Name:
A 62-Year-Old with Chest Pain and Dyspnea
Description:
A 62-Year-Old with Chest Pain and Dyspnea
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Duration:
T00H07M33S
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Upload Date:
2022-02-28T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
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CATHY: Hi. Welcome to Harrison's Podclass, where we discuss important concepts in internal medicine. I'm Cathy Handy.
CHARLIE: And I'm Charlie Wiener,
CHARLIE: and we're coming to you from the Johns Hopkins School of Medicine. Today's episode is Episode 22: A 62-Year-Old with Chest Pain and Dyspnea I'll start with the question leading. Mr. Abraham is a 62-year-old former sea urchin collector with a history of a right total knee replacement ten years ago and prior tobacco abuse. He presents to your office after complaining of chest pain with moderate exertion and some mild dyspnea while walking up hills.
CATHY: Well, as you know, Charlie, chest pain is a really common complaint to the doctors' offices and especially to emergency departments. Most of the time, it's not a life-threatening issue, and, in fact, most of the time, it's not even caused by cardiac disease. But you really want to make sure that you're ruling out acute coronary syndrome or any other cardiac disease, because those diagnoses, you don't want to miss. This man, at 62 years old, is definitely in the relevant age range and has some risk factors for those considerations.
CATHY: Definitely, the tobacco abuse puts him at higher risk, so I definitely want more information.
CHARLIE: The question does not list any additional history, but, instead, today we're going to focus on the physical examination. The question goes on. On examination, you note a mid-systolic murmur. After careful listening, you were unsure whether this is the murmur of aortic stenosis or of the obstructive form of hypertrophic cardiomyopathy, or HOCM.
CATHY: Well, those are two very different diseases but can have similar sounding murmurs, definitely on initial cardiac exam. The symptoms described-- here we have chest pain and dyspnea on exertion-- are symptoms that are common in both of those diseases. So, when thinking about aortic stenosis, that's due to degenerative calcification of the aortic cusps. And it occurs most commonly in people with a history of either a congenital disease, like having a bicuspid aortic valve, or if there's chronic deterioration of the valves in normal trileaflet valves, or if there's been previous rheumatic inflammation from a rheumatic heart disease.
CATHY: The process of aortic valve deterioration shares many features with vascular atherosclerosis. So, you get endothelial dysfunction, lipid accumulation, inflammatory cell activation, cytokine release. And you can get upregulation of several signaling pathways that results in the calcification of aortic cusps.
CHARLIE: So, aortic stenosis is pretty common, especially in this age group. But what about HOCM?
CATHY: Well, HOCM is the asymmetric left ventricular hypertrophy that's distinct from the more common LVH, or left ventricular hypertrophy that comes from longstanding hypertension. And because of misalignment and disarray of the enlarged myofibrils and myocytes of the septum, you get bulging into the left ventricular outflow tract, and that's what causes the obstruction.
CHARLIE: What are the demographics of HOCM?
CATHY: The average age of diagnosis is about 35-40 for HOCM, but it can present in patients with their 60s. And most patients will have a sarcomere mutation, usually about 60%. And aortic stenosis tends to be more common in older people.
CHARLIE: Okay, let's go back to the question and talk more about the physical examination findings. What is typical in each case?
CATHY: Okay, let's start with aortic stenosis. So, there, the murmur is usually loudest to the right of the sternum in the second intercostal space, and it radiates to the carotids. Aortic stenosis or a sclerosis is the most common cause of a midsystolic murmur in an adult. HOCM, on the other hand, is associated with a midsystolic murmur, and that's usually loudest along the sternal border or between the left lower sternal border and apex. The murmur is produced by both dynamic left ventricular outflow tract obstruction and also mitral regurgitation.
CATHY: So, the murmur that you end up hearing is a configuration of the hybrid between the ejection and the regurgitant phenomenon.
CHARLIE: Okay. So, I'm going to move on with the question because the question is going to ask us what additional physical examination maneuvers we can utilize to distinguish between aortic stenosis and HOCM? The question says: Which maneuver is appropriately matched to the clinical finding that would suggest that this murmur is due to HOCM as opposed to aortic valvular stenosis? Option A says, a handgrip maneuver will diminish the intensity of the murmur.
CHARLIE: Option B says, initiating milrinone intravenously will augment the systolic murmur. Option C says, palpation of the carotid impulse will demonstrate a diminished or delayed carotid upstroke. Option D says, going from the standing position to the squatting position will cause augmentation of the intensity of the murmur. And Option E says, the Valsalva maneuver will cause augmentation of the intensity of the murmur.
CHARLIE: And again, we're trying to figure out which one out of these will distinguish between aortic stenosis and HOCM.
CATHY: Alright, let's go through these one by one. So, let's consider Option A first. Handgrip maneuver augments or increases afterload. And when that happens, it decreases the intensity of the murmurs of both aortic stenosis and HOCM. So, it's not really that helpful to distinguish them. So, I would rule out Option A for this question. The similar option here is Option D, because it turns out that going from standing to squatting also increases the afterload.
CATHY: So, you will get decreased intensity of both murmurs and it doesn't help you to distinguish those.
CHARLIE: Okay. Option B asked about milrinone. Milrinone is a positive cardiac inotrope. What will that do to the murmur of aortic stenosis and HOCM?
CATHY: This will increase the intensity of both of the murmurs. So, again, it doesn't really help you to distinguish. And similarly, Option C, or diminished or delayed carotid upstroke, can be present in both, so isn't the best to help you distinguish between the two. But it is a common and important physical finding in patients who have moderate to severe aortic stenosis, who are maybe later on in that course than this patient.
CHARLIE: I will point out that other auscultatory findings of severe aortic stenosis, which are really important to distinguish because they portend a poor prognosis, include a soft or absent aortic component of the second heart sound, paradoxical splitting of S2 and apical S4, or a late peaking systolic murmur. These should all be checked in patients with suspected hemodynamically significant aortic stenosis. Okay, for this question, that leaves Option E, Valsalva. Tell me about that, Cathy.
CATHY: Well, the Valsalva maneuver is where you bear down against a closed glottis, and that increases the intrathoracic pressure. By doing that, you decrease the venous return and the preload. So, in this case, the murmur of HOCM will be increased and the murmur of aortic stenosis is decreased. So, this is the most useful physical exam finding when you're in the clinic, and it's easy to do, that will help you distinguish between the two diseases.
CHARLIE: So, the answer is E, Valsalva maneuver. Will an echocardiogram distinguish the two?
CATHY: Yes, echocardiogram will definitely help you distinguish the two and is probably the best diagnostic test and, honestly, probably something that you would do next in this case.
CHARLIE: Okay. So, the teaching point here is that both aortic stenosis and HOCM can present initially with similar symptoms, that is dyspnea and maybe some chest pain. The initial examination on both cases may show a midsystolic murmur. But a more detailed examination and having the patient do a Valsalva maneuver can help distinguish between these two murmurs.
CATHY: To learn more about this, you can check out Harrison's chapter on the Cardinal Manifestations of Disease, under the Approach to a Patient with a Heart Murmur. ♪ (music) ♪