Today we will discuss another Q76 cardiology PLAB 1/ UKMLA exam style question.

A 72-year-old retired school teacher presents to the clinic complaining of episodes of dizziness and one episode of syncope while climbing a flight of stairs at his home. He describes associated shortness of breath and a mild, central chest discomfort on moderate exertion. He denies any palpitations or nocturnal symptoms. On examination, you notice that his pulse is regular, blood pressure is 115/75 mmHg, and respiratory rate is 18 breaths per minute. His jugular venous pressure is not elevated. On cardiac auscultation, you notice an ejection systolic murmur best heard in the aortic area, radiating to the carotids. Given his clinical presentation, what would be the SINGLE most definitive investigation to confirm the diagnosis?

A. ECG

B. Echocardiogram

C. Ambulatory blood pressure monitoring

D. Holter ECG

E. CT head

Answer is given below

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Answer: B. Echocardiogram.

Explanation:

This patient's presentation is highly suggestive of Aortic Stenosis (AS):

- Symptoms: The combination of exertional dyspnea, chest discomfort, and syncope in an elderly patient is classic for symptomatic AS.

- Physical Examination: The described ejection systolic murmur that is best heard in the aortic area and radiates to the carotids is the characteristic murmur of AS.

Echocardiogram (Choice B) is the gold standard investigation to diagnose and assess the severity of AS. It allows visualization of the aortic valve, assessment of the valve's anatomy, calculation of the valve area, and determination of the transvalvular gradient. Echocardiography can also provide valuable information about left ventricular function, which is crucial in determining the timing of aortic valve replacement in these patients.

Let's analyze the other options:

- ECG (Choice A) can show left ventricular hypertrophy or other non-specific changes in the context of AS, but it is not diagnostic for the condition.

- Ambulatory blood pressure monitoring (Choice C) would be more relevant if we were assessing hypertension or its management, not AS.

- Holter ECG (Choice D) is essential for evaluating arrhythmias, not valve pathologies. While patients with AS can have arrhythmias, the primary diagnosis of AS is not made with a Holter monitor.

- CT head (Choice E) is not relevant to this presentation. It would be indicated in the workup of neurological symptoms not explained by other causes.

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