A 25-year-old female is being seen for genetic counseling. She has a significant family history of Marfan syndrome, with her mother and sister having lens dislocation and aortic aneurysm with dissection. She is asymptomatic, and her aortic root measures 45 mm. She wants to go ahead with pregnancy. What do you recommend?

1. Start a beta blocker before pregnancy
   
2. Start angiotensin-converting-enzyme inhibitor before pregnancy
   
3. Avoid pregnancy
   
4. Start angiotensin-receptor blocker before pregnancy

A 36-year-old African American female is referred to you. She complains of progressive dyspnea. She denies any prior cardiovascular history. She is 38 weeks pregnant and is her first pregnancy. On examination, she is tachycardiac, blood pressure (BP) is 110/70 mmHg, jugular venous pressure (JVP) is elevated up to her angle of the mandible, apical impulse is diffuse, she has S3 and S4 gallops, 2/6 apical systolic murmur, and crackles up to middle of the back. Electrocardiogram (ECG) confirms sinus tachycardia. Echocardiogram reveals global left ventricular (LV) hypokinesis and an ejection fraction (EF) of 20%. What is the most likely diagnosis?

1. Viral myocarditis
   
2. Coronary artery disease
   
3. Peripartum cardiomyopathy
   
4. Dissection of the coronary artery

You start the patient in Question 27.2 on diuretics and beta blockers. She complains of persistent shortness of breath. What is your next recommendation?

1. Intra-aortic balloon pump
   
2. Lisinopril
   
3. Bromocriptine
   
4. Ventricular assist device

The patient in Question 27.2 has a successful vaginal delivery. She is now maintained on anti-failure therapy, which includes a diuretic and beta blocker. Her LV function by echocardiogram is now 40%, which has improved from 20%. She evinces interest in a second pregnancy. What do you recommend?

1. To go ahead with pregnancy
   
2. Recommend reassessing LV function in 6 months and if normal, then proceed
   
3. Counsel against pregnancy
   
4. Recommend addition of angiotensin-receptor blocker and then proceed with pregnancy

A 30-year-old female, now 34 weeks pregnant, presents to the hospital with acute onset of severe squeezing chest pressure associated with nausea and diaphoresis. She has a prior history of hypertension and is on medications. She used to smoke up until her pregnancy. In the emergency room her heart rate is 76 bpm, BP is 160/80 mmHg, and examination is otherwise unremarkable. Her ECG reveals anterior ST elevation. What do you recommend?

1. Medical management with heparin, aspirin, nitrates, and beta blocker
   
2. Immediate coronary angiogram with possible intervention
   
3. Thrombolytic therapy
   
4. Colchicine and indomethacin

A 29-year-old Hispanic female is referred to you for complaints of dyspnea. She is 33 weeks pregnant and has recently moved from India. She reports a history of murmur from her childhood. On examination her heart rate is 110 bpm, BP is 120/80 mmHg, JVP is 14 cmH₂O, S1 is increased, S2 is normal with an opening snap, 2/6 diastolic murmur heard along with a holosystolic murmur at the apex. You initiate diuretic therapy. Echocardiogram reveals mitral stenosis with a mean gradient of 17 mmHg. What would your next step would?

1. Beta blocker therapy
   
2. Amiodarone
   
3. Synchronized cardioversion
   
4. Percutaneous mitral balloon valvotomy

A 26-year-old G2P2 presents to the hospital with complaints of severe substernal chest pressure. She had a normal vaginal delivery 15 days ago. She describes her chest pressure as severe pressure-like, in the central chest, radiating to her jaw, started when she was vacuuming her house. She denies any prior medical history. An ECG performed in the emergency room shows 3 mm ST elevations in V1–V6 with ST depression in leads II, III and aVF. Chest X-ray is unremarkable. What is the most likely diagnosis?

1. Acute pulmonary embolus
   
2. Coronary artery disease with plaque rupture
   
3. Spontaneous coronary dissection
   
4. Acute pericarditis
   
5. Aortic dissection