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  #1  
Old 08-26-2012
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Stethoscope Systolic Ejection Murmur at the left sternal border

A 27 year old woman comes to the physician because of 2 year history of episodic chest pain that lasts for approximately 10-12 mins and occurs during rest or after exercise. Her pulse is 68/min and her BP is 135/84 mm Hg. Cardiac exam shows a grade II/VI systolic ejection murmur along the left sternal border that intensifies when the patient stands. ECG shows non specific ST segment and T wave abnormalities. Which of the following is the most appropriate pharmacotherapy for this patient?

A. Aspirin
B. Captopril
C. Digoxin
D. Mexiletine
E. Nifedipine

Can you guys plz specify the diagnosis too. Thanks
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Old 08-26-2012
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Post E

i hope ...
HOCM------systolic ejection murmur at left sternal border...that intensifies on standing( as venous return decrease,HOCM murmur intensifies)

and stable angina-----chestpain on exertion----show ecg changes only when diagnosed during pain

but for HOCM treatment must be verapamil or propanolol

well, digoxin is contraindicated.....
as there is no other option, i would like to go with E) nifedipine

waiting for answer....
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Old 08-26-2012
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Default my answer

diagnosis: HOCM
Tx: antiarrhytmic needed
D. Mexiletine used in ventricular arrhythmias (mc arrhythmias in HOCM)
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Quote:
Originally Posted by venky2600 View Post
i hope ...
HOCM------systolic ejection murmur at left sternal border...that intensifies on standing( as venous return decrease,HOCM murmur intensifies)

and stable angina-----chestpain on exertion----show ecg changes only when diagnosed during pain

but for HOCM treatment must be verapamil or propanolol

well, digoxin is contraindicated.....
as there is no other option, i would like to go with E) nifedipine

waiting for answer....
if we give nifedipine we may actually put this pt in danger bc if we lower BP too much there might be a reflex tachycardia that will not be blocked bc this pt is not on beta-blockers (yet), so pt may develop arrhythmias (ventricular)
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Old 08-26-2012
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Quote:
Originally Posted by Casandra View Post
if we give nifedipine we may actually put this pt in danger bc if we lower BP too much there might be a reflex tachycardia that will not be blocked bc this pt is not on beta-blockers (yet), so pt may develop arrhythmias (ventricular)
i agree with u....mexiletene would be bettr answer as it has greater potential to treat against ischemic tissues and arrythmias too..
thank u
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one more thing to consider here is also ASA. but it's being used when AF occurs, so not an issue here. I think prevention of ventricular arrhythmia is more important in this case since it's HCM
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Old 08-31-2012
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@koolkiller88 - what's the answer?
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Old 09-01-2012
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Default Answer is E. Nifedipine

The patient is presenting with symptoms characteristic of variant angina (also called Prinzmental angina). Variant angina is caused by coronary artery vasospasm. Patients with variant angina most commonly present with chest pain (variable time frame) and or shortness of breath. The ECG typically shows ST segment elevation and T-wave inversion, but may be normal. Ejection murmur are also commonly found. The drugs of choice for the treatment of the patient are CCBs(er-nifedipine or amlodipine) and nitrates.

C. digoxin is cardiac glycoside indicated for the treatment of heart failure and atrial arrhythmias.
D. Mexiletine is a class IB antiarrhythmic indicated for the treatment of ventricular arrhythmias.
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Quote:
Originally Posted by venky2600 View Post
i hope ...
HOCM------systolic ejection murmur at left sternal border...that intensifies on standing( as venous return decrease,HOCM murmur intensifies)

and stable angina-----chestpain on exertion----show ecg changes only when diagnosed during pain

but for HOCM treatment must be verapamil or propanolol

well, digoxin is contraindicated.....
as there is no other option, i would like to go with E) nifedipine

waiting for answer....
Sorry for late reply. Actually i was not able to find this question.
I also thought the way you guys thought and marked D.
but they have a complete different diagnosis. As explanation is also not proper. any ideas?
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Quote:
Originally Posted by koolkiller88 View Post
Sorry for late reply. Actually i was not able to find this question.
I also thought the way you guys thought and marked D.
but they have a complete different diagnosis. As explanation is also not proper. any ideas?
hmm.. where's this question from???

