Transcript Trevor L. Jenkins, MD UH Harrington Heart & Vascular Institute

5/14/2014 CV Board Review
Trevor L. Jenkins, M.D.
UH Harrington Heart & Vascular Institute
Institute for Transformative Molecular Medicine
University Hospitals Case Medical Center
Case Western Reserve School of Medicine
Question 1
•
A 45-year-old woman is evaluated in the emergency department for acute severe
shortness of breath. She has a history of mitral valve prolapse for more than 30
years. Before today, she has been able to swim for 1 hour without symptoms. Two
hours ago while moving furniture she experienced acute dyspnea and chest
discomfort. She has had no fever or chills.
•
Physical examination shows a thin woman with labored breathing. Temperature is
37.2 °C (99.0 °F), blood pressure is 115/76 mm Hg, heart rate is 120/min and
regular, and respiration rate is 20/min. Oxygen saturation is 88% on ambient air.
There is no jugular venous distention, and carotid upstrokes are brisk. The apical
impulse is not displaced. S1 is reduced and there is a grade 2/6 early systolic
murmur at the apex with radiation to the back. An S3 is present. Her lungs have
bilateral crackles. Extremities are cool.
•
Electrocardiogram shows sinus tachycardia and prominent QRS voltage. Chest
radiograph shows normal cardiac size and pulmonary edema. Urgent transthoracic
echocardiogram shows normal left and right ventricular size and systolic function, left
ventricular ejection fraction of 70%, and partial flail of the anterior mitral valve leaflet
with severe mitral regurgitation. The left atrium is not dilated and no other valve
abnormalities are detected.
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Question 1
• In addition to supplemental oxygen and diuretic therapy, which
of the following is the most appropriate next treatment of this
patient?
A. Captopril
B. Esmolol
C. Mitral Valve surgery
D. Vancomycin and gentimicin after blood cultures are drawn
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Question 1
Stout, Circ 2009;119:3232
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Question 1
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Question 2
•
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, 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; mild mitral regurgitation; and mild tricuspid
regurgitation. Estimated pulmonary artery systolic pressure is 58 mm Hg.
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Question 2
• Which of the following is the most appropriate treatment?
A. Balloon mitral valvuloplasty
B. Metoprolol
C. Mitral Valve replacement
D. Open surgical commissurotomy
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Question 2
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Question 2
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Question 3
•
•
A 72-year-old man is evaluated in the emergency department for worsening shortness of
breath for several weeks, orthopnea, and bilateral lower extremity edema. He has had chest
heaviness with exertion, but no presyncope or syncope.
Physical examination shows a diaphoretic man in mild distress. Blood pressure is 118/74 mm
Hg, pulse rate is 96/min, respiration rate is 20/min. Oxygen saturation is 88% on ambient air.
Estimated central venous pressure is 10 cm H2O. There is a regular rhythm and S2 is
diminished in intensity. There is a grade 3/6 late-peaking systolic murmur at the left lower
sternal border. An S3 is audible. Lung examination demonstrates bibasilar crackles. There is
bilateral lower extremity edema to the knees.
•
Chest radiograph shows cardiomegaly and increased bilateral interstitial markings.
•
Electrocardiogram shows sinus rhythm and left ventricular hypertrophy. Transthoracic
echocardiogram shows left ventricular dilatation with mild concentric hypertrophy. The
ejection fraction is 30% with global hypocontractility. The aortic valve leaflets are thickened
with reduced mobility and severe calcification. The aortic valve peak instantaneous gradient
is 54 mm Hg and mean gradient is 38 mm Hg. The calculated aortic valve area is 0.8 cm 2.
The patient is treated with intravenous furosemide with symptomatic improvement in dyspnea
and oxygen saturation.
•
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Question 3
• Which of the following is the most appropriate treatment for this
patient?
A. Balloon aortic valvuloplasty
B. Intravenous nitroprusside
C. Surgical aortic valve replacement (SAVR)
D. Transcatheter aortic valve replacement (TAVR)
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Question 3
• Factors supporting SAVR
– Severe aortic stenosis (Valve area < 1.0 cm2)
– Left ventricular dysfunction
– Symptomatic patient
• CHF
• Exertional chest pain
• Syncope
– Low operative risk
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Question 4
•
•
•
A 63-year-old man is evaluated for pleuritic left-sided anterior chest pain, which has
persisted intermittently for 1 week. The pain lasts for hours at a time and is not
provoked by exertion or relieved by rest but is worse when supine. He reports
transient relief with acetaminophen and codeine and occasionally when leaning
forward. He has had a low-grade fever for 3 days, without cough or chills. Medical
history is significant for acute pericarditis 7 months ago. He was treated at that time
with ibuprofen and had rapid resolution of his symptoms. His only current
medications are acetaminophen and codeine.
