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All you need to do to sign up is go to pacesahead.com. And I advertise for these two sponsors because I genuinely believe that combined they essentially guarantee you'll get that all important parts in Paces. So use the discount code Pre Paces 15 at Quasimade.com and sign up today! Welcome listeners to this episode of the Pre Paces podcast with me, Dr Sam Williams. And this episode I'm continuing on the theme of last week's episode of the Mont-Wort Exotic Causes of Exertional Breathlessness. Now there's a list as long as your arm of causes of this presentation. And while last time we covered what some would say are the most likely culprits in covering the respiratory causes, that is not the only cause of this symptom. And so the idea for this episode is for you to be able to consider some alternative causes should this come up in your clinical consultation station. And I'm flying solo for this episode as most of the causes that I'm going to go through a cardiac in nature. And now in the autumn of my cardiology training is, I feel I've got just a little bit of credibility in talking about this. So I'm flying solo this episode. And some of you might be asking, why might this come up as a concept at all? Surely it's all going to be respiratory isn't it? Well yes, to a degree. But in reality, paces can throw up all sorts of conditions. And whilst the last episode with Giles Dixon, we covered most of the respiratory causes of exertional breathlessness. That might be all too easy for your garden variety medical reg. And the examiners or the powers that be want to test you to your maximum capability. And in paces, that means not only depth of knowledge, but in specific circumstances such as the stations we see more regularly in the examination stations. But in the clinical consultation stations, there is such a vast array and diverse set of conditions they could test you on. It is more or less limitless. And so through this podcast, I will try and be quite comprehensive with a variety of things which could come up from a cardiac standpoint. All with the intent of opening your mind and a fluckers on your side on exam day, your exam will feature something we've covered here on the pod. That otherwise you may not have thought about. And just going one further, we have to think carefully about what paces is trying to assess, which is as I mentioned, it's breadth and depth of knowledge. But if we get a little bit meta about things and going back to what I said to Giles in the previous episode of the podcast, there are a number of different scenarios which could come up in your clinical consultation station. If you imagine in your mind for a moment, a 2x2 squared grid where the x-axis has the condition, the examiner is presenting to you. And the condition can either be a common condition or it can be an uncommon condition. And if you imagine on the y-axis, this is giving you the type of presentation. Will they present the case to you in a typical fashion? I.e. the patient presents in a way that is presented in the textbooks or will they present the patient in an A typical fashion? A presentation of the condition which is less common. Now at the front, I'll just say I don't think there's a chance they will give you an A typical presentation of a rare condition. That's just not fair. Giving you an A typical presentation of rare condition just isn't realistic for most candidates to have a good crack out. I don't think they would do that. On the flip side, it is arguably possible that they could give you a typical presentation of a common condition. But with the same thing in mind, that really wouldn't be stretching the legs of our patients candidate. But I do think this is potentially possible. Just for example, I covered collapses very early on in the life of this podcast all the way back in episode 8. And the reason I chose to include that so early on in the podcast was because it came up for me in one of my exams and it was actually just Vesavegal synchpy. It was a typical presentation of a common condition with the aim of assessing my ability to recognize that the presentation was benign and not to over investigate and in fact reassure the patient. So I guess my point is it goes to show that common conditions can come up in paces even when they're presenting typically. However, I think the lion's share of stations which are likely to come up are of the other varieties. Either patients presenting with textbook presentations of uncommon conditions or alternatively A typical presentations of otherwise common conditions. And I should probably say as well, the one I say A typical presentations. This can also include the symptoms being typical but being presented to you in a patient that you may not expect such as an unusually young patient. So that's why I'm hoping to run you through in this episode of racked my brains to come up with what I think would be some realistic cardiology cases for you presenting with exertional breathlessness just with the aim of hopefully opening your mind to some of the possibilities that could come up in your exam. And the last thing just to consider and again thinking about paces in a sort of meta way the examiners can either provide real patients with clinical signs or they can provide actors with no clinical signs but can provide a history. Now don't forget that actors or surrogates can be of any age and the actors aren't necessarily only young. In fact, having examined on some medical school osquies there are a whole heap of willing actors in their 50s or 60s who are more than willing to give up some time and learn a patient vignette and actors a patient in these exams. And this is just something I'll touch on as we discuss some of the cases through this episode. So without further ado, I think let's get into funky shortness of breath brackets cardiology. Okay, listeners, we're going to start off with one of the themes that I discussed earlier. This is the atypical presentations of common