Whether you’re gearing up for your Family Medicine or Cardiology Board Exam, you’ll need to master the topic of Hypertrophic Cardiomyopathy (HCM). The BoardVitals Family Medicine and Cardiology Board Practice Question Banks features the following question which has been particularly tricky for our users. We turned to Dr. Roger Seheult from MedCram to help break down the topic. Try the question below before watching the explanation. Did you get it right?
The Question:
A 40-year-old male presents to your medical clinic to establish care. He has no known prior medical history and does not take any medications. He complains of occasional shortness of breath on walking more than 2 blocks. He has never had any chest pain. He has never smoked and denies any alcohol or drug abuse history. He was adopted and does not know anything about his parents or siblings. He takes occasional multivitamins. His vitals in your office are BP 110/80 mm Hg, HR 90/min. He is in no acute distress on physical examination. He has a normal JVD, clear lungs and a harsh crescendo-decrescendo systolic murmur that begins slightly after S1 and is heard best at the apex and lower left sternal border. ECG is shown below. Which of the following is the best statement to describe further clinical management?
A. No further workup is indicated
B. Echocardiogram is indicated (Correct)
C. Start furosemide for diuresis
D. Start aspirin and Plavix
Correct answer: (B)
(B) Echocardiogram is indicated.
Explanation: Shown electrocardiogram suggests left ventricular hypertrophy. It is crucial for every medical physician to recognize patients who are at risk of sudden cardiac death due to their underlying medical condition. Hypertrophic cardiomyopathy is one of them.
Shown electrocardiogram suggests left ventricular hypertrophy. It is crucial for every medical physician to recognize patients who are at risk of sudden cardiac death due to their underlying medical condition. Hypertrophic cardiomyopathy is one of them. Presentation may be subtle in a young patient with grave prognosis if not recognized. Characteristic murmur should not be missed. Patients with HCM may develop several types of systolic murmurs, but the two most common- a harsh crescendo-decrescendo systolic murmur that begins slightly after S1 and is heard best at the apex and lower left sternal border is typical and another one may be mid-late systolic murmur at the apex. While the first one may radiate to the axilla and base, but usually not into the neck, it does reflect both aortic outflow obstruction and mitral regurgitation in patients with a large gradient. The second murmur is usually related to concomitant posteriorly directed mitral regurgitation murmur secondary to systolic anterior motion of the mitral valve. Of note, An increase in intensity, due to the enhancement of obstruction, is seen with the assumption of an upright posture from a squatting, sitting, or supine position; the Valsalva maneuver; during the more forceful contraction that follows the compensatory pause after a ventricular premature beat; and following the administration of nitroglycerin. A decrease in intensity, due to attenuation of obstruction, is heard after going from a standing to a sitting or squatting position, with a handgrip, and following passive elevation of the legs. On the other hand, the murmur in valvular aortic stenosis does not change substantially or decreases slightly following the Valsalva maneuver. Of note, that the clinical suspicion warrants an echocardiographic evaluation of the left ventricle for septal hypertrophy and elevated gradients.
(A) It is crucial for every medical physician to recognize patients who are at risk of sudden cardiac death due to their underlying medical condition. Hypertrophic cardiomyopathy is one of them. Presentation may be subtle in a young patient with grave prognosis if not recognized. Hence, this option is incorrect. Further work up is indicated. Clinical suspicion of hypertrophic cardiomyopathy warrants an echocardiographic evaluation of the left ventricle for septal hypertrophy and elevated gradients.
(C) Diuresis is not indicated at this time. Clinical examination is consistent with a well-compensated patient. There are no signs of acute congestion. Lungs are clear and there is no elevation in jugular venous pressure. Blood pressure is within the goal as well. In fact, exam takers should be aware that any interventions that decrease preload in patients with hypertrophic cardiomyopathy, may have worsening of symptoms and signs. Patients with HCM may develop several types of systolic murmurs, but the two most common- a harsh crescendo-decrescendo systolic murmur that begins slightly after S1 and is heard best at the apex and lower left sternal border is typical and another one may be mid-late systolic murmur at the apex. While the first one may radiate to the axilla and base, but usually not into the neck, it does reflect both aortic outflow obstruction and mitral regurgitation in patients with a large gradient. The second murmur is usually related to concomitant posteriorly directed mitral regurgitation murmur secondary to systolic anterior motion of the mitral valve. Of note, an increase in intensity, due to enhancement of obstruction, is seen with the assumption of an upright posture from a squatting, sitting, or supine position; the Valsalva maneuver; during the more forceful contraction that follows the compensatory pause after a ventricular premature beat; and following the administration of nitroglycerin. A decrease in intensity, due to attenuation of obstruction, is heard after going from a standing to a sitting or squatting position, with a handgrip, and following passive elevation of the legs. (D) There is no indication for antiplatelet agents in presented scenario. It is crucial for every medical physician to recognize patients who are at risk of sudden cardiac death due to their underlying medical condition. Hypertrophic cardiomyopathy is one of them.
(D) There is no indication for antiplatelet agents in presented scenario. It is crucial for every medical physician to recognize patients who are at risk of sudden cardiac death due to their underlying medical condition. Hypertrophic cardiomyopathy is one of them. Presentation may be subtle in a young patient with grave prognosis if not recognized. Characteristic murmur should not be missed.
Reference:
Wigle ED, Rakowski H, Kimball BP, Williams WG. Hypertrophic cardiomyopathy. Clinical spectrum and treatment. Circulation. 1995;92(7):1680.
Family Medicine Board Exam
The ABIM Family Medicine Board Exam consists of four sections administered over 9 hours. Each section is 100 minutes long and contains 80 multiple choice questions (MCQ). The content is broken down as follows:
- Cardiovascular 10%
- Endocrine 7%
- Gastrointestinal 6%
- Hematologic/Immune 3%
- Integumentary 5%
- Musculoskeletal 10%
- Nephrologic 3%
- Neurologic 3%
- Nonspecific 8%
- Psychogenic 6%
- Reproductive—Female 3%
- Reproductive—Male 1%
- Respiratory 11%
- Special Sensory 2%
- Population-based Care 4%
- Patient-based Systems 4%
- Module (Selected from eight possible choices at the time of the examination) 13%
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Cardiology Board Exam
The ABIM Cardiology Board Exam lasts 2 days and is broken down into the Multiple-Choice Component and the ECG and Imaging Studies Component. According to the ABIM Blueprint, the following topics are covered.
Multiple-Choice Component
- Arrhythmias 15%
- Coronary Artery Disease 23%
- Heart Failure and Cardiomyopathy 17%
- Valvular Disease 15%
- Pericardial Disease 4%
- Congenital Heart Disease 5%
- Vascular Diseases 6%
- Systemic Hypertension and Hypotension 7%
- Pulmonary Circulation Disorders 5%
- Systemic Disorders Affecting the Circulatory System 3%
ECG and Imaging Studies Component
- Electrocardiograms 48%
- Echocardiograms 37%
- Coronary Angiograms 15%
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