to haveeclipsed the art of making a clinical diagnosis In this scenario, it would beworthwhile to amalgamate the conventional with the contemporary as inseveral other aspects of life in general and the field of clinical medicine inparticular

It gives me immense pleasure to present Tips and Tricks of Bedside

Cardiology, a harmonious blend of the time-honored clinical approach withthe modern technical approach, towards the diagnosis of heart disease Thebook is formatted as clinical cases, giving the reader an opportunity tomentally construct a plausible diagnosis from symptoms and signs.Illustrations of electrocardiograms, chest radiographs and echocardiogramsthat follow, aid in clinching the diagnosis Each case description is followed

by a discussion which incorporates the differential diagnosis in thatparticular patient The clinical pearls given at the end provide the key

‘take-home’ messages

It has been my endeavor to incorporate most cardiac diseasesencountered in heart-clinics and ward-rounds but there may be someomissions While avoiding case duplication to the extent possible, someclinically important facts may have been emphasized repeatedly I sincerelyhope that the wealth of clinical material presented in a concise, readableand assimilable form will rekindle the romance between the clinician andclinical cardiology These tips and tricks should benefit students undergoingtraining in cardiology and preparing for examinations as much as theywould interest clinicians involved in the care of heart patients

Atul Luthra

www.atulluthra.inatulluthra@sify.com

I am extremely grateful to:

• My school teachers who helped me to acquire command over spoken andwritten English language

• My professors at medical college who taught me the science and art ofclinical medicine

• My heart patients whose clinical examination and investigation resultsstimulated my grey matter and made me wiser

• Authors of books on ECG, ECHO and X-ray to which I referred liberallywhile writing the manuscript

• M/s Jaypee Brothers Medical Publishers (P) Ltd who felt confident toassign this project to me and provided expert editorial assistance at allstages of publication

• My wife Arti and daughters Ankita and Aastha who left me to myselfwhile preparing and finalizing the manuscript of the book