conditions. And one case which I know has come up in the past in paces is a case of exertional breathlessness presenting as an atypical presentation of angina. So a schemic heart disease being presented in paces in an atypical fashion and again potentially in a patient that may not be the usual age or demographic that you'll see on a day-to-day basis. So just thinking about this carefully for a moment, this could either be in the form of a young patient who presents with exertional breathlessness with or without the associated chest pain who has a surprising amount of cardiovascular risk factors despite their young getting a patient. And so just to consider the type of vignette which might be presented to you something like a letter from a GP to your clinic or to the same day emergency care unit which says, for example, this 45 year old man has presented with exertional breathlessness and tight chestedness which is relieved by rest. He has an incidental history of high cholesterol found on a well-man check and has a strong family history of myocardial infarction at young ages. And things to think about here in your extended history, the patient might have a sedentary occupation. The patient might be overweight or have obstructive sleep apnea or have diabetes. Whilst in the social history, he might also be a smoker to really hammer the point home that whilst this man is really quite young, he has high cardiovascular risk. Whilst yes, if they are a smoker, you could offer COPD as a differential diagnosis. The family history of ischemic heart disease at young ages in the presence of other cardiovascular risk factors should hopefully point you in the right direction. So the skill here is to interpret the breathlessness in the right way in combination with the extended history to come to the conclusion of possible angina. Another thing which may be present in the vignette or the letter from the GP is maybe they've already been treated for something which could be a possible explanation. For example, they may have been trialed on inhalers and the patient has not responded to treatment. And this should initially really make you think that the diagnosis isn't correct and they're barking up the wrong tree. And they should really be looking for alternative causes such as those less common in this age group like angina.
[Bell] And now, keeping on the same theme, another case I had considered, along a similar theme of a common cardiology condition presenting in an atypical fashion, or in a patient you may not expect, is a young patient with symptoms of heart failure. So, exertional shortness of breath combined with orthopnea, paroxysmal, nocturnal dysnia, and peripheral edema. And the atypical part may mean this presents to the younger patient, but one who maybe has risk factors for heart failure now, there are a few reasons why a younger patient may present with symptoms of heart failure. One is, as we discussed before, having premature coronary artery disease, as I described in the last case. But there are many other risk factors to ask about in a young patient presenting with heart failure symptoms, and one of these is alcohol. As I'm sure many of you listeners will know, alcohol can contribute to the development of a dilated cardiomyopathy, particularly in a young person who has otherwise relatively few risk factors other than alcohol consumption. So, alcohol at cardiomyopathy, definitely one thing to think about. Another is chemotherapy agents. So, there are a range of chemotherapy agents, which are associated with cardiac dysfunction, anthrocycline, such as doxorubicin or epirubicin, trustuzumab or herceptin, which is the drug used to treat her to positive breast cancer, among others. And so, a background of any cancer recently or historically treated may be relevant, but I feel this is probably quite advanced for paces. But still worth thinking about, as it would signpost to the examiners that you have an idea of the types of things which can cause heart failure in a young patient. And in my eyes, the only other likely cause of this type of presentation would be a familial cardiomyopathy, such as an inherited dilated cardiomyopathy. So, there might be a strong family history of premature heart failure, possibly premature sudden cardiac death, in the absence of other typical cardiovascular risk factors. And these patients can often present in their 30s and 40s. And for those of you that have a cardiological interest, I would say that a dilated cardiomyopathy is far more likely than a hypertrophic cardiomyopathy. Because HCM quite often doesn't present initially with heart failure symptoms, not saying that it never happens, but it's just generally not the typical first presentation. And going back to what I said at the start of the episode, HCM is a rare condition, and it presenting atypically, such as having heart failure symptoms, for me, doesn't seem likely. These patients can present with breastlessness in severe disease, due to diastolic dysfunction, or heart failure with preserved ejection fraction, hef-pef, because their hearts are so hypertrophic that they become stiff. These patients can also get left ventricular outflow tract obstruction, due to basal septal hypertrophy, obstructing the flow of blood out of the heart. So, these patients can present with exertional breathlessness, and the extended history may reveal several clues for you. And I think the real giveaway would be a history of unexplained exertional syncopy, which is typical for HCM, or at least, that's what they tell you in the textbooks. They may have palpitations with precincties, suggestive of non-sustained ventricular tachycardia, as well as a family history of sudden cardiac death. And similar to the dilated cardiomyelopathy patients, they may have implantable defibrillators, they may have an ejection systolic murmur on oscultation. So, if the right patient is available in the right area, it is possible, but in my view, probably unlikely. (upbeat music) Now, the next topic I wanted to discuss