Self-Assessment Test

UI
Fc,
tr
CONI.
Follow-ing intravenous nitrclglycerin, blood pressure
increases and chest pain subsides. Follow-up ECG is shown.
atrial fibrillation is diagnosed. He also has chronic lympho-
cytic leukemia. He began ibrutinib 1 month ago.
On physical examination, pulse rate is 128/min and
E
q,
tr
irregularly irregular. Oxygen saturation is 95'X, u'ith the U!
UI
patient breathing ambient air. Other than a rapid, irregular o
t
rhythm, the cardiopulmonary examination is normal. Sple UI
nomegaly is present. There is no lower extremity edema.
Laboratory studies show a nclrmal D-dimer level. The
g(,
initial high sensitivity cardiac troponin level is normal vt
(<99th percentile upper rel'erence limit). Thyroid-stimulating
hormone and free thyroxine levels are normal.
ECG shows atrial flbrillation with rapid ventricular
response. nonspecific ST-T abnorrnality, and incomplete
right bundle branch block. Echocardiogram shows normal
biventricular size and f'unction. normal valvular structure
and function. and normal atrial size.

Which of the following is the most likely contributor to

I the patient's atrial fitrrillation?
(A) Acute myocardial infarction
(B) lbrutinib
(C) Pulmonarythromboembolism
(D) Thyrotoxicosis
Which of the following is the most likely diagnosis?
I (A) Coronary embolism

(
(B) Coronaryvasospasm
(C) Pulmonary embolism
ttem 98
A 71'year old woman is hospitalized with cardiogenic
tr
(D) Stress (takotsubo) cardiomyopathy shock.
On physical examination, blocld pressure is B7l51 mm
Hg, pulse rate is 112/min, respiration rate is 22lmin, and
Item 96 oxygen saturation is 92')(, with the patient breathing 40')(,
Fror. An S.,, jugular venous distention, pulmonary crackles,
A 68-year-old man is evaluated for increasingly frequent
ar,d cool extremities are present.
angina. One month ago, coronary angiography was per-
formed because of the occurrence of angina at lower levels of
Laboratory studies show an elevated seruln high-
sensitivity cardiac troponin level (>9gth percentile upper
exertion. It showed diffuse coronary disease without lesions
ref'erence limit) and serum creatinine level of t.8 mg/dl
amenable to revascularization and preserved left ventricu-
(ls9 Uraoli L).
lar function. Following coronary angiography, the patient
An ECC demonstrates 2-mm ST-segment depressions
increased his dosage of isosorbide mononitrate to twice
in leads V., through V,,.
daily; however, his exertional chest discomfort worsened.
Emergent cardiac catheterization shows critical lesions
He also has hypertension and diabetes mellitus. Previously,
in the left ilnterior descending and circumflex arteries, and
diltiazem was substituted for metoprolol because of intoler-
stents are placed. Following stenting, the patient's clinical
ance. Medications are aspirin, metformin, liraglutide, ator-
status is unchanged.
vastatin, lisinopril, diltiazem, and isosorbide mononitrate.
Medications are aspirin. prasugrel, f'urosemide, and
On physical examination, blood pressure is 135/80 mm
norepinephrine.
Hg, pulse rate is 67lmin, and respiration rate is l8/min. The
remainder of the examination is unremarkable.
ECG shows sinus rhythm and nonspeciflc intraventric-
Which of the following is the most appropriate additional
ular conduction delay, unchanged from 1 month ago. management?
(A) Digoxin
Which of the following is the most appropriate management? (B) Intra'aortic balloon pump placement
(A) Add amlodipine (C) N4etoprolol
(B) Decrease Iisinopril dosage (D) Urgent cardiac transplantation
(C) Reduce isosorbide mononitrate dosage to once daily (Fl) Vasopressin
(D) Repeatcoronaryangiography

Item 99
Item 97 A 66-year-old man is seen in the office after hospitaliza
A 70-year-old man is evaluated in the emergency depart tion for an embolic stroke 7 days ago. His initial neurologic
ment for 3 days of palpitations and dyspnea. New-onset flndings were minimal and have since resolved. An embolic

149
 Self-Assessment Test
1

ut
(D
source has not been identifled. He has no other pertinent Item 102
la personal or family history. Medications are aspirin and
UI An 80 year old man is evaluated for a 6-week history of
(D clopidogrel.
la resting right foot and flrst toe pain. He has type 2 diabe
tt Physical examination, including vital signs and neuro
tes mellitus, hypertension, and hyperlipidemia. He has a
logic examination, is normal. SO-pack-year smoking history but quit 10 years ago. Med-
.D
Ambulatory 4S-hour ECG monitoring showed no ications are low-dose aspirin, metformin, lisinopril, and
{
.D
arrhythmias. atorvastatin.
l^ On physical examination, vital signs are normal. The
Which of the following is the most reasonable management? right foot is pale and mottled. A 4 x 4 cm ulceration is
(A) Discontinue aspirin and clopidogrel; begin warfarin noted on the lateral aspect ofthe right flfth metatarsal. Pedal
pulses are diminished on the left and absent on the right.
(B) Left atrial appendage occlusion
The ankle-brachial index is 0.62 on the left and 0.44 on
(C) Loop recorder implantation the right.
(D) Test for thrombophilia
Which ofthe following is the most appropriate next step in
management?
Item 10O
A S5-year-old man is evaluated for easy bruising. The patient
(A) CT angiography
underwent mechanical mitral valve replacement l year ago. (B) Hyperbaric oxygen treatment
He reports no bleeding. His only medication is warfarin. (C) Invasiveangiography
On physical examination, vital signs are normal. Car- (D) Primarybelow-the-knee amputation 1
diac examination reveals a normal mechanical valve sound
without murmur. The remainder of the cardiopulmonary
examination is normal. Examination of the arms reveals Item 103
numerous ecchymoses.
A 42 year old woman is evaluated for an episode of syncope
Laboratory studies reveal a normal hemoglobin level;
that occurred 2 weeks ago while she was hurrying to catch
INR is 3.4 and has ranged between 2.6 and 3.5 over the past
a bus. She has hypertrophic cardiomyopathy. Before this
3 months.
episode, her symptoms had been very well controlled. She
continues to accomplish activities of daily living with only
Which of the following is the most appropriate treatment? occasional mild dyspnea. She has no family history of sud-
(A) Continue current warfarin dosage den cardiac death. Her only medication is metoprolol.
(B) Decrease warfarin dosage
Twenty-four-hour ambulatory ECG monitoring shows
one three beat run of nonsustained ventricular tachycar
(C) Discontinue warfarin and start aspirin
dia. Echocardiogram shows maximum left ventricular wall
(D) Discontinue warfarin and start dabigatran thickness of 30 mm, asymmetric septal hypertrophy, and
(E) Discontinue warfarin and start rivaroxaban systolic anterior motion of the mitral valve. Resting lelt
ventricular outflow tract gradient is 24 mm Hg, increasing
to 36 mm Hg during Valsalva maneuver.
Item 101
A SO-year-old man is evaluated for 8 weeks of progressive Which of the following is the most appropriate treatment?
exertional dyspnea and a syncopal event. He has been well (A) Disopyramide :

otherwise and takes no medications.

