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Difficulty: MediumCardiovascular System

A 69-year-old man presents to the emergency department complaining of progressively worsening shortness of breath over the past 2 days. His medical history is significant for chronic obstructive pulmonary disease, essential hypertension, and a myocardial infarction 5 years ago. The patient reports a cough productive of clear sputum and states he has been sleeping in his recliner chair because lying flat makes him feel as though he is suffocating. His temperature is 37.0 C (98.6 F), blood pressure is 168/96 mmHg, pulse is 108/min, and respiratory rate is 24/min. Oxygen saturation is 90% on room air. On physical examination, the patient is in moderate respiratory distress and is using accessory muscles of respiration. Lung auscultation demonstrates bilateral end-expiratory wheezes and prominent crackles in the lower two-thirds of both lung fields. Cardiac auscultation reveals a regular tachycardia with a distinct third heart sound (S3). The jugular venous pressure is 12 cm H2O. Which of the following findings is most likely to be present on this patient's chest radiograph?

  1. Prominence of the upper lobe pulmonary vesselsAnswer
  2. B
    Hyperlucency of the lung fields with flattened hemidiaphragms
  3. C
    Focal airspace opacity with air bronchograms
  4. D
    Enlargement of the central pulmonary arteries with rapid peripheral tapering
  5. E
    Visceral pleural line with absent peripheral lung markings

Answer

Prominence of the upper lobe pulmonary vessels
This patient's clinical presentation of progressive dyspnea, orthopnea (manifested by sleeping in a recliner), crackles, elevated jugular venous pressure, and a third heart sound (S3) strongly suggests acute decompensated heart failure (ADHF). Although he has a history of chronic obstructive pulmonary disease (COPD) and presents with wheezing ('cardiac asthma'), the presence of an S3 gallop is highly specific for left ventricular systolic dysfunction and volume overload. The chest radiograph in ADHF classically reveals signs of pulmonary venous hypertension. The earliest radiographic sign is the redistribution of pulmonary blood flow to the upper lobes (cephalization), which appears as prominence of the upper lobe pulmonary vessels.

Step-by-Step Solution

1
Analyze the patient's presenting symptoms and medical history.
The patient has progressive dyspnea, severe orthopnea, and a history of both a myocardial infarction and COPD.
Identifying the baseline risk factors helps frame the differential diagnosis for acute respiratory distress, which here primarily includes acute decompensated heart failure and COPD exacerbation.
2
Evaluate the physical examination findings to differentiate the cause of the acute dyspnea.
Findings include an S3 gallop, elevated jugular venous pressure, bibasilar crackles, and wheezing.
While wheezing can occur in both conditions ('cardiac asthma' in heart failure), an S3 gallop and severe orthopnea are highly specific for left ventricular fluid overload, confirming acute decompensated heart failure.
3
Correlate the clinical diagnosis with expected radiographic findings.
The diagnosis is acute decompensated heart failure, which classically shows signs of pulmonary venous hypertension on imaging.
Cephalization (prominence of upper lobe vessels) is an early and characteristic chest x-ray finding in pulmonary venous congestion.

Key Concept

Patients with acute decompensated heart failure can present with wheezing (often termed 'cardiac asthma'), but specific findings like a third heart sound (S3) and orthopnea help distinguish it from a COPD exacerbation. The expected initial radiographic finding is pulmonary venous congestion, typically presenting as cephalization.
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Topics

Cardiovascular System

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