was valvular heart disease. And I'm sure many of us have seen patients present with breathlessness who have a form of valvular heart disease. So, there are a few things I'd like you all to consider here for what might indicate valvular heart disease in an otherwise well-young person. First off, does the patient look marphinoid? Are they tall with a wide wingspan? Can you see any scoliosis? Marphans is typically associated with aortic root dilation. And so, these patients can have a degree of aortic regurgitation, which can cause breathlessness. And if your patient's center has patients with marphans that have any degree of aortic regurgitation, and it need not necessarily be severe. But if they have signs relevant to the condition which would be in keeping with a story of worsening valvular heart disease, then this is something to remember. These patients might be able to come into pace of centers, provide a history, have some paces counted, that's take their history and listen to their totally stable AR. Of course, this is then reliance on you listening to their chest, hopefully noting any pectus excavator along the way and appreciating the early diastolic murmur of aortic regurgitation. And considering whether they're AR maybe the cause of their breathlessness. And the other thing to consider is that they can also develop mitral valve prolapse, although in this situation, you would clearly expect a pansystolic murmur. And the textbooks would tell you they have a midsystolic click. But I think I've only heard this once or twice in my career today. So you may not be expected to detect this as it can be very subtle. Other forms of valve disease at younger ages than one might expect would be something like aortic stenosis presenting in a patient in their 40s or 50s, rather than in their 70s or 80s. Now in very young ages, such as 20s to sort of early 40s, rheumatic heart disease is the usual cause, but this is very uncommon in the UK. However, a reasonably common cause that we see in patients like this is a bicuspid aortic valve. And whilst this diagnosis is made on echocardiography, if they have a very stable patient on their books with a murmur of aortic stenosis, whether this is moderate or severe, but yet to be intervened on, these patients again can come in and have their heart listen to. And simply enough, they would be in their 50s or 60s and provide a history of symptomatic severe AS. So this may include angina or syncopy in association with progressive exertional breathlessness, as well as having an ejection systolic murmur, which should be enough to set up a clinical consultation station for you with a patient with aortic stenosis. And onto the last set of patients with valveular heart disease that could be presented to you in a paces-style scenario with exertional breathlessness, are those with mechanical heart valves. Now, as I've discussed on this podcast many times before, these patients are commonly used in the clinical examination station, but they're also very suitable for the clinical consultation as whilst they've got clinical signs, which are very stable and unlikely to change, they can usually readily come in to help with the exam, and examiners may choose to rather than simply park them in the clinical examination station, ask them to memorize a vignette, which would then demonstrate that there is possibly a complication with the mechanical valve. This might include, for example, a valve thrombosis due to a subtheraputic INR. This would present as exertional breathlessness and potentially precipitated by either not having enough medication, possibly going away on holiday, which means they don't have access to their regular doses, before then presenting with exertional breathlessness suggestive of valve thrombus. However, another possible option would be, in fact, their INR is supertheraputic and the level is too high, causing gastrointestinal bleeding and resultant enemia, which again would cause exertional breathlessness. And this could be associated with dosing errors, but I thought a really neat way of tying in a patient's presentation in this way would be to incorporate a cytochrome P450 enzyme inhibitor, and this could include antibiotic treatment for something straightforward, like a chest infection, or even a fungal infection. I'm sure many of you know the common culprits which can inhibit the P450 enzymes, and therefore increase the INR levels, include things such as sipprofroxacin, a reethromycin, chlorithromycin, as well as antifungals, ketoconazole, fluconazole. Of course, there are more of these, but I'm thinking of an easy way the examiners could throw in a reason for the patient's INR to be affected, causing occult bleeding and enemia. And keeping on the theme of anemia just for a moment, as we've mentioned before on this podcast, mechanical valves can also cause himolosis through the valve, which may cause a similar presentation, but honestly, I think this would be more of a footnote, less likely to be the actual diagnosis, but nonetheless, something to maybe mention in your discussion with the examiners if you're faced with this type of case. (upbeat music) (cars honking) Another possible cardiac cause of exertional breathlessness would be an arrhythmia. And the main culprits I would consider on this front are twofold, one being atrial fibrillation. Now, some patients can become very symptomatic from being in AF, and the symptomatology can vary widely between patients. Some experienced palpitations as the predominant feature was others can only experience fatigue and you guessed it, exertional breathlessness. I have to say, though,
