Aashi
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A 52-year-old Hispanic woman presents for an employment physical examination. The patient is a recent immigrant, and she hasn't seen a doctor for fifteen years. She denies chest pain or shortness of breath. She has good exercise tolerance and doesn't have a history of cardiac problems. The blood pressure is 165/70 mm Hg, and heart rate is 72/min. No jugulovenous distention is seen, and carotid bruits are absent. On heart examination, there is a normal S1, a physiologically split S2, a II/VI systolic ejection murmur at the base, and a III/VI diastolic decrescendo murmur at the left sternal border. This diastolic murmur is best heard when the patient holds her breath while sitting or leaning forward. Which of the following is most likely to benefit this patient?
(A) Digoxin
(B) Metoprolol
(C) Nifedipine
(D) Balloon manipulation
(E) Valve replacement
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| CocaCola
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sounds like aortic regur superimposed on mitral stenosis... best treatment is aortic valve replcement... however the patient is asymptomatic so better to just decrease afterload...
c - nifedipine
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| fox
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b) metaprolol
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| Aashi
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Answer:
(C) Nifedipine
Explanation:
This patient has aortic valve insufficiency (AI). She has a decrescendo diastolic murmur and a wide pulse pressure. The most likely cause of aortic insufficiency in this case is a congenital bicuspid aortic valve. The coexistence of aortic stenosis and AI is almost always from rheumatic fever or congenital disease. The first step is an echocardiogram to confirm the diagnosis, establish the cause of valve disease, and evaluate the ventricular size and systolic function. Some patients with chronic aortic regurgitation have irreversible left ventricular (LV) systolic dysfunction before the onset of symptoms.
If an echocardiogram reveals LV dilatation in patients with aortic valve insufficiency, afterload reduction therapy should be started with ACE inhibitors or nifedipine. Nifedipine can help delay the progression of the disease and delay the need for surgical valve replacement. Beta-blockers have not been found to be useful in AI. They may increase the severity of regurgitation by prolonging diastole. Valve replacement is not definitely necessary because she is not symptomatic. Valve replacement can be useful in asymptomatic patients if the patient has progressive LV dysfunction with an ejection fraction of <55%. Digoxin is of extremely limited value in aortic regurgitation.
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| vrach
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agree with cocacola - C
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