Musuq
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A 72-year-old woman comes to the physician because of an episode of acute substernal chest pain that occurred while she was rushing to catch a bus. She has basilar crackles at both lung bases. S1 is normal and S2 is decreased. A grade 3/6 systolic murmur is heard best at the upper right sternal border and radiates to the neck. The following data obtained during cardiac catheterization were taken before and during exercise:
While exercising, the patient has shortness of breath but no chest pain. Which of the following is the most likely cause of the shortness of breath?
A) Decreased cardiac output during exercise
B) Decreased pulmonary blood flow
C) Increased aortic pressure
D) Increased end-diastolic pressure of the left ventricle during exercise
E) Tachycardia
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| young_doc
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D??
At first i guess A, but that can't be, because the SV is clearly greater during exercise, and CO is directly proportional to SV.
It can't be B, cuz that won't give pulmonary edema.
C well aortic pressure seems fine under normal conditions.
E the SV is fine, so don't see how tachy alone would be responsible for backward pump failure.
JUST MY GUESS!
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| Luckyall
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is definetelly the incr in EDP in LV....due to incr EDV in LV.... that means when the LA contracts, trying to empty its blood in last part of LV dyastole, it cannot, due to an already filled LV---> hence blood will go back into pulm veins ( backup )----> pulmon EDEMA ---> SOB
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| blueocean
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D
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| klimt
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agree D
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| ManuNastai
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i'd go with E
Increased heart rate would decrease the amount of blood acumulating upstream (pulmonary circulation) because of decreased time for the ventricle to fill. it's not D because that would lead to ischemia and this is not the case
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| ashfaque
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answer A,
Bc age 72 yrs, common valvular lesion in old age is aortic stenosis which results in decrease cardiac ouytput esp during exercise or exertion .plus the question clearly indicating a systolic murmur at 2nd intercostal space at right side radiating to neck which is a description of murmur of aortic stenosisheart rate is also 120 again ventricle get less time to fill and they contract before filling properly this also favours dec cardiac out put
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| mohelgamal
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Ashfaque I don't agree it is A because the systolic bp is 160 in exercise so the stenosis is not causing a low co here
I choose d but not sure
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| ManuNastai
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musuq, what's the answer?
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| Allison
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Answer A: This is aortic stenosis: As the aortic valve becomes more narrow, the pressure increases inside the left heart ventricle. This causes the left heart ventricle to become thicker, which decreases blood flow and can lead to chest pain. As the pressure continues to increase, blood may back up into the lungs and you may feel short of breath
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| filatino
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i would go with D. the direct reason of shortness of breath is increased ED pressure.
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| dreamer
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what is the change of aortic pressure in aortic stenosis and aortic regurgitation?
could someone explain to me? 
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| ing
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A. It like left side HF.
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| ssrpk
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definitey D!
cmn one can easliy calculate the CO at rest and during excercise!
here, resting Cardiac output : 90 X 85 = 7650
during excercise : 107 X 120 = 12840
besides, Low cardiac output in pts with aortic stenosis during excercise would give them syncope, light headedness, not so much for the shortness of breath unless there is CHF i.e.advanced stage!
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| ssrpk
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on second thought! it can't even be D!
because ejection fraction is well maintained [64%] during rest and during excercise! besides why wud an increase in end-diastolic pressure would matter so much for pulmonary circulation,as long as EF is maintained it would keep the end-systolic pressure from rising, which would otherwise hv resulted in backward failure and overloading of pulmonary circulation!
as for me,none of the options makes sense!
a) well in this case cardiac output has'nt decreased! [increased by 18%]
b)not possible
c) does HTN lead to dyspnea?? - definitely not!
and e) well i get tachycardia whenever i work out but i don't get any dyspnea, coz i maintain my cardiac variables well during my workout! same case here! then why shud it be the reason!
i can't think of a logical answer in this case!
whtz the answer musuq, and plz provide explanation as well!
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| ManuNastai
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ssrpk wrote:
and e) well i get tachycardia whenever i work out but i don't get any dyspnea, coz i maintain my cardiac variables well during my workout! same case here! then why shud it be the reason!
that it's because you have a healthy heart! this guy's is not!
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| vallia
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I think it's A
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| Luckyall
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Definetelly D !
incr EDP leads to incr LA Press -----> incr pulm venous Press--->Pulm Edema---> SOB
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| Luckyall
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Even more Mean LA press is a good estimate of LV EDPress, if LA Press incr---> Incr pulm venous Press----> pulmon edema
So thas why incr. EDP (choiseD )is the answer and not decr. in CO ( choise A )
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| ssrpk
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well.....i can feel the norepinephrine crossing my synapses now!
why shud there be an increase in LVEDP or volume....if there is tachycardia there ain't enuff time for ventricles to fill up!
but if the ventricles are hypofunctioning then its posible even despite tachycardia.....hmmmmm makes perfect sense to me now...was lost in the variables previously!
thanks lucky!
answer is most definitely D
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