On physical examination, vital signs are normal. Car
(B) Implantable cardioverter-deflbrillator
diac examination reveals a late-peaking systolic crescendo (C) Septal reduction therapy
decrescendo murmur heard at the right upper sternal (D) Verapamil
border with loss of Sr. The remainder of the examination is
normal.
An ECG shows normal sinus rhythm and left ventricu
Iar hypertrophy with repolarization abnormalities.
An echocardiogram shows a severely thickened, min-
Item 104
477 year old ra,,oman is hospitalized for intennittent recur tr
rent chest pain. Her ECG is shon'n (top of next page).
imally mobile bicuspid aortic valve. Hemodynamic mea The patient had a moderately severe ischemic stroke
surements on echocardiogram are consistent with severe 2 years ago and has oxygen dependent COPD. Nledications
aortic stenosis and normal left ventricular function. The are aspirin, atorvastatin, and inhaled albuterol and tiotro
ascending aorta could not be adequately assessed. pium.
On physical examination. blood pressure is 145 85 mm
Which ofthe following is the most appropriate management? Hg, pulse rate is 82'min, and respiration rate is 18 n1in.
(A) Cardiac catheterization Oxygen saturation is 909i on 2 L ofoxl,gen by nasal cannula.
(B) CT angiography of the thoracic aorta BMI is 18. An erpiratory wheeze is heard on auscultation
of the lungs. Cardiac examination reveals an Sr. Estimated
(C) Exercise treadmill stress testing central venous pressure is 10 cm HrO. Minimal left-sided
(D) Transcatheter aortic valve implantation weakness is present.

150
 Self-Assessment Test

t
(l,
t-

I AvR V1 (u

.,I
ra
q,
tt
UI

q,
rrt
II v2

III

II

ITEM 104

'lhe initiai high-sensitivity troponin level is elevated

tr
CONT
(>99th percentile upper reference limit).
lntravenous unfractionated heparin is initiated, and
Item 105
A 74-year-old man is evaluated for shortness of breath that
occurs when walking around the house and occasionally
coronary angiography is planned fbr the morning. when getting dressed. History is significant for ischemic car
diomyopathy and three heart failure hospitalDations over
Which of the following is the most appropriate additional the past 6 months. He was treated for colon cancer 2 years
treatment? agoi there is no evidence of recurrence. He has an implant
(A) Clopidogrel able cardioverter defibrillator. Medications are lisinopril,
(B) Prasugrel high dose furosemide, and spironolactone. He previously
took carvedilol and isosorbide dinitrate hydralazine, which
(C) Reteplase were discontinued because of symptomatic hypotension.
(D) f irofiban On physical examination, blood pressure is 94166 mm
Hg and pulse rate is BB/min. Cardiac examination reveals

tr ItemA 73
1O5
year oldwoman is evaluated in the emergencydepart
an S. but no jugular venous distention or dependent edema.
Laboratory studies show a serum creatinine Ievel of
1.7 mgldL (150 pmol/L) and a serum sodium level of
ment fbr a 1 day history of recurrent ischemic chest pain.
'lhe last episode began 30 minutes ago and is ongoing despite 132 mEqrL (132 mmol L).
Echocardiogram performed during his last hospitaliza
escalating doses of sublingual ancl parenteral nitroglycerin.
tion showed an ejection fraction of l0'7,.
History is signiflcant for hypertension and dyslipidemia.
The patient is engaged in a discussion regarding man
Medications are enalapril and atorvastatin.
agement options.
On physical examination, blood pressure is 119184 mm
Hg, and pulse rate is 104/min. Other than an S.,, the cardio
pulmonary examination is normal. Which of the following is the most reasonable next step in
The flrst set of cardiac biomarker levels is normal.
management?
ECG shows sinus tachycarclia and new 2 mm ST (A) Heart transplant
segnlent depressions in the inf'erior leads. (B) Hospitalization
Which of the following is the most appropriate imagtng
(C) Left ventricular assist device placement
test in this patient? (D) Low dose P blocker
(A) Coronary artery calcium scoring
(B) CoronaryCTangiography Item 107
(C) lnvasive coronary angittgraphy A 69-year old woman is evaluated during a follow up visit
(D) Transthoracic echocardiography 7 months after coronary stent placement for non ST-elevation

151
 .)

Self-Assessment Test

UI
.D

tt
tt
myocardial infarction. History is also notable for paroxys-
mal atrial flbrillation, hypertension, and gastrointestinal
bleeding due to diverticulosis 5 years ago. Medications are
Item 1 10
A 56 year old man is hospitalized for an ST elevation m1'o
tr
.D
t^ cardial infarction. He is treated with percutaneous coronary l
UI aspirin, clopidogrel, rivaroxaban, metoprolol, lisinopril, intervention and is now asymptomatic. Medical history is
3 and rosuvastatin. significant for hypertension and paroxysmal atrial fibrilla
\
.D
On physical examination, vital signs are normal. The tion. Outpatient n-redications are flecainide. rivaroxaban.
= patient weighs B0 kg (u6.4 lb). Bruising is present on the t
metoprolol. and lisinopril.
o
lrt arms and legs. The remainder of the examination is unre- A predischarge ECG shows sinus rh1'thm (heart rate.
markable.
58 min). a QRS complex duration o1 124 ms, and a right
Serum creatinine level is 1.0 mg/dl (88.a pmol/L).
bundle branch block pattern. An echocardiogram reveals
a mildly reduced left ventricular ejection fraction $'ith an
Which ofthe following is the most appropriate inferior u'al1 motion abnormalitv. 1

management?
(A) Discontinueaspirin Which of the following is the most appropriate :

(B) Discontinuerivaroxaban management?

(C) Switch rivaroxaban to reduced-dose apixaban (A) Ambulatory ECG monitoring
(D) Switch rivaroxaban to warfarin (B) Discontinueflecainide
(C) Discontinuemetoprolol I
:
Item 108 (D) Exercise stress testing \
A 35 year-old man is evaluated during a routine offlce visit.
t
He underwent atrial septal defect closure with a transcath
eter device l year ago. His past medical history is otherwise Item 111 :

:
unremarkable, and he has no other medical problems. He A 78 year old woman is evaluated during follow up of
takes no medications. nonischemic heart failure with reduced ejection fraction
On physical examination, vital signs and the remainder diagnosed 6 months ago. She has New York Heart Associa
of the examination are normal. tion functional class III symptoms. She is receiving optimal I
The patient will have periodontal cleaning next week. guideline-directed medical therapy consisting of valsartan-
sacubitril, carvedilol, spironolactone, and furosemide.
Which ofthe following is the most appropriate endocarditis On physical examination, blood pressure is lo4l62
prophylaxis? mm Hg and pulse rate is 58/min. A grade 2/6 holosystolic
murmur is heard at the apex, and a grade 1/6 crescendo
(A) Amoxicillin decrescendo systolic murrnur is heard at the base. There is
(B) Azithromycin no jugular venous distention or peripheral edema.
(C) Ceftriaxone ECG shows sinus rhythm and left bundle branch block
(D) Clindamycin with QRS duration of 155 ms. Echocardiogram shows an
(E) ejection fraction of 307,, left ventricular end systolic dimen-
No endocarditis prophylaxis
sion of 53 mm, mild to moderate mitral regurgitation, and
mild aortic stenosis.
Item 109 i
A 63 year-old man is evaluated during a follow-up exam- Which of the following is the most appropriate treatment?
t
ination for rheumatic aortic valve disease. He is asymptom (A) Cardiacresynchronizationtherapy
atic and has no exercise limitations. He has no other medical
problems. (B) Ivabradine :

On physical examination, blood pressure is 134/32 mm (C) Mitral valve clip placement
Hg. A grade 3/6 holodiastolic murmur is heard best at the (D) Transcatheter aortic valve implantation
left sternal border. Peripheral pulses are bounding. There is
no evidence ofheart failure.
A transthoracic echocardiogram with good image qual- Item 112
ity shows a left ventricular ejection fraction greater than a
A S8-year-old man with stable exertional angina returns
55'1, and a tricuspid aortic valve with severe aortic regur-
for follow-up evaluation. He has normal left ventricular -a
gitation. The left ventricular end systolic dimension is ele
function and no high-risk features on exercise ECG. Angina
vated at 45 mm.
symptoms include chest pressure that routinely occurs
while walking 25 yards despite maximally tolerated medi-
Which of the following is the most appropriate cal therapy. Medications are aspirin, metoprolol, isosorbide
management? mononitrate, and atorvastatin.
(A) Repeat evaluation in 6 months On physical examination, blood pressure is 110/70 mm
(B) Surgical aortic valve replacement Hg, pulse rate is 54/min, and respiration rate is 16/min. BMI
is 25.
(C) Transcatheter aortic valve implantation
A coronary angiogram shows a 70% proximal right cor-
(D) Transesophageal echocardiography onary artery stenosis and an 80'/n second obtuse marginal

