A 91-year-old woman with a history of hypertension, hypercholesterolemia, and stage 3 renal insufficiency presented for a routine office visit. She reported no chest pain, dyspnea on exertion, presyncope, orthopnea, paroxysmal nocturnal dyspnea, or pedal edema.
Physical examination demonstrated blood pressure of 140/76 mm Hg and a heart rate of 72/min. Carotid upstrokes were slightly delayed with a transmitted murmur. Lungs were clear bilaterally. Cardiac examination demonstrated a regular rate and rhythm, normal S1, 3/6 harsh, late-peaking systolic murmur that radiated to the carotids with soft A2, 2/4 diastolic decrescendo murmur at the left lower sternal border, and 2/6 holosystolic murmur at the apex. Distal pulses were 2+ bilaterally. There was no edema.
Foppa M, Rao SN, Manning WJ. Doppler Echocardiography in the Evaluation of a Heart Murmur. JAMA. 2015;313(10):1050-1051. doi:10.1001/jama.2015.1278