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  #1  
Old 06-09-2012
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Heart Global Cardiac Hypokinesis and Ejection Fraction < 35%

A 55-year-old man with a past medical history significant for diabetes for 15 years presents to your office complaining of
increasing shortness of breath over the past few months.
Although he is pain-free today, he has had angina-like chest pain over the last several months. There is no radiation of the pain or nausea, vomiting, or diaphoresis. The patient's medications consist of metformin, glyburide, and lisinopril. He
denies alcohol, tobacco, or illicit drug use.
On physical examination, the patient appears as an age appropriate obese male. Blood pressure is 130/170 mm Hg, and
heart rate is 66/min. Jugulovenous distention is present. There is an S3 gallop with lateral displacement of the point of maximal impulse and some minimal rales at the lung bases. There is no peripheral edema. An EKG reveals a normal sinus rhythm at a rate of 64/min with no ST elevation and no T wave inversions. Anterior and inferior leads have QS waves. An echocardiogram reveals four chamber dilatation, global hypokinesis, and an ejection fraction of 35%.

What is the next diagnostic step for this patient?

(A) Coronary angiography
(B) 24-hour Holter monitor
(C) Transesophageal echocardiogram
(D) Thallium stress test
(E) Endomyocardial biopsy
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i think A. you want to find out why his heart has failed (EF of 35 and hypokinesis on ECHO), normally stress test will help but the question says he is has shortness of breath, if that option was thallium echo i would have gone for it, but i dont think you want to stress a man who is in CHF
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  #3  
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-this dilated cardiomyopathy ,ithink (A)
(Right-sided heart catheterization (RHC) can be beneficial in initially determining the volume status of a patient with equivocal clinical signs and symptoms of heart failure. RHC in a patient with dilated cardiomyopathy demonstrates elevated filling pressures (central venous pressure, pulmonary artery wedge pressure, right ventricular end-diastolic pressure) and decreased cardiac output).
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I think it's A...the patient probably had silent M.I(he has QS waves) so we have to diagnose and treat his ischemia....and as he has S3 gallop and other signs of CHF so probaobly stress test is not the best choice....So I'll go with the angiography...emedicine says:The utility of cardiac catheterization in a person with dilated cardiomyopathy is very limited and should be undertaken only when a strong likelihood of an ischemic etiology (eg, Q waves with systolic dysfunction, angina, positive imaging stress test finding) is present.
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I would pick (D) - Thallium stress test
I would like to know if he has areas of reversible ischemia which can be corrected with cardiac intervention.

This man definitely has CHF as result of Dilational Cardiomiopathy. Most common causes of DC are long standing hypertenison and ichemic heart disease, as well as alcohol abuse. Idiopathic DC is far less common.
This man is obese and diabetic (single strongest risk factor for CAD). EKG findings support this idea even stronger

(A) Is incorrect because angiography is invasive procedure that should be performed only after reversible ischemia was confirmed by stress tests. Or in case of emergency (STEMI). This NOT seems to be an emergency situation. Even if it was MI, Q wave appears quite late to perform emergency angiography
(B) is incorrect, because he has sinus rythm on routine EKG and no history of palpitations, syncope or other signs of serious paroxismal arrythmias. Risk of life-threatening arrhytmias in CHF generally increases when EF is below 35%, so Holter will add nothing to our tactics.
(C) Is incorrect because we have already defined EF and thus confirmed CHF, so it won't add anything to the case.
(E) Can help to estabilsh diagnosis of DC which is caused by myocardial infiltrative disease (like amyloidosis or idiopathic DC). But I think we should rule out more common causes of DC first (like CAD or HT)...

Last edited by Antonosjn; 06-10-2012 at 08:18 AM.
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Quote:
Originally Posted by Antonosjn View Post
I would pick (D) - Thallium stress test
I would like to know if he has areas of reversible ischemia which can be corrected with cardiac intervention.

This man definitely has CHF as result of Dilational Cardiomiopathy. Most common causes of DC are long standing hypertenison and ichemic heart disease, as well as alcohol abuse. Idiopathic DC is far less common.
This man is obese and diabetic (single strongest risk factor for CAD).

(A) Is incorrect because angiography is invasive procedure that should be performed only after reversible ischemia was confirmed by stress tests. Or in case of emergency (STEMI). This NOT seems to be an emergency situation. Even if it was MI, Q wave appears quite late to perform emergency angiography
(B) is incorrect, because he has sinus rythm on routine EKG and no history of palpitations, syncope or other signs of serious paroxismal arrythmias. Risk of life-threatening arrhytmias in CHF generally increases when EF is below 35%, so Holter will add nothing to our tactics.
(C) Is incorrect because we have already defined EF and thus confirmed CHF, so it won't add anything to the case.
(E) Can help to estabilsh diagnosis of DC which is caused by myocardial infiltrative disease (like amyloidosis or idiopathic DC). But I think we should rule out more common causes of DC first (like CAD or HT)...
loved the way you handled the q. i also did the same.. but qbank doesnt

