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Gilbert Program in Medical Simulation Simulation Casebook Harvard Medical School Draft of the 1 st edition (2011), updated 3/2/12 f. Treatment i. Effect of nitroglycerin: increased chest pain when preload and afterload drops in setting of aortic stenosis ii. Role of IV fluids: increase back flow to coronary arteries iii. More definitive management: will need echocardiography for the diagnosis and assessment of AS severity. iv. Stress imaging will also be important given the need to ROMI, however, if significant AS is found on echo, together with symptoms of angina, coronary angiography should be considered, given that noninvasive tests for cardiac ischemia are less accurate in AS patients 3. Didactic material: Part II a. Pathophysiology i. LVH as a response to increased afterload 1. Resulting S4 2. Hypotension due to loss of atrial kick in atrial fibrillation and impaired filling of stiff ventricle ii. Rales: interstitium "popping open" against water surface tension iii. Atrial fibrillation and implications of rapid ventricular response iv. Troponin elevation due to leak secondary to strain from rapid ventricular response b. Treatment i. Effect of B-blocker on contractility and pressure ii. Urgent cardioversion to control rate given hemodynamic instability iii. Rate control if patient is hemodynamically stable iv. More thorough discussion on chemical/electrical cardioversion and aftercare v. Comment on classic symptoms of AS (syncope, angina, heart failure/DOE) and dramatic increase in mortality once patients become symptomatic IX. Development and Deployment This two step/paired case was developed as an exercise within the medical school’s physiology class, and is a required experience for the entire first-year class. It has been used for several years. X. Authors/Contributors Case drafted by James Gordon, M.D., with contributions and updates by the Gilbert Simulation Team. Compiled and formatted by Elan Guterman. Reviewed and edited with references by Jeffrey Siegelman, M.D. and Zoë Howard, M.D. XI. References Bonow, RO, Carabello, BA, Chatterjee, K, et al. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease. A report of the American College of Cardiology/American Heart 20
Gilbert Program in Medical Simulation Simulation Casebook Harvard Medical School Draft of the 1 st edition (2011), updated 3/2/12 Association Task Force on Practice Guidelines (Writing committee to revise the 1998 guidelines for the management of patients with valvular heart disease). J Am Coll Cardiol 2006; 48(3):e1-148. Valvular emergencies. In: Tintinalli JE, Kelen GD, Stapczynski JS, eds. Emergency Medicine: A Comprehensive Study Guide. 6 th ed. New York: McGraw-Hill; 2004:54. Dunmire, SM. “Infective Endocarditis and Valvular Heart Disease.” In: Rosen’s Emergency Medicine: Concepts and Clinical Practice, 6th ed. Marx, et al, eds. pp 1306-1307. 21
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