1 Systemic Hypertension, Headache and Dizziness 1

2 Exertional Angina & Fainting Episodes 5

3 Young Hypertensive, Exertional Fatigue 9

4 Thin and Tall Male & Early Diastolic Murmur 13

5 Severe Chest Pain, Cold & Blue Hand 17

6 Sudden Chest Pain & Continuous Murmur 21

7 Palpitation and Dyspnea, Mid-diastolic Murmur 25

8 Dynamic Precordium & Pansystolic Murmur 29

9 Episodic Palpitation & Vague Chest Discomfort 33

10 Exertional Fatigue & Syncopal Episodes 37

11 Exertional Dyspnea, Stiff Back and Red Eye 41

12 Sudden Breathlessness & New Systolic Murmur 45

13 Strong Collapsing Pulse & Early Diastolic Murmur 49

14 Anemia, Dyspnea & Soft Systolic Murmur 53

15 Incidentally Detected Pansystolic Murmur 57

16 Strong Bounding Pulse & Systolo-diastolic Murmur 61

17 Squatting Attacks, Blue Lips & Tips 65

18 Raised, Jerky JVP & Pansystolic Murmur 69

19 Prominent ‘a’ Wave & Ejection Systolic Murmur 73

20 Flu-like Syndrome, Fatigue & Orthopnea 77

21 High Fever, Joint Pains, Sore Throat & Skin Rash 81

22 Weak Pulse & Basilar Rales 85

23 Raised JVP & No Murmur 89

24 Angina, Syncope & Double Apex Beat 93

25 Low Fever with Bodyache & Chest Pain on Inspiration 97

26 Low BP, Raised JVP & Silent Precordium 101

27 Raised JVP, Edema & Distended Abdomen 105

28 Productive Cough, Dyspnea & Wheeze 109

29 Chest Pain & Dyspnea after Air Travel 113

30 Exertional Dyspnea, Cyanosis and Fainting 117

31 Fever with Chills & Petechial Spots 121

32 Fever with Chills & Illicit Drug Abuse 125

33 Constitutional Symptoms & Sudden Hand Cyanosis 129

34 Exertional Dyspnea & Sudden Hemiparesis 133

35 Displaced & Diffuse Apical Impulse 137

36 Retrosternal Discomfort upon Climbing Stairs 141

37 Recent Increase in Angina Frequency 145

38 Severe Chest Pain, Sweating and Sinking 149

39 Myocardial Infarction & New Murmur on Day 5 153

40 Myocardial Infarction & Sudden Worsening on Day 3 157

41 Low BP and High JVP after Acute Infarction 161

42 Precordial Bulge after Myocardial Infarction 165

43 Chronic Effort Angina & Recent Heart Failure 169

44 Treated Hypertension & Weakness in Both Arms 173

45 T2DM-HTN-ESRD & Abnormal ECG 177

46 LV Dysfunction & Multifocal VPCs 181

47 LV Dysfunction & Inducible VT 185

48 Episodic “Machine-like”Fluttering in the Chest 189

49 Palpitation, Weight-loss and Thyromegaly 193

50 ASMI-STK-CCU & Sudden ECG Change 197

51 Palpitation & Abrupt Symptom Termination 201

52 Systemic Hypertension, Dizziness & Confusion 205

53 Athletic Youth & Alarming ECG 209

54 Healthy Man & Unique ECG 213

Index 217

Patient Profile

Chief Complaints

• Frequent headaches and dizzy spells with blurring of vision

• Easy fatigability and breathlessness on mild physical exertion

Relevant History

• The patient was diagnosed to have systemic hypertension at the age of

28 years At that time, he was investigated for possible secondary tension but no abnormality was detected on detailed renal and endocrineinvestigations

hyper-• He was prescribed some antihypertensive medicines, but did not takethem regularly and was not on periodic medical follow-up

• Patient had always been overweight and detected to be a diabetic about

10 years back He had not got his lipid profile checked recently

• He smoked 8 to 10 cigarettes per day and consumed 2 to 3 pegs ofwhiskey on most days of the week

Physical Examination

• Pulse: 84, BP: 160/100, Temp.: 98.2, Resp.: 22

• Pulse: regular, good volume, bounding in character

• JVP: normal, Thyroid: not palpable, Edema: nil

• CVS: Apex beat sustained heaving in nature

Systolic pulsations seen in the aortic area

S1 normal, S2 normally split, A2 loud, S4 heard

Gr II /VI soft systolic murmur in the aortic area

• Chest: normal breath sounds, no rhonchi or crepts

An ECG was obtained

Systemic Hypertension, Headache and Dizziness

1

Case

ECG Findings:

• Tall R waves in leads V5, V6

• Deep S waves in leads V1, V2

An ECHO was also performed

ECHO Findings:

• Thick septum and LV posterior wall

• Small size of left ventricular cavity

Systemic Hypertension, Headache and Dizziness 3

Diagnosis

HYPERTENSIVE HEART DISEASE

Discussion

Indications for Echo in Hypertension are:

• Detection of left ventricular hypertrophy (LVH)

• Assessment of LV systolic and diastolic dysfunction

• Detection of coexisting coronary artery disease

• Detection of mitral and aortic valve degeneration

• Detection of aortic dilatation or coarctation of aorta

Echo features of LV Hypertrophy are:

• Thickening of the interventricular septum (IVS) and left ventricularposterior wall (LVPW) The thickness of septum and free wall exceeds

12 mm (normal 6 to 11 mm)

• Small left ventricular cavity size Thickening of the IVS and LVPW leads

to obliteration of the LV cavity in systole Thick papillary muscles withprominent trabeculae carnae are seen parallel to the LV posterior wall

• The echo picture of LVH due to hypertension is simulated by LVH due

to other conditions causing LV pressure overload such as aortic valvestenosis and coarctation of aorta

• LVH may be indicated on the ECG by presence of tall QRS complexes.The voltage criteria of S in V1 / V2 plus R in V5 / V6 greater than 35 mm(Sokolow criteria) is often used There may be an associated ‘strainpattern’ with ST segment depression and T wave inversion in the lateralleads

Clinical Pearls

• Presence of LVH is the most common abnormality on echo in ahypertensive patient Systemic hypertension is also the most importantcause of LVH Echo cardiography is 5 to 10 times more sensitive thanECG at detecting LVH

