Browse the corpus

Answers and Critiques Item 1 Answer: D Bibliography Educational Objective: Treat stable heart failure with Maddox l M, Januzzi )L lr. Allen t.A. et al; Writing Committee. 2O2l Update to the 2017 ACC expert consensus decision pathway for optimization of reduced ejection fraction with valsartan-sacubitril. heart failure treatment: ansu,ers to l0 pivotal issues about heart failure with reduced ejection fiaction: a report of the American College of The most appropriate treatment is to switch lisinopril to Cardiologr Solution Set Oversight Commifiee. J Am Coll Cardiol. 2O2t; 77 :77'2 81O. LPMID: 334.16.1i01 doi:l0.l0l6ij.jacc.2O2O.ll.O22 valsartan-sacubitril (Option D). This patient with hearl fail ure with reduced ejection fraction (HFTEF) and New York Heart Association (NYHA) functional class II symptoms, as UI evidenced by dyspnea with moderate exerlion, is stable and Item 2 Answer: B q,

Answers and Critiques Item 1 Answer: D Bibliography Educational Objective: Treat stable heart failure with Maddox l M, Januzzi )L lr. Allen t.A. et al; Writing Committee. 2O2l Update to the 2017 ACC expert consensus decision pathway for optimization of reduced ejection fraction with valsartan-sacubitril. heart failure treatment: ansu,ers to l0 pivotal issues about heart failure with reduced ejection fiaction: a report of the American College of The most appropriate treatment is to switch lisinopril to Cardiologr Solution Set Oversight Commifiee. J Am Coll Cardiol. 2O2t; 77 :77'2 81O. LPMID: 334.16.1i01 doi:l0.l0l6ij.jacc.2O2O.ll.O22 valsartan-sacubitril (Option D). This patient with hearl fail ure with reduced ejection fraction (HFTEF) and New York Heart Association (NYHA) functional class II symptoms, as UI evidenced by dyspnea with moderate exerlion, is stable and Item 2 Answer: B q, has no evidence of volume overload on examination. In the Educational Objective: Treat a patient with symptom- ET PARADIGM-HF trial of patients with symptomatic heart atic bradycardia. failure and Ieft ventricular ejection fraction less than 40'1,, L' Pacemaker implantation (Option B) is the most appropri- ?t valsartan sacubitril reduced mortality and heart failure hospi E ate next step in management for this patient who presents at talization by 20'2, compared with enalapril. Based on this study. vt with signs and symptoms of sinus node dysfunction. Com- the American College of Cardiologr/American Heart Associ o mon indications for permanent pacemaker implantation ation heart failure guidelines recommend replacing an ACE vt = include symptomatic bradycardia without reversible cause; E inhibitor or angiotensin receptor blocker (ARB) with valsartan permanent atrial flbrillation with symptomatic bradycar sacubitril in patients with chronic symptomatic HFrEFl, In dia; alternating bundle branch block; and complete heart addition, for patients with new-onset heart failure, directly ini block, high degree atrioventricular (AV) block, or Mobitz tiating valsartan-sacubitril, rather than a pretreatment period type 2 second degree AV block, irrespective of symptoms. with an ACE inhibitor or ARB, is a safe and effective strateg/ This patient is bradycardic at baseline, does not mount a in patients with HFrEFl, Because of the risk for angioedema, tachycardic response to activity on ambulatory ECG moni ACE inhibitors (but not ARBs) should be discontinued at least toring, and has low energr. There is no threshold that deflnes 36 hours before starting valsafian sacubitril. an inadequate heart rate response; it is determined by lsosorbide dinitrate hydraluine (Option A), when used symptoms suggesting that the heart rate is not meeting the in combination with an ACE inhibitor, p-blocker, and aldoste patient's physiologic demands. A common challenge among rone antagonist, reduces mortality compared with placebo in these patients, many of whom are older, is differentiating Black patients with N1TIA functional class III to IV slmptoms. between age-related decline in physical activity and patho Guidelines recommend adding this drug combination in Black logic, symptomatic sinus node dysfunction. The former is patients who remain rynnptomatic on maximal doses of an ACE less likely to improve with cardiac pacing, and the latter inhibitor, ARB, or angiotensin receptor'-neprilysin inhibitor; often improves dramatically. In this case, the patient is very B blocker; and aldosterone antagonist. lf this patient were White, active, with distinct loss of energr and ECG flndings of sinus isosorbide dinitrate hydralazine would not be indicated, and if bradycardia. Recent stress test results conflrm normal left this patient were Black, it would be initiated if lnHA class III ventricular function and no ischemia; thus, cardiac pacing slmptoms persisted after initiation of valsartan-sacubitril. is the next appropriate step. ln