A 65-year-old man presents to his primary care physician complaining of dyspnea, chest pain, and several syncopal episodes. His symptoms have worsened over the past few months and his third syncopal episode prompted this visit. On examination, a systolic ejection murmur is auscultated with an ejection click in the right second intercostal space. Rales are present at the lung bases. He has a history of rheumatic fever in his twenties. Which of the following might explain the angina pectoris in this patient?
A 65-year-old man presents to his primary care physician complaining of dyspnea, chest pain, and several syncopal episodes. His symptoms have worsened over the past few months and his third syncopal episode prompted this visit. On examination, a systolic ejection murmur is auscultated with an ejection click in the right second intercostal space. Rales are present at the lung bases. He has a history of rheumatic fever in his twenties. Which of the following might explain the angina pectoris in this patient?
💡 Explanation
**Core Concept**
Mitral stenosis is a valvular heart disease characterized by the narrowing of the mitral valve orifice, leading to increased pressure and volume overload on the left atrium. This can result in left atrial enlargement, increased pulmonary pressures, and eventual right heart failure.
**Why the Correct Answer is Right**
The patient's history of rheumatic fever in his twenties is a classic risk factor for mitral stenosis. The increased pressure and volume overload on the left atrium due to mitral stenosis can lead to angina pectoris due to coronary artery ischemia secondary to increased left atrial pressure and subsequent coronary perfusion pressure drop. This is known as "coronary steal syndrome."
**Why Each Wrong Option is Incorrect**
* **Option A:** Coronary artery disease is not directly related to the patient's symptoms and history. While it is a possible cause of angina pectoris, it does not explain the patient's mitral stenosis and associated symptoms.
* **Option B:** Hypertrophic cardiomyopathy is a possible cause of angina pectoris, but it does not explain the patient's history of rheumatic fever or the auscultated ejection click.
* **Option D:** Pulmonary embolism is not a direct cause of angina pectoris and does not explain the patient's mitral stenosis and associated symptoms.
**Clinical Pearl / High-Yield Fact**
Remember that mitral stenosis can lead to increased pulmonary pressures and eventual right heart failure, which can manifest as symptoms such as peripheral edema, jugular venous distension, and hepatomegaly.
**Correct Answer:** C.
✓ Correct Answer: A. Increased ventricular wall tension limits perfusion
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