A 75-year-old woman presents to a general cardiology clinic for the first time. She has a history of atrial fibrillation, sick-sinus syndrome requiring a permanent pacemaker, hypertension, and dyslipidemia. She has no specific complaints other than shortness of breath on exertion. Her medications include aspirin (81 mg daily), carvedilol (25 mg twice daily), lisinopril (5…

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An 89-year-old woman with severe aortic stenosis is referred to a cardiologist at a major academic center that offers transcatheter aortic valve implantation (TAVI). A widow for 20 years, the patient lives alone and does well with the assistance of her daughter, who lives nearby. She has two more children in the same town, as…

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A 22-year-old white man presented to the ER with acute non-ST-segment-elevation MI, after playing basketball. He had experienced chest pain on and off for more than 10 hours before presentation. His initial EKG showed T-wave inversions in leads III and avF (see image), and his troponin T level was 1.2 ng/mL. The patient’s initial pain…

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A 21-year-old Division I college football player presented with palpitations that had started during athletic practice. He was referred to a cardiologist for further evaluation. Vital signs and physical exam were normal. An EKG showed prominent R waves, inverted T waves in leads V1–V2, along with a biphasic T wave in lead V3. QRS axis and…

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A 52-year-old man presented with 3 episodes of transient dysarthria and right-sided facial numbness within a 2-week period. A carotid ultrasound revealed >70% stenosis of the left-internal carotid artery and 50%–69% stenosis of the right coronary artery. At age 40, the man had been diagnosed with non-Hodgkin lymphoma, which was treated with cranial radiation and…

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An 11-year-old boy presents with palpitations. He has no family history of heart disease and is asymptomatic while playing competitive sports. His cardiac physical examination is normal, but his ECG (shown below) shows a Wolff-Parkinson-White pattern with a short PR interval and delta waves. A systematic echocardiogram reveals normal LV function, normal atrioventricular valves, and…

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Discuss whether to implant an ICD near the end of a patient’s life.

An 85-year-old woman with a history of hypertension and Crohn’s disease presented with severe pain in the left hand and was admitted to the hospital. Examination revealed a diminished left-radial pulse; arterial Doppler imaging showed a thrombus in the radial artery. The patient underwent surgical thrombectomy. The workup, including a hypercoagulability profile, was negative. Transthoracic…

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A 37-year-old prisoner with end-stage nonischemic cardiomyopathy was transferred from a local county hospital to a tertiary care center for heart failure therapy. Soon after his arrival, he developed ventricular tachycardia and cardiogenic shock. He was sent urgently to the cardiac catheterization laboratory, where he underwent placement of an intra-aortic balloon pump (IABP). Right-heart catheterization, on dobutamine…

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A 77-year-old man with metformin-treated type 2 diabetes, high blood pressure, moderate renal insufficiency, stable angina, and a history of phlebitis stopped taking aspirin in preparation for palpebral surgery. A day after the surgery, he presented to the ER with two transient ischemic attacks (TIAs) affecting the left arm. The patient complained to the examining neurologist…

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