Question 1

A 34-year-old woman comes to the office due to a 10-day history of malaise, fever, headache, and nasal discharge.  Her symptoms initially improved with an oral decongestant and nasal glucocorticoid spray but then worsened.  Medical history is notable for moderate, persistent asthma and gastroesophageal reflux disease.  The patient is allergic to penicillin and experienced a skin reaction when given penicillin as a child.
Temperature is 38.3 C (101 F).  Physical examination shows focal tenderness over the right frontal sinus.  The lungs are clear to auscultation.
Trimethoprim-sulfamethoxazole is prescribed.  Five days later, the patient calls to report that the headaches have improved but she has developed redness and "some blisters" on her arms.  Which of the following is the best response to this patient's concerns?

Accepted Answer

11ec193a_9777_53f9_853d_3f392a1830d5_MD0002_00 This patient's description of her rash is concerning for Stevens-Johnson syndrome (SJS) due to trimethoprim-sulfamethoxazole. SJS and toxic epidermal necrolysis (TEN) are related clinical syndromes characterized by acute epidermal necrosis and are differentiated based on the percentage of body surface involved. By convention, SJS denotes <10% of body surface area involvement, >30% is designated as TEN, and 10%-30% is SJS/TEN overlap. SJS and TEN are commonly triggered by medications (eg, sulfonamides) and are up to 3 times more common in patients with HIV. SJS presents with an initial prodrome of fever and influenza-like symptoms, followed by rapid onset of painful erythematous or purpuric macules. The skin lesions then progress to bullae formation with necrosis and sloughing. Mucosal lesions (eg, ocular, oral, genital, respiratory surfaces) are also present in most cases. Secondary infections are common in SJS and TEN, and fatalities may occur despite treatment. Patients should be evaluated immediately and managed in a hospital setting, often in an intensive care burn unit (Choices B and C). All suspected and unnecessary medications should be immediately discontinued as the prognosis of SJS or TEN improves with early removal of causative medications (Choice A). Treatment is supportive and involves wound care, with consideration for systemic glucocorticoids and/or intravenous immune globulin in moderate to severe cases. (Choice D) Antihistamines are effective for mild allergic reactions but ineffective in treating SJS or TEN. Educational objective: Patients with suspected Stevens-Johnson syndrome or toxic epidermal necrolysis should be immediately evaluated and managed in a hospital setting. In addition, immediate discontinuation of the suspected causative medication(s) and all other unnecessary medications is mandatory. __________ References: Stevens-Johnson syndrome and toxic epidermal necrolysis: an update. (http://www.ncbi.nlm.nih.gov/pubmed/26481651) Effects of treatments on the mortality of Stevens-Johnson syndrome and toxic epidermal necrolysis: A retrospective study on patients included in the prospective EuroSCAR Study. (http://www.ncbi.nlm.nih.gov/pubmed/17919775)

Question 2

A 30-year-old man comes to the physician for a pre-employment physical examination. He has no past medical history. He exercises regularly and tries to eat a healthy diet. The patient's blood pressure is 122/70 mm Hg and pulse is 78/min and regular. The jugular venous pressure is estimated at 5 mm H₂O. There are no carotid bruits. A 3/6 short systolic murmur is heard at the left lower sternal border and the apex in the supine position, and the murmur gets longer with standing. There is a normal splitting of the second heart sound. The apical impulse is not displaced. Femoral pulses are full and symmetric. Which of the following is the most likely diagnosis?

Accepted Answer

11ec193a_976f_1690_853d_05959a9b1d42_MD0002_00 The presence of a short systolic murmur at the left sternal border and cardiac apex that gets longer with standing is most consistent with mitral valve prolapse (MVP) with mitral regurgitation (MR). Cardiac auscultation in patients with MVP typically shows single or multiple non-ejection clicks (caused by snapping of mitral chordae during systole) and/or mid to late systolic murmur of mitral regurgitation. Standing from a supine position and the Valsalva maneuver decrease the venous return to the heart, decreasing left ventricular (LV) volume and cavity size. This causes a greater degree of prolapse of the mitral valve, making the murmur of MVP more pronounced. Maneuvers that increase LV filling (ie, squatting, leg raise) will improve the closure of the mitral leaflets, delay the click, and soften the murmur. (Choice A) Patients with atrial septal defect (ASD) usually have a wide, fixed splitting of second heart sound. Patients with large left-to-right shunt can develop a mid-systolic or ejection murmur due to increased flow across the pulmonary valve or a diastolic rumble due to increased flow across the tricuspid valve. This patient has normal splitting of the second heart sound, which is not consistent with ASD. (Choice B) Bicuspid aortic valve typically causes a prominent ejection click followed by a mid-systolic murmur, heard best over the right second intercostal space. Bicuspid aortic valve (Choice D) Pulmonic stenosis typically causes an early systolic murmur with maximal intensity at the left upper sternal border. Abrupt standing from a supine position decreases the venous return to the heart and decreases the intensity of the murmur. (Choice E) Tricuspid stenosis causes a mid-diastolic murmur heard best along the left lower sternal border. The murmur increases in intensity with inspiration and/or leg elevation and diminishes in intensity with standing from a supine position due to decrease in the venous return to the right side of the heart. Educational objective: Mitral valve prolapse is associated with single or multiple non-ejection clicks and/or mid to late systolic murmur of mitral regurgitation. Standing or the Valsalva maneuver causes an earlier systolic click and longer murmur (due to decreased venous return and left ventricular volume). Squatting or leg elevation causes a delayed systolic click and shorter murmur (due to increased left ventricular volume). __________ References: Mitral valve prolapse: causes, clinical manifestations, and management. (http://www.ncbi.nlm.nih.gov/pubmed/2667419)

Question 3

A 69-year-old man comes to the office with a 4-week history of fatigue. He feels "drained" by the end of the day. He has no chest pain, shortness of breath, or body aches but does have decreased exercise tolerance. He reports good appetite and no recent weight changes. His medications include amlodipine for hypertension and rosuvastatin for hyperlipidemia. His temperature is 36.8 C (98.3 F) and blood pressure is 144/90 mm Hg. Body mass index is 22 kg/m². Initial laboratory studies show hemoglobin of 14.2 g/dL, serum potassium of 4.6 mEq/L, and serum creatinine of 0.8 mg/dL. Fasting glucose level is 98 mg/dL. Electrocardiogram is shown here. Which of the following is the best next step in management of this patient?

Accepted Answer

This patient's presentation is consistent with atrial fibrillation (AF). Electrocardiogram shows an irregularly irregular rhythm with varying R-R intervals and no clearly discernible P waves. Patients may be asymptomatic but typically present with chest pain, dyspnea, palpitations, weakness, decreased exercise tolerance, dizziness, or presyncope. Electrocardiogram AF is the most common supraventricular arrhythmia and can occur due to a variety of cardiac and/or systemic disorders. Patients with hyperthyroidism have an increased risk of developing AF, and the risk is also increased in those with subclinical hyperthyroidism (low serum thyroid-stimulating hormone [TSH] and normal serum T4 concentration in clinically euthyroid patients). As a result, all patients with new-onset AF should have serum TSH levels obtained as part of initial evaluation for early diagnosis and appropriate management of hyperthyroidism. disorders (Choice A) Ankle brachial index measurement is used to detect peripheral arterial disease in patients with intermittent claudication. (Choice B) Patients using statin drugs (eg, rosuvastatin) can develop statin-induced myopathy with myalgia, muscle weakness, and/or elevation of serum creatine kinase levels. This patient has no such signs/symptoms. (Choice D) Treadmill exercise stress test may be used for diagnosis in patients with an intermediate probability of coronary artery disease. Atrial fibrillation is usually not associated with stable coronary heart disease and is also a relative contraindication to exercise treadmill testing. (Choice E) Urine albumin excretion is increased in patients with glomerular diseases (eg, focal or diffuse glomerulonephritis, nephrotic syndrome) and in systemic illnesses such as diabetes mellitus. The presence of albuminuria (micro or macro) has been found to be associated with a higher AF risk; however, routine measurement of urine albumin levels is not recommended. Educational objective: Patients with clinical or subclinical hyperthyroidism have a higher risk of developing atrial fibrillation (AF). Serum thyroid-stimulating hormone levels should be measured during the initial evaluation of all patients with new-onset AF. __________ References: Subclinical hyperthyroidism as a risk factor for atrial fibrillation. (http://www.ncbi.nlm.nih.gov/pubmed/11685172) Subclinical hyperthyroidism and the risk of coronary heart disease and mortality. (http://www.ncbi.nlm.nih.gov/pubmed/22529182)

