NYACP Board Review Question of the Week
Every other Tuesday, NYACP members are sent a Board Review Question from ACP's MKSAP 18 to test professional knowledge and help prepare for the exam. Participant totals and answer percentages are distributed on the first Thursday of the month in IM Connected, the Chapter's eNewsletter, and are also published on this page.
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July 2, 2024
MKSAP 18 Cardiovascular Medicine Question 113
Stem:
An 81-year-old man is evaluated before elective hip arthroplasty. Medical history is significant for hypertension and osteoarthritis. He reports no chest pain, palpitations, exertional dyspnea, or other symptoms of cardiovascular disease. His medications are lisinopril and celecoxib.
On physical examination, vital signs are normal. The cardiopulmonary examination is normal. Range of motion of the right hip is limited by pain without overlying erythema or warmth.
Laboratory studies reveal normal kidney function and electrolyte levels.
A 12-lead electrocardiogram is shown. Findings are unchanged from 7 years ago.
Which of the following is the most appropriate management?
A. Dobutamine echocardiography
B. Echocardiography
C. Prophylactic pacemaker insertion
D. No further testing or intervention
Responses Received from Members (Response numbers and distribution posted on Thursday):
The Correct Answer is: D. No further testing or intervention
Educational Objective
Manage first-degree atrioventricular block accompanied by bifascicular block.
Critique
No further testing or intervention is required at this time. This asymptomatic patient has first-degree atrioventricular (AV) block (PR interval >200 ms), right bundle branch block, and left posterior fascicular block. Right bundle branch block is diagnosed by the findings of a widened QRS complex (>120 ms); an RSR′ pattern in lead V1; and a wide negative S wave in leads I, V5, and V6. Blocks may also occur in the anterior or posterior divisions (fascicles) of the left bundle; these are termed fascicular blocks (or hemiblocks). Left anterior fascicular block is recognized by a positive QRS complex in lead I and a negative QRS complex in lead aVF. Left posterior fascicular block is recognized by a negative QRS complex in lead I and a positive QRS complex in lead aVF. Conduction disturbances involving the right bundle branch and one of the two fascicles (anterior or posterior) of the left bundle branch are commonly referred to as bifascicular block. The presence of first- degree AV block with bifascicular block is often called “trifascicular block”; however, the term is misleading because true trifascicular block would indicate complete AV block.
There is no need for extensive cardiac evaluation of patients with asymptomatic bifascicular block other than a careful history and physical examination to exclude the diagnosis of occult cardiac disease. Therefore, echocardiography and dobutamine echocardiography are not indicated because occult ischemic or structural heart disease is not suspected in this patient.
Pacemakers are indicated in patients with symptomatic bradycardia in the absence of a reversible cause, hence the importance of establishing symptoms when evaluating patients with bradycardia. Pacing is not indicated in asymptomatic patients with first-degree AV block accompanied by bifascicular block because the risk for progression to complete heart block is less than 2% to 3% per year. As such, pacemaker insertion is not needed in this patient.
Key Points
Asymptomatic first-degree atrioventricular block with bifascicular block does not require pacemaker implantation.
Da Costa D, Brady WJ, Edhouse J. Bradycardias and atrioventricular conduction block. BMJ. 2002;324:535-
8. PMID: 11872557
Copyright 2018, American College of Physicians.
June 18, 2024
MKSAP 18 Gastroenterology & Hepatology Question 49
Stem:
A 55-year-old man is evaluated for ascites. He recently went to the emergency department, where paracentesis was performed. He was then discharged for outpatient follow-up. He has a history of cirrhosis due to nonalcoholic steatohepatitis and also has hypertension. Endoscopy 3 months earlier showed small varices without stigmata, making prophylaxis for esophageal variceal bleeding unnecessary. His only medication is lisinopril.
On physical examination, vital signs are normal; BMI is 28. Abdominal examination shows abdominal distention without tenderness.
Laboratory studies of the ascitic fluid show a leukocyte count of 80/µL with 20% neutrophils and protein level of 1.6 g/dL (16 g/L). Serum studies show a creatinine level of 1.3 mg/dL (114.9 µmol/L) and sodium level of 134 mEq/L (134 mmol/L).
An abdominal ultrasound from the emergency department shows changes consistent with cirrhosis. The portal vein and hepatic veins are patent with normal flow direction. A moderate amount of free-flowing ascites is seen.
In addition to initiating a sodium-restricted diet, which of the following is the most appropriate next step in management?
A. Discontinue lisinopril
B. Initiate free-water restriction
C. Initiate propranolol
D. Insert an indwelling drain into the peritoneal cavity
Responses Received from Members (805 Responses):
The Correct Answer is: A. Discontinue lisinopril
Educational Objective
Treat ascites caused by portal hypertension.
Critique
Discontinuing lisinopril is the most appropriate next step in the management of this patient with ascites. Blood pressure falls with worsening cirrhosis, resulting in reduced renal blood flow and glomerular filtration. A compensatory upregulation of the renin-angiotensin system results in increased levels of vasoconstrictors, including vasopressin, angiotensin, and aldosterone, which support systemic blood pressure and kidney function. ACE inhibitors and angiotensin receptor blockers impair the compensatory response to cirrhosis- related hypotension and thereby impair the ability to excrete excess sodium and water and may also affect survival. Medications that decrease kidney perfusion, including NSAIDs, ACE inhibitors such as lisinopril, and angiotensin receptor blockers, should be discontinued because their use often worsens ascites due to portal hypertension. The mainstay of therapy of ascites is to initiate dietary changes, restricting sodium intake to less than 2000 mg (87 mEq) daily. If sodium restriction does not result in significant improvement of ascites, the initiation of diuretic therapy with spironolactone with or without furosemide can be effective in increasing urinary sodium excretion.
Free-water restriction can be useful for the management of dilutional hyponatremia that is sometimes seen in patients with advanced liver dysfunction. This patient has a normal serum sodium concentration, so free- water restriction is not indicated.
Propranolol and other nonselective β-blockers are often used prophylactically for the prevention of variceal hemorrhage, but they do not have a role in the management of ascites. Furthermore, in some patients with ascites that is refractory to medical management, β-blockers may worsen clinical outcomes, including survival.Indwelling drains for ascites have been used for patients with malignant ascites, but in the setting of portal hypertensive ascites, such as seen in this patient, indwelling drains are associated with a high risk for infection and their use is contraindicated.
Key Points
Medications that decrease kidney perfusion, including NSAIDs, ACE inhibitors, and angiotensin receptor blockers, should be discontinued in patients with ascites.
Bibliography
Runyon BA; AASLD. Introduction to the revised American Association for the Study of Liver Diseases Practice Guideline management of adult patients with ascites due to cirrhosis 2012. Hepatology. 2013;57:1651-3. PMID: 23463403 doi:10.1002/hep.26359
Copyright 2018, American College of Physicians.