Download Board Review Cardiovascular Medicine

January 15, 2018 | Author: Anonymous | Category: , Science, Health Science, Cardiology
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Board Review Cardiovascular Medicine Lida and Justin 9/17/15

1. A 55-year-old man is evaluated for a 2-month history of dyspnea on exertion without chest pain. Medical history is significant for type 2 diabetes mellitus, hypertension, and hyperlipidemia. Medications are metformin, lisinopril, pravastatin, and aspirin. On physical examination, blood pressure is 110/75 mm Hg and pulse rate is 60/min. BMI is 35. Jugular venous distention is noted, and trace lower extremity edema is present. The point of maximal impulse is normal in size and location. Cardiac examination reveals a regular rate and rhythm, and the chest is clear to auscultation. Laboratory studies show a serum B-type natriuretic peptide level of 110 pg/mL.

Electrocardiogram is shown :. Echocardiogram shows inferior wall hypokinesis and ejection fraction of 35%. Which of the following is the most appropriate diagnostic test to perform next? • A. Adenosine thallium stress test • B. Cardiac magnetic resonance (CMR) imaging • C. Cardiopulmonary exercise test • D. Coronary angiography

1. A 55-year-old man is evaluated for a 2-month history of dyspnea on exertion without chest pain. Medical history is significant for type 2 diabetes mellitus, hypertension, and hyperlipidemia. Medications are metformin, lisinopril, pravastatin, and aspirin. On physical examination, blood pressure is 110/75 mm Hg and pulse rate is 60/min. BMI is 35. Jugular venous distention is noted, and trace lower extremity edema is present. The point of maximal impulse is normal in size and location. Cardiac examination reveals a regular rate and rhythm, and the chest is clear to auscultation. Laboratory studies show a serum B-type natriuretic peptide level of 110 pg/mL. Electrocardiogram is shown :. Echocardiogram shows inferior wall hypokinesis and ejection fraction of 35%. Which of the following is the most appropriate diagnostic test to perform next? • A. Adenosine thallium stress test • B. Cardiac magnetic resonance (CMR) imaging • C. Cardiopulmonary exercise test • D. Coronary angiography

Answer is D • Coronary angiography is indicated in the evaluation of new-onset heart failure in patients with angina or new-onset left ventricular dysfunction in the setting of a condition that may predispose to silent ischemia.

2. A 54-year-old woman is evaluated by a PCP. She has no symptoms at the time of the exam. On physical examination, blood pressure is 158/68 mm Hg, pulse rate is 92/min, and respiration rate is 20/min. Jugular venous distention is visible 2 cm above the clavicle in the upright position. There is a regular rhythm with normal S1 and S2. There is a grade 2/6 early-peaking systolic murmur at the right upper sternal border and a grade 3/6 diastolic decrescendo murmur at the left lower sternal border. Lungs are clear to auscultation. Transthoracic echocardiogram is ordered and shows a dilated and mildly hypertrophied left ventricle (end-diastolic diameter 80 mm, end-systolic diameter 45 mm) with estimated left ventricular ejection fraction of 50%. There is a bicuspid aortic valve with moderate calcification of the leaflets. The peak aortic valve gradient is 35 mm Hg, and the calculated aortic valve area is 1.3 cm2. There is severe aortic regurgitation. The ascending aortic maximum diameter is 40 mm. Which of the following is the most appropriate treatment? A. Aortic valve replacement B. Aortic valve replacement and ascending aortic graft placement C. Begin carvedilol and reassess in 3 months

D. Repeat Echocardiogram in 3 months

When to repair AI - Symptomatic patient - If EF < 50 %

- If End Diastolic dimension is > 75 mm (or end systolic dimension > 55 mm

To graft or not to graft • A bicuspid aortic valve is frequently associated with dilation of the ascending aorta, which is now recognized to be caused by abnormal connective tissue or an aortopathy in patients with a bicuspid aortic valve

• So if ascending aortic diameter greater than 45 mm at the time of planned aortic valve surgery, repair of the ascending aorta, performed by placement of a graft

3. A 75-year-old woman is evaluated in the emergency department for a 7-day history of nausea, poor oral intake, and confusion. Medical history is significant for persistent atrial fibrillation and hypertension. Medications are metoprolol, digoxin, and warfarin. On physical examination, temperature is normal, blood pressure is 105/74 mm Hg, and pulse rate is 49/min. She is oriented to name, but does not know the date or that she is in the emergency department. The remainder of the examination is normal. Laboratory studies reveal a serum creatinine level of 3.2 mg/dL (283 µmol/L), potassium level of 4.8 meq/L (4.8 mmol/L), and INR of 2.3. Which of the following is the most appropriate management? • A. Direct-current cardioversion • B. Insert a temporary pacemaker • C. Measure the digoxin level • D. Start dobutamine