sorry, to me this is not a classical presentation of Printzmental's although I agree that few symptoms fit perfectly.
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Quote:
Originally Posted by koolkiller88 View Post
Sorry for late reply. Actually i was not able to find this question.
I also thought the way you guys thought and marked D.
but they have a complete different diagnosis. As explanation is also not proper. any ideas?
prinzmetal angina...is presented with ST elevation mostly.......it may also be nonspecific btw,but it's rare.......
by looking at ST changes ..i went for HOCM..
where did u find it..?
though it is late for reply,thanx for the question.....
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Quote:
Originally Posted by venky2600 View Post
prinzmetal angina...is presented with ST elevation mostly.......it may also be nonspecific btw,but it's rare.......
by looking at ST changes ..i went for HOCM..
where did u find it..?
though it is late for reply,thanx for the question.....
in my case what totally directed me onto HOCM was the murmur intensyfing when standing up. I totally don't get it how would THAT be typical for Printzmental's...
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Quote:
Originally Posted by Casandra View Post
in my case what totally directed me onto HOCM was the murmur intensyfing when standing up. I totally don't get it how would THAT be typical for Printzmental's...
yes indeed...me too went for HOCM for murmur intensifying standing up only...but i didnt go for prinzmetal becoz of no ST changes......even i'm thinking how murmur could fit into prinzmetal.....i thought angina too as stable angina......
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Quote:
Originally Posted by Casandra View Post
in my case what totally directed me onto HOCM was the murmur intensyfing when standing up. I totally don't get it how would THAT be typical for Printzmental's...
YES you are right,hadnt they given such tips then may be we can think about prinzmetal angina.but the question is specifically directing to HOCM.
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YES you are right,hadnt they given such tips then may be we can think about prinzmetal angina.but the question is specifically directing to HOCM.
exactly!
my question is what is the mechanism (in Printzmental angina) of an increase of murmur severity when the patient is standing? any ideas????

bc we know the reasoning in HOCM
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Quote:
Originally Posted by Casandra View Post
exactly!
my question is what is the mechanism (in Printzmental angina) of an increase of murmur severity when the patient is standing? any ideas????

bc we know the reasoning in HOCM
wat i know is.....only in mitral valve prolapse and HOCM..murmur intensify by standing.......
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Originally Posted by Casandra View Post
exactly!
my question is what is the mechanism (in Printzmental angina) of an increase of murmur severity when the patient is standing? any ideas????

bc we know the reasoning in HOCM
as far as i know there is no such murmur in prinzmetal.may be if there is some other underlying cardiac disease.not sure.
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Originally Posted by Casandra View Post
hmm.. where's this question from???

sorry, to me this is not a classical presentation of Printzmental's although I agree that few symptoms fit perfectly.
Don't worry this question is not from UW
Its from Kaplan diagnostic test.
Ya i also think, There is nothing specific to think about prinzmental angina.
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Quote:
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as far as i know there is no such murmur in prinzmetal.may be if there is some other underlying cardiac disease.not sure.
There are murmurs and ST elevation but not specific to prizmental angina
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wat i know is.....only in mitral valve prolapse and HOCM..murmur intensify by standing.......
Ya thats my point of concern-
What exactly happens when person stand.
I know-
Coronary arteries filling take place in diastole
and when person stands is murmur intensity increased due to decreased preload.

So, only thing i can think of is due to decreased preload there will be decreased diastolic vol. which cause spasm of coronary arteries but if that would be the situation then we could have prizmental angia in lot of Cardiac output related disorder.
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Quote:
Originally Posted by koolkiller88 View Post
Don't worry this question is not from UW
Its from Kaplan diagnostic test.
Ya i also think, There is nothing specific to think about prinzmental angina.
hahahahaha I'm glad it's not from UWorld. It doesn't surprise me that this is from K qbank
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