Q175) A 28 Year old man is evaluated in your office during a pre-employment health check-up . His history is notable for severe hypertension for which he was started on beta blocker a year ago. He says he stopped the medication 6 months ago because it interfered with his sexual activity. On examination his blood pressure is 172/94. Cardiovascular examination revealed a systolic murmur that radiates to the back and associated with ejection click. Brachio-femoral delay in pulses is noted. The patient is agreeable to restart antihypertensive therapy. The most appropriate management option for this patient:
A) Cardiac catheterization with Stenting
B) Percutaneous coronary intervention
C) Surgery
D) Medical management of Hypertension
E) Aortic valvulotomy
C) Surgery
Medical management seems to b e the answer. If he has a severe aortic stenosis then eventually he will need replacement
whats the answer Dr Red???
i would say medical mgmt to another drug. hes asymptomatic. hes non compliant because of the side effects, so we would give him another drug which doesnt interfere with his sexual activity.
c
why patient has brachio femoral delay. the murmur radiates to back. could it be coartication of aorta
D) Medical management of Hypertension
surely this is coarctation of the aorta, surgical is needed (htn developed); angioplasty can also be considered, but no a choice here.
Symptomatic or medical failure – surgery (not this case)
Asymptomatic (this case) – avoid surgery as long as you can.
Don’t offer surgery unless medical options are exhausted. Don’t do surgery for elevated blood pressure. Study showes 68% of patient have hypertension after surgery. There are serious morbidity, mortality and recurrence issues with surgical intervention, not to mention the cost of CT surgery and its complications. (Aortic aneurysm, paraplegia, recoarctation,phrenic nerve palsy, MANY many more).This patient’s sexual dysfunction and non compliance and hypertension can be addressed medically first with inexpensive or safer options like cardio selective beta blockers (nebivolol, atenolol, metoprolol). These agents do not have sexual adverse effects. Until these agents are tried, BP is poorly controlled, surgery is unsafe, & non compliance is the issue not failed medical management. This patient will bleed heavily if his blood pressure is not controlled first.
Some may argue that this is severe obstructive symptom because there is radio femoral delay and it requires surgery. True if this patient was a neonate or infant but adults with the disease have a LARGE collateral circulation that can compensate oxygenation through polycythemia even in slower blood flow. Hypertension has to be controlled right now as priority.
Medical management of hypertension, I think, (d), is the answer
Asymptomatic adults with coarctation of aorta have normal life expectancy without surgery if their blood pressure is under control. Asymptomatic infants with radio femoral delay need surgery because collateral circulation is not well developed in them and there is risk of renal and infra diaphragmatic organ compromise. Radio femoral delay in an adult is best for preliminary diagnosis of the disease but why do surgery when the kidneys are not compromised, the adrenals are perfused and the patient is not complaining of leg weakness or leg pains? His sexual dysfunction has not persisted after he stopped the ‘alleged’ beta-blocker otherwise, he would have complained.
Surgery has a lot of complications that are best avoided unless an organ below the diaphragm is poorly perfused, evident by symptoms.
I think the answer should be medical management of hypertension. (d)