Case Discussion

Live Class #1
Case #1
A 20-year-old female college student is evaluated at the student health center to
establish care. She had no major medical problems prior to college, and there is
no family history of cardiovascular disease.
BP: 110/60 mm Hg and pulse is 70/min. S1 and S2 are normal and there is an S4
present. There is a harsh grade 2/6 midsystolic murmur heard best at the lower
left sternal border. The murmur does not radiate to the carotid arteries. A
Valsalva maneuver increases the intensity of the murmur; moving from a
standing position to a squatting position, performing a passive leg lift while
recumbent, and performing isometric handgrip exercises decrease the intensity.
Rapid upstrokes of the carotid pulses are present. Blood pressures in the upper
and lower extremities are equal.
1. Identify diff dx.
2. Discuss the treatment plans for each
A 76-year-old woman residing in an independent living facility is evaluated during a
routine examination. She ambulates well, using a cane because of hip pain, but does
not exercise regularly and takes public transportation to complete her daily shopping.
She does not have exertional chest discomfort, dizziness, palpitations, dyspnea, or
fatigue. She has hypertension. There is no known history of coronary artery disease.
She does not smoke. Medications are hydrochlorothiazide and low-dose aspirin.

On physical examination, temperature is normal and blood pressure is 150/80 mm Hg.

BMI is 22. Cardiac examination reveals a sustained apical impulse; normal S1; and a
single, soft S2. An S4 is present. There is a grade 3/6 early-onset systolic, late-peaking
murmur that is heard best at the right upper sternal border and radiates to the left
carotid artery. Carotid pulses are delayed. There is trace pedal edema.

Transthoracic echocardiography demonstrates severe aortic stenosis. No other

valvular abnormalities are seen. Biventricular function is normal. There is concentric
left ventricular hypertrophy. Pulmonary pressures are at the upper limits of normal.

Which of the following is the most appropriate test to perform next? Explain.
1. Cardiac CT angiography
2. Coronary angiography
3. Exercise Treadmill Stress Test
4. Transesophageal echocardiography
5. No diagnostic testing at this time
What are the appropriate treatment plan?
A 54-year-old man is evaluated for right-sided chest pain that is described as sharp, begins
following large meals, lasts for several minutes, and usually resolves spontaneously. The episodes
are not clearly related to activity, nor are they relieved by rest. He has been experiencing the pain
for about 4 months. Several of the episodes have resolved with antacids. The most recent
episode, which occurred yesterday while walking, lasted 20 minutes and resolved.
Medical history includes hypertension and hyperlipidemia. Family history is notable for a brother
who had coronary stent placement at the age of 43 years. Current medications are aspirin,
atenolol, and atorvastatin.
Physical examination is notable for estimated central venous pressure of 6 cm H2O; normal
carotid upstroke; and no cardiac murmurs, rubs, or S3. Lung fields are clear. Extremities show no
edema, and peripheral pulses are normal bilaterally.
Hematocrit, 44%; troponin I at presentation is 0.0 ng/mL; troponin I at 4 hours is 0.0 ng/mL ;
creatine kinase, 50 U/L.
EKG: shows normal sinus rhythm and no ST- or T-wave changes. CXR: shows a normal cardiac
silhouette, no infiltrates, and no pleural effusions.

Which of the following is the best diagnostic option? Explain.

1. Coronary angiography
2. Esophagogastroduodenoscopy
3. Exercise stress test
4. Empiric treatment with a proton pump inhibitor
What are the treatment plan?
A 68-year-old woman is evaluated for atypical chest pain of 3 months’ duration. She describes the
pain as a left-sided burning that occurs both at rest and when she exercises. It lasts for about 10
minutes, and is relieved by rest and eating. The patient has no history of cardiac disease. She has
hypertension, for which she currently takes hydrochlorothiazide. She is a smoker and she has
asthma, for which she takes inhaled corticosteroids and frequently uses inhaled bronchodilators.
If she pretreats herself with the inhaled bronchodilator, she can walk long distances at a brisk
pace.
She is afebrile, her blood pressure is 158/84 mm Hg, her pulse is 64/min, and her respiration rate
is 18/min. Estimated central venous pressure is 5 cm H2O. On cardiac examination, no murmurs,
rubs, or extra heart sounds are noted. The lungs are clear to auscultation. There is trace
peripheral edema.
Total cholesterol, 200 mg/dL LDL 140; and HDL 50 mg/dL EKG: normal

Which of the following is the most appropriate diagnostic test for this patient? Explain.

