A 74-year-old man comes to the office for a follow-up visit for hypertension. His last visit was a year ago. He has no chest pain, shortness of breath, leg swelling, or dizziness. The patient is compliant with his medications and can tolerate a moderate level of physical activity. Blood pressure is 145/75 mm Hg and pulse is 67/min and regular. Auscultation findings at the base of the heart are depicted in the exhibit below. Which of the following is the most likely cause of this patient's physical findings?

Question

A 74-year-old man comes to the office for a follow-up visit for hypertension.  His last visit was a year ago.  He has no chest pain, shortness of breath, leg swelling, or dizziness.  The patient is compliant with his medications and can tolerate a moderate level of physical activity.  Blood pressure is 145/75 mm Hg and pulse is 67/min and regular.  Auscultation findings at the base of the heart are depicted in the exhibit below.  Which of the following is the most likely cause of this patient's physical findings?

Quizplus · Accepted Answer

The exhibit shows a systolic ejection murmur best heard at the base of the heart, consistent with aortic stenosis. The most common cause of aortic stenosis in the elderly population is degenerative valvular calcification. The diagram above depicts a crescendo-decrescendo systolic murmur peaking in midsystole, characteristic of aortic or pulmonic stenosis.xa0 The most common cause of aortic stenosis (AS) in elderly patients (age >70) is degenerative calcification of the aortic valve leaflets.xa0 Calcific AS is caused by chronic hemodynamic stress or atherosclerotic inflammation that eventually leads to progressive aortic valve leaflet thickening, calcification, and stenosis.xa0 The murmur of valvular AS is best heard over the right second interspace (where the aorta leaves the base of the heart) with radiation to neck and carotid arteries.xa0 A longer and late-peaking murmur usually indicates severe AS, whereas a brief and early-peaking murmur indicates less severe stenosis.xa0 However, the intensity of the murmur does not correlate with the severity of stenosis. (Choice A)xa0 Ankylosing spondylitis is a chronic inflammatory disease of the axial skeleton characterized by progressive pain and stiffness of the spine, sacroiliitis, and increased risk of aortic regurgitation. (Choice B)xa0 Chordal rupture would lead to flail mitral leaflet with mitral valve prolapse and mitral regurgitation.xa0 Mitral regurgitation associated with chordal rupture would lead to a holosystolic decrescendo murmur. (Choice C)xa0 Coronary artery disease is not associated with a systolic murmur on auscultation. (Choice D)xa0 Cystic medial necrosis predisposes to the formation of thoracic aortic aneurysms with an increased risk of aortic dissection.xa0 It can also cause dilation of the aortic root leading to aortic regurgitation. (Choice E)xa0 Infectious endocarditis of the aortic or mitral valve typically causes aortic or mitral regurgitation, respectively.xa0 Aortic regurgitation leads to an early diastolic murmur, best heard over the lower left sternal border or right second interspace with the patient sitting and leaning forward with breath held in full expiration.xa0 Mitral regurgitation causes a holosystolic murmur best heard at the cardiac apex in the left lateral decubitus position. (Choice F)xa0 Rheumatic heart disease is the most common cause of AS in the developing world and is invariably accompanied by rheumatic mitral valve disease (mitral stenosis and/or regurgitation).xa0 It is an uncommon cause of AS in developed nations. (Choice G)xa0 Right ventricular failure leads to jugular venous distension, along with hepatomegaly, ascites, and peripheral edema.xa0 Significant right ventricular dilation can cause tricuspid insufficiency, which is characterized by a holosystolic murmur at the left lower sternal border. Educational objective: The murmur of valvular aortic stenosis is typically an ejection or midsystolic murmur of crescendo-decrescendo configuration with maximum intensity over the right second interspace and radiation to neck and carotid arteries.xa0 The most common cause of aortic stenosis in elderly patients (age >70) is degenerative calcification of the aortic valve leaflets. __________ References: The evolving epidemiology of valvular aortic stenosis. The Tromsø study. (http://www.ncbi.nlm.nih.gov/pubmed/22942293)

A 74-Year-Old Man Comes to the Office for a Follow-Up