Trevor L. Jenkins, M.D.

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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

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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?
• Captopril
• Esmolol
• Mitral Valve surgery
• Vancomycin and gentimicin after blood cultures
  are drawn

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Question 1
Stout, Circ 20091193232
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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?
• Balloon mitral valvuloplasty
• Metoprolol
• Mitral Valve replacement
• 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 cm2.
• 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?
• Balloon aortic valvuloplasty
• Intravenous nitroprusside
• Surgical aortic valve replacement (SAVR)
• Transcatheter aortic valve replacement (TAVR)

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Question 3

• Factors supporting SAVR
• Severe aortic stenosis (Valve area lt 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?
• Azathioprine
• Chest CT
• Colchicine and aspirin
• Pericardiectomy
• Prednisone

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Question 4

• COPE (COlchicine for acute Pericarditis) trial.
• Imazio, Circ 20051122012
• 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 20051651967
• 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?
• Electrophysiology study
• 24 hour continuous ambulatory electrocardiographic
  monitor
• Implantable loop recorder
• 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 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?
• Blood pressure
• Hemoglobin A1c
• LDL cholesterol level
• 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 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?
• B-type natriuretic peptide
• Cardiac CT angiography
• High-sensitivity C-reactive protein
• 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 (lt130 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?
• Continue warfarin
• Switch to aspirin
• Switch to clopidogrel
• 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 lt35), DM, HTN,
  Age gt 75 2 points CVA/TIA

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Question 8
Annual Stroke Risk Annual Stroke Risk Annual Stroke Risk
CHADS2 Score Stroke Risk  95 CI
0 1.9  1.23.0
1 2.8  2.03.8
2 4.0  3.15.1
3 5.9  4.67.3
4 8.5  6.311.1
5 12.5  8.217.5
6 18.2 10.527.4
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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 cardioverter-defibrillator (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?
• Insert a temporary pacemaker
• Place a magnet over the ICD
• Turn shock therapy off and change to asynchronous
  mode
• No programming changes need to ICD

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