Patients may present with chest pain, dyspnea, dizziness, paipila-tions. and syncope (caused by tachyarrhythmias or decreased cardiac output from outflow obstruction). Ventricular tachycardia is common and increases the likelihood of sudden death. Supraventricular tachyar¬rhythmias, more likely to occur as atrial dimensions increase, are also common. Because the atrial contribution to ventricular filling is impor¬tant for maintaining stroke volume in the elderly, atrial fibrillation may cause rapid hemodynamic deterioration.
A characteristic late systolic murmur from the lower left sternal bor¬der to the apex terminates before the second heart sound. The charac¬teristic bisferious carotid pulse has a rapid upstroke and a subsequent percussion wave. A prominent fourth heart sound is typical, but it dis¬appears at the onset of atrial fibrillation. The apex impulse is double in character. Provocative maneuvers (eg, Valsalva) accentuate the sys¬tolic murmur, which decreases or disappears on squatting; however, many elderly patients cannot adequately perform these maneuvers. The murmur may also disappear as systolic dysfunction and cavity dila¬tation occur. An aortic regurgitant murmur may be due to coexisting calcific aortic valvular disease.