Running From Her Past

Abstract

A 51-year-old woman presented to the emergency room with progressive dyspnea on exertion. She was an avid runner, and had completed a half-marathon 2 months before presentation. Since then, she had experienced a rapid decline in exercise capacity such that, on presentation, she was unable to climb a flight of stairs without stopping to catch her breath. She had recently completed a course of azithromycin prescribed by her primary care physician without benefit. She denied chest pain, lower extremity swelling, fevers, chills, or cough. She had had stage II left breast adenocarcinoma successfully treated 2 years before with Adriamycin-containing chemotherapy, radiation to the left chest, and bilateral mastectomy. Her only medication was fexofenadine for seasonal allergies. She had no previous heart disease or cardiovascular risk factors, with the exception of a distant 10 -pack-year smoking history. She had no family history of premature cardiovascular disease. There was no history of illicit substance abuse. Dr John R. Teerlink:The differential diagnosis for rapidly progressive dyspnea on exertion includes cardiac, pulmonary, rheumatologic, and hematologic disorders. The notable aspects of the patient's history include her dyspnea on exertion in the absence of any other symptoms and her previous vigorous exercise capacity, which suggests a rapidly progressive process. Her previous breast cancer and associated treatment raises the possibility of Adriamycin-induced cardiomyopathy, radiation-induced coronary artery disease or constrictive pericarditis, or pulmonary embolus.On examination, the patient was comfortable but tachypneic. Her temperature was 36.6°C and her blood pressure was 112/73 mm Hg. Her heart rate was 100 bpm with a respiratory rate of 22 breaths per minute and an oxygen saturation of 94% while breathing 5 L/min oxygen via nasal cannula. The jugular venous pressure was Ͼ15 cm H 2 O with prominent V-waves. The Kussmaul sign was present. Her heart sounds were tachycardic with an accentuated P2 and a 2/6 early systolic murmur most prominent at the left lower sternal border with radiation to the left upper sternal border. There was a mild left parasternal heave. Breath sounds were slightly diminished at both lung bases. There was hepatomegaly to 1 cm below the costal margin, and the liver was softly pulsatile. Abdominal tenderness was noted in the right upper quadrant. Trace bilateral lower extremity edema was present. Dr John R. Teerlink:The elevated jugular venous pressure suggests volume overload. More specifically, a positive Kussmaul sign-paradoxically increasing plethora and elevation of the jugular pulse during inspiration-is suggestive of diminished right ventricular compliance. The most common etiologies for this finding are right ventricular (RV) infarction, constrictive pericarditis, and restrictive cardiomyopathy. The systolic murmur is consistent with tricuspid regurgitation, which would explain the prominent V waves noted in the jugular pulsation. Tricuspid regurgitation, in association wit...

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