Cardiomegaly

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Template:WikiDoc Cardiology News Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Associate Editor in Chief: Cafer Zorkun, M.D., Ph.D. [2]

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Overview

  • Cardiomegaly is defined as an enlargement of the heart above its normal size.
  • Cardiomegaly is generally first detected on chest X ray, and less often it is detected on routine physical examination.
  • Cardiomegaly may be the first sign of an occult systemic or cardiovascular disease.

Pathophysiology

The left ventricle can be enlarged from two broad underlying conditions: dilation and hypertrophy.

  • Left ventricular dilation:

Differential Diagnosis of Cardiomegaly

In alphabetical order. [1] [2]

Differential Diagnosis of Specific Chamber Enlargements

Left Atrial Enlargement

Left Ventricular Hypertrophy

Right Atrial Enlargement

Right Ventricular Hypertrophy

Diagnosis

History and Symptoms

Physical Examination

Heart

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. Normally the left heart border should not

  • Extend left of the mid clavicular line
  • Extend more than 10 cm to the left of the mid sternal line
  • Occupy a diameter > 3 cm
  • Extend below the 5th intercostal space

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.

Laboratory Findings

Based upon the history and physical, a standard evaluation might include:

Common high yield tests:

Less frequent low yield tests:

Electrolyte and Biomarker Studies

Electrocardiogram


Images shown below are courtesy of Professor Peter Anderson DVM PhD and published with permission. © PEIR, University of Alabama at Birmingham, Department of Pathology

Chest X Ray

  • 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.
  • 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.
    • Postero Anterior (PA) Projection: adult heart is 12 cm from base to apex and 8-9 cm in transverse direction
    • Lateral Projection: The adult heart is 6 cm in the Antero Posterior (AP) direction

X-ray findings for left ventricular enlargement

  • Left heart border is displaced leftward, inferiorly, or posteriorly.
  • Rounding of the cardiac apex
Cardiomegaly.
Image courtesy of C. Michael Gibson MS. MD


Cardiomegaly in a patients after mitral valve replacement. AP view. Image courtesy of RadsWiki


Cardiomegaly in a patients after mitral valve replacement. Lateral view. Image courtesy of RadsWiki.


X-ray findings for left atrial enlargement

  • Double density sign: Occur when the right side of the left atrium pushes into the adjacent lung.
  • Convex left atria appendage: usually reflect prior rheumatic heart disease
  • Splaying of the carina
  • Posterior displacement of the left main stem bronchus on lateral radiograph
  • Superior displacement of the left main stem bronchus on frontal view
  • Posterior displacement of a barium filled esophagus
Double density sign


Double density sign


X-ray findings for right ventricular enlargement

  • Frontal view
  • Rounded left heart border
  • Uplifted apex
  • Lateral view
  • Filling of the retrosternal space
  • Rotation of the heart posteriorly

X-ray findings for right atrial enlargement

  • On a frontal view, the right atrium is visible because of its interface with the right middle lobe.
  • 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.

Echocardiography or Ultrasound

  • Echocardiogram recommended for those patients presenting suspected valvular disease, chamber size, ventricular function, and wall motion abnormalities

Other Diagnostic Studies

Pathological Findings

Image courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology

Right ventricular enlargement due to a patent ductus arteriosus in a patient with hyaline membrane disease


Treatment

Pharmacotherapy

Acute Pharmacotherapies

Chronic Pharmacotherapies

A combination of diuretics and angiotensin converting enzyme (ACE) inhibition is currently the standard of care. Digoxin may reduce the frequency of rehospitalization, but does not improve mortality.

Surgery and Device Based Therapy

Transplantation

Future or Investigational Therapies

Mechanical strategies currently under investigation include:

  1. Development of devices to reduce the size of the heart
  2. Development of a device to exclude that portion of the apex where clots may form.

Pathological Findings

Images shown below are courtesy of Professor Peter Anderson DVM PhD and published with permission. © PEIR, University of Alabama at Birmingham, Department of Pathology





References

  1. Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016
  2. Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X

Additional Reading

  • 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
  • Hurst's the Heart, Fuster V, 12th ed. 2008, ISBN 978-0-07-149928-6
  • Willerson JT, Cardiovascular Medicine, 3rd ed., 2007, ISBN 978-1-84628-188-4

Acknowledgements

The content on this page was first contributed by C. Michael Gibson, M.S., M.D.

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