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Self-Assessment Questions


Management of Aortic Valve Disease: Review Questions

Josh Leitner, MD, and Wen-Chih Wu, MD

Dr. Leitner is a clinical fellow in cardiology, Warren Alpert Medical School of Brown University, Providence, RI. Dr. Wu is an assistant professor of medicine, Providence VA Medical Center and Warren Alpert Medical School at Brown University.
The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veteran Affairs.
This work is supported by the Target Research Enhancement Program, Providence VA Medical Center, providing research time for Dr. Wu; and the Brown Fellowship Program

Choose the single best answer for each question.

Questions 1 and 2 refer to the following case.
A 72-year-old man with a past medical history noteworthy only for hypertension controlled on hydrochlorothiazide and a described “heart murmur with a tight valve” presents to the emergency department (ED) complaining of weeks of progressive exertional dyspnea and an episode of dyspnea awakening him from sleep. The patient reports no chest pain. Upon presentation, his blood pressure is 102/68 mm Hg, heart rate is 98 bpm and regular, respiratory rate is 18 breaths/min, and oxygen saturation is 90% on room air, which improves to 99% following oxygen supplementation at a rate of 4 L/min via nasal cannula. Physical examination reveals a diminished A2, late-peaking systolic crescendo-decrescendo murmur, delayed and diminished carotid upstroke, an audible S3, dilated jugular veins, and bibasilar rales. Chest radiograph shows pulmonary edema. An electrocardiogram (ECG) shows sinus tachycardia, left ventricular (LV) hypertrophy, left atrial enlargement, and 0.5-mm ST depressions in the anterior and lateral leads, with T-wave inversions in the lateral precordial leads.

1. What is the next most appropriate step in the management of this patient?
  1. Immediate cardiothoracic surgery consultation for emergent aortic valve replacement surgery
  2. Immediate measurement of brain natriuretic peptide (BNP) level and bedside echocardiogram to assess ejection fraction and valve function; initiate intravenous (IV) furosemide only if either of the tests is abnormal
  3. Initiation of IV furosemide accompanied by IV nitroglycerine drip
  4. Initiation of IV furosemide without nitroglycerine, with accurate monitoring of weight and urine output; readminister diuretic only if there are persistent findings of volume overload
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2. The following morning, the patient’s clinical status is improved, with normal oxygen saturation on room air. Serial ECGs show sinus rhythm with normalization of the T-wave inversions noted previously. Troponin levels are undetectable. An echocardiogram shows normal LV size, moderate LV hypertrophy, a LV ejection fraction (LVEF) of 40%, and a calcified aortic valve with severe stenosis (aortic valve area = 0.8 cm2). Which of the following is indicated in the workup and management of the patient at this time?

  1. Cardiology consultation for invasive coronary angiography prior to planned aortic valve replacement
  2. Exercise stress test with nuclear myocardial perfusion imaging to assess for ischemia and exercise tolerance
  3. High-dose statin therapy for reduction of aortic valve calcification
  4. Initiation of a β-blocker, an angiotensinconverting enzyme (ACE) inhibitor, oral furosemide, and long-acting nitrates to reduce further hospitalizations and consideration of valve surgery if symptoms recur
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3. A 71-year-old woman with medication-controlled hypertension, hypercholesterolemia, and osteoarthritis presents in the outpatient setting for routine care. Physical examination reveals a harsh, midpeaking systolic murmur radiating to the neck, a slightly diminished carotid upstroke, no jugular venous distension, clear lungs, and no peripheral edema. She notes that her ambulation is at times limited by knee pain, but generally she is able to complete her activities of daily living, including walking through the supermarket, with no limiting dyspnea or chest discomfort. She denies any history of syncope. An echocardiogram performed 2 weeks prior demonstrates normal biventricular systolic function, moderate LV hypertrophy, normal LV dimensions, mild mitral regurgitation with mitral annular calcification, and a heavily calcified aortic valve with severe aortic stenosis. Which of the following interventions is indicated at this time?

