Decreased Exercise Tolerance in a Young Woman—What Would You Do Next? | Cardiology | JN Learning | AMA Ed Hub [Skip to Content]
[Skip to Content Landing]

Decreased Exercise Tolerance in a Young Woman

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 31-year-old woman presented to clinic with decreased exercise tolerance due to shortness of breath for the past 2 weeks. She has no chest pain but was experiencing heart palpitations a few times per week. She denies any significant medical history, takes only multivitamins, and mentions a childhood heart murmur that was never evaluated.

On examination, her blood pressure was 125/85 mm Hg, with a heart rate of 71/min and respiratory rate of 18/min. Physical examination revealed a fixed split S2 and a 2/6 systolic murmur at the left upper sternal border. An electrocardiogram demonstrated sinus rhythm with incomplete right bundle-branch block. A chest radiograph was obtained (Figure 1). Transthoracic echocardiography demonstrated an enlarged right atrium and right ventricle; results of contrast echocardiography were negative.

Please finish quiz first before checking answer.

You answered correctly!

Read the answer below and download your certificate.

You answered incorrectly.

Read the discussion below and retake the quiz.

Sinus venosus atrial septal defect (ASD)

A. Order cardiac magnetic resonance imaging

The key to the correct diagnosis is correlating the presence of a heart murmur as a child with the chest radiography findings of increased vascularity and cardiomegaly as well as the echocardiogram findings of an enlarged right atrium and ventricle. In patients presenting with existing murmurs and signs of increased pulmonary blood flow, cardiac magnetic resonance imaging (CMR) provides more diagnostic information and should be performed prior to adding new medications (choice B), invasive study (choice C), or referral to a specialist (choice D). If a sinus venosus ASD (SVASD) is found, a CMR can delineate anatomy, shunt size, and estimate shunt flow, thus eliminating the need for cardiac catherization.

Survey Complete!

Sign in to take quiz and track your certificates

Buy This Activity

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

Article Information

Published Online: August 12, 2020. doi:10.1001/jama.2020.8415

Correction: This article was corrected on July 20, 2021, for incorrect labels in Figure 2 and to update the Figure 2 legend.

Corresponding Author: John E. Mayer Jr, MD, Department of Cardiovascular Surgery, Children’s Hospital Boston, 300 Longwood Ave, BCH 3084, Boston, MA 02115 (john.mayer@cardio.chboston.org).

Conflict of Interest Disclosures: Dr Mayer reported serving on a data safety and monitoring board for Medtronic. No other disclosures were reported.

Additional Contributions: We thank the patient for providing permission to share her information.

References
1.
Van Praagh  S , Carrera  ME , Sanders  SP , Mayer  JE , Van Praagh  R .  Sinus venosus defects: unroofing of the right pulmonary veins—anatomic and echocardiographic findings and surgical treatment.   Am Heart J. 1994;128(2):365-379. doi:10.1016/0002-8703(94)90491-XPubMedGoogle ScholarCrossref
2.
Pascoe  RD , Oh  JK , Warnes  CA , Danielson  GK , Tajik  AJ , Seward  JB .  Diagnosis of sinus venosus atrial septal defect with transesophageal echocardiography.   Circulation. 1996;94(5):1049-1055. doi:10.1161/01.CIR.94.5.1049PubMedGoogle ScholarCrossref
3.
Dudzinski  DM , Bhatt  DL , Aragam  JR , Maron  BA .  Explaining unexplained dyspnea: the ever “holesome” heart.   Circulation. 2014;130(23):2057-2066. doi:10.1161/CIRCULATIONAHA.114.010810PubMedGoogle ScholarCrossref
4.
Attenhofer Jost  CH , Connolly  HM , Danielson  GK ,  et al.  Sinus venosus atrial septal defect: long-term postoperative outcome for 115 patients.   Circulation. 2005;112(13):1953-1958. doi:10.1161/CIRCULATIONAHA.104.493775PubMedGoogle ScholarCrossref
5.
Wang  ZJ , Reddy  GP , Gotway  MB , Yeh  BM , Higgins  CB .  Cardiovascular shunts: MR imaging evaluation.   Radiographics. 2003;23(Spec No):S181-S194. doi:10.1148/rg.23si035503PubMedGoogle Scholar
6.
 Correction to: 2018 AHA/ACC guideline for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.   Circulation. 2019;139(14):e833-e834.PubMedGoogle Scholar
7.
Stewart  RD , Bailliard  F , Kelle  AM , Backer  CL , Young  L , Mavroudis  C .  Evolving surgical strategy for sinus venosus atrial septal defect: effect on sinus node function and late venous obstruction.   Ann Thorac Surg. 2007;84(5):1651-1655. doi:10.1016/j.athoracsur.2007.04.130PubMedGoogle ScholarCrossref
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_Multimedia_LoginSubscribe_Purchase
Close
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_Multimedia_LoginSubscribe_Purchase
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close

Name Your Search

Save Search
Close
With a personal account, you can:
  • Track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
jn-learning_Modal_SaveSearch_NoAccess_Purchase
Close

Lookup An Activity

or

Close

My Saved Searches

You currently have no searches saved.

Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close