A 70-year-old man is brought to the Emergency Room because he lost consciousness while working in the garden. He says that he had several episodes of near-syncope on exertion recently. His past medical history is insignificant. He is not taking any medications. His blood pressure is 110/85 mmHg and heart rate is 80/min. Point of maximal impulse is increased in intensity. Cardiac auscultation reveals ejection-type systolic murmur at the base of the heart with radiation to the carotid arteries. ECG demonstrates left ventricular hypertrophy, and secondary ST segment and T wave changes. What is the most probable cause of this patient's condition?
This patient most probably has aortic stenosis. Physical examination findings are characteristic for this condition (increased intensity of apical impulse, narrow pulse pressure, and typical systolic murmur). Exertional syncope is explained by aortic stenosis, which restricts activity-induced increment in cardiac output. Age-dependant idiopathic sclerocalcific changes are the most frequent cause of isolated aortic stenosis in elderly patients. Usually these changes do not result in significant narrowing of the aortal orifice, but sometimes stenosis is severe.
Bicuspid aortic valve (Choice D) is a congenital anomaly that can lead to severe calcification and aortic stenosis, but usually manifests earlier in life.
Hypertension (Choice C) may contribute to aortal sclerocalcific changes, but does not cause aortic stenosis.
Rheumatic endocarditis (Choice A) rarely leads to isolated aortic stenosis; besides that, valvular abnormalities typically present earlier in life.
Bacterial endocarditis (Choice B) may lead to aortic insufficiency, but not stenosis.
Educational Objective:
Age-dependent idiopathic sclerocalcific changes are the most frequent cause of isolated aortic stenosis in elderly patients. These changes are common and usually have minimal hemodynamic significance, but sometimes may be severe.