A 32-year-old woman with a history of HIV presents to the hospital with severe shortness of breath. She completed her last round of chemotherapy for non-Hodgkin lymphoma 6 months ago, and has since been in remission. She is afebrile and normotensive, but has a respiratory rate of 28 breaths per minute. She has an S3 on examination with distended neck veins and wet rales at the bases of her lungs. A chest x-ray shows bilateral opacities with air bronchograms and small pleural effusions.
Which of the following is the most appropriate next step in management?
IV furosemide. The question asks for the management of acute heart failure, but there are a couple of quick teaching points. First, the patient is HIV+ and therefore is at risk for opportunistic infections (OIs) as well as some cancers (including lymphoma, which occurred in this patient). Second, anthracycline chemotherapy (doxorubicin, daunorubicin) is commonly given for treatment of non-Hodgkin lymphoma (part of CHOP or R-CHOP therapy); a high-yield adverse effect of these drugs is cardiotoxicity, which can result in heart failure. This patient is presenting with findings of acute heart failure, and the management of this condition can be remembered using the mnemonic LMNOP (Lasix, Morphine, Nitrates, Oxygen, Position). These patients require diuresis with IV loop diuretics to remove excess fluid, which will reduce excessive filling pressures and improve the cardiac output of the heart.
(A) Although pneumonia may be considered in the differential, the physical examination findings (especially jugular venous distention) is more consistent with heart failure. The fact that she is afebrile does not rule out infection, since HIV patients often do not mount an appropriate immune response to infections. (B) PCP pneumonia is a common OI in patients with HIV, and treatment with prednisone prior to trimethoprim–sulfamethoxazole is warranted with severe infections. (C) Although myocardial infarction can cause heart failure, there is nothing in the question stem to suggest this as the cause. In addition, PCI would only be appropriate after other tests are performed to confirm the diagnosis (ECG, troponins, etc.).
A 38-year-old man with no medical history presents to the hospital with worsening shortness of breath. He reports that the symptoms are worse while lying down and in certain positions. On examination, he is afebrile with a normal blood pressure. A mid-diastolic murmur is heard at the apex and there is a plopping noise heard during early diastole. The nature of the murmur changes with body positioning. An echocardiogram is performed which shows a mass arising from the left atrium.
Which of the following is the most likely diagnosis?
Atrial myxoma. Although tumors of the heart are rare, a murmur similar to mitral stenosis that changes with position and is associated with a plopping noise should raise a concern for this diagnosis. Atrial myxomas are the most common primary cardiac tumors and are benign. Surgery is required to remove the mass and prevent complications such as obstructive shock and tumor emboli. Metastases to the heart are more common than primary cardiac tumors, and melanoma is a cancer that can metastasize here (always think of melanoma as metastasizing to strange locations); however, this was not provided as an answer choice. (A) The echocardiogram described a mass arising from the atrium, and on examination there was a characteristic “tumor plop” sound as the tumor falls back in place during diastole. A thrombus would not present with cause these findings. (B) The patient is afebrile and does not meet the modified Duke criteria, making infective endocarditis less likely. (C) Atrial sarcomas are malignant cardiac tumors; however, they are not the most common primary cardiac tumor.
A 62-year-old man presents to the Emergency Department with difficulty breathing. The dyspnea began acutely earlier in the day without any trigger, and was accompanied by nausea and sweating. He denies any fevers, chest pain, abdominal pain, or frequent urination. He has a long history of type 2 diabetes mellitus, hypertension, and diabetic neuropathy, for which he takes metformin, lisinopril, and gabapentin, respectively. His vitals are taken and he is afebrile with a blood pressure of 98/60 mmHg, heart rate of 111 beats per minute, respiratory rate of 30 breaths per minute, and oxygen saturation of 94% on room air. He is extremely uncomfortable and short of breath during examination. His neck veins are distended with no cardiac murmurs auscultated. Rales are heard over both lung bases. When pressure is applied to his upper abdomen, the neck veins distend further and return to baseline after 15 seconds. Initial laboratory values are shown below:
Which of the following is the most appropriate first order to make?
