Cardiomegaly - Clinicals, Diagnosis, and Management

Cardiovascular

Clinicals - History

Fact Explanation
Asymptomatic Symptoms manifest when it progresses to congestive cardiac failure, till then patients are asymptomatic. Symptoms also manifest due to underlying disease which caused cardiomegaly Asymptomatic
Symptoms manifest when it progresses to congestive cardiac failure, till then patients are asymptomatic. Symptoms also manifest due to underlying disease which caused cardiomegaly
Dyspnoea This is related to pulmonary venous congestion which results from left ventricular dysfunction associated with congestive cardiac failure. Dyspnoea
This is related to pulmonary venous congestion which results from left ventricular dysfunction associated with congestive cardiac failure.
orthopnoea, Paroxymal nocturnal dyspnoea This is related to pulmonary venous congestion which results from left ventricular dysfunction associated with congestive cardiac failure. orthopnoea, Paroxymal nocturnal dyspnoea
This is related to pulmonary venous congestion which results from left ventricular dysfunction associated with congestive cardiac failure.
Ankle swelling This is due to increased fluid accumulation which occurs due to activation of various neuroendocrine mechanisms in congestive cardiac failure Ankle swelling
This is due to increased fluid accumulation which occurs due to activation of various neuroendocrine mechanisms in congestive cardiac failure
Weight gain This is due to increased fluid accumulation which occurs due to activation of various neuroendocrine mechanisms in congestive cardiac failure Weight gain
This is due to increased fluid accumulation which occurs due to activation of various neuroendocrine mechanisms in congestive cardiac failure
Palpitations When the artia and ventricles stretch various arrhythmia result such as atrial fibrillation, ventricular arrhythmias which is sensed as pounding of the heart. Sudden cardiac death also occur Palpitations
When the artia and ventricles stretch various arrhythmia result such as atrial fibrillation, ventricular arrhythmias which is sensed as pounding of the heart. Sudden cardiac death also occur
Exertional chest pain If the underlying cause for cardiomegaly is due to coronary artery disease, patient may give a history of exertional chest pain Exertional chest pain
If the underlying cause for cardiomegaly is due to coronary artery disease, patient may give a history of exertional chest pain

Clinicals - Examination

Fact Explanation
Dependent edema This is due to increased fluid accumulation which occurs due to activation of various neuroendocrine mechanisms in congestive cardiac failure Dependent edema
This is due to increased fluid accumulation which occurs due to activation of various neuroendocrine mechanisms in congestive cardiac failure
Increased jugular venous pressure Systemic venous congestion related to congestive cardiac failure results in increased jugular venous pressure Increased jugular venous pressure
Systemic venous congestion related to congestive cardiac failure results in increased jugular venous pressure
Cardiomegaly As a result of enlargement of the heart, the apex of the heart may be displaced from it's usual position which is considered as just medial to the left mid clavicular line in the 5th intercostal space. Cardiomegaly
As a result of enlargement of the heart, the apex of the heart may be displaced from it's usual position which is considered as just medial to the left mid clavicular line in the 5th intercostal space.
Hepatomegaly Systemic venous congestion related to congestive cardiac failure results in increased jugular venous pressure Hepatomegaly
Systemic venous congestion related to congestive cardiac failure results in increased jugular venous pressure
Ascitis This is due to increased fluid accumulation which occurs due to activation of various neuroendocrine mechanisms in congestive cardiac failure Ascitis
This is due to increased fluid accumulation which occurs due to activation of various neuroendocrine mechanisms in congestive cardiac failure
Fine end inspiratory crepitations This is related to pulmonary venous congestion which results from left ventricular dysfunction associated with congestive cardiac failure. Fine end inspiratory crepitations
This is related to pulmonary venous congestion which results from left ventricular dysfunction associated with congestive cardiac failure.
Irregular pulse When the artia and ventricles stretch various arrhythmia result such as atrial fibrillation, ventricular arrhythmias which is sensed as pounding of the heart. Sudden cardiac death also occur Irregular pulse
When the artia and ventricles stretch various arrhythmia result such as atrial fibrillation, ventricular arrhythmias which is sensed as pounding of the heart. Sudden cardiac death also occur
High blood pressure If the underlying cause of cardiomegaly is hypertensive heart disease, this could be found High blood pressure
If the underlying cause of cardiomegaly is hypertensive heart disease, this could be found
Heart murmurs If the underlying cause is due to valvular heart disease, murmurs can be heard. Heart murmurs
If the underlying cause is due to valvular heart disease, murmurs can be heard.
Pallor If the underlying cause for cardiomegaly is anaemia by high output cardiac failure, pallor can be observed Pallor
If the underlying cause for cardiomegaly is anaemia by high output cardiac failure, pallor can be observed