3. A 75-year-old woman is evaluated in the emergency department for a 7-day history of nausea, poor oral intake, and confusion. Medical history is significant for persistent atrial fibrillation and hypertension. Medications are metoprolol, digoxin, and warfarin. On physical examination, temperature is normal, blood pressure is 105/74 mm Hg, and pulse rate is 49/min. She is oriented to name, but does not know the date or that she is in the emergency department. The remainder of the examination is normal. Laboratory studies reveal a serum creatinine level of 3.2 mg/dL (283 µmol/L), potassium level of 4.8 meq/L (4.8 mmol/L), and INR of 2.3. Which of the following is the most appropriate management? • A. Direct-current cardioversion • B. Insert a temporary pacemaker • C. Measure the digoxin level • D. Start dobutamine

Answer is C • A regularized ventricular rate in the setting of atrial fibrillation is concerning for complete atrioventricular block with a junctional or ventricular escape and the possibility of digoxin toxicity. • Associated with hyperK • Use Dig-specific fab antibody fragments to reverse toxicity within 4 hours. Watch out for low K after admin due to restoration of the Na-K pump.

4. A 72-year-old woman is evaluated during a routine follow-up appointment for aortic stenosis. She does not have any symptoms, including chest pain or dyspnea. She feels that she is in good health “for her age.” On physical examination, vital signs are normal. Estimated central venous pressure is normal. Carotid upstrokes are diminished and delayed. The apical impulse is sustained but not displaced. S1 is normal, but S2 is decreased in intensity. There is a grade 3/6 late-peaking, systolic, crescendo-decrescendo murmur at the right upper sternal border which radiates to the right carotid. Lungs are clear to auscultation. Transthoracic echocardiogram shows normal left ventricular ejection fraction (62%) with moderate concentric hypertrophy (septal and posterior wall thickness 1.4 cm). The aortic valve leaflets are calcified with poor mobility. There is severe aortic stenosis with a peak aortic valve gradient of 65 mm Hg, mean gradient of 42 mm Hg, and calculated aortic valve area of 0.8 cm2. Which of the following is the most appropriate management of this patient? A. Aortic valve replacement surgery B. Balloon aortic valvuloplasty C. Dobutamine stress echocardiography D. Repeat echocardiography in 12 months

4. A 72-year-old woman is evaluated during a routine follow-up appointment for aortic stenosis. She does not have any symptoms, including chest pain or dyspnea. She feels that she is in good health “for her age.” On physical examination, vital signs are normal. Estimated central venous pressure is normal. Carotid upstrokes are diminished and delayed. The apical impulse is sustained but not displaced. S1 is normal, but S2 is decreased in intensity. There is a grade 3/6 late-peaking, systolic, crescendo-decrescendo murmur at the right upper sternal border which radiates to the right carotid. Lungs are clear to auscultation. Transthoracic echocardiogram shows normal left ventricular ejection fraction (62%) with moderate concentric hypertrophy (septal and posterior wall thickness 1.4 cm). The aortic valve leaflets are calcified with poor mobility. There is severe aortic stenosis with a peak aortic valve gradient of 65 mm Hg, mean gradient of 42 mm Hg, and calculated aortic valve area of 0.8 cm2. Which of the following is the most appropriate management of this patient? A. Aortic valve replacement surgery B. Balloon aortic valvuloplasty C. Dobutamine stress echocardiography D. Repeat echocardiography in 12 months

Answer is D • In patients with severe aortic stenosis without symptoms, aortic valve replacement is indicated if left ventricular ejection fraction is below 50%, exercise results in hypotension or symptoms, or rapid progression of stenosis or very severe stenosis (mean gradient >60 mm Hg) has occurred.

5. A 42-year-old woman is evaluated in the emergency department for progressive shortness of breath for 3 weeks. Medical history is noncontributory. She takes no medications. On physical examination, temperature is 37.4 °C (99.3 °F), blood pressure is 112/64 mm Hg, pulse rate is 62/min, and respiration rate is 20/min. Estimated central venous pressure and carotid upstrokes are normal. Cardiac auscultation discloses an opening snap, loud P2, a grade 2/6 diastolic low-pitched murmur at the apex, and a grade 2/6 holosystolic murmur at the apex radiating to the axilla. Electrocardiogram demonstrates sinus tachycardia, left atrial enlargement, and right axis deviation. Transthoracic echocardiogram demonstrates normal biventricular size and function; a dilated left atrium; reduced posterior mitral leaflet excursion without leaflet calcification or significant thickening; severe mitral stenosis with mean gradient 15 mm Hg; moderate mitral regurgitation; and mild tricuspid regurgitation. Estimated pulmonary artery systolic pressure is 58 mm Hg. Which of the following is the most appropriate treatment?

A. Balloon mitral valvuloplasty B. Metoprolol C. Mitral valve replacement D. Open surgical commissurotomy E. Repeat TTE in 3 months

C. MV Repair vs replacement • Mitral valve is the Best valve – Easy to repair with valvuloplasty (anatomically ) • So prefer repair unless MS with Moderate to severe MR Concomitant other valve disease needing surgery - like AR needing replacement

Indication for intervention AORTIC STENOSIS AORTIC REGURGITATION

MITRAL STENOSIS MITRAL REGURGITAION

SYMPTOMS

SYMPTOMS

SYMPTOMS

LVEF
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