{"version":"1.0.0","segments":[{"startTime":1.471,"endTime":3.121,"body":"♪ (music) ♪"},{"startTime":3.121,"endTime":5.672,"body":"(Cathy) Hi, welcome"},{"startTime":3.121,"endTime":5.672,"body":"to \u003ci\u003eHarrison's Podclass\u003c/i\u003e,"},{"startTime":5.672,"endTime":8.782,"body":"where we discuss important concepts"},{"startTime":5.672,"endTime":8.782,"body":"in internal medicine."},{"startTime":8.782,"endTime":11.058,"body":"- I'm Cathy Handy."},{"startTime":8.782,"endTime":11.058,"body":"- (Charlie) And I'm Charlie Wiener,"},{"startTime":11.058,"endTime":14.1,"body":"and we're coming to you"},{"startTime":11.058,"endTime":14.1,"body":"from the Johns Hopkins School of Medicine."},{"startTime":14.1,"endTime":15.75,"body":"♪ (music) ♪"},{"speaker":"(Cathy) Welcome to Episode 48","startTime":15.75,"endTime":20.312,"body":"A 25-Year-Old with Heart Failure."},{"speaker":"(Charlie) Here's the question","startTime":21.564,"endTime":24.157,"body":"You're evaluating a new patient in clinic."},{"speaker":"(Charlie) Here's the question","startTime":24.157,"endTime":28.065,"body":"This 25-year-old was diagnosed"},{"speaker":"(Charlie) Here's the question","startTime":24.157,"endTime":28.065,"body":"with heart failure in another state"},{"speaker":"(Charlie) Here's the question","startTime":28.065,"endTime":29.845,"body":"and has since relocated."},{"speaker":"(Charlie) Here's the question","startTime":29.845,"endTime":34.253,"body":"He has New York Heart Association"},{"speaker":"(Charlie) Here's the question","startTime":29.845,"endTime":34.253,"body":"Class II symptoms and denies any angina."},{"speaker":"(Charlie) Here's the question","startTime":34.253,"endTime":35.523,"body":"(Cathy) So, just to review,"},{"speaker":"(Charlie) Here's the question","startTime":35.523,"endTime":38.458,"body":"the New York Heart Association"},{"speaker":"(Charlie) Here's the question","startTime":35.523,"endTime":38.458,"body":"heart failure symptoms scales"},{"speaker":"(Charlie) Here's the question","startTime":38.458,"endTime":39.863,"body":"are all on the same page."},{"speaker":"(Charlie) Here's the question","startTime":39.863,"endTime":42.413,"body":"So, Class I is when patients"},{"speaker":"(Charlie) Here's the question","startTime":39.863,"endTime":42.413,"body":"have no symptoms,"},{"speaker":"(Charlie) Here's the question","startTime":42.413,"endTime":45.285,"body":"no limitation in any ordinary activity."},{"speaker":"(Charlie) Here's the question","startTime":45.285,"endTime":47.965,"body":"Class II, I think about mild symptoms,"},{"speaker":"(Charlie) Here's the question","startTime":47.965,"endTime":51.891,"body":"maybe some limitation"},{"speaker":"(Charlie) Here's the question","startTime":47.965,"endTime":51.891,"body":"during ordinary activity, but only slight."},{"speaker":"(Charlie) Here's the question","startTime":51.891,"endTime":55.971,"body":"Class III, there'd be marked limitation"},{"speaker":"(Charlie) Here's the question","startTime":51.891,"endTime":55.971,"body":"inactivity that's due to symptoms,"},{"speaker":"(Charlie) Here's the question","startTime":55.971,"endTime":58.541,"body":"and really patients are only comfortable"},{"speaker":"(Charlie) Here's the question","startTime":55.971,"endTime":58.541,"body":"when they're resting."},{"speaker":"(Charlie) Here's the question","startTime":58.541,"endTime":61.091,"body":"And then Class IV is when"},{"speaker":"(Charlie) Here's the question","startTime":58.541,"endTime":61.091,"body":"there are severe limitations"},{"speaker":"(Charlie) Here's the question","startTime":61.091,"endTime":63.431,"body":"and you get symptoms even at rest."},{"speaker":"(Charlie) Here's the question","startTime":63.431,"endTime":65.191,"body":"(Charlie) Yeah, he confirms"},{"speaker":"(Charlie) Here's the question","startTime":63.431,"endTime":65.191,"body":"that, in general,"},{"speaker":"(Charlie) Here's the question","startTime":65.191,"endTime":68.381,"body":"he's been relatively stable clinically"},{"speaker":"(Charlie) Here's the question","startTime":65.191,"endTime":68.381,"body":"for the past few months."