case 185

case 185


A 84-year-old male patient presented a proximal humeral fracture after suffering ground level fall associated with syncope. Reports repetitive syncope, angina and slight limitation by shortness of breath during moderate exertion. As comorbities he has hypertension, type 2 diabetes mellitus, dyslipidemia, stage G3b chronic kidney disease (CKD) − glomerular filtration rate (GFR) of 33.3 L/min per 1.73 m2. In use of ACE inhibitors, diuretics and nitrate. On physical examination, he presented decreased breath sounds in pulmonary bases, grade II/IV ejection systolic murmur, heard best in second intercostal space on the right, with harsh quality, radiating to neck . Also, it was observed that arterial pulse was reduced in amplitude and delayed in occurrence. Electrocardiogram (ECG) showed regular sinus rhythm, left ventricular hypertrophy. Laboratory tests: creatinine: 1.9; Hb: 11.5; Htc: 39.

Image 1: Doppler echocardiography.

Image 2: Pretreatment Aortography


Com base no exame clí­nico do paciente e nos exames complementares, qual o diagnóstico mais provável e a conduta mais adequada?