The patient is a 65-year-old woman with heart failure and proteinuria

Abstract

A 65-year-old woman sought medical assistance due to dyspnea on mild exertion and edema.She complained that 6 months earlier, dyspnea on moderate exertion appeared, rapidly evolving to dyspnea on mild exertion and even at rest. Simultaneously, dizziness and edema of the lower limbs appeared and she lost 10 kg. She denied precordial pain, palpitation, and syncope during this time, as well as hypertension and diabetes mellitus. Twenty-five years earlier, she underwent a partial thyroidectomy because of multinodular goiter.On physical examination, her heart rate was 74 bpm, her blood pressure 110/70 mmHg, and the jugular venous pressure was increased (++/4+). Examination of the lungs revealed crepitant rales at both bases. Heart examination showed reduction in the intensity of heart sounds. The liver was tender on palpation and could be felt 4cm from the right costal margin and 6cm from the xiphoid process. Marked edema of the lower limbs occurred.Electrocardiogram showed atrial rhythm with a heart rate of 63 bpm, QRS duration of 0.08s; QRS axis of +120º backwards, a low voltage in the frontal plane, a small progression of the R wave from V 1 to V 3 , a probably inactive lateral area, and diffuse alterations of ventricular repolarization ( fig. 1).Chest X-ray showed a moderate increase in the cardiac silhouette (++/4+) and bilateral pleural effusion.Laboratory tests were as follows: hemoglobin -14g/ dL; hematocrit -42%; glycemia -105mg/dL; creatinine -0.8 mg/dL; total cholesterol -155 mg/dL (HDL -27mg/dL; LDL -105mg/dL; VLDL -23mg/dL); triglycerides -117mg/dL. Urine analysis revealed density of 1028, pH of 5.0, proteinuria of 3.2g/L, and a normal sediment except for 660 cylinders/mL.The diagnosis of heart failure due to cardiomyopathy with ventricular dilation was established and the investigation for anatomical and etiologic characterization of the clinical findings was started. The patient was prescribed 80mg of furosemide, 50mg of hydrochlorothiazide in association with 5mg of amiloride and 20mg of enalapril.One week later, she sought medical assistance due to severe dyspnea even at rest and orthopnea. On physical exa-