48 A 67-Year-Old Male With Syncope


Case 48

A 67-Year-Old Male With Syncope



Patrick E. Sarte, Seth Politano, Eric Hsieh



A 67-year-old male presents with a complaint of syncope after carrying a bag of groceries up a flight of stairs. He has a 20-year history of hypertension and has an 80-pack-year smoking history. He had a heart attack 7 years ago and has been medically managed with enalapril and simvastatin daily.



What are the considerations for the differential diagnosis of this patient’s presenting symptom?


In a patient presenting with syncope, one can divide up the etiology into broad categories, of which the majority are cardiac and neurologic in origin. However, as can be seen in Table 48.1, other causes include pulmonary, vascular, and even psychiatric.



On physical exam, the patient’s blood pressure is 160/96 mm Hg, pulse rate is 84/min, respiration rate is 14/min, and oxygen saturation is 100% on room air. There are no orthostatic changes in blood pressure or pulse. The patient is alert and without pallor. Lungs are clear to auscultation bilaterally. The cardiac exam reveals a nondisplaced apical impulse. There is a crescendo–decrescendo systolic murmur heard best in the aortic area with radiation to the carotids. The intensity of the murmur decreases with the Valsalva maneuver. There is no lower extremity edema or cyanosis, and capillary refill is less than 2 seconds. The neurologic exam is grossly normal, with no motor or sensory deficits.




Given this physical exam, what do you think is the most likely cause of this patient’s syncope?


The presence of a murmur on cardiac exam suggests a cardiac etiology, particularly a valvular disorder. In addition to the patient’s age, the description and location of the murmur are most consistent with aortic stenosis. A definitive diagnosis is established with echocardiogram.



Step 2/3


Clinical Pearl


Aortic sclerosis is thickening of the valve causing turbulent flow but no stenosis. The murmur may be similar to that of aortic stenosis but without radiation to the carotids or supraclavicular area. Similarly, a flow murmur (in a hyperdynamic state such as thyrotoxicosis, infection, or anemia) can be a systolic murmur similar to aortic stenosis but without the characteristic crescendo–decrescendo pattern or radiation.



What are the physical exam findings of aortic stenosis?


Aortic stenosis classically has a systolic ejection murmur with a crescendo–decrescendo quality heard best in the aortic area (i.e., the right second intercostal space) with radiation to the carotids. When severe, there is a characteristic delay and decrease in the intensity of the pulse, which is also referred to as pulsus tardus et parvus. Patients may also have an audible S4 and laterally displaced point of maximal cardiac impulse because they develop concentric left ventricular hypertrophy as a compensatory response by the left ventricle to pump blood across a stenotic aortic valve to maintain systemic perfusion pressures. The patient may likewise have the same physical findings of congestive heart failure such as elevated jugular venous distension, bibasilar rales on pulmonary auscultation, and/or lower extremity pitting edema in advanced cases of aortic stenosis.



Step 1


Basic Science Pearl


Other auscultatory findings for aortic stenosis include a soft or absent S2.



Step 1/2/3


Basic Science/Clinical Pearl


The grade of the murmur does not reflect the severity of the stenosis. However, severe aortic stenosis may present with a delayed S2 or reversed split S2 (P2 precedes A2).



What maneuvers are performed to accentuate or diminish the murmur associated with aortic stenosis, and why do they have that effect?


The typical maneuvers that are performed and that affect the murmurs of valvular disorders are the Valsalva maneuver, passive leg raise, and hand grip (Table 48.2). The Valsalva maneuver is performed by asking the patient to bear down, which causes an increase in intrathoracic pressure and thus a decrease in venous return. The passive leg raise is performed by the examiner on the patient in the supine position, and this results in an increase in venous return. The hand grip is performed by the patient, and this causes an increase in afterload. During a Valsalva maneuver, as the venous return decreases, the gradient across the stenotic aortic valve also decreases, and thus the magnitude of the murmur decreases as well. The opposite effect on the aortic stenosis murmur is achieved when a passive leg raise is performed, which increases the venous return to the heart and increases the pressure gradient across the stenotic aortic valve. Finally, as mentioned above, the hand grip leads to an increase in afterload, which causes a decrease in the pressure gradient across the stenosed aortic valve, and this results in a diminishment of murmur intensity.


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Jun 15, 2016 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on 48 A 67-Year-Old Male With Syncope

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