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| | __NOTOC__ |
| | '''For the WikiPatient page for this topic, click [[{{PAGENAME}} (patient information)|here]]''' |
| {{DiseaseDisorder infobox | | | {{DiseaseDisorder infobox | |
| Name = Cardiomegaly | | | Name = Cardiomegaly | |
| ICD10 = {{ICD10|I|51|7|i|30}} |
| | Image = cardiomegaly-2.jpg| |
| ICD9 = {{ICD9|429.3}} |
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| ICDO = |
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| Image = cardiomegaly-2.jpg|
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| Caption = |
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| OMIM = |
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| MedlinePlus = |
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| eMedicineSubj = |
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| eMedicineTopic = |
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| DiseasesDB = 30769 |
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| MeshID = D006332 |
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| }} | | }} |
| {{SI}} | | {{Template:Cardiomegaly}} |
| {{WikiDoc Cardiology Network Infobox}}
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| {{WikiDoc Cardiology News}}
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| {{CMG}} | | {{CMG}} |
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| '''Associate Editor in Chief:''' {{CZ}}
| | {{SK}} Enlarged heart; heart enlargement; |
| | | ==[[Cardiomegaly overview|Overview]]== |
| {{Editor Help}}
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| ==Overview==
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| * '''Cardiomegaly''' is defined as an enlargement of the heart above its normal size.
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| * '''Cardiomegaly''' is generally first detected on [[chest X ray]], and less often it is detected on routine physical examination.
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| * '''Cardiomegaly''' may be the first sign of an occult systemic or cardiovascular disease.
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| ==Pathophysiology== | | ==[[Cardiomegaly historical perspective|Historical Perspective]]== |
| The left ventricle can be enlarged from two broad underlying conditions: dilation and hypertrophy.
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| *'''Left ventricular dilation:'''
| | ==[[Cardiomegaly pathophysiology|Pathophysiology]]== |
| :*Can occurs as a result of volume overload. Conditions that cause volume overload can be further broken down as follows:
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| :*'''Valvular Disease:''' More common underlying [[valvular heart disease]] conditions would include [[mitral regurgitation]] and [[aortic regurgitation]]
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| :*'''Congenital Heart Disease:''' [[Patent ductus arteriosus]] and a [[ventricular septal defect]].
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| :*'''High output states resulting in volume overload:''' [[Anemia]] and [[thyrotoxicosis]].
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| :*'''High stroke volume states:''' [[Complete heart block]] and prolonged severe [[sinus bradycardia]]
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| :*Can occur as a result of [[ischemia]] and remodeling
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| == Differential Diagnosis of Cardiomegaly== | | ==[[Cardiomegaly causes|Causes]]== |
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| In alphabetical order. <ref>Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016</ref> <ref>Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X</ref>
| | ==[[Cardiomegaly differential diagnosis|Differentiating Cardiomegaly from other Diseases]]== |
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| * [[Acromegaly]]
| | ==[[Cardiomegaly epidemiology and demographics|Epidemiology and Demographics]]== |
| * [[Cardiomyopathy|Alcoholic cardiomyopathy]]
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| * [[Amyloidosis]]
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| * [[Anemia]]
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| * [[Primary Cardiac Tumors|Atrial myxoma]]
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| * [[Carcinoid]]
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| * [[Chronic Obstructive Pulmonary Disease]] ([[COPD]])
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| * [[Congenital heart disease]]
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| * [[Congestive Heart Failure]] [[CHF]]
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| * [[Ddx:Cor Pulmonale|Cor pulmonale]]
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| * [[Drug]]s
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| * [[Endocardial fibroelastosis]]
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| * Epicardial fat pad
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| * [[Fabry's Disease]]
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| * [[Hemochromatosis]]
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| * [[Hurler's Syndrome]]
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| * [[Hyperparathyroidism]]
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| * [[Hypertension]]
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| * [[HOCM|Hypertrophic cardiomyopathy]]
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| * [[Ddx:Hypocalcemia|Hypocalcemia]]
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| * [[Hypomagnesemia]]
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| * [[Hypoparathyroidism]]
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| * [[Hypophosphatemia]]
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| * [[Cardiomyopathy|Idiopathic cardiomyopathy]]
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| * [[CAD|Ischemic heart disease]]
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| * [[Kyphoscoliosis]]
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| * [[Marfan's Syndrome]]
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| * [[Mediastinal mass]]
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| * [[Myocarditis]]
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| * Normal, "athletic" heart
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| * [[Pompe's Disease]]
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| * [[Postradiation]]
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| * [[Pregnancy]]
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| * [[Primary pulmonary hypertension]]
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| * [[Pulmonary embolism]]
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| * [[Renal failure]]: [[Acute Renal Failure]] and [[Chronic Renal Failure]]
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| * [[Scleroderma]]
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| * [[Sickle cell disease]]
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| * [[Subacute bacterial endocarditis]]
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| * [[Systemic Lupus Erythematosus]]
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| * [[Valvular heart disease]]
