Case 8 Cardiology

Heart Failure

Work it one clue at a time. The diagnosis stays hidden until you reveal it.

Clue 1

A man presents to you with the clinical syndrome of heart failure (weight gain, orthopnea, elevated JVP, etc.). BP is 144/48 mm Hg.

This should generate a hypothesis. Yoo you look for other specific physical findings. What do you notice in this video?

Clue 2

Quincke’s pulse is consistent with your hypothesis, so you look for more evidence in his neck. And you have found it.

Clue 3

You then listen to the patient’s heart in anticipation of hearing a decrescendo diastolic murmur and confirming your suspicions.

But there is no decrescendo diastolic murmur. Further, his echocardiogram is totally normal. There is no aortic valve pathology. There is no systolic dysfunction.

Wide pulse pressure, Quincke’s pulse, and Corrigan’s pulse are not specific for aortic regurgitation. They are physical manifestations of a hyperkinetic state from ANY cause.

The combination of high-output physiology and HF should generate a new hypothesis. You test your hypothesis with right heart catheterization.

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