Endgames Case report

An elderly man who suddenly lost consciousness

BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.a3009 (Published 08 January 2009) Cite this as: BMJ 2009;338:a3009
  1. Radhakrishnan Ramaraj, resident physician
  1. 1Department of Internal Medicine, University of Arizona College of Medicine, 1501, N Campbell Avenue, Tucson, AZ 85724, USA
  1. drkutty2{at}gmail.com

    While walking on the beach, a 76 year old man lost consciousness suddenly and woke up to find his family looking over him. He had no convulsions, tongue biting, or urinary or faecal incontinence. He did not recall the event, but his daughter reported that he fell over without warning.

    He had no history of losses of consciousness, but he did admit to occasional chest pain and breathlessness on exertion. He took no regular drugs.

    Electrocardiography showed sinus rhythm with no ST/T changes. His pulse rate was regular at 68 beats/min, and his blood pressure was 132/76 mm Hg. Pulses were equal in all four extremities, and pedal oedema was not present. His venous pressure was not raised. On auscultation, his lungs were clear. He had delayed and subdued carotid upstrokes with a loud, late peaking, systolic crescendo-decrescendo murmur over the sternal border near the second intercostal space. The second heart sound was faintly audible.


    • 1 What investigations would you perform?

    • 2 What is this patient’s condition and how would you manage it?

    • 3 How would you manage patients with the same condition who were asymptomatic?


    Short answers

    • 1 Transthoracic echocardiography, exercise testing, and coronary angiography.

    • 2 This patient has aortic stenosis. No effective medical management exists for severe aortic stenosis. Drugs such as angiotensin converting enzyme inhibitors, digitalis, or diuretics can alleviate the symptoms of heart failure but do not slow or modify the progress of the disease. Valve replacement is recommended for patients with severe aortic stenosis (valve area <1.0 cm2 or gradient >40 mm Hg) who have classic symptoms of syncope, angina, or dyspnoea; those with left ventricular systolic dysfunction (ejection fraction <50%); and those who require coronary artery bypass grafting or surgery on the aorta or heart valves.

    • 3 Follow-up visits for patients with asymptomatic aortic stenosis …

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