Question 4

A 28-year-old woman is evaluated after a brief episode of syncope in the shopping mall.  The patient walked into an overcrowded store where she felt hot and nauseated before passing out.  She also had some palpitations.  Her past medical history is significant for 2 prior episodes of syncope and a recent urinary tract infection.  Electrocardiogram (ECG) is shown in this exhibit. 
Which of the following medications should be avoided in this patient?

Accepted Answer

11ec193a_9771_fcc3_853d_7d0d0b5d41ec_MD0002_00 This patient's baseline electrocardiogram shows prolonged QT interval. QT interval varies inversely with the heart rate and may be "corrected" using Bazett's formula: electrocardiogram Corrected QT interval (QTc) = (QT interval) / ? (RR interval) A QTc >450 msec in male patients and >470 msec in female patients is considered a prolonged QT interval. Long QT syndrome (LQTS) can be congenital or acquired and is associated with an increased risk of torsades de pointes (TdP), a form of polymorphic ventricular tachycardia. Episodes of TdP may terminate spontaneously, occur in rapid succession, or deteriorate to ventricular fibrillation. Patients with LQTS may be asymptomatic or can present with palpitations, presyncope or syncope, seizures, or sudden cardiac arrest. Electrolyte abnormalities (eg, hypomagnesemia, hypokalemia) and drug therapy (eg, fluoroquinolones, antipsychotics) are the 2 most common causes of acquired LQTS. As a general rule, implicated drugs (eg, levofloxacin) should not be initiated if the baseline QTc >450 msec. If the QTc becomes >500 msec during therapy, the drug dose should be reduced or discontinued. (Choices A and B) Penicillins and cephalosporins are not associated with any significant risk of prolonged QT interval or TdP. (Choice D) Class IB antiarrhythmic drugs (lidocaine and phenytoin) are occasionally used for acute management of TdP. (Choice E) Beta-blockers (atenolol, metoprolol, or propranolol) are recommended as a first-line therapy in both symptomatic and asymptomatic patients with congenital LQTS to reduce the risk of sudden cardiac death. Educational objective: Prolonged QTc interval can be congenital or acquired, and increases risk of torsades de pointes, a form of polymorphic ventricular tachycardia. Electrolyte abnormalities (eg, hypomagnesemia, hypokalemia) and certain drugs (eg, fluoroquinolones, antipsychotics) are the most common causes of acquired long QT syndrome. __________ References: Mechanisms, risk factors, and management of acquired long QT syndrome: a comprehensive review. (http://www.ncbi.nlm.nih.gov/pubmed/22593664)

Question 5

A 77-year-old woman is transferred to a skilled nursing facility after a 2-week hospital stay for hip fracture repair.  Her hospital course was complicated by a lower gastrointestinal hemorrhage and subsequent bacteremia from an intravenous line.
Vital signs are within normal limits.  The patient is alert and oriented to person and date; she appears thin.  She has a 4x5-cm pressure ulcer over her presacral area that extends through the skin, but no muscle or bone is exposed.  The ulcer has little exudate and minimal surrounding erythema.
In addition to nutritional support, which of the following is indicated for this patient's pressure ulcer?

Accepted Answer

11ec193a_9776_dec8_853d_e33dda834f9e_MD0002_00 This patient has a stage 3 pressure ulcer. All patients with such ulcers require pressure relief measures, including scheduled patient turning, and optimized nutritional status. Wound fluids contain tissue growth factors that facilitate reepithelialization and wound healing, but excess fluid may cause wound maceration. Therefore, it is important to provide a balanced moist wound environment while keeping the surrounding skin dry. stage 3 pressure ulcer Absorbent dressings are appropriate for wounds with significant exudate as they can remove the excess exudate while maintaining a moist environment. This patient has a dry wound without exudate or evidence of infection and would benefit from a semipermeable dressing (eg, hydrocolloid, hydrogel) to promote a moist wound environment. Dressings should generally be changed every 1-2 days. (Choice B) Occlusive dressings (eg, DuoDerm) can be used on stage 2 ulcers, but they are not recommended for full-thickness (stage 3, 4, or unstageable) ulcers. These dressings can create an anaerobic environment that promotes infection, prevents inspection, and causes deep fistula formation. (Choice C) Wet-to-dry and wet-to-wet saline gauze dressings are frequently used to aid debridement of wounds with extensive exudate. However, gauze dressings are labor intensive and do not reliably maintain a moist wound environment. (Choice D) Systemic antibiotics should be used for pressure ulcers with evidence of cellulitis or osteomyelitis. Topical antibiotics (eg, silver sulfadiazine) can be used for ulcers with superficial infection or overgrowth. However, this patient has no specific signs of infection (eg, purulence, warmth, erythema, excessive bleeding, foul odor). (Choice E) Vacuum-assisted closure (VAC) devices continuously or intermittently apply negative pressure to the wound surface. This promotes tissue remodeling and increased blood flow and decreases tissue edema. VAC has been found effective for diabetic foot wounds but has uncertain benefit for pressure ulcers. Educational objective: Pressure ulcer management requires pressure relief and attention to nutrition. Dressings should be chosen to maintain a moist wound environment. Occlusive dressings should not be applied to full-thickness wounds. __________ References: Pressure ulcers: prevention, evaluation, and management. (http://www.ncbi.nlm.nih.gov/pubmed/19035067) Treatment of pressure ulcers: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/19066385) Wound care in the geriatric client. (http://www.ncbi.nlm.nih.gov/pubmed/19554098)

Question 6

A 49-year-old woman comes to the office to discuss her risk of heart disease. Her husband recently died of an acute myocardial infarction, and she says, "I need to take care of myself so I can be there for my kids." The patient's medical history is unremarkable and she takes no medications. Her mother died of dementia at age 76, and her father died of chronic obstructive pulmonary disease at age 68. She has a 30-pack-year smoking history but quit after her husband's heart attack, and she drinks a can of beer every day. The patient has a sedentary occupation and does not engage in regular exercise. Blood pressure is 129/79 mm Hg and pulse is 80/min. BMI is 32 kg/m². Physical examination shows central obesity but is otherwise unremarkable. Laboratory results are as follows: In addition to providing guidance on increasing physical activity, which of the following is the most appropriate recommendation to reduce the risk of cardiovascular disease in this patient?

