From the Guidelines
The most appropriate study to order next is echocardiography (option E). This patient presents with classic signs of heart failure, including exertional dyspnea, peripheral edema, and weight gain, as well as a harsh grade 3/6 systolic murmur that is heard best at the base of the heart and is loudest at the second intercostal space on the right, which is concerning for aortic stenosis, a condition commonly found in elderly patients 1.
Given the patient's symptoms and physical examination findings, echocardiography is recommended for the diagnosis and assessment of aortic stenosis severity, as well as for the assessment of left ventricular wall thickness, size, and function 1. The American College of Cardiology/American Heart Association guidelines suggest that echocardiography is indicated when there is a systolic murmur that is grade 3/6 or greater, or symptoms that might be due to aortic stenosis, which is the case in this patient 1.
Echocardiography would provide crucial information about cardiac structure and function, including valve assessment, ejection fraction, and chamber dimensions, helping to confirm the suspected diagnosis of heart failure and determine its etiology, which appears likely to be valvular 1. While other studies such as ECG, complete blood count, CT scan of the chest, or D-dimer level may be helpful in certain contexts, they do not provide the detailed anatomical and functional information needed to evaluate the murmur and assess cardiac function in this scenario.
Key points to consider in this decision include:
- The patient's age and symptoms suggestive of heart failure
- The presence of a harsh systolic murmur concerning for aortic stenosis
- The need for detailed assessment of cardiac structure and function to guide management
- The recommendation for echocardiography in patients with suspected aortic stenosis or heart failure, as per guidelines 1.
From the Research
Patient Presentation
The patient presents with a 1-month history of shortness of breath with activity, progressive swelling in the legs, and a 2.3-kg (5.0-lb) weight gain, which are indicative of heart failure symptoms. The patient's past medical history of hypertension and hyperlipidemia, and the presence of a harsh grade 3/6 systolic murmur, suggest a possible cardiac etiology.
Diagnostic Considerations
Given the patient's symptoms and physical examination findings, the most likely diagnosis is aortic stenosis, which is supported by the presence of a systolic murmur heard best at the base of the heart and loudest at the second intercostal space on the right 2.
Appropriate Diagnostic Test
The most appropriate study to order next would be echocardiography, as it is the recommended diagnostic test for evaluating aortic stenosis and assessing left ventricular function 2, 3, 4. Echocardiography can provide valuable information on the severity of aortic stenosis, left ventricular systolic function, and the presence of any other cardiac abnormalities.
Rationale for Echocardiography
Echocardiography is a non-invasive and widely available diagnostic test that can provide detailed information on cardiac structure and function. The use of echocardiography in patients with suspected aortic stenosis is supported by guidelines and has been shown to be effective in diagnosing and managing this condition 2, 4. Additionally, studies have demonstrated that echocardiography is a useful tool in evaluating patients with heart failure symptoms and can help guide management decisions 5.
Other Diagnostic Options
While other diagnostic tests, such as a complete blood count, CT scan of the chest, D-dimer level, and ECG, may be useful in evaluating the patient's overall condition, they are not the most appropriate next step in diagnosing aortic stenosis. Echocardiography is the most direct and informative test for evaluating the patient's cardiac function and diagnosing aortic stenosis.