},{"speaker":"(Charlie) Here's the question","startTime":68.381,"endTime":71.601,"body":"He's coming now to see you"},{"speaker":"(Charlie) Here's the question","startTime":68.381,"endTime":71.601,"body":"for evaluation and management,"},{"speaker":"(Charlie) Here's the question","startTime":71.601,"endTime":73.901,"body":"and, unfortunately, he doesn't bring"},{"speaker":"(Charlie) Here's the question","startTime":71.601,"endTime":73.901,"body":"any records with him."},{"speaker":"(Charlie) Here's the question","startTime":73.901,"endTime":75.181,"body":"But you immediately notice"},{"speaker":"(Charlie) Here's the question","startTime":75.181,"endTime":77.861,"body":"that he's wheelchair-bound"},{"speaker":"(Charlie) Here's the question","startTime":75.181,"endTime":77.861,"body":"with severe scoliosis."},{"speaker":"(Charlie) Here's the question","startTime":77.861,"endTime":80.927,"body":"(Cathy) Okay, I wasn't expecting"},{"speaker":"(Charlie) Here's the question","startTime":77.861,"endTime":80.927,"body":"that piece of information."},{"speaker":"(Charlie) Here's the question","startTime":80.927,"endTime":82.527,"body":"(Charlie) So, additional history reveals"},{"speaker":"(Charlie) Here's the question","startTime":82.527,"endTime":86.247,"body":"that he has no family history"},{"speaker":"(Charlie) Here's the question","startTime":82.527,"endTime":86.247,"body":"of hyperlipidemia or atherosclerosis."},{"speaker":"(Charlie) Here's the question","startTime":86.247,"endTime":90.52,"body":"His physical examination is notable"},{"speaker":"(Charlie) Here's the question","startTime":86.247,"endTime":90.52,"body":"for a blood pressure of 105/75,"},{"speaker":"(Charlie) Here's the question","startTime":90.52,"endTime":94.964,"body":"a heart rate of 84, he's afebrile,"},{"speaker":"(Charlie) Here's the question","startTime":90.52,"endTime":94.964,"body":"his respiratory rate is 18"},{"speaker":"(Charlie) Here's the question","startTime":94.964,"endTime":97.789,"body":"with room air saturation of 91%."},{"speaker":"(Charlie) Here's the question","startTime":97.789,"endTime":101.132,"body":"He does have an elevated JVP"},{"speaker":"(Charlie) Here's the question","startTime":97.789,"endTime":101.132,"body":"while sitting in his wheelchair."},{"speaker":"(Charlie) Here's the question","startTime":101.132,"endTime":105.887,"body":"There are also bilateral lung crackles"},{"speaker":"(Charlie) Here's the question","startTime":101.132,"endTime":105.887,"body":"and an S3, but no cyanosis."},{"speaker":"(Charlie) Here's the question","startTime":105.887,"endTime":110.007,"body":"Neurologic examination shows"},{"speaker":"(Charlie) Here's the question","startTime":105.887,"endTime":110.007,"body":"severe muscle weakness in all extremities."},{"speaker":"(Charlie) Here's the question","startTime":110.007,"endTime":114.617,"body":"An ECG is obtained in clinic"},{"speaker":"(Charlie) Here's the question","startTime":110.007,"endTime":114.617,"body":"and shows tall R waves in V1 and V2"},{"speaker":"(Charlie) Here's the question","startTime":114.617,"endTime":117.533,"body":"with deep Qs in V5 and V6."},{"speaker":"(Charlie) Here's the question","startTime":117.533,"endTime":121.263,"body":"Furthermore, you receive"},{"speaker":"(Charlie) Here's the question","startTime":117.533,"endTime":121.263,"body":"an echocardiogram report in clinic"},{"speaker":"(Charlie) Here's the question","startTime":121.263,"endTime":124.683,"body":"that shows that he has severe global"},{"speaker":"(Charlie) Here's the question","startTime":121.263,"endTime":124.683,"body":"left ventricular dysfunction"},{"speaker":"(Charlie) Here's the question","startTime":124.683,"endTime":127.173,"body":"with a reduced ejection fraction."},{"speaker":"(Charlie) Here's the question","startTime":127.174,"endTime":130.824,"body":"Okay, Cathy, based on this"},{"speaker":"(Charlie) Here's the question","startTime":127.174,"endTime":130.824,"body":"somewhat limited information,"},{"speaker":"the question is going to ask you","startTime":130.824,"endTime":135.139,"body":"\"What is the most likely diagnosis?