A 72-year-old man comes to the office due to chest discomfort for the past 6 months. He describes a pressure-like sensation in the middle of his chest that is brought on by brisk walking. It lasts 2-3 minutes and subsides with rest. The patient has not had shortness of breath, palpitations, syncope, or lower extremity swelling. Medical history is significant for hypertension and hyperlipidemia. He is a former smoker with a 25-pack-year smoking history. Recent pulmonary function tests are consistent with mild chronic obstructive pulmonary disease. He does not drink alcohol. Blood pressure is 145/82 mm Hg and pulse is 77/min and regular. Echocardiogram shows left atrial dilation, mild concentric left ventricular hypertrophy, and an ejection fraction of 62%. The aortic valve is calcified with restricted opening. Estimated aortic valve area is 1.6 cm². No other valvular abnormalities are noted. Which of the following conditions is most likely responsible for this patient's current symptoms?

Question

Quizplus · Accepted Answer

This patient has had chest pain consistent with classic stable angina, and his echocardiogram reveals aortic stenosis (valve area <3 cm²). Aortic stenosis (AS) is a common cause of angina as well as syncope and heart failure; however, such symptoms do not typically occur until the stenosis becomes severe, which is usually indicated by valve area <1 cm². As such, the angina in this man with multiple risk factors for coronary artery disease (CAD) (ie, advanced age, hypertension, hyperlipidemia, history of smoking) is most likely due to obstructive CAD. classic Because severe AS restricts stroke volume and typically leads to low pulse pressure (eg, <25 mm Hg), this patient's high pulse pressure (ie, 145 mm Hg − 82 mm Hg = 63 mm Hg) provides further evidence that the AS is not severe enough to contribute to his symptoms (Choice D). (Choice B) Severe AS increases the pressure load on the left ventricle and can lead to concentric left ventricular hypertrophy (LVH); however, as with symptoms, LVH due to AS does not typically occur until the valve area is <1 cm². This patient's mild LVH is likely due to systemic hypertension. concentric ² (Choice C) Patients with advanced chronic obstructive pulmonary disease (COPD) can experience chest pain when rupture of a pulmonary bleb occurs. However, such pain is acute and not reproducible in nature as with anginal pain. In addition, pulmonary bleb rupture is unlikely in this patient with only mild COPD. (Choice E) Vasospastic angina causes chest pain similar to classic angina; however, the pain tends to occur at rest rather than with exertion, and it typically affects young patients without significant risk factors for CAD. This elderly patient with multiple CAD risk factors is far more likely to have angina due to obstructive CAD. Educational objective: Aortic stenosis (AS) is a common cause of angina, syncope, and heart failure; however, such symptoms are rare until the AS becomes severe (usually indicated by valve area <1 cm²). In patients with mild to moderate AS, anginal symptoms are likely due to another cause, most commonly obstructive coronary artery disease. ²

A 72-Year-Old Man Comes to the Office Due to Chest