  1. Hospitalization for further workup and management of severe aortic valve disease
  2. Initiation of oral furosemide and a statin
  3. Repeat clinical assessment in 3 to 6 months and repeat echocardiographic assessment within 1 year or sooner if symptoms develop
  4. Treadmill exercise stress testing with nuclear myocardial perfusion imaging to assess for the presence of coronary artery disease
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4. A 64-year-old man with hypertension requiring 3 medications for control presents in the outpatient setting for routine care, having recently moved to the area. He denies any limiting dyspnea, orthopnea, or chest discomfort and notes that he can complete his activities of daily living effortlessly. He denies recent illness, hospitalization, or fevers. Physical examination reveals a symmetric blood pressure of 138/52 mm Hg, heart rate of 92 bpm, no jugular venous distension, markedly bounding pulses, and a decrescendo pandiastolic murmur at the left upper sternal border. The patient has a copy of an echocardiogram report from his prior assessment showing a moderately dilated left ventricle (internal dimension in diastole: 6.3 cm), an LVEF of 60%, a dilated aortic root (4.8 cm) with moderate to severe aortic insufficiency, and a bicuspid aortic valve. A repeat echocardiogram confirms the bicuspid aortic valves with the same left ventricle internal dimensions, but also shows an LVEF of 50%, an aortic root diameter of 4.9 cm, and severe aortic insufficiency. The patient is seen the following week, still without any limiting symptoms. Which of the following interventions is indicated at this time?
  1. Cardiology consultation for coronary angiography and referral for aortic valve replacement with or without aortic graft
  2. Initiation of ACE inhibitor and furosemide and repeat echocardiogram in 6 months or sooner if symptoms develop
  3. Initiation of β-blocker and diuretic and reassessment in 6 months
  4. Transfer to emergency department for urgent contrast computed tomography (CT) of the aorta to assess for dissection
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5. A 73-year-old woman with known mild to moderate aortic insufficiency and normal LV systolic function returns for follow-up after a repeat echocardiogram, which is of good quality, demonstrating mildly dilated left ventricle with internal dimensions of 5.9 cm in diastole and 4.0 cm in systole, an LVEF of 65%, and moderate aortic insufficiency. Although she feels generally able to meet her activities of daily living, she notes having slightly less energy compared to 6 months prior. She denies any marked exertional or nocturnal dyspnea, orthopnea, or chest discomfort, and denies any recent fevers, illnesses, or hospitalizations. Her blood pressure and cholesterol are normal without the need of medications. According to recent ACC/AHA guidelines, which of the following is routinely recommended for further assessment and management of this patient?

  1. Recommendation of antibiotic prophylaxis for all surgical and dental procedures
  2. Referral for cardiac catheterization and aortography to accurately quantify the grade of aortic regurgitation
  3. Referral for elective aortic valve replacement
  4. Repeat clinical assessment in 6 to 12 months with repeat transthoracic echocardiogram in 1 year, or sooner if symptoms develop
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6. A 51-year-old man who has been hospitalized for delayed presentation of a pneumococcal pneumonia complicated by bacteremia and hypotension has clinical improvement after initiation of antibiotics and aggressive hydration but has persistent lowgrade fevers. Two days later, he develops increasing sinus tachycardia, dyspnea without chest or back pain, and diaphoresis. Physical examination reveals a blood pressure of 98/68 mm Hg, heart rate of 122 bpm, oxygen saturation of 90% on room air, a faint early diastolic murmur, bibasilar rales, and cool distal extremities. ECG reveals sinus tachycardia without other abnormality. Chest radiograph shows normal heart size, pulmonary vascular congestion, and mild pulmonary edema. Bedside transesophageal echocardiography reveals severe destruction of the aortic valve with severe aortic insufficiency. Which of the following interventions are indicated at this time?

  1. Aggressive intravenous hydration, repeat blood cultures, addition of broad-spectrum antibiotics, and repeat transesophageal echocardiogram after 3 days of therapy
  2. Aspirin, nitroglycerine, IV heparin, and evaluation of serial troponin levels every 8 hours
  3. Cautious administration of IV nitroprusside drip, intensive blood pressure monitoring, and referral for emergent valve replacement surgery
  4. IV β-blockers for improved heart rate control and urgent interventional cardiology consultation for intra-aortic balloon pump placement for his cardiogenic shock
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