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Challenging Cases in Cardiology with Your Participation Kuwait IM Course, Kuwait City March 2019 Duane Pinto, MD, MPH, FACC Director, Cardiac Intensive Care Unit Director, Interventional Cardiology Section Beth Israel Deaconess Medical Center


  1. Challenging Cases in Cardiology with Your Participation Kuwait IM Course, Kuwait City March 2019 Duane Pinto, MD, MPH, FACC Director, Cardiac Intensive Care Unit Director, Interventional Cardiology Section Beth Israel Deaconess Medical Center HARVARD MEDICAL SCHOOL

  2. Question 1 All of the following are true about oral direct thrombin and Xa inhibitors except : A. These agents are not safe in patients with mechanical valves B. These agents are renally cleared and may require dose adjustment C. Nonvalvular atrial fibrillation is the only approved indication D. Edoxaban is a Xa inhibitor. E. Compliance is not as easy to monitor as with warfarin HARVARD MEDICAL SCHOOL

  3. Coagulation Cascade Initiation Vlla/TF X IX Propagation IXa VllIa Rivaroxaban/apixiban Xa Dabigitran Va II IIa (Thrombin) Fibrin Formation HARVARD Fibrin Fibrinogen MEDICAL SCHOOL

  4. Question 2 A 65 year old male presents to the Emergency Room with two days of progressive weakness and fatigue. On arrival, he is lethargic and has BP of 90/50. Electrocardiogram is shown below: HARVARD MEDICAL SCHOOL

  5. Question 2 HARVARD MEDICAL SCHOOL

  6. Question 2 The most appropriate treatment would be: A. Lidocaine 1 mg/kg IV bolus. B. tPA 100 mg over 90 minutes. C. Dopamine 10 mcg/kg/min. D. Sodium bicarbonate 50 mg IV bolus. E. IV Normal Saline 250 cc/hr. HARVARD MEDICAL SCHOOL

  7. Question 3 Aortic Valve Replacement is most appropriate for the following 88 year old patients who have calcified aortic stenosis, no evidence of coronary disease one month ago by coronary angiography, and no other significant health problems? A. An asymptomatic patient with normal left ventricular systolic function but calculated aortic valve area of 0.5 cm2 B. An asymptomatic patient with normal left ventricular systolic function;mean aortic valve gradient is 68 mm Hg C. An asymptomatic patient calculated aortic valve area of 1.5 cm2 ’ left ventricular ejection fraction is 30% D. A patient with 2 month history of moderate exertional dyspnea; calculate aortic valve area is 0.8 cm2, and left ventricular ejection fraction is 45% HARVARD MEDICAL SCHOOL

  8. Question 4 You are asked to see a 62 year old man in consultation prior to elective prostatectomy. He is status post an uncomplicated inferior myocardial infarction 4 years ago. He underwent coronary artery bypass surgery (CABG) 2 years ago for progressive angina. He walks 2 miles/day, plays singles tennis on weekends and he has experienced no angina since his CABG. His only medications are metoprolol and aspirin. HARVARD MEDICAL SCHOOL

  9. Question 4 Which of the following diagnostic strategies would you recommend before his surgery? A.Approve for surgery without further diagnostic workup B.Order an exercise test without thallium C.Order an exercise test with thallium D.Order a coronary angiogram E.Order a dobutamine echocardiogram HARVARD MEDICAL SCHOOL

  10. ACC/AHA Guideline For Perioperative Cardiovascular Evaluation for Noncardiac Surgery “ The overriding theme of these guidelines is that preoperative intervention is rarely necessary simply to lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context” HARVARD MEDICAL SCHOOL

  11. Stepwise approach to perioperative cardiac assessment of CAD Fleisher et. al Circulation 2014;130: 2215 HARVARD MEDICAL SCHOOL

  12. Question 5 A 45 year old premenopausal woman with history of diabetes and smoking, no prior cardiac history, presents with unremitting substernal chest pain and the following electrocardiogram. HARVARD MEDICAL SCHOOL

