A 67-Year-Old Man Comes to the Office for Routine Follow-Up

A 67-year-old man comes to the office for routine follow-up.  He has a history of hypertension, osteoarthritis, and chronic aortic regurgitation.  He reports that he is doing well overall and plays doubles tennis three times a week for exercise, which he does without any chest pain or pressure.  He denies shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, or edema.  His medications include aspirin, nebivolol, simvastatin, chlorthalidone, and acetaminophen.  
His blood pressure is 128/60 mm Hg and pulse is 67 /min. His BMI is 27 kg/m².  Cardiovascular examination reveals a normal S1 and S2.  There is 2/6 mid-systolic murmur at the right upper sternal border followed by a high-pitched diastolic decrescendo murmur best heard at the left upper sternal border.  The intensity of the diastolic murmur is increased with handgrip.  His peripheral pulses are 3+ bilaterally.
A transthoracic echocardiogram demonstrates normal left ventricular size and function.  The aortic valve is calcified and demonstrates mild stenosis (mean gradient = 13 mm Hg) with moderate aortic regurgitation.  When compared to the echocardiogram from two years ago, both the aortic stenosis and regurgitation are worse.
Which of the following would be the most appropriate next step?

A) Aortic valve replacement
B) Coronary angiography
C) Lisinopril
D) Repeat echocardiogram in 6-12 months
E) Transesophageal echocardiography

Correct Answer:

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