Asymptomatic Severe Aortic Stenosis

Information about a real patient is presented in stages (boldface type) to an expert clinician (Dr Patrick O'Gara), who responds to the information, sharing his or her reasoning with the reader (regular type). A Discussion by the authors follows. A 62-year-old man with a past medical history presents to the cardiology clinic for evaluation after a routine echocardiogram obtained for evaluation of palpitations. His clinical history is remarkable for infrequent self-terminating episodes of regular rapid heartbeat over the last 2 months. The events are not associated with chest discomfort, dyspnea, lightheadedness, dizziness, or flushing. He denies any symptoms of rest or exertional chest discomfort or dyspnea, recent syncope or presyncopal sensations, or paroxysmal nocturnal dyspnea. He states that he has been reducing his physical activity over the last several years because of fatigue. His past medical history is remarkable for hyperlipidemia and erectile dysfunction. He has no drug allergies. His medications include a multivitamin, simvastatin, and tadalafil. He smokes 1 pack of cigarettes per day and has a >30 pack-year smoking history. He neither drinks alcohol nor uses illicit drugs. He is a retired store clerk. Dr Patrick O'Gara: The history does not provide the context in which the episodes of self-terminating, rapid, regular heart action occur. It would be important to establish their relation to activity, meals, time of day, caffeine intake, cigarette use, or ingestion of any over-the-counter medications or supplements. Asking the patient to tap out the cadence of his heartbeat could be helpful. His limited physical activity may mask appreciation of early symptoms of underlying cardiovascular disease and should serve as a warning that the history may be misleading or falsely reassuring. Specific reasons for his fatigue should be explored, including the possibilities of insomnia, sleep-disordered breathing, depression, anemia, hypothyroidism, smoking-related pulmonary disease, and symptoms suggestive …