Accepted Answer

11ec193a_9775_5826_853d_b1e1b8fbdb22_MD0002_00 This patient has quit smoking, which, if sustained, is associated with a reduced risk of heart disease. However, she also has mild obesity, elevated blood pressure, hyperglycemia, and suboptimal lipid values, all of which are likely to worsen with age and increase her cardiovascular risk. These risk factors do not require medication at this time, but the patient would benefit from changes in lifestyle to address them now. The Mediterranean-style diet emphasizes plant-based foods (eg, fruits, vegetables, whole grains, nuts), olive oil (in place of butter), fish and poultry (in place of red meat), and moderate salt intake. Studies have found reductions in the risk of cardiac events and cardiovascular mortality with the Mediterranean diet compared with a conventional diet. Alternately, the similar Dietary Approaches to Stop Hypertension (DASH) diet has been shown to lower blood pressure and can reduce the risk of cardiovascular disease. Either of these dietary interventions would be appropriate for this patient. (Choice A) Diets high in antioxidant-containing foods (eg, DASH diet, Mediterranean diet) are associated with a lower risk of coronary events. However, randomized trials of antioxidant supplements have consistently shown no benefit in preventing coronary events. (Choice B) Heavy alcohol intake (>4 drinks/day for men, >2 drinks/day for women) is associated with an increased risk of heart failure. However, this patient's moderate alcohol intake has minimal impact on her risk of heart failure and is associated with a slightly reduced overall cardiovascular risk. (Choice C) Both low-fat and low-carbohydrate diets are effective for weight loss, but evidence for reduced cardiac risk is weak. Patients who adhere to either the DASH diet or the Mediterranean diet frequently lose weight, and these programs are likely more effective for reducing cardiac risk. (Choice E) A moderate reduction in sodium intake may be helpful for some patients. However a very-low sodium diet (eg, <1,500 mg/day) is unlikely to benefit most individuals, is difficult to sustain, and is generally advised only for patients with uncontrolled hypertension. Educational objective: Lifestyle interventions that can reduce the risk of cardiovascular disease include regular physical exercise, a Mediterranean-style diet, the Dietary Approaches to Stop Hypertension (DASH) diet, smoking cessation, and moderate but not excessive alcohol intake. __________ References: Diet and physical activity for cardiovascular disease prevention. (http://www.ncbi.nlm.nih.gov/pubmed/27281836)

Question 7

A 31-year-old woman recently diagnosed with mitral valve prolapse asks about complications of the disease.
Which of the following is the most important determinant of adverse cardiovascular events in this patient?

Accepted Answer

Mitral valve prolapse (MVP) is present in about 2%-3% of the general population, with a slightly higher prevalence in women than men. It is a common cause of mitral regurgitation (MR); however, most patients with MVP have only trace to mild MR, with severe MR noted in <5% of patients at initial diagnosis. Complications associated with MVP include cardiac arrhythmias (atrial or ventricular premature beats, ventricular or supraventricular tachycardia), worsening MR and congestive heart failure, infective endocarditis, and transient ischemic attack or stroke. Most patients with MVP have a risk of cardiovascular morbidity and mortality similar to that of the general population, though moderate to severe MR and LV ejection fraction <50% have been noted in some studies to increase the risk of adverse cardiac events. Other risk factors for cardiovascular morbidity include a left atrium size >40 mm, flail mitral leaflet, atrial fibrillation, and age >50. (Choices A, C, D, and E) Anxiety disorders, nonexertional chest pain, bradycardia, and/or ventricular premature beats have not been associated with adverse cardiovascular events in patients with MVP. Educational objective: Moderate to severe mitral regurgitation and a reduced ejection fraction <50% are associated with increased risk of adverse cardiovascular events in patients with mitral valve prolapse. __________ References: Natural history of asymptomatic mitral valve prolapse in the community. (http://www.ncbi.nlm.nih.gov/pubmed/12221052)

Question 8

A 35-year-old woman comes to the office for a routine physical examination.  She is in good health and has no significant medical history.  The patient does not use tobacco or alcohol.  She takes no medications or supplements.  Her paternal aunt had an unexpected death at age 32.  Physical examination, including cardiac examination, is unremarkable.  ECG shows normal sinus rhythm with a corrected QT interval of 505 msec.  Serum electrolytes are normal.  Echocardiogram shows normal heart structure and function.
The patient is advised about lifestyle modification and medication safety.  Which of the following is the best initial management for this patient?

Accepted Answer

11ec193a_9772_71f4_853d_5d8ba295b6f3_MD0002_00 This patient's presentation - prolonged corrected QT interval (QTc) and family history of sudden death - is suggestive of congenital long QT syndrome (LQTS). A normal QTc interval is 370-440 msec. A QTc >450 msec in male patients and >470 msec in female patients is considered a prolonged QT interval. Patients with congenital LQTS may be asymptomatic or have palpitations, presyncope/syncope, seizures, or cardiac arrest. LQTS is associated with an increased risk of ventricular arrhythmias, such as torsades de pointes, which may terminate spontaneously or degenerate into ventricular fibrillation. QT interval Management includes avoidance of conditions (eg, strenuous exercise, electrolyte abnormalities such as hypokalemia or hypomagnesemia) and medications (eg, antipsychotics, fluoroquinolones) that may prolong the QT interval. Current guidelines also recommend that all patients with congenital LQTS (symptomatic or asymptomatic) be treated with beta blockers (eg, propanolol, nadolol) to decrease the risk of symptomatic arrhythmias and sudden cardiac death (Choice E). (Choice A) Diltiazem is commonly used to treat supraventricular tachycardias. It has no role in the management of patients with LQTS. (Choice B) Disopyramide is a class Ia antiarrhythmic agent that can cause further prolongation of the QT interval. (Choice C) An implantable cardioverter-defibrillator (ICD) is recommended for patients with LQTS who have syncope (especially if recurrent) or ventricular tachycardia (eg, torsade de pointes) on beta blocker therapy. ICDs may be considered in patients with a strong family history of sudden cardiac death. However, a beta blocker should be used as initial treatment for this patient, particularly given the risks associated with ICD placement (infection, lead fracture). ICDs are also used as secondary prevention in patients with an aborted cardiac arrest. Educational objective: Beta blockers are recommended for patients with congenital long QT syndrome to reduce the risk of symptomatic arrhythmias and sudden cardiac death. An implantable cardioverter-defibrillator is recommended for patients with syncope (especially if recurrent) or ventricular tachycardia (eg, torsade de pointes) on beta blocker therapy or for those with aborted cardiac arrest. __________ References: Congenital long QT syndrome: considerations for primary care physicians. (http://www.ncbi.nlm.nih.gov/pubmed/18756841)

Question 9

A 77-year-old man with a long-standing history of hypertension comes to the office due to exertional shortness of breath and fatigue. He went to the emergency department 4 weeks ago for shortness of breath and was treated with intravenous diuretics. Echocardiogram at that time showed left atrial enlargement, left ventricular hypertrophy, and a left ventricular ejection fraction of 65%. Medications include daily furosemide 40 mg, amlodipine 10 mg, spironolactone 12.5 mg, and low-dose aspirin. Blood pressure is 128/76 mm Hg and pulse is 74/min. Jugular venous pressure is estimated at 9 cm H₂O. Cardiac examination is notable for an S4 gallop and nondisplaced apical impulse. Lung auscultation reveals bibasilar crackles. The abdomen is nondistended and nontender to palpation. There is bilateral pitting ankle edema. ECG shows normal sinus rhythm and voltage criteria for left ventricular hypertrophy. Serum potassium is 4.1 mEq/L and serum creatinine is 0.9 mg/dL. Which of the following is the best treatment option for this patient?