152
 Self-Assessment Test

vt
artery stenosis. The left anterior descending artery has non- G'
Item 1 14 F
obstructive lesions in the proximal segment.
A 65-year-old woman is evaluated in the oIflce after several (l,
visits to the emergency department for paroxysmal atrial
Which of the following beneflts can the patient expect flbrillation and acute heart failure. Medications are apix- UI
UI
following coronary artery bypass grafting? aban, metoprolol, furosemide, and losartan. c,
UI
UI
(A) Discontinuation of cardioprotective medications Vital signs are normal. Cardiopulmonary examination
(B) Improvement in symptoms and the remainder of the physical examination are normal.
Results of laboratory studies show a normal serum o
t!
(C) Increased survival
thyroid-stimulating hormone level.
(D) Reduced risk for myocardial infarction An ECG shows sinus rhythm with a heart rate of
58/min. An echocardiogram reveals a left ventricular ejec-
tion fraction of 45%.
Item 1 13
A 30 year-old man is seen in the offlce for slowly pro- Which of the following is the most appropriate
gressive dyspnea that flrst appeared when walking rap- treatment?
idly or uphill. He denies orthopnea, palpitations, or chest
pain. He has no other medical problems and takes no (A) Atrioventricular node ablation with permanent pace-
medications. maker implantation
On physical examination, vital signs are normal. (B) Implantable cardioverter-deflbrillator placement
Jugular venous distention is present. There is a left para- (C) Left atrial appendage occlusion
sternal impulse. A grade 2/6 systolic murmur is heard (D) Rhythm control
at the second left intercostal space, and a diastolic flow
rumble is heard over the tricuspid valve. Fixed splitting
of the S, is present. The remainder of the examination is
normal.
An ECG is shown. Chest radiograph reveals right heart
Item 1 15
A 57 year old man is evaluated in the emergency department tr
tbr sudden onset anterior chest pain. He has hypertension,
enlargement, a prominent pulmonary artery, and increased
hyperlipidemia, and coronary artery disease. Medications
pulmonary vascularity.
are hydrochlorothiazide. aspirin, amlodipine, olmesartan,
labetalol, and atorvastatin.
Which of the following is the most likely diagnosis? On physical examination, blood pressure is 172i 64 mm
(A) Atrial septal defect IJg in the right arm and 135/63 mm I{g in the left arm, pulse
(B) rate is 110/min, respiration rate is 24lmin, and oxygen sat-
Bicuspid aortic valve with aortic regurgitation
uration with the patient breathing ambient air is 96'X,. Car
(C) Mitral stenosis diac examination reveals a grade 3/6 decrescendo diastolic
(D) Ventricular septal defect murmur heard at the left sternal border.

ITEM 1 13

153
 Self-Assessment Test

t,l
(D
Item 118
D
la
tr
tr
CONT,
A serum high-sensitivity cardiac troponin measure-
ment is indeterminate.
An ECG shows sinus tachycardia and lateral S'f
A 78-year oldwoman is evaluated in follow up for a 3-month
history of intermittent claudication, which is worse in the left
.D
u!
UI segment clepressions. Chest radiograph is normal' leg than in the right. Her symptoms have become life limiting
de"spite adherenie to a structured exercise program' Medical
.D
Which of the following is the most appropriate diagnostic history is sigfficant for type 2 diabetes mellitus and hyper
test to perform in this Patient? tension. She has a 60-pack-year smoking history and quit
(D
(a l year ago. Medications are aspirin, metformin, canagliflozin,
(A) Coronary artery catheterization cilostazol. atorvastatin, and olmesartan.
(B) Invasive aortography On physical examination, vital signs are normal' Dor
(C) Magnetic resonance angiography salis pedis and posterior tibialis pulses are faint bilaterally'
(D) Transthoracic echocardiography and CT angiography The ankle brachial index is 0.82 on the right and 0'64
on the left.
CT angiogram reveals dilluse calcified atherosclerotic

tr Item 1 16
A76 year old woman is evaluated in the emergency depart
plaques in both iliac arteries, with a 30% stenosis on the
right and an 80u1, stenosis in the left iliac artery.
ment lor an episode ofnear syncope. She has also had progres
sive dyspnea and nonproductive cough over a :l week period Which of the following is the most appropriate treatment?
and an unintentional weight loss o14.1 kg (9 lb) over the past (A) Pentoxif,zlline
3 months. She reports no f'ever. She has a S0-pack-year history
of cigarette smoking, but she stopped smoking 3 weeks ago.
(B) Revascularization
On physical examination, the patient is af'ebrile. Blood (C) Stop canagliflozin
pressure is 132/60 mm Hg, with a fall in systolic pressure ol (D) Switch olmesartan to ramipril
24 mm tlg during inspiration. Pulse rate is 110/min and regu
lar. Oxygen saturation is 90'X, with the patient breathing ambi
ent air. BMI is 17. Jugular venous distention is present. I leart
souncls are distant. Crackles are present at the lung bases.
A chest radiograph shows a 6 cm right upper lobe mass
Item 119
A 50 year-old woman is evaluated tbr a 3 month history
tr
of progressive chest pain. The pain is worse with ph1'sical
and an enlarged cardiac silhouette. activity, radiates to the lett arm, and is associatecl with dia-
phoresis.'lhe pain is relieved by rest.
Which ofthe following is the most appropriate diagnostic test? On physical examination. blood pressure is 167,i98 mm
(A) Cardiaccatheterization Hg. and pulse rate is 58rmin. Cardiac examination reveals
an S.,and no murmurs.
(B) CT directed needle biopsy
ECG shows sinus rhythm and left ventricular hyper-
(C) Fiberopticbronchoscopy trophy,*,ith a strain pattern.
(D) PET/CT
(E) Transthoracic echocardiography Which ofthe following is the most appropriate diagnostie test?
(A) Dobutamine echocardiography
Item 117 (B) Dobutamine myocardial perfusion imaging
(C) Exercise ECG
A 57 year-old woman is seen during a routine follow-up
visit for heart failure. She has a S-year history of ischemic (D) Exercise myocardial perfusion imaging
cardiomyopathy with an ejection fraction of 38'/". She also
has a 15 year history of type 2 diabetes mellitus and diabetic
kidney disease. She has had no hospitalizations. Medica- Item 120
tions are aspirin, atorvastatin, valsartan sacubitril, metop A 49-year-old woman is evaluated for a 3 month history
rolol succinate. and metfbrmin. of substernal chest heaviness that occurs when walking
Physical examination, including vital signs, is unre- up a small hill near her home. The discomfort does not
markable. radiate. Each episode lasts for approximately 5 minutes and
Laboratory studies show an elevated B,type natriuretic improves as she continues walking.
peptide level, a hemoglobin A,. level of 7.0"/,,, a serum cre, On physical examination, vital signs are normal. BMI
atinine level of 1.5 mgi dL (132.6 pmol/L), and an estimated is 37. The remainder of the examination is unremarkable.
glomerular flltration rate of 50 mL/min/1.73 m2. Resting ECG shows normal sinus rhythm without
ischemic changes.
Which of the following is the most appropriate additional
treatment? Which of the following is the most likely diagnosis?
(A) Dapagliflozin (A) Atypical angina
(B) Glimepiride (B) Nonanginal chest pain
(C) Liraglutide (C) Typical angina
(D) Saxagliptin (D) Unstable angina

