Management of Chronic Disease/ Cardiology for the Internist

Here are a few common clinical scenarios.  Your job now is to say what you would do in these situations and why.  In extreme detail.  Detail the parts of your recommendation which stand on a firm evidence base and the parts which stand on shaky or non-existent evidence.  The idea is to practice making clinical decisions  in a hyper-rational, evidence based way.  This entails knowing the evidence-base, extrapoloating from the evidence base where appropriate, and winging it well when there is no good evidence. Secondary sources such as the In the Clinic article attached here, UptoDate, The Hopkins module, and The Cochrane reviews are good places to start your research.  However, your presentation should refer to important primary studies and not just quote recommendations or guidelines. 

Patient 1:  A 65 year old woman with type II diabetes, hypertension, and hypercholesterolemia complains of  shortness of breath when climbing hills.  Her meds include aspirin, zocor, lisinopril, hctz, metformin, and glyburide.  Exam is normal including BP of 120/ 79 and HR 72.  Resting EKG shows nonspecific T wave changes similar to baseline.  On a treadmill stress test, she reaches 100% of MPHR.   There are half mm horizontal ST depressions in II, III, and aVF at stage III that correspond to shortness of breath.  The thallium portion of the test shows a small perfusion defect in the inferior wall of moderate intensity.

            – Should the patient receive a cardiac catheterization?

            – What if she is started on beta blockers and becomes asymptomatic?  Is catheterization indicated?

            -What if she cannot tolerate beta blockers or nitrates and remains symptomatic only when climbing hills?

            – Which therapies, medical or interventional, alter the prognosis of CAD, and by how much?

Patient 2:  A 72 year-old woman with a history of diabetes, hypertension and coronary artery disease diagnosed by catheterization 6 months ago (70%  OM1 lesion, a 40% RCA, and a 30% LAD, normal EF and wall motion) comes to walk-in complaining of right parasternal sticking chest pain similar to the pain which led to her catheterization. since this morning  The pain had gone away when she took her daily dose of isosorbide mononitrate but started again two hours ago while she was mopping.  This time it lasted about ten minutes, went away, and then came back while she was watching television and lasted another ten minutes.  She had palpitations and slight shortness of breath with the first bout but not with the second.   Exam is normal and EKG is unchanged. 

            – What is the probability that she is suffering an MI?  Should she be admitted?

            – What if the chest wall was tender?   Would the probability change?

            – What if the pain was left sided?  What if it was squeezing?

            – What if the catheterization had been two years ago and she had come to the hospital five times since with a similar presentation?

Patient 3:  A 54 year old woman without known past medical history (she hasn’t been to a doctor in twenty years) except 30 years of cigarette smoking presents with 6 months of progressive DOE, orthopnea, and edema.  There is no history of chest pain.  Exam is notable for BP of 170/90, HR 92, bibasilar rales, S3 gallop, and 2+ dependent edema.   Workup reveals normal labs except for Cr 1.9, UA trace protein, LDL 130, HDL 42, CMG with PVC on CXR, LBBB on EKG, and echo with EF 40%, global hypokinesis, and LVH. 

            – What further workup, if any, is warranted?

            – With which medicines should she be treated, started in which order? 

Patient 4:  You have taken a new job at the Avoid Evidence Clinic of Medicine replacing Dr. Methusalah, who recently died.  Your first patient is Mrs. Faithful, a 74 yo woman with a history of atrial fibrillation.  Looking through the chart, you see that Dr. M. first noted the A Fib 4 years ago after the patient came in as walk-in the day after a syncopal episode.  Her ventricular rate then was 120.  Dr. M. started her on tenormin and lanoxin, which lowered her rate into the 50-60s.  Subsequently she infrequently complained of palpitations for which he prescribed her propranolol 10 mg prn.  The patient has no complaints.  She can walk the 4 blocks to the pharmacy without stopping.  There are about 15 EKGS in the chart, half of which show AFib, half of which are in NSR.  She also has HTN, for which she has been prescribed Lozol 2.5 mg and “AODM,” for which she takes Diabeta 5 mg.   She also takes ASA 325 mg.  PMH is otherwise negative.  On exam, she is in Afib with an apical rate of 56, BP of 145/85, clear lungs, 2/6 holosystolic murmur, and trace pedal edema. Pedal pulses are full.  EKG shows Afib with ventricular rate 64, LVH by voltage criteria.  You order an echo which shows EF 58% with increased LV mass and concentric hypertrophy as well as moderate mitral regurgitation and LA diameter of 4.5 cm and estimated RVSP of 40.

– What further workup, if any, is warranted?

– Should she be anticoagulated?  If so, with what medication?

– What changes, if any, do you recommend for her cardiovascular medications?