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A 72-year-old woman presented with a 3-day history of increasing breathlessness on effort, orthopnoea, and nocturnal dyspnoea in the absence of chest pain or haemoptysis. She was a life-long smoker of 10 cigarettes per day but her medical history was otherwise without note and she was not taking any regular medication. On examination she was thin, neither anaemic nor clubbed and was clinically euthyroid. The pulse was 150 beats/min, blood pressure 130/90 mmHg. There were signs of biventricular failure with a raised venous pressure, bilateral ankle oedema, bibasal crackles and a left pleural effusion. A 3/6 pan systolic murmur was audible at the cardiac apex with radiation to the left axilla. Routine blood tests, including thyroid function tests, were normal apart from a mild derangement in liver function tests consistent with hepatic congestion. An electrocardiogram revealed atrial flutter with a 2 : 1 AV block and a chest X-ray was consistent with cardiac failure. A subsequent echocardiogram confirmed a dilated cardiomyopathy, severe mitral regurgitation, secondary tricuspid regurgitation and a globally reduced cardiac output. A small pericardial effusion was also noted.
The patient was treated along standard lines with diuretics and an angiotensin-converting enzyme …
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