patients with NYHA functional class II to IV heart Patients with sinus node dysfunction are rarely unsta- failure symptoms, ivabradine (Option B) has been shown to ble, but if there is evidence of hemodynamic instability, reduce heart failure hospitalizations when added to standard hospitalization (Option A) is indicated. Warning signs and heart failure therapy. Ivabradine is approved for patients symptoms of hemodynamic instability warranting hospital- with symptomatic HFrEF (ejection lraction <357,) who are ization include hypotension, altered mental status, ischemic in sinus rhythm with a heart rate of 7Olmin or higher and chest pain, and acute heart failure. This patient's condition taking a maximally tolerated B blocker. This patient has a is not acute or dangerous, and thus inpatient care is not heart rate of 60/min and is therefore not a candidate. warranted. This patient has a heart rate of 60/min and does not Lisinopril is unlikely to be contributing to this patient's require p-blocker dosage escalation (Option C) at this time. bradycardia, although his hypertension is likely a risk factor I(EY POITI fbr sinus node dysfunction. Although amlodipine is a dihy o Valsartan-sacubitril signifi cantly reduces heart failure dropyridine calcium channel blocker, use of this drug may actually worsen bradycardia; therefbre, switching lisinopril hospitalizations and mortality in patients with symp- to amlodipine (Option C) is not indicated. tomatic heart failure with reduced ejection fraction Reassurance with ongoing monitoring (Option D) is and is recommended in preference to an ACE inhibitor not appropriate, because it is likely that this patient's loss of or angiotensin receptor blocker. energz is pathologic and related to symptomatic bradycardia.

has no evidence of volume overload on examination. In the Educational Objective: Treat a patient with symptom- ET PARADIGM-HF trial of patients with symptomatic heart atic bradycardia. failure and Ieft ventricular ejection fraction less than 40'1,, L' Pacemaker implantation (Option B) is the most appropri- ?t valsartan sacubitril reduced mortality and heart failure hospi E ate next step in management for this patient who presents at talization by 20'2, compared with enalapril. Based on this study. vt with signs and symptoms of sinus node dysfunction. Com- the American College of Cardiologr/American Heart Associ o mon indications for permanent pacemaker implantation ation heart failure guidelines recommend replacing an ACE vt = include symptomatic bradycardia without reversible cause; E inhibitor or angiotensin receptor blocker (ARB) with valsartan permanent atrial flbrillation with symptomatic bradycar sacubitril in patients with chronic symptomatic HFrEFl, In dia; alternating bundle branch block; and complete heart addition, for patients with new-onset heart failure, directly ini block, high degree atrioventricular (AV) block, or Mobitz tiating valsartan-sacubitril, rather than a pretreatment period type 2 second degree AV block, irrespective of symptoms. with an ACE inhibitor or ARB, is a safe and effective strateg/ This patient is bradycardic at baseline, does not mount a in patients with HFrEFl, Because of the risk for angioedema, tachycardic response to activity on ambulatory ECG moni ACE inhibitors (but not ARBs) should be discontinued at least toring, and has low energr. There is no threshold that deflnes 36 hours before starting valsafian sacubitril. an inadequate heart rate response; it is determined by lsosorbide dinitrate hydraluine (Option A), when used symptoms suggesting that the heart rate is not meeting the in combination with an ACE inhibitor, p-blocker, and aldoste patient's physiologic demands. A common challenge among rone antagonist, reduces mortality compared with placebo in these patients, many of whom are older, is differentiating Black patients with N1TIA functional class III to IV slmptoms. between age-related decline in physical activity and patho Guidelines recommend adding this drug combination in Black logic, symptomatic sinus node dysfunction. The former is patients who remain rynnptomatic on maximal doses of an ACE less likely to improve with cardiac pacing, and the latter inhibitor, ARB, or angiotensin receptor'-neprilysin inhibitor; often improves dramatically. In this case, the patient is very B blocker; and aldosterone antagonist. lf this patient were White, active, with distinct loss of energr and ECG flndings of sinus isosorbide dinitrate hydralazine would not be indicated, and if bradycardia. Recent stress test results conflrm normal left this patient were Black, it would be initiated if lnHA class III ventricular function and no ischemia; thus, cardiac pacing slmptoms persisted after initiation of valsartan-sacubitril. is the next appropriate step. ln patients with NYHA functional class II to IV