\""},{"speaker":"the question is going to ask you","startTime":135.139,"endTime":139.615,"body":"Option A is"},{"speaker":"the question is going to ask you","startTime":135.139,"endTime":139.615,"body":"amyotrophic lateral sclerosis, or ALS;"},{"speaker":"the question is going to ask you","startTime":139.615,"endTime":142.921,"body":"option B is an atrial septal defect;"},{"speaker":"the question is going to ask you","startTime":142.921,"endTime":146.399,"body":"option C is chronic"},{"speaker":"the question is going to ask you","startTime":142.921,"endTime":146.399,"body":"thromboembolic disease;"},{"speaker":"the question is going to ask you","startTime":146.399,"endTime":149.908,"body":"option D is Duchenne muscular dystrophy;"},{"speaker":"the question is going to ask you","startTime":149.908,"endTime":153.168,"body":"and option E is ischemic cardiomyopathy."},{"speaker":"the question is going to ask you","startTime":153.168,"endTime":155.578,"body":"(Cathy) Well, actually, we definitely"},{"speaker":"the question is going to ask you","startTime":153.168,"endTime":155.578,"body":"have enough information"},{"speaker":"the question is going to ask you","startTime":155.578,"endTime":158.188,"body":"from the history and physical alone"},{"speaker":"the question is going to ask you","startTime":155.578,"endTime":158.188,"body":"and with the EKG"},{"speaker":"the question is going to ask you","startTime":158.188,"endTime":160.148,"body":"to figure out what the diagnosis is."},{"speaker":"the question is going to ask you","startTime":160.148,"endTime":164.148,"body":"So, we hear about a very young male"},{"speaker":"the question is going to ask you","startTime":160.148,"endTime":164.148,"body":"with a systemic muscular disease,"},{"speaker":"the question is going to ask you","startTime":164.148,"endTime":166.648,"body":"as well as the EKG pattern"},{"speaker":"the question is going to ask you","startTime":164.148,"endTime":166.648,"body":"that you mentioned--"},{"speaker":"the question is going to ask you","startTime":166.648,"endTime":168.708,"body":"and that makes"},{"speaker":"the question is going to ask you","startTime":166.648,"endTime":168.708,"body":"Duchenne muscular dystrophy,"},{"speaker":"the question is going to ask you","startTime":168.708,"endTime":170.628,"body":"your option D, the right answer."},{"speaker":"the question is going to ask you","startTime":170.628,"endTime":172.138,"body":"(Charlie) Yeah, that's a good call."},{"speaker":"the question is going to ask you","startTime":172.138,"endTime":174.888,"body":"He tells you that he was diagnosed"},{"speaker":"the question is going to ask you","startTime":172.138,"endTime":174.888,"body":"with Duchenne muscular dystrophy"},{"speaker":"the question is going to ask you","startTime":174.888,"endTime":175.898,"body":"at age three,"},{"speaker":"the question is going to ask you","startTime":175.898,"endTime":179.568,"body":"and he became 100%"},{"speaker":"the question is going to ask you","startTime":175.898,"endTime":179.568,"body":"wheelchair-dependent at age 17."},{"speaker":"the question is going to ask you","startTime":179.577,"endTime":181.417,"body":"Tell me more about muscular dystrophy."},{"speaker":"the question is going to ask you","startTime":181.417,"endTime":184.257,"body":"(Cathy) It's one of the X-linked"},{"speaker":"the question is going to ask you","startTime":181.417,"endTime":184.257,"body":"recessive muscular dystrophies"},{"speaker":"the question is going to ask you","startTime":184.257,"endTime":186.857,"body":"caused by mutations"},{"speaker":"the question is going to ask you","startTime":184.257,"endTime":186.857,"body":"in the dystrophin gene."},{"speaker":"the question is going to ask you","startTime":186.857,"endTime":189.307,"body":"So, therefore,"},{"speaker":"the question is going to ask you","startTime":186.857,"endTime":189.307,"body":"it's really a disease of males."},{"speaker":"the question is going to ask you","startTime":189.307,"endTime":192.817,"body":"Early on, you get hypertrophy"},{"speaker":"the question is going to ask you","startTime":189.307,"endTime":192.817,"body":"of the distal muscles, like the calves,"},{"speaker":"the question is going to ask you","startTime":192.817,"endTime":194.947,"body":"and those are really early signs."