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ECG Quiz: A Heart Murmur and Dyspnea in a 65-Year-Old Runner

John D. Cantwell, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 25 - NO. 5 - MAY 97


[FIGURE 1]A 65-year-old veteran distance runner noticed shortness of breath during his 5-mile walk-jog, which he performed three times a week. He particularly noticed the dyspnea while running with the Olympic torch for 0.1 miles.

His medical history included a grade 1 short systolic murmur at the upper right sternal border, which ceased with Valsalva's maneuver and was not felt to be of hemodynamic importance. His history also included chronic, stable hypertension, for which he took nifedipine 30 mg and enalapril 10 mg, once daily each. Other medical problems included degenerative joint disease of the knees, treated with diclofenac sodium, and mild hyperlipidemia (total cholesterol 226 mg/dL, low-density lipoprotein 152 mg/dL), treated with a low-fat diet. An echocardiogram had been done 4 years earlier, because of an abnormal resting electrocardiogram (ECG) and ventricular ectopy on a treadmill test. The result was normal, with no evidence of hypertrophic cardiomyopathy, mitral valve prolapse, or hypertensive cardiomegaly.

On physical examination, his blood pressure was 140/82 mm Hg, and pulse was 60 beats per minute and regular. His neck veins were not distended, and his chest was clear to auscultation. On cardiac examination, a grade 1 systolic murmur was again noted at the upper right sternal border. After he ran in place for a minute, the murmur increased to grade 3, was heard also at the cardiac apex, and had a more musical quality than before. He seemed more dyspneic than one would expect for a veteran exerciser. His resting ECG is shown in figure 1.

What is your interpretation of the ECG? How do you explain the impressive change in his heart murmur with exercise? Why is he short of breath with relatively low levels of exercise?

Dr Cantwell is director of preventive cardiology and cardiac rehabilitation at Georgia Baptist Medical Center and clinical professor of medicine at Morehouse School of Medicine in Atlanta. He is a member of the editorial board of The Physician and Sportsmedicine. Address correspondence to John D. Cantwell, MD, 755 Mt Vernon Hwy, Suite 530, Atlanta, GA 30328.


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