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| == Differential Diagnosis of Specific Chamber Enlargements== | | ==[[Cardiomegaly risk factors|Risk factors]]== |
| === Left Atrial Enlargement ===
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| * [[Atrial]] [[aneurysm]]
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| * [[Infective endocarditis]]
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| * [[Left heart failure]]
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| * [[Mitral regurgitation]]
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| * [[Mitral stenosis]]
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| * [[Mitral valve prolapse]]
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| * [[Myxedma]]
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| * [[Patent Ductus Arteriosus]]
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| * [[Ventricular septal defect]]
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| === Left Ventricular Hypertrophy === | | ==[[Cardiomegaly screening|Screening]]== |
| * [[Acromegaly]]
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| * [[Alcoholic cardiomyopathy]]
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| * [[Aortic coarctation]]
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| * [[Aortic regurgitation]]
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| * [[Aortic stenosis]]
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| * [[Chronic Renal Failure]]
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| * [[Familial dilated and hypertrophic cardiomyopathy]]
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| * [[Hypertrophic cardiomyopathy]] ([[HCM]])
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| * [[Idiopathic dilated cardiomyopathy]]
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| * [[Mitral regurgitation]]
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| * [[Patent Ductus Arteriosus]]
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| * [[Restrictive cardiomyopathy]]
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| * [[Thalassemia]]
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| === Right Atrial Enlargement === | | ==[[Cardiomegaly natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| * [[Atrial]] [[aneurysm]]
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| * [[Atrial septal defect]]
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| * [[Ebstein's anomaly]]
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| * [[Pulmonic stenosis]]
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| * [[Cor pulmonale|Right heart failure]]
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| * [[Tricuspid prolapse]]
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| * [[Tricuspid regurgitation]]
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| * [[Tricuspid stenosis]]
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| * [[Primary Cardiac Tumors|Tumor]]
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| === Right Ventricular Hypertrophy ===
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| * [[Atrial septal defect]]
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| * [[Chronic Obstructive Pulmonary Disease]] ([[COPD]])
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| * [[Ddx:Cor Pulmonale|Cor pulmonale]]
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| * [[Eisenmenger's Syndrome]]
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| * [[Left ventricular hypertrophy]] or [[Left ventricular dilation]]
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| * [[Mitral stenosis]]
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| * [[Pickwickian Syndrome]]
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| * [[Pulmonic regurgitation]]
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| * [[Pulmonic stenosis]]
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| * [[Tetralogy of Fallot]]
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| * [[Transposition of the Great Vessels]]
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| * [[Tricuspid regurgitation]]
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| * [[Ventricular septal defect]]
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| == Diagnosis == | | == Diagnosis == |
| | | [[Cardiomegaly history and symptoms|History and Symptoms]] | [[Cardiomegaly physical examination|Physical examination]] | [[Cardiomegaly laboratory findings|Laboratory Findings]] | [[Cardiomegaly electrocardiogram|Electrocardiogram]] | [[Cardiomegaly chest x ray|Chest X ray]] | [[Cardiomegaly MRI|MRI]] | [[Cardiomegaly CT|CT]] | [[Cardiomegaly echocardiography or ultrasound|Echocardiogpraphy or Ultrasound]] | [[Cardiomegaly other imaging findings|Other Imaging Findings]] | [[Cardiomegaly other diagnostic studies|Other Diagnostic Studies]] |
| === History and Symptoms ===
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| * In the history, the physician should inquire as to:
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| *:* History of [[chest pain]] to suggest [[ischemic heart disease]]
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| *:* History of [[rheumatic fever]] or known [[valvular heart disease]]
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| *:* History of [[congenital heart disease]]
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| *:* History of [[drug]] and [[alcohol]] use (recreational)
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| *:* [[Family history]] (heart disease or sudden death)
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| * Associated symptoms:
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| *:* [[Dizziness]]
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| *:* [[Syncope]]
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| *:* [[Fatigue]]
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| *:* [[Dyspnea]]
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| *:* [[Palpitation]]s
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| === Physical Examination ===
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| === Heart ===
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| There is downward and leftward displacement of the heart on percussion of heart border. The heart should be percussed with the patient supine and the head of the bed elevated 30 degrees.
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| Normally the left heart border should not
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| *Extend left of the mid clavicular line
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| *Extend more than 10 cm to the left of the mid sternal line
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| *Occupy a diameter > 3 cm
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| *Extend below the 5th intercostal space
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| The body habitus of the individual must be taken into account in performing the examination. In athletic individuals who are thin, the impulse maybe strongly transmitted. In muscular or obese patients, the opposite is true. In patients with [[pectus excavatum]], the apex can be displaced laterally.