154
Answers and Critiques
Item 1 Answer: D Bibliography
Educational Objective: Treat stable heart failure with Maddox l M, Januzzi )L lr. Allen t.A. et al; Writing Committee. 2O2l Update
to the 2017 ACC expert consensus decision pathway for optimization of
reduced ejection fraction with valsartan-sacubitril. heart failure treatment: ansu,ers to l0 pivotal issues about heart failure
with reduced ejection fiaction: a report of the American College of
The most appropriate treatment is to switch lisinopril to Cardiologr Solution Set Oversight Commifiee. J Am Coll Cardiol. 2O2t;
77 :77'2 81O. LPMID: 334.16.1i01 doi:l0.l0l6ij.jacc.2O2O.ll.O22
valsartan-sacubitril (Option D). This patient with hearl fail
ure with reduced ejection fraction (HFTEF) and New York
Heart Association (NYHA) functional class II symptoms, as UI
evidenced by dyspnea with moderate exerlion, is stable and Item 2 Answer: B q,

has no evidence of volume overload on examination. In the Educational Objective: Treat a patient with symptom- ET
PARADIGM-HF trial of patients with symptomatic heart atic bradycardia.
failure and Ieft ventricular ejection fraction less than 40'1,,
L'
Pacemaker implantation (Option B) is the most appropri- ?t
valsartan sacubitril reduced mortality and heart failure hospi E
ate next step in management for this patient who presents at
talization by 20'2, compared with enalapril. Based on this study. vt
with signs and symptoms of sinus node dysfunction. Com-
the American College of Cardiologr/American Heart Associ o
mon indications for permanent pacemaker implantation
ation heart failure guidelines recommend replacing an ACE vt
=
include symptomatic bradycardia without reversible cause; E
inhibitor or angiotensin receptor blocker (ARB) with valsartan permanent atrial flbrillation with symptomatic bradycar
sacubitril in patients with chronic symptomatic HFrEFl, In dia; alternating bundle branch block; and complete heart
addition, for patients with new-onset heart failure, directly ini
block, high degree atrioventricular (AV) block, or Mobitz
tiating valsartan-sacubitril, rather than a pretreatment period type 2 second degree AV block, irrespective of symptoms.
with an ACE inhibitor or ARB, is a safe and effective strateg/ This patient is bradycardic at baseline, does not mount a
in patients with HFrEFl, Because of the risk for angioedema, tachycardic response to activity on ambulatory ECG moni
ACE inhibitors (but not ARBs) should be discontinued at least toring, and has low energr. There is no threshold that deflnes
36 hours before starting valsafian sacubitril.
an inadequate heart rate response; it is determined by
lsosorbide dinitrate hydraluine (Option A), when used symptoms suggesting that the heart rate is not meeting the
in combination with an ACE inhibitor, p-blocker, and aldoste patient's physiologic demands. A common challenge among
rone antagonist, reduces mortality compared with placebo in these patients, many of whom are older, is differentiating
Black patients with N1TIA functional class III to IV slmptoms. between age-related decline in physical activity and patho
Guidelines recommend adding this drug combination in Black logic, symptomatic sinus node dysfunction. The former is
patients who remain rynnptomatic on maximal doses of an ACE less likely to improve with cardiac pacing, and the latter
inhibitor, ARB, or angiotensin receptor'-neprilysin inhibitor; often improves dramatically. In this case, the patient is very
B blocker; and aldosterone antagonist. lf this patient were White, active, with distinct loss of energr and ECG flndings of sinus
isosorbide dinitrate hydralazine would not be indicated, and if bradycardia. Recent stress test results conflrm normal left
this patient were Black, it would be initiated if lnHA class III ventricular function and no ischemia; thus, cardiac pacing
slmptoms persisted after initiation of valsartan-sacubitril. is the next appropriate step.
ln patients with NYHA functional class II to IV heart Patients with sinus node dysfunction are rarely unsta-
failure symptoms, ivabradine (Option B) has been shown to ble, but if there is evidence of hemodynamic instability,
reduce heart failure hospitalizations when added to standard hospitalization (Option A) is indicated. Warning signs and
heart failure therapy. Ivabradine is approved for patients symptoms of hemodynamic instability warranting hospital-
with symptomatic HFrEF (ejection lraction <357,) who are ization include hypotension, altered mental status, ischemic
in sinus rhythm with a heart rate of 7Olmin or higher and chest pain, and acute heart failure. This patient's condition
taking a maximally tolerated B blocker. This patient has a is not acute or dangerous, and thus inpatient care is not
heart rate of 60/min and is therefore not a candidate. warranted.
This patient has a heart rate of 60/min and does not Lisinopril is unlikely to be contributing to this patient's
require p-blocker dosage escalation (Option C) at this time. bradycardia, although his hypertension is likely a risk factor
I(EY POITI fbr sinus node dysfunction. Although amlodipine is a dihy
o Valsartan-sacubitril dropyridine calcium channel blocker, use of this drug may
signifi cantly reduces heart failure
actually worsen bradycardia; therefbre, switching lisinopril
hospitalizations and mortality in patients with symp-
to amlodipine (Option C) is not indicated.
tomatic heart failure with reduced ejection fraction
Reassurance with ongoing monitoring (Option D) is
and is recommended in preference to an ACE inhibitor
not appropriate, because it is likely that this patient's loss of
or angiotensin receptor blocker. energz is pathologic and related to symptomatic bradycardia.

155
 Answers and Critiques

Elevated homocysteine levels are associated with an

XEY POIXI
increased risk for cerebrovascular and cardiovascular dis-
. Pacemaker implantation is indicated in patients with ease. Patients with PAD have higher plasma homocysteine
symptomatic bradycardia in the absence of a reversi levels than those without PAD. However, there is no evi
ble cause. dence that B-complex vitamin supplementation (Option E)
to lower homocysteine levels improves clinical outcomes,
Bibliography including cardiovascular death, myocardial infarction, or
Kusumoto FM. Schoenfeld MH, Barrett C, et al. 2018 ACC/AHA/HRS guide stroke. Vitamin B complex vitamins are not recommended.
line on the evaluation and management ofpatients with bradycardia and
cardiac conduction delayr a report ofthe American College ofCardiologl/
American Heart Association Task Force on Clinical Practice Guidelines
IEY POITIT
and the Heart Rhythm Sociery Circulation. 2019;140:e382-e482. [PMID: . In patients with peripheral artery disease and inter-
3058677 2l doi:10.1161/CIR.0000000000000628
mittent claudication, cilostazol is recommended to
improve limb symptoms in addition to smoking ces-
Item 3 Answer: A sation, aspirin, statin therapy, and supervised exercise.
(a
E Ed ucation a I Obj ective : Treat intermittent claudication .
ID Cilostazol is contraindicated in patients with heart
with cilostazol.
U) failure.
o,
The most appropriate additional treatment is cilostazol
CL (Option A). Cilostazol, a phosphodiesterase inhibitor with
a-l
Bibliography
antiplatelet and vasodilator activity, increases pain-free Gerhard-Herman MD, Gornik HL, Barrett C, et al. 2016 AHA/ACC guideline
walking distance and overall walking distance in patients on the management of patients with lo\ €r extremity peripheral artery
ll disease: a report of the American College of Cardiolos//American Heart
E with claudication. This patient with established peripheral Association Task Force on Clinical Practice Guidelines. I Am Coll Cardiol.
.D
la artery disease (PAD) is receiving guideline-directed medical 2077 ;69 :e71-e126. IPMID: 27851992] doi:10.1016/j.jacc.2016.11.007

