ITE - Internal Medicine In-Training Valvular Heart Disease Management Questions and Answers — Questions and Answers
Question 1: A 72-year-old male with a history of hypertension presents for a routine evaluation. He denies chest pain, dyspnea, or syncope. On physical exam, you note a grade 3/6 late-peaking systolic ejection murmur at the right upper sternal border that radiates to the carotids. An echocardiogram reveals a calcified aortic valve with a peak velocity of 4.5 m/s, a mean gradient of 50 mm Hg, and an aortic valve area of 0.8 cm². His left ventricular ejection fraction (LVEF) is 65%. Which of the following is the most appropriate next step in management?
- Initiate medical therapy with a beta-blocker and schedule a follow-up in one year.
- Perform an exercise stress test to confirm asymptomatic status. (Correct answer)
- Refer for surgical aortic valve replacement (SAVR).
- Begin afterload reduction with an ACE inhibitor.
Correct answer: Perform an exercise stress test to confirm asymptomatic status.
According to the 2020 ACC/AHA guidelines, for asymptomatic patients with severe aortic stenosis, exercise testing is reasonable to confirm the absence of symptoms and to assess hemodynamic response. The development of symptoms during exercise would be an indication for intervention. Medical therapy with beta-blockers or ACE inhibitors has not been proven to alter the natural history of aortic stenosis and is not the primary treatment. While the patient has severe aortic stenosis based on echocardiographic criteria, intervention is primarily indicated for symptomatic patients or those with LV dysfunction. Therefore, confirming his asymptomatic status with objective testing is the most appropriate next step before considering valve replacement.
Question 2: A 65-year-old female is diagnosed with severe, symptomatic, degenerative mitral regurgitation (MR) and is referred for surgical evaluation. Her LVEF is 65% and left ventricular end-systolic dimension (LVESD) is 38 mm. Which of the following is the preferred surgical approach?
- Mitral valve replacement with a bioprosthetic valve.
- Mitral valve replacement with a mechanical valve.
- Mitral valve repair. (Correct answer)
- Transcatheter edge-to-edge repair (TEER).
Correct answer: Mitral valve repair.
For patients with severe primary mitral regurgitation who are symptomatic and have preserved left ventricular function, mitral valve repair is the preferred surgical technique over replacement when it is feasible and likely to be durable. Repair is associated with lower operative mortality, better preservation of postoperative LV function, and improved long-term survival compared to mitral valve replacement. Mechanical and bioprosthetic replacements are typically reserved for cases where repair is not possible. TEER is generally considered for patients who are at high or prohibitive surgical risk.
Question 3: A 58-year-old male with a bicuspid aortic valve is found to have severe chronic aortic regurgitation (AR) on a routine echocardiogram. He is completely asymptomatic. His LVEF is 52% and his LV end-diastolic dimension is 72 mm. Blood pressure is 130/50 mmHg. According to the most recent guidelines, which of the following is the strongest indication for aortic valve replacement in this patient?
- The presence of a bicuspid aortic valve.
- The wide pulse pressure.
- The left ventricular ejection fraction. (Correct answer)
- The severe degree of regurgitation.
Correct answer: The left ventricular ejection fraction.
The 2020 ACC/AHA guidelines lowered the threshold for intervention in asymptomatic severe aortic regurgitation. Aortic valve replacement is recommended for asymptomatic patients with severe AR if the LVEF is 55% or less. This patient's LVEF is 52%, which is a clear indication for surgery to prevent irreversible left ventricular dysfunction. While the bicuspid valve is the etiology and the wide pulse pressure is a physical finding, the LVEF is the key parameter guiding the timing of intervention in this asymptomatic patient.
Question 4: A 45-year-old female immigrant from Southeast Asia presents with progressive exertional dyspnea. She has a history of rheumatic fever in childhood. On exam, she has an opening snap and a low-pitched diastolic rumble at the apex. She is found to be in atrial fibrillation with a rapid ventricular response. Echocardiography confirms severe rheumatic mitral stenosis (valve area 0.9 cm²). Which of the following medications is contraindicated for anticoagulation in this patient?
- Warfarin.
- Heparin.
- Dabigatran. (Correct answer)
- Enoxaparin.
Correct answer: Dabigatran.
In patients with atrial fibrillation and moderate-to-severe rheumatic mitral stenosis, anticoagulation with a vitamin K antagonist (VKA) like warfarin is recommended. Non-vitamin K antagonist oral anticoagulants (NOACs), such as dabigatran, are not recommended and are considered contraindicated in this specific patient population due to a lack of evidence and potential for harm. Heparin and enoxaparin can be used for bridging or acute anticoagulation.
Question 5: Which of the following is an established indication for intervention in a patient with asymptomatic severe primary mitral regurgitation?
- Left ventricular end-systolic dimension (LVESD) of 38 mm.
- Left ventricular ejection fraction (LVEF) of 65%.
- Pulmonary artery systolic pressure (PASP) at rest of 55 mmHg. (Correct answer)
- Age greater than 75 years.
Correct answer: Pulmonary artery systolic pressure (PASP) at rest of 55 mmHg.
For asymptomatic patients with severe primary mitral regurgitation and preserved LV function (LVEF >60% and LVESD <40 mm), surgery is indicated if new-onset atrial fibrillation or pulmonary hypertension (pulmonary artery systolic pressure >50 mmHg at rest) develops. An LVEF of 65% and LVESD of 38 mm are within the normal range and would not trigger intervention on their own. Advanced age is a factor in risk assessment but not a primary indication for surgery.
Question 6: A 68-year-old female with severe chronic aortic regurgitation and an LVEF of 35% is symptomatic with dyspnea on exertion despite being on optimal medical therapy for heart failure, including a beta-blocker and diuretic. Her blood pressure is 145/70 mmHg. Which medication class, if added, would be most beneficial for afterload reduction in this patient?
- Non-dihydropyridine calcium channel blockers.
- Angiotensin-converting enzyme (ACE) inhibitors. (Correct answer)
- Hydralazine.
- Digoxin.
Correct answer: Angiotensin-converting enzyme (ACE) inhibitors.
In patients with symptomatic severe chronic aortic regurgitation who are not surgical candidates, or in those with LV systolic dysfunction, afterload reduction is a key component of medical management. ACE inhibitors or Angiotensin Receptor Blockers (ARBs) are preferred agents for this purpose, as they reduce systemic vascular resistance, decrease the regurgitant volume, and improve forward cardiac output. While hydralazine also reduces afterload, ACE inhibitors have more established benefits in heart failure with reduced ejection fraction. Non-dihydropyridine calcium channel blockers can have negative inotropic effects and are generally avoided. Digoxin may be used for rate control or symptoms but does not primarily address afterload.
ITE - Internal Medicine In-Training Valvular Heart Disease Management Questions and Answers
A 72-year-old male with a history of hypertension presents for a routine evaluation.
He denies chest pain, dyspnea, or syncope.
On physical exam, you note a grade 3/6 late-peaking systolic ejection murmur at the right upper sternal border that radiates to the carotids.
An echocardiogram reveals a calcified aortic valve with a peak velocity of 4.5 m/s, a mean gradient of 50 mm Hg, and an aortic valve area of 0.8 cm².
His left ventricular ejection fraction (LVEF) is 65%.
Which of the following is the most appropriate next step in management?