What the cause of dyspnea in this patient?

[DrNada]

A 77-year-old woman comes to the physician because of a 1-year history of progressive swelling of the ankles and a 3-month history of shortness of breath with exertion. She has not had chest pain, orthopnea, or paroxysmal dyspnea. She takes hydrochlorothiazide for hypertension, verapamil for paroxysmal atrial tachycardia, and levothyroxine for hypothyroidism. Her blood pressure is 145/72 mmHg, pulse is 78/min and regular, and respirations are 18/min. there is no jugular venous distention. The lungs are clear to auscultation. Examination shows large superficial venous varicosities on the lower extremities and moderate ankle and pedal edema bilaterally. There is loss of hair and mild hyperpigmentation over the legs. Oxygen saturation is 96% at rest and 90% with exertion. An X-ray of the chest and ECG shows no abnormalities. Ventilation-perfusion lung scans show two subsegmental perfusion with defects but no ventilation abnormalities. Echocardiography shows mitral annular calcifications.

Which of the following is the most likely explanation for this patient’s dyspnea?


A Cardiac emboli secondary to intermittent arrhythmia
B Coronary ischemia
C Left ventricular diastolic dysfunction
D Mitral insufficiency
E Recurrent pulmonary emboli

[1TA2B]

I'll go with recurrent thromboemobolic -pulmonary disease although tachyarrhythmia/carciac embolisation also a good option!

[bebix]

Recurrent pulmonary emboli

[soulhead]

B is my answer

[DrNada]

i would have chosen E too but i was told the correct answer was actually C and i dont know why (

[1TA2B]

Originally Posted by DrNada

i would have chosen E too but i was told the correct answer was actually C and i dont know why (

I'm surprised with the answer! Is there any explanation? Anybody can help?

[healer2b]

Could it be that the mitral annular calcifications suggest mitral stenosis, leading to decreased diastolic filling and dyspnea? I think the widened pulse pressure suggests mitral regurge as well.

[Haisook]

The dyspnea, together with the edema, all point to heart failure. Diastolic heart failure means the heart cannot stretch out enough, so filling is less, and blood accumulates in the pulmonary venous system, causing dyspnea, and the back pressure further reaches to the right heart and the systemic venous system, causing edema.

A Cardiac emboli secondary to intermittent arrhythmia: totally meaningless.
B Coronary ischemia: she never had angina or heart attacks.
D Mitral insufficiency: mitral annular calcifications would cause MS, not MR.
E Recurrent pulmonary emboli: would explain the dyspnea, but not the edema.

That's one good question!

[1TA2B]

Originally Posted by Haisook

The dyspnea, together with the edema, all point to heart failure. Diastolic heart failure means the heart cannot stretch out enough, so filling is less, and blood accumulates in the pulmonary venous system, causing dyspnea, and the back pressure further reaches to the right heart and the systemic venous system, causing edema.

A Cardiac emboli secondary to intermittent arrhythmia: totally meaningless.
B Coronary ischemia: she never had angina or heart attacks.
D Mitral insufficiency: mitral annular calcifications would cause MS, not MR.
E Recurrent pulmonary emboli: would explain the dyspnea, but not the edema.

That's one good question!

Thanks Haisook! Helpful!

[healer2b]

Thanks for the great explanation Haisook!

Regarding the mitral annular calcifications, UpToDate actually suggested that while they are usually asymptomatic, MACs lead to MR more frequently than MS.

"Mitral annular calcification (MAC) is a common degenerative process involving the fibrous annulus of the mitral valve. It is generally an incidental finding associated with aging although it is occasionally associated with significant mitral regurgitation and can rarely cause symptomatic mitral stenosis."

Also, I would argue that recurrent pulmonary emboli would lead to pulmonary hypertension and subsequent edema, though I agree that the overall clinical picture is that of CHF.

Do you make anything of the absence of JVD and the clear lung fields? I was wondering the peripheral vascular disease in the absence of JVD and pulmonary edema made an argument for atherosclerosis and possible angina.....

Originally Posted by Haisook

The dyspnea, together with the edema, all point to heart failure. Diastolic heart failure means the heart cannot stretch out enough, so filling is less, and blood accumulates in the pulmonary venous system, causing dyspnea, and the back pressure further reaches to the right heart and the systemic venous system, causing edema.

A Cardiac emboli secondary to intermittent arrhythmia: totally meaningless.
B Coronary ischemia: she never had angina or heart attacks.
D Mitral insufficiency: mitral annular calcifications would cause MS, not MR.
E Recurrent pulmonary emboli: would explain the dyspnea, but not the edema.

That's one good question!

[Haisook]

Originally Posted by healer2b

Regarding the mitral annular calcifications, UpToDate actually suggested that while they are usually asymptomatic, MACs lead to MR more frequently than MS.

"Mitral annular calcification (MAC) is a common degenerative process involving the fibrous annulus of the mitral valve. It is generally an incidental finding associated with aging although it is occasionally associated with significant mitral regurgitation and can rarely cause symptomatic mitral stenosis."

Well, thanks for pointing that out!

But now, I think there will be conflicting answers. Seems like the question is broken then, unless we're missing something.

May we know the source of this question, DrNada?

[healer2b]

Ya, I think there could be round about arguments made for a lot of the answers, but I like that it got me thinking :-)

[DrNada]

Actually i dont know the true origin of the question, it was handed to me on a piece of paper by a friend ..... and she too wanted to answer E but got stuck on trying to rule C out... i was kinda hoping someone else had seen this question before somewhere and has the right answer to it... it is a good question and it got everyone who saw it thinking :P ... just hope it doesent show up on my exam, though !!

[gkoutso201]

it is from internal medicine NBME practice shelf form 1

[Ahmedsamim2010]

How come there is no pulmonary edema and bi-basilar crepitations , the question says clear lung fields !!! How can a diastolic failure reach the venous system and cause leg edema without causing a pulmonary edema !
THANKS