Cardiomegaly: Clinical Presentation, Diagnostic Evaluation, Management, and Outcomes – A Case Report

Abstract

Cardiomegaly, defined as an enlargement of the heart, is a radiological and clinical finding rather than a disease entity itself. It reflects underlying cardiac pathology such as hypertensive heart disease, cardiomyopathy, valvular disorders, or ischemic heart disease. Patients may present with a spectrum ranging from asymptomatic findings on imaging to overt heart failure.

We report the case of a 52-year-old male presenting with progressive breathlessness and fatigue. Imaging studies revealed cardiomegaly, and further evaluation confirmed dilated cardiomyopathy secondary to long-standing uncontrolled hypertension. The patient was managed with guideline-directed medical therapy, resulting in significant symptomatic improvement.

This case emphasizes the importance of early detection, comprehensive evaluation, and targeted management of cardiomegaly to prevent progression to heart failure and improve clinical outcomes.

Introduction

Cardiomegaly refers to an abnormal increase in the size of the heart, typically identified through imaging modalities such as chest X-ray, echocardiography, or cardiac MRI. It is most commonly associated with conditions that impose chronic pressure or volume overload on the heart, leading to structural remodeling.

The condition may involve dilation of cardiac chambers, hypertrophy of myocardial walls, or a combination of both. While cardiomegaly itself may be asymptomatic, it often signifies underlying cardiovascular pathology that requires prompt diagnosis and management.

Globally, cardiomegaly is frequently associated with hypertension, coronary artery disease, and cardiomyopathies. In developing regions, additional etiologies such as rheumatic heart disease and infectious causes also contribute significantly.

Early recognition is essential, as untreated cardiomegaly can progress to heart failure, arrhythmias, thromboembolic events, and sudden cardiac death.

Case Report

Patient History

A 52-year-old male presented to the outpatient department with:

• Progressive shortness of breath over 6 months
• Easy fatigability
• Occasional palpitations
• Mild bilateral lower limb swelling

There was no history of chest pain, syncope, or fever. The patient had a known history of hypertension for 10 years but reported poor compliance with medications. There was no history of diabetes, smoking, or alcohol abuse.

Family history was unremarkable for cardiovascular disease.

Clinical Examination

General Examination

• Patient conscious and oriented
• Blood pressure: 160/100 mmHg
• Pulse: 96 beats per minute, regular
• Respiratory rate: 20 breaths per minute
• Mild pedal edema present

Cardiovascular Examination

• Apex beat displaced laterally (6th intercostal space, anterior axillary line)
• Diffuse and sustained apical impulse
• Presence of S3 gallop
• No significant murmurs

Respiratory Examination

• Bilateral basal crepitations

Abdominal Examination

• Mild hepatomegaly

Clinical Evaluation

Differential Diagnosis

Based on clinical findings, the following were considered:

• Dilated cardiomyopathy
• Hypertensive heart disease
• Ischemic cardiomyopathy
• Valvular heart disease
• Pericardial effusion

The presence of long-standing hypertension and displaced apex beat suggested a structural cardiac abnormality.

Investigations

Laboratory Tests

• Complete blood count: Within normal limits
• Renal function tests: Mildly elevated creatinine
• Liver function tests: Mild elevation in liver enzymes
• BNP (B-type natriuretic peptide): Elevated
• Thyroid profile: Normal

Imaging

Chest X-ray

• Enlarged cardiac silhouette
• Cardiothoracic ratio >50%
• Mild pulmonary congestion

Electrocardiogram (ECG)

• Left ventricular hypertrophy
• Non-specific ST-T changes

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Echocardiography

• Dilated left ventricle
• Reduced ejection fraction (~35%)
• Global hypokinesia
• Mild mitral regurgitation

Cardiac MRI (if performed)

• Confirmed dilated cardiomyopathy
• No evidence of infiltrative disease

Diagnosis

A diagnosis of cardiomegaly secondary to dilated cardiomyopathy due to uncontrolled hypertension was established based on clinical findings, imaging, and functional assessment.

