Terrance K. is a 60-year-old gentleman who comes to the emergency room after experiencing an episode of retrosternal chest discomfort. This occurred while he was walking on his treadmill at home. The pain was mid-sternal, non-radiating, and resolved approximately two minutes after he stopped his treadmill. He admits to several recent episodes of similar chest discomfort, each occurring during exercise. His first episode occurred 6 months ago, though they have become more frequent over the last month. He has noted these episodes only with exertion and never at rest. He became particularly alarmed with today's episode because he also felt quite lightheaded and thought he was going to faint. His past medical history is unremarkable, though he admits to not having been to a doctor in over 30 years. He is on no medications and denies any drug allergies. On examination, his heart rate is 76 bpm and regular, his BP is 110/70 mmHg, and his respiratory rate is 12. He is afebrile with a temperature of 36.8 degrees Celsius. His JVP is elevated at 5 cm above the sternal angle. His carotid pulse is somewhat delayed and with a diminished upstroke. There is a palpable thrill over both carotids. His chest reveals bibasilar crackles on auscultation. His cardiac exam reveals a sustained but not displaced point of maximal impulse. There is a palpable S4. The first heart sound is normal though the second heart sound is diminished in intensity. There is an easily heard fourth heart sound. There is also a harsh, grade 3/6, crescendo-decrescendo systolic murmur that peaks late in systole. The murmur radiates into both subclavian arteries as well as both carotids. It is also heard throughout the precordium.