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A 68-year-old man with acute exertional dyspnoea and holosystolic murmur
  1. Kosuke Ishizuka,
  2. Kiyoshi Shikino,
  3. Masatomi Ikusaka
  1. Department of General Medicine, Chiba University Hospital, Chiba, Japan
  1. Correspondence to Mr Kosuke Ishizuka, Department of General Medicine, Chiba University Hospital Department of General Medicine, Chiba 260-8677, Japan; e103007c{at}

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Clinical introduction

A 68-year-old man presented to the ED with dizziness, nausea and cold sweats. Three days before presentation, he developed pink foamy sputum and exertional dyspnoea. On physical examination, the patient had a Levine III/VI holosystolic murmur, with the strongest point at the left sternal border of the third intercostal space. His N-terminal pro-brain natriuretic peptide (NT-proBNP) (5970 pg/mL) and troponin T (0.733 ng/mL) were elevated. Electrocardiography revealed ST elevation, abnormal Q wave, and coronary T wave in II, III and augmented Vector Foot (aVF). Echocardiography was performed (figure 1 and online supplemental video 1).

Supplementary video

Figure 1

Echocardiography: apical two-chamber view.


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  • Contributors KI identified the significance of the case. KI wrote the manuscript, and KS and MI revised it. All authors approved the final version of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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