A 70-year-old man is admitted to the telemetry unit for workup of dizziness of 2 days’ duration. He denies chest pain or shortness of breath. His heart rate is 60 bpm and blood pressure is 130/50 mmHg. On physical examination, a systolic murmur is heard over the left sternal border. Carotid duplex ultrasound is performed demonstrating the spectral waveforms of the bilateral internal carotid and vertebral arteries illustrated in Figure below.
Which of the following conditions is suggested by the carotid duplex waveforms?
Aortic valve stenosis. The waveforms in the bilateral internal carotid and vertebral arteries have a Tardus-Parvus morphology. They have a blunted and slow upstroke, suggesting more proximal or central narrowing. In this patient, these findings along with a systolic murmur are suggestive of aortic valve stenosis.
A 55-year-old woman presents to the ED with precordial chest discomfort and shortness of breath. Her body mass index is 34. Her medical history includes essential hypertension, diabetes mellitus type 2, and a 30 pack-year smoking history. Laboratory results include a troponin of 2.4 mg/mL and a B-type natriuretic peptide of 840 pg/mL. An ECG reveals no ST-segment elevation and nonspecific ST-T wave changes. The ED physician requests cardiology consultation for an NSTEMI. When you arrive to see the patient you order an IV contrast-enhanced chest CT scan of the lungs. Findings are demonstrated in Figure below.
What is the diagnosis?
Saddle pulmonary embolism. This patient has a pulmonary embolism involving both main pulmonary arteries. Massive and submassive pulmonary embolism can cause an increase in troponin and B-type natriuretic peptide as seen in acute myocardial infarction. The image shown illustrates a filling defect within the main pulmonary artery at the bifurcation. There are no findings suggestive of aortic dissection, pneumonia, or interstitial fibrosis.
Which of the following cardiovascular risk factor assessment tools has not been demonstrated to be useful in the risk assessment for a first atherosclerotic cardiovascular event?
Carotid intima-media thickness. According to the latest American College of Cardiology/American Heart Association cardiovascular risk assessment guidelines, there is insufficient evidence available to recommend use of carotid intima-media thickness, ApoB, albuminuria, glomerular filtration rate, or cardiorespiratory fitness in cardiovascular risk assessment. There is adequate evidence to recommend use of high-sensitivity C-reactive protein, ABI, coronary artery calcium score, and a family history of premature cardiovascular disease for refinement of cardiovascular risk assessment.
Goff Jr DC, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk. J Am Coll Cardiol. 2013. doi:10.1016/j.jacc.2013.11.005.
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