A 48-year-old man comes to the office due to progressive exertional dyspnea. It has become especially bothersome over the past 2 months. He now becomes short of breath after climbing one flight of stairs. He has no known medical problems. He is not taking any medications and does not use tobacco or alcohol. Temperature is 37.2 C (98.9 F), blood pressure is 130/75 mm Hg, pulse is 78/min, and respirations are 14/min. Chest examination reveals a harsh systolic murmur that is best heard at the right second intercostal space with radiation along the carotid arteries. An S4 is heard at the apex. Based on these findings, what is the most likely cause of this patient's symptoms?

Question

A 48-year-old man comes to the office due to progressive exertional dyspnea.  It has become especially bothersome over the past 2 months.  He now becomes short of breath after climbing one flight of stairs.  He has no known medical problems.  He is not taking any medications and does not use tobacco or alcohol.  Temperature is 37.2 C (98.9 F), blood pressure is 130/75 mm Hg, pulse is 78/min, and respirations are 14/min.  Chest examination reveals a harsh systolic murmur that is best heard at the right second intercostal space with radiation along the carotid arteries.  An S4 is heard at the apex.  Based on these findings, what is the most likely cause of this patient's symptoms?

Quizplus · Accepted Answer

This patient likely has congestive heart failure due to aortic stenosis. A harsh systolic, crescendo-decrescendo murmur at the right upper sternal border with radiation to the carotid arteries is a classic description of the murmur caused by aortic stenosis. The S4 occurs as the result of left atrial kick against a stiff left ventricle. In aortic stenosis, the high resistance generated by the stenosed aortic valve causes concentric hypertrophy and stiffening of the left ventricle, resulting in the S4. The 3 most common causes of aortic stenosis in the general population are senile calcific aortic stenosis, bicuspid aortic valve, and rheumatic heart disease. The most important hint to the underlying etiology of this patient's aortic stenosis is his relatively young age. A bicuspid aortic valve is the cause of aortic stenosis in the majority of patients age <70 and is the most likely cause of this patient's aortic stenosis. (Choice A) The murmur of hypertrophic cardiomyopathy can be easily confused with that of aortic stenosis. Both entities can cause a systolic crescendo-decrescendo murmur and an S4. However, the murmur of hypertrophic cardiomyopathy is usually best appreciated in the lower left sternal border and does not typically radiate to the carotids. (Choice B) Myxomatous valve degeneration is the typical pathologic entity that causes mitral valve prolapse, which is typically associated with a click and a murmur of mitral regurgitation (holosystolic murmur best heard at apex). (Choice C) Rheumatic heart disease can be a cause of aortic stenosis. However, it is a much less common cause than either senile calcific aortic stenosis or a bicuspid aortic valve. (Choice E) Senile calcific aortic stenosis is the most common cause of aortic stenosis in patients age >70. With age, the aortic valve can accumulate calcium, causing stenosis. Educational objective: The 3 most common causes of aortic stenosis in the general population are senile calcific aortic stenosis, bicuspid aortic valve, and rheumatic heart disease. A bicuspid aortic valve is the cause of aortic stenosis in the majority of patients age <70.

A 48-Year-Old Man Comes to the Office Due to Progressive