Skill Checkup: A 68-Year-Old Man With Acute Decompensated Heart Failure, Worsening Dyspnoea and Lower Extremity Oedema

Marco Luigetti, MD, PhD


August 18, 2022

The Skill Checkup series provides a quick, case-style interactive quiz, highlighting key guideline- and evidence-based information to inform clinical practice.

A 68-year-old Black man in Europe was admitted to the hospital for acute decompensated heart failure (HF). He had a history of hypertension, paroxysmal atrial fibrillation and coronary artery disease that required angioplasty. He received an implantable cardioverter-defibrillator owing to recurrent non-sustained ventricular tachycardia. The patient reported worsening dyspnoea, weight gain, bilateral lower extremity oedema and orthopnoea.

Initial vital signs included an oral temperature of 36.9°C (98.4°F), a heart rate of 87 bpm and a blood pressure of 101/75 mm Hg. Respiratory rate was 22 breaths/min with an oxygen saturation of 97%. Physical examination was significant for an S3 gallop, markedly elevated jugular venous pressure and bibasilar crackles. Chest radiograph revealed pulmonary oedema. B-type natriuretic peptide level was 3206 pg/mL. Cardiac troponin T levels were persistently elevated, 400 ng/L. Serum creatinine was 1.29 mg/dL, and blood urea nitrogen was 45 mg/dL. Complete blood cell count was significant for an iron deficiency anaemia. A hepatic function panel revealed hypoalbuminaemia (2.2 g/dL), but no other significant abnormality.

Transthoracic echocardiography revealed grade 3 diastolic dysfunction with biatrial enlargement and severe concentric left ventricular (LV) hypertrophy (17.8 mm thick). Left ventricular systolic function was normal with a calculated ejection fraction of 55%. The 12-lead ECG showed normal QRS voltage.

The differential diagnosis of HF with concentric LV hypertrophy focused on genetic and acquired primary cardiomyopathies, including hereditary transthyretin amyloid cardiomyopathy (hATTR-CM). Genetic considerations included neutral septal hypertrophic cardiomyopathy (CM), mitochondrial myopathies, glycogen storage diseases (eg Danon disease) and Fabry disease.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.