A 34-year-old man comes to the office due to heart palpitations that are particularly prominent at night. With moderate exertion he also experiences head-pounding accompanied by involuntary head-bobbing. The patient recently emigrated from Southeast Asia and remembers being diagnosed with a heart murmur years before, but he cannot recall the type of murmur and has never received any treatment. He has no other medical conditions and takes no medications. He does not use tobacco, alcohol, or illicit drugs. The patient's father has coronary artery disease and his mother has type 2 diabetes mellitus. Based on this patient's history, which of the following findings is most likely to be present on further evaluation?

Question

A 34-year-old man comes to the office due to heart palpitations that are particularly prominent at night.  With moderate exertion he also experiences head-pounding accompanied by involuntary head-bobbing.  The patient recently emigrated from Southeast Asia and remembers being diagnosed with a heart murmur years before, but he cannot recall the type of murmur and has never received any treatment.  He has no other medical conditions and takes no medications.  He does not use tobacco, alcohol, or illicit drugs.  The patient's father has coronary artery disease and his mother has type 2 diabetes mellitus.  Based on this patient's history, which of the following findings is most likely to be present on further evaluation?

Quizplus · Accepted Answer

11ec160b_3a79_92fa_9249_05649a8730eb_MD0001_00 This patient has a number of clinical findings that are characteristic of chronic aortic regurgitation (AR). Failure of the aortic valve to tightly seal off the aorta from the left ventricle at the end of systole leads to rapid loss of aortic pressure and an overall decrease in diastolic blood pressure. In addition, the left ventricle undergoes eccentric hypertrophy to initially compensate for an increase in left ventricular end-diastolic volume, which leads to increased stroke volume and cardiac output. Because pulse pressure (the difference between diastolic and systolic blood pressure) is proportional to stroke volume, the compensatory increased stroke volume on top of reduced diastolic pressure causes the characteristic widened pulse pressure seen with AR. This high-amplitude pulsation with rapid diastolic collapse is responsible for the unusual pulsation findings in AR. Forceful pulsations in the intracranial arteries can cause head bobbing with each heart beat (de Musset sign), and patients may experience palpitations due to forceful left ventricular contraction. In addition, physical examination can show abrupt distension and collapse of the carotid arteries (Corrigan sign) and peripheral arteries ("water-hammer" pulse), and reveal "pistol-shot" femoral pulses (Traube sign) on auscultation. (Choice A) Impaired left ventricular contractility occurs later in the course of AR and eventually leads to heart failure. Because head-bobbing and other characteristic findings in AR are due to increased stroke volume and high-amplitude, rapid rise-rapid fall pulsation, these findings are less prominent once impaired left ventricular contractility (and decreased stroke volume) sets in. (Choices B and C) Left ventricular outflow tract obstruction, such as occurs with aortic stenosis, leads to reduced stroke volume and characteristic weak and delayed pulses (pulsus parvus et tardus). Restriction of left ventricular filling, as occurs in mitral stenosis, also reduces stroke volume due to reduced left ventricular end-diastolic volume (reduced preload). Clinical findings associated with high-amplitude pulsation will not be present with reduced stroke volume. (Choice D) Combined systolic and diastolic hypertension is not necessarily accompanied by widened pulse pressure; the signs of high amplitude, rapid rise-rapid fall pulsation are more characteristic of chronic AR. Educational objective: Chronic aortic regurgitation (AR) causes a reduction in diastolic blood pressure and a compensatory increase in left ventricular stroke volume. These changes create a high-amplitude, rapid rise-rapid fall pulsation (ie, widened pulse pressure) and the other characteristic findings of AR (eg, head bobbing, "pistol-shot" femoral pulses).

A 34-Year-Old Man Comes to the Office Due to Heart