A 75-year-old male with chest pain, dyspnea, and syncope has a harsh systolic murmur at the right second intercostal space. Which accompanying finding would you expect?

• A. Laterally displaced PMI
• B. Diminished radial pulses
• C. S4 heart sound
• D. Wide pulse pressure

Answer: (A)

Aortic stenosis creates a long-standing pressure overload on the left ventricle, leading to concentric LV hypertrophy. That increased wall thickness and mass make the ventricle enlarge and push the point of maximal impulse (PMI) farther to the left and downward, so you feel a laterally displaced apical impulse. In this patient with chest pain, dyspnea, syncope, and a harsh systolic murmur at the right upper sternal border, this LV remodeling is the most expected accompanying finding.

S4 can be present with LVH, reflecting a stiff ventricle, but the hallmark here is the physically displaced PMI due to LV hypertrophy from chronic afterload. Wide pulse pressure points to conditions like aortic regurgitation, not isolated aortic stenosis, and diminished radial pulses are less specific for AS.