Cardiovascular Pathology Case Studies


CASE 1: Cardiomyopathy


Clinical History:

A 34-year-old man works as an administrator in a nursing home. His job is not strenuous, but he comes to his physician complaining of shortness of breath on weekends when he is more active in sports with his family. Sleeping is becoming more difficult, and he reports a better night's sleep if he props himself up on a couple of pillows. He reports no chest pain. He has no history of alcohol or tobacco use. On physical examination he is found to have a pulse of 75, respirations 28, temperature 36 C, and blood pressure 115/75 mm Hg. Examination of the chest reveals bilateral lower lung field rales. The heart has a regular rate and rhythm, but there is a faint murmur suggesting tricuspid insufficiency. He also has lower extremity edema.
  1. What is the diagnosis?

    2. This is a cardiomyopathy of the "dilated" variety.

  2. What is the etiology of this disease?

    3. The etiology in this patient is not clear, and the process is termed "idiopathic congestive cardiomyopathy". Some persons with morbid obesity may develop a dilated cardiomyopathy ("obesity cardiomyopathy"). Congestive cardiomyopathy may be due to alcoholism or may occur following viral myocarditis. Hypertrophic cardiomyopathy is idiopathic and can be respresented by an entity such as idiopathic hypertrophic subaortic stenosis (IHSS). The third form of cardiomyopathy called restrictive or infiltrative can be due to a process such as amyloidosis or hemochromatosis.

  3. How do you explain the signs and symptoms manifested in this patient?

    4. The patient could have signs and symptoms of congestive heart failure. Pain is usually not a feature of cardiomyopathy. Since both left and right heart are failing, he could have pulmonary congestion and edema from left heart failure, and peripheral edema from right heart failure.

  4. Explain the mechanism for increased comfort at night derived from using extra pillows.

    5. Discomfort when lying in bed "orthopnea" is secondary to a reduced venous return from regions caudal to the heart as a result of the loss of gravitational force pulling blood back the heart when upright. By propping up on pillows, gravity increases the venous return from the caudal regions. Heart Failure in the early days prior to NY Heart Association Classification often referred to the number of pillows used at bed time (1 pillow, 2 pillow, 3 pillow etc) to class the severity of thwe failure.

  5. Is this process in the lung more typical of right or of left-sided failure?

    6. It is more typical of left-sided heart failure.

  6. Where does the hemosiderin seen in the alveolar macrophages come from?

    7. The hemosiderin comes from hemorrhage as a result of congestion.

  7. What are treatment options?

    8. Reduction in sodium and volume via diuretics may be of benefit. The beta-adrenergic antagonists may aid in preload and afterload reduction on the heart. Persons with a history of thromboembolism, with atrial fibrillation, or with evidence for mural thrombosis may benefit from oral anticoagulation.

    Cardiac transplantation is a consideration for persons who could gain considerable quality years of useful life. Orthotopic heart transplantation has a good five year survival, but there are far more people waiting for hearts than the number of organs. How should they be allocated? The number of persons from underserved populations receiving transplants is lower than the general population with access to medical care. How does this happen?