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Case 72

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A 35-year-old female patient complained of recurrent precordial chest pain referred to her left shoulder which lasted a few minutes and went away upon rest. She also reported a dyspnea after walking about three blocks on level ground. These symptoms had started two years before. She also mentioned a history of rheumatic fever during childhood and a non-specified cardiac surgery in 2001. Physical examination revealed: BP: 160/100 mmHg, PR = 64/min and RR = 28/min; carotid pulsus parvus et tardus; normal jugular venous pulse, sustained apex beat. Cardiac auscultation: regular cardiac rhythm, paradoxical splitting of the second heart sound and a harsh loud (grade 4) meso-systolic murmur heard best at the heart base which radiated to the clavicles but not to the axilla, vanished over the sternum and reappeared faintly at the apex. She had been taking benzathine penicillin 1.200.000 UI IM every three weeks.

Based on the clinical scenario and the imaging presented, which is the most likely diagnosis?

a) Aortic stenosis

25%

b) Mitral insufficiency

25%

c) Combined aortic stenosis and mitral insufficiency

25%

d) Interventricular communication

25%
   

Comments

- Leading causes of valvular aortic stenosis: congenital bicuspid aortic valve, degenerative aortic valve disease and rheumatic heart disease.

- Symptoms (typically occurring on exertion): angina, dyspnea and syncope.

- Physical examination: carotid pulsus parvus et tardus, paradoxical splitting of the second heart sound (S2), fourth heart sound (S4), harsh meso-systolic murmur over the heart base which radiates to the carotids and sternal notch.

- Predictors of severity: occurrence of symptoms (syncope, angina or dyspnea), paradoxical splitting of S2, prolonged and/or late peaking systolic murmur.

- Propaedeutics: electrocardiogram (ECG), echocardiography and chest radiograph.

- Treatment: aortic valve replacement (the mainstay therapy), prophylaxis of rheumatic fever (if it is the underlying cause) and bacterial endocarditis (only in selected patients).

References

- Up to date: Clinical features and evaluation of aortic stenosis in adults

- CECIL, Russell L.; GOLDMAN, Lee; AUSIELLO, D. A. Cecil medicine. 23. ed. Philadelphia: Saunders Elsevier, c2008. xxxiii, 3078 p.

- SERRANO JR., Carlos V.; TIMERMAN, Ari; STEFANINI, Edson; Sociedade de Cardiologia do Estado de São Paulo. Tratado de cardiologia SOCESP. 2.ed. São Paulo: SOCESP: Manole, 2009. 2v.

- Tarasoutchi, F.; Montera, M. W.; Grinberg, M.; Barbosa, M. R.; Piñeiro, D. J. Sánchez CRM, Barbosa MM et al. Diretriz Brasileira de Valvopatias - SBC 2011 / I Diretriz Interamericana de Valvopatias - SIAC 2011. Arq Bras Cardiol 2011; 97(5 supl. 1): 1-67.

- Braunwald, E.; Perloff, J. Physical examination of the heart and circulation. In  Zipes, D.P.; Fuller, J. K.; Libby, P.; Braunwald, E.; Bonow, R. O. (eds): Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 7th edition. Elsevier, 2004, pp.77-106.

Author

Daniel Moore Freitas Palhares – 5th year medical student of UFMG School of Medicine. E-mail: danielmoore2[arroba]msn.com

Advisor

Professor Rose Mary Ferreira Lisboa da Silva – Cardiologist, and member of the Department of Internal Medicine (UFMG School of Medicine). E-mail: roselisboa[arroba]uol.com.br

Reviewers

Fernanda Foureaux e Júlio Guerra

Commentics

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