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A 54-year-old man from Thailand presents to your office complaining of occasional shortness of breath. He claims that the shortness of breath occurs shortly after having intercourse with his wife. He denies any chest pain, nausea, vomiting, or diaphoresis. He also denies hemoptysis or palpitations. He claims that be has been married for 30 years and he has noticed this shortness of breath increasing in frequency over the past year. He denies any medical history and denies taking any medications. On examination, the patient is noted to have a diastolic murmur, best heard in the left lateral recumbent position. The remainder of the exam is unremarkable. The patient is sent for transthoracic echocardiogram, which reveals a mitral area of 1.8 cm2 with a transmitral gradient of 3 mm Hg. No left atrial enlargement or thrombus is seen. What is the next best step in the management of this patient?
(A) Transesophageal echocardiogram (TEE)
(B) Cardiac catheterization
© Echo-stress test
(D) Start the patient on atenolol 25 mg daily
(E) Schedule patient for valvulotomy
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Mild exertional Symptoms... why not go for Stress test first..?? CC???
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Answer:
© Echo-stress test
Explanation:
In a patient who is minimally symptomatic with a mitral valve area of greater than 1.5 cm2, the best management would be to assess the patient's symptoms while performing exercise. This is done to measure the pulmonary artery pressure and transmitral gradient during a stress echocardiogram test during either bicycle or treadmill exercise. One can also confirm the effect of exercise by actually seeing the effects of exercise while performing a right heart catheterization. If the patient does not have a pulmonary artery pressure of >60 mm Hg, or a gradient of >15 mm Hg across the mitral valve, the patient can be followed up yearly for changes in symptoms and valve area.
Cardiac catheterization is not needed to confirm the diagnosis of mitral stenosis. The role of cardiac catheterization comes into play when a patient is scheduled for mitral valve surgery to evaluate for underlying coronary artery disease and a more exact measurement of the valve area and gradient. The role of transesophageal echocardiogram (TEE) in mitral stenosis would be to evaluate for a left atrial thrombus in a patient who presents with new-onset atrial fibrillation in the setting of mitral stenosis. TEE is also crucial for evaluation for a left atrial thrombus prior to commissurotomy because any evidence of a left atrial thrombus is a contraindication a commissurotomy. If the patient has no symptoms and the echocardiogram shows only mild stenosis, the patient can be sent home and followed up yearly for changes in valve area and symptoms.
If the patient is not a candidate for valvulotomy because of mild symptoms and mild stenosis, he can be started on a beta-blocker after appropriate evaluation with a stress echocardiogram. In patients with mitral stenosis, the increased heart rate -- as this patient experienced during intercourse -- results in a decreased diastolic filling period, thereby increasing the transmitral gradient and increasing the backflow of blood into the lungs.
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antigen what is the source of these q's and answers..??