that because this diagnosis is made purely on the basis of an ECG, it would be a little challenging to diagnose clinically without that. Unless, of course, you're a. unless, of course, you're provided with an ECG in the station, which is not totally unheard of. I suspect the examiners could easily bring a patient with long-standing AF and have absolutely no trouble in asking them to provide a history. The only other thing I would consider in a patient like this from an arrhythmiast standpoint is something called "cronotropic incompetence". This is where the heart's electrical system is unable to increase the heart rate to meet the demands of the body. Honestly, I'm not sure how this would be illustrated to you. The only thing I can think of is a relatively elderly patient in their 70s or upwards who has a persistent unexplained bradycardia. And equally, the examiner may throw in an element of presyncopy, which may indicate higher degrees of bradycardia or heart block. But again, this is a challenging diagnosis to make clinically and there are probably many other common causes to consider in the older patient. And lastly, write down at the bottom of our barrel of differential diagnosis for cardiac causes of exertional breathlessness. You may be more likely to find this in a young patient and this would be a case of the examiner being really mean to you. This is a form of congenital heart disease causing left to right shunting resulting in shortness of breath. This might be something like a patent foramen ovale, something like an atrial or ventricular septal defect. And what's the likelihood of this coming up is quite remote. These conditions do typically cause exertional shortness of breath. And the diagnosis is often confirmed on echo, but I guess the key learning points from these conditions is that they can remain dormant and asymptomatic for many years with patients often presenting in the third or fourth decade of life. There will be relatively little in the way of alternative explanations for their symptoms, but there is one crucial pathognomic sign which is worth discussing. And that is a symptom known as platypnea orthodeoxia. And whilst most of you probably think that this sounds more like a spell from the world of Harry Potter, if it is present in their history, it will probably give you a solid indication that there is an intracardiach shunt present. Platypnea orthodeoxia is assigned characterized by shortness of breath and deoxygenation related to a change of position. And specifically, this is changing from a recumbent or a lying position to an upright position. The patient becomes more breathless sitting up or standing. One thing to mention is that this is extremely rare. And so as I said at the start, quite unlikely to come up. And interestingly, in my research of this particular symptom, it is associated with an anatomic component, so the ASD or the VSD causing the shunt in addition to another disease process such as pericardial effusions, tricuspid regurgitation, aortic aneurysms, pulmonary embolive, the list goes on. I just thought I would mention this interesting, almost pathognomic finding in case any of you encounter this, either in your clinical practice, but also in paces. But heading back to the ASDs and the VSDs, the key clinical finding on examination will be a murmur of some sort. For PFOs and ASDs, this will likely be a fixed split second heart sound. In a VSD, typically causes a loud pan systolic murmur, her best at the left lower sternal edge. And one important note for this part of the clinical examination is that small VSDs actually make the louder murmurs. And I guess the only things which might tip you off to this being a possible diagnosis is if the examiners choose to give you the information that the patient tells you they had a hole in their heart and childhood which was either left alone or they hadn't been back to cardiology clinic and then the onus would be on you to determine what type of hole in the heart the patient has. But as I say, I think the likelihood of this coming up is low. But as ever with paces, you never know what can come up and more or less anything is fair game. Well, listeners, that is pretty much all of the exertional breathlessness. And I feel breathless just talking about this to be honest. But I'm just going to quickly recap what we've talked about today. And like I said, go back, listen to Jarls' episode, which I think was genuinely fantastic. But we're talking about exertional breathlessness where there is an absence of interesting respiratory features. So first up, I talked about angina presenting a young patient with multiple cardiovascular risk factors. And again, this might be angina presenting it to patient at a young age. Second off, I talked about heart failure presenting again in a younger patient, important to think about alcoholic cardiomyopathy, cardiotoxic chemotherapy or if there's a relevant family history, then think about an inherited cardiomyopathy. Then we talked about vascular heart disease. Does the patient look like they have a marphinoid body havetis, which can be associated with aortic regurgitation or mitral valve prolapse, or is the patient in their 50s or 60s with an ejection systolic murmur giving a history of symptoms, possibly related to aortic stenosis, and is this a bi-cuspid aortic valve, or does the patient have a mechanical valve and is presenting with a possible complication such as a valve thrombus or, as a footnote, hemolysis through the valve. Next up, I talked about arrhythmia. I think without an ECG, this is going to be really tricky. So things to consider AF or cronotropic incompetence. And finally, as I said at the bottom of the barrel, adult congenital heart disease and platypnea orthodeoxia. But listeners, I hope you found this helpful. That's just about all the time we've got for this week's show. Please don't forget to like, follow, subscribe to the show, or leave a five-star review wherever you get your podcasts. I always love to hear from my listeners, so give us a shout on the website prepacespodcast.com, or email
[email protected]. And if you want to go above and beyond and support the show, you can do that at bimicoffee.com/prepacespodcast. But for now we're just about out of time. Thank you so much for listening, I've been Dr Sam Williams, and we'll see you next time on the prepaces podcast.
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