A 58-year-old man is brought in by paramedics after a witnessed syncopal episode while walking with friends. He denies headache, chest pain, or shortness of breath prior to the event, or now. He has hypertension and takes lisinopril. Vital signs are BP 150/100, HR 78, RR 18, T 98.6, room air saturation 97%. Physical examination is notable for a harsh, systolic murmur at the right base, which radiates into the neck. His lungs are clear to auscultation. A transthoracic echocardiogram is pending. The ECG shows normal sinus rhythm with left atrial enlargement but is otherwise normal. What is the MOST appropriate next step in management?
Admit patient
+Arrange computed tomography (CT) of chest
+Arrange EEG
+Arrange outpatient electrophysiologic testing
+Arrange outpatient tilt-table testing
This patient has strong evidence of a structural cardiac abnormality, most likely aortic stenosis, and should be admitted for further evaluation of cardiac function. A transthoracic echocardiography is essential. Critical aortic stenosis is associated with a classic triad of chest pain, dyspnea on exertion, and syncope. Older patients with aortic stenosis and syncope who are asymptomatic upon ED presentation should still be admitted due to the increases risk of death. Patients with documented cardiac syncope have a 6-month mortality exceeding 10%. Electrophysiologic testing is done for patients with dysrhythmias, preexcitation, or conduction delays. Tilt-table testing is performed on patients with recurrent unexplained syncope, suspected to have a reflex-mediated etiology. EEGs would be reserved for patients with suspected seizures.