NYACP - MedQuest IM Board Review Question of the Week 1.14.20
A 55-year-old woman presents to cardiology clinic with intermittent episodes of exertional dyspnea, pedal edema, fatigue, and orthopnea. She feels well today. She does not have angina. She has a long history of hypertension and diabetes mellitus with suboptimal control. She is a nonsmoker with normal cholesterol levels. Current medications include metoprolol and hydrochlorothiazide. Vital signs today: BP 140/90 mmHg and HR 64 bpm and regular. In physical examination, JVP 12 cm, lungs are clear to auscultation with bilateral decrease in breath sounds, LV impulse prominent and sustained, S3 gallop presents but no murmurs. Extremities exam shows +2 lower extremity pedal edema bilaterally. EKG: regular sinus rhythm, rate 65 bpm. Chest radiograph shows bilateral pleural effusion. What is the next step in the management of this patient?
A. Coronary Angiography
C. Start digoxin
D. Start Patient on hydralazine/nitrates
E. Low salt diet
NYACP-MedQuest IM Board Review Question of the Week from Jan 6, 2020:
As promised in the chapter’s December 31st email correspondence, NYACP is pleased to provide you with the answer to the NYACP-MedQuest IM Question of the Week in this edition of IM Connected. For your convenience, this week we repeat the question in this newsletter in addition to the correct answer and explanation below. Did you miss our NYACP-MedQuest IM Question of the Week from January 7th? No problem, because another question is headed your way on Tuesday, January 14th!
A 79-year-old man is brought to the emergency department due to a loss of consciousness. He was unconscious for approximately four minutes after he fell. He had been walking home after spending the morning at the supermarket and then suddenly fell to the ground. The patient remembers regaining consciousness and woke to find himself face down on the sidewalk with abrasions on his nose and forehead. This is the patient’s first syncopal event, and he is otherwise in good health. He recalls feeling lightheaded and shaky just before the fall and currently is experiencing nausea.
His blood pressure is 78/52 mmHg, pulse is regular at 165/min, and respiratory rate is 23/min. There are no tongue abrasions, jugular venous distention, or focal neurological deficits. There are no murmurs.
What is the best treatment for this patient?
These are the Responses Received from Members (719 Total):
The Correct Response is: Synchronized cardioversion
This patient presents with syncope. Syncope is defined as a transient loss of consciousness and postural tone due to inadequate cerebral blood flow. The sudden loss of consciousness in this patient with a resulting fall that causes abrasions to the face is consistent with cardiogenic syncope. The best management is synchronized cardioversion. The point of this question is to understand that even without the EKG, the evidence for hemodynamic instability makes a cardioversion the best answer.
The etiology of cardiogenic syncope can be either mechanical obstruction to the flow of blood or an arrhythmia. There are no murmurs evident on physical examination, making aortic stenosis or hypertrophic obstructive cardiomyopathy unlikely. Cardiac syncope is commonly due to disorders of automaticity, such as sick sinus syndrome; conduction disorders, such as atrioventricular block; and tachyarrhythmias, as is the case in this patient.
Although no EKG results are given, the patient presents with symptomatic hypotension and a pulse of 165/min. Maximum heart rate is calculated as 220 minus the age. In a 79-year-old patient, it is virtually impossible to have a sinus rhythm at a rate >140/min. The rate of 165/min therefore must be from an arrhythmia. No matter what the specific etiology is, synchronized cardioversion is the correct therapy in a hypotensive patient. Although vagal maneuvers may treat supraventricular tachycardia (SVT), this is less likely to be the cause of a tachyarrhythmia that leads to a syncopal event. Regardless, you would still cardiovert the patient if he were hypotensive, rather than perform vagal maneuvers that could easily lower the blood pressure further. Ventricular tachycardia is the arrhythmia that would most likely result in a loss of consciousness.
The fact that this patient is symptomatic with a systolic blood pressure of <90 mm Hg is the reason to cardiovert this patient with a synchronized cardioversion of 100 to 200 Joules (J). The cardioversion is synchronized if there is a rhythm present to synchronize. All cardioversions are synchronized, except for ventricular fibrillation. If the patient had no symptoms and a systolic pressure of >90 mm Hg, you could use medical therapy. Lidocaine or amiodarone by intravenous bolus injection may terminate the arrhythmia.
An echocardiogram would be the correct choice if a murmur of aortic stenosis, pulmonary stenosis, or hypertrophic cardiomyopathy was heard, or if you suspected cardiac tamponade. An EKG is, of course, essential. The question tests your understanding of who needs cardioversion and who can be treated with medications. We are not implying that you would not do the EKG prior to delivering therapy. You should do an EKG but the point of the question is knowing who needs cardioversion.
Link MS, Atkins DL, Passman RS, Halperin HR, Samson RA, White RD, Cudnik MT, Berg MD, Kudenchuk PJ, Kerber RE. Part 6: electrical therapies: automated external defibrillators, defibrillation, cardioversion, and pacing: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care. Circulation. 2010 Nov 2;122(18 Suppl 3):S706-1910.1161/CIRCULATIONAHA.110.970954. Review. Erratum in: Circulation. 2011 Feb 15;123(6):e235. PubMed PMID: 20956222.
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