Intended for healthcare professionals

Endgames Picture Quiz

A man with hypertension and two murmurs

BMJ 2012; 344 doi: (Published 15 February 2012) Cite this as: BMJ 2012;344:e956
  1. Stuart C G Rison, final year medical student1,
  2. Toby P Locke, final year medical student1,
  3. Eric Rosenthal, consultant paediatric cardiologist2,
  4. Sandeep Gandhi, consultant cardiologist3
  1. 1King’s College London, London SE1 1UL, UK
  2. 2Evelina Children’s Hospital, St Thomas’ Hospital, London, UK
  3. 3Medway Maritime Hospital, Gillingham, UK
  1. Correspondence to: S C G Rison stuart.rison{at}

A 34 year old white man was referred by his general practitioner to our cardiology clinic with hypertension and a six month history of intermittent lower midsternal chest pain. The pain radiated to the left side of his back and was unrelated to physical exertion. He also reported two episodes of sudden onset dyspnoea, which lasted a few minutes, occurred at rest, and was not associated with chest pain or cardiac symptoms. He had not experienced such symptoms previously. His exercise tolerance was normal.

On examination, he was comfortable at rest. His heart rate was regular, at 80 beats/min. He had a large volume “collapsing” pulse, a prominent carotid pulse, and bounding peripheral pulses. His jugular venous pressure was not raised. There was no radioradial delay but radiofemoral delay was noted. His blood pressure was 210/70 mm Hg. The apex beat was visible and displaced 3 cm left of the midclavicular line in the fifth intercostal space. A left parasternal heave was noted. On auscultation, a loud early diastolic murmur and a systolic murmur were heard. Examination of the respiratory, abdominal, and neurological systems was unremarkable. Figure 1 shows his chest radiograph.

Fig 1 Posteroanterior chest radiograph


  • 1 On the basis of the clinical findings and chest radiograph, what diagnoses can be made?

  • 2 What investigations might help you confirm the suspected diagnoses?

  • 3 What are the management options and long term prognoses?


1 On the basis of the clinical findings and chest radiograph, what diagnoses can be made?

Short answer

Rib notching (fig 2), cardiomegaly, loss of aortic knuckle, systolic hypertension, and systolic murmur are consistent with coarctation of the aorta; the widened pulse pressure, loud early diastolic murmur, and prominent carotid pulse suggest aortic valve regurgitation. The aortic valve is bicuspid, thus prone to regurgitation, in 20-85% of patients with coarctation.

Fig 2 Posteroanterior chest radiograph showing characteristic inferior rib notching (Roesler’s sign, red …

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