Case Study 6

Question 1

A 72 year old male smoker with no previous cardiac history presents to GP with progressive dyspnoea, worsening over a few months.
On examination:
- regular pulse
- normal BP of 130/80
- no evidence of cardiac failure
- systolic murmur maximal on expiration
Give three likely causes of the systolic murmur

Answer 1

• aortic sclerosis
• aortic stenosis
• mitral regurgitation

Question 2

For the possible causes of the murmur, give findings on examination which may help you to identify the cause for his murmur

Answer 2

• Aortic sclerosis - does not radiate to carotids
• Aortic stenosis - may be associated with slow rising upstroke in the pulse waveform, low output pulse and murmur radiating to carotids
• Mitral regurgitation - loudest at apex, radiates to axilla, pan systolic murmur, maximal on expiration

Question 3

Give three basic investigations that should be carried out in primary care prior to hospital referral

Answer 3

• FBC
• biochemical screen including thyroid function
• CXR
• ECG

Question 4

The GP finds nothing wrong in his initial investigation and refers the patient to his local cardiology clinic. What key outpatient investigation should subsequently be performed?

Answer 4

Echocardiogram

Question 5

Severe aortic stenosis is diagnosed with a gradient across the valve estimated to be approximately 80mmHg with good left ventricular function. Coronary angiography is subsequently found to be normal. What is the recommended treatment for his condition?

Answer 5

Surgical aortic valve replacement