therapy and has completed a supervised exercise program,

but he has persistent symptoms. The most appropriate treat-
ment is to add cilostazol to his medication regimen. As with
other oral phosphodiesterase inhibitors (e.9., milrinone), the
Item 4 Answer: C
Educational Objective: Evaluate acute ehest pain using
tr
coronary CT angiography.
FDA has placed a black box warning on use of cilostazol in
patients with heart failure. Side effects of cilostazol include Coronary CT angiography (Option C). by allor,ving visualiza
headache, diarrhea, dizziness, and palpitations. Up to 20% tion of coronary ancl other thoracic patholoS,. is the' most
of patients discontinue cilostazol within 3 months due to appropriate cliagnostic test to perfbrm next in this patieltt
side effects. lvith acnte chest pain. Coronary,' CT angiographl' plays an
Guidelines from the American College of Cardiologz/ irnportant role in the evaluation of acute chest pain in the
American Heart Association (ACC/AHA) recommend anti- emergency departlnent. This patient presents \\:ith signs and
platelet monotherapy for patients with PAD to reduce the symptonls that could ir.rdicate an acute coronary syndronte.
risk for myocardial infarction, stroke, or vascular death. This aortic syndrorle. pulnronary embolism, clr other acute chest
patient does not have an indication for dual antiplatelet pain etiolo6Xr. I;or patients with chest pain, coronirry C1'
therapy (e.g., recent acute coronary syndrome or percuta- angiography also mav be useful in patients w'ith a possible
neous coronary intervention), and there is no evidence to diagnosis of non ST elevation acllte coronary syndrorne
support the use of dual antiplatelet therapy with aspirin u'ho hare equirocal initial tropor.rin levels or a single tropt-r
and clopidogrel (Option B) over antiplatelet monotherapy in nin eler:ation r.tithor-rt lurther symptoms of acute coronary
patients with PAD. syndrome, or in patients lr,ho have iscl.remic symptorns that
PAD is considered a coronary heart disease risk equiva- rcsolved hours belore undergoing testing.
lent, and the ACC/AHA guideline recommends that patients Cardiac stress testing is a reasonable approach fbr this
with PAD be treated with a high intensity statin to prevent patient: hortever. adenosine mlrlcardial perfusion irnaging
cardiovascular events. Although there is emerging evidence (Option A) is not an appropriate option fbr this patient
from subgroup analyses that patients with lower extrem- bccause she has reactive ainval,s disease. Broncl.rospastic
ity PAD benefit from the proprotein convertase subtilisin/ reactive airw'ays disease is a contraindication to adenosine
kexin type 9 (PCSK9) inhibitors evolocumab (Option C) based vasodilatory agents for stress testing.
and alirocumab, there is no evidence that the addition of a Cardiac nlagnetic resonance in.r:rging (Option B) may,be
PCSK9 inhibitor in a patient with an LDL cholesterol level uscd rvith dotrutamine to assess ltall motion abnornralities
less than 70 mg/dl (1.8 mmol/L) is associated with improved or with vasodilators to assess pertusion. [t is commonly lter-
outcomes. tbrmed to e\"luate the degree of infarctiolr. \,'iability can be
Pentoxifylline (Option D) has not been associated determined by evaluating the extent of myocardial fibrosis
with an improvement in symptoms in patients with within the left ventricle. Cardiac magnetic resonarrce imag
intermittent claudication and PAD, and the ACC/AHA ing is not a helpfirl test in assessing acLtte chest pain ir.r the
guideline does not recommend pentoxifylline for treat emergency department because of the relatively longer time
ment of claudication. fbr image acquisition compared'"r,ith other modalities.

156
 Answers and Critiques

'lhis patient's presentation does not indicate a specific

I tr
CONT
carcliac structural or functionirl c;tuse that rvould make
ejection murmur, are commonly present, as more than 50'/.
of patients with coarctation also have a bicuspid aortic valve.
transthoracic echocardiography (Option D) usefirl at this The ECG demonstrates left ventricular hypertrophy, and a
point. 'l'ransthor:rcic echocardiography is the mainstay <tf typical chest radiograph shows abnormal aortic contour and
noni nvasive clrdior,ascular imagi ng for structural abnonnal rib notching.
ities. The patient's presclttation potentiirlly indicates other A small patent ductus arteriosus (PDA) (Option C) gen-
causes of the chest pain that are l)etter evaluated u,ith coro erally causes no cardiovascular symptoms. A continuous
nary C'f angiography'. murmur heard beneath the left clavicle that envelops the
S, is typical. Occasionally, no murmur is heard, and the
IEY POIilT
diagnosis is made by echocardiography. The ECG and chest
. Coronary CT angiography, by allowing visualization radiograph are normal in a patient with a small PDA.
ofcoronary and other thoracic pathologr, plays an
important role in the evaluation of acute chest pain XEY POITIS
UI
e A small ventricular septal defect presents with a loud 6'
in the emergency department.
(often palpable) holosystolic murmur located at the t
Bibliography left sternal border that obliterates the Sr.
U
Rybicki FJ, Udelson JE, Peacock WF, et al. 20ts ACR/ACC/AHA/AATS/ACEp/ o Ventricular septal defect closure is not indicated for ?,
ASNC/NASCI/SAEM/SCCT/SCMR/SCPC/SNMMI/STR/STS appropriate
utilization of cardiovascular imaging in emergency department patients patients with a small left-to-right shunt and no cham tu
with chest pain: a joint document of the American College of Radiolog, vt
ber enlargement or valve disease, but periodic clinical
Appropriateness Criteria Committee and the American College of 0,
Cardiologz Appropriate Use Criteria Task Force. J Am Coll Cardiol. 20161 evaluation and imaging are recommended. 3
a
67 :853 79. IPMID: 26809772] doi:10.1016/j.jacc.2015.09.011

Bibliography
Stout KK, Daniels CJ, Aboulhosn JA, et al. 2018 AHA/ACC guideline for the
Item 5 Answer: D management of adults with congenital heart disease: a report of the
American College of Cardiolos,/American Heart Association Task Force
Educational Objective: Diagnose ventricular septal on Clinical Practice Guidelines. J Am Coll Cardiol. 2Ol9:73:e9l-e192.
IPMID' 301212391 doi:10.1016/j.jacc.2018.08.1029
defect.

The most likely diagnosis in this patient is a small (restrictive)

ventricular septal defect (VSD) (Option D). The presentation Item 6 Answer: h
of an isolated VSD depends on the VSD size and pulmonary
Ed ucationa I Objective: Treat complex multivessel
vascular resistance. Small VSDs are usually asymptomatic. A
coronary artery disease.
palpable systolic murmur (thrill) is often noted at the left ster
nal border, accompanied by a loud holosystolic murmur that The most appropriate management is coronary artery bypass
obliterates the Sr, as observed in this patient. Small VSDs do grafting (CABG) (Option A). This patient has complex mul
not cause left heart enlargement or pulmonary hlpertension, tivessel coronary artery disease (CAD) involving the left
and the ECG and chest radiograph reveal norrnal flndings. main coronary artery distal bifurcation, proximal left cir
VSD closure is not indicated for patients with a small left-to cumflex artery and proximal left anterior descending and
right shunt and no chamber enlargement or valve disease, but flrst diagonal artery bifurcation. CABG, especially with use
periodic clinical evaluation and imaging are recommended. of arterial (internal mammary artery) conduits, is indicated
Patients with small VSDs do not require activity restrictions. in patients with multivessel CAD and no contraindications,
An adult with an atrial septal defect (ASD) (Option because it is associated with enhanced survival compared
A) most often presents with dyspnea, atrial arrhythmias, with medical therapy alone. CABG also results in decreased
or right heart enlargement. Physical examination findings recurrence of angina, lower rates of myocardial infarction,
include elevation in venous pressure, a right ventricular and fewer repeat revascularization procedures compared
Iift, flxed splitting of the Sr, a pulmonary midsystolic flow with percutaneous coronary intervention or medical ther
murmur, and, when there is a large shunt, a tricuspid dia apy alone in these patients.
stolic flow rumble. The ECG demonstrates right axis devi Guideline-directed medical therapy (Option B) is essen
ation and incomplete right bundle branch block, and the tial for improved prognosis before and after surgical or per
chest radiograph generally demonstrates features of right cutaneous revascularization. Aspirin, B blockade, and statin
heart enlargement and enlarged pulmonary arteries with therapy, along with ACE inhibition in patients with systolic
increased pulmonary blood flow. left ventricular (LV) dysfunction, such as this patient, are
Typical physical examination flndings in aortic coarcta indicated for secondary prevention of major adverse vas-
tion (Option B) include upper extremity hypertension, radial cular events. However, anti ischemic and cardioprotective
artery-to-femoral artery pulse and blood pressure differ medical therapy would be inferior to revascularization in
entials, and a systolic murmur over the left chest related to improving survival in this patient with complex CAD involv
obstruction from the coarctation. In addition, findings of ing the left main coronary artery and a large area of poten-
bicuspid aortic valve, including ejection click and systolic tially ischemic myocardium.

