A 50 year old man was admitted  with severe dyspnoea and hypotension.

Clinical examination  revealed a tachypnoeic patient  with a HR of 130/min, SR and a blood pressure of 90/60 mm Hg. On CVS examination,  the JVP was raised, and a cardiac murmur was audible although because of the tachycardia, it could not be timed with certainty. Hemodynamic  monitoring revealed the following:

CVP     14 mmHg,

Pulmonary artery 48/24 mmHg,

PAOP    22 mmHg.

List 3 likely causes for the above clinical and hemodynamic presentation.

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College Answer

1.  Left ventricular failure/cardiogenic shock

2.  Mitral regurgitation

3.  Acute aortic incompetence

Discussion

What would give you hypotension, tachycardia and a murmur? What could compel the Australian College of Intensive Care Medicine to use the American spelling of "haemodynamic"?

The abnormalities are:

  • Hypotension
  • Dyspnoea and tachypnoea
  • Tachycardia
  • Raised JVP/CVP
  • Raised PA pressure
  • Raised PAWP
  • A murmur of some sort

With the raised PAWP and CVP, one starts thinking about cardiac causes. Certainly such a presentation might result from the sudden failure of the aortic or mitral valves (with ensuing pulmonary oedema). With a major pulmonary embolus, the PAWP should actually be low (though it generally does not have much of a relationship with the LVEDP in that setting). The college include cardiogenic shock in their answer, which one one hand is reasonable because it certainly describes "the above clinical and hemodynamic presentation". However on the other hand, cardiogenic shock is what you get as the result of any number of possible pathologies, i.e. it describes a constellation of clinical features rather than any specific aetiology. One might argue that the question is worded in a way which requires a list of such aetiologies.  One possible list could include:

  • Dilated cardiomyopathy  (explains everything, including the murmur -as the mitral annulus would be stretched the valve would become regurgitant)
  • Mitral regurgitation (acute, eg. prolapse) - which explains everything, including the respiratory symptoms which are presumably due to pulmonary oedema. The PAWP would be raised, which it is. 
  • Aortic regurgitation (acute, eg. aortic dissection or root dilatation) which explains everything
  • Cardiac tamponade (which explains everything except for the murmur, which might be confused with a pericardial rub)
  • Aortic stenosis (which, if severe enough, could give rise to this picture)
  • Hypertrophic obstructive cardiomyopathy (which explains all of the findings)

References

Quintana, E., et al. "Erroneous interpretation of pulmonary capillary wedge pressure in massive pulmonary embolism." Critical care medicine 11.12 (1983): 933-935.