A 63-year-old man was evaluated in consultation for unexplained dyspnea. At the time of the initial clinical encounter at our institution, the patient endorsed a 10-year history of progressive exertional dyspnea, which had become debilitating over the preceding 3 months and was characterized by shortness of breath accompanying subtle physical activities such as tying shoelaces. The patient underwent multiple hospital admissions reportedly for the treatment of congestive heart failure ascribed to impaired left ventricular (LV) diastolic function. Review of systems identified postural dizziness and history of near syncope, possible nocturnal dyspnea, and peripheral neuropathy, but not cardiac angina, orthopnea, nocturia, edema, cough, palpitations, syncope, claudication, or other cardiopulmonary symptoms. He related that he was first noted to have a cardiac murmur detected 4 decades previously during a military service physical examination but that the murmur was not characterized further and that he served in the Vietnam conflict without functional limitation.
The patient’s relevant medical history included rate-controlled atrial fibrillation, 90 pack-year tobacco use (3 packs daily between 21 and 51 years of age), dyslipidemia, systemic hypertension, type 2 diabetes mellitus, moderate chronic obstructive pulmonary disease, obstructive sleep apnea not currently treated, and gastrointestinal bleed caused by colon cancer treated with hemicolectomy 11 years earlier. There was no illicit drug use, but a remote history of heavy alcohol consumption was reported. Family history was unremarkable except that his father died at 55 years of age of myocardial infarction.
Medications included aspirin 81 mg daily, warfarin 2 mg daily, losartan 50 mg daily, metoprolol tartrate 25 mg twice daily, simvastatin 10 mg daily, fenofibrate 48 mg daily, albuterol inhaler 90-μg puffs as needed, and gabapentin 300 mg 3 times daily.
Keywords: atrial septal defect sinus venosus; heart defects, congenital; heart failure; hypertension, pulmonary.