CASE
A 73-year-old Hispanic male noted worsening fatigue and shortness of breath for the past 2 months. The dyspnea was so severe that he had to sit for 15 minutes when walking from his car to his house. Episodes of paroxysmal nocturnal dyspnea forced him to sit up on the edge of the bed for 10 minutes before he could lie down again. He denied fever, chills, nausea, vomiting, and swelling of the lower extremities or abdomen. He reported no specific chest pain, heaviness, pressure, or tightness. One sister had diabetes and another sister had coronary artery disease. The patient did not smoke but said he drank two to three beers a week. He took metoprolol for hypertension.
Physical examination Initially, the patient had noteworthy tachypnea, which resolved after 15 to 20 minutes. He was afebrile; BP was 136/90 mm Hg and pulse was 100 beats per minute. No jugular venous distention or thyromeg aly was apparent. Auscultation revealed a regular tachycardic heart rate with a grade 2 systolic murmur heard best at the apex; no rubs or gallops were noted. The remainder of the examination and a CBC, including hemoglobin and hematocrit, were within normal limits.
An ECG demonstrated a sinus tachycardic rhythm with a left bundle branch block, and echocardiography revealed markedly distended heart chambers with global hypokinesis (see Figure 1). Left ventricular ejection fraction (EF) was less than 10% (normal range, 50%- 80%), and pulmonary artery pressure was 54 mm Hg (normal range, 14-25 mm Hg). Angiography revealed no lesions in the left coronary arteries, but an 80% occlusion in the right coronary artery (RCA) required stent placement. A repeat EF determination was 8%.
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