},{"speaker":"the question is going to ask you","startTime":194.947,"endTime":197.937,"body":"On echo, you see global"},{"speaker":"the question is going to ask you","startTime":194.947,"endTime":197.937,"body":"left ventricular dysfunction,"},{"speaker":"the question is going to ask you","startTime":197.937,"endTime":202.177,"body":"and the ECG pattern"},{"speaker":"the question is going to ask you","startTime":197.937,"endTime":202.177,"body":"of Duchenne muscular dystrophy is unique"},{"speaker":"the question is going to ask you","startTime":202.177,"endTime":205.487,"body":"and consists of tall R waves"},{"speaker":"the question is going to ask you","startTime":202.177,"endTime":205.487,"body":"in the right precordial leads"},{"speaker":"the question is going to ask you","startTime":205.487,"endTime":207.517,"body":"with an R/S ratio that's over 1,"},{"speaker":"the question is going to ask you","startTime":207.517,"endTime":211.277,"body":"and often also with deep Q waves"},{"speaker":"the question is going to ask you","startTime":207.517,"endTime":211.277,"body":"in the limb and precordial leads,"},{"speaker":"the question is going to ask you","startTime":211.277,"endTime":212.757,"body":"which we hear about in this case."},{"speaker":"the question is going to ask you","startTime":212.757,"endTime":215.417,"body":"(Charlie) Okay, anything else"},{"speaker":"the question is going to ask you","startTime":212.757,"endTime":215.417,"body":"you worry about in these patients"},{"speaker":"the question is going to ask you","startTime":215.417,"endTime":216.827,"body":"from a cardiac perspective?"},{"speaker":"the question is going to ask you","startTime":216.827,"endTime":218.677,"body":"(Cathy) These patients"},{"speaker":"the question is going to ask you","startTime":216.827,"endTime":218.677,"body":"often have a variety"},{"speaker":"the question is going to ask you","startTime":218.677,"endTime":221.677,"body":"of supraventricular"},{"speaker":"the question is going to ask you","startTime":218.677,"endTime":221.677,"body":"and ventricular arrhythmias,"},{"speaker":"the question is going to ask you","startTime":221.677,"endTime":225.007,"body":"and they're at risk of sudden death"},{"speaker":"the question is going to ask you","startTime":221.677,"endTime":225.007,"body":"due to the intrinsic cardiomyopathy"},{"speaker":"the question is going to ask you","startTime":225.007,"endTime":226.897,"body":"as well as the low ejection fraction."},{"speaker":"the question is going to ask you","startTime":226.897,"endTime":229.317,"body":"So, implantable cardioverter-defibrillator"},{"speaker":"the question is going to ask you","startTime":229.317,"endTime":231.987,"body":"should be considered"},{"speaker":"the question is going to ask you","startTime":229.317,"endTime":231.987,"body":"in the appropriate patients."},{"speaker":"the question is going to ask you","startTime":231.991,"endTime":235.091,"body":"Charlie, you're in a Multi-D Clinic"},{"speaker":"the question is going to ask you","startTime":231.991,"endTime":235.091,"body":"that takes care of patients like this."},{"speaker":"the question is going to ask you","startTime":235.091,"endTime":237.871,"body":"What are the pulmonary findings"},{"speaker":"the question is going to ask you","startTime":235.091,"endTime":237.871,"body":"that you guys worry about there?"},{"speaker":"the question is going to ask you","startTime":237.871,"endTime":240.231,"body":"(Charlie) Yeah, it's important"},{"speaker":"the question is going to ask you","startTime":237.871,"endTime":240.231,"body":"to note that, in this disease,"},{"speaker":"the question is going to ask you","startTime":240.231,"endTime":242.256,"body":"the inspiratory and the expiratory"},{"speaker":"the question is going to ask you","startTime":240.231,"endTime":242.256,"body":"respiratory muscles"},{"speaker":"the question is going to ask you","startTime":242.256,"endTime":243.601,"body":"are typically involved,"},{"speaker":"the question is going to ask you","startTime":243.601,"endTime":246.611,"body":"and they usually progress"},{"speaker":"the question is going to ask you","startTime":243.601,"endTime":246.611,"body":"at a pace typically consistent"},{"speaker":"the question is going to ask you","startTime":246.611,"endTime":249.071,"body":"with the other skeletal"},{"speaker":"the question is going to ask you","startTime":246.611,"endTime":249.071,"body":"muscle dysfunction."