Question 1 of 36

A 63-year-old man presents with a 24-hour history of progressive dyspnea. Vital signs: respiratory rate 28/min; heart rate irregular at 110/min; blood pressure 110/80 mm Hg. You notice decreased carotid upstroke and you hear bibasilar rales. You hear a prominent S3 and a grade 3/6, late peaking crescendo-decrescendo murmur at the right second intercostal space. Chest radiograph shows a normal heart size and pulmonary congestion. EKG shows left ventricular hypertrophy (LVH) with atrial fibrillation. You recognize that:

Without treatment, his life expectancy is less than 2 years.

He will require higher than average doses of diuretics to control his symptoms.

Appropriate medical therapy includes sublingual captopril to decrease afterload.

Acute and chronic vasodilator therapy will be beneficial.

Bedside ultrasound will show a hypodynamic right ventricle.

The findings are typical for valvular aortic stenosis (AS). The three most common presenting signs are syncope, angina and heart failure. Untreated, the prognosis for AS presenting with angina or syncope is less than 5 years; however, heart failure worsens the prognosis and lowers the average survival to less than 2 years. Atrial fibrillation and other tachyarrhythmias are poorly tolerated and may result in acute deterioration. Specific treatment in this patient would be to control his ventricular rate. Because these patients are dependent on an adequate filling pressure, administering diuretics may be hazardous. Vasodilators are often not tolerated, as they can increase the gradient across the valve and worsen left ventricular function.