A 75-Year-Old Man Is Being Evaluated for a Heart Murmur

A 75-year-old man is being evaluated for a heart murmur.  He has had no exertional chest pain, shortness of breath, palpitations, fatigue, dizziness, or syncope.  The patient's only other medical condition is hypertension, for which he takes chlorthalidone and amlodipine.  He has a 20-pack-year smoking history but quit 25 years ago.  Temperature is 36.9 C (98.4 F) , blood pressure is 130/80 mm Hg, pulse is 80/min, and respirations are 16/min.  Physical examination shows a sustained apical impulse.  S1 is normal; a single, soft S2 and an S4 are present.  A grade 3/6 late-peaking systolic murmur is heard best at the right 2nd intercostal space, with radiation to the right carotid artery.  Carotid pulses are delayed.  Transthoracic echocardiogram shows a thickened left ventricular wall with no regional wall motion abnormalities.  The ejection fraction is 45%.  There is a trileaflet aortic valve with heavy calcification, valve area of 0.9 cm², and transvalvular gradient consistent with severe aortic stenosis.  Which of the following is the most appropriate next step in management of this patient?

A) Follow with serial echocardiography
B) Reassure with no additional intervention
C) Recommend aortic valve intervention
D) Recommend cardiac exercise program
E) Recommend medical therapy

Correct Answer:

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