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| == Laboratory Findings ==
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| Based upon the history and physical, a standard evaluation might include:
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| Common high yield tests:
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| * [[Complete blood count]] ([[CBC]]): to rule out [[anemia]]
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| * [[Thyroid stimulating hormone]] ([[TSH]])
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| * [[Blood urea nitrogen]] ([[BUN]]) / [[creatinine]]
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| Less frequent low yield tests:
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| * [[Erythrocyte sedimentation rate]] ([[ESR]]): to evaluate autoimmune causes
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| * [[Calcium]]: to rule out [[hypocalcemia]]
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| * [[Magnesium]]: to rule out [[hypomagnesemia]]
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| * [[Rheumatoid factor]]
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| * [[Antinuclear antibody]] ([[ANA]])
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| * [[Glucose]]
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| * [[Pheochromocytoma]] screening
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| * [[Phosphorus]]: to rule out [[hypophosphatemia]]
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| * [[Blood culture]]s
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| === Electrolyte and Biomarker Studies ===
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| * [[Electrolyte]]s should be periodically checked in the patient treated with a [[diuretic]] to avoid [[hypokalemia]].
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| * [[Brain Natriuretic Peptide]] ([[BNP]]) levels may provide insight into the ongoing magnitude of LV dysfunction.
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| === Electrocardiogram ===
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| *The presence of [[q wave]]s suggest a prior [[MI]] to account for the enlargement.
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| *[[ST segment elevation]] would suggest either ongoing or resolving [[ST Elevation Myocardial Infarction]] or [[Myocarditis]] or [[Pericarditis]].
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| *The EKG may suggest signs of [[left atrial enlargement]], [[right atrial enlargement]] or [[right axis deviation]] which may point toward a specific diagnosis.
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| ''Images shown below are courtesy of Professor Peter Anderson DVM PhD and published with permission. [http://www.peir.net © PEIR, University of Alabama at Birmingham, Department of Pathology]''
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| <div align="left">
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| <gallery heights="125" widths="175">
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| Image: RA enlargement EKG.jpg|Right atrial enlargement
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| Image: Biatrial enlargement EKG.jpg|Biatrial enlargement
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| </gallery>
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| </div>
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| === Chest X Ray ===
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| *Cardiomgaly is traditionally defined as an increase in the cardiothoracic ratio to be > 0.5 on a '''PA''' film. To calculate the thoracic ratio, the width of the cardiac silhouette is divided by the width of the entire thoracic cage.
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| *'''If the heart is viewed on an AP film, the heart can appear to be artificially enlarged because the X ray beam moves from anterior to posterior direction and therefore the heart which lies anterior is magnified.'''
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| *:* Postero Anterior (PA) Projection: adult heart is 12 cm from base to apex and 8-9 cm in transverse direction
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| *:* Lateral Projection: The adult heart is 6 cm in the Antero Posterior (AP) direction
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| [[image:cardiomegaly-2.jpg|left|400px|thumb|Cardiomegaly. <br> <small>Image courtesy of [[C. Michael Gibson]] MS. MD</small>]]
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| <br clear="left"/>
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| Image:Cardiomegaly-prosthetic-mitral-valve-001.jpg|left|400px|thumb|Cardiomegaly in a patients after mitral valve replacement. AP view. <br><small>Image courtesy of RadsWiki</small>]]
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| <br clear="left"/>
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| [[Image:Cardiomegaly-prosthetic-mitral-valve-002.jpg|left|400px|thumb|Cardiomegaly in a patients after mitral valve replacement. Lateral view. <br> <small>Image courtesy of RadsWiki</small>]] | |
| <br clear="left"/>
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| ====X-ray findings for left atrial enlargement====
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| *'''Double density sign:''' Occur when the right side of the left atrium pushes into the adjacent lung.
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| *Convex left atria appendage: usually reflect prior [[rheumatic heart disease]]
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| *Splaying of the carina
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| *Posterior displacement of the left main stem bronchus on lateral radiograph
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| *Superior displacement of the left main stem bronchus on frontal view
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| *Posterior displacement of a barium filled esophagus
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| [[Image:Left-atrial-enlargement-001.jpg|left|400px|thumb|Double density sign]] | |
| <br clear="left"/>
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| [[Image:Left-atrial-enlargement-002.jpg|left|400px|thumb|Double density sign]] | |
| <br clear="left"/>
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| ====X-ray findings for right ventricular enlargement====
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| *Frontal view
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| :*Rounded left heart border
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| :*Uplifted apex
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| *Lateral view
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| :*Filling of the retrosternal space
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| :*Rotation of the heart posteriorly
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| ====X-ray findings for right atrial enlargement====
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| *On a frontal view, the right atrium is visible because of its interface with the right middle lobe.
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| *Subtle and moderate right atrial enlargement is not accurately determined on plain films because there is normal variability in the shape of the right atrium.
