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  #1  
Old 10-21-2011
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Default Cardiology

A 52-year-old woman comes to the clinic complaining of progressive dyspnea on exertion and worsening fatigue over the last 6 months. She has a known history of moderate to severe mitral regurgitation, which, until recently, has been asymptomatic and well compensated. Aside from this condition and stage I hypertension, her past medical history is unremarkable. Her physical examination today reveals a holosystolic murmur that radiates to the axilla. A repeat echocardiogram is performed, which confirms the suspicion of worsening mitral regurgitation. While the leaflets are only mildly thickened, there is minimal prolapse, and there is no subvalvular scarring or calcification, ejection fraction is borderline normal and the left ventricle and atria are mildly enlarged. Which of the following is the most appropriate treatment for this patient?
A. Afterload reduction with nitrates and/or hydralazine
B. Begin anticoagulation with warfarin, follow clinically
C. Cardiothoracic surgery consultation for mitral valve repair
D. Cardiothoracic surgery consultation for mitral valve replacement
E. No treatment, repeat echocardiogram in 6 months

A 62-year-old man is brought to the emergency department after complaining of feeling lightheaded and dizzy as well as having chest palpitations. He denies any sense of pain or chest tightness, and does not feel sweaty or short of breath, although he has had myocardial infarctions in the past. However, he does note that he has had a bad “cold” and productive, purulent cough for the last week. His pulse is 138/min and examination confirms an irregularly irregular rhythm. Right-sided crackles, egophony, and dullness to percussion are present on chest examination. A chest radiograph shows a corresponding infiltrate, and an electrocardiogram confirms the suspicion of atrial fibrillation. The patient is admitted with a diagnosis of pneumonia and atrial fibrillation and treated appropriately. Over the course of his hospital stay he receives diltiazem, metoprolol, and amiodarone for atrial fibrillation, in addition to empiric antibiotics for community-acquired pneumonia. His outpatient digoxin, used as part of his treatment regimen for congestive heart failure, is continued. Which of the following medications, if given, is most likely to convert his rhythm from atrial fibrillation to sinus rhythm?
A. Amiodarone
B. Digoxin
C. Diltiazem
D. Metoprolol
E. Sotalol
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Old 10-22-2011
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C. Cardiothoracic surgery consultation for mitral valve repair
B. Digoxin
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Old 10-22-2011
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A.afterload reduction
B.digoxin

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Old 10-22-2011
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A. Afterload reduction with nitrates and/or hydralazine
A. Amiodarone
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  #5  
Old 10-23-2011
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The correct answer is C. The procedure of choice for symptomatic mitral regurgitation is mitral valve repair. Significantly lower operative mortality, increase in ejection fraction postoperatively, and overall 10-year survival are associated with mitral valve repair than with mitral valve replacement (choice D). In certain situations, such as severe prolapse, chordal fusion, or severe subvalvular disease, replacement is the only alternative.
Afterload reduction (choice A) is commonly used in the treatment of chronic, asymptomatic mitral regurgitation. However, there is a paucity of data supporting any beneficial effect to afterload reduction in chronic mitral regurgitation, though it is theoretically appealing. For symptomatic patients, surgery offers well-defined risks and benefits.
Anticoagulation with warfarin (choice B) for patients with mitral regurgitation is generally recommended in patients with massively dilated atria and/or a history of embolic events, or if atrial fibrillation (either chronic or paroxysmal) is present.
Treatment is indicated now that this patient is symptomatic. If this patient were not symptomatic, and had little or no evidence of cardiac decompensation on echocardiogram, then deferring treatment and repeating an echocardiogram in 6 months (choice E) would be an appropriate strategy.

2.
The correct answer is A. This patient has underlying heart disease and with this episode of pneumonia went into atrial fibrillation. Amiodarone can chemically convert patients into a sinus rhythm, though it is not highly effective in this role. Its major role is in the maintenance of sinus rhythm once a patient has converted out of atrial fibrillation.
Digoxin (choice B), diltiazem (choice C), and metoprolol (choice D) are all agents used to treat atrial fibrillation. They work by controlling the rapid ventricular response to atrial fibrillation. They are no more successful than placebo for converting atrial fibrillation into a sinus rhythm. However, recently completed studies have shown no difference in mortality among rate-controlled versus rhythm-controlled patients.
Sotalol (choice E) is a class III antiarrhythmic drug. It has not been proven to chemically convert patients out of atrial fibrillation. It is used in a variety of situations to prevent recurrence of supraventricular tachycardias once sinus rhythm is restored
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