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Category: Cardiology--->Pulmonary Hypertension And Pericardium
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Question 11#Print Question

You are reviewing a 42-year-old man in the outpatient clinic who is under follow-up for recurrent troublesome attacks of acute pericarditis. He has had 16 episodes of pericarditis which initially followed a viral illness. No underlying systemic cause has been found despite extensive investigations. The episodes are associated with small- to moderate-sized pericardial effusions. Initially, the episodes respond well to systemic steroids; however, he has troublesome steroid side effects. On weaning the steroids with appropriate colchicine cover, the episodes recur.

What is the best option with regard to management?

a. Plan to continue steroids long term at a lower dose as dual therapy with colchicine; appropriate bone protection should be given
b. Leave him off treatment and advise him to return immediately to the ED for early pericardiocentesis with topical high-dose steroid administration if his symptoms recur
c. Liaise with the rheumatological team regarding administration of immunosuppressant therapy as the most likely underlying pathological process is one of autoimmunity
d. Refer to cardiothoracic surgeons for consideration of total pericardiectomy
e. Continue to manage episodes with steroids and colchicine and monitor with annual echocardiograms for development of constrictive pericarditis


Question 12#Print Question

A 62-year-old man is admitted with chronic obstructive pulmonary disease (COPD) and mild left ventricular (LV) dysfunction (ejection fraction [EF] 45%) as well as symptomatic, recurrent atrial fibrillation (heart rate [HR] 120s to 150s) despite antiarrhythmic drug therapy and direct current cardioversion in the past. After rate control with intravenous (IV) βblockers, the HR improves and the patient feels better. Given his recurrent atrial fibrillation despite optimal medical therapy, the patient is referred for radiofrequency ablation of atrial fibrillation (pulmonary vein isolation) procedure. The procedure is performed on anticoagulation (international normalized ratio >2.0) and is deemed a success, with no inducible atrial fibrillation at the end of the case. A small atrial septal defect (ASD) was noted with intracardiac echocardiography at the end of the case, with no other remarkable findings. That evening in the post-anesthesia care-unit (PACU), the patient is noted to be hypotensive and tachycardic with increasing dyspnea. There is a concern for cardiac tamponade; however, the arterial line does not show a significant respiratory variation of the blood pressure (BP) waveform (pulsus paradoxus). An echocardiogram is performed, demonstrating a large circumferential effusion and the patient is referred for urgent pericardiocentesis.

Which of the following explains why the patient did not develop a pulsus on the arterial line, despite a large, hemodynamically significant pericardial effusion?

a. Presence of an ASD
b. Administration of excess IV fluid during the ablation
c. LV dysfunction
d. COPD


Question 13#Print Question

A 38-year-old patient with no prior medical history presents to the emergency room with 4 days of chest discomfort. He denies any recent trauma, fever, or use of anticoagulants. The pain is positional and the patient reports mild upper respiratory infection (URI) symptoms in the preceding week. Laboratory work is notable for elevated white blood cell count (neutrophil predominance) as well as elevated erythrocyte sedimentation rate (ESR)/high-sensitivity C-reactive protein (hsCRP); his troponin and other laboratory work is otherwise negative/normal. Electrocardiogram (ECG) is consistent with pericarditis. There is a low suspicion for acute coronary syndrome, and acute pericarditis is diagnosed with small effusion on the echocardiogram; the pain improves with analgesics.

Which of the following regimens is the most appropriate therapy for this patient to treat the acute episode and maintain remission?

a. Ibuprofen 600 TID for 2 weeks followed by taper and colchicine 0.5 mg BID for 3 months
b. Aspirin 325 daily and colchicine 0.5 mg BID for 2 weeks followed by taper
c. Ibuprofen 400 BID and colchicine 0.5 mg BID for 2 weeks followed by no taper
d. Prednisone 10 mg daily and ibuprofen 600 TID for 3 months followed by no taper


Question 14#Print Question

A 62-year-old man with cardiac risk factors of tobacco use, hypertension, and diabetes mellitus returns for follow-up after late-presenting mid-left anterior descending artery (LAD) ST-elevation myocardial infarction (MI). He had an occluded mid-LAD, which was successfully aspirated and stented with a single drug-eluting stent; no significant disease elsewhere is noted. The next day he reports progressive chest discomfort and mild fever and has developed a two-component pericardial friction rub on physical examination. His ECG is concerning for pericarditis (Dressler syndrome) and an echo is performed showing no interval change from discharge other than the presence of a small pericardial effusion.

Which of the following regimens would be the most appropriate therapy in this patient?

a. Aspirin 650 TID for 2 weeks with taper to 81 mg daily + colchicine 0.5 mg BID for 3 months
b. Aspirin 325 daily for 2 weeks, then taper to 81 mg daily + ibuprofen 600 mg TID for 3 months
c. Ibuprofen 600 mg TID for 2 weeks with taper + colchicine 0.5 mg BID for 3 months
d. Indomethacin 50 mg TID for 3 months as well as aspirin 650 mg TID for 3 months with taper to 81 mg


Question 15#Print Question

A 45-year-old male patient with a history of acute pericarditis now returns for outpatient follow-up with increasing dyspnea and lower extremity edema. The patient was seen and started on high-dose aspirin and colchicine (no nonsteroidal anti-inflammatory drugs [NSAIDs] due to allergy) and has not been able to taper for the past 6 months due to persistent low-level symptoms. He has an elevated jugular venous pulse without inspiratory decline, 2+ pedal edema, and congested liver without ascites, as well as a soft pericardial knock. Laboratory values are notable for mild transaminitis as well as elevated ESR/hsCRP. ECG is unremarkable and echo shows a small persistent pericardial effusion with tubular-shaped LV with normal function, along with diastolic bounce and conical-shaped right ventricle (RV) as well as plethoric inferior vena cava and respirophasic transmitral and trans-tricuspid variation all consistent with constrictive pericarditis.

Which of the following would be the next most appropriate step in management?

a. Initiate steroid therapy (0.25 to 0.5 mg/kg/day) along with colchicine, and initiate PO diuretic
b. Admit for IV diuresis and transition to PO diuretic regimen after cardiac catheterization for constriction evaluation
c. Repeat echo in 2 to 3 months aspirin and colchicine at current doses
d. Surgical evaluation for pericardiectomy/stripping




Category: Cardiology--->Pulmonary Hypertension And Pericardium
Page: 3 of 8