Question of the Week # 175

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

14 Responses

  1. C) Surgery

  2. Medical management seems to b e the answer. If he has a severe aortic stenosis then eventually he will need replacement

  3. whats the answer Dr Red???

  4. 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.

  5. c

  6. why patient has brachio femoral delay. the murmur radiates to back. could it be coartication of aorta

  7. D) Medical management of Hypertension

  8. surely this is coarctation of the aorta, surgical is needed (htn developed); angioplasty can also be considered, but no a choice here.

  9. 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

  10. 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)

    • Significant arterial hypertension is indication for surgical management of coarctation .if not eventually pt will develop permanent hypertension from renal compromise . Ans = C :-surgery

  11. Medical management according to uptodate – surgery done after age 20 will not reverse the hypertension. Surgery should be done in childhood, very few cases in adulthood.

    • The question is, ‘what is the most appropriate management option for THIS PATIENT?’.
      It is tempting to think surgery (option C) because severe hypertension is staring at us in the question. As I said, medical management (Option D) is the most appropriate option for this patient.
      This patient most appropriately needs medical management (Option D), not surgery right now.
      For a second let’s assume u see severe hypertension staring at you, what would you do? Wheel the patient for surgery? No
      Let’s assume your patient agrees to take anti hypertensive meds, what would you do next? Surgery? No, Blood pressure has to be controlled first, which is medical management. Surgery is inappropriate right now, though it is a management option.
      No one has any justification to wheel this patient for surgery except if this blood pressure failed to correct itself on pressure meds.
      This is not a neonate, there is no urgency in adults unless medical treatment has failed or it is ineffective. Our patient here has collateral circulation. Neonates present with severe acidosis and respiratory distress and this warrants urgent surgery.
      For now, surgery is an elective option at best. Medical management is the most appropriate management option for this patient right now.
      Don’t jump the gun, you can not say surgery as long as medical management is staring at you in the same answer stem.
      If they asked what is the definitive treatment, I would have agreed surgery. But in the management protocol, the most appropriate management option is medical management ( which has not been restarted yet) No elective surgery can take place without medical management of severe hypertension.
      Thinking of surgery right now is INAPPROPRIATE, tricky distractor, but inappropriate at best.
      [side talk – is this symptomatic hypertension?, answer, No. A symptom is something a patient complains about. Elevated blood pressure is not a symptom, it’s a sign. This patient is clinically asymptomatic but he has a clinical sign suggestive of MODERATE hypertension. Severe hypertension is systolic greater than 180 or diastolic greater than 120. This patient doesn’t even have severe hypertension, but he still needs surgery, just that surgery is not the most appropriate management option for this case scenario. (For this patient)
      No one will go for surgery as long as medical management is in the list of items.
      Think of yourself as a patient lying on the stretcher, with blood pressure 170/94, and the chief surgeon asks his residents,’ what is the most appropriate management option, medical or surgical? & suddenly somebody starts to wheel you into the theatre. If I were you, I will disappear FAST, meet my GP, develop stable BP profile and then undergo elective surgery.
      It’s like you are going to Japan from Nigeria for an update course and a policeman stops you on the highway and ask you where you’re headed. You will mention the next city et route to the airport. We all know that theoretically, you are headed for Japan but if you keep insisting with conviction that ‘ I am going to Japan!’ the policeman may take you to the nearest psych evaluation unit and you will end up getting IM haldol made in japan.
      Play safe pls comrade. Whenever anything is said in step 3, I feel it is said in the context of a real case scenario. It is inappropriate to dissociate from this line of thought and talk theoretical options.
      Surgery is inappropriately a theoritical option because medical management is in the list of options and medical management is the most appropriate management option FOR this patient” sorry there is no urgentcy to bypass medical management.

  12. Between surgical and medical option, what is MOST APPROPRIATE in this patient? Appropriate means the right thing to do in the given scenario. Clearly medical option is most appropriate, followed by surgery.

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