A 60-year-old man comes to the office due to several episodes of lightheadedness over the last 3 months. He experiences these episodes while trying to walk quickly or climb stairs. He "almost passed out" during the last episode. The patient describes his lifestyle as active but recently has felt more tired than usual during his daily activities. He has had no chest pain or palpitations. Medical history is significant for diverticulosis, for which he takes fiber supplements. The patient is on no other medications. Temperature is 37.1 C (98.8 F), blood pressure is 108/92 mm Hg, pulse is 88/min and regular, and respirations are 14/min. On examination, he has a 3/6 systolic murmur that is best heard over the right upper sternal border. Carotid pulses are slow-rising and delayed bilaterally. The lung fields are clear to auscultation. There is no peripheral edema. Which of the following additional findings is most likely to be seen on physical examination?
This patient's clinical presentation—progressive fatigue with exertional lightheadedness and presyncope, delayed carotid pulses, and systolic murmur over the right upper sternal border—is suggestive of aortic stenosis (AS). Patients with AS are asymptomatic for a prolonged period, and classic symptoms (eg, angina, syncope or presyncope, heart failure symptoms) typically occur only after progression to severe AS (valve area <1 cm2). Some physical examination findings suggestive of severe AS include:
The severe valvular stenosis obstructs left ventricular outflow, reducing pulse pressure and weakening systemic pulsation. The highly thickened and calcified valve leaflets necessitate the generation of higher left ventricular pressure before they open, causing peak blood flow across the valve (and peak murmur intensity) to occur later in systole. The severely stenotic valve leaflets also cause soft aortic valve closure (A2) and delay it to the point that during inspiration it is nearly simultaneous with pulmonic valve closure (P2) (ie, narrowed splitting). Expiration delays A2 closure even further and paradoxical splitting may be appreciated.
(Choice A) A mid-diastolic murmur at the cardiac apex is typically heard in patients with mitral stenosis. As the mitral stenosis becomes severe, the diastolic murmur starts earlier and is heard immediately after the opening snap.
(Choice B) An S3 can be heard in patients with chronic severe mitral regurgitation, chronic aortic regurgitation, and heart failure, and occasionally in those with high cardiac output states such as pregnancy or thyrotoxicosis. Patients with severe AS may develop an S4 due to increased pressure load and concentric left ventricular hypertrophy, but an S3 is not typical.
(Choice C) An early-peaking systolic murmur suggests mild to moderate AS. This patient with exertional presyncope and delayed carotid upstroke most likely has severe AS, and a late-peaking systolic murmur is expected.
(Choice D) A loud S1 is typically heard in patients with mitral stenosis, but S1 is typically unaffected in patients with AS.
Educational objective:
Patients with severe aortic stenosis can have angina, syncope/presyncope, and heart failure symptoms. Physical examination typically reveals diminished and delayed carotid pulses, a soft and single S2, and a late-peaking, crescendo-decrescendo systolic murmur best heard at the right upper sternal border.