A 46-year-old man was admitted to the hospital after a severe bout of chest pain. The pain had had sudden onset, lasted one hour, and was located over the anterior aspect of the chest and upper part of the abdomen. The quality of the discomfort was dull and aching, and it radiated to the neck, mandible, and interscapular area. Nausea and sweating accompanied the pain. After the initial chest pain, there was rapid radiation into both sides of the groin while largely subsiding in the chest. There was no prior history of hypertension.
The patient's blood pressure was 126/74 mm Hg, and his pulse rate was 80 beats per minute. A grade 3/6 midsystolic murmur was heard over the second right intercostal space and radiated to the neck. A grade 2/6 diastolic blowing murmur was heard in the second right intercostal space and along the left sternal border. Pulses were