Intended for healthcare professionals

Endgames Case Review

An unusual cause of shortness of breath and palpitations

BMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k3883 (Published 18 October 2018) Cite this as: BMJ 2018;363:k3883
  1. G Abraham, clinical teaching fellow,
  2. M A Ghazanfar, senior house officer,
  3. A Bajpai, consultant cardiologist
  1. Cardiology, Epsom General Hospital, Epsom, UK
  1. Correspondence to G Abraham george.abraham{at}nhs.net

A 33 year old woman with recurrent short lived episodes of breathlessness and palpitations for over two years was referred to the cardiology clinic as an outpatient.

She had attended the emergency department several times during the two years of her symptoms, and had undergone various investigations, including two computed tomography pulmonary angiograms for suspected pulmonary embolism (normal both times) and a 24 hour electrocardiogram, which showed sinus rhythm with isolated ventricular ectopics only. She had also experienced one episode of sudden onset slurred speech and right arm weakness which resolved rapidly. Computed tomography imaging of the brain had been normal.

Her symptoms were originally attributed to anxiety and she was prescribed antidepressant medication for anxiety and depression.

In the cardiology clinic, she appeared anxious but otherwise comfortable and well. On examination of the cardiovascular system, heart sounds were normal with no obvious murmur. After review in the cardiology clinic she had an echocardiogram (figs 1, 2).

Fig 1

Echocardiogram, apical 4 chamber view, of the heart in diastole

Fig 2

Echocardiogram, apical 4 chamber view, of the heart in systole

Questions

  • 1. What are the differential diagnoses for intermittent palpitations and paroxysmal dyspnoea in a young woman?

  • 2. What is the most likely diagnosis?

  • 3. What clinical signs are often associated with this diagnosis?

Answers

1. What are the differential diagnoses for intermittent palpitations and paroxysmal dyspnoea in a young woman?

Cardiac causes: primary arrhythmias (eg, supraventricular tachycardia), autonomic dysfunction (eg, postural orthostatic tachycardia syndrome), valvular heart disease, intracardiac masses, cardiomyopathies.

Drug causes: sympathomimetics, excess caffeine, alcohol, salbutamol, cocaine, amphetamines.

Metabolic causes: thyrotoxicosis, …

View Full Text

Log in

Log in through your institution

Subscribe

* For online subscription