1. A 74-year old man is seen in clinic. He was recently diagnosed with ischemic cardiomyopathy and not for revascularization. LVEF was noted to be 30% on a recent a 2D echo. His current medications include captopril, bisoprolol, aspirin, and simvastatin. He is feeling well but endorses marked limitation with physical activity. On physical examination, blood pressure is 128/79 mm Hg and pulse rate is 65/min. Cardiac examination reveals a regular rate with no extra heart sounds. JVP is normal, no crackles present with no edema.

What changes should be made to his medication? 

A. Stop bisoprolol
B. Add clopidogrel
C. Add spironolactone
D. Add warfarin

2. A 24-year old man is evaluated during a clinic visit for a syncopal episode during exercise. He is healthy and takes no medications nor uses any recreational drugs. On physical examination, blood pressure is 114/72 mm Hg, pulse rate is 66/min. There is an audible grade 2/6 early peaking systolic murmur along the left lower sternal border that is increased with valsalva maneuver and decreases in intensity with a hand-grip maneuver. An Sgallop is heard with a palpable double apical impulse is noted on examination.

What is the most likely diagnosis?

A.  Aortic stenosis
B. Hypertrophic cardiomyopathy
C. Tricuspid regurgitation
D. Bicuspid aortic valve

3. A 66-year old woman is scheduled to undergo surgery for large uterine fibroids along with a total abdominal hysterectomy. She has a single-chamber implantable cardioverter-defibrillator (ICD) and is also pacemaker dependent. Her other relevant medical history is significant for ischemic cardiomyopathy, atrial fibrillation and high grade AV block. Current medications include: aspirin, bisoprolol, captopril, warfarin, and rosuvastatin. Her warfarin is held and perioperative  anticoagulation is provided with heparin.

What should be done with her ICD peri-operatively?

A. Place a magnet on the ICD
B. Set the ICD to VOO (aka asynchronous) mode before surgery
C. Place transcutaneous pacing pads for surgery
D. Place a temporary pacing wire.

4.  A 28-year old woman is seen in clinic for shortness of breath with exercise. She is otherwise healthy and on no medications. Her physical exam showed a blood pressure of 127/78 mm Hg. JVP of 4 cm  and a left parasternal heave on exam. There is a fixed splitting of the S2. A grade 2/6 systolic murmur is noted at the second left intercostal space.

What is the most likely diagnosis?

A. Tricuspid regurgitation
B. Atrial septal defect
C. Pulmonary arterial hypertension
D. Mitral stenosis


1.C- This patient should be placed on spironolactone as he has heart failure with a reduced ejection fraction (< 35%) and NYHA class III symptoms. The RALES trial showed a significant (30% all mortality) benefit for patients with a similar clinical picture and history as this patient when placed on spironolactone. Read more about the RALES trial here.

2. B-  This is a case of hypertrophic obstructive cardiomyopathy (HOCM). The key learning point in terms of differentiating the murmur of HOCM from Aortic Stenosis is that the murmur intensity increases in the former with decreased venous return to the heart as is the case with a Valsalva maneuver. The double apical impulse is also a feature of HOCM. This is caused by an initial normal arterial upstroke with systole but the mitral valve transiently goes into the LVOT with SAM (systolic anterior motion of mitral valve) causing the pulse to drop transiently. The pressure rises and overcomes the obstruction by the mitral valve and then the arterial upstroke rises once again giving rise to the double apical impulse or also the bifid pulse felt with carotid palpation.

3. B- This patient is pacemaker dependent but with the use of electrocautery during surgery poses risk as the device cannot differentiate between true ventricular activity and electrocautery during surgery and will deliver shock therapy as if the patient were in ventricular fibrillation. Therefore given her pacemaker dependency it would be best to reprogram the device to turn off shock therapy and change to an asynchronous mode such as VOO.  This means that ventricular pacing will remain despite native ventricular electrical activity or electrocautery from surgery. A magnet would have been a reasonable option if this patient was not pacemaker dependent.

4. B- This patient has an atrial septal defect. The learning point from this case is that the presence of a fixed-split S2 is virtually diagnostic of an ASD. As a result of the increased flow across the pulmonic valve a systolic murmur is heard in this patient’s exam which driven by left-to-right shunting. The parasternal heave is attributable to right ventricular enlargement.

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