heart Patients with sinus node dysfunction are rarely unsta- failure symptoms, ivabradine (Option B) has been shown to ble, but if there is evidence of hemodynamic instability, reduce heart failure hospitalizations when added to standard hospitalization (Option A) is indicated. Warning signs and heart failure therapy. Ivabradine is approved for patients symptoms of hemodynamic instability warranting hospital- with symptomatic HFrEF (ejection lraction <357,) who are ization include hypotension, altered mental status, ischemic in sinus rhythm with a heart rate of 7Olmin or higher and chest pain, and acute heart failure. This patient's condition taking a maximally tolerated B blocker. This patient has a is not acute or dangerous, and thus inpatient care is not heart rate of 60/min and is therefore not a candidate. warranted. This patient has a heart rate of 60/min and does not Lisinopril is unlikely to be contributing to this patient's require p-blocker dosage escalation (Option C) at this time. bradycardia, although his hypertension is likely a risk factor I(EY POITI fbr sinus node dysfunction. Although amlodipine is a dihy o Valsartan-sacubitril signifi cantly reduces heart failure dropyridine calcium channel blocker, use of this drug may actually worsen bradycardia; therefbre, switching lisinopril hospitalizations and mortality in patients with symp- to amlodipine (Option C) is not indicated. tomatic heart failure with reduced ejection fraction Reassurance with ongoing monitoring (Option D) is and is recommended in preference to an ACE inhibitor not appropriate, because it is likely that this patient's loss of or angiotensin receptor blocker. energz is pathologic and related to symptomatic bradycardia. 155

Answers and Critiques Elevated homocysteine levels are associated with an XEY POIXI increased risk for cerebrovascular and cardiovascular dis- . Pacemaker implantation is indicated in patients with ease. Patients with PAD have higher plasma homocysteine symptomatic bradycardia in the absence of a reversi levels than those without PAD. However, there is no evi ble cause. dence that B-complex vitamin supplementation (Option E) to lower homocysteine levels improves clinical outcomes, Bibliography including cardiovascular death, myocardial infarction, or Kusumoto FM. Schoenfeld MH, Barrett C, et al. 2018 ACC/AHA/HRS guide stroke. Vitamin B complex vitamins are not recommended. line on the evaluation and management ofpatients with bradycardia and cardiac conduction delayr a report ofthe American College ofCardiologl/ American Heart Association Task Force on Clinical Practice Guidelines IEY POITIT and the Heart Rhythm Sociery Circulation. 2019;140:e382-e482. [PMID: . In patients with peripheral artery disease and inter- 3058677 2l doi:10.1161/CIR.0000000000000628 mittent claudication, cilostazol is recommended to improve limb symptoms in addition to smoking ces- Item 3 Answer: A sation, aspirin, statin therapy, and supervised exercise. (a E Ed ucation a I Obj ective : Treat intermittent claudication . Cilostazol is contraindicated in patients with heart ID with cilostazol. U) failure. o, The most appropriate additional treatment is cilostazol CL (Option A). Cilostazol, a phosphodiesterase inhibitor with a-l Bibliography antiplatelet and vasodilator activity, increases pain-free Gerhard-Herman MD, Gornik HL, Barrett C, et al. 2016 AHA/ACC guideline walking distance and overall walking distance in patients on the management of patients with lo\ €r extremity peripheral artery ll disease: a report of the American College of Cardiolos//American Heart E with claudication. This patient with established peripheral Association Task Force on Clinical Practice Guidelines. I Am Coll Cardiol. .D la artery disease (PAD) is receiving guideline-directed medical 2077 ;69 :e71-e126. IPMID: 27851992] doi:10.1016/j.jacc.2016.11.007

Elevated homocysteine levels are associated with an XEY POIXI increased risk for cerebrovascular and cardiovascular dis- . Pacemaker implantation is indicated in patients with ease. Patients with PAD have higher plasma homocysteine symptomatic bradycardia in the absence of a reversi levels than those without PAD. However, there is no evi ble cause. dence that B-complex vitamin supplementation (Option E) to lower homocysteine levels improves clinical outcomes, Bibliography including cardiovascular death, myocardial infarction, or Kusumoto FM. Schoenfeld MH, Barrett C, et al. 2018 ACC/AHA/HRS guide stroke. Vitamin B complex vitamins are not recommended. line on the evaluation and management ofpatients with bradycardia and cardiac conduction delayr a report ofthe American College ofCardiologl/ American Heart Association Task Force on Clinical Practice Guidelines IEY POITIT and the Heart Rhythm Sociery Circulation. 