  13. Question 5 Appropriate treatment would be: A. Thrombolytic therapy B. Beta blockers and nitrates C. Reassurance and valium D. Lasix E. Nonsteroid anti-inflammatory (NSAID) HARVARD MEDICAL SCHOOL

  14. Question 6 A 32 year old woman comes to your office after an episode of syncope. She has had several syncopal episodes since the age of 13, the most recent one two years ago. One episode was after learning of an uncle dying in a car accident, another was after an IV insertion prior to wisdom teeth extraction. The current episode occurred while riding in a car. She had just eaten, was feeling motion sick, became nauseated and diaphoretic and lost consciousness. She recovered 15 seconds later, alert and oriented. In your office her physical exam and EKG are normal. HARVARD MEDICAL SCHOOL

  15. Question 6 Which diagnostic/therapeutic strategy would you recommend? A. Tilt table test B. Holter monitor C. Echocardiogram D. Reassurance E. Electrophysiology study HARVARD MEDICAL SCHOOL

  16. Question 7 A 47 year old obese, diabetic woman with hypertension and hyperlipidemia describes increasing weakness, dyspnea over the last several days. On physical examination: Her pulse was 100 bpm, BP was 84/56 mm Hg, RR 26 JVP was not visible due to obese neck. Lungs were clear. The right breast was indurated and erythematous with “ peau d ’ orange ” appearance. Heart was tachycardic, distant S1, S2, no rub, murmur,gallop. The extremities were cool and there was 2+bilateral edema. You obtain the following ECG: HARVARD MEDICAL SCHOOL

  17. Question 7 HARVARD MEDICAL SCHOOL

  18. Question 7 Which of the following is the next step? A. IVF hydration, surgical consultation B. Echocardiogram then urgent transfer to cardiac catheterization laboratory C. Empiric heparin, CT angio, consider thrombolysis based on findings D. Aspirin, IV Lopressor, enoxaparin, telemetry, cardiac enzymes HARVARD MEDICAL SCHOOL

  19. Question 8 The renal lesion here: A. is typical for an 85 year old longstanding hypertensive smoker with CAD B. is typical for a 70 year old woman presenting with abrupt pulmonary edema C. Should be treated with stent placement D. is best treated with balloon angiopasty alone HARVARD MEDICAL SCHOOL

  20. Question 9 22 year old man is evaluated in the emergency department for a rapid heart rate and lightheadedness. He reports episodes of a racing heart a few times year since his early teens. Today ’ s episode was different, his pulse started out regular but became erratic. In addition he has never had lightheadedness with the episodes before. He is otherwise healthy and takes no medication. On examination, the patient is diaphoretic. Blood pressure is 73/42. Lungs are clear, cardiac examination reveals irregular rate no murmurs. EKG is shown on next slide: HARVARD MEDICAL SCHOOL

  21. 22 year old with palpitations and lightheadedness HARVARD MEDICAL SCHOOL

  22. Question 9 What is the therapy of choice in this patient? A. Intravenous procainamide B. Direct-current cardioversion C. Intravenous verapamil D. Overdrive atrial pacing. HARVARD MEDICAL SCHOOL

  23. 10. All of the following statements about dual antiplatelet therapy (DAPT) after coronary stenting are true except: A. Duration of therapy for a drug eluting stent (DES) is 6-12 months B. The primary reason for DAPT is to prevent coronary restenosis C. Proton pump inhibitors such as pantoprazole may inhibit the effectiveness of clopidogrel D. Prasugrel and ticagrelor are platelet P2Y 12 receptor blockers HARVARD MEDICAL SCHOOL

  24. BONUS QUESTION: This angiogram demonstrates a condition that: A.Is a known complication of cardiac catheterization procedures B.Is a condition associated with cardiac failure C.Requires cardiac surgical repair in most instances D.Is congenital HARVARD MEDICAL SCHOOL

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