Accepted Answer

11ec193a_976f_8bc1_853d_5d90ba2337fc_MD0002_00 This patient's presentation is consistent with heart failure with preserved ejection fraction (HFpEF), resulting from impaired left ventricular diastolic relaxation (ie, diastolic dysfunction). Diastolic heart failure accounts for approximately half of decompensated heart failure hospitalizations. Patients characteristically have normal left ventricular ejection fraction (>50%) and objective evidence of diastolic dysfunction (elevated left ventricular filling pressures) by noninvasive or invasive measurement. In comparison with heart failure with reduced ejection fraction (HFrEF), HFpEF has overall demonstrated less response to neurohormonal antagonists (eg, angiotensin system blockers, beta blockers); however, aldosterone antagonists (eg, spironolactone) have been shown to reduce hospitalizations and possibly improve survival. Optimal management of HFpEF involves the following: Afterload reduction (ie, blood pressure <130/80 mm Hg). Aldosterone antagonists are first-line therapy.Treatment of volume overload with diureticsTreatment of exacerbating conditions (eg, rate control of atrial fibrillation, coronary revascularization) Afterload reduction (ie, blood pressure <130/80 mm Hg). Aldosterone antagonists are first-line therapy. Treatment of volume overload with diuretics Treatment of exacerbating conditions (eg, rate control of atrial fibrillation, coronary revascularization) This patient with dyspnea, bibasilar crackles, and peripheral edema would benefit from an increased dose of furosemide. (Choice A) Combination therapy with hydralazine and isosorbide dinitrate causes balanced vasodilation and can be useful in patients with HFrEF who cannot tolerate angiotensin system blockers. However, these drugs are not indicated in this normotensive patient with HFpEF. (Choice B) Losartan improves symptoms and mortality in patients with HFrEF but is not indicated in this normotensive patient with HFpEF. (Choice C) The thiazide diuretic metolazone is often used to potentiate the effect of loop diuretics in patients with severe heart failure. This patient is on a relatively low dose of furosemide; increasing (eg, doubling) the dose is likely to result in adequate diuresis, and metolazone is not needed at this time. (Choice D) Patients with HFpEF are poorly tolerant of elevated ventricular rates that can occur with comorbid atrial fibrillation, and metoprolol is useful in such patients. However, in the absence of atrial fibrillation or another clear indication (eg, stable angina), beta blockers are not recommended for HFpEF. Educational objective: Heart failure with preserved ejection fraction (HFpEF) results from impaired left ventricular diastolic relaxation (ie, diastolic dysfunction). Optimal therapy for HFpEF involves blood pressure control, treatment of volume overload with diuretics, and management of exacerbating conditions (eg, atrial fibrillation, coronary artery disease). __________ References: Pharmacologic management of heart failure with preserved ejection fraction. (http://www.ncbi.nlm.nih.gov/pubmed/21098754)

Question 10

A 22-year-old man comes to the office for evaluation of an abnormal ECG.  The patient was seen recently at an urgent care clinic for chest pain and was diagnosed with costochondritis.  The chest pain subsequently resolved with ibuprofen.  He has no prior history of chest pain, palpitations, or lightheadedness.  However, he had an abnormal ECG finding on that visit and was advised to follow-up with a primary care physician.  The patient does not use tobacco, alcohol, or illicit drugs.  He has no family history of heart disease or arrhythmia.
His blood pressure is 118/78 mm Hg and pulse is 88/min.  Cardiopulmonary, abdominal, and neurological examination findings are unremarkable.
Resting ECG performed in the primary care office is shown here.  The ECG from the urgent care clinic also has similar findings.
Which of the following is the best next step in management of this patient?

Accepted Answer

The ECG findings of a short PR interval (<0.12 seconds) and slurred upstroke of the QRS complex (delta wave) are typical of Wolff-Parkinson-White (WPW) pattern due to an atrioventricular (AV) accessory pathway. Most patients are asymptomatic, and this abnormality is often detected on a routine evaluation done for other reasons. However, patients are at increased risk for arrhythmias such as atrial fibrillation (AF) and AV reentrant tachycardia (AVRT). AF with rapid ventricular response can degenerate into ventricular fibrillation and cause sudden cardiac death (SCD). ECG Patients at highest risk for arrhythmias include those with a history of AF or AVRT and with a short refractory period (<250 msec) of the accessory pathway. Risk stratification of asymptomatic patients can be performed with noninvasive tests (eg, exercise testing or procainamide challenge) and/or electrophysiologic study (EPS) to identify those at greatest risk for SCD. Intermittent loss of preexcitation (ie, loss of delta waves on ECG) during faster heart rates with exercise or procainamide challenge suggests a longer refractory period that will not be able to conduct often enough during AF to degenerate into VF. These low-risk patients can be managed conservatively without further evaluation or treatment. (Choices A and B) Amiodarone and/or AV nodal blocking agents (beta blockers, calcium channel blockers, adenosine, digoxin) can result in preferential conduction of impulses via the accessory pathway and cause VF in patients with AF and underlying WPW pattern. (Choice C) Electrophysiologic testing with a catheter ablation procedure is indicated in selected symptomatic patients with cardiac arrhythmias (AVRT, preexcited AF or flutter) and asymptomatic patients with high risk occupations (eg, airline pilots, truck drivers, athletes). (Choice E) An implantable defibrillator is not indicated in patients with WPW pattern. Educational objective: Risk stratification of asymptomatic patients with WPW pattern on ECG can be performed with noninvasive tests (eg, exercise testing or procainamide challenge) and/or electrophysiologic study (EPS) to identify those at greatest risk of sudden cardiac death. Low-risk patients with intermittent loss of preexcitation during faster heart rates can be managed conservatively without further evaluation or treatment. __________ References: Noninvasive risk stratification for sudden death in asymptomatic patients with Wolff-Parkinson-White syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/25662922)

Question 11

A 74-year-old man comes to the physician for follow-up of type 2 diabetes mellitus.  His diabetes is managed with diet and metformin, and he has shown good compliance with medical visits.  The patient has no history of chest pain, dyspnea, lightheadedness, syncope, or falls.  He does not use tobacco, alcohol, or illicit drugs.
Blood pressure and pulse are 145/75 mm Hg and 67/min while supine, and 122/64 mm Hg and 72/min after standing for 2 minutes.  Physical examination is otherwise unremarkable.  His last HbA1c was 7% and creatinine was 0.8 mg/dL.  The postural blood pressure changes are reproduced during the subsequent visit, but the patient consistently reports no symptoms.
This patient has an elevated risk for which of the following?

Accepted Answer

Orthostatic (postural) hypotension (OH) is defined as a drop in systolic blood pressure >20 mm Hg or in diastolic blood pressure >10 mm Hg within 2-5 minutes of standing from a supine position. It is more common in the elderly and is often seen in patients with volume depletion (hypovolemia due to hemorrhage, hyperglycemia, or diuretics), medication side effect (vasodilators, adrenergic blocking agents), or autonomic dysfunction (Parkinson disease, Lewy body dementia). Orthostatic (postural) hypotension OH is associated with an increased risk of recurrent falls and decline in cognitive function in older individuals. In several population-based studies, symptomatic and asymptomatic OH have each been found to be an independent risk factor for cardiovascular disease and all-cause mortality. (Choice A) Risk factors associated with abdominal aortic aneurysm (AAA) include male sex, advancing age, history of smoking, hypertension, and systemic atherosclerosis. OH is not an independent risk factor for AAA. (Choice C) Risk factors for chronic venous insufficiency include advanced age, prolonged standing, obesity, smoking, pregnancy, prior venous thrombosis, and family history of venous disease. OH is not associated with increased risk of venous insufficiency. (Choice D) Parkinson disease is characterized by progressive motor dysfunction and varying degrees of autonomic failure, which can lead to or worsen OH. In some reports, OH has been linked to cognitive decline or dementia; however, it does not increase the risk of developing Parkinson disease. (Choice E) There is no association between OH and the risk of subarachnoid bleeding. Educational objective: Orthostatic hypotension is associated with an increased risk of cardiovascular disease and all-cause mortality. __________ References: Orthostatic hypotension and mortality risk: a meta-analysis of cohort studies. (http://www.ncbi.nlm.nih.gov/pubmed/23878177) Orthostatic hypotension predicts all-cause mortality and coronary events in middle-aged individuals (The Malmo Preventive Project). (http://www.ncbi.nlm.nih.gov/pubmed/19696189)