• LVH is an independent predictor of cardiovascular morbidity andmortality as a risk factor for myocardial infarction, heart failure andsudden cardiac death

• The apex beat is displaced downwards and outwards, is sustained inentire diastole and heaving in nature It indicates the presence of LVHand is also observed in aortic valve stenosis and coarctation of aorta

• A loud aortic component (A2) of the second heard sound (S2) is a reliableindicator of systemic hypertension In aortic stenosis, the A2 is muffled

An audible S4 in presystole indicates atrial contraction against a compliant and hypertrophied left ventricle

non-• Prominent systolic pulsations felt along with a soft systolic murmurheard in the second right intercostal space adjacent to the sternum (aorticarea) indicate dilatation of the proximal aortic root

Patient Profile

Chief Complaints

• Retrosternal discomfort on climbing stairs, since 2 months

• Orthostatic dizziness on standing up from sitting position

• Episodes of light-headedness and fainting after exertion

• Pulse: 68, BP: 140/76, Temp.: 98.2, Resp.: 20

• Pulse: regular, fair volume, normal in character

• JVP: normal, Thyroid: not palpable, Edema: nil

• CVS: Normal precordium and apex beat location

Systolic pulsations seen in the aortic area

S1 normal, A2 loud, S4 audible in presystole

Gr II /VI soft systolic murmur in aortic area

• Chest: no rhonchi or crepts audible

An X-RAY was ordered

Exertional Angina & Fainting Episodes

2

Case

X-RAY Findings:

• Enlargement of heart

• Prominent aortic knuckle

An ECHO was also performed

ECHO Findings:

A Calcified aortic valve

B Calcific mitral annulus

Exertional Angina & Fainting Episodes

Diagnosis

AORTIC VALVE SCLEROSIS

MITRAL ANNULAR CALCIFICATION

Discussion

• Sclerosis of the aortic valve with some degree of aortic stenosis isfrequently observed in elderly subjects Calcification of the aortic valve

is the hallmark of aortic sclerosis with or without stenosis

• Whenever angina pectoris is accompanied by syncopal episodes, oneshould always consider the possibility of aortic stenosis.Aortic stenosis

per se can cause both angina and syncope Alternatively, it causes onlysyncope while coronary atherosclerosis causes the angina

• On chest X-ray, cardiac enlargement with left ventricular contour and

aortic root dilatation could also be due to hypertension per se or aortic

valve regurgitation

• Sclerosis of the aortic valve is sometimes accompanied by calcification

of the mitral valve annulus There is a localized highly reflectiveechodensity in the posterior segment of the mitral valve annulus Thecalcification also involves the base of the posterior mitral leaflet (PML)

Clinical Pearls

• Systolic pulsations visible in the aortic area with an audible systolicmurmur are indicative of dilatation of the aortic root Such dilatationoccurs due to aortic sclerosis with systolic hypertension or aortic stenosiswith poststenotic dilatation In aortic sclerosis the A2 sound is loud while

in aortic stenosis the A2 is muffled

• Whenever angina and syncope occur together, clinical possibilities are:– aortic valve stenosis with coronary ostial occlusion

– atherosclerotic coronary disease with arrhythmia

– aortic valve stenosis and coronary artery disease

• Patients who have angina pectoris with mild hypertension rarely haveECG signs of LV hypertrophy When LV hypertrophy is evident, onemust search for a cause other than coronary artery disease

• This patient should undergo cardiac catheterization and coronaryangiography before aortic valve surgery is contemplated, to judge thestatus of the coronary arteries The coronary arteries may be normalwith only ostial stenosis or they may show luminal occlusion byatherosclerotic plaques

Young Hypertensive, Exertional Fatigue

Patient Profile

Chief Complaints

• Easy fatigability on walking and climbing stairs

• Episodic headache, blurring of vision and dizziness

Relevant History

• Patient was diagnosed to have systemic hypertension at the age of

16 years and had been on antihypertensive medication eversince

• For the last 6 years, his dyspnea on exertion had increased considerablyand he complained of early fatigue on climbing stairs

• His episodes of headache and dizziness were related to strenuousexertion, emotional upset and missing of his medication

• He denied chest pain, palpitation or syncope There was no history oforthopnea or paroxysmal nocturnal dyspnea

