Clinical Skills · Supplementary · from Clinical Skills

Case 1: Focused Cardiac Examination with New Murmur

Patient Presentation

Demographics: 72-year-old male retired postal worker

Chief Complaint: "I've been getting short of breath climbing the stairs to my apartment."

History of Present Illness: A 72-year-old male presents with a 4-month history of progressive exertional dyspnea. He lives in a third-floor walk-up apartment and previously climbed the stairs without difficulty. Over the past 4 months, he has needed to stop and rest at the second-floor landing. In the past 2 weeks, he has also noted lightheadedness when standing quickly from a seated position, and his wife observed that he briefly lost consciousness while gardening 3 days ago, recovering spontaneously within seconds.

He denies chest pain at rest, orthopnea, paroxysmal nocturnal dyspnea, or lower extremity swelling. He has not seen a physician in 4 years. He reports a prior physician mentioning a "heart sound" during a routine exam approximately 10 years ago, but no follow-up was pursued.

His symptoms are concerning for hemodynamically significant valvular heart disease, and a careful cardiac physical examination is critical for initial assessment and guiding further workup.

Past Medical History:

• Hypertension (diagnosed 20 years ago, inconsistently treated)
• Hyperlipidemia (untreated)
• Benign prostatic hyperplasia
• No prior cardiac history documented

Medications:

• Hydrochlorothiazide 25 mg daily (inconsistent adherence)
• Tamsulosin 0.4 mg daily

Social History:

• Retired postal worker (mail carrier for 35 years)
• Non-smoker
• Occasional glass of wine with dinner
• Lives with wife in third-floor apartment
• Previously active, now limited by dyspnea

Family History:

• Father: died of "heart problems" at age 78
• Mother: hypertension, died of stroke at age 81

Physical Examination

• Vital Signs: BP 138/62 mmHg (narrow pulse pressure when corrected for systolic hypertension), HR 72 bpm, RR 18/min, Temp 36.7°C, SpO2 96% on room air
• General: Elderly male, appears older than stated age, mildly dyspneic after walking to exam room
• Carotid pulse: Parvus et tardus (diminished and slow-rising carotid upstroke bilaterally); no carotid bruits
• JVP: Prominent a-wave at 8 cm above sternal angle, consistent with decreased right ventricular compliance
• Precordial palpation:
• PMI sustained and laterally displaced to 6th intercostal space, anterior axillary line
• Systolic thrill palpable at right 2nd intercostal space (aortic area)
• No parasternal heave
• Auscultation:
• S1 normal intensity
• S2: Soft and single (absent A2 component)
• Grade 4/6 harsh, crescendo-decrescendo systolic ejection murmur, loudest at right upper sternal border (aortic area), radiating to bilateral carotid arteries
• Murmur peaks late in systole (late-peaking correlates with severe stenosis)
• S4 gallop present at apex (stiff, hypertrophied left ventricle)
• No S3 gallop
• No diastolic murmur detected
• Lungs: Bibasilar fine crackles, lower one-third bilaterally
• Abdomen: Soft, non-tender, no hepatomegaly
• Extremities: Trace bilateral ankle edema, pulses diminished but palpable

Workup and Results

Laboratory Studies:

Imaging/Additional Studies:

• ECG: Normal sinus rhythm, left ventricular hypertrophy by voltage criteria (Sokolow-Lyon), left atrial enlargement, no ST-T wave changes
• Transthoracic Echocardiogram:
• Severely calcified trileaflet aortic valve with restricted opening
• Aortic valve area: 0.7 cm² (severe AS: <1.0 cm²)
• Mean transaortic gradient: 48 mmHg (severe: >40 mmHg)
• Peak aortic velocity: 4.5 m/s (severe: >4.0 m/s)
• LVEF: 55% (preserved)
• Concentric LV hypertrophy (septal wall thickness 1.5 cm)
• Left atrial enlargement
• Mild mitral regurgitation
• Chest X-ray: Cardiomegaly, aortic valve calcification visible, mild pulmonary vascular congestion

Clinical Image

Diagram of the anterior chest wall showing the four primary cardiac auscultation areas (aortic, pulmonic, tricuspid, mitral) with phonocardiogram tracings demonstrating the crescendo-decrescendo systolic murmur of aortic stenosis. Source: Educational illustration.

Diagnosis

Severe Calcific Aortic Stenosis with Symptomatic Heart Failure (Exertional Dyspnea and Syncope)

Key Diagnostic Criteria:

• Classic symptom triad: exertional dyspnea, syncope, and (eventually) angina
• Harsh crescendo-decrescendo systolic ejection murmur at aortic area radiating to carotids
• Late-peaking murmur with diminished and delayed carotid upstroke (parvus et tardus)
• Soft/absent A2 component of S2
• Systolic thrill at aortic area
• S4 gallop (LV hypertrophy with diastolic dysfunction)
• Echo confirms: AVA 0.7 cm², mean gradient 48 mmHg, peak velocity 4.5 m/s

Treatment Plan

1. Urgent cardiology referral for evaluation for aortic valve replacement (surgical AVR or transcatheter TAVR)
2. Avoid vasodilators (nitrates, ACE inhibitors in high doses) due to risk of severe hypotension in critical AS
3. Avoid excessive diuresis; cautious low-dose furosemide 20 mg daily for pulmonary congestion
4. Activity restriction: avoid strenuous exertion until valve intervention
5. Cardiac catheterization for coronary angiography pre-operatively
6. STS risk score and Heart Team assessment to determine SAVR vs. TAVR
7. Optimize comorbidities pre-operatively (renal function, anemia workup)

Key Learning Points

• The classic physical examination findings of severe aortic stenosis are a late-peaking crescendo-decrescendo systolic murmur, parvus et tardus carotid pulse, diminished A2, systolic thrill, and S4 gallop
• Murmur intensity does not reliably correlate with severity in aortic stenosis; in critical AS with low cardiac output, the murmur may actually become quieter
• The presence of syncope in aortic stenosis indicates hemodynamically significant obstruction and is associated with a 50% mortality rate at 3 years without intervention
• Parvus et tardus (small and late) carotid pulse is a specific finding for severe AS, reflecting delayed and diminished transmission of the pressure wave across the stenotic valve
• Careful cardiac physical examination can reliably identify severe aortic stenosis and guide urgent echocardiographic confirmation

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