What type of murmur does an elderly male patient with a harsh systolic murmur at the second intercostal space radiating to the carotid and a history of syncopal episode have?

Aortic Stenosis

This elderly male patient with syncope and a harsh systolic murmur at the second right intercostal space radiating to the carotids has aortic stenosis, which is pathologic and requires urgent echocardiography given the history of syncope. 1, 2

Clinical Reasoning

The combination of clinical features points definitively to aortic stenosis:

• Location and radiation pattern: A harsh systolic murmur at the second intercostal space (right upper sternal border) that radiates to the carotid arteries is the classic presentation of aortic stenosis 3, 1, 4

• Syncope as a red flag: Syncope in the context of a systolic murmur strongly suggests severe aortic stenosis, as it indicates hemodynamically significant obstruction to left ventricular outflow 1, 2

• Elderly population: Aortic stenosis is highly prevalent in elderly patients, with 18% of elderly patients with systolic murmurs having moderate to severe aortic stenosis 4

Critical Distinction from Other Murmurs

This is not a carotid bruit (an innocent murmur), despite the radiation to the carotids, because: 3

• Carotid bruits disappear with bilateral shoulder hyperextension 3
• Carotid bruits are typically heard in the supraclavicular region or anterior neck, not at the second intercostal space 3
• The presence of syncope makes an innocent murmur extremely unlikely 1

This is not hypertrophic cardiomyopathy because the maximal intensity is at the second intercostal space rather than the fourth left intercostal space 5

Immediate Management Required

Urgent echocardiography is mandatory because: 1

• Any murmur with syncope requires immediate echocardiographic evaluation 1
• Syncope indicates potentially severe aortic stenosis with average survival of only 3 years after syncope onset without surgical intervention 2
• Classic physical examination signs may be unreliable in elderly patients for determining severity 6, 7

Physical Examination Caveats in the Elderly

Be aware that traditional signs of severe aortic stenosis may be absent or misleading in elderly patients: 6, 4

• The carotid upstroke may appear normal due to vascular aging and arterial stiffness 6
• The murmur may be softer or radiate apically rather than to the carotids 6
• The only reliable physical finding to exclude severe aortic stenosis is a normally split S2 6
• If S2 is single or paradoxically split, severe aortic stenosis is likely present 1, 6

Diagnostic Accuracy Considerations

Physical examination alone has limitations: 8

• Sensitivity for detecting aortic stenosis is only 71% 8
• The degree of stenosis severity is frequently misjudged clinically, particularly when left ventricular function is impaired 8
• Echocardiography should be performed in all patients with systolic murmurs suspected of having significant heart disease 8

Prognostic Implications

The presence of syncope with aortic stenosis carries grave prognostic significance: 2

• Average survival is 3 years after syncope onset without aortic valve replacement 2
• Sudden death can occur with little warning once symptoms develop 7
• Doppler echocardiography has approximately 95% agreement with cardiac catheterization for quantifying stenosis severity 2