• His current medication included lisinopril 10 mg, amlodipine 5 mg,metoprolol 50 mg and hydrochlorthiazide 12.5 mg

Physical Examination

• Comfortable, no tachypnea, orthopnea or distress

• Pulse: 90, BP: 170/100, Temp: 98.6, Resp.: 18

• Pulse: regular, good volume, bounding in nature

visible carotid pulsations

reduced volume and delay in femoral pulse

• Thinner and atrophic legs compared to the arms

• BP in lower limbs 140/80 (popliteal reading)

• CVS: Apex beat displaced down and out, heaving in nature

S1 normal, A2 loud, S4 heard

Gr III/VI systolic murmur to the left of sternum Same murmuralso heard in interscapular region

Continuous murmurs heard over both scapulae

• Chest: clear or auscultation, no rhonchi or crepts

3

Case

An ECG was obtained.

ECG Findings:

• Tall R waves in leads V5,V6

• Deep S waves in leads V1, V2

An ECHO was also performed

from the suprasternal notch

ECHO Findings:

• Focal narrowing of the aorta

Young Hypertensive, Exertional Fatigue 11

• Shelf-like luminal projection

• In pseudo-coarctation of the aorta, there is only tucking at theligamentum arteriosum without luminal narrowing In case ofhypoplastic aorta, there is diffuse narrowing of the aortic root lumen

• The chest X-ray is often pathognomic of aortic coarctation There isnotching or indentation of the lower surface of the ribs due to largecollateral vessels The indentation of the aorta at the site of coarctationalong with dilatation on either side of narrowing produces acharacteristic “figure-of-3” sign

• The narrowing of the aorta is detected from the suprasternal notch.The aortic arch is more pulsatile proximal to the coarctation than distal

to it On CW Doppler, there is a high velocity jet directed away fromthe transducer

• Abnormalities associated with coarctation of aorta are:

– VSD and PDA

– Bicuspid aortic valve

– Aneurysm of sinus of Valsalva

– Berry aneurysm, circle of Willis

• The apex beat is displaced downwards and outwards, is sustained inentire diastole and heaving in nature A heaving apex beat is alsoobserved in essential systemic hypertension and in aortic valve stenosis

• The ejection systolic murmur is due to narrowing of the aorta and can

be heard both anteriorly as well as posteriorly Continuous murmursheard over the scapular region are due to high flow in the collateralvessels along the ribs

• Causes of death in coarctation of aorta are:

– Left ventricular failure

– Dissection of the aorta

– Endocarditis at the site

– Intracranial aneurysmal bleed

– Ruptured sinus of Valsalva aneurysm

Patient Profile

Chief Complaints

• Progressive shortness of breath over 3 months

• Severe dyspnea and orthopnea since 3 days

• There was no history of recurrent sore throat, prolonged fever or jointpains during childhood and he had never received monthly shots

• None of his family members suffered from systemic hypertension,diabetes mellitus, coronary artery disease or bronchial asthma

Physical Examination

• Extremely thin and lanky physical appearance

• Long and tapering fingers, high joint mobility

• High-arched palate, dislocated lens in eyes

• Pulse: 96, BP: 160/50, Temp.: 98.6, Resp.: 24

• Pulse: regular, good volume, collapsing in nature

carotid pulsations brisk with rapid descent

nodding of the head with each heart beat

• CVS: hyperdynamic precordium with anterior systolic motion

Apex beat in 6th space, ill-sustained heaving in nature

S1 and S2 normal, S3 gallop in early diastole

Gr III /VI soft, early diastolic murmur along left sternal border

• Chest: bilateral basilar rales over lower-thirds of lung fields

An ECHO was performed

Thin and Tall Male & Early Diastolic Murmur

4

Case

ECHO Findings:

• Aneurysmal dilatation of proximal aorta

• Compression of left atrium in systole

• Aortic cusps distant from aortic walls

Thin and Tall Male & Early Diastolic Murmur 15

• The typical body habitus is a tall and slender figure with long taperingfingers and increased joint mobility The pubis-to-heel measurementexceeds the crown-to-pubis length Associated abnormalities include

a high-arched palate, pectus carinatum, dislocated ocular lenses(ectopia lentis) and presence of inguinal hernias

