A 58-Year-Old Man With Congestive Heart Failure

Introduction. A 58-year-old man presents with symptoms of congestive heart failure (CHF).

History. In the last 2 months, he has developed significant dyspnea on exertion with previously well-tolerated activities, a degree of orthopnea, and significant pedal edema. He denies any chest pain, and his yearly periodic checkup has not shown any cardiac murmurs or systemic diseases such as hypertension or diabetes. He currently does not take any medications.

The patient immigrated to the United States from Argentina more than 25 years ago and manages several family-owned restaurants. He has not traveled outside the United States since immigrating. He has no family history of cardiac disease, and no family members have been ill in recent months.

Physical examination. The patient was well appearing. His temperature was normal, pulse was 108 beats/min, respiratory rate was 16 breaths/min, and blood pressure was 105/75 mm Hg. The head, eyes, ears, nose, and throat examination was normal. Fine rales were present at both lung bases. Cardiac examination revealed tachycardia, with a heart rate of 104 to 108 beats/min, without murmurs. The apical impulse was diffuse. The abdominal examination was normal. He had 2+ to 3+ pedal edema extending above the ankles.

Routine laboratory test results, including a complete blood cell count, metabolic panel, and comprehensive biochemical panel, were within normal limits. The albumin level was 4.0 g/dL. Chest radiography showed diffuse cardiomegaly with pulmonary congestion. Echocardiography showed no primary valvular disease but demonstrated 4-chamber enlargement, with no left ventricular hypertrophy or regional wall-motion abnormalities. The left ventricular ejection fraction was 22%. Electrocardiography showed low voltage, sinus tachycardia, and first-degree atrioventricular block, without acute or chronic ischemic changes. The N-terminal pro–B-type natriuretic peptide level was 2200 pg/mL (reference range, <900 pg/mL).