A 77-Year-Old Woman Comes to the Physician Because She "Passed

question 692

Multiple Choice

A 77-year-old woman comes to the physician because she "passed out."  She says that over the last few months she has had several episodes where she feels very lightheaded and must sit down.  On one occasion, she did actually lose consciousness and hit her head against a bathroom counter.  There are no clear precipitants of these episodes.  She denies chest pain or pressure.  She thinks that she is more short of breath while playing tennis than she used to be in the past.  Her other medical problems include hypertension and mild chronic kidney disease.  Her medications include amlodipine, lisinopril, simvastatin, and aspirin.
Her blood pressure is 115/70 mm Hg, pulse is 62/min, and BMI is 23 kg/m².  The patient is in no acute distress.  There is a normal S1 and a soft S2.  There is a III/VI mid-peaking systolic ejection murmur at the right upper sternal border that radiates to both carotid arteries.  Her lungs are clear to auscultation.  Her abdomen is soft and non-distended.  Peripheral pulses are 2+ and symmetric.
An echocardiogram showed normal left ventricular function, mild left ventricular hypertrophy, and moderate calcific aortic stenosis with an estimated aortic valve area of 1.4 cm² (normal 3-4 cm²) .
The patient was given a 24-hour Holter monitor.  The tracing below was recorded at 1:25 pm.

Which of the following would be the best next step in managing this patient?

• A)Aortic valve replacement
• B)Discontinuation of amlodipine with close follow-up
• C)Exercise stress testing
• D)Permanent pacemaker placement
• E)Tilt table testing

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Definitions:

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