Troponins and an ECG. This is a diabetic patient presenting with evidence of end-organ damage from this disease. He has an elevated creatinine and proteinuria, with a history of neuropathy. In patients with diabetic neuropathy, innervation to the heart may also be affected and these patients can have myocardial infarctions without chest pain. Because diabetes and hypertension are risk factors for cardiovascular events, it is important to have a very low index of suspicion for ACS in these patients. The sudden onset of symptoms and findings of cardiac failure on examination (distended neck veins, positive abdominojugular reflex) make ACS a concern. Therefore, the next step should be to order troponins and an ECG.
(A) A chest x-ray would not add much additional information at this point other than to confirm the presence of pulmonary edema. (B) Urine and serum ketones would assess for diabetic ketoacidosis; however, there are no other historical or examination findings to suggest this as a likely diagnosis; the acute onset of symptoms also argue against this. (C) Although pulmonary embolism could present like this and certainly should be on the differential, a CT angiogram contains contrast and therefore should not be ordered immediately given that the patient has evidence of renal failure. A V/Q scan would be more appropriate in this case. (D) An infection is unlikely since the patient is afebrile with a normal white count. Excessive IV fluids may harm the patient, since the patient’s hypotension is cardiogenic in nature and not due to hypovolemia (distended neck veins).
A 26-year-old woman presents to the Emergency Department after fainting. She is a graduate student and reports staying up all night to finish a paper and drinking several energy drinks. While sitting at her desk, she felt her heart racing and then lost consciousness. She awoke without any memory loss but is concerned that it will happen again. She currently has a normal heart rate and blood pressure. Her ECG is shown in Figure below.
Which of the following agents should be avoided while the patient is in the Emergency Department?
Metoprolol. The ECG shows the classic delta waves and short PR interval of Wolff–Parkinson–White (WPW) syndrome, which is caused by an accessory pathway that bypasses the AV node and can cause serious tachyarrhythmias. The gradual upslope of the QRS complexes (delta waves) are caused by early depolarization of the ventricles through the accessory pathway. Asymptomatic patients do not require treatment; however, this patient experienced syncope and thus deserves treatment to prevent further episodes. Catheter ablation of the accessory pathway should be offered to symptomatic patients, since there are high success rates without the need for chronic medications. β-blockers, calcium channel blockers, and digoxin are contraindicated in WPW since they slow down conduction through the AV node and thus can facilitate conduction down the accessory pathway and precipitate a life-threatening tachyarrhythmia. (An important caveat is that these agents may be used during an acute tachyarrhythmia to stop conduction through the AV node, terminating the reentrant tachycardia.)
(B, C) If catheter ablation is refused, then the first-line choice for a chronic prophylactic agent is a class IC anti-arrhythmic (e.g., flecainide, propafenone). (D) Amiodarone is an alternative to class IC anti-arrhythmics for chronic prophylaxis.
An elderly man is hospitalized for chest pain and requires cardiac catheterization with placement of a stent. He recovers and is discharged. One month later, he presents to your clinic with a 1-week history of fever and stabbing chest pain. His vitals are within normal limits, and there is a scratching noise that is best heard at the left lower sternal border.
What is the most appropriate treatment at this time?
Ibuprofen. This patient is presenting with Dressler syndrome, which is a self-limited autoimmune pericarditis that typically occurs 2 to 10 weeks after a myocardial infarction. It presents like acute pericarditis (pleuritic chest pain relieved by leaning forward), and the treatment is NSAIDs. The scratching noise heard during physical examination is a friction rub, which typically has three parts and is caused by inflamed pericardium rubbing together during cardiac motion.
(E) Prednisone is not necessary in these patients. (C, D) The antibiotic regimens are for community-acquired pneumonia (azithromycin) and health care–associated pneumonia (ceftriaxone, levofloxacin, and vancomycin); although it may be tempting to consider pneumonia in a patient presenting with fever and chest pain, the association with a recent myocardial infarction should lead the reader to suspect one of the postmyocardial infarction complications rather than pneumonia.
Click to expand