Want to take quizzes and track your credits?
A man in his mid-50s with no significant medical history was referred with 2 years of insidious exertional dyspnea and neck fullness. Examination of the jugular venous contour with the patient sitting upright at 90° is shown in Video 1. Auscultatory findings at the left lower sternal border showed normal S1 and S2 heart sounds with a diastolic sound and no murmurs (Figure 1; Video 2). Abdominal examination revealed an enlarged, pulsatile liver with smooth edges palpable 4 cm below the costal margin. Electrocardiography showed resting abnormalities (rightward axis and inferolateral T-wave inversions). Posteroanterior chest radiography showed normal heart size and clear lungs (Figure 1). Transthoracic echocardiography was performed, which showed normal left ventricular size and function without valvular abnormalities.
Please finish quiz first before checking answer.
Read the answer below and download your certificate.
Read the discussion below and retake the quiz.
B. Right and left heart catheterization
This patient has classic clinical findings of calcific constrictive pericarditis on physical examination. The jugular venous pressure is elevated to 20 cm H2O with prominent x and y descents. The jugular venous pressure contour distinguishes constriction from other clinical entities, which can present with subacute dyspnea on exertion (prominent a wave in pulmonary hypertension, giant c to v wave in severe tricuspid regurgitation, and blunted x descent in restrictive cardiomyopathy). The high-pitched early diastolic sound on auscultation is a prominent pericardial knock (Figure 2). The high-pitch frequency distinguishes it from the low-pitch middiastolic rumble of an S3 heart sound. The pericardial knock results from sudden cessation of rapid ventricular filling due to pericardial constraint1 and coincides with the y descent on jugular venous contour and the rapid diastolic filling wave in the ventricular tracing (Figure 2).
Sign in to take quiz and track your certificates
JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 CME Credit™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC
Corresponding Author: D. Brian Newman, MD, Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (email@example.com).
Published Online: September 4, 2019. doi:10.1001/jamacardio.2019.1677
Conflict of Interest Disclosures: Dr Vogt reports receiving advisory board fees from Bioplus Specialty Pharmacy Services. No other disclosures were reported.
Additional Contributions: We thank the patient for granting permission to publish this information.
You currently have no searches saved.