Aortic Stenosis
The most appropriate provisional diagnosis is severe aortic stenosis (AS). This 65-year-old patient presents with the classic triad of symptoms—exertional dyspnea, angina, and presyncope—combined with pathognomonic physical examination findings that strongly indicate hemodynamically significant valvular obstruction.
Clinical Presentation Supporting Severe AS
The patient demonstrates all three cardinal manifestations of severe AS 1, 2:
- Exertional dyspnea progressing over one month, now worsening and taking longer to resolve with rest 1
- Angina (chest discomfort) occurring with exertion despite potentially normal coronaries, due to supply-demand mismatch from left ventricular hypertrophy 3, 2
- Presyncope (lightheadedness and feeling like he might faint) from inadequate cardiac output during exertion 1, 2, 4
The progressive worsening of symptoms over the past week with delayed recovery indicates advancing disease severity and decompensation 1.
Physical Examination Findings
The examination findings are highly characteristic of severe AS 1, 5:
- Soft systolic murmur at the right upper sternum is the classic location for an aortic stenosis murmur 1, 5, 2
- Low volume pulse (pulsus parvus et tardus) reflects delayed and dampened carotid upstroke, a hallmark of severe AS 5, 2, 4
- Narrow pulse pressure (110/95 mmHg = 15 mmHg) is characteristic of severe AS 6, 4
- Bibasilar crackles suggest early left ventricular decompensation and pulmonary congestion 1
Critical diagnostic point: The disappearance or marked softening of the second aortic sound (A2) is specific to severe AS, though the absence of this finding doesn't exclude the diagnosis 1, 5. The murmur may be deceptively soft in severe AS, particularly in elderly patients with low cardiac output 1, 4.
Age and Epidemiology
At 65 years, this patient falls into the typical demographic for calcific degenerative AS, which affects 2-7% of the population over 65 years and represents the most common valvular heart disease in Europe and North America 1, 7.
Diagnostic Approach
Echocardiography is the essential next step and should be performed urgently given the symptomatic presentation 1, 6, 7. The echocardiogram will:
- Confirm AS presence and assess valve calcification 1, 6
- Quantify severity via transvalvular gradients and valve area 1
- Evaluate left ventricular function, wall thickness, and chamber dimensions 1, 6
- Detect associated valvular disease 1, 6
Severe AS is defined as valve area <1.0 cm² (critical if <0.8 cm²) or mean gradient ≥40 mmHg 1.
Common Pitfalls to Avoid
- Do not dismiss a soft murmur as insignificant—severe AS can present with a faint murmur, especially in low-output states 1, 4
- Do not attribute symptoms solely to age or deconditioning—patients may subconsciously reduce activities and deny symptoms 1
- Do not delay echocardiography—once symptoms appear in severe AS, survival decreases rapidly without intervention 7, 8
- Do not assume normal coronaries exclude AS—angina in AS often occurs despite unobstructed coronaries due to subendocardial ischemia from supply-demand mismatch 3, 2
Urgency of Evaluation
This patient requires urgent cardiology referral and echocardiography 7. The combination of progressive symptoms, classic triad presentation, and characteristic physical findings indicates severe symptomatic AS, which carries a poor prognosis without intervention 1, 7, 8. Aortic valve replacement is recommended for symptomatic patients with confirmed severe AS on echocardiography 1, 7.