In an older patient with aortic stenosis and a systolic murmur, which symptom would be most concerning?

• A. Exertional dyspnea
• B. Asymptomatic murmur
• C. Mild hypertension
• D. Tachycardia at rest

Answer: (A)

Exertional dyspnea signals progression to symptomatic severe aortic stenosis and early heart failure from the fixed outflow obstruction. When the valve area is critically reduced, the heart can’t increase forward flow enough during exercise. The left ventricle raises filling pressures to meet demand, which backs up into the lungs and causes shortness of breath with activity. This symptom carries a worse prognosis and is a key trigger for evaluating for valve replacement.

An asymptomatic murmur isn’t necessarily dangerous by itself, mild hypertension is common and not specific to severe AS, and resting tachycardia can have many causes and doesn’t alone indicate decompensation.