Case Presentation

A 77-year-old man with a past medical history of essential hypertension, diabetes mellitus, dyslipidemia, and stage III chronic kidney disease (CKD) presents with his adult daughter for an outpatient cardiology consultation for recently discovered severe aortic stenosis that was detected during a hospitalization for pneumonia one month prior. A compilation of hospital records and a subsequent geriatric assessment is available for review prior to the appointment.

Medications:

Aspirin 81 mg PO daily
Atorvastatin 40 mg PO nightly
Metoprolol 25 mg PO every 12 hours
Lisinopril 40 mg PO daily
Insulin glargine 30 units subQ nightly

Medication Allergies:

Penicillin, reaction of rash

Pertinent Social, Family History:

Denies drug use, denies alcohol use, is a former smoker.
Lives alone and independent with activites of daily living, retired construction worker, has two adult children, and has brothers who also have type 2 diabetes mellitus.

Review of Systems at the Recent Hospitalization:

Constitutional: Fatigue
Head, Eyes, Ears, Nose, and Throat: Hearing loss
Gastrointestinal: Loss of appetite and low caloric intake
Musculoskeletal: Minor joint pain

All other items in the review of systems were negative.

Vitals
Height: 67 inches
Weight: 152 lbs
Body Mass Index: 23.8
Heart Rate: 76 bpm
Blood Pressure: 128/82 mm Hg
O₂ Saturation: 99% on RA

Focused Physical Exam

General: Well-groomed, Caucasian man, no acute distress
Neck: No jugular venous distension appreciated, delayed carotid upstroke
Cardiovascular: Regular rate and rhythm, S₁ normal with soft S₂, grade II systolic crescendo-decrescendo murmur heard best in the right upper sternal border with radiation to the carotids.
Respiratory: Clear to auscultation bilaterally
Abdomen: BS+, S/NT/ND, no abdominal bruits auscultated
Neurological: Cranial nerves II-XII intact
Extremities: Dorsalis pedis and posterior tibialis pulses 1+ bilaterally, no cyanosis/clubbing/edema, no open wounds

Fried Frailty Score (if Available) or Other Evidence for Frailty

Shrinking (-)
Weakness (+)
Poor Endurance (+)
Slowness (-)
Low Activity (-)
Total Score = 2 intermediate frailty

Pertinent Laboratory Data:

Creatinine: 2.09 mg/dL
Random Glucose: 180 mg/dL
Hemoglobin: 12.0 grams/dL Hct 36
High-Density Lipoprotein: 30 mg/dL
Low-Density Lipoprotein: 90 mg/dL
Alkaline Phosphatase and Serum Calcium: Within normal limits

Pertinent Cardiac Studies

Electrocardiogram: Normal sinus rhythm, borderline left ventricular hypertrophy (LVH), biatrial enlargement, no significant ST-T segment abnormality

Transthoracic Echocardiography (TTE)

Conclusion: Heavily calcific trileaflet aortic valve with a valve area of 0.9 cm² by the continuity equation, mean gradient of 44 mm Hg, peak jet velocity of 4.1 m/s. The aortic root is normal in size. Left ventricular ejection fraction is preserved at 60%, and there is mild LVH. There is mild left atrial enlargement with mild-to-moderate tricuspid regurgitation, mild pulmonary artery hypertension, and no other abnormalities noted.

Cardiac Catheterization

Coronary Angiography

Left Main: Medium-sized, normal
Left Anterior Descending Artery: Large in caliber, transapical, 70% calcified stenosis in the mid portion after a large D1 branch, D1 has a 30% stenosis
Left Circumflex Coronary Artery: Small, mild luminal irregularities
Right Coronary Artery: Large in caliber, right dominant with posterior descending artery and posterolateral artery branches visualized, 60% calcified stenosis in the distal portion of the vessel prior to the bifurcation

Pertinent Non-Cardiac Procedures

Mini Mental Status Exam Score: 28/30

Consultation Notes

Nephrology: The consultation was performed prior to cardiac catheterization. The nephrologist states that the patient has a confirmed diabetic nephropathy and is at risk for further renal injury with preexisting chronic kidney disease (CKD) stage 3 if subjected to periods of hemodynamic instability. The patient's mild anemia is likely a result of CKD. Efforts should be made to reduce contrast exposure and renally dose medications.

If Undergoing Cardiac Surgery, Society of Thoracic Surgery Risk Score (STS)

Mortality: 4.1%
Morbidity or Mortality: 30.1 %
Long Length of Stay: 13.8 %
Short Length of Stay: 19.9 %
Permanent Stroke: 2.9 %
Prolonged Ventilation: 15.4%
Deep Sternal Infection: 0.6 %
Renal Failure: 13.5%
Reoperation: 10.8%

After reviewing the information above, you attempt to conduct an interview with the patient. During the interview process, he seems generally disinterested, and his daughter has to answer for him. When you ask him questions to determine if he has had symptoms of angina, dyspnea, and syncope, he just shrugs his shoulders. The daughter says that he lives alone, but when she visits him on Sundays, he has not mentioned any problems. She apologizes for his low level of participation in the interview and explains that they were in a rush to the appointment, and left his hearing aids in the car, and that he is generally more talkative with the aids in place.