1. Adenosine nuclear perfusion stress test

2. Coronary angiography
3. Coronary artery calcium score
4. Dobutamine stress echocardiography
5. Exercise stress test
What are the treatment plans?
A 65-year-old man is evaluated during a routine follow-up examination for coronary artery
disease. He was diagnosed with a myocardial infarction 5 years previously, and was started on
medical therapy with aspirin, metoprolol, atorvastatin, lisinopril, and sublingual nitroglycerin. He
was asymptomatic until 3 months ago, when he noted progressive exertional angina after walking
two blocks. He now uses sublingual nitroglycerin on a daily basis. He has not had any episodes of
pain at rest or prolonged chest pain that were not relieved by sublingual nitroglycerin. He has
hyperlipidemia and hypertension.
PE: a well-developed man who appears comfortable. BP 140/60 mm Hg HR 85/min. Carotid
upstrokes are normal with no bruits. Cardiac examination reveals no murmurs. The lungs are
clear. Peripheral pulses are equal throughout and there is no peripheral edema.
His electrocardiogram is unchanged since the last visit, with no evidence of acute changes.

In addition to adding a long-acting nitrate, which of the following is the most appropriate
management for this patient? Explain.

1. Add ranolazine
2. Increase metoprolol
3. Coronary angiography
4. Exercise treadmill stress testing
A 66-year-old man is evaluated in the emergency department for left-sided chest pain that began
at rest, lasted for 15 minutes, and has since resolved. A similar episode occurred at rest
yesterday, and multiple similar episodes that were associated with exertion have occurred over
the past 2 weeks. Pertinent medical history includes hypertension and type 2 diabetes mellitus.
Family history is notable for his father undergoing coronary artery bypass graft surgery at age 69
years and his brother undergoing coronary artery bypass graft surgery at age 54 years. Current
medications are amlodipine, glyburide, and aspirin.
BP 125/65 mm Hg, HR 70/min, RR 12/min. Estimated central venous pressure is 6 cm H2O, carotid
upstroke is normal, there are no cardiac murmurs, and the lung fields are clear. Extremities show
no edema, and peripheral pulses are normal bilaterally.

Troponin I level of 1.2 ng/mL and a creatinine 1.4 mg/ dL

EKG: 1-mm ST-segment depression in leads aVL, V5, and V6. CXR: normal cardiac silhouette, with
no infiltrates and no pleural effusions.
The patient is treated with aspirin, intravenous nitroglycerin, unfractionated heparin, metoprolol,
and pravastatin.

Which of the following should be the next step in this patient’s management? Explain.
1. Coronary angiography
2. Obtain B-type natriuretic peptide level
3. Pharmacologic stress testing
4. Thrombolytic therapy
A 65-year-old woman is evaluated in the hospital 36 hours after presenting in the emergency department with
midsternal chest pain. Electrocardiogram on presentation demonstrated no ST-segment shifts, but T-wave
inversion was present in leads V3 and V4. She was given nitroglycerin, unfractionated heparin, and a
glycoprotein IIb/IIIa inhibitor and was admitted to the hospital. She has a history of hypertension and
hyperlipidemia and is a prior smoker. Her medications prior to admission were metoprolol, 25 mg twice daily;
atorvastatin, 80 mg/d; and aspirin, 325 mg/d.
The patient is afebrile. BP 132/82 mm Hg, HR 68/min and regular, RR 16/min. BMI is 25. There is no jugular
venous distention, and no crackles are auscultated. Heart sounds are normal. There is no rub, murmur, or
gallop.
Her serum cardiac troponin I level rose to a peak of 4.2 ng/mL at 24 hours following the index event. Results of
a basic metabolic profile, including blood glucose levels, are normal.
Coronary angiography demonstrates diffuse, mild luminal irregularities in all coronary arteries, along with
diffuse severe disease in the distal left anterior descending coronary artery not amenable to percutaneous
coronary intervention. Left ventriculography demonstrates a left ventricular ejection fraction of 55% with a
small focal region of hypokinesis in the apex. The left ventricular end-diastolic pressure is 12 mm Hg.
The glycoprotein IIb/IIIa inhibitor is discontinued.

