This is the largest heart I've ever seen on chest xray (CXR). It's massive! A big heart is called cardiomegaly. A reader says this unfortunate guy presented with shortness of breath. His 42 year old frame carrying 550 pounds finally caught up to him. Imagine the daily stress of trying to pump blood against a resistance the human heart was never meant to endure. What happens? The heart thickens to try to overcome such high peripheral resistance. Eventually it can't thicken anymore and becomes dilated. You're left with a big floppy dilated cardiomyopathy, and massive cardiomegaly. His underlying ejection fraction was reportedly around 20%.
I know there are probably some bigger hearts out there. I've seen cardiomegaly almost fill an entire CXR before. But this posterior-anterior view is shocking. What are some possible causes of his cardiomegaly? The differential diagnosis includes these most common causes
- Coronary artery disease, myocardial infarction
- Hypertension
- Thyroid disease
- Obstructive sleep apnea
- Alcohol abuse
- Stimulant abuse
- Valvular heart disease
- Super morbid obesity.
- Drug toxicity
The treatment of acute heart failure should focus initially on symptom control by reducing his dyspnea, mostly with diuretics. In this case he was reportedly up about 70 pounds of fluid over one month time. Often, in folks in acute heart failure, before you can even do procedural evaluations on them, you must get their dyspnea stabilized. You can't lay a 550 pound guy with heart failure flat and expect hims to lay still for a couple hours.
Many cardiac cath tables will hold up to 250 kg (550 pounds). The stress test tables will only hold up to 400 pounds. Thus, for some people, they either gets a catheterization or the get medical management without a stress test. Unfortunately, heart catheterizations add another layer of complexity with potential complications. These folks often meet criteria for placment of a defibrillator as well based solely on their ejection fraction. Thus is the nature of obesity in this country. We can't control health care costs until we as a nation make a giant leap forward by getting off our butts and moving again.
