An elderly patient presents with dyspnea, angina and exertional syncope. The EKG is normal. The most likely diagnosis is:

• A. Aortic regurgitation
• B. Pulmonary hypertension
• C. Aortic stenosis
• D. Mitral stenosis

Answer: (C)

Aortic stenosis best fits this presentation. In an elderly patient, the classic triad of dyspnea, angina, and exertional syncope arises from an obstruction to the left ventricular outflow. This increases afterload, provoking concentric left ventricular hypertrophy to maintain stroke volume. During exercise, the stressed heart can’t boost forward flow adequately, leading to reduced cerebral perfusion and syncope, while the higher myocardial demand and relatively reduced coronary perfusion cause angina. Dyspnea stems from elevated filling pressures and potential pulmonary congestion.

A normal EKG does not rule out aortic stenosis, especially early on; LV hypertrophy changes may be subtle or develop later, so the clinical picture remains the key clue.

Aortic regurgitation would present more with a wide pulse pressure and a diastolic murmur, not the classic exertional syncope with this triad. Pulmonary hypertension can cause dyspnea and syncope but the combination described is less characteristic, and the murmur/physical findings differ. Mitral stenosis tends to produce dyspnea from pulmonary congestion and signs like a diastolic murmur with left atrial enlargement on ECG, rather than the angina-syncope dyspnea pattern seen here.