• Cardiovascular complications are initiated by cystic medial necrosis ofthe ascending aorta There is dilation of the aorta root with aortic valveinsufficiency and left ventricular volume overload Catastrophicdissection involving the proximal aorta is a serious and potentially lethalcomplication

• Dilatation of the aortic root beyond 40 mm is observed in:

Clinical Pearls

• Classical signs of aortic regurgitation are:

– Collapsing radial pulse

– Wide pulse pressure

– Visible carotid pulsations

– Hyperdynamic precordium

– Displaced apex beat

– Early diastolic murmur

• Cause of aortic aneurysm are:

• Echo features of Marfan syndrome are:

– Aortic root dilatation

• He was irregular with his medication and often skipped his doses withthe result that most of the time his blood pressure hovered around160/100 mm of Hg.

• He led a sedentary life and did not restrict his caloric intake Moreover,

he consumed 3 to 4 pegs of whiskey and smoked 10 to 12 cigarettes onmost days of the week

Physical Examination

• Patient apprehensive, dyspneic and diaphoretic

• BP: right arm 100/80, left arm 200/120

• Pulse: right radial feeble, left radial bounding

femoral pulses well felt and systolic bruit heard

• CVS: Normal precordium and apex beat location

S1 and S2 normal; S3 gallop audible

Faint early-diastolic murmur along left sternal border

• Chest: few scattered basilar rales bilaterally

An ECHO was performed

Severe Chest Pain, Cold & Blue Hand

5

Case

ECHO Findings:

• Cleavage of the anterior aortic wall

• False lumen (c) between outer and inner walls (a)

• Intimal flap between true (b) and false lumens (c)

Severe Chest Pain, Cold and Blue Hand 19

– Trauma: accidental or surgical

• Dissection of aorta is caused by cleavage of the media of the aortic wall,with the adventitia and outer media forming the outer wall and theintima and inner media forming the inner wall A false lumen appearsbetween the two walls which has one blind end while the other endcommunicates with the true lumen at the site of the entrance tear Theintimal flap oscillates between the true and false lumens If an exitintimal tear is also present, the aorta has a double- barreled appearance

• The best imaging modality for confirming the diagnosis of dissection isunder debate Transesophageal echocardiography, MRI, CT scanningand Aortography all have high sensitivity and specificity

• Aortic dissection has been classified by De Bakey as type I which begins

in the ascending aorta just above the aortic valve; type II, which is limited

to the ascending aorta; and type III, which begins at or just distal to theorigin of the left subclavian artery If dissection is limited to thedescending thoracic aorta, it is classified as type IIIA; type IIIb extends

to the abdominal aortic bifurcation and lower down

• Another and simpler classification system that works wellprognostically, categorizes dissection as proximal (type A) when theascending aorta is involved, and distal (type B) when the ascendingaorta is spared Type A includes De Bakey types I and II, and type B isanalogous to De Bakey type III

Classification of aortic dissection according to its location

De Bakey Stanford Location of dissection Incidence type group

Clinical Pearls

• Patients with aortic dissection have severe chest pain that reaches itsmaximum intensity almost instantaneously Pain may be located overthe anterior or posterior chest

• Pulses can become absent or diminished as the dissection advances toinvolve major arteries If the aortic root is involved, aortic insufficiencymay occur The aorta also may rupture into the pericardial cavity,producing tamponade and cardiovascular collapse Partial occlusion

of the branches of the aorta can produce difference in blood pressurebetween the two upper extremities

• Chest pain may lead to the misdiagnosis of an acute myocardialinfarction However, the lack of Q waves on the ECG, the lack of serumenzyme elevation, and the persistence of pain associated withhypertension should lead to the presumptive diagnosis of dissection.Rarely, the dissection involves the ostium of a coronary vessel and causes

a Q wave myocardial infarction Such patients usually have associatedaortic valve insufficiency

• Classical echo features of aortic dissection are:

– Dilatation of the proximal aortic root > 42 mm

– Anterior or posterior wall thickness > 15 mm

– Double echo of the involved aortic wall

– Space between outer and inner walls > 5 mm

– False lumen within aortic wall with blind end

– Intimal flap between true and false lumens

• Associated echo features of aortic dissection are:

– Occlusion of neck vessels

– Aortic valve regurgitation

– Left ventricular dysfunction

– Myocardial infarction

– Pericardial effusion

• There was no previous history of exertional fatigue, chest pain orshortness of breath and he rode a bicycle to work everyday.

