NBME F1B1Q33- 37yo woman with progressive SOB - maritzasf

[ArchivalUser]

Q-33.
A 37-year-old woman comes to the physician because of progressive shortness of breath over the past 5 years; she now has fatigue and shortness of breath with mild exertion. She has a history of mitral stenosis secondary to rheumatic fever at the age of 15 years. She was asymptomatic until 5 years ago when she developed severe shortness of breath during pregnancy. She was treated with diuretics, low-sodium diet, and bed rest, and she was able to deliver the baby at term. Her only medication is hydrochlorothiazide. Her temperature is 37 C (98.6 F), blood pressure is 110/80 mm Hg, pulse is 100/min and regular, and respirations are 26/min. Cardiac examination shows an obvious opening snap in S2. A grade 3/6, late diastolic murmur is heard at the apex. A right ventricular lift is palpated along the left sternal border. Which of the following is most likely increased in this patient?

A) Blood flow to the lower lung fields
B) Diastolic filling time
C) Left-to-right shunt of blood
D) Left ventricular end-diastolic pressure
E) Pulmonary artery pressure

[ArchivalUser]

e.
this is a classic case of ms LV diastolic pressure and EF are normal in isolated ms pap increase often cause secondary elevation of rv diastolic pressure

[ArchivalUser]

Answer:
E) Pulmonary artery pressure

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Mitral Stenosis
Narrowing of the MV causes obstruction to blood flow into the LV during Diastole. The normal mitral valve orifice area is 4-5cm2. Symptoms typically occur when the orifice area is less than 2.5

The MCC is Rheumatic Heart Disease (60% of cases). Mitral stenosis may present with Afib and Systemic Embolism
A latent period of 20-40 years before symptoms of left-sided heart failure may occur. If untreated, MS can lead to *** PULMONARY HYPERTENSION and to a 10-year mortality rate of 45% due to *** PROGRESSIVE PULMONARY AND SYSTEMIC CONGESTION.


PE:
The murmur of MS is a diastolic rumble after an opening snap, which can be described as an “extra sound” in diastole. The S1 is louder.
As the mitral stenosis worsens, the opening snap moves closer to S2. The murmur will increase in intensity with leg raising, squatting, and expiration.


Diagnostic Testing
TTE is the best initial diagnostic test. TEE is more accurate.
Left heart catheterization is the most accurate test. EKG and a chest X-ray will show left atrial hypertrophy. On chest X-ray, there is straightening of the left heart border and elevation of the left mainstem bronchus. There may also be a description of a double density in the cardiac silhouette (from left atrial enlargement).


Treatment
Diuretics are the best initial therapy. They do not alter progression.
Balloon valvuloplasty is the most effective therapy. Pregnant women can and should be readily treated with balloon valvuloplasty. Pregnancy is not a contraindication to valvuloplasty.


Urgent action
One needs to establish whether the patient is, or wishes to become, pregnant. Pregnancy in a patient with severe mitral stenosis has a high rate of both maternal and fetal complications, including death.

[The American College of Cardiology]