03-08-2009, 06:48 PM
A 46-year-old gentleman with aortic stenosis comes
to your office noting dyspnea upon climbing 1 flight
of stairs. He denies chest pain, palpitations or syncope.
On exam, his blood pressure is 125/80 mm Hg,
heart rate 88 beats per minute and respiratory rate is
an unlabored 16 breaths per minute. He has no
jugular venous distention (JVD). You note a delayed
carotid upstroke that is decreased in volume. S1 is
normal, S2 is physiologically split. No click is appreciated.
An S4 is present. He has a late peaking, II/VI
systolic ejection murmur. You refer him for an
echocardiogram that reveals a left atrium of 5.5 cm
(upper limit of normal 4.5 cm), septal and posterior
wall thicknesses of 1.3 cm (both upper limits of normal
1.0 cm), a left ventricular internal diastolic
dimension of 6.6 cm (upper limit of normal of 5.5
cm) with moderate aortic stenosis, and a peak gradient
of 30 m/sec with an aortic valve area of 1.1 cm2.
His left ventricular ejection fraction (LVEF) is 58%.
Of the following choices, the next best step is:
a) Reevaluate in 12 months with a transthoracic
echocardiogram.
b) Reevaluate in 6 months with a transthoracic
echocardiogram.
c) Cardiac catheterization.
d) Cardiopulmonary exercise testing.
e) Referral for urgent surgery.
to your office noting dyspnea upon climbing 1 flight
of stairs. He denies chest pain, palpitations or syncope.
On exam, his blood pressure is 125/80 mm Hg,
heart rate 88 beats per minute and respiratory rate is
an unlabored 16 breaths per minute. He has no
jugular venous distention (JVD). You note a delayed
carotid upstroke that is decreased in volume. S1 is
normal, S2 is physiologically split. No click is appreciated.
An S4 is present. He has a late peaking, II/VI
systolic ejection murmur. You refer him for an
echocardiogram that reveals a left atrium of 5.5 cm
(upper limit of normal 4.5 cm), septal and posterior
wall thicknesses of 1.3 cm (both upper limits of normal
1.0 cm), a left ventricular internal diastolic
dimension of 6.6 cm (upper limit of normal of 5.5
cm) with moderate aortic stenosis, and a peak gradient
of 30 m/sec with an aortic valve area of 1.1 cm2.
His left ventricular ejection fraction (LVEF) is 58%.
Of the following choices, the next best step is:
a) Reevaluate in 12 months with a transthoracic
echocardiogram.
b) Reevaluate in 6 months with a transthoracic
echocardiogram.
c) Cardiac catheterization.
d) Cardiopulmonary exercise testing.
e) Referral for urgent surgery.