Question 12

A 46-year-old man comes to the physician with recurrent palpitations that wake him up at night.  One year ago, he was diagnosed with paroxysmal atrial fibrillation.  The patient had been treated with metoprolol, diltiazem, and flecainide in the past with temporary relief, but the symptoms had always recurred.  Recently, flecainide was stopped, and he was started on sotalol.  His other medical problems are hypertension and hyperlipidemia.
Electrocardiogram shows normal sinus rhythm with a QTC interval of 420 msec.  Echocardiogram shows left atrial enlargement, mild mitral regurgitation, and left ventricular ejection fraction of 50%.  A 24-hour Holter monitor shows episodes of atrial fibrillation with rapid ventricular rate.
Which of the following is the best next step to maintain sinus rhythm in this patient?

Accepted Answer

11ec193a_976e_a15f_853d_83a882c86410_MD0002_00 Antiarrhythmic drugs (AADs) are preferred over catheter ablation as first-line therapy for rhythm control in most patients with symptomatic atrial fibrillation (AF). However, catheter ablation for AF has rapidly evolved as an alternate therapy to AADs for rhythm control for patients who have failed AAD therapy. This patient has recurrent, symptomatic, paroxysmal AF despite the use of 2 separate AADs. The best next step in management is to refer the patient for AF ablation in an attempt to maintain long-term sinus rhythm. (Choice A) Digoxin inhibits conduction through the atrioventricular node. It is occasionally used to slow the ventricular rate in patients with AF, especially when therapy with beta blockers and/or calcium channel blockers is ineffective in adequately controlling the rate. It is not an AAD and does not reduce the frequency of AF episodes. (Choice B) A surgical Maze procedure for AF should be considered only in patients who are undergoing cardiac surgery for other indications (eg, valve repair/replacement, coronary artery bypass grafting). (Choice D) Mexiletine is a class 1B AAD used in the management of patients with refractory ventricular arrhythmias. It has no role in the management of patients with recurrent AF. (Choice E) Propafenone and flecainide ("pill in the pocket") are class IC AADs used in patients without structural heart disease for rhythm control of AF. This patient has failed flecainide for AF control, so propafenone is not likely to be effective in reducing the frequency of AF episodes. Educational objective: Catheter ablation is recommended in patients with symptomatic paroxysmal atrial fibrillation who have failed treatment or become intolerant to one or more antiarrhythmic drugs. __________ References: Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of paroxysmal atrial fibrillation (RAAFT-2): a randomized trial. (http://www.ncbi.nlm.nih.gov/pubmed/24549549)

Question 13

A 69-year-old man with a history of coronary artery disease comes to the office with chest pain on moderate exertion.  Over the last year, he has experienced pressure-like chest pain when walking at a fast pace or climbing stairs.  He thinks this affects his quality of life as he has to stop to rest and take sublingual nitroglycerin each time.  The patient has no shortness of breath, lightheadedness, syncope, or lower extremity swelling.  He underwent coronary artery bypass surgery 8 years ago and has had 2 percutaneous coronary interventions over the last 2 years.  Current medications include metoprolol succinate, amlodipine, lisinopril, extended-release isosorbide mononitrate, aspirin, clopidogrel, high-intensity rosuvastatin, and sublingual nitroglycerin as needed.  He stopped smoking 10 years ago and does not drink alcohol.
Blood pressure is 105/65 mm Hg and pulse is 55/min.  The lungs are clear on auscultation.  ECG shows normal sinus rhythm with T-wave inversion in leads III and aVF and a QTc interval of 410 msec.  His last serum creatinine was 0.8 mg/dL and LDL cholesterol level was 68 mg/dL.  Echocardiogram shows apical hypokinesis with left ventricular ejection fraction of 55%.  Myocardial perfusion imaging reveals moderate ischemia of the inferior wall.  Coronary angiography shows no intervenable lesions.
Which of the following is the best next step in management of this patient's symptoms?

Accepted Answer

11ec193a_976d_68dd_853d_ef1f8bf5f70c_MD0002_00 This patient continues to have activity-limiting chronic stable angina despite optimal medical therapy and coronary revascularization. When initial treatment is unsuccessful in relieving anginal symptoms, the addition of ranolazine may be used as a substitute for or in combination with beta blockers and other antianginal therapies. Ranolazine is a late sodium channel blocker that causes decreased influx of calcium into cardiomyocytes, resulting in lower ventricular wall tension and reduced myocardial oxygen consumption. This drug has the advantage of decreasing the frequency and severity of anginal symptoms and improving overall exercise capacity without significantly affecting heart rate or blood pressure. However, ranolazine has not been shown to improve other cardiovascular outcomes, including mortality and incidence of myocardial infarction. (Choice A) This patient is already taking a calcium channel blocker (amlodipine), and the addition of another agent from a similar class (eg, diltiazem, verapamil, felodipine) is not indicated. (Choice C) Although ACE inhibitors and angiotensin-receptor blockers reduce myocardial oxygen consumption by decreasing afterload, their overall effect on improving anginal pain is small. Furthermore, the addition of an angiotensin receptor blocker (eg, valsartan) to an ACE inhibitor (eg, lisinopril) is not typically recommended due to limited additional benefit and risk of side effects (eg, hyperkalemia, hypotension). (Choice D) Beta blockers are the preferred first-line therapy for patients with stable angina because beta blockers, unlike calcium channel blockers, improve long-term survival in patients with prior myocardial infarction or left ventricular systolic dysfunction. Discontinuing metoprolol and starting diltiazem is not indicated in the absence of beta blocker intolerance. (Choice E) Long-acting nitrates (eg, isosorbide mononitrate) are effective in improving chronic stable angina symptoms; however, long-term use is limited by the development of nitrate tolerance. Extended-release isosorbide mononitrate is typically dosed once daily; increasing to twice daily is unlikely to provide significant benefit. Educational objective: Ranolazine decreases myocardial oxygen consumption and provides effective treatment for chronic stable angina without significantly affecting heart rate or blood pressure. It may be used as a substitute for or in combination with beta blockers and other antianginal therapies when initial treatment is unsuccessful in relieving chronic stable angina. __________ References: Ranolazine: a review of its use as add-on therapy in patients with chronic stable angina pectoris. (http://www.ncbi.nlm.nih.gov/pubmed/23329466) 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. (http://www.ncbi.nlm.nih.gov/pubmed/23166211) 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary disease of the European Society of Cardiology. (http://www.ncbi.nlm.nih.gov/pubmed/23996286)

Question 14

A 72-year-old woman comes to the office for follow-up of shortness of breath. For the last year, the patient has had increasing dyspnea on exertion and can now walk only 2-3 blocks at a slow pace. She has had no associated chest pain or lightheadedness. The patient was seen at an urgent care facility a month ago and was found to have bibasilar crackles and 1+ bilateral pedal edema. She was started on daily furosemide, with significant improvement in her symptoms, and was instructed to see her regular physician for further evaluation. Medical history is notable for hypertension treated with amlodipine and spironolactone, and the patient has no history of myocardial infarction or stroke. She is a lifetime nonsmoker and does not use alcohol. Blood pressure is 125/70 mm Hg and pulse is 75/min and regular. Oxygen saturation is 98% on room air. BMI is 24 kg/m². Cardiac auscultation shows an S4 and no murmurs. Lung sounds are normal. There is no peripheral edema. ECG shows normal sinus rhythm with left ventricular hypertrophy. Complete blood count and basic metabolic panel are unremarkable. Transthoracic echocardiogram shows left atrial enlargement, left ventricular hypertrophy, left ventricular ejection fraction of 65%, and pulmonary artery systolic pressure of 50 mm Hg. Which of the following is most likely to improve quality of life in this patient?