},{"speaker":"the question is going to ask you","startTime":249.071,"endTime":251.471,"body":"These patients usually"},{"speaker":"the question is going to ask you","startTime":249.071,"endTime":251.471,"body":"do not have pharyngeal problems,"},{"speaker":"the question is going to ask you","startTime":251.471,"endTime":253.111,"body":"so that they can swallow,"},{"speaker":"the question is going to ask you","startTime":253.111,"endTime":255.756,"body":"and that's in contrast"},{"speaker":"the question is going to ask you","startTime":253.111,"endTime":255.756,"body":"to patients with ALS."},{"speaker":"the question is going to ask you","startTime":255.756,"endTime":258.316,"body":"However, most of these patients"},{"speaker":"the question is going to ask you","startTime":255.756,"endTime":258.316,"body":"will require initiation"},{"speaker":"the question is going to ask you","startTime":258.316,"endTime":261.116,"body":"of nocturnal non-invasive"},{"speaker":"the question is going to ask you","startTime":258.316,"endTime":261.116,"body":"ventilation in their teens,"},{"speaker":"the question is going to ask you","startTime":261.116,"endTime":263.816,"body":"and that may progress"},{"speaker":"the question is going to ask you","startTime":261.116,"endTime":263.816,"body":"to the need for 24-hour"},{"speaker":"the question is going to ask you","startTime":263.816,"endTime":267.946,"body":"either non-invasive or invasive"},{"speaker":"the question is going to ask you","startTime":263.816,"endTime":267.946,"body":"mechanical ventilation over time."},{"speaker":"the question is going to ask you","startTime":267.946,"endTime":269.731,"body":"I'm also aggressive"},{"speaker":"the question is going to ask you","startTime":267.946,"endTime":269.731,"body":"with the administration"},{"speaker":"the question is going to ask you","startTime":269.731,"endTime":271.176,"body":"of cough-assist machines"},{"speaker":"the question is going to ask you","startTime":271.176,"endTime":273.356,"body":"because their abdominal muscles"},{"speaker":"the question is going to ask you","startTime":271.176,"endTime":273.356,"body":"are also weak,"},{"speaker":"the question is going to ask you","startTime":273.356,"endTime":276.316,"body":"and therefore they can't generate"},{"speaker":"the question is going to ask you","startTime":273.356,"endTime":276.316,"body":"a deep cough."},{"speaker":"the question is going to ask you","startTime":276.32,"endTime":277.73,"body":"Finally, as a reminder,"},{"speaker":"the question is going to ask you","startTime":277.73,"endTime":281.18,"body":"the most sensitive and specific finding"},{"speaker":"the question is going to ask you","startTime":277.73,"endTime":281.18,"body":"for diaphragmatic weakness"},{"speaker":"the question is going to ask you","startTime":281.18,"endTime":283.12,"body":"in all neuromuscular patients"},{"speaker":"the question is going to ask you","startTime":283.12,"endTime":286.53,"body":"is the presence of paradoxical"},{"speaker":"the question is going to ask you","startTime":283.12,"endTime":286.53,"body":"respiration while supine;"},{"speaker":"the question is going to ask you","startTime":286.53,"endTime":290.98,"body":"that is, if you see the patient's stomach"},{"speaker":"the question is going to ask you","startTime":286.53,"endTime":290.98,"body":"going inwards on inspiration,"},{"speaker":"the question is going to ask you","startTime":290.98,"endTime":293.89,"body":"that suggests severe"},{"speaker":"the question is going to ask you","startTime":290.98,"endTime":293.89,"body":"diaphragmatic weakness."