Test Yourself on the ABCs

Test YourselfOn the ABCsOf Heart Disease

If you haven’t already, you shouldreview the lecture entitled “The ABCs of Heart Disease ”

The next slide is a review of thescheme for evaluating the heart fromthe frontal chest x-ray

Review

Is the Left

Atrium

Enlarged?

If yes,

then

If no,

then

Look at the

Pulmonary

Vasculature

Normal

Increased

Pulmonary

venous

hypertension

Is the Main

Pulmonary

Artery Big

Bulbous?

If yes,

then

If no,

then

Look at the

Pulmonary

Vasculature

Is the Main

Pulmonary

Artery

Segment

Concave?

If yes,

then

If no,

then

Is the

Heart

Dilated or

Delta-

Shaped?

If yes,

then

Don't Look at

Pulmonary

Vasculature.

Look at Aorta

Normal

Increased

Pulmonary

hypertension

Cardiomyopathy

Pericardial

Effusion

Multiple valve dz

Mitralregurgitation

Mitral

Stenosis

L Myxoma

VSD, PDA

Pulmonic

stenosis

ASD

(VSD)

Idiopathic

2° to lung dz

Normal

Ascending

dilated

Whole Aorta

Dilated

Cardiomyopathy

Aortic

Stenosis

Aorticregurgitation

HBP

Unknowns

Unknown Case 1

Here is unknown 1.It’s a 43 year-old female with shortness of breath.

The first question to ask is : A - Is the left atriumenlarged? To answer that question, you look at thecardiac contour where you will see left atrialenlargement. Is there a concavity there or is it straightor convex outward?

If you said the left atrium is not enlarged, you werecorrect. There is a normal concavity where the yellowarrow is.

If you said the MPA protrudes beyond the tangent line(yellow arrow), you were correct. This is a “B” heart.

Is the Main

Pulmonary

Artery Big

Bulbous?

If yes,

then

Look at the

Pulmonary

Vasculature

Normal

Increased

Pulmonary

hypertension

Pulmonic

stenosis

ASD

(VSD)

Idiopathic

2° to lung dz

This is the algorithm for a “B” heart. The next thing you needto look at is the pulmonary vasculature. You have threechoices for the pulmonary vasculature for a “B” heart:

• Normal flow

• Increased flow

• Pulmonary arterial hypertension

The next thing to look at is the right descendingpulmonary artery (RDPA). In normal people it usuallymeasures less than 17 mm. It has been measured foryou in this patient. It measures 31 mm.

That excludes “Normal vasculature” and leaves eitherIncreased flow to the lungs or pulmonary hypertension.Next look at the peripheral pulmonary vasculature.

If you think the peripheral pulmonary vasculature looksincreased, then this is increased flow to the lungs.

If you think the peripheral pulmonary vasculature looksnormal, then you have described a discrepancy in sizebetween the central vessels (which are enlarged) andthe peripheral vessels, which aren’t. That discrepancydefines pulmonary arterial hypertension.

Increased flowIncreased flow

To help you make that decision, hereis an inset of increased flow to thelungs.

The peripheral pulmonary vasculature is normalwhereas the central vasculature is prominent.

1 PulmonaryHypertension

This is a case of pulmonary arterial hypertension, inthis instance primary or idiopathic pulmonary arterialhypertension.

Unknown Case 2

Here is unknown 2.It’s a 67 year-old female with hemoptysis.

The first question to ask is : A - Is the leftatrium enlarged? To answer that question,you look at the cardiac contour where youmight see left atrial enlargement. Is there aconcavity there or is it straight or convexoutward?

If you said the left atrium is enlarged, youwere correct. There is a bump outwardwhere a normal concavity should be.This is an “A” heart.

Is the Left

Atrium

Enlarged?

If yes,

then

Look at the

Pulmonary

Vasculature

Normal

Increased

Pulmonary

venous

hypertension

Mitralregurgitation

Mitral

Stenosis

L Myxoma

VSD, PDA

PulmonaryArterialHypertension

Mitral

Stenosis

VSD,PDA

This is the algorithm for an “A” heart. The next thing youneed to look at is the pulmonary vasculature. You have fourchoices for the pulmonary vasculature for an “A” heart:

• Normal flow

• Pulmonary venous hypertension

• Increased flow

• Pulmonary arterial hypertension

The next thing to look at is the rightdescending pulmonary artery (RDPA). Innormal people it usually measures lessthan 17 mm. It has been measured for youin this patient. It measures 19 mm.

Next look at the peripheral pulmonaryvasculature. We’re going to compare thesize of the vessels at the base with those atthe apex. The next slide has blown upinsets of the apex and base.