Investigations - Diagnosis

Fact Explanation
Chest X-ray The heart is considered enlarged if the cardiothoracic ratio is greater than 50% on a Postero-anterior view. Other signs of heart failure such as pulmonary oedema, septal (Kerley B) lines, and pleural effusions can also be present Chest X-ray
The heart is considered enlarged if the cardiothoracic ratio is greater than 50% on a Postero-anterior view. Other signs of heart failure such as pulmonary oedema, septal (Kerley B) lines, and pleural effusions can also be present
Electrocardiogram Features of left ventricular hypertrophy can be observed and they are increased R wave amplitude in the left-sided ECG leads (I, aVL and V4-6) , increased S wave depth in the right-sided leads (III, aVR, V1-3). Features of right ventricular hypertrophy are Right axis deviation , tall R-waves in Right ventricular leads, deep S-waves in left ventricular leads. Additionally atrial and ventricular arrhythmias may be present Electrocardiogram
Features of left ventricular hypertrophy can be observed and they are increased R wave amplitude in the left-sided ECG leads (I, aVL and V4-6) , increased S wave depth in the right-sided leads (III, aVR, V1-3). Features of right ventricular hypertrophy are Right axis deviation , tall R-waves in Right ventricular leads, deep S-waves in left ventricular leads. Additionally atrial and ventricular arrhythmias may be present
Echocardiogram This test helps in the assessment of left ventricular size, chamber diameters, mass and function in the form of ejection fraction. It also helps to exclude valvular diseases and other causes Echocardiogram
This test helps in the assessment of left ventricular size, chamber diameters, mass and function in the form of ejection fraction. It also helps to exclude valvular diseases and other causes
Exercise Electrocardiogram As ischemic heart disease due to coronary artery disease is a common cause for cardiomegaly, this test may help in determining the cardiac function in exertion Exercise Electrocardiogram
As ischemic heart disease due to coronary artery disease is a common cause for cardiomegaly, this test may help in determining the cardiac function in exertion
Coronary angiogram As ischemic heart disease due to coronary artery disease is a common cause for cardiomegaly, this test may help in determining the patency of coronary arteries Coronary angiogram
As ischemic heart disease due to coronary artery disease is a common cause for cardiomegaly, this test may help in determining the patency of coronary arteries
Cardiac MRI Ejection fraction and regional wall motion can be assessed. Cardiac MRI
Ejection fraction and regional wall motion can be assessed.
Full blood count To exclude anemia causing high output cardiac failure Full blood count
To exclude anemia causing high output cardiac failure
Serum iron studies To exclude anemia causing high output cardiac failure and also to exclude haemachromatosis Serum iron studies
To exclude anemia causing high output cardiac failure and also to exclude haemachromatosis
Serum cholesterol level As atherosclerosis contributes to coronary artery disease, this will be helpful in determining the serum cholesterol levels. Serum cholesterol level
As atherosclerosis contributes to coronary artery disease, this will be helpful in determining the serum cholesterol levels.
B-type natriuretic peptide levels increase with ventricular wall stretch and help in the diagnosis of heart failure B-type natriuretic peptide
levels increase with ventricular wall stretch and help in the diagnosis of heart failure

Investigations - Management

Fact Explanation
full blood count In patient serial full blood counts are done to detect anaemia if it's the cause, and response to treatment full blood count
In patient serial full blood counts are done to detect anaemia if it's the cause, and response to treatment
Echocardiography Serial echocardiographic investigations are done to evaluate ejection fraction, diastolic dysfunction and response to treatment. Echocardiography
Serial echocardiographic investigations are done to evaluate ejection fraction, diastolic dysfunction and response to treatment.
Serum electrolytes Since patients are put on diuretics for congestive cardiac failure and angiotensinogen converting enzyme inhibitors it's important to monitor serum electrolytes Serum electrolytes
Since patients are put on diuretics for congestive cardiac failure and angiotensinogen converting enzyme inhibitors it's important to monitor serum electrolytes
Prothrombin time and international normalization ratio As patients are put on Warfarin to combat thrombo-embolism especially in dilated cardiomyopathy it's important to monitor this Prothrombin time and international normalization ratio
As patients are put on Warfarin to combat thrombo-embolism especially in dilated cardiomyopathy it's important to monitor this
Serum cholesterol level As atherosclerosis is a main contributory factor for coronary artery disease and subsequent cardiomegaly, serum cholesterol levels are done in follow up Serum cholesterol level
As atherosclerosis is a main contributory factor for coronary artery disease and subsequent cardiomegaly, serum cholesterol levels are done in follow up
Full blood count This is done to exclude significant anaemia Full blood count
This is done to exclude significant anaemia
Serum Creatinine and Blood urea nitrogen, and serum electrolytes Patients with heart failure are on long term diuretics and diuretics are notorious to cause electrolyte abnormalities such as hpokalemia, hyponatremia, and sometimes uremia. Hypokalemia is also found in cardiac surgical patients. This test is also done to assess renal function before anesthesia Serum Creatinine and Blood urea nitrogen, and serum electrolytes
Patients with heart failure are on long term diuretics and diuretics are notorious to cause electrolyte abnormalities such as hpokalemia, hyponatremia, and sometimes uremia. Hypokalemia is also found in cardiac surgical patients. This test is also done to assess renal function before anesthesia
Coagulation profile To exclude any coagulopathy, and also specially since patients are on Warfarin this is important Coagulation profile
To exclude any coagulopathy, and also specially since patients are on Warfarin this is important
Echocardiography To evaluate the ejection fraction, and valvular regurgitation prior to cardiac surgery Echocardiography
To evaluate the ejection fraction, and valvular regurgitation prior to cardiac surgery
Cardio-pulmonary exercise testing To evaluate the cardiac function before cardiac surgery Cardio-pulmonary exercise testing
To evaluate the cardiac function before cardiac surgery
Genetic testing for dilated cardiomyopathy This is done in patients who have a family history of dilated cardiomyopathy and the presence for specific genes are tested and more than 10 genes have been identified. Genetic testing for dilated cardiomyopathy
This is done in patients who have a family history of dilated cardiomyopathy and the presence for specific genes are tested and more than 10 genes have been identified.
Genetic testing for hypertrophic obstructive cardiomyopathy There's a familial form inherited as autosomal dominant inheritance Genetic testing for hypertrophic obstructive cardiomyopathy
There's a familial form inherited as autosomal dominant inheritance

