A 75-year-old man with a history of hypertension and type 2 diabetes presents to the emergency department with a complaint of dyspnea and shortness of breath after exercise for the past few weeks. The patient notes that he generally stays active and does not live a sedentary lifestyle. He denies nausea, vomiting, fevers, and chills. He drinks alcohol socially and smokes 3-4 cigarettes daily. Current medications include amlodipine and metformin. Vital signs in the emergency department are temperature 36°C (98.6°F), blood pressure 134/84 mmHg, pulse 75 beats/min, and respirations 17/min. Body mass index (BMI) is 30 kg/m2. Physical examination reveals a high-pitched, crescendo-decrescendo, midsystolic ejection murmur at the right sternal border. All lung fields are clear to auscultation. Laboratory values are within normal limits.
Which of the following most reflects increased severity of this patient’s condition?
- A) Continuous, machine-like murmur
- B) Long, late-peaking murmur
- C) Presence of S4
- D) Short, early peaking murmur
- E) Short time from S2 to opening snap
B) Long, late-peaking murmur
This patient has aortic stenosis and is presenting with complaints secondary to this valvular insufficiency. When aortic stenosis is mild, the murmur will peak in mid systole; as the disease becomes more severe, more time is needed to complete systole, and aortic valve closure becomes delayed. Therefore, the murmur peaks later in systole.
Answer choice A: Continuous, machine-like murmur. A continuous, machine-like murmur is present in patent ductus arteriosus, not aortic stenosis.
Answer choice C: Presence of S4, is incorrect. Presence of an S4 is usually consistent with left ventricular hypertrophy and does present in aortic stenosis.
Answer choice D: Short, early peaking murmur, is incorrect. Increased severity of aortic stenosis is indicated by a long, late peaking murmur, not a short, early-peaking one.
Answer choice E: Short time from S2 to opening snap, is incorrect. A short time from S2 to opening snap is indicative of increased disease severity in mitral stenosis.
Key Learning Point
Aortic stenosis presents with a high-pitched, crescendo-decrescendo, ejection murmur heard best at the right sternal border. When aortic stenosis is mild, the murmur will peak in mid systole; as the disease becomes more severe, more time is needed to complete systole, and aortic valve closure becomes delayed, peaking later in systole.
Dr. Ted O'Connell