A 55-year-old man comes to the office because of a 4- to 6-week history of what he describes as "chest pounding" that worsens when he lies on his back. He also reports occasional episodes of nonexertional chest pain lasting 1 to 2 minutes. He is unable to further characterize the pain. He says that he has had moderate shortness of breath after walking three blocks, but he has not had nocturnal dyspnea. Medical history is remarkable for type 2 diabetes mellitus and gastroesophageal reflux disease. Current medications include simvastatin, metformin, esomeprazole, and 81-mg aspirin. The patient has smoked one pack of cigarettes daily for the past 35 years. Family history is remarkable for myocardial infarction in his father at age 58 years. The patient is 183 cm (6 ft) tall and weighs 91 kg (200 lb); BMI is 27 kg/m2. Temperature is 36.7°C (98.1°F), pulse is 88/min, respirations are 16/min, and blood pressure is 165/55 mm Hg. There is no jugular venous distention. Carotid pulses are brisk and bounding. Auscultation of the lungs discloses mild, diffuse wheezes. Cardiac examination discloses a point of maximal impulse that is displaced laterally. There is a soft S1 and S2; a grade 3/6 blowing murmur is audible at the lower left sternal border that extends through two-thirds of diastole. Systolic and diastolic bruits are heard over both femoral arteries. Results of laboratory studies are shown:
Serum
Cholesterol
Total 300 mg/dL
HDL 30 mg/dL
LDL 180 mg/dL
Triglycerides 190 mg/dL
Urea nitrogen 28 mg/dL
Creatinine 1.4 mg/dL

Blood
Hemoglobin 13.0 g/dL
WBC 10,500/mm3

ECG shows normal sinus rhythm and left ventricular hypertrophy. Chest x-ray shows an enlarged cardiac silhouette and prominent ascending aorta.
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