Quote:
In the patient described, the physical examination and history paint a
picture of dilated cardiomyopathy, although one should not come to a
precise diagnosis until the EKG and echocardiogram are done. The patient
denies any previous alcohol use, and there is no medical history
suggesting the use of cardiotoxic drugs. The QS waves on the EKG
probably represent previous ischemic events, such as a myocardial
infarction
. These might have gone unnoticed because of the patient's
diabetes, leading to a "silent" myocardial infarction. Because this patient is
symptomatic with anginal pain and dyspnea, the next diagnostic step in the
management of this patient should be coronary angiography.
An
endomyocardial biopsy has a very limited role in restrictive
cardiomyopathy, where you would want to distinguish between a primary
versus an infiltrative process. The Holter is not a part of the routine
evaluation of ischemic heart disease. A transesophageal echocardiogram
would not reveal any additional information, which would be useful in the
management of a patient with probable ischemic heart disease. Stress
testing is used when there is a question of the possibility of coronary
disease. Between the patient's symptoms of pain and shortness of breath,
as well as an EKG consistent with a previous infarction, there is little doubt
that he has ischemic disease. His history is more important that this test.
Even with the injection of thallium, there is still only a 90 to 95% sensitivity.
Even in the unlikely event that the test is negative, you would still want to
perform angiography because, in a case like this, it would be one of the
false negatives.
i still dont know why thallium is wrong ans. any1?
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Quote:
Originally Posted by tyagee View Post
loved the way you handled the q. i also did the same.. but qbank doesnt



i still dont know why thallium is wrong ans. any1?
Take it easy, bro
Qbanks are written by people, and they contain mistakes=)
Although explanation is right and we are wrong, this question is at least controversial. Of course, if you'll perform angiography anyway it makes stress test unnecessary. On the other hand, we definitely have NOT ENOUGH REASON to suggest acute STEMI in this particular case and start right away with angiography. Chronic Angina protocol starts with stress tests not angiography. Maybe you sould send feedback on this question )))

Anyway, as it was said by Jose Raul Capablanca (great chessmaster) - "one lost but analyzed game worth more than 100 won and forgotten"
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so whats the answer plz...?
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Quote:
Originally Posted by dryogi View Post
so whats the answer plz...?
(A) angiography is correct
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Quote:
Originally Posted by tyagee View Post
i still dont know why thallium is wrong ans. any1?
I think in a diabetic patient with symptomatic CAD with evidence of silent MI you go straight for Angio because it's both diagnostic and therapeutic (PCI). Also stress test doesn't give much additional information over which we already know and you don't want to stress the heart of a patient who had a recent MI since diabetic patient tend to have much worse CAD compared to general population.
SWISS II trial showed improvement in EF in this patient population compared to stress testing followed my medical management.
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Quote:
Originally Posted by Novobiocin View Post
I think in a diabetic patient with symptomatic CAD with evidence of silent MI you go straight for Angio because it's both diagnostic and therapeutic (PCI). Also stress test doesn't give much additional information over which we already know and you don't want to stress the heart of a patient who had a recent MI since diabetic patient tend to have much worse CAD compared to general population.
SWISS II trial showed improvement in EF in this patient population compared to stress testing followed my medical management.
Yes I agree, but only partially. Of course we cant go against Trial, but:
1. In this question it is unclear if we have emergency situation or not.
2. If it was acute phase STEMI (or patient in acute distress) then yes, we should proceed straight to PCI. But even so, PCI seems to be useless if >12 hours passed since MI onset. In that case we'd better to treat medically, then perform stress test before discharge --> reversible ischemia present --> perform PCI...
3. If it is not an acute phase STEMI then we sould again perform stress test (chemical stress if he cant tolerate exercise) before PCI. In that case, stress is NOT to confirm presence/absence of CAD (which is obvious), but to show whether there is REVERSIBLE ichemia present. Of course, PCI itself is most accurate study for detecting sthenosis of coronary vessels, but it won't show if there is viable myocardium down there. And there is no point in revascularizing dead fibrous tissue (logically).

But if the Trial has shown... Well, let it be=) Unfortunately, we can't be up to date in all the recent trials for all particular situationos
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Quote:
Originally Posted by tyagee View Post
A 55-year-old man with a past medical history significant for diabetes for 15 years presents to your office complaining of
increasing shortness of breath over the past few months.
Although he is pain-free today, he has had angina-like chest pain over the last several months. There is no radiation of the pain or nausea, vomiting, or diaphoresis. The patient's medications consist of metformin, glyburide, and lisinopril. He
denies alcohol, tobacco, or illicit drug use.
On physical examination, the patient appears as an age appropriate obese male. Blood pressure is 130/170 mm Hg, and
heart rate is 66/min. Jugulovenous distention is present. There is an S3 gallop with lateral displacement of the point of maximal impulse and some minimal rales at the lung bases. There is no peripheral edema. An EKG reveals a normal sinus rhythm at a rate of 64/min with no ST elevation and no T wave inversions. Anterior and inferior leads have QS waves. An echocardiogram reveals four chamber dilatation, global hypokinesis, and an ejection fraction of 35%.

What is the next diagnostic step for this patient?

(A) Coronary angiography
(B) 24-hour Holter monitor
(C) Transesophageal echocardiogram
(D) Thallium stress test
(E) Endomyocardial biopsy
I think the key words here are "global" and "Stress".
Accrding to MTB Page 73 (Tip) stress testing is contraindicated in a symptomatic patient. This patient clearly is symptomatic (angina and heart failure). Stress testing on this patient will be akin to "flogging a tired horse" the "horse" will simply give up and die. Does anyone really think that this patient can bring up his HR to 80% above his normal HR and not have another MI which maybe "silent"?

Also, he has "four chamber dilatation" and "global hypokinesis" so all you will find on a Thalium stress test is entire myocardium to be underperfused. This doesn't make us any wiser regarding his management since his entire myocardium cannot be dead or fibrotic.

However, this indicates that he has triple vessel disease and the only test which can tell us more is Angigraphy. His only chance of any improvement lies with a CABG and Angio is needed for CABG.

Bottomline:

Thalium stress test is contraindicated.

Angiography will be needed anyway even if you perform Thalium stress test

Last edited by Novobiocin; 06-11-2012 at 09:52 AM.
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  #13  
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Ok, now I see
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