},{"speaker":"the question is going to ask you","startTime":293.89,"endTime":296.31,"body":"(Cathy) And important to note"},{"speaker":"the question is going to ask you","startTime":293.89,"endTime":296.31,"body":"that multidisciplinary care"},{"speaker":"the question is going to ask you","startTime":296.31,"endTime":297.83,"body":"is essential for these patients"},{"speaker":"the question is going to ask you","startTime":297.83,"endTime":299.84,"body":"because there are"},{"speaker":"the question is going to ask you","startTime":297.83,"endTime":299.84,"body":"multiple systems involved"},{"speaker":"the question is going to ask you","startTime":299.84,"endTime":303.05,"body":"and oftentimes a lot of social services"},{"speaker":"the question is going to ask you","startTime":299.84,"endTime":303.05,"body":"and other healthcare services"},{"speaker":"the question is going to ask you","startTime":303.05,"endTime":304.076,"body":"that are needed."},{"speaker":"the question is going to ask you","startTime":304.076,"endTime":305.262,"body":"(Charlie) Absolutely true."},{"speaker":"the question is going to ask you","startTime":305.262,"endTime":306.912,"body":"Cathy, what about the cardiac findings"},{"speaker":"the question is going to ask you","startTime":306.912,"endTime":309.252,"body":"and the other options"},{"speaker":"the question is going to ask you","startTime":306.912,"endTime":309.252,"body":"that were listed in this question?"},{"speaker":"the question is going to ask you","startTime":309.252,"endTime":312.112,"body":"(Cathy) So, as you mentioned,"},{"speaker":"the question is going to ask you","startTime":309.252,"endTime":312.112,"body":"some of the differences with ALS--"},{"speaker":"the question is going to ask you","startTime":312.112,"endTime":315.482,"body":"ALS usually doesn't involve the heart,"},{"speaker":"the question is going to ask you","startTime":312.112,"endTime":315.482,"body":"it's a disease of motor neurons"},{"speaker":"the question is going to ask you","startTime":315.482,"endTime":317.832,"body":"and also usually presents"},{"speaker":"the question is going to ask you","startTime":315.482,"endTime":317.832,"body":"in older patients."},{"speaker":"the question is going to ask you","startTime":317.832,"endTime":320.902,"body":"So, wouldn't expect that here"},{"speaker":"the question is going to ask you","startTime":317.832,"endTime":320.902,"body":"in this 25-year-old."},{"speaker":"the question is going to ask you","startTime":320.902,"endTime":323.402,"body":"An atrial septal defect"},{"speaker":"the question is going to ask you","startTime":320.902,"endTime":323.402,"body":"may be asymptomatic"},{"speaker":"the question is going to ask you","startTime":323.402,"endTime":324.742,"body":"and only heard on exam,"},{"speaker":"the question is going to ask you","startTime":324.742,"endTime":327.282,"body":"but if it's severe,"},{"speaker":"the question is going to ask you","startTime":324.742,"endTime":327.282,"body":"it can present with cyanosis"},{"speaker":"the question is going to ask you","startTime":327.282,"endTime":329.847,"body":"because of the right-to-left"},{"speaker":"the question is going to ask you","startTime":327.282,"endTime":329.847,"body":"intracardiac shunting"},{"speaker":"the question is going to ask you","startTime":329.847,"endTime":331.772,"body":"or Eisenmenger's physiology."},{"speaker":"the question is going to ask you","startTime":331.772,"endTime":335.932,"body":"This patient wasn't cyanotic,"},{"speaker":"the question is going to ask you","startTime":331.772,"endTime":335.932,"body":"so that goes down lower on my list."},{"speaker":"the question is going to ask you","startTime":335.932,"endTime":338.765,"body":"Chronic thromboembolic disease"},{"speaker":"the question is going to ask you","startTime":335.932,"endTime":338.765,"body":"causes pulmonary hypertension,"},{"speaker":"the question is going to ask you","startTime":338.765,"endTime":340.985,"body":"and you would get"},{"speaker":"the question is going to ask you","startTime":338.765,"endTime":340.985,"body":"right-sided heart failure,"},{"speaker":"the question is going to ask you","startTime":340.985,"endTime":344.455,"body":"not the left-sided heart failure"},{"speaker":"the question is going to ask you","startTime":340.985,"endTime":344.455,"body":"that we hear about in this case."