A 37 year old man comes to see you in the office for the first time. His chief complaint is that of heaviness in the chest. It bothers him whenever he climbs the two flights of stairs at his office. This has been going on for a month or so and whenever he stops for a few minutes, the discomfort disappears.

He takes an Aspirin upon the advice of his wife who has forced him to come see you today.

He is unable to miss much work due to a busy schedule and wants to be treated ASAP.

On examination, he has a BP of 134/80, pulse 82, RR 16, T 98.2.

Cardiac exam reveals an Ejection systolic murmur best heard in the right second intercostal space close to the sternum. His pulse is slow rising and late peaking.

What is the best next step?

1. Dobutamine stress test - Nuclear

2. Persantine stress test - Nuclear

3. Non nuclear stress test by exercise

4. Nuclear stress test by exercise

5. Cardiac catheterization.

Answer is 5.

CARDIOLOGY

Recognize the need for Coronary angiography in a young patient with new onset angina.

Explanation:

Besides being more aggressively treated they are less likely to have cardiac disease therefore a stress test is warranted before a cath except in certain situations.  In the above patient, AS is the indication for cardiac cath immediately as opposed to waiting for the stress test to be completed. Also - this patient has typical anginal symptoms - which is another indication of doing a cath.

Angio may be performed if the patient has either a positive stress test or has continuing symptoms of unstable angina unrelieved by medical therapy or has Aortic stenosis or heart failure - situations where stress testing will be detrimental.

Which one of the following is a reasonable way of treating the patient

1. Start him on Aspirin

2. Start him on a beta blocker

3. Start him on Isosorbide dinitrate

4. Start him on Isosorbide mononitrate

The answer is 2. In a patient with AS, Nitrates are to be avoided.   thus 3 & 4 are incorrect choices. He is already on Aspirin so there is no need to start it. Beta blockers are a good choice in patients with AS and angina. In a patient with AS, there is an urgency to replace the valve once symptoms due to the valve start. The critical stenosis is understood to exist if AV area is less than 0.7 cm²    . Ventriculo-aortic gradient is greater than 75. Asymptomatic patients should be told that there is a danger of death of about 1% per year. They should avoid lifting heavy objects. There is no urgency to operate asymptomatic patients.

You diagnose after investigations that the patient has Aortic stenosis - what is an acceptable way to treat this patient?

1. Immediate surgery

2. If cath shows no coronary disease, wait until the EF is below 45% and then operate the patient

3. If patient suffers near syncope, then operate him but currently warn him that this is one of the symptoms of importance and he should return if this occurs.

4. Start him on Warfarin and schedule him for elective surgery in a few weeks when the INR is stable.

Answer is 1. The symptoms of AS include CP (Angina), SOB (Heart failure and syncope (Low cerebral perfusion). When any one of the symptoms start and can be attributed to AS, replace the valve. Mechanical valve placement is followed by lifelong anticoagulation. For procedures in a patient with a mechanical valve, we need to stop Warfarin, start Lovenox/other heparinoid and schedule surgery when acceptably low INR is reached (usually 3 days after stopping Warfarin).