Aashi
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A 78-year-old man reports a 2-month history of gradually decreasing exercise tolerance with shortness of breath on exertion. He has a long history of stable angina and hypercholesterolemia. He is currently taking aspirin, metoprolol, furosemide, and atorvastatin. On physical examination, his pulse is 72/min, and his blood pressure is 110/70 mm Hg. Jugular venous pressure is 6 cm H2O. Carotid upstrokes are delayed, left ventricular impulse is displaced laterally, and a systolic thrill is present at the base of the heart. There is a normal S1, a paradoxical split of S2, an S4 gallop, and a grade IV/VI, low-pitched, crescendo-decrescendo midsystolic murmur at the base of the heart. The murmur is transmitted upward along the carotid arteries. Which of the following would you do next?
(A) Maximize the beta-blocker dosage
(B) Catheterization of the left side of the heart
(C) Begin captopril
(D) Percutaneous balloon aortic valvuloplasty
(E) Start digoxin
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| CocaCola
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D - Valvuloplasty... although Fisher said valvuloplasty isn't as good for aortic stenosis in older people because the stenosis is due to calcifications...
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| prathapdoctor
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next step would be better to start digoxin therapy then go for surgery.
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| Aashi
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U guys are in for a SURPRISE 
Waiting for some more active participation on this q...
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"Obstacles are those frightful things you see when you take your EYES off your goal."
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| Aashi
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Sorry Guys THE ANSWER IS :-
(B) Catheterization of the left side of the heart
Explanation:
This patient has a midsystolic crescendo-decrescendo murmur radiating to the carotid arteries -- all signs that are consistent with aortic stenosis (AS). When angina pectoris, syncope, or left ventricular (LV) decompensation develops in adults with severe aortic stenosis, the outlook -- despite medical treatment -- is very poor and can only be improved significantly by aortic valve replacement. This is usually when the aortic orifice surface area is <0.7 cm2/m2 of body surface area. In this patient, the exact valve surface area is not that important because of his severe symptoms. The operative risk is considerably lower than the risk of nonoperative treatment. Symptomatic improvement in survivors of operation can be remarkable. Regression of LV hypertrophy may occur after relief of the obstruction.
Catheterization of the left side of the heart and coronary arteriography should generally be carried out in patients older than the age of 45 who are suspected of having severe AS and are being considered for operative treatment. The catheterization allows for the most accurate assessment of the transvalvular gradient, as well as to see who will need a coronary bypass at the same time as the valve replacement. In younger patients in whom coronary bypass is not a consideration, echocardiography is sufficient.
Percutaneous balloon aortic valvuloplasty is preferable to operation in children and young adults with congenital, noncalcified AS. It is not commonly used in elderly patients with severe calcific AS because of a high rate of restenosis. Nitrates and other vasodilators, such as ACE inhibitors, should be avoided in patients with severe AS. These agents reduce LV filling pressure, resulting in hemodynamic collapse. Digoxin will not help. Occasionally, patients with AS who develop angina may require treatment with nitrates. Such therapy should be initiated under strict supervision by a physician at the bedside. Volume expansion with saline may be necessary to avoid excessive preload reduction. Increasing the dose of the beta-blockers will not help because it will do nothing to relieve the mechanical obstruction of the flow of blood out of the left ventricle.
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"Obstacles are those frightful things you see when you take your EYES off your goal."
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