},{"speaker":"the question is going to ask you","startTime":344.455,"endTime":346.665,"body":"And finally, for ischemic cardiomyopathy,"},{"speaker":"the question is going to ask you","startTime":346.665,"endTime":350.035,"body":"you'd see focal wall-motion"},{"speaker":"the question is going to ask you","startTime":346.665,"endTime":350.035,"body":"abnormalities on echo,"},{"speaker":"the question is going to ask you","startTime":350.035,"endTime":352.895,"body":"and angina would be"},{"speaker":"the question is going to ask you","startTime":350.035,"endTime":352.895,"body":"a more prominent symptom."},{"speaker":"the question is going to ask you","startTime":352.903,"endTime":356.293,"body":"I would also expect a family history"},{"speaker":"the question is going to ask you","startTime":352.903,"endTime":356.293,"body":"of ischemic heart disease"},{"speaker":"the question is going to ask you","startTime":356.293,"endTime":359.443,"body":"in someone who is presenting"},{"speaker":"the question is going to ask you","startTime":356.293,"endTime":359.443,"body":"with this at this young age."},{"speaker":"the question is going to ask you","startTime":359.443,"endTime":361.393,"body":"So, that's also why I'm ruling this out."},{"speaker":"the question is going to ask you","startTime":361.393,"endTime":363.783,"body":"(Charlie) Okay,"},{"speaker":"the question is going to ask you","startTime":361.393,"endTime":363.783,"body":"so the teaching point of this case"},{"speaker":"the question is going to ask you","startTime":363.783,"endTime":367.673,"body":"is that muscular dystrophies,"},{"speaker":"the question is going to ask you","startTime":363.783,"endTime":367.673,"body":"particularly Duchenne muscular dystrophy,"},{"speaker":"the question is going to ask you","startTime":367.673,"endTime":371.333,"body":"commonly involve the heart"},{"speaker":"the question is going to ask you","startTime":367.673,"endTime":371.333,"body":"and may present with heart failure,"},{"speaker":"the question is going to ask you","startTime":371.333,"endTime":375.774,"body":"global left ventricular dysfunction,"},{"speaker":"the question is going to ask you","startTime":371.333,"endTime":375.774,"body":"and ECG abnormalities."},{"speaker":"the question is going to ask you","startTime":375.774,"endTime":378.484,"body":"A cardiologist with experience"},{"speaker":"the question is going to ask you","startTime":375.774,"endTime":378.484,"body":"in these genetic disorders"},{"speaker":"the question is going to ask you","startTime":378.484,"endTime":381.454,"body":"should be involved"},{"speaker":"the question is going to ask you","startTime":378.484,"endTime":381.454,"body":"in their multidisciplinary care."},{"speaker":"the question is going to ask you","startTime":381.454,"endTime":384.961,"body":"There are some new disease-modifying"},{"speaker":"the question is going to ask you","startTime":381.454,"endTime":384.961,"body":"medications that are coming out,"},{"speaker":"the question is going to ask you","startTime":384.961,"endTime":388.569,"body":"but, in general, these patients"},{"speaker":"the question is going to ask you","startTime":384.961,"endTime":388.569,"body":"are managed symptomatically."},{"speaker":"the question is going to ask you","startTime":388.569,"endTime":391.329,"body":"(Cathy) And to learn more about this,"},{"speaker":"the question is going to ask you","startTime":388.569,"endTime":391.329,"body":"you can go to \u003ci\u003eHarrison's\u003c/i\u003e chapter"},{"speaker":"the question is going to ask you","startTime":391.329,"endTime":393.619,"body":"on Disorders of the Cardiovascular System"},{"speaker":"the question is going to ask you","startTime":393.619,"endTime":396.42,"body":"and also the chapter"},{"speaker":"the question is going to ask you","startTime":393.619,"endTime":396.42,"body":"on muscular dystrophies."},{"speaker":"the question is going to ask you","startTime":396.42,"endTime":398.49,"body":"♪ (music) ♪"}]}