MEDizzy - A 63-year-old man presents with signs of congestive heart

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Cardiovascular System

A 63-year-old man presents with signs of congestive heart failure, including shortness of breath, cough, and paroxysmal nocturnal dyspnea. Physical examination reveals a hyperdynamic, bounding, “water-hammer” pulse and a high-pitched decrescendo diastolic murmur at the left sternal border after the second heart sound. His hyperdynamic pulse causes “bobbing” of his head. Which of the following is the most likely diagnosis?

ExplanationA highpitched decrescendo diastolic murmur at the left sternal border after the second heart sound is a hallmark clinical finding of aortic regurgitation (AR). Other clinical manifestations of aortic regurgitation include exertional dyspnea, angina, and left ventricular failure. Owing to the rapidly falling arterial pressure during late systole and diastole, there is often wide pulse pressure, Corrigan “water-hammer” pulse, capillary pulsations at the nail beds, and a pistol-shot sound over the femoral arteries. Volume overload of the heart is the basic defect and results in left ventricular dilation and hypertrophy. AR is rheumatic in origin in approximately 70% of cases. Much less frequently it is due to syphilis, ankylosing spondylitis (rarely), infective endocarditis, aortic dissection, or aortic dilation from cystic medial necrosis. Congenital forms of aortic stenosis occur fairly frequently, but AR is rarely congenital in origin. In contrast to the decrescendo diastolic murmur of AR, aortic stenosis is characterized by a crescendo-decrescendo midsystolic ejection murmur with a paradoxically split S2, mitral regurgitation with a high-pitched “blowing” holosystolic murmur, and mitral stenosis with a rumbling late diastolic murmur with an opening snap.