Mr Jones, a new patient to the practice came to see the doctor with a six-month history of progressive breathlessness on exertion. He was a 65-year-old retired plumber and had smoked 20 cigarettes a day since he was a boy. Being averse to anything medical, he had not seen a doctor for 30 years since he broke his arm.
There was no history of wheeze but he admitted to have a smoker’s cough without any blood for several years. His weight was stable. Importantly, there was no chest tightness on exertion. On reviewing other systems, he commented he felt particularly light-headed once when he had to run for a train. He denied any loss of consciousness.
Mr Jones was of slim build and was comfortable at rest. On examination, there was no finger clubbing but abundant tar staining was noted. His pulse was a little hard to feel but in sinus rhythm. BP was 108/88mmHg. Auscultation of his chest revealed only a few crepitations at the left base.
Respiratory disorder was a concern, perhaps COPD or a neoplastic process such as bronchogenic carcinoma or mesothelioma, given he was a plumber. An FBC, chest X-ray and spirometry were urgently arranged.
On review, his Hb was at the upper end of normal perhaps reflecting mild secondary polycythaemia from long-term smoking. Spirometry was surprisingly normal. His FEV1 was 96% predicted for his demographic and FEV1:FVC ratio was 0.80.
There was no evidence of early airway collapse on the flow volume loop, which can sometimes cause a false FEV reading. The chest X-ray reported some subtle calcification around the origin of the aorta and radiological evidence of cardiac failure.
The praecordium was examined, which revealed a harsh ejection systolic murmur at the left sternal edge and aortic region radiating to the carotids. The second heart sound was inaudible. He also examined his abdomen given the Hb. Except for mild right upper quadrant tenderness likely due to cardiac congestion, no abnormalities were found and in particular, no splenomegaly.
Given the symptom complex of breathlessness and dizziness, and that the second heart sound was attenuated, it was likely the stenosis was severe. A working diagnosis of aortic stenosis complicated by cardiac failure was made.
An urgent referral to the cardiology team was arranged who confirmed the diagnosis of severe aortic stenosis with left ventricular systolic dysfunction (LVSD). Carotid Doppler showed minimal stenosis only. Valve replacement with concomitant CABG was recommended given a pre-operative angiogram revealed significant coronary artery disease.
The patient made an uneventful recovery and was discharged on a variety of drugs, including ramipril, bisoprolol, furosemide, atorvastatin and warfarin, given he had a metallic valve.
Subsequent follow up echocardiography demonstrated a normally functioning replacement valve and that whilst he still had LVSD, his ejection fraction has significantly improved. A diagnosis of ischaemic cardiomyopathy was also made. In addition to cardiac rehabilitation, the cardiology team requested his GP uptitrate his cardiac drugs to maximum tolerated doses.
Mr Jones was monitored in primary care and smoking cessation was discussed. A referral to a smoking cessation counsellor was arranged. The reasons for taking each medicine were discussed, as was the importance of regular monitoring.
The ramipril and bisoprolol were uptitrated over time to their maximum tolerated doses to minimise his risks of worsening cardiac failure. Other co-morbidities were checked and optimised, lifestyle advice given and drug adherence reviewed regularly. He was also encouraged to weigh himself daily and to seek advice if his weight increased (suggesting fluid overload) or if he became breathless.
He subsequently offered to be part of the practice patient participation group and to join the local clinical commissioning group cardiology steering team.
Overall, Mr Jones' case was well managed. There was an error early on, namely assuming he had an underlying respiratory disorder given the history of smoking and plumbing, and consequently ignoring the dizziness and the narrow pulse pressure. It is likely a cardiac cause would have been explored eventually but a general examination including auscultation of heart sounds may have changed the initial management.
Aortic stenosis is a common condition that is generally caused mainly by calcification, biscuspid aortic valve or rheumatic fever. Sinister features include breathlessness, dizziness, syncope or exertional chest pain.
The main diagnostic modality is echocardiography although exercise testing, imaging and catheterisation are used under certain circumstances or pre-operativlely. Treatment is surgical (open or percutaneous) and prognosis of symptomatic disease without treatment carries a 50% two-year mortality.
- Dr Thakkar is a GP in Wooburn Green, Buckinghamshire