Trevor L. Jenkins, M.D. UH Harrington Heart & Vascular Institute

5/14/2014 CV Board Review Trevor L. Jenkins, M.D. UH Harrington Heart & Vascular Institute Institute for Transformative Molecular Medicine University Hospitals Case Medical Center Case Western Reserve School of Medicine

Question 1 • A 45-year-old woman is evaluated in the emergency department for acute severe shortness of breath. She has a history of mitral valve prolapse for more than 30 years. Before today, she has been able to swim for 1 hour without symptoms. Two hours ago while moving furniture she experienced acute dyspnea and chest discomfort. She has had no fever or chills. • Physical examination shows a thin woman with labored breathing. Temperature is 37.2 °C (99.0 °F), blood pressure is 115/76 mm Hg, heart rate is 120/min and regular, and respiration rate is 20/min. Oxygen saturation is 88% on ambient air. There is no jugular venous distention, and carotid upstrokes are brisk. The apical impulse is not displaced. S1 is reduced and there is a grade 2/6 early systolic murmur at the apex with radiation to the back. An S3 is present. Her lungs have bilateral crackles. Extremities are cool. • Electrocardiogram shows sinus tachycardia and prominent QRS voltage. Chest radiograph shows normal cardiac size and pulmonary edema. Urgent transthoracic echocardiogram shows normal left and right ventricular size and systolic function, left ventricular ejection fraction of 70%, and partial flail of the anterior mitral valve leaflet with severe mitral regurgitation. The left atrium is not dilated and no other valve abnormalities are detected. University Hospitals Harrington Heart & Vascular Institute

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 University Hospitals Harrington Heart & Vascular Institute

Question 1 Stout, Circ 2009;119:3232 University Hospitals Harrington Heart & Vascular Institute

Question 1 University Hospitals Harrington Heart & Vascular Institute

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. University Hospitals Harrington Heart & Vascular Institute

Question 2 • Which of the following is the most appropriate treatment? • Balloon mitral valvuloplasty • Metoprolol • Mitral Valve replacement • Open surgical commissurotomy University Hospitals Harrington Heart & Vascular Institute

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. University Hospitals Harrington Heart & Vascular Institute

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) University Hospitals Harrington Heart & Vascular Institute

Question 3 • Factors supporting SAVR • Severe aortic stenosis (Valve area < 1.0 cm2) • Left ventricular dysfunction • Symptomatic patient • CHF • Exertional chest pain • Syncope • Low operative risk University Hospitals Harrington Heart & Vascular Institute

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. University Hospitals Harrington Heart & Vascular Institute

Question 4 • Which of the following is the most appropriate management? • Azathioprine • Chest CT • Colchicine and aspirin • Pericardiectomy • Prednisone l University Hospitals Harrington Heart & Vascular Institute

Question 4 • COPE (COlchicine for acute Pericarditis) trial. • Imazio, Circ 2005;112:2012 • 120 patients assigned to ASA vs ASA + Colchicine for first episode of acute pericarditis • Colchicine decreased the recurrence rate at 18 months (10.7% vs 32.3%, P = .004, NNT = 5) and symptoms at 72 hours (11.7% vs 36.7%, P = .003). Corticosteroid use was an independent risk factor for recurrence. Colchicine stopped in 5 cases for GI intolerance. • CORE (COlchicine for REcurrent pericarditis) trial. • Imazio, Arch Intern Med 2005;165:1967 • 84 patient assigned to ASA vs ASA + Colchicine for recurrent episode of acute pericarditis • Colchicine decreased the recurrence rate (24.0% vs 50.6%, P = .02, NNT = 4) and symptoms at 72 hours (10% vs 31%, P = .03). In multivariate analysis, prior corticosteroid use was an independent predictor of further recurrent pericarditis University Hospitals Harrington Heart & Vascular Institute

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. University Hospitals Harrington Heart & Vascular Institute

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 l University Hospitals Harrington Heart & Vascular Institute

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. University Hospitals Harrington Heart & Vascular Institute

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. University Hospitals Harrington Heart & Vascular Institute

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 l University Hospitals Harrington Heart & Vascular Institute

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. University Hospitals Harrington Heart & Vascular Institute

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. University Hospitals Harrington Heart & Vascular Institute

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 l University Hospitals Harrington Heart & Vascular Institute

Question 7 • Measurement of hsCRP has been demonstrated to be clinically useful for guiding primary prevention strategies in persons with an intermediate risk of future cardiovascular events (Framingham risk score of 10%-20%), with up to 30% of these patients reclassified as either low risk or high risk based on hsCRP measurement. • The JUPITER trial tested the hypothesis that healthy middle-aged and older persons with elevated hsCRP but without elevated LDL cholesterol (<130 mg/dL [3.37 mmol/L]) would benefit from statin treatment. Statin treatment was associated with lowering of median LDL cholesterol level from 108 to 55 mg/dL (2.80 to 1.42 mmol/L, 50% reduction) and median hsCRP level from 0.42 to 0.22 mg/dL (4.2 to 2.2 mg/L, 37% reduction). The JUPITER trial was terminated early after a median follow-up of 1.9 years because of reduction in the primary end point rate (incidence of a first major cardiovascular event) from 1.36 to 0.77 per 100 patient-years of follow-up. The absolute reduction was relatively small at 1.2%. University Hospitals Harrington Heart & Vascular Institute

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. University Hospitals Harrington Heart & Vascular Institute

Question 8 • Which of the following is the most appropriate treatment? • Continue warfarin • Switch to aspirin • Switch to clopidogrel • Switch to aspirin and clopidogrel l University Hospitals Harrington Heart & Vascular Institute

Question 8 • Warfarin should be continued in this patient. For the first 2 to 3 months after an atrial fibrillation ablation, all patients should take warfarin. The best management strategy thereafter is to provide anticoagulation as if the ablation did not occur, using a tool such as the CHADS2 score to risk stratify. Although the patient has had no symptoms of atrial fibrillation since his ablation procedure, patients may have either asymptomatic episodes or a symptomatic recurrence of atrial fibrillation after the ablation and can be at risk for stroke. This patient has hypertension and diabetes mellitus and a CHADS2 score of 2 (4.0% risk of stroke per year). • CHADS2 score: 1 point: CHF (EF <35%), DM, HTN, Age > 75 2 points: CVA/TIA University Hospitals Harrington Heart & Vascular Institute

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. University Hospitals Harrington Heart & Vascular Institute

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 l University Hospitals Harrington Heart & Vascular Institute

Trevor L. Jenkins, M.D. UH Harrington Heart & Vascular Institute