On physical examination, temperature is 37.8 °C (100.0 °F), blood pressure is
132/78 mm Hg, pulse rate is 98/min, and respiration rate is 16/min. No jugular
venous distention is noted. A two-component pericardial friction rub is heard over
the left side of the sternum. Pulsus paradoxus of 6 mm Hg is noted. Lung
auscultation reveals normal breath sounds with no wheezing. No pedal edema is
present.
Electrocardiogram demonstrates sinus rhythm and no ST-segment shift.
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Question 4
• Which of the following is the most appropriate
management?
A. Azathioprine
B. Chest CT
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C. Colchicine and aspirin
D. Pericardiectomy
E. Prednisone
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Question 4
• COPE (COlchicine for acute Pericarditis) trial.
–
Imazio, Circ 2005;112:2012
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120 patients assigned to ASA vs ASA + Colchicine for first episode of acute pericarditis
–
Colchicine decreased the recurrence rate at 18 months (10.7% vs 32.3%, P = .004, NNT = 5) and
symptoms at 72 hours (11.7% vs 36.7%, P = .003). Corticosteroid use was an independent risk factor
for recurrence. Colchicine stopped in 5 cases for GI intolerance.
• CORE (COlchicine for REcurrent pericarditis) trial.
–
Imazio, Arch Intern Med 2005;165:1967
–
84 patient assigned to ASA vs ASA + Colchicine for recurrent episode of acute pericarditis
–
Colchicine decreased the recurrence rate (24.0% vs 50.6%, P = .02, NNT = 4) and symptoms at 72
hours (10% vs 31%, P = .03). In multivariate analysis, prior corticosteroid use was an independent
predictor of further recurrent pericarditis
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Question 5
• A 68-year-old woman is evaluated for palpitations. Her
symptoms occur daily during both rest and exertion. She
describes the palpitations as intermittent “hard” beats that “take
her breath away.” Her symptoms are made worse by caffeine
consumption. She reports no dizziness or syncope. Medical
history is significant for hypertension and hyperlipidemia.
Medications are an ACE inhibitor and a statin.
• On physical examination, she is afebrile, blood pressure is
138/80 mm Hg, pulse rate is 83/min, and respiration rate is
18/min. On cardiac examination, the rhythm is regular. There
are no murmurs or extra sounds. The lungs are clear. The
remainder of the general physical examination is normal.
• The electrocardiogram shows normal sinus rhythm with minor
ST-segment abnormalities.
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Question 5
• Which is the most appropriate testing option to utilize next in this
patient?
A. Electrophysiology study
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B. 24 hour continuous ambulatory electrocardiographic monitor
C. Implantable loop recorder
D. Post-symptom event recorder
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Question 5
• For patients with palpitations that occur on a daily basis, 24- or
48-hour continuous ambulatory electrocardiographic monitoring
is appropriate to correlate symptoms with heart rhythm.
• Patient describes PVC events
• A PVC is followed by a compensatory pause, often described by
patients as a “skipped beat.”
• PVCs are often caused or made worse by agents such as
caffeine, alcohol, and nicotine.
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Question 6
•
•
A 68-year-old woman is seen for an evaluation. Medical history is
significant for ischemic cardiomyopathy and hypertension. She had an
implantable cardioverter-defibrillator placed 5 years ago. She has good
functional capacity and is able to walk three blocks without limitations.
Medications are lisinopril, carvedilol, aspirin, and pravastatin.
On physical examination, she is afebrile, blood pressure is 137/70 mm
Hg, pulse rate is 82/min, and respiration rate is 18/min. BMI is 23. The
remainder of the examination is normal.
Laboratory studies:
Hemoglobin A1c
6.9%
Total cholesterol
115 mg/dL (2.98 mmol/L)
LDL cholesterol
53 mg/dL (1.37 mmol/L)
HDL cholesterol
40 mg/dL (1.04 mmol/L)
Triglycerides
112 mg/dL (1.27 mmol/L)
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Question 6
• Which of the following clinical measures is most important to
target in this patient to reduce her risk of a cardiovascular
event?
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A. Blood pressure
B. Hemoglobin A1c
C. LDL cholesterol level
D. Triglyceride level
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Question 6
•
The American Heart Association recommends targeting a blood
pressure reduction to less than 130/80 mm Hg in patients with coronary
heart disease (CHD) or a CHD risk equivalent (carotid disease,
peripheral vascular disease, abdominal aortic aneurysm) and to below
120/80 mm Hg for those with heart failure or a left ventricular ejection
fraction below 40%.
•
There is no benefit to strict glycemic control on the impact of
macrovascular disease. For most patients, a reasonable goal is a
hemoglobin A1c value of 7.0% or below.
•
In patients with a high risk of a cardiovascular event, LDL cholesterol
levels should be treated aggressively with lipid-lowering therapy with a
target LDL goal of below 100 mg/dL (2.59 mmol/L), with a reasonable
goal of further reduction to below 70 mg/dL (1.81 mmol/L) in patients at
very high risk.
