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Bacterial endocarditis
1%
1/105
Bicuspid aortic valve
93%
98/105
Cardiac myxoma
2%
2/105
Mitral insufficiency
Senile calcific changes
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This patient is presenting with chest pain and dyspnea with exertion in the setting of a murmur heard along the right upper sternal border suggesting a diagnosis of aortic stenosis. The most common cause of aortic stenosis in a young patient is a bicuspid aortic valve. Aortic stenosis is a significant cause of chronic heart failure in elderly patients and is often due to senile calcification. Younger patients may also present with aortic stenosis due to underlying congenital valvular defects such as a bicuspid aortic valve (most common) or rheumatic fever (though the mitral valve is more commonly damaged). Aortic stenosis causes a crescendo-decrescendo murmur during systole heard best near the right upper sternal border with radiation to the carotids. The intensity of the murmur is dependent on the difference in pressures between the left ventricle and the aorta. As the condition worsens, the intensity of the murmur peaks later in systole. Late in the disease, the A2 component may also be diminished. When symptomatic, aortic stenosis may cause the triad of syncope, angina, and heart failure. The diagnosis can be confirmed with echocardiography. Incorrect Answers: Answer 1: Bacterial endocarditis would present with a fever and signs and symptoms of septic embolization (such as septic emboli to the lungs or extremities). The classic presentation is a fever and a murmur in a patient with a history of IV drug abuse or immunosuppression. Answer 3: Cardiac myxoma presents with a loud first heart sound and may cause syncope but would be unlikely to present with chest pain, dyspnea, and a murmur heard along the right upper sternal border with radiation to the carotids. Answer 4: Mitral insufficiency can cause dyspnea and pulmonary crackles and would present with a systolic murmur head at the cardiac apex. Answer 5: Senile calcific changes are the most common cause of aortic stenosis but would be expected in an elderly patient as the etiology of their symptoms. Bullet Summary: The most common cause of aortic stenosis in a young patient without any risk factors is a congenital bicuspid valve.
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