A 64-Year-Old Woman With Extremity Swelling and Cough

Francisco Aguilar, MD; Carla Arellano Pizano, MD


July 17, 2018

Physical Examination and Workup 

A physical exam reveals blood pressure of 183/84 mm Hg, heart rate of 77 beats/min, respiratory rate of 20 breaths/min, oxygen saturation of 90% on room air, temperature of 98.4°F (36.9°C), and a body mass index of 35.5 kg/m2. She is awake and alert.

Jugular venous distention is noted. Upon auscultation, bilateral crackles are present in the lower two thirds of the thorax. Her heart sounds are audible and regular, with normal S1 and S2. An S3 gallop is present. No audible murmurs are noted. Apex impulse is present and nondisplaced from the midclavicular line. Her abdomen is soft, nondistended, and nontender to palpation. Moderate bilateral pitting edema in the lower extremities is present.

Initial laboratory workup reveals a serum creatinine level of 1.2 mg/dL (same as baseline level). Her brain natriuretic peptide (BNP) level is 4,237 pg/mL. Her serum troponin I level is 0.42 ng/mL. Lipase and liver function test results are within normal limits. Her ferritin level is 150 ng/mL. Her plasma and 24-hour urine fractionated metanephrine and catecholamine levels are within normal limits. Urine drug screen results are negative for cocaine.

An ECG reveals sinus rhythm with a heart rate of 75 beats/min and new T-wave inversion in the anterolateral leads compared with a previous ECG. Chest radiography reveals diffuse patchy opacities on bilateral lung fields that are suggestive of moderate pulmonary edema and blunting of costophrenic angle, which is suggestive of bilateral pleural effusion. Two-dimensional (2D) transthoracic echocardiography reveals hypokinesis of the septal, lateral, and anterior mid-distal segments with a left ventricular ejection fraction of 30% to 35% (Figures 1-2).

Figure 1.

Figure 2.

Given the patient's symptoms, ECG changes, elevated troponin levels, and 2D echocardiography findings, urgent left heart catheterization with angiography is performed. Coronary angiography reveals 40% obstruction of the left anterior descending artery, 30% obstruction of the left circumflex artery, and 30% to 40% obstruction of the right coronary arteries. Left ventriculography revealing systole is shown in Figure 3.

Figure 3.


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