Compare the size, not thenumber, of the vessels atthe apex and base.Normally the vessels atthe base should be largerthan those at the apexwith the person in theerect position. Is that truehere?

In this person, thevessels at the apex arelarger than those at thebase. This iscephalization. What kindof pulmonary vasculaturedoes cephalizationimply?

If you said pulmonary venous hypertension(PVH), you were correct. What is the firstdiagnosis in the “A” heart algorithm forpulmonary venous hypertension?

MitralStenosis

This is a patient with mitral stenosis.

Unknown Case 3

Here is unknown 3.It’s a 2 year-old male with a murmur.

The first question to ask is : A - Is the left atriumenlarged? To answer that question, you look atthe cardiac contour where you will see left atrialenlargement. Is there a concavity there or is itstraight or convex outward?

If you said the left atrium is not enlarged, youwere correct. There is a normal concavity wherethe yellow arrow is.

If you said the MPA protrudes beyond the tangentline (yellow arrow), you were correct.This is a “B” heart.

Is the Main

Pulmonary

Artery Big

Bulbous?

If yes,

then

Look at the

Pulmonary

Vasculature

Normal

Increased

Pulmonary

hypertension

Pulmonic

stenosis

ASD

(VSD)

Idiopathic

2° to lung dz

This is the algorithm for a “B” heart. The next thing you needto look at is the pulmonary vasculature. You have threechoices for the pulmonary vasculature for a “B” heart:

• Normal flow

• Increased flow

• Pulmonary arterial hypertension

The first thing to look at is the right descendingpulmonary artery (RDPA). In normal people itusually measures less than 17 mm. It has beenmeasured for you in this patient at 26 mm.

That excludes “Normal vasculature” and leaveseither Increased flow to the lungs or pulmonaryhypertension. Next look at the peripheralpulmonary vasculature.

If you think the peripheral pulmonary vasculaturelooks increased, then this is increased flow to thelungs.

If you think the peripheral pulmonary vasculaturelooks normal, then you have described adiscrepancy in size between the central vesselsand the peripheral vessels.

PAH

To help you make that decision, hereis an inset of PAH.

If you said increased flow to the lungs, you werecorrect. Look at the algorithm for a “B” heart underincreased flow. What are the diseases listed?

This patient had an atrial septal defect.

AtrialSeptalDefect

Unknown Case 4

Here is unknown 4.It’s a 57 year-old male with chest pain.

This is obviously a “D” heart. If youfollowed the ABCs schema in a systematicfashion, you would come to the sameconclusion.

This is the algorithm for a “D” heart. There are two major causes of a dilated or a delta-shaped heart:

• Cardiomyopathy

• Pericardial effusion

Is the

Heart

Dilated or

Delta-

Shaped?

If yes,

then

Cardiomyopathy

Pericardial

Effusion

Multiple valve dz

It is oftenimpossible todifferentiate apericardialeffusion from acardiomyopathyfrom the chest x-ray alone. In thiscase, the heart isa typical “waterbottle” shape ofa pericardialeffusion. It hascontour-lessborders typicalof a largeeffusion.

Causes

• Viral

• TB

• Lupus

• Mets

• Trauma

• Post-MI

• Uremia

There arenumerouscauses for apericardialeffusionand it isusuallyimpossibleto find otherclues on thechest film totell you theexactcause. Howmanycauses canyou name?

The patient had uremic pericarditis.

Unknown Case 5(Last case)

Here is unknown 5.It’s a 43 year-old male with syncope.

The first question to ask is : A - Is the left atriumenlarged? To answer that question, you look atthe cardiac contour where you will see left atrialenlargement. Is there a concavity there or is itstraight or convex outward?

If you need help,click here.

If you said the left atrium is not enlarged, youwere correct. There is a normal concavitywhere the yellow arrow is.

The next question to ask is: B – Is the mainpulmonary artery (MPA) big? To answer thatquestion you need to draw the tangent line fromthe apex of the left ventricle to the aortic knoband determine if the MPA protrudes beyond thetangent line. Does it?The next question to ask is: B – Is the mainpulmonary artery (MPA) big? To answer thatquestion you need to draw the tangent line fromthe apex of the left ventricle to the aortic knoband determine if the MPA protrudes beyond thetangent line. Does it?

If you said no, you were correct.If you said yes, click here.

The next question to ask is: C - Is the MPAsegment concave? Is it more than 15mm fromthe tangent line?

The answer to question C is yes.This is a “C” heart.

This is the algorithm for a “C” heart. Since almost all “C”hearts have normal pulmonary vasculature, that won’t helpto differentiate one from another. So we will look at theconfiguration of the thoracic aorta. In particular:

Is the thoracic aorta entirely normal?

Is only the ascending aorta prominent?

Is the entire thoracic aorta abnormal?