Management - Supportive

Fact Explanation
Patient education Patient should be educated on the aetiology of the disease, the course, importance of follow up, the advices regarding Warfarin and other medication, diet and exercise, and to cut down drinking if it's dilated cardiomyopathy due to alcohol Patient education
Patient should be educated on the aetiology of the disease, the course, importance of follow up, the advices regarding Warfarin and other medication, diet and exercise, and to cut down drinking if it's dilated cardiomyopathy due to alcohol
Diet Special restrictions in the diet is unnecessary except for low salt diet and in congestive cardiac failure and low cholesterol if patient is having atherosclerosis Diet
Special restrictions in the diet is unnecessary except for low salt diet and in congestive cardiac failure and low cholesterol if patient is having atherosclerosis
Exercise Moderate endurance aerobic activities are recommended but strenuous activities are better avoided Exercise
Moderate endurance aerobic activities are recommended but strenuous activities are better avoided

Management - Specific

Fact Explanation
Management of heart failure with pharmacological therapy Patients are put on heart failure regime once the heart failure ensues. Diuretics, Digoxin, After-load reduction with angiotensinogen converting enzyme inhibitors are used Management of heart failure with pharmacological therapy
Patients are put on heart failure regime once the heart failure ensues. Diuretics, Digoxin, After-load reduction with angiotensinogen converting enzyme inhibitors are used
Anticoagulant therapy Anticoagulant therapy is started with Warfarin to combat thrombo-embolism due to dilated cardiomyopathy, valvular heart disease. Anticoagulant therapy
Anticoagulant therapy is started with Warfarin to combat thrombo-embolism due to dilated cardiomyopathy, valvular heart disease.
Pharmacological therapy with anti-hypertensives If the cause is long standing hypertension, treatment can be started with antihypertensives such as angiotensinogen converting enzyme inhibitors, beta blockers, calcium channel blockers, or thiazide diuretics and these drugs are used according to guidelines Pharmacological therapy with anti-hypertensives
If the cause is long standing hypertension, treatment can be started with antihypertensives such as angiotensinogen converting enzyme inhibitors, beta blockers, calcium channel blockers, or thiazide diuretics and these drugs are used according to guidelines
Cardiac Resynchronization Therapy When medical therapy fails this is one option. As patients tend to have arrhythmias, implantable cardioverter defibrillators are used. The patient selection criteria are QRS complex duration >120 to 130 ms, heart failure with NYHA class III or IV symptoms, and optimal medical treatment for heart failure, including β-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and diuretics. Cardiac Resynchronization Therapy
When medical therapy fails this is one option. As patients tend to have arrhythmias, implantable cardioverter defibrillators are used. The patient selection criteria are QRS complex duration >120 to 130 ms, heart failure with NYHA class III or IV symptoms, and optimal medical treatment for heart failure, including β-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and diuretics.
Valve repair/ replacement If the cause of the cardiomegaly is valvular heart disease, the affected valve can be surgically repaired or replaced. Valve repair/ replacement
If the cause of the cardiomegaly is valvular heart disease, the affected valve can be surgically repaired or replaced.
Ventricular assist device It does the action of the heart by pumping blood and this is a treatment option for patients awaiting heart transplant Ventricular assist device
It does the action of the heart by pumping blood and this is a treatment option for patients awaiting heart transplant
Heart Transplant The final treatment option for cardiomegaly is a heart transplant. Heart Transplant
The final treatment option for cardiomegaly is a heart transplant.

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