Case 40 Cardiology

Undifferentiated Heart Failure

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

Clue 1

An older man presents with the clinical syndrome of heart failure (weight gain, orthopnea, elevated JVP, etc.)
Here is a video of his neck in the upright position:

Clue 2

Echo shows normal EF with severe concentric hypertrophy of the LV. This allows us to narrow our differential diagnosis.

What would you expect to see on EKG in a patient with severe concentric LVH? Do you see it on this EKG?

In fact, we see the opposite. Low voltage of the limb leads (with preservation of the precordial lead voltage) + anterior Q waves and poor R wave progression (pseudoinfarction pattern). Does this info help you narrow your differential diagnosis even further?

Let’s revisit the neck veins from the opening post.
There are three components to the JVP exam:

Identification
Quantitative assessment
Qualitative assessment

Clue 3

The diffuse undulating nature of the pulse here, along with the “inward” movement being most conspicuous, indicates this is no doubt a venous pulse.
It is several cm above the clavicle in the upright position. Quite elevated.
What about qualitative assessment? What do you notice about the waveform?

There is one single dominant trough that is quick/sharp. It is the Y descent. This patient has Friedreich’s sign.
He also has a second qualitative finding, demonstrated in this video:

Clue 4

Are Friedreich’s and Kussmaul’s signs associated with any of the subcategories of heart failure with preserved systolic function?

You begin to look for other clues on exam. And you find some. Easy bruising.

Let’s put the clues together:

Heart failure
Preserved systolic fxn
Low voltage EKG
Friedreich’s sign
Kussmaul’s sign
Easy bruising
What’s your diagnosis?

This patient has an infiltrative process causing restrictive CM.
PYP cardiac scan is positive for cardiac amyloidosis.

Remember, “heart failure” is not an end-point diagnosis. Good clinicians make the diagnosis of HF, but then begin to seek the underlying cause.

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For more on

End of case.