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A 69-year-old woman was referred to by her local medical practitioner with worsening exertional dyspnea (NYHA III). She found difficulty mobilizing to her mailbox (120 m on a flat surface), as well as doing light housework and dressing. Her background history is relevant for long-standing hypertension (HTN), dyslipidemia, obesity, stage 3 renal impairment, and paroxysmal atrial fibrillation. Her medication profile is listed in Table 6-1. Physical examination revealed a well-looking woman with a blood pressure of 155/80 mm Hg on both arms, a heart rate of 72 in a regular rhythm, and respiratory rate of 20. Anthropomorphic measurements were a height of 162 cm and weight of 84 kg, with a calculated body mass index (BMI) of 32 kg/m2. Precordial examination revealed the apex beat to be nondisplaced, with no palpable heaves or thrills. No murmurs were auscultated. The jugular venous pressure was estimated at 2 cm, and there was trace pedal edema. The remainder of the physical examination was normal. The electrocardiogram (ECG) confirmed sinus rhythm, with features of left ventricular hypertrophy (LVH) and left axis deviation. Chest radiography demonstrated clear lung fields and borderline cardiomegaly.

Table 6-1Medication Profile for Introductory Patient Case

Laboratory profile demonstrated a mild anemia, with hemoglobin of 10.5 g/dL and a mean red cell volume of 92. Renal function was impaired with a urea of 22.4 mg/dL and creatinine of 1.02 mg/dL, leading to an estimated glomerular filtration rate (GFR) of 57.2 mL/min/1.73 m2 via the MDRD equation, or 57.5 mL/min using the Cockcroft-Gault equation adjusted for the overweight patient. A resting N-terminal pro-brain natriuretic peptide (NT-proBNP) was mildly elevated at 385 pg/mL.

A transthoracic echocardiogram demonstrated moderate global concentric hypertrophy with normal systolic function, with an ejection fraction calculated via Simpson’s biplane method of 68%. The left atrium was mildly enlarged, with satisfactory valvular function and E/e’ ratio of 13. A recently performed stress echocardiogram was negative for inducible ischemia. Respiratory function tests revealed normal ventilatory function with no significant bronchodilator response. Exercise right heart catheterization was performed (Table 6-2), with evidence of a normal pulmonary capillary wedge pressure (PCWP) at rest, and a marked rise with exercise.

Table 6-2Invasive Hemodynamics at Rest and with Exercise

In summary, this 69-year-old woman presents with worsening NYHA III exertional dyspnea on a background ...

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