Figure 87.1. Electrocardiogram for patient in Question 19.

    QUESTION 20. A 64-year-old man is scheduled for right hip replacement. He presents to your clinic for preoperative assessment. He has a past medical history of hypercholesterolemia, hypertension, benign prostate enlargement, and coronary artery disease with a stent placement in the left anterior descending artery 2 years ago due to angina with single vessel disease. He exercises daily by walking 2 miles without limitations or symptoms. What is the best option for preoperative management?

ANSWERS

1. D. This is a common problem faced by the clinician and is frequently asked on the boards. These are all post-MI complications (table 87.1). Persistent ST elevation after an acute MI is classically described in patients with a left ventricular aneurysm, although it can be the result of a large infarct as well. Left ventricular aneurysms more commonly occur after occlusion of a vessel in which there was not adequate collateral blood supply and thus are not as common in multivessel coronary disease. An acute anterior wall MI is less likely given the stable clinical presentation in the outpatient clinic and lack of chest pain, although silent injury may occur in some patient populations. Pericarditis is often associated with pleuritic chest pain often radiating to the ridge of the trapezius and the EKG often has diffuse PR depression and ST elevation although one can see regional pericarditis in situations such as post-bypass surgery. The pain can occur between 1 day and 6 weeks post-MI and can be difficult to distinguish from recurrent angina. Dressler syndrome is associated with pain, fever, elevated sedimentation rate and white blood cell count, generalized malaise, and pericardial effusion. It typically occurs 1–8 weeks post-MI. The lack of jugular vein distension (JVD), ascites, peripheral edema, and right ventricle (RV) heave decreases the likelihood of right-heart failure.

Table 87.1 TYPICAL POST-MYOCARDIAL INFARCTION COMPLICATIONS

SOURCE: Antman et al. (2004).

    2. A. This patient has amyloid heart disease. Amyloidosis is due to protein deposition, which can affect many organs. Once there has been a significant infiltration, clinical manifestations typically occur. The discordance of the LV wall thickness on echocardiography with low voltage on EKG is highly suggestive of an infiltrative process. Rapid increase of LV wall thickness over the years also suggests infiltrative process. Patients commonly have hoarseness and bruisability due to amyloid deposits. They develop a restrictive physiology and can develop massive right-sided heart failure, including ascites. Atrial fibrillation is common due to electromechanical uncoupling and thrombus formation is a concern. These patients typically have a poor prognosis (median survival ~6 months post onset of symptoms); however, there are some variants with better prognosis which is the rationale for a workup, including an endomyocardial biopsy. Hypertension is a cause of LV hypertrophy, which is not the case in this patient. ACE inhibitors have not been tested in large randomized trials in patients with amyloid cardiomyopathy. There should be cautious use of vasodilators given the autonomic dysregulation that may be present in these patients. Defibrillators have not been demonstrated to dramatically improve survival in limited studies. Digitalis should be avoided given the propensity for dig toxicity. Heart transplant can be offered in highly selected patients with isolated cardiac amyloid and is often followed by a stem cell transplant to prevent recurrent amyloid depositions in the transplanted heart.

3. C. This patient is at risk for a cardiomyopathy due to adriamycin exposure and there can be a delay in the development of LV dysfunction, especially in younger patients. Echocardiography excludes this etiology. Radiation exposure places her at risk for coronary artery disease (CAD), constrictive pericarditis, restrictive cardiomyopathy, and valvular disease. Classically, patients develop CAD approximately 10 years post radiation exposure and have a unique pattern with stenosis in the ostia of the major coronary arteries, possibly due to more intense radiation exposure in these areas. Her right-sided heart failure symptoms suggest restrictive versus constrictive physiology. Cardiac MRI can be helpful, as well as echocardiography with Doppler interrogation, Chest computed tomography (CT) to evaluate pericardial thickness, and cardiac catheterization (gold standard). Table 87.2 details findings in these conditions.

    4.

Stay updated, free articles. Join our Telegram channel

Join