A 62-Year-Old Man With Syncope and Chest Pain: Osmosis USMLE Study Question

December 25, 2020

This patient reports exertional dyspnea, angina, and syncope, which are nonspecific symptoms associated with many cardiac conditions. However, the finding of a systolic ejection murmur radiating to the carotids is classically associated with aortic stenosis; the murmur results from turbulent flow of blood through a narrowed aortic valve as it is ejected from the left ventricle during systole. The diagnosis of aortic stenosis is further supported by a soft S2, as A2 (the sound of aortic valve closure) is delayed and may disappear as the condition progresses.

Aortic stenosis, which results from thickening or calcification of the aortic valve, acts as a cause of left ventricular outflow obstruction. Consequently, the amount of blood that can be ejected from the left ventricle into the aorta in a single beat is reduced. Decreased stroke volume, in turn, leads to decreased systolic but normal diastolic pressure, causing a narrower pulse pressure. The indicated profile shows a blood pressure of 110/80 mm Hg, consistent with these expectations. However, the systemic arterial pressure profile would not show signs of the patient's systolic murmur, which results from turbulent flow of blood through the diseased aortic valve.

Major Takeaway: Aortic stenosis leads to decreased systolic pressure and narrowed pulse pressure. Patients may report exertional dyspnea or angina and classically present with a systolic ejection murmur that radiates to the carotid arteries.

Read more on aortic stenosis.


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