A 56-Year-Old Male With Shortness of Breath on Exertion
The patient is a 56-year-old male who presents with shortness of breath. The patient had been in his usual state of health until approximately three months prior to evaluation. At that time, he developed progressive shortness of breath on exertion, lower extremity edema, and in the last month three pillow orthopnea with PND 2-3 times per week. He denied any ongoing chest pain, pressure, tightness, or squeezing.
Intermittent non-steroidal use for aches and pains.
Physical Examination: BP 95/60 mmHg. Heart rate 65 BPM. Respiratory rate 22.
HEENT: JVD to the neck at 45º
Lungs: bibasilar rales
Cardiac: regular rate and rhythm. No murmurs. (+) S4
Abdomen: mildly obese, bowel sounds present, nontender, non-extended
Peripheral pulses: 2+ without bruits
Extremities: 1-2+ bilateral, symmetrical lower extremity edema.
BUN/creatinine 25/1.0 mg/dl
hemoglobin 10.8 gm/L
troponin-I 0.22 ng/ml (normal < 0.04 ng/ml)
BNP 460 pg/ml (normal < 100 pg/ml)
Echocardiography (Figures 2 and 3):
- Normal LV cavity size (LVDD 4.5 cm, septum 1.5 cm, posterior wall 1.5 cm) with severe left ventricular hypertrophy (LV mass=180 gm/mm²) and severe systolic dysfunction (LVEF 40%)
- Mild mitral regurgitation
- Mild tricuspid regurgitation
- Normal right ventricular size with moderately reduced function.
Given this initial presentation, what would be your next diagnostic choice?