Which one of the following agents should be added to this patient’s medication regimen? Explain.

1. Verapamil
2. Clopidogrel
3. Eplerenone
4. Warfarin
A 67-year-old woman is evaluated in the ED for substernal chest pressure that has lasted for just over 3 hours.
The pressure has not remitted despite administration of one dose of sublingual nitroglycerin on the way to the
hospital. The emergency department is in a community hospital that does not have percutaneous coronary
intervention (PCI) capability. The nearest hospital with PCI capability is 45 minutes away.
The patient has a history of hypertension and hyperlipidemia. There is no history of recent surgery or bleeding
diathesis. Current medications include lisinopril, hydrochlorothiazide, and simvastatin. She has no known drug
allergies. Aspirin and sublingual nitroglycerin are administered upon arrival.
Temperature is 37.2 °C (99.0 °F), BP 146/92 mm Hg, HR 104/min and regular, RR 18/min. The patient appears
uncomfortable. Crackles are heard at the bases of both lung fields. The S1 is normal; the S2 is paradoxically split.
No murmur or gallop is present.
Results of a complete blood count, basic metabolic profile, and clotting studies are normal. Initial serum
troponin I level is 0.5 ng/mL. A stool sample tests negative for occult blood.
EKG: normal sinus rhythm with a left bundle branch block. No prior tracing is available for comparison.
Intravenous heparin, β-blockers, and morphine are administered.

Which of the following is the most appropriate next step in the management of this patient? Explain.

1. Administer thrombolytics
2. Administer glycoprotein IIb/IIIa
3. Obtain serial cardiac enzyme measurements
4. Transfer to nearest hospital with PCI capability
A 62-year-old woman is brought to the emergency department by paramedics for chest pain that
has been present for 5 hours. Medical history is notable for type 2 diabetes mellitus,
hypertension, and a stroke 1 year ago. Medications include glyburide, lisinopril, atorvastatin, and
aspirin.
On physical examination, she appears comfortable. She is afebrile, blood pressure is 190/90 mm
Hg, pulse rate is 88/min and respiration rate is 16/min. Cardiac examination shows no murmurs,
extra sounds, or rubs. The lungs are clear and pulses are equal bilaterally. Neurologic examination
is normal.
The electrocardiogram shows 2-mm ST-segment elevation in leads II, III, and aVF.
A coronary catheterization laboratory is not available, and the nearest hospital with
percutaneous intervention capability is 1 hour away.
What is the best management option for this patient?
A 48-year-old man is evaluated in the emergency department for sudden onset of
severe discomfort in the chest and between the shoulder blades. The pain was
maximal in intensity at its onset 90 minutes ago and is unaffected by position or
breathing. He has a history of hypertension, for which he takes hydrochlorothiazide,
25 mg/d; and lisinopril, 40 mg/d.
BP is 200/120 mm Hg, pulse is 100/min, and respiration rate is 20/min. An S4 gallop is
present. No cardiac murmur or pericardial rub is present. The lungs are clear to
auscultation. Distal pulses are equal and symmetric. Results of a neurologic
examination are normal.
UDS: positive for cocaine. Serum creatinine is 2.2 mg/dL. His creatinine 0.8 mg/dL at
the time of his last office evaluation. Serum cardiac troponin and myoglobin levels are
normal. An electrocardiogram reveals left ventricular hypertrophy with a secondary
repolarization abnormality and sinus tachycardia. Chest radiograph is normal.

In addition to emergently lowering the blood pressure and heart rate, which of the
following diagnostic tests should be performed next? Explain.

1. CT scan of chest with intravenous contrast

2. Nuclear myocardial perfusion scan
3. Transesophageal echocardiogram
4. Ventilation-perfusion lung scan