Differential Diagnosis for 77-year-old Male with Cardiovascular Symptoms

Single Most Likely Diagnosis

• Aortic Stenosis: The presence of a systolic murmur, high blood pressure, and left bundle branch block (LBBB) suggests aortic stenosis, a common condition in elderly patients that can lead to systolic murmurs due to the narrowing of the aortic valve. The LBBB can be a result of the long-standing hypertension or a direct consequence of the aortic stenosis affecting the conduction system of the heart.

Other Likely Diagnoses

• Hypertensive Heart Disease: Given the high blood pressure (170/90 mmHg), hypertensive heart disease is a likely diagnosis. It can lead to LBBB, systolic dysfunction, and heart failure symptoms such as bilateral basal crepitations, which are indicative of pulmonary congestion.
• Heart Failure with Preserved Ejection Fraction (HFpEF): The symptoms of bilateral basal crepitations without pedal edema, in the context of hypertension and LBBB, could also suggest heart failure with preserved ejection fraction. HFpEF is common in elderly patients with hypertension and can present with signs of pulmonary congestion.
• Cardiac Amyloidosis: Although less common, cardiac amyloidosis could be considered given the patient's age, systolic murmur, and the presence of LBBB. It can cause restrictive cardiomyopathy leading to heart failure symptoms.

Do Not Miss Diagnoses

• Acute Coronary Syndrome (ACS): Despite the absence of chest pain, ACS should not be missed, especially in elderly patients who may present atypically. The presence of LBBB can be associated with ACS, and timely diagnosis is crucial for management.
• Cardiac Tamponade: Although less likely given the absence of specific symptoms like pulsus paradoxus, cardiac tamponade is a life-threatening condition that should be considered, especially if there's a significant drop in blood pressure or signs of cardiac chamber collapse on imaging.

Rare Diagnoses

• Cardiac Sarcoidosis: This is a rare condition that can cause heart failure, arrhythmias, and conduction abnormalities, including LBBB. It might be considered if other diagnoses are ruled out and there are systemic symptoms suggestive of sarcoidosis.
• Fabry Disease: A rare genetic disorder that can lead to hypertrophic cardiomyopathy, heart failure, and conduction abnormalities. It's less likely but should be considered in patients with unexplained hypertrophic cardiomyopathy or systemic symptoms suggestive of Fabry disease.