MEDizzy - A 24-year-old male seeks medical attention for the recent

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Disorders of the Cardiovascular System

A 24-year-old male seeks medical attention for the recent onset of headaches. The headaches are described as “pounding” and occur during the day and night. He has had minimal relief with acetaminophen. Physical examination is notable for a blood pressure of 185/115 mmHg in the right arm, a heart rate of 70 beats/min, arterioventricular (AV) nicking on funduscopic examination, normal jugular veins and carotid arteries, a pressure-loaded PMI with an apical S4, no abdominal bruits, and reduced pulses in both lower extremities. Review of symptoms is positive only for leg fatigue with exertion. Additional measurement of blood pressure reveals the following: Right arm 185/115 Left arm 188/113 Right thigh 100/60 Left thigh 102/58 Which of the following diagnostic studies is most likely to demonstrate the cause of the headaches?

ExplanationThis patient has a coarctation of the aorta presenting with marked hypertension proximal to the lesion. The narrow - ing most commonly occurs distal to the origin of the left subclavian artery, explaining the equal pressure in the arms and reduced pressure in the legs. Coarctations account for approximately 7% of congenital cardiac abnormalities, occur more frequently (2×) in men than in women, and are associated with gonadal dysgenesis and bicuspid aortic valves. Adults will present with hypertension, manifestations of hypertension in the upper body (headache, epistaxis), or leg claudication. Physical examination reveals diminished and/or delayed lower extremity pulses, enlarged collateral vessels in the upper body, or reduced development of the lower extremities. Cardiac examination may reveal findings consistent with left ventricular (LV) hypertrophy. There may be no murmur, a midsystolic murmur over the anterior chest and back, or an aortic murmur with a bicuspid valve. Transthoracic (suprasternal/parasternal) or transesophageal echocardiography, contrast CT or MRI of the thorax, or cardiac catheterization can be diagnostic. MRI of the head would not be useful diagnostically. The clinical picture is not consistent with renal artery stenosis, pheochromocytoma, carcinoid, or Cushing’s syndrome.