2019;140:e382-e482. [PMID: . In patients with peripheral artery disease and inter- 3058677 2l doi:10.1161/CIR.0000000000000628 mittent claudication, cilostazol is recommended to improve limb symptoms in addition to smoking ces- Item 3 Answer: A sation, aspirin, statin therapy, and supervised exercise. (a E Ed ucation a I Obj ective : Treat intermittent claudication . Cilostazol is contraindicated in patients with heart ID with cilostazol. U) failure. o, The most appropriate additional treatment is cilostazol CL (Option A). Cilostazol, a phosphodiesterase inhibitor with a-l Bibliography antiplatelet and vasodilator activity, increases pain-free Gerhard-Herman MD, Gornik HL, Barrett C, et al. 2016 AHA/ACC guideline walking distance and overall walking distance in patients on the management of patients with lo\ €r extremity peripheral artery ll disease: a report of the American College of Cardiolos//American Heart E with claudication. This patient with established peripheral Association Task Force on Clinical Practice Guidelines. I Am Coll Cardiol. .D la artery disease (PAD) is receiving guideline-directed medical 2077 ;69 :e71-e126. IPMID: 27851992] doi:10.1016/j.jacc.2016.11.007 therapy and has completed a supervised exercise program, but he has persistent symptoms. The most appropriate treat- ment is to add cilostazol to his medication regimen. As with other oral phosphodiesterase inhibitors (e.9., milrinone), the Item 4 Answer: C Educational Objective: Evaluate acute ehest pain using tr coronary CT angiography. FDA has placed a black box warning on use of cilostazol in patients with heart failure. Side effects of cilostazol include Coronary CT angiography (Option C). by allor,ving visualiza headache, diarrhea, dizziness, and palpitations. Up to 20% tion of coronary ancl other thoracic patholoS,. is the' most of patients discontinue cilostazol within 3 months due to appropriate cliagnostic test to perfbrm next in this patieltt side effects. lvith acnte chest pain. Coronary,' CT angiographl' plays an Guidelines from the American College of Cardiologz/ irnportant role in the evaluation of acute chest pain in the American Heart Association (ACC/AHA) recommend anti- emergency departlnent. This patient presents \\:ith signs and platelet monotherapy for patients with PAD to reduce the symptonls that could ir.rdicate an acute coronary syndronte. risk for myocardial infarction, stroke, or vascular death. This aortic syndrorle. pulnronary embolism, clr other acute chest patient does not have an indication for dual antiplatelet pain etiolo6Xr. I;or patients with chest pain, coronirry C1' therapy (e.g., recent acute coronary syndrome or percuta- angiography also mav be useful in patients w'ith a possible neous coronary intervention), and there is no evidence to diagnosis of non ST elevation acllte coronary syndrorne support the use of dual antiplatelet therapy with aspirin u'ho hare equirocal initial tropor.rin levels or a single tropt-r and clopidogrel (Option B) over antiplatelet monotherapy in nin eler:ation r.tithor-rt lurther symptoms of acute coronary patients with PAD. syndrome, or in patients lr,ho have iscl.remic symptorns that PAD is considered a coronary heart disease risk equiva- rcsolved hours belore undergoing testing. lent, and the ACC/AHA guideline recommends that patients Cardiac stress testing is a reasonable approach fbr this with PAD be treated with a high intensity statin to prevent patient: hortever. adenosine mlrlcardial perfusion irnaging cardiovascular events. Although there is emerging evidence (Option A) is not an appropriate option fbr this patient from subgroup analyses that patients with lower extrem- bccause she has reactive ainval,s disease. Broncl.rospastic ity PAD benefit from the proprotein convertase subtilisin/ reactive airw'ays disease is a contraindication to adenosine kexin type 9 (PCSK9) inhibitors evolocumab (Option C) based vasodilatory agents for stress testing. and alirocumab, there is no evidence that the addition of a Cardiac nlagnetic resonance in.r:rging (Option B) may,be PCSK9 inhibitor in a patient with an LDL cholesterol level uscd rvith dotrutamine to assess ltall motion abnornralities less than 70 mg/dl (1.8 mmol/L) is associated with improved or with vasodilators to assess pertusion. [t is commonly lter- outcomes. tbrmed to e\"luate the degree of infarctiolr. \,'iability can be Pentoxifylline (Option D) has not been associated determined by evaluating the extent of myocardial fibrosis with an improvement in symptoms in patients with within the left ventricle. Cardiac magnetic resonarrce imag intermittent claudication and PAD, and the ACC/AHA ing is not a helpfirl test in assessing acLtte chest pain ir.r the guideline does not recommend pentoxifylline for treat emergency department because of the relatively longer time ment of claudication. fbr image acquisition compared'"r,ith other modalities.

