Cardiology and vascular for AMC MCQ

A 74 year old man has exertional breathlessness, two episodes of collapse on exertion, and chest tightness climbing stairs. He has a harsh ejection systolic murmur at the right upper sternal edge radiating to both carotids, with a slow-rising, low-volume pulse and a narrow pulse pressure. An echocardiogram shows a small valve area with a high gradient. What is the most likely diagnosis?

1. Heart failure Breathlessness and oedema without a discrete valve lesion. The syncope-angina-dyspnoea triad with a slow-rising pulse and carotid radiation points elsewhere.
2. Innocent murmur A soft systolic murmur with no structural disease. The syncope-angina-dyspnoea triad with a slow-rising pulse and carotid radiation argues against pathology.
3. Acute coronary syndromes Angina from coronary disease rather than valvular. The syncope-angina-dyspnoea triad with a slow-rising pulse and carotid radiation makes it worth separating.
4. Aortic valve disease correct Correct. An ejection systolic murmur radiating to the carotids with a slow-rising pulse and the symptom triad is severe aortic stenosis.
5. Mitral valve disease A mitral murmur with a different site and radiation. The syncope-angina-dyspnoea triad with a slow-rising pulse and carotid radiation makes the auscultation matter.

The point: The two aortic valve lesions are separated at the bedside. Aortic stenosis gives an ejection systolic murmur at the right upper sternal edge radiating to the carotids, a slow-rising low-volume pulse, and a narrow pulse pressure, and the ominous triad is exertional syncope, angina and breathlessness, which marks a poor prognosis and the need for valve replacement. Aortic regurgitation gives an early diastolic murmur at the left sternal edge, a collapsing water-hammer pulse and a wide pulse pressure, from valve or aortic root disease. An echocardiogram grades severity and guides timing. Symptomatic severe aortic stenosis is treated with surgical valve replacement or, in older or higher-risk patients, transcatheter aortic valve implantation, which is now widely used in Australia. Severe aortic regurgitation is repaired before the ventricle fails. Avoid vasodilators and be cautious with nitrates in severe aortic stenosis, because they can drop the pressure precipitously. Antibiotic prophylaxis for endocarditis is now reserved for high-risk patients.

Source: National Heart Foundation of Australia / CSANZ — valvular heart disease National Heart Foundation of Australia / CSANZ · tier 2, specialty society or college

A 74 year old man has exertional breathlessness, two episodes of collapse on exertion, and chest tightness climbing stairs. He has a harsh ejection systolic murmur at the right upper sternal edge radiating to both carotids, with a slow-rising, low-volume pulse and a narrow pulse pressure. An echocardiogram shows a small valve area with a high gradient. What is the most appropriate initial investigation?

1. Assessment of symptom status Syncope, angina and breathlessness change the management. The syncope-angina-dyspnoea triad with a slow-rising pulse and carotid radiation makes it key.
2. Chest radiograph Shows cardiomegaly or calcification. The syncope-angina-dyspnoea triad with a slow-rising pulse and carotid radiation makes it worthwhile.
3. Transthoracic echocardiogram correct Correct. It graded the stenosis as severe with a small valve area and high gradient, guiding intervention.
4. ECG Shows left ventricular hypertrophy or strain. The syncope-angina-dyspnoea triad with a slow-rising pulse and carotid radiation makes it necessary.
5. Coronary angiography before valve surgery Assesses the coronaries prior to intervention. The syncope-angina-dyspnoea triad with a slow-rising pulse and carotid radiation indicates it.

The point: The two aortic valve lesions are separated at the bedside. Aortic stenosis gives an ejection systolic murmur at the right upper sternal edge radiating to the carotids, a slow-rising low-volume pulse, and a narrow pulse pressure, and the ominous triad is exertional syncope, angina and breathlessness, which marks a poor prognosis and the need for valve replacement. Aortic regurgitation gives an early diastolic murmur at the left sternal edge, a collapsing water-hammer pulse and a wide pulse pressure, from valve or aortic root disease. An echocardiogram grades severity and guides timing. Symptomatic severe aortic stenosis is treated with surgical valve replacement or, in older or higher-risk patients, transcatheter aortic valve implantation, which is now widely used in Australia. Severe aortic regurgitation is repaired before the ventricle fails. Avoid vasodilators and be cautious with nitrates in severe aortic stenosis, because they can drop the pressure precipitously. Antibiotic prophylaxis for endocarditis is now reserved for high-risk patients.

Source: National Heart Foundation of Australia / CSANZ — valvular heart disease National Heart Foundation of Australia / CSANZ · tier 2, specialty society or college

A 74 year old man has exertional breathlessness, two episodes of collapse on exertion, and chest tightness climbing stairs. He has a harsh ejection systolic murmur at the right upper sternal edge radiating to both carotids, with a slow-rising, low-volume pulse and a narrow pulse pressure. An echocardiogram shows a small valve area with a high gradient. What is the most appropriate next step in management?

1. Treat heart failure symptoms cautiously Diuretics for congestion with care in stenosis. The syncope-angina-dyspnoea triad with a slow-rising pulse and carotid radiation makes it symptomatic.
2. Valve surgery before ventricular failure in severe regurgitation Timed to preserve ventricular function. The syncope-angina-dyspnoea triad with a slow-rising pulse and carotid radiation makes it targeted.
3. Endocarditis prophylaxis for high-risk patients Reserved for defined high-risk situations. The syncope-angina-dyspnoea triad with a slow-rising pulse and carotid radiation makes it selective.
4. Surgical aortic valve replacement for symptomatic severe stenosis correct Correct. Symptomatic severe aortic stenosis is treated with valve replacement.
5. Monitor asymptomatic disease with serial echocardiography Until symptoms or criteria for intervention. The syncope-angina-dyspnoea triad with a slow-rising pulse and carotid radiation makes it conditional.

The point: The two aortic valve lesions are separated at the bedside. Aortic stenosis gives an ejection systolic murmur at the right upper sternal edge radiating to the carotids, a slow-rising low-volume pulse, and a narrow pulse pressure, and the ominous triad is exertional syncope, angina and breathlessness, which marks a poor prognosis and the need for valve replacement. Aortic regurgitation gives an early diastolic murmur at the left sternal edge, a collapsing water-hammer pulse and a wide pulse pressure, from valve or aortic root disease. An echocardiogram grades severity and guides timing. Symptomatic severe aortic stenosis is treated with surgical valve replacement or, in older or higher-risk patients, transcatheter aortic valve implantation, which is now widely used in Australia. Severe aortic regurgitation is repaired before the ventricle fails. Avoid vasodilators and be cautious with nitrates in severe aortic stenosis, because they can drop the pressure precipitously. Antibiotic prophylaxis for endocarditis is now reserved for high-risk patients.

Source: National Heart Foundation of Australia / CSANZ — valvular heart disease National Heart Foundation of Australia / CSANZ · tier 2, specialty society or college