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| === Echocardiography or Ultrasound ===
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| * Echocardiogram recommended for those patients presenting suspected valvular disease, chamber size, ventricular function, and wall motion abnormalities
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| === Other Diagnostic Studies ===
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| * Exercise or pharmacologic stress testing may be indicated in those patients suspected of having [[coronary artery disease]]
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| * Patients suspected of having valvular disease or [[coronary artery disease]] may need a [[cardiac catheterization]] for full evaluation following [[echocardiography]]
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| ==Pathologic Findings==
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| Image shown below is courtesy of Professor Peter Anderson DVM PhD and published with permission. [http://www.peir.net © PEIR, University of Alabama at Birmingham, Department of Pathology]
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| <div align="left">
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| <gallery heights="125" widths="125">
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| Image: RVE Hyalin membran disease.jpg|Right ventricular enlargement due to a patent ductus arteriosis in a patient with hyaline membrane disease
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| </gallery>
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| </div>
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| == Treatment == | | == Treatment == |
| | [[Cardiomegaly medical therapy|Medical therapy]] | [[Cardiomegaly surgery|Surgery]] | [[Cardiomegaly prevention|Prevention]] | [[Cardiomegaly cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Cardiomegaly future or investigational therapies|Future or Investigational therapies]] |
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| == Pharmacotherapy == | | ==Case Studies== |
| | | [[Cardiomegaly case study one|Case #1]] |
| === Acute Pharmacotherapies ===
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| * Administration of [[digoxin]], [[diuretic]]s, [[antiarrhythmics]] and/or [[preload]] and [[afterload]] reducers per clinical indication
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| === Chronic Pharmacotherapies ===
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| A combination of [[diuretic]]s and [[angiotensin converting enzyme]] ([[ACE]]) inhibition is currently the standard of care. [[Digoxin]] may reduce the frequency of rehospitalization, but does not improve mortality.
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| == Surgery and Device Based Therapy ==
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| * In patients who are awaiting a transplant for end-stage symptomatic [[heart failure]], implantable [[ventricular assist devices]] may serve as a temporary aid for compensation.
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| === Transplantation ===
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| * In patients who are in end-stage symptomatic [[heart failure]], a [[heart transplant]] my be necessary.
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| == Future or Investigational Therapies ==
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| Mechanical strategies currently under investigation include:
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| #Development of devices to reduce the size of the heart
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| #Development of a device to exclude that portion of the apex where clots may form.
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| ==Pathological Findings==
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| Images shown below are courtesy of Professor Peter Anderson DVM PhD and published with permission. [http://www.peir.net © PEIR, University of Alabama at Birmingham, Department of Pathology]
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| <div align="left">
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| <gallery heights="140" widths="140">
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| Image:Biventricular Hypertrophy.jpg|Biventricular Hypertrophy
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| Image:Biventricular Hypertrophy 1.jpg|Biventricular Hypertrophy
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| </gallery>
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| </div>
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| <div align="left">
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| <gallery heights="140" widths="140">
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| Image:Left ventricular hypertrophy 2.jpg|Gross excellent example of concentric left ventricular hypertrophy
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| Image:Left ventricular hypertrophy 1.jpg|Left Ventricular Hypertrophy: Gross natural color anterior view intact heart showing disproportionate size of left ventricle by its inferior extent much below the right ventricle apex (quite good example)
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| </gallery>
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| </div>
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| <div align="left">
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| <gallery heights="140" widths="140">
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| Image:Right ventricular hypertrophy.jpg|Myocardial Infarct: Gross natural color apical section showing large left ventricle infarct and right ventricular hypertrophy
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| Image:Right ventricular hypertrophy 1.jpg|Right ventricular hypertrophy
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| </gallery>
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| </div>
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| == References ==
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| {{reflist}}
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| ==Additional Reading==
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| * Moss and Adams' Heart Disease in Infants, Children, and Adolescents Hugh D. Allen, Arthur J. Moss, David J. Driscoll, Forrest H. Adams, Timothy F. Feltes, Robert E. Shaddy, 2007 ISBN 0781786843
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| * Hurst's the Heart, Fuster V, 12th ed. 2008, ISBN 978-0-07-149928-6
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| * Willerson JT, Cardiovascular Medicine, 3rd ed., 2007, ISBN 978-1-84628-188-4
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| == Acknowledgements ==
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| The content on this page was first contributed by C. Michael Gibson, M.S., M.D.
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| {{Electrocardiography}}
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| {{Circulatory system pathology}}
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| {{SIB}}
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| {{WikiDoc Sources}} | | {{WikiDoc Sources}} |
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| [[Category:Physical examination]]
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| [[Category:Cardiology]] | | [[Category:Cardiology]] |
| [[Category:Signs and symptoms]] | | [[Category:Disease]] |