Accepted Answer

11ec193a_9775_f467_853d_e160cf4c7ea6_MD0002_00 This patient has heart failure with preserved ejection fraction (HFpEF), with signs and symptoms of volume overload, normal left ventricular ejection fraction (LVEF) (>50%), and left ventricular hypertrophy. In comparison with heart failure with reduced ejection fraction (HFrEF), HFpEF has overall demonstrated less response to neurohormonal antagonists (eg, angiotensin system blockers, beta blockers); however, aldosterone antagonists (eg, spironolactone) have been shown to reduce hospitalizations and possibly improve survival. Optimal management of HFpEF involves the following: Afterload reduction (ie, blood pressure <130/80 mm Hg). Aldosterone antagonists are first-line therapy.Treatment of volume overload with diureticsTreatment of exacerbating conditions (eg, rate control of atrial fibrillation, coronary revascularization) Afterload reduction (ie, blood pressure <130/80 mm Hg). Aldosterone antagonists are first-line therapy. Treatment of volume overload with diuretics Treatment of exacerbating conditions (eg, rate control of atrial fibrillation, coronary revascularization) In addition, exercise training in a cardiac rehabilitation program has been shown to improve functional capacity and overall quality of life in patients with HFpEF. (Choice A) Beta blockers improve survival in patients with HFrEF, but they have not shown similar benefit in patients with HFpEF. In the management of HFpEF they are useful for reducing the ischemic burden of coronary artery disease and for rate control of atrial fibrillation, but in the absence of these indications they provide minimal clinical benefit. (Choice C) This patient's blood pressure is currently under control and long-acting nitrates have not shown any particular benefit in patients with HFpEF. In fact, these drugs are associated with decreased activity levels and occasional hypotension in such patients and should be avoided. Suitable options for blood pressure control in patients with HFpEF include aldosterone antagonists, angiotensin system blockers, dihydropyridine calcium channel blockers, and beta blockers (eg, carvedilol). (Choice D) Obese patients with HFpEF can have improvement in symptoms and exercise capacity with weight loss; however, this patient with HFpEF is not obese, and no specific diet has been shown to be superior in such patients. (Choice E) Phosphodiesterase-5 inhibitors (eg, sildenafil) are indicated for pulmonary arterial hypertension (ie, group 1 pulmonary hypertension), but they have demonstrated no benefit for pulmonary hypertension resulting from left-sided heart disease (ie, group 2 pulmonary hypertension). Educational objective: Management of heart failure with preserved ejection fraction includes blood pressure control, diuretics to reduce volume overload, and management of exacerbating conditions (eg, atrial fibrillation, coronary artery disease). In addition, exercise training has been shown to improve functional capacity and quality of life. __________ References: Exercise training as therapy for heart failure: current status and future directions. (http://www.ncbi.nlm.nih.gov/pubmed/25605639) Exercise training in patients with heart failure and preserved ejection fraction: meta-analysis of randomized control trials. (http://www.ncbi.nlm.nih.gov/pubmed/25399909) 2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. (http://www.ncbi.nlm.nih.gov/pubmed/23741057)

Question 15

A 64-year-old man with diet-controlled type 2 diabetes mellitus, ischemic cardiomyopathy, and systolic heart failure comes to the physician for follow-up.  The patient has New York Heart Association functional class II symptoms and shows no signs of fluid overload.  His daily medications include furosemide, carvedilol, lisinopril, atorvastatin, and low-dose aspirin.
The patient's blood pressure is 155/90 mm Hg and pulse is 60/min.
His potassium level is 4.2 mEq/L and serum creatinine level is 0.9 mg/dL.
Adding losartan to this patient's current regimen is most likely to result in which of the following?

Accepted Answer

Blockade of the renin-angiotensin system with ACE inhibitors or angiotensin receptor blockers (ARBs) significantly improves cardiovascular outcomes and overall mortality in patients with congestive heart failure due to left ventricular systolic dysfunction. However, dual blockade with both ACE inhibitors and ARBs has not been shown to provide any significant improvement in cardiovascular or all-cause mortality compared to monotherapy alone (Choice C). In addition, dual therapy is associated with an increased risk for hyperkalemia (Choice E), symptomatic hypotension, and worsening renal function and therefore is not recommended. In contrast, the addition of an aldosterone antagonist to existing beta-blocker and ACE inhibitor therapy is recommended in certain patients with heart failure. certain patients (Choice A) While not improving mortality or total hospitalizations, dual blockade of the renin-angiotensin system with ACE inhibitors and ARBs is associated with a reduction in the risk of heart failure-associated hospital admission. (Choice D) Dual therapy is not associated with any significant change in the risk of arrhythmia compared to monotherapy alone. Educational objective: Dual blockade of the renin-angiotensin system with both ACE inhibitors and ARBs does not provide any significant benefit to cardiovascular or all-cause mortality over ACE inhibitors alone. Dual therapy is associated with an increased risk for hyperkalemia, hypotension, and worsening renal function. __________ References: Efficacy and safety of dual blockade of the renin-angiotensin system: meta-analysis of randomised trials. (http://www.ncbi.nlm.nih.gov/pubmed/23358488) Adverse effects of combination angiotensin II receptor blockers plus angiotensin-converting enzyme inhibitors for left ventricular dysfunction: a quantitative review of data from randomized clinical trials. (http://www.ncbi.nlm.nih.gov/pubmed/17923591)

Question 16

A 26-year-old man comes to the physician for a pre-employment physical evaluation.  He has no known medical problems.
The patient weighs 65 kg (143.3 lb) and is 190.5 cm (6' 3") tall.  There is a faint early diastolic murmur best heard in the second right intercostal space.  He has mild scoliosis.  Physical examination findings in the extremities are shown in the exhibits. 
Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Aortic regurgitation (early diastolic murmur at the second right intercostal space) in association with long extremities and scoliosis are suggestive of Marfan syndrome (MFS) with aortic root dilation. MFS is an autosomal dominant disorder that causes abnormalities in the skeleton, eyes (lens dislocation), and cardiovascular system. This patient also has positive wrist (thumb overlaps other fingers when wrapped around the contralateral wrist) and thumb (entire distal phalanx protrudes beyond the ulnar border of a clenched fist) signs due to long slender fingers (arachnodactyly). abnormalities skeleton Aortic root dilation can be found in approximately 50% of children and 60%-80% of adults with MFS. Aortic dissection is the cause of death in 30%-45% of patients, followed by heart failure. Transthoracic echocardiography is recommended at the initial diagnosis and at routine intervals for close monitoring of the aortic root and ascending aorta. Elective operation is recommended for aortic root diameter >50 mm to reduce the risk of aortic dissection or rupture. (Choice A) Antinuclear antibody testing is used for the diagnosis of systemic lupus erythematosus (SLE) and other autoimmune diseases (eg, systemic sclerosis, rheumatoid arthritis). Some studies have reported an association of Klinefelter syndrome (KS) with SLE, but there is no such association with MFS. (Choice B) Chromosomal karyotype analysis is indicated for diagnosis of KS (47,XXY karyotype). KS is characterized by hypogonadism (small testes, azoospermia, oligospermia), gynecomastia, and learning disabilities and/or behavioral problems. There are usually no cardiac abnormalities associated with KS. KS (Choice C) Homocystinuria is an autosomal recessive disorder that presents with fair complexion, Marfanoid body habitus, developmental delays, and hypercoagulability. It is not associated with aortic root dilation. (Choice D) Diagnosis of MFS is based on the presence of aortic root dilation, ectopia lentis, family history, fibrillin-1 (FBN1) gene mutation, and other systemic signs/symptoms of MFS. Skin biopsy is not helpful for MFS diagnosis but may be performed in the evaluation of patients with Ehlers-Danlos syndrome. Ehlers-Danlos syndrome Educational objective: Aortic root disease, leading to aneurysmal dilation and dissection, is a common complication of Marfan syndrome, and is the main cause of morbidity and mortality in these patients. Transthoracic echocardiogram is recommended at initial diagnosis and at regular follow-up intervals. __________ References: Recent developments in the diagnosis of Marfan syndrome and related disorders. (http://www.ncbi.nlm.nih.gov/pubmed/23121584) Critical appraisal of the revised Ghent criteria for diagnosis of Marfan syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/21332468) Aortic root disease in athletes: aortic root dilation, anomalous coronary artery, bicuspid aortic valve, and Marfan's syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/23674060)

