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Answer 6
  1. Cautious administration of IV nitroprusside drip, intensive blood pressure monitoring, and referral for emergent valve replacement surgery. This patient has acute severe aortic insufficiency from acute infective endocarditis. Acute severe aortic insufficiency is a clinical emergency that requires a high index of suspicion in the appropriate clinical setting (chest trauma, aortic dissection, or acute infective endocarditis), and generally requires emergent surgical valve replacement. Many of the classic physical examination manifestations of chronic aortic insufficiency are not evident in acute aortic insufficiency, including normal or only minimally increased pulse pressure. Emergent echocardiography is invaluable in quickly establishing the diagnosis, etiology, and severity. Cautious afterload reduction with nitroprusside and intensive blood pressure monitoring are useful to stabilize the patient’s symptoms and serve as a bridge to emergent surgery in patients with acute severe aortic insufficiency, especially in the setting of heart failure.3
    Given the hemodynamic instability of the patient and the fact that aortic insufficiency occurs during diastole, β-blockers are contraindicated as they can prolong diastole. Similarly, an intra-aortic balloon pump exerts its actions by inflating during cardiac diastole, exacerbating aortic insufficiency, and it is also contraindicated. There is no evidence to suggest that this patient has an acute coronary syndrome, and thus there is no role for aspirin, nitroglycerine, IV heparin, and evaluation of serial troponin levels every 8 hours.

    3. Bonow RO, Carabello BA, Chatterjee K, et al. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing committee to revise the 1998 guidelines for the management of patients with valvular heart disease). J Am Coll Cardiol 2008;52(13):el–142.

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