A 78-year-old woman sought medical attention for severe dyspnea. She had morbid obesity, hypothyroidism, and long-standing hypertension, and was taking captopril 150 mg, furosemide 40 mg, digoxin 0.25 mg, and levothyroxine 75µg daily.For a long time she had dyspnea on heavy exertion, which became worse during the previous week, progressing to dyspnea at rest, orthopnea, nonproductive cough, and lower extremity edema. The patient had been diagnosed with heart failure at another medical institution. She was then medicated and discharged from hospital; nevertheless, her dyspnea worsened, and she sought emergency care at InCor.Physical examination (April 28, 2007) revealed tachypnea (36 breaths/min), heart rate of 120 bpm, blood pressure of 150/80 mm Hg, and body mass index of 46,9 kg/m². She weighted 275.5 pounds and was 5 feet and 3 inches tall. Chest auscultation revealed bilateral rales in the lower lung fields and occasional wheezing. Examinations of the heart and abdomen were unremarkable. Bilateral lower-extremity edema was noted, greater in the right leg. Oxygen saturation (measured percutaneously) was 88%.Laboratory data were as follows: urea 85 mg/dL, creatinine 1.8 mg/dL, blood glucose 116 mg/dL, hemoglobin 18 g/dL, hematocrit 57%, platelet count 228,000/mm³, troponin 2.8 ng/ml, CK-MB 10.8 g/L, fibrin D-dimer > 5000 g; and activated partial thromboplastin time (APTT) ratio 1.41.The electrocardiogram (ECG) showed sinus rhythm with a heart rate of 114 bpm, PR interval of 175 msec, QRS duration of 94 msec, QT interval of 282 msec, QRS axis +150 oriented posteriorly, S 1 Q 3 T 3 pattern, and right bundle branch block (Figure 1).The echocardiogram yielded the following measurements: aortic diameter of 32 mm, left atrial diameter of 32 mm, interventricular septal thickness of 10 mm and free wall thickness of 9 mm. The right atrium was markedly dilated, and the right ventricle was dilated and hypokinetic, with a systolic pressure of 85 mm Hg. The left ventricle was found to be normal.
