Cardiovascular · Moderate
This case is fictional and exists for study. It describes no real patient.
74 years · male
A 74-year-old man presents to the emergency department after experiencing a transient loss of consciousness while climbing a flight of stairs. He reports feeling lightheaded and breathless immediately before fainting. He recovered completely within two minutes without post-ictal confusion or neurological deficits. Over the past six months, he has noticed progressive shortness of breath on exertion and occasional exertional chest tightness. On cardiovascular examination, he has a slow-rising carotid pulse and a harsh crescendo-decrescendo systolic murmur heard loudest at the right upper sternal border, radiating to both carotid arteries.
Vital signs
- HR
- 78 bpm
- BP
- 110/70 mmHg
- RR
- 18/min
- Temp
- 36.8 °C
- SpO₂
- 97%
Examination findings
- Slow-rising carotid pulse (pulsus parvus et tardus)
- Harsh ejection systolic murmur at the right second intercostal space radiating to the carotids
- Soft second heart sound (S2)
Investigations
| Haemoglobin | 13.5 g/dL | reference: 13.0-17.0 |
| Serum Creatinine | 90 µmol/L | reference: 60-110 |
| Serum Potassium | 4.2 mmol/L | reference: 3.5-5.0 |
Question 1 of 3
Which of the following is the most likely cause of this patient's syncope?
The classic symptom triad of severe aortic stenosis is angina, dyspnoea, and exertional syncope. Physical examination typically reveals a slow-rising pulse (pulsus parvus et tardus) and an ejection systolic murmur that radiates to the carotids. Vasovagal syncope usually occurs in response to emotional or postural triggers and is preceded by prodromal autonomic symptoms. Hypertrophic obstructive cardiomyopathy presents similarly with exertional symptoms, but the murmur typically increases with the Valsalva maneuver and does not radiate to the carotids. Orthostatic hypotension occurs upon standing rather than during active physical exertion.
Teaching point: Exertional syncope combined with an ejection systolic murmur radiating to the carotids strongly suggests severe aortic stenosis.
Question 2 of 3
Which of the following is the most appropriate next investigation to confirm the diagnosis?
Transthoracic echocardiography is the primary diagnostic investigation to evaluate valve structure, measure transvalvular pressure gradients, and confirm the severity of aortic stenosis. 24-hour Holter monitoring is indicated for suspected cardiac arrhythmias. CT coronary angiography assesses coronary artery disease rather than valve gradient severity. Exercise tolerance testing is strictly contraindicated in patients with symptomatic severe aortic stenosis due to the risk of life-threatening arrhythmias and sudden cardiac arrest.
Teaching point: Transthoracic echocardiography is the non-invasive diagnostic standard for evaluating aortic valve disease and confirming aortic stenosis severity.
Question 3 of 3
Once the diagnosis of symptomatic severe aortic stenosis is confirmed, what is the most appropriate definitive management step?
Symptomatic severe aortic stenosis has a poor prognosis without definitive mechanical intervention. Urgent cardiology evaluation for aortic valve replacement (surgical aortic valve replacement or transcatheter aortic valve implantation) is indicated. Medical therapy such as beta-blockers does not alter disease progression and can exacerbate heart failure or haemodynamic collapse. Reassurance and fluids are inappropriate for fixed structural heart disease. Permanent pacemakers treat high-grade conduction block or symptomatic bradycardia, not fixed valvular outflow obstruction.
Teaching point: Medical management cannot improve survival in symptomatic severe aortic stenosis; urgent referral for aortic valve replacement or implantation is required.
Key learning points
- Symptomatic aortic stenosis presents with the classic triad of exertional dyspnoea, angina, and exertional syncope.
- Physical findings of aortic stenosis include a slow-rising carotid pulse, a soft S2, and a crescendo-decrescendo ejection systolic murmur radiating to the carotids.
- Transthoracic echocardiography is the initial test of choice to assess severity, and definitive management requires aortic valve replacement or transcatheter implantation.
This is one of 158 free cases
AskPreceptor is a study tool for medical students: answer first, then see the reasoning — including why each wrong option is wrong. Free, no sign-up required.