A 48-year-old man with no remarkable medical history was sent to the emergency department from a local urgent care facility because of cough, dyspnea, mild chest discomfort, lower extremity edema, and a blood pressure (BP) of 210/150 mm Hg. He had no fever, constitutional symptoms, blurry vision, headaches, back pain, weakness, palpitations, or tremors and no personal or family history of hypertension. He did not use alcohol, tobacco, or illicit drugs.Physical examination at the emergency department revealed an overweight man with a BP of 222/ 167 mm Hg, pulse rate of 123 beats/min, temperature of 36.7°C, respiratory rate of 16 breaths/min, and oxygen saturation of 91% while the patient received 2 L/min of oxygen by nasal cannula. Peripheral pulses were equal and synchronous. Findings on cardiac examination were notable for a sustained laterally displaced apical impulse and a third heart sound with no murmurs. Pulmonary examination revealed bibasilar crackles and reduced breaths sounds at the right lung base. No masses or bruits were noted on abdominal examination. Pitting lower extremity edema was present to the knees bilaterally. There were no focal neurologic deficits. A funduscopic examination was not performed.Initial laboratory studies yielded the following results (reference ranges shown parenthetically): hemoglobin, 16 g/dL (13.5-17.5 g/dL); creatinine, 2.0 mg/dL (0.8-1.3 mg/dL); sodium, 137 mEq/L (135-145 mEq/L); potassium, 3.8 mEq/L (3.6-5.2 mEq/L); and serum urea nitrogen, 38 mg/dL (8-24 mg/dL). The N-terminal pro-B-type natriuretic peptide level was 12,629 pg/mL (Յ56 pg/mL). The troponin T value was 0.4 ng/mL at baseline, 0.2 ng/mL at 3 hours, and 0.3 ng/mL at 6 hours after presentation (Ͻ0.01 ng/mL). Urinalysis revealed no abnormalities. Findings on electrocardiography included sinus tachycardia, rightward axis, left atrial enlargement, and left ventricular hypertrophy with secondary ST-T abnormalities. Chest radiography showed notable cardiac enlargement as well as mild pulmonary vascular congestion and a small right pleural effusion.