What is the most appropriate diagnostic test for a 60-year-old man with symptoms of heart failure, including abdominal distension, dyspnea, orthopnea, elevated Jugular Venous Pressure (JVP), pitting edema, hepatomegaly, and bibasilar crackles, with an echocardiogram showing dilated atria and normal left ventricular ejection fraction (LVEF)?

Cardiac CT Scan is the Most Appropriate Diagnostic Test for This Patient

For this 60-year-old man with signs of heart failure but preserved left ventricular ejection fraction, a cardiac CT scan (option B) has the highest diagnostic value to determine the underlying cause of his condition.

Clinical Presentation Analysis

This patient presents with classic features of heart failure:

• Abdominal distension, dyspnea, and orthopnea
• Markedly elevated JVP with failure to descend during inspiration (Kussmaul's sign)
• Massive pitting edema up to the thighs
• Bibasilar crackles
• Hepatomegaly and shifting dullness (ascites)

The echocardiogram shows:

• Dilated atria
• Normal left and right ventricles
• Preserved LVEF (60%)
• No valve lesions

Diagnostic Reasoning

This presentation is consistent with heart failure with preserved ejection fraction (HFpEF) with features suggesting constrictive pericarditis or restrictive cardiomyopathy. The key findings supporting this are:

1. Elevated JVP that fails to decrease with inspiration (Kussmaul's sign) 1
2. Preserved LVEF with dilated atria
3. Signs of right heart failure (hepatomegaly, ascites, peripheral edema)

Evaluation of Diagnostic Options

A. Holter Monitor

• Low diagnostic value in this scenario as the primary issue appears structural rather than arrhythmic
• Only 13% diagnostic yield for conditions other than syncope or stroke 2
• Even for unexplained heart failure exacerbation/dyspnea, diagnostic yield is only 17% 2
• Not recommended as first-line for diagnosing the etiology of heart failure with preserved ejection fraction 3

B. Cardiac CT Scan

• Excellent for evaluating pericardial thickness and calcification
• Can detect constrictive pericarditis, which is consistent with the clinical presentation
• Provides detailed assessment of cardiac chambers and myocardial tissue
• The ESC guidelines recommend cardiac imaging to establish heart failure etiology 3
• Can rule out coronary artery disease as a potential cause 3

C. Coronary Angiogram

• Indicated primarily when ischemia is suspected or for patients with angina 3
• This patient has no clear indication of ischemia
• No valve lesions that would require hemodynamic assessment
• Invasive procedure with risks that may not be justified given the clinical presentation

D. Exercise ECG Stress Testing

• Limited value in diagnosing the etiology of heart failure 3
• More useful for detecting inducible ischemia or assessing functional capacity
• Not the first-line test for evaluating constrictive or restrictive pathologies
• The ESC guidelines note that a normal exercise test excludes heart failure, but this patient already has confirmed heart failure 3

Conclusion

The clinical presentation strongly suggests constrictive pericarditis or restrictive cardiomyopathy. Given the preserved LVEF, normal ventricular size, dilated atria, and prominent right-sided heart failure signs (especially Kussmaul's sign), a cardiac CT scan would provide the most valuable diagnostic information by:

1. Evaluating pericardial thickness and calcification
2. Assessing cardiac chamber morphology in detail
3. Ruling out coronary artery disease
4. Providing information about myocardial tissue characteristics

According to the ESC guidelines, cardiac imaging plays a central role in diagnosing heart failure and guiding treatment 3. While echocardiography is the first-line imaging modality, in cases where the etiology remains unclear after echocardiography (as in this case), additional imaging such as cardiac CT is recommended.