157
 Answers and Critiques

Myocardial viability testing (Option C) uses imaging Exercise echocardiography (Option B) is useful fbr diag
to detect potentially reversible states of ischemic ventric nosing coronary artery disease and evaluating valvular heart
ular dysfunction. Myocardial viability is associated with disease. tt is not indicated for this patient with no anginal
improved survival and ventricular recovery following revas symptoms and near normal left ventricular (LV) systolic
cularization in patients with LV dysfunction; horvever, per function.
fbrming viability testing befbre revascularization has not Right and left heart catheterization (Option C) may
been shown to predict or enhance outcomes and is not demonstrate hemodynamic features consistent with restric
indicated in this patient. tive physiologr but would not diagnose the underlying cause
Drug eluting stent based percutaneous coronary of this patient's symptoms without concomitant endomyo
intervention (Option D) is a reasonable option in patients cardial biopsy. Endomyocardial biopsy may be uselul if the
with symptomatic CAD. including those with unprotected diagnosis of an infiltrative cardiomyopathy is unclear, but
left main CAD (without bypass to the left coronary circu given the risks of this inrasive test, it would not be indicated
D lation). However, in patients with complex CAD including as the initial test ol choice.
la multiple bifurcations and/or long lesions who are not at Fabry disease is a lysosomal storage disorder that aflects
(D increased surgical risk, CABG is the preferred revascular the heart, with marked diltuse LV hypertrophy. The ECG
= usually demonstrates marked LV hypertrophy with prom
UI ization strateg/.
q, inent ST T abnormalities, rather than the low voltage seen
I(EY POIl{I
CL in this patient. Neuropathy in Fabry disease often presents
n . In patients with multivessel coronary artery disease, as burning dysesthesia. not carpal tunnel syndrome. Onset
coronary artery bypass grafting is associated with of Fabry disease occurs in childhood, and the diagnosis is
.,El
enhanced survival compared with medical therapy established through genetic testing or an abnormal serum
.D
t^ alone. o. galactosidase level (Option D).

f,tY POTilTS
Bibliography
RltCI MR. CAIhOOTT JII. DChNTCT GJ, Ct AI. ACCIA,\TS/AIIA/ASEIASNC/SCAI
o Cardiac magnetic resonance imaging with gadolin
SCCT'STS 2017 appropriate Llse critcria for coronan rerascullriz:tion in ium is highly sensitive and specific for cardiac amy
patients s,ith stablc ischemic hearl disease: a report of the Americar-r College
of Cardiokrgr Appr)priate Use Criteril'lask Force, Americf,n Association fi)r loidosis, but it does not distinguish between AL
'lhoracic Surgery American Heart Associittion, Anlerican Societ-n.' ot (immunoglobulin light-chain) amyloidosis and
I:chocardiographl: Americirn Societ) of Nuclear Cardiokrs: Societ)' ti)r
Cardiovlscular Angiography and Interventions. Society of Cardiovascullr transthyretin amyloidosis.
Computed Tomogrrrphy: and Societ-v ol Thoracic Surget)ns. J Am Coll Cardi(r.
')017 $9)212 22.11. IPMtD' 2829166i]l doi:10.1016 j.jacc.20l7.02.0Ol
r In patients with cardiac magnetic resonance imaging
findings consistent with cardiac amyloidosis, an
abnormal 99m-technetium pyrophosphate scan
Item 7 Answer: A would confirm transthyretin amyloidosis without the
Educational Objective Diagnose infi ltrative cardiac need fbr a biopsy.
disease.
Bibliography
Cardiac magnetic resonance (CMR) imaging with gadolin Ruberg l;l-. Grogrn M. Hanna \{. et rl.'lransth}retin iim}'loid cardiomy)p,
ium contrast (Option A) is the most appropriate test to thy: J;\CC state of the trt revieu: J Am Coll Cardiol. 2019:73:2872 9l
perform next. The patient's history and physical exam IPMID: :]l l7l094l doi:10. l0l6/j.jacc.2019.01.003

ination are consistent with heart failure, and the elevated

B type natriuretic peptide level supports this. Signilicantly Item 8 Answer: D
increased wall thickness is present on the echocardiogram.
Educational Objective: Treat a patient with symptom-
with discordantly low voltage on the ECG. These findings with transcatheter aortic valve
atic severe aortic stenosis
suggest an inflltrative cardiomyopathy and, in combination
implantation.
with the patient's history of carpal tunnel syndrome, suggest
possible transthyretin amyloid (ATTR) amyloidosis. ATTR The most appropriate next step in treatment is transcath
amyloidosis is much more common in men. and the patho eter aortic valve implantation (TAVI) (Option D). Aortic
logic V1221 mutation in the TTR gene is present in 3'l, to 3.5',1, valve replacement is a life prolonging procedure in patients
of Black persons. If cardiac amyloidosis is present in this with severe aortic stenosis. The indications for aortic valve
patient, CIvIR imaging with gadolinium contrast would likely replacement in severe aortic stenosis are (1) the presence of
show diffuse late mid myocardial gadolinium enhancement symptoms, (2) left ventricular systolic dysfunction (ejection
in a noncoronary distribution. CMR imaging with gadolin fiaction <50'X,) in an asymptomatic patient. or (3) a con
ium is highly sensitive and speciflc fbr cardiac amyloidosis, comitant cardiac surgical procedure for other indications.
but it does not distinguish between AL (immunoglobulin Flxertional dyspnea. syncope, and angina are the most com
light chain) amyloidosis and ATTR amyloidosis. An abnor mon presenting symptoms that result in aortic valve inter-
mal 99m technetium pyrophosphate scan would conflrm vention. Aortic valve replacement can be performed with
ATTR amyloidosis without the need fbr a biopsy. surgical aortic valve replacement (SAVR) or via transcatheter

