73-Year-Old Man With Dyspnea on Exertion

Abstract

dicine, te ester, o t in Care A 73-year-old man presented to the cardiology clinic in early fall for evaluation of shortness of breath that had worsened over the previous year. He had numerous comorbidities, including hypertension, hyperlipidemia, type 2 diabetes mellitus, medically complicated obesity, stage 3 chronic kidney disease, obstructive sleep apnea, and a 10-year history of nonischemic cardiomyopathy after biventricular pacemaker placement for cardiac resynchronization therapy (CRT). He was receiving maximal medical therapy for his heart failure. He had considerable improvement in his exercise tolerance with CRT, but over the preceding year he had noticed a marked decline in exercise capacity. He could now walk only 30 to 40 feet before becoming dyspneic, whereas a year before he had been able to walk twice this distance. His symptoms had worsened over the past few months, which he attributed to the summer heat. He did not have dyspnea at rest, orthopnea, paroxysmal nocturnal dyspnea, or exertional chest pain/pressure. He had gained about 9 kg over the past 2 years but had no increase in lower extremity edema. He was compliant with continuous positive airway pressure treatment and tolerated it well. He was a former smoker with an 11-pack-year history but had quit smoking more than 30 years ago. He had been seen by his local cardiologist 6 months before the current presentation, and his echocardiogram revealed no changes from previous testsddiffuse, mild reduction in systolic function with ejection fraction of 43%, grade 1/4 left ventricular diastolic dysfunction, and no regional wall motion or valvular abnormalities. No other imaging studies were obtained at that time, and a review of systems was otherwise unremarkable.