therapy and has completed a supervised exercise program, but he has persistent symptoms. The most appropriate treat- ment is to add cilostazol to his medication regimen. As with other oral phosphodiesterase inhibitors (e.9., milrinone), the Item 4 Answer: C Educational Objective: Evaluate acute ehest pain using tr coronary CT angiography. FDA has placed a black box warning on use of cilostazol in patients with heart failure. Side effects of cilostazol include Coronary CT angiography (Option C). by allor,ving visualiza headache, diarrhea, dizziness, and palpitations. Up to 20% tion of coronary ancl other thoracic patholoS,. is the' most of patients discontinue cilostazol within 3 months due to appropriate cliagnostic test to perfbrm next in this patieltt side effects. lvith acnte chest pain. Coronary,' CT angiographl' plays an Guidelines from the American College of Cardiologz/ irnportant role in the evaluation of acute chest pain in the American Heart Association (ACC/AHA) recommend anti- emergency departlnent. This patient presents \\:ith signs and platelet monotherapy for patients with PAD to reduce the symptonls that could ir.rdicate an acute coronary syndronte. risk for myocardial infarction, stroke, or vascular death. This aortic syndrorle. pulnronary embolism, clr other acute chest patient does not have an indication for dual antiplatelet pain etiolo6Xr. I;or patients with chest pain, coronirry C1' therapy (e.g., recent acute coronary syndrome or percuta- angiography also mav be useful in patients w'ith a possible neous coronary intervention), and there is no evidence to diagnosis of non ST elevation acllte coronary syndrorne support the use of dual antiplatelet therapy with aspirin u'ho hare equirocal initial tropor.rin levels or a single tropt-r and clopidogrel (Option B) over antiplatelet monotherapy in nin eler:ation r.tithor-rt lurther symptoms of acute coronary patients with PAD. syndrome, or in patients lr,ho have iscl.remic symptorns that PAD is considered a coronary heart disease risk equiva- rcsolved hours belore undergoing testing. lent, and the ACC/AHA guideline recommends that patients Cardiac stress testing is a reasonable approach fbr this with PAD be treated with a high intensity statin to prevent patient: hortever. adenosine mlrlcardial perfusion irnaging cardiovascular events. Although there is emerging evidence (Option A) is not an appropriate option fbr this patient from subgroup analyses that patients with lower extrem- bccause she has reactive ainval,s disease. Broncl.rospastic ity PAD benefit from the proprotein convertase subtilisin/ reactive airw'ays disease is a contraindication to adenosine kexin type 9 (PCSK9) inhibitors evolocumab (Option C) based vasodilatory agents for stress testing. and alirocumab, there is no evidence that the addition of a Cardiac nlagnetic resonance in.r:rging (Option B) may,be PCSK9 inhibitor in a patient with an LDL cholesterol level uscd rvith dotrutamine to assess ltall motion abnornralities less than 70 mg/dl (1.8 mmol/L) is associated with improved or with vasodilators to assess pertusion. [t is commonly lter- outcomes. tbrmed to e\"luate the degree of infarctiolr. \,'iability can be Pentoxifylline (Option D) has not been associated determined by evaluating the extent of myocardial fibrosis with an improvement in symptoms in patients with within the left ventricle. Cardiac magnetic resonarrce imag intermittent claudication and PAD, and the ACC/AHA ing is not a helpfirl test in assessing acLtte chest pain ir.r the guideline does not recommend pentoxifylline for treat emergency department because of the relatively longer time ment of claudication. fbr image acquisition compared'"r,ith other modalities. 156