An

82-years-old retired solicitor presents to the ED with chest pain radiating to

his jaw. He has hypertension treated with ramipril 5 mg bid (ACE inhibitor) but

is otherwise normally fit and well. His admission ECG shows sinus rhythm with

ventricular rate of 57 bpm, LV hypertension, and widespread ST segment

depression. His peak troponin is 110 ng/l (normal <30 ng/l). He is started

on treatment for an acute coronary syndrome and listed for an inpatient

angiogram. You are asked to perform bedside echocardiogram as a systolic murmur

is heard on the post-take ward round. His aortic valve is heavy calcified,

maximal trans-aortic jet velocity is 4.3 m/s, peak trans-aortic gradient is 75

mmHg, mean trans-aortic gradient is 46 mmHg (Figure below).