QUESTION: 153

A 60-year-old morbidly obese man presents with complaints of fatigue, worsening exertional dyspnea, three-pillow orthopnea, lower extremity edema, and cough occasionally productive of frothy sputum. He has a long-standing history of type II diabetes and hypertension. On examination, you note the presence of bibasilar rales, an S3 gallop, jugular venous distention, and 2+ pitting edema in both legs up to the knees. There does not appear to be an arrhythmia present. Which of the following has been shown to prolong survival in patients with this condition?

digoxin
nonsteroidal anti-inflammatory drugs(NSAIDs)
warfarin
carvedilol
diltiazem

Answer(s): D

Explanation:

This patient's presentation is most consistent with pulmonary edema from decompensated CHF. The BNP test has been found to be both sensitive and specific for the diagnosis of CHF. It can be a very useful test to order when a patient is dyspneic to help to determine if CHF is the cause. Troponin, CK- MB, and LDH are markers of damage to cardiac muscle and can be diagnostic in a MI. While MI can be a cause of CHF, and most patients presenting with CHF will have cardiac enzymes drawn as part of their evaluation, cardiac enzymes are neither sensitive nor specific for CHF. Similarly, a CXR can determine the presence of pulmonary edema but not its cause.

Acute pulmonary edema secondary to CHF will require management with diuresis for acute symptomatic relief. ACE inhibitors and beta-blockers do decrease mortality and morbidity in CHF; however their use in acute decompensated heart failure is suspected as they may induce hypotension and further cardiogenic shock. Digoxin is used for symptomatic relief either when other modalities fail or when rate control from atrial fibrillation is an issue. In patients with CHF and atrial fibrillation, beta- blockers have shown better effect and reduced morbidity than digoxin. Nevertheless, in the acute setting of decompensated heart failure with pulmonary edema, diuresis is the optimal initial treatment, not digoxin. In chronic heart failure, digoxin is reserved for patients with systolic failure that are symptomatic despite adequate ACE inhibitor and beta-blocker use. Furosemide is effective in treating the acute pulmonary edema associated with CHF by virtue of its potent diuretic action, which rapidly eliminates excess body fluid volume.

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QUESTION: 154

A 60-year-old morbidly obese man presents with complaints of fatigue, worsening exertional dyspnea, three-pillow orthopnea, lower extremity edema, and cough occasionally productive of frothy sputum. He has a long-standing history of type II diabetes and hypertension. On examination, you note the presence of bibasilar rales, an S3 gallop, jugular venous distention, and 2+ pitting edema in both legs up to the knees.
There does not appear to be an arrhythmia present.

A transesophageal echocardiogram (TEE) is performed which reveals a left ventricular ejection fraction (LVEF) of 30%. Which of the following accurately describes this patient and his condition?

A transthoracic echocardiogram (TTE) would give a more accurate estimation of the patient's true LVEF.
He has diastolic heart failure.
Digoxin would be an appropriate choice in attempting to control symptoms.
He has class I heart failure according to the New York Heart Association (NYHA) classification.
Hypertension is the most common cause.

Answer(s): C

Explanation:

This patient's presentation is most consistent with pulmonary edema from decompensated CHF. The BNP test has been found to be both sensitive and specific for the diagnosis of CHF. It can be a very useful test to order when a patient is dyspneic to help to determine if CHF is the cause. Troponin, CK- MB, and LDH are markers of damage to cardiac muscle and can be diagnostic in a MI. While MI can be a cause of CHF, and most patients presenting with CHF will have cardiac enzymes drawn as part of their evaluation, cardiac enzymes are neither sensitive nor specific for CHF. Similarly, a CXR can determine the presence of pulmonary edema but not its cause.

Acute pulmonary edema secondary to CHF will require management with diuresis for acute symptomatic relief. ACE inhibitors and beta-blockers do decrease mortality and morbidity in CHF; however their use in acute decompensated heart failure is suspected as they may induce hypotension and further cardiogenic shock. Digoxin is used for symptomatic relief either when other modalities fail or when rate control from atrial fibrillation is an issue. In patients with CHF and atrial fibrillation, beta- blockers have shown better effect and reduced morbidity than digoxin. Nevertheless, in the acute setting of decompensated heart failure with pulmonary edema, diuresis is the optimal initial treatment, not digoxin. In chronic heart failure, digoxin is reserved for patients with systolic failure that are symptomatic despite adequate ACE inhibitor and beta-blocker use. Furosemide is effective in treating the acute pulmonary edema associated with CHF by virtue of its potent diuretic action, which rapidly eliminates excess body fluid volume.

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QUESTION: 155

A 70-year-old male is seen in the office for chest pain. He reports that he is getting substernal chest pain, without radiation, when he mows his lawn. The pain resolves with 1015 minutes of rest. He has never had pain at rest. He has no other cardiac complaints and his review of systems is otherwise negative. He has an unremarkable medical history and takes only a baby aspirin a day. On examination, his blood pressure is 160/70, pulse 85, and respiratory rate 16. His cardiac examination is notable for a harsh, 3/6 systolic ejection murmur along the sternal border that radiates to the carotid arteries. His carotid pulsation is noted to rise slowly and is small and sustained. His lungs are clear. The remainder of his examination is normal.

