Case Report. A 60-year-old man without significant past medical history presented to the emergency department with a six-day history of intermittent mid-epigastric pain with associated nausea, diaphoresis and exertional dyspnea. Aspirin was self administered for analgesia with increasing frequency over the six days prior to admission with minimal relief. The patient described gradual worsening of exertional dyspnea over a six-day period prior to admission; however, no other associated symptoms such as palpitations, paroxysmal nocturnal dyspnea or leg edema, were present upon presentation to the emergency room. His cardiovascular risk factors included a 40-year history of tobacco use, sedentary lifestyle due to occupation (truck driver), male sex, and age. Physical examination revealed: blood pressure 100/60 mmHg in both arms in supine position, heart rate 90 beats per minute, temperature 95.9?F and respiratory rate 24 breaths per minute with digital oximetry demonstrating 88% saturation on room air. His neck examination revealed no jugular venous distention and no carotid bruits. The cardiac examination demonstrated a regular S1and S2 with a II/VI holo-systolic murmur heard loudest at the left lower sternal border. The pulmonary exam revealed decreased breath sounds throughout both lung fields. His abdomen was soft and non-tender with normal bowel sounds. His extremity and neurological exam was unremarkable. His laboratory data included normal electrolytes, a hemoglobin of 11.2 g/dL, a troponin-I of 5.6 ng/dL (normal
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