A patient with cardiomegaly on Chest Xray

Peter Ruygrok

Mrs DD

65 year old woman Persistent cough for approx. 4 years Investigated by respiratory physicians Diagnosed - Upper airway cough syndrome

Past history of excision carotid tumour

Examination - normotensive, grade 2/6 systolic murmur, fixed split

second sound ECG & CXR CT chest showed mildly dilated pulmonary arteries

CXR

CXR – CTR 53%

ECG

Transthoracic echo

Transoesophageal echocardiogram

ASD closure – 20mm Amplatzer occluder

Chest Xray - quality

Good deep inspiration

Check it is a PA film

Important if there is a change from previous CXR – even if CTR still < 50% (e.g. 38% to 45%)

Other clues on CXR to assist diagnosis

Cardiac contours - RA or LA enlargement

Prominent PA

Prominent or unfolded ascending aorta

Lung fields - Evidence of heart failure

Plethora

Pulmonary arteries

Cardiac contours on CXR

Causes of cardiomegaly

Revisit clinical history and examination findings

History Previous MI

SOB

Malignancy

Risk factors

Exercise

Atrial fibrillation

Thyroid problems

Causes of cardiomegaly

Examination findings Murmurs

Heart failure

Wheeze

Crackles

Raised JVP

Oedema

ECG

Causes of cardiomegaly

Hypertension Valvular heart disease Ischaemic heart disease – previous MI Dilated cardiomyopathy HOCM Pericardial effusions – e.g. malignancy Right heart dilatation – Pulmonary hypertension ASD Thyroid disorders Infiltrative heart disease – amyloid Congenital heart disease

Key learning points

Cardiomegaly on CXR should be investigated further

Think of possible causes & look for clinical clues that may assist diagnosis

An echocardiogram is recommended

CXR’s pre & post LVAD implantation, and post transplantation