Which of the following would be most likely to be seen on an ECG?

S-T segment elevations in the precordial leads
Q waves in the precordial leads
low-voltage QRS complexes
left ventricular hypertrophy pattern
normal ECG

Answer(s): D

Explanation:

Aortic stenosis is one of the most common valvular abnormalities found in adults. It can be congenital -- such as a unicuspid or bicuspid valve--or acquired. In young adults, acquired aortic stenosis is often seen as a consequence of rheumatic fever. This is becoming less common in developed nations. In adults over the age of 65, the most common cause of aortic stenosis is age-related degenerative, calcific aortic stenosis. The valvular cusps are immobilized and the stenosis caused by calcium deposits along the flexion lines of the valves. Acquired aortic stenosis typically has a prolonged asymptomatic period. During this time the stenosis may be found incidentally by auscultation of the characteristic harsh, holosystolic murmur in the aortic valve area that radiates to the carotid arteries. There may also be a slow, small, and sustained arterial pulsation (pulsus parvus and tardus) due to the relative outflow obstruction. The cardinal symptoms of aortic stenosis that signal advancing disease, and increased risk of mortality, are angina, heart failure, and syncope. An ECG will show left ventricular hypertrophy in approximately 85% of symptomatic cases of aortic stenosis.

A normal ECG is possible but would be more likely in early, asymptomatic stages. S-T segment elevation would be more consistent with acute cardiac ischemia and Q waves would be more consistent with a completed MI. Low-voltage QRS complexes can be seen in several conditions, including pericardial effusion, COPD, or obesity. When considering the diagnosis of aortic stenosis, the initial diagnostic test of choice would be echocardiography. It would provide information on both the structure (bicuspid, tricuspid, and the like) and the function (valve area, pressures) of the valve. The size and function of the left ventricle can also be determined. If aortic stenosis is found on echocardiogram and the patient is symptomatic, the next test would be cardiac catheterization.

This would allow for direct measurement of the pressure gradient across the valve. It would also allow for evaluation of the status of the coronary arteries in order to determine whether CABG would need to be performed along with valve replacement. Exercise stress testing is relatively contraindicated in the setting of symptomatic aortic stenosis. Holter monitoring would only be useful if there were a concomitant arrhythmia. Electrophysiologic studies would not play a role in the typical evaluation of aortic stenosis.

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QUESTION: 156

A 70-year-old male is seen in the office for chest pain. He reports that he is getting substernal chest pain, without radiation, when he mows his lawn. The pain resolves with 1015 minutes of rest. He has never had pain at rest. He has no other cardiac complaints and his review of systems is otherwise negative. He has an unremarkable medical history and takes only a baby aspirin a day. On examination, his blood pressure is 160/70, pulse 85, and respiratory rate 16. His cardiac examination is notable for a harsh, 3/6 systolic ejection murmur along the sternal border that radiates to the carotid arteries. His carotid pulsation is noted to rise slowly and is small and sustained. His lungs are clear. The remainder of his examination is normal.

Which of the following would be the most appropriate test to order next?

echocardiogram
exercise stress test
cardiac catheterization
24-hour Holter monitor
electrophysiologic studies

Answer(s): A

Explanation:

Aortic stenosis is one of the most common valvular abnormalities found in adults. It can be congenital -- such as a unicuspid or bicuspid valve--or acquired. In young adults, acquired aortic stenosis is often seen as a consequence of rheumatic fever. This is becoming less common in developed nations. In adults over the age of 65, the most common cause of aortic stenosis is age-related degenerative, calcific aortic stenosis. The valvular cusps are immobilized and the stenosis caused by calcium deposits along the flexion lines of the valves. Acquired aortic stenosis typically has a prolonged asymptomatic period. During this time the stenosis may be found incidentally by auscultation of the characteristic harsh, holosystolic murmur in the aortic valve area that radiates to the carotid arteries. There may also be a slow, small, and sustained arterial pulsation (pulsus parvus and tardus) due to the relative outflow obstruction. The cardinal symptoms of aortic stenosis that signal advancing disease, and increased risk of mortality, are angina, heart failure, and syncope. An ECG will show left ventricular hypertrophy in approximately 85% of symptomatic cases of aortic stenosis.

A normal ECG is possible but would be more likely in early, asymptomatic stages. S-T segment elevation would be more consistent with acute cardiac ischemia and Q waves would be more consistent with a completed MI. Low-voltage QRS complexes can be seen in several conditions, including pericardial effusion, COPD, or obesity. When considering the diagnosis of aortic stenosis, the initial diagnostic test of choice would be echocardiography. It would provide information on both the structure (bicuspid, tricuspid, and the like) and the function (valve area, pressures) of the valve. The size and function of the left ventricle can also be determined. If aortic stenosis is found on echocardiogram and the patient is symptomatic, the next test would be cardiac catheterization.

This would allow for direct measurement of the pressure gradient across the valve. It would also allow for evaluation of the status of the coronary arteries in order to determine whether CABG would need to be performed along with valve replacement. Exercise stress testing is relatively contraindicated in the setting of symptomatic aortic stenosis. Holter monitoring would only be useful if there were a concomitant arrhythmia. Electrophysiologic studies would not play a role in the typical evaluation of aortic stenosis.

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