158
 Answers and Critiques

approach (TAVI). TAVI is reconrmended in preference to ventricular frlnction, an ICD is 'uvarranted before dischargc.
SAVR for symptomatic patients with severe aortic stenosis barring a clear. acute contrailldication (e.g., active bacterc
who are older than 80 years or fbr younger patients with a mia). [CDs are ir-rdicated and eflective in the sefting of second
life expectancy less than l0 years. 'IAVI is also recommended lry prevention of sudden cardiac death, even if the causc is
lbr symptomatic patients ol any age with severe aortic ste- not confirmed (unless it is very clear that the cause is acutely
nosis and a high or prohibitive surgical risk if predicted reversibie and correctable). l{owever, her presentation is not
postprocedure survival is more thar.r 12 months with an unusual fbr arrlrythmogenic right ver-rtricular cardion.ryopathy
acceptable quality of iife. For symptomatic patients aged (AltVC). an inherited "r,tear and tear" disorder that primarily
65 to B0 years, either SAVR or TAVI is appropriate following itfibcts the right ventricle but nta1, be seen in the left. Ventric
shared decision making. ular arrhythmias are often tl.re initial presentation. and somc
Balloon aortic valvuloplasty (Option A) was previously rlre very clrarnatic (as in tl-ris case); they are also lery likely to
used to treat symptomatic severe aortic stenosis by tempo recur. Cardiac magnetic resoltzlnce imaging lr,ould be helplul
rarily increasing the aortic valve area in patients who were to ,ssess m),,ocardial inliltration, ideally before ICD placement. t
(u
not surgical candidates. With the advent of the less invasive A nrajor facet of her treatnlent will be exertional limitation,
TAVI, balloon valvuloplasty is now rarely used. EF
of ten a major challenge lor patients who are athletes.
Although the patient is at prohibitive surgical risk and Arniodarone (Option A) is a multichannel antiarrhythmic
would not likely be approved for SAVR, she would likely be a agent that ma1, be necessary in patiellts with ARVC and re{rac'
\,
candidate for TAVI. Thus, simply continuing medical therapy tory ventricular arrhl.thrnias. [-lower,er, this patient has 1at tcr
=,
.E
(Option B) would be inappropriate, given the mortality and htle a trial ol exerlional limitation andior a p blocker (e.g., {^
quality of-life benefit associated with TAVI. r.netoprolol). and she is quite )our1g to commit to amiodarone c,
The patient's comorbid conditions*atrial fibrillation, as Iirst line therapy Furthennorc. amiodarone is not nearly as vt
=
E
stage G3a chronic kidney disease, COPD, and hypertension e {lective as is :rn ICD ir, preventing sudden cardiac death.
make her a poor candidate lor SAVR (Option C). Her high Genetic testing (Option B) n.ray be helpful to under
surgical risk is further quantified by her Society ofThoracic star.rcl this patient's disease risl< and severity, and results muy
Surgeons adult cardiac surgery risk score. have implications fbr ITer future children and other family
nrcnrbers. Ift.lwever, genetic testing is not required for diag
IEY POtXTS
r.rosis or ICD placement, irnd it should not be undertaken
o Transcatheter aortic valve implantation is recom- i,r,,ithout prior genetic counseling. 'lherefore. it is not nec
mended in preference to surgical aortic valve replace essary befbre discharge, ls it is unlikely to affect immediatc
ment for symptomatic patients with severe aortic ste- decision rn:rking regarding ICI) placement.
nosis who are older than 80 years or younger patients Lisinopril (Option D) may be helpful fbr patients n'ith
with a life expectancy less than 10 years. ne'ut lcfl rrentricular d1'sfurT ction and has been recommended
. Transcatheter aortic valve implantation is recom- in patients r,r,ith ARVC n,ith right ventricular dysfunctior.rr
mended for symptomatic patients of any age with holtever. it has no current role in this patient. Furthermore,
severe aortic stenosis and a high or prohibitive surgi it is not irs imperative bcfbre discharge as is an lCD.
cal risk if predicted postprocedure survival is more XEY POIilI
than 12 months with an acceptable quality of life. . Patients with zustained ventricular arrhy'thmias
(>30 seconds) or cardiac arrest without a revenible cause
Bibliography have a class 1 recommendation for secondary prevention
Otto CM. Nishimura RA. Bonon' RO. et rl. 2020 ACC AI IA guideline frrr thc
manirgement of patients with \'rlvular heart disease: a report of the
with implantable cardioverter-defibrillator placement.
American College of Cardiolog Anlerican Heart Association Joint
(i)mmittee on Clinical Practice Guidelines. Circulation. 2o21:111]:e72
e227. IPMID: 33332150] doi:10.1161 (11R.0000000000000923
Bibliography
Al Khatib SM. Stevenson WG. Ackernrrn l\4J. et al. 2017 AHAIACCIHRS
guicleline for management of patients with ventricular affhythmias and
the prevention ofsudden cardiirc deilth: r report ofthe American College

tr Item 9 Answer: C
Educational Objective: Provide secondary prevention of
of Cirrdiologr/American Hean Association Trsk Force on Clinical Practice
Cuidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2018r72:
c9l e220. [PN4ID: 290972961 doi:10.1016ij.jacc.2017.10.054
sudden cardiac death using an implantable cardioverter-
defibrillator.
Item 10 Answer: B
Jhc rnost appropriate aclclitional nranagenrent before dis
Educational Objective: Treat a patient with diabetes
cl.rarge is implantable cardiovefter defibrillator (lCD) place
mellitus and heart failure with a sodium-glucose cotrans-
(Option C) in this athletc r,r'ho presented lvith rescuecl
n.rcr-rt
porter 2 inhibitor.
sudden cardiac death. P:rtients $'ith sustained r,entricular
arrhythmitrs (>30 secor-rcls) <tr carcliac arrest \\rithollt a revers The most appropriate additional treatment is empagliflozin
ible cause have a class I recommendation for secondary (Option B). Sodium-glucose cotransporter 2 (SGLI2) inhibi
prevention with ICD placement. Despite her nornral left tors have been studied in patients with diabetes mellitus and

159
 Answers and Critiques

in patients with heart failure with or without diabetes. For EAST AFNET 4 randomized clinical trial, which evaluated a
patients with diabetes, studies have shown a reduction in rhythm control strates/ versus usual care (typically includ
cardiovascular events, including heart lailure-related mor ing rate control) in patients with a recent diagnosis (within
tality and hospitalizations, with use of these agents. SGLI2 12 months) of atrial flbrillation and coexisting cardiovas-
inhibitors (empagliflozin, canagliflozin, and dapagliflozin) cular conditions. The inclusion criteria were age older than
seem to reduce the risk for heart failure hospitalization and 75 years or previous transient ischemic attack or stroke, or
cardiovascular death by 1.9"/,' and death from any cause by two of the following: age older than 65 years, female sex,
2.3'7,, independent of glucose control. The mechanisms of heart failure, hypertension, diabetes mellitus, severe coro
this reduction are unclear but are thought to be independent nary artery disease, chronic kidney disease, and left ventric
of increased diuresis due to glucose excretion. The American ular hypertrophy. The trial demonstrated improved clinical
Diabetes Association Standards of Medical Care in Diabetes. outcomes. including a reduction in the primary composite
endorsed by the American College of Cardiologr, recom- end point of cardiovascular death, stroke, or hospitaliza
mends initiating an SGLT2 inhibitor with proven cardiovas- tion for heart failure or acute coronary syndrome, among
U} cular beneflt to reduce the risk for worsening heart failure patients randomly assigned to an early rhythm control
o and cardiovascular death in patients with type 2 diabetes strates/, including asymptomatic patients. The intervention
= included either antiarrhy'thmic drugs or catheter ablation,
ut and established heart failure with reduced ejection fraction.
q,
Digoxin (Option A) reduces the risk for heart failure but importantly, it included aggressive concomitant medical
EL hospitalization but does not reduce mortality. It is occasion therapy (e.g., oral anticoagulation when indicated, hyper-
a.l
ally used in patients r.r,ith heart failure symptoms refractory tension treatment) in both the intervention and the control
4t to optimal therapy, but because of its associated toxiciry groups. Based on the trial results, this patient is mostly likely
(D
digoxin is not recommended as routine therapy in most to beneflt from early rhythm control for atrial flbrillation.
UI patients with heart failure. This patient is appropriately receiving stroke prevention
Loop diuretics, such as furosemide (Option C), are the therapy with a direct oral anticoagulant (DOAC), and he has
primary diuretic therapy for volume overload in heart failure had no recurrent stroke or signiflcant bleeding episodes on
because of increased potency compared with other diuretics. the current therapy. Therefore, left atrial appendage occlu-
However, this patient has no clinical evidence of volume sion (Option A) is not indicated.
overload. and furosemide is not indicated. Among the common indications for permanent pace-
Guidelines recommend the addition of isosorbide maker implantation (Option B) are symptomatic bradycar
dinitrate-hydralazine (Option D) in Black patients who dia without reversible cause; permanent atrial flbrillation
remain s),,rnptomatic on maximal doses of a p blocker; ACE with symptomatic bradycardia; alternating bundle branch
inhibitor, angiotensin receptor blocker (ARB), or valsartan- block; and complete heart block, high-degree atrioventric
sacubitril; and aldosterone antagonist. In patients who are ular (AV) block, or Mobitz type 2 second-degree AV block,
intolerant of ACE inhibitor or ARB therapy, especially those irrespective of symptoms. This patient has no indications for
with chronic kidney disease, isosorbide dinitrate hydralazine pacemaker implantation.
may be considered as a therapeutic option. Oral anticoagulation in patients with atrial flbrillation
can be accomplished with a vitamin K antagonist (warfarin)
I(EY POIl{T
or DOAC, such as rivaroxaban. Rivaroxaban is noninferior to
o A sodium-glucose cotransporter 2 inhibitor is recom warfarin in the prevention of stroke or systemic embolism
mended to reduce risk for worsening heart failure and and is associated with less intracranial and fatal bleeding.
cardiovascular death in patients with type 2 diabetes The 2019 American College of Cardiologz/American Heart
mellitus and established heart failure with reduced Association atrial flbrillation guideline recommends DOACs
ejection fraction. in preference to warfarin in DOAC eligible patients. Thus,
there is no suggestion that switching to warlarin (Option D)
Bibliography would improve outcomes in this patient.
Dunlay SM, Givertz MM, Aguilar D, et al; American Heart Association Heart Offering no additional therapy (Option E) would be
Failure and Transplantation Committee of the Council on Clinical
Cardiologz. Type 2 diabetes mellitus and heart failure, a scientific state-
inappropriate because early rhythm control is associated
ment from the American Heart Association and Heart Failure Society of with improved clinical outcomes in patients such as this one.
America. I Card Fail. 2019;25:584 619. IPMID: 31174952] doi:10.1016/j.
cardfai1.2019.05.007
XEY POIilI
. In patients with recently diagnosed atrial fibrillation
Item 11 Answer: C and concomitant cardiovascular conditions, early
Educational Objective: Manage atrial fibrillation with rhl.thm control (antiarrhyhmic drugs or ablation)
early rhythm control. reduces the primary composite end point of cardio-
vascular death, stroke, or hospitalization for heart
Rhythm control (Option C) is the most appropriate treat
failure or acute coronary syndrome compared with
ment for this patient who presents with paroxysmal atrial
usual care.
flbrillation. This patient is reflective of those included in the