• He did not suffer from diabetes, hypertension or asthma and there was

no family history of heart disease or sudden premature death

• He did not smoke, consume alcohol or abuse illicit drugs and hardlyever took any medication

Physical Examination

• Patient anxious looking and mildly dyspneic

• No pallor, diaphoresis or peripheral cyanosis

• All extremities cold; pulses feeble

• Pulse: 120, BP: 80/60, Temp.: 98.0, Resp.: 24

• CVS: normal precordium and apex beat location

Gr III /VI continuous murmur along the sternum

• Chest: bilateral basilar crackles over the lower lung fields

An ECHO was performed

Sudden Chest Pain & Continuous Murmur

6

Case

ECHO Findings:

• Outpouch (SOV) anterior to aortic valve (AV)

• Protrusion into the RV outflow tract (RVOT)

Sudden Chest Pain & Continuous Murmur 23

of infective endocarditis

• Aneurysm of the noncoronary sinus ruptures into the right atrium whilethat of the right coronary sinus ruptures into the right ventricle In eithercase, there is continuous flow from the aorta to the right- sided chamber,since the aortic pressure is always higher than the chamber pressure.This forms the basis of the continuous murmur heard when theaneurysm ruptures

• An aneurysm of sinus of Valsalva (SOV) appears as an outpouching ofthe dilated coronary sinus anterior to the anterior aortic wall, protrudinginto the right ventricular outflow tract (RVOT) A rupture of thisaneurysm into the right ventricle produces right ventricular volumeoverload Aneurysm of sinus of Valsalva or the fistula created by itsrupture, is best visualized on transesophageal echo (TEE)

Clinical Pearls

• Rupture of sinus of Valsalva aneurysm into a right-sided chamberproduces a continuous systolo-diastolic murmur Other causes of acontinuous murmur are:

– Patent ductus arteriosus

– Aortico-pulmonary window

– Coronary arterio-venous fistula

– Ventricular septal defect with

aortic valve regurgitation

• Causes of sudden onset of chest pain with dyspnea are:

– Myocardial infarction

– Pulmonary embolism

– Acute aortic dissection

• If the acute chest pain with dyspnea is preceded by trauma to the chest,the diagnosis of ruptured sinus of Valsalva aneurysm must beconsidered In that case, another possibility is of pneumothorax Bothaneurysmal rupture as well as pneumothorax can occur spontaneously

or after isometric exercise

• Abnormalities associated with aneurysm sinus of Valsalva are:– Bicuspid aortic valve

– Coarctation of aorta

– Ventricular septal defect

Patient Profile

Chief Complaints

• Easy fatigability and breathlessness on exertion since 2 years

• Episodes of light-headedness and fainting preceded by flutteringsensation in the chest

• Patient restless, anxious and moderately tachypneic

• Mild pallor, no cyanosis or jaundice, slight sweating

• Pulse: 96, BP: 100/70, Temp.: 98.8, Resp.: 22

• Pulse: regular, low volume, normal systolic upstroke

• JVP: raised, Thyroid: normal, Edema: mild

• CVS: Apex beat tapping, left parasternal heave palpable

S1 loud, P2 loud, opening snap audible in early diastole

Gr III /VI mid-diastolic murmur in the mitral area

Pre-systolic accentuation of the murmur noticed

• Chest: few basilar rales over lower third of lung fields

An X-RAY was ordered

Palpitation and Dyspnea, Mid-diastolic Murmur

7

Case

X-RAY Findings:

• Straightening of the left cardiac border

• Above downwards, structures seen are:

– the aortic knuckle

– pulmonary artery

– left atrial appendage

– the left ventricle

An ECHO was also performed

ECHO Findings:

• Reverberation of echoes from valve

• Reduced anterior excursion of AML

• Paradoxical anterior motion of PML

• Flattening of the E-F slope of AML