Question 17

A 34-year-old man comes to the office for a routine preventive visit.  He has had low back pain intermittently for the past 2 months and believes he injured his back while exercising at the gym.  The patient has taken naproxen as needed and says that the pain is slowly improving.  He has no fevers, focal weakness, or bowel or bladder difficulties.  The patient has a 20-pack-year smoking history.  His father was diagnosed with prostate cancer at age 66, and his mother had a myocardial infarction at age 59.
Vital signs, weight, and physical examination are unremarkable.  The patient is interested in improving his health and asks if he should be screened for any other diseases.
Which of the following is the most appropriate screening test for this patient?

Accepted Answer

This patient is being seen to discuss preventive services. His initial evaluation, including blood pressure and physical examination, is unremarkable, but his smoking history and family history of premature coronary heart disease (CHD) (eg, first-degree male relative diagnosed at age <50, female relative at age <60) significantly increases his risk for CHD. Screening for lipid disorders is recommended for men age ≥35 and women age ≥45 but is not generally recommended for younger adults because the prevalence of lipid disorders is low, and the benefit of specific interventions (eg, statin therapy) is small. However, screening should be considered on an individual basis for younger patients who have additional CHD risk factors, such as this patient (Choice D). Serum total cholesterol and HDL generally have the greatest prognostic utility, but LDL and triglyceride levels are also useful and are typically included in the lipid panel. (Choice A) There is insufficient evidence regarding the benefit of screening for diabetes in young, otherwise healthy individuals. Most professional organizations recommend screening select patients who fall within higher prevalence groups (eg, overweight or obese, age ≥45, hypertension, dyslipidemia) or who are more likely to benefit from early treatment. (Choice C) Screening for lung cancer with a low-dose noncontrast CT scan is recommended for individuals age 50-80 who have a ≥20-pack-year smoking history and currently smoke or quit smoking within the past 15 years. Screening in younger patients has not been shown to be effective and is not recommended. (Choice E) Screening for prostate cancer with a serum prostate-specific antigen level is not universally recommended due to low disease-specific mortality and significant risk of overtreatment. It can be considered in men age 55-69 who are at increased risk (eg, family history of prostate cancer, high-risk racial groups) but is not recommended for younger men. Educational objective: Screening for lipid disorders is recommended for men age ≥35 and women age ≥45, and for younger patients who have additional risk factors (eg, smoking, hypertension, diabetes mellitus, family history of premature coronary heart disease) for coronary heart disease. __________ References: The adult well male examination. (http://www.ncbi.nlm.nih.gov/pubmed/22612046) Statin use for the primary prevention of cardiovascular disease in adults: us preventive services task force recommendation statement. (http://www.ncbi.nlm.nih.gov/pubmed/27838723)

Question 18

A 72-year-old man with a history of heart failure and reduced ejection fraction comes to the office for follow-up.  The patient reports no change in his chronic dyspnea on exertion but says he has had a persistent, nonproductive cough for the past 4 weeks.  The cough occurs during the day and night, and he has not been able to get restful sleep.  The patient has had no fever, chills, night sweats, or loss of appetite.  In the past year, he has had several hospitalizations due to decompensated heart failure, and 6 months ago he was treated with coronary stenting for an episode of non-ST elevation myocardial infarction.  A recent echocardiogram revealed a left ventricular ejection fraction of 30%.  The patient's other medical problems include hypertension, hyperlipidemia, and osteoarthritis.  He takes aspirin, ticagrelor, atorvastatin, furosemide, carvedilol, sacubitril-valsartan, and spironolactone.  He smoked a half pack of cigarettes daily for 10 years, but quit at age 40.  The patient does not use alcohol or illicit drugs.
Temperature is 36.6 C (98 F), blood pressure is 106/60 mm Hg, pulse is 72/min and regular, and respirations are 16/min.  Pulse oximetry shows 96% on ambient air.  Weight is 75 kg (165.3 lb), unchanged from previous visits.  Physical examination reveals normal nasal and oropharyngeal mucous membranes, poor dentition, normal jugular venous pressure, clear lungs, and a grade 2/6 systolic murmur at the left sternal border.  The abdomen is soft and nontender with no hepatosplenomegaly.  Trace bilateral lower extremity pitting edema is present.
Chest x-ray reveals no parenchymal opacities.
Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Neprilysin is an enzyme that degrades endogenous vasoactive peptides, including atrial natriuretic peptide (ANP), brain natriuretic peptide (BNP), bradykinin, and angiotensin II. Sacubitril inhibits neprilysin, resulting in elevated circulating levels of these vasoactive peptides. The elevated ANP and BNP levels promote diuresis and cause venous and arteriolar dilation, providing beneficial hemodynamic effects in patients with heart failure. However, these effects come at the expense of elevated angiotensin II levels, leading to vasoconstriction and fluid retention, and elevated bradykinin levels, sometimes leading to cough. To counteract the elevated angiotensin II levels, sacubitril is paired with an angiotensin II receptor blocker for clinical use. Compared to an ACE inhibitor (enalapril), sacubitril-valsartan reduces heart failure hospitalization and improves cardiovascular and all-cause mortality in patients with symptomatic heart failure with reduced ejection fraction. A nonproductive cough, similar to that seen in patients taking ACE inhibitors, occurs in approximately 10% of patients taking sacubitril-valsartan, and is sometimes use-limiting. Other adverse effects include hypotension, hyperkalemia, dizziness, renal failure, and (rarely) angioedema. (Choice B) This patient has stable weight, normal pulmonary examination and chest x-ray, and only trace pedal edema. It is unlikely that fluid overload is responsible for his cough, and increasing the dose of furosemide is not indicated. (Choices C and D) CT scan of the chest and pulmonary function testing allow evaluation for chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD), both of which can cause chronic cough. However, the absence of sputum production and pulmonary crackles makes COPD and ILD, respectively, less likely. (Choice E) Cough due to gastroesophageal reflux disease (GERD) often responds to a trial of a proton pump inhibitor. However, in the absence of other signs or symptoms suggestive of GERD (eg, heartburn, regurgitation), discontinuing sacubitril, a known cause of cough, is initially preferred. Educational objective: Sacubitril inhibits neprilysin, resulting in elevated levels of atrial natriuretic peptide, brain natriuretic peptide, bradykinin, and angiotensin II. Sacubitril-valsartan improves cardiovascular mortality but causes a nonproductive cough, similar to that seen with ACE inhibitors, in approximately 10% of patients. __________ References: Angiotensin-neprilysin inhibition versus enalapril in heart failure. (http://www.ncbi.nlm.nih.gov/pubmed/25176015) 2016 ACC/AHA/HFSA focused update on new pharmacological therapy for heart failure: an update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. (http://www.ncbi.nlm.nih.gov/pubmed/27208050)