160
 Answers and Critiques

Bibliography Bibliography
Kirchhof B Camm AJ, Goette A, et al; EAST AFNET ,t Trial Investigators. Katz D, Gavin MC. Stable ischemic heart disease. Ann Intern Med. 2019;171:
Early rhythm-control therapy in patients with atrial fibrillation. N Engl J ITC17 ITC32. IPMtD: 31382288] doi:10.7326lAITC2019O806O
Med. 2020;383:1305 1316. [PMID: 328653751 doi:10.los6/NEJMoa20l9422

Item 12 Ansurer: A
Educational Objective: Treat stable angina pectoris in
Item 13 Answer:
Educational Objective: Diagnose peripartum
C
tr
cardiomyopathy.
an aspirin-intolerant patient.
'lhe most likely diagnosis is
lteripartunt cardionryoprrtltl,
Clopidogrel (Option A) is the most appropriate cardiopro (Option C). Peripartum clrdiomyoprrthl, is newly notecl
tective medication for this patient. The patient's chest pain
lcft vcntricular s1'stolic dysfunction n'ith onset in the.
symptoms, which occur with exertion and subside with rest,
trot.tths after delivery or toward thc end of pregnancf in
are consistent with typical angina. Therefore, he has a high tt
the absence of another identifiable ciruse. Paticnts usuirlly (l,
pretest likelihood ofcoronary artery disease and is a candi-
present u'ith feltures of heart failure. Trcltnrent u'itl.r ET
date for secondary preventive therapy. All patients with sta-
stndard medical therap),'. including B blockers. digoxin.
ble ischemic heart disease should receive guideline directed (J
hyclralazine, nitrates, ancl tliuretics, is appropriate. AOIi
therapies consisting of risk factor modiflcation with regular inhibitors. xngiotelrsin receptor blockers. anrl alclostenrnc
physical exercise, attention to diet, weight loss, and smoking =,
rntagor.lists sl-toulcl be i.trtrided until ittter delive rt'becuusc .E
cessation, as well as cardioprotective therapy to improve tt
of teratogenicity. (l,
prognosis and antianginal medication as needed to improve
Pulrnonarr enrbolisnr (PIr) (Option A) nr:r1, occur post
functional capacity. The Antithrombotic Trialists' Collabora vl
=
prrtunr. particularly in patierlts requiring prokrnged becl
tion collaborative meta analysis of nearly 3000 patients with rest. Patierlts with l)1,) tiequently present with dysprrea. ilow
stable ischemic heart disease found an association between cver, this patient's elevatect \renous prcssure. pnlmonary
aspirin use and reduced risk for serious vascular events, c<rngestion. and global recluctior-r in lelt ver-rtricular function
including a 46% decrease in the risk for unstable angina and suggest heart tailurc; in aclclition, thc nornral right herrt
a 53% risk reduction in the need for coronary angioplasty. size ancl {irnctiorr noted by echocarcliography lrgue :rgainst
Therefore, in the absence of contraindications, antiplatelet henroclvnirmicalll significlnt PIJ.
therapy in the form of low dose aspirin (75 162 mg/d) is Thc patient's presentirtioll does trot sup;urrt a clilg
indicated indeflnitely for secondary prevention to reduce rrosis of irscending irortic clissection (Option B). I'he risk
the risk for myocardial infarction and cardiovascular death. firr aortic clissection is incrcased in tl.re peri itnd p<tst
In patients who have an intolerance or allergz to aspirin, partur-lr pcriods. [)atients usttally ]r:tve sudclerr orlset chcst
clopidogrel therapy is considered an acceptable alternative. irncl bacl< plin and often clescribe a tcuring cluality. Ph_vsi
Aspirin desensitization is another approach. cill exalrinirtion of'ten denlorlstrates right Ief t dift'erentirtl
This patient has experienced an adverse reaction to pulse ancl blood pressure. I'.cl.tocarcliography iu ascetrtlitrg
aspirin. Aspirin desensitization can be performed safely aortic clissection usually dcnronstrates aortic tiilatiltiott.
under medical supervision in patients who require initiation rrnd thc clissectior-t tlap rnrrv be visualized. Lctl ventric
of aspirin (for example, those who require dual antiplatelet tular funclior.r is usualll' trrlnnal in petienls witlr aortic
therapy after percutaneous coronary intervention). How clissect iou.
ever, in a patient with aspirin allergr or sensitivity, lowering Spontirneous coronar)' rrtery clissection (Option D) is
the aspirin dose (Option B) will not improve tolerance. the most comnlon cause ot'pregnarlcy associlted tnYoctlr
Prasugrel (Option C) and ticagrelor (Option D) are newer, dial inlrrrction irncl riccurs ntost contrnol.rly during the filst
more potent, and more costly antiplatelet agents with potential nrontl-r postpartnrn. Patients usually ltresent r,r'ith symptotrrs
for increased bleeding events, and their use as monotherapy of chesl piiin. and nryocarcliitl ischentic changes ltre expectcci
has not been studied in the context of secondary prevention orr the [i(](1. Regionirl wall nrotion abnormirlitics are iclen
fbr patients with stable ischemic heart disease; they are not tified by echocirrctiography in patients lvitlt sllotttanctltts
suggested for this indication in current guidelines. coronary ilrtery dissectioll.

XEY POIl{TS I(EY POIl{T

. All patients with stable ischemic heart disease should . Peripartum cardiomyopathy is left ventricular systolic
receive guideline directed therapies consisting of life- dysfunction with onset toward the end of pregnancy
style modification, cardioprotective therapy, and or in the months after delivery in the absence of
antianginal medication. another identifiable cause; patients often present with
o features of heart failure.
Patients with stable ischemic heart disease should
receive antiplatelet therapy (low-dose aspirin or clo-
pidogrel in aspirin-intolerant patients) for secondary Bibliography
prevention of cardiovascular events. Douglass EJ, Blauwet LA. Peripartum cardiomyopathy. Cardiol Clin.2o21;
39:ll9 42. IPMID: 332228081 doi:10.1016/j.cc1.2020.09.008

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