Management and Outcome

Management Strategy

The treatment approach focused on:

• Symptom control
• Improvement of cardiac function
• Prevention of complications
• Management of underlying hypertension

Medical Management

• ACE inhibitors (for afterload reduction)
• Beta-blockers (for heart rate control and remodeling)
• Diuretics (for fluid overload)
• Aldosterone antagonists
• Lifestyle modifications including salt restriction and weight control

Supportive Measures

• Fluid restriction
• Regular blood pressure monitoring
• Patient education on medication adherence

Clinical Course

During hospitalization:

• Symptomatic improvement in breathlessness
• Reduction in edema
• Stabilization of blood pressure

Follow-Up

At 2 Weeks

• Improved exercise tolerance
• Reduced pedal edema

At 1 Month

• Stable vitals
• Improved functional status

At 6 Months

• Ejection fraction improved to 45%
• No hospital readmissions
• Good compliance with therapy

Discussion

Pathophysiology

Cardiomegaly results from adaptive and maladaptive changes in the myocardium due to chronic hemodynamic stress. These include:

• Pressure overload (e.g., hypertension) → concentric hypertrophy
• Volume overload (e.g., valvular regurgitation) → chamber dilation

Over time, these changes lead to:

• Reduced contractility
• Ventricular remodeling
• Neurohormonal activation

This progression ultimately culminates in heart failure if untreated.

Etiology

Common causes of cardiomegaly include:

• Hypertension
• Coronary artery disease
• Cardiomyopathies (dilated, hypertrophic, restrictive)
• Valvular heart disease
• Congenital heart defects
• Pericardial diseases

In this case, uncontrolled hypertension was the primary contributing factor.

Epidemiology

• More common in middle-aged and elderly individuals
• Higher prevalence in patients with chronic hypertension
• Increasing incidence due to lifestyle-related risk factors

Clinical Manifestations

Early Stage

• Often asymptomatic
• Incidental finding on imaging

Progressive Stage

• Dyspnea
• Fatigue
• Palpitations
• Edema

Advanced Stage

• Heart failure symptoms
• Arrhythmias
• Syncope

Diagnostic Considerations

A systematic approach is essential:

1. Clinical evaluation
2. Imaging (Chest X-ray, Echocardiography)
3. Functional assessment (ejection fraction)
4. Identification of underlying cause

Echocardiography remains the cornerstone for diagnosis and evaluation of cardiac function.

Treatment Considerations

Management depends on the underlying cause and severity.

Medical Therapy

• First-line treatment in most cases
• Focuses on reversing remodeling and improving function

Device Therapy

• Implantable cardioverter-defibrillator (ICD) in selected cases
• Cardiac resynchronization therapy (CRT)

Surgical Options

• Valve repair or replacement
• Coronary artery bypass grafting (if ischemic cause)

Complications

If untreated, cardiomegaly can lead to:

• Heart failure
• Arrhythmias
• Thromboembolism
• Sudden cardiac death

Prognosis

The prognosis depends on:

• Underlying etiology
• Degree of cardiac dysfunction
• Timeliness of intervention
• Patient compliance

With appropriate management, many patients experience significant improvement in quality of life.

Conclusion

Cardiomegaly is a significant clinical finding that often reflects underlying cardiovascular pathology. This case underscores the importance of early diagnosis, especially in patients with risk factors such as hypertension.

A structured approach involving clinical evaluation, imaging, and functional assessment is essential for accurate diagnosis. Timely initiation of guideline-directed medical therapy can significantly improve outcomes and prevent disease progression.

While cardiomegaly may initially present as a silent condition, its potential complications necessitate vigilant monitoring and long-term management. Patient education, adherence to therapy, and regular follow-up play a critical role in optimizing clinical outcomes.

A comprehensive, individualized treatment strategy ensures not only symptom relief but also improved survival and quality of life for affected patients.

References

1. Levy D, Garrison RJ, Savage DD, Kannel WB, Castelli WP. Prognostic implications of echocardiographically determined left ventricular mass in the Framingham Heart Study. N Engl J Med. https://pubmed.ncbi.nlm.nih.gov/2934510/
2. McMurray JJV, Adamopoulos S, Anker SD, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. https://pubmed.ncbi.nlm.nih.gov/20805041/
3. Yancy CW, Jessup M, Bozkurt B, et al. ACC/AHA guideline for the management of heart failure. J Am Coll Cardiol. https://pubmed.ncbi.nlm.nih.gov/23747642/
4. StatPearls. Cardiomegaly – Clinical Overview and Management. https://www.ncbi.nlm.nih.gov/books/NBK542296/
5. Braunwald E. Heart Disease: A Textbook of Cardiovascular Medicine. https://www.sciencedirect.com/book/9780323463423/braunwalds-heart-disease

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