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Question 7
•
•
A 65-year-old man asks for advice on cardiac risk assessment during a
routine evaluation. He is asymptomatic, does not smoke cigarettes, has
no pertinent medical or family history, and takes no medications.
On physical examination, blood pressure is 148/90 mm Hg, pulse rate
is 83/min, and respiration rate is 18/min. The remainder of the physical
examination is normal. The patient's Framingham risk score predicts a
15% chance of a myocardial infarction or coronary death in the next 10
years.
Laboratory studies:
Total cholesterol
217 mg/dL (5.62 mmol/L)
LDL cholesterol
125 mg/dL (3.24 mmol/L)
HDL cholesterol
48 mg/dL (1.24 mmol/L)
Triglycerides
269 mg/dL (3.04 mmol/L)
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Question 7
• Which of the following is the most appropriate test to perform
next?
A. B-type natriuretic peptide
B. Cardiac CT angiography
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C. High-sensitivity C-reactive protein
D. Stress echocardiography
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Question 7
•
Measurement of hsCRP has been demonstrated to be clinically useful
for guiding primary prevention strategies in persons with an
intermediate risk of future cardiovascular events (Framingham risk
score of 10%-20%), with up to 30% of these patients reclassified as
either low risk or high risk based on hsCRP measurement.
•
The JUPITER trial tested the hypothesis that healthy middle-aged and
older persons with elevated hsCRP but without elevated LDL
cholesterol (<130 mg/dL [3.37 mmol/L]) would benefit from statin
treatment. Statin treatment was associated with lowering of median
LDL cholesterol level from 108 to 55 mg/dL (2.80 to 1.42 mmol/L, 50%
reduction) and median hsCRP level from 0.42 to 0.22 mg/dL (4.2 to 2.2
mg/L, 37% reduction). The JUPITER trial was terminated early after a
median follow-up of 1.9 years because of reduction in the primary end
point rate (incidence of a first major cardiovascular event) from 1.36 to
0.77 per 100 patient-years of follow-up. The absolute reduction was
relatively small at 1.2%.
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Question 8
•
A 61-year-old man is evaluated during a follow-up examination. He has
a 4-year history of atrial fibrillation and underwent atrial fibrillation
ablation 6 months ago. He has had no symptoms of palpitations,
fatigue, shortness of breath, or presyncope since the procedure. He
has hypertension and type 2 diabetes mellitus. Medications are
lisinopril, atenolol, metformin, and warfarin.
•
Blood pressure is 124/82 mm Hg and pulse rate is 72/min. Cardiac
examination discloses regular rate and rhythm. The rest of the physical
examination is normal.
•
Electrocardiogram demonstrates normal sinus rhythm.
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Question 8
• Which of the following is the most appropriate
treatment?
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A. Continue warfarin
B. Switch to aspirin
C. Switch to clopidogrel
D. Switch to aspirin and clopidogrel
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Question 8
• Warfarin should be continued in this patient. For the first 2 to 3
months after an atrial fibrillation ablation, all patients should take
warfarin. The best management strategy thereafter is to provide
anticoagulation as if the ablation did not occur, using a tool such
as the CHADS2 score to risk stratify. Although the patient has
had no symptoms of atrial fibrillation since his ablation
procedure, patients may have either asymptomatic episodes or
a symptomatic recurrence of atrial fibrillation after the ablation
and can be at risk for stroke. This patient has hypertension and
diabetes mellitus and a CHADS2 score of 2 (4.0% risk of stroke
per year).
• CHADS2 score: 1 point: CHF (EF <35%), DM, HTN, Age > 75
2 points: CVA/TIA
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Question 8
Annual Stroke Risk
CHADS2 Score
Stroke Risk %
95% CI
0
1.9
1.2–3.0
1
2.8
2.0–3.8
2
4.0
3.1–5.1
3
5.9
4.6–7.3
4
8.5
6.3–11.1
5
12.5
8.2–17.5
6
18.2
10.5–27.4
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Question 9
• A 62-year-old woman is awaiting a procedure in the presurgical
area. She has a single-chamber implantable cardioverterdefibrillator (ICD) and is about to undergo a hemicolectomy for
colon cancer. Medical history is pertinent for ischemic
cardiomyopathy, chronic atrial fibrillation, complete heart block,
and pacemaker dependence. Medications are aspirin,
carvedilol, lisinopril, digoxin, warfarin (withheld), and
rosuvastatin. Perioperative anticoagulation is provided with
unfractionated heparin.
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Question 9
• Which of the following is the most appropriate perioperative
management of the patient's ICD?
A. Insert a temporary pacemaker
B. Place a magnet over the ICD
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C. Turn shock therapy off and change to asynchronous mode
D. No programming changes need to ICD
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