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  #1  
Old 04-19-2010
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Default Heart Defect after Cancer

A 62-year-old breast cancer survivor visits her physician because of weakness, fatigue, fever, and weight gain 5 years following her radiation therapy. The physician also elicits complaints about abdominal discomfort and exertional dyspnea. Physical examination reveals hepatomegaly and jugular venous distention that fails to subside on inspiration, but shows no evidence of hypotension or pulsus paradoxus. An echocardiogram shows reduced end-diastolic volumes and elevated diastolic pressures in both ventricles. Which of the following is the most likely diagnosis?


A. Cardiac tamponade
B. Congestive heart failure
C. Constrictive pericarditis
D. Dilated cardiomyopathy
E. Recurrence of breast cancer
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  #2  
Old 04-19-2010
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This patient history of breast cancer makes her a candidate for having probably been prescribed doxorubicin in the past for her disease. The pt presents with symptoms of systolic cardiac dysfunction. The relation between doxorubicin and dilated cardiomyopathy (which is the only cardiomyopathy related to systolic dysfunction) has been well established (correct answer is D).

The exam taker should not be confused with constrictive pericarditis (or even restrictive cardiomyopathy, should this be an available option). Although this entity may have been related to mediastinal radiation, it is more commonly evident in radiotherapy following lymphomas and would present more likely as cardiac tamponade. (ie pulsus paradoxus and hypotension should be present).
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  #3  
Old 04-19-2010
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Thanks to both of you for the question and the answer...
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  #4  
Old 04-20-2010
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awesome.

i didnt think she was on doxorubicin, but my clues to dilated cardiomyopathy were reduced end-diastolic volumes and elevated diastolic pressures in both ventricles.
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Old 04-20-2010
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Default The Correct answer is C not D!

The correct answer is C. Constrictive pericarditis interferes with the filling of the ventricles because of granulation tissue formation in the pericardium. It can follow purulent viral infections, trauma, neoplastic diseases, mediastinal irradiation, and other chronic diseases. Pericardial thickening and calcification are sometimes apparent on CT and MRI.


Answer A is not correct. Cardiac tamponade is very similar in presentation to constrictive pericarditis. One defining characteristic of cardiac tamponade is the absence of Kussmaul’s sign (failure of cervical venous distention to subside on inspiration). In addition, pulsus paradoxus (decrease in systolic pressure by ?10 mm Hg during inspiration) is usually present. X-ray of the chest should reveal an enlarged cardiac silhouette with pericardial effusion.


Answer B is not correct. Congestive heart failure (CHF) produces signs and symptoms similar to those of constrictive pericarditis. However, in CHF there would be significant enlargement and hypertrophy of the ventricles.


Answer D is not correct. The echocardiogram results are not consistent with dilated cardiomyopathy, as diastolic volumes are reduced in this patient but end-diastolic volumes are increased in dilated cardiomyopathy.


Answer E is not correct. Breast and lung carcinomas, lymphomas, and melanomas are the most common metastases to the pericardium and should therefore be considered in this case. However, metastasis causing constrictive pathology is much less common than pericarditis.
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  #6  
Old 04-20-2010
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Mea culpa! As I said before, I'll step back for a while; too much posting seems to have affected my clinical judgment...
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Old 04-21-2010
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oh man i hate it when this happens. it took me a while to understand the previous concept and now i have to re-understand it!

this i better remember for future similar type question!
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