Question 19

A 29-year-old woman who immigrated to the United States from India comes to the office to establish care. She has a mild sore throat that she believes may have come from her toddler, who recently had a fever. The patient has no other concerns. She has a history of gestational diabetes during her 2 pregnancies. In childhood, the patient had a febrile illness associated with loss of motor control. She takes no medications and does not use tobacco or alcohol. Temperature is 36.7 C (98.1 F), blood pressure is 130/80 mm Hg, pulse is 70/min, and respirations are 14/min. Examination shows mild erythema of the nasal mucosa and posterior pharynx. Jugular venous pulsation is normal and there is no cervical lymphadenopathy. The lungs are clear. There is a low-pitched diastolic murmur with presystolic accentuation at the apex. Neurologic examination is normal. She is referred for transthoracic echocardiography that shows normal left ventricular function with moderate left atrial enlargement and doming of the mitral valve leaflets in diastole. The estimated mitral valve area is 1.7 cm². There is mild mitral regurgitation. Which of the following is the most appropriate recommendation regarding antibiotic therapy in this patient?

Accepted Answer

11ec193a_9770_4f12_853d_b17216b0f571_MD0002_00 This patient's childhood history of a febrile illness with movement disorder (chorea) is consistent with previous rheumatic fever complicated by persistent valvular disease (mitral stenosis). Rheumatic fever occurs as a complication of group A beta-hemolytic Streptococcus (GAS) pharyngitis; the initial acute disease and recurrences can be characterized by fever, arthritis, chorea, and heart failure. This patient's current presentation is not consistent with rheumatic fever recurrence; however, the sore throat raises suspicion for GAS pharyngitis. With repeated exposure to GAS, patients with prior rheumatic fever are at high risk for recurrent rheumatic fever and consequent progression of rheumatic heart disease. Therefore, they should receive continuous antibiotic prophylaxis to prevent GAS pharyngitis. Long-acting penicillin G benzathine given intramuscularly every 3-4 weeks is the preferred approach for secondary prevention of rheumatic fever recurrence, and the duration of antibiotic prophylaxis depends on the severity of underlying rheumatic heart disease (presence or absence of carditis and valvular disease). The first dose of intramuscular penicillin would also treat any current GAS colonization/infection. Regardless of whether this patient was previously on antibiotics for rheumatic fever, she should receive an intramuscular dose of penicillin now and should be on continuous antibiotic prophylaxis until age 40 (given her valvular disease). (Choice A) Antibiotic prophylaxis to lower the risk of infective endocarditis is indicated prior to dental procedures in only patients with the highest-risk cardiac conditions. It is not indicated for rheumatic disease of a native heart valve. highest-risk cardiac conditions (Choice B) Antistreptococcal antibody titers can be helpful in the initial diagnosis of rheumatic fever, but do not play a role in guiding antibiotic prophylaxis for secondary prevention. (Choice C) This patient is at risk for further heart damage with recurrent GAS infection, and long-term antibiotic prophylaxis is indicated. Recommending no antibiotic therapy is not appropriate. (Choice E) Oral penicillin V potassium is an acceptable treatment option for acute GAS pharyngitis (primary prevention of rheumatic fever). It is also an alternate treatment for secondary prevention of rheumatic fever recurrence; however, due to increased failure rates with orally administered antibiotics, intramuscular penicillin G is preferred. Educational objective: Patients with rheumatic fever should receive continuous antibiotic prophylaxis to prevent recurrent GAS pharyngitis and limit the risk of progression of rheumatic heart disease. Intramuscular penicillin G benzathine every 3-4 weeks is preferred, and the duration of therapy is determined by the severity of underlying rheumatic heart disease (presence or absence of carditis and valvular disease). __________ References: Prevention of rheumatic fever and diagnosis and treatment of acute streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics. (http://www.ncbi.nlm.nih.gov/pubmed/19246689)

Question 20

A 78-year-old man is evaluated for syncope.  He was hospitalized a week ago after passing out in his garden and sustaining a minor head injury.  He had no prodromal symptoms, chest pain, or palpitations.  After the syncopal episode, he was not confused and had only a mild headache due to trauma.  Four months ago, the patient had a similar episode at home but sustained no injuries.  He has hypertension, for which he takes lisinopril and amlodipine.  He does not use tobacco, alcohol, or illicit drugs.  He walks 4 miles a day.
Blood pressure is 140/90 mm Hg supine and 138/88 mm Hg standing, and pulse is 75/min and regular.  Fourth heart sound is heard on cardiac auscultation.  There are no carotid bruits.  Carotid sinus massage does not provoke long pauses.
Electrocardiogram shows normal sinus rhythm with tall R waves.  An echocardiogram done in the hospital showed left atrial enlargement, left ventricular hypertrophy, and ejection fraction of 60%.
Which of the following is the best next step in management of this patient?

Accepted Answer

11ec193a_976e_2c2e_853d_3d1087e94d6d_MD0002_00 Although syncope is usually benign and self-limiting, it can be the initial presenting symptom of a life-threatening disease process. This patient has recurrent syncopal episodes that occur infrequently (months apart) with no prodromal symptoms. He does not have carotid sinus hypersensitivity. As a result, the next step in management is to proceed with continuous ambulatory electrocardiographic monitoring with an implantable loop recorder (ILR) to assess for arrhythmias and conduction abnormalities. syncope An ILR is a subcutaneous monitoring device for the detection of cardiac arrhythmias. It has a significantly higher diagnostic yield than shorter-term monitoring when symptoms occur infrequently (<1 event/month). An ILR can provide continuous monitoring for months to years, increasing the likelihood of determining the cause of syncope. < (Choice A) This patient has occasional episodes of syncope (2 episodes in 4 months) and has no other symptoms between episodes. A 24-hour monitor would have a very low diagnostic yield in this setting. (Choice B) Dizziness or syncope can occur from orthostatic hypotension or from an excessive drop in blood pressure due to antihypertensive therapy. This effect is more often seen in patients with volume depletion or hypovolemia due to concomitant use of diuretics. This patient has adequate blood pressure with no orthostatic change with standing, and discontinuation of medications is not indicated. orthostatic hypotension (Choice C) Features suggestive of seizures include the presence of triggers (eg, lack of sleep, emotional stress, loud music, flashing lights), a prolonged postictal phase with confusion and disorientation, prodromal aura, head deviation or unusual body posturing, and tongue laceration. This patient has no such history, and an electroencephalogram would not be helpful. (Choice E) A permanent cardiac pacemaker is not indicated at this time without a clear diagnosis of the syncopal episodes. Educational objective: An implantable loop recorder is a subcutaneous monitoring device for the detection of cardiac arrhythmias. It has a significantly higher diagnostic yield than 24-hour Holter monitoring in patients with infrequent (<1 event/month) symptoms of palpitations or syncope of undetermined etiology. < __________ References: Early application of an implantable loop recorder allows effective specific therapy in patients with recurrent suspected neutrally mediated syncope. (http://www.ncbi.nlm.nih.gov/pubmed/16569653) Use of implantable loop recorders in the diagnosis and management of syncope. (http://www.ncbi.nlm.nih.gov/pubmed/15246645)

Exam 3: Office/Health Center

A 31-year-old woman recently diagnosed with mitral valve prolapse asks about complications of the disease. Which of the following is the most important determinant of adverse cardiovascular events in this patient?