What has the highest diagnostic value for a patient with suspected right-sided heart failure, dilated atria, normal-sized ventricles, and no valve lesions, presenting with abdominal distension, dyspnea, orthopnea, elevated JVP (Jugular Venous Pressure), and massive pitting edema?

Cardiac CT Scan Has the Highest Diagnostic Value

For this patient with biventricular diastolic dysfunction and dilated atria (likely constrictive pericarditis or restrictive cardiomyopathy), cardiac CT scan (Option B) provides the definitive diagnostic information needed to distinguish between these two critical etiologies that present identically on echocardiography.

Clinical Presentation Analysis

This patient demonstrates classic right-sided heart failure with:

• Markedly elevated JVP that fails to descend during inspiration (Kussmaul's sign) 1
• Massive pitting edema extending to the thighs 2
• Hepatomegaly and ascites (shifting dullness) 1, 2
• Bibasilar crackles indicating pulmonary congestion 1
• Orthopnea and dyspnea 1

Critical Echocardiographic Findings

The echocardiogram reveals a specific pattern that narrows the differential diagnosis considerably:

• Both atria are dilated - indicating chronically elevated filling pressures 1
• Normal ventricular size and preserved LVEF (60%) - ruling out dilated cardiomyopathy 1
• No valve lesions - excluding valvular heart disease as the primary etiology 1

This constellation points to either constrictive pericarditis or restrictive cardiomyopathy - two conditions that are notoriously difficult to distinguish by echocardiography alone 1.

Why Each Option Falls Short or Succeeds

Option A: Holter Monitor - NOT Indicated

• Holter monitoring evaluates for arrhythmias 1
• This patient has normal heart sounds with no mention of irregular rhythm 1
• While atrial fibrillation can occur with biatrial enlargement, it would not explain the underlying pathophysiology or guide definitive treatment 1
• Does not differentiate between constrictive versus restrictive physiology

Option B: Cardiac CT Scan - HIGHEST DIAGNOSTIC VALUE ✓

• Cardiac CT is the gold standard for evaluating pericardial thickness 1
• Pericardial thickness >4mm on CT strongly suggests constrictive pericarditis 1
• Can identify pericardial calcification, which is pathognomonic for constrictive pericarditis 1
• Provides definitive anatomic information that echocardiography cannot reliably assess 1
• This distinction is therapeutically critical: constrictive pericarditis is surgically curable with pericardiectomy, while restrictive cardiomyopathy requires medical management 1

Option C: Coronary Angiogram - Limited Value

• While coronary angiography remains the gold standard for diagnosing coronary artery disease 1, this patient has:
  • Preserved LVEF of 60% 1
  • No regional wall motion abnormalities (normal-sized ventricles) 1
  • No anginal symptoms mentioned 3
• Coronary disease would typically present with reduced LVEF or regional wall motion abnormalities 1
• Does not address the primary diagnostic question of constrictive versus restrictive physiology

Option D: Exercise ECG Testing - Contraindicated

• Exercise stress testing is contraindicated in decompensated heart failure 1
• This patient has:
  • Massive peripheral edema to the thighs 1, 2
  • Orthopnea (cannot lie flat) 1
  • Hepatomegaly and ascites 2
• These findings indicate severe volume overload and decompensation 1
• Exercise testing would provide no diagnostic information for distinguishing constrictive versus restrictive disease 1

The Critical Diagnostic Dilemma

Constrictive pericarditis and restrictive cardiomyopathy present identically:

• Both cause biatrial enlargement with normal ventricular size 1
• Both produce elevated filling pressures and diastolic dysfunction 1
• Both manifest with right-sided heart failure symptoms 1, 2
• Echocardiography alone cannot reliably distinguish between them 1

The distinction is therapeutically essential:

• Constrictive pericarditis: Surgical pericardiectomy is curative 1
• Restrictive cardiomyopathy: Medical management only, often progressive 1

Common Pitfalls to Avoid

• Do not assume this is simply "heart failure" requiring diuretics - the underlying etiology must be identified 1
• Do not rely on echocardiography alone when constrictive pericarditis is in the differential - pericardial thickness assessment requires CT or MRI 1
• Do not order coronary angiography first in patients with preserved LVEF and no ischemic symptoms - it will not change management 1, 3
• Do not perform exercise testing in decompensated patients with severe volume overload 1

Additional Supportive Testing

After cardiac CT establishes the diagnosis:

• Right heart catheterization may be needed to confirm hemodynamics if CT findings are equivocal 1
• Cardiac MRI can provide complementary tissue characterization if restrictive cardiomyopathy is confirmed (e.g., amyloidosis, sarcoidosis) 1
• BNP/NT-proBNP levels are typically lower in constrictive pericarditis than restrictive cardiomyopathy, providing additional diagnostic clues 1, 3