Dyspnea and pain in the left lower limb in a 52-year-old male patient

Abstract

A 52-year-old male patient was admitted to the hospital complaining of dyspnea and pain in the left lower limb.The patient reported that he sought medical care 7 years earlier due to dyspnea triggered by moderate exertion, which lasted for 3 months. He also reported at that time an episode of dizziness and an episode of nocturnal paroxysmal dyspnea.Two months before, he was diagnosed with hypertension. He reported smoking until 10 years ago.On physical examination, the patient was in good condition, his pulse was regular, his heart rate was 72bpm, and his blood pressure was 170/110mmHg. His lung examination revealed no abnormalities. His heart examination showed normal first and second heart sounds, and a systolic murmur (+/4) in the aortic area. His liver was palpable 2cm from the right costal margin. No edema existed in the lower limbs.The electrocardiogram showed sinus rhythm, a heart rate of 72bpm, a QRS axis of -10° backwards, left chamber hypertrophy, and alterations of ventricular repolarization ( fig. 1).The echocardiogram (Table I) revealed diffuse left ventricular hypokinesia, calcification of the aortic valve, and double dysfunction of the aortic valve.Serology for the diagnosis of Chagas' disease was negative.The following diagnoses were established: hypertension, mild aortic stenosis, and ventricular dysfunction.The continuous treadmill stress test showed a good physical capacity, a duration of exertion of 8 minutes, and initial and final velocities of 2 miles/hour and 5 miles/hour, respectively. The patient's heart rate at rest was 100bpm and on maximum exertion 143bpm; his blood pressure ranged from 160/99mmHg to 220/74mmHg.Rest-exercise equilibrium radionuclide ventriculography with red blood cells labeled with technecium-99m revealed diffuse left ventricular hypokinesia. Left ventricular ejection fraction at rest was 0.30 and on exertion (25 W), 0.37.The patient remained asymptomatic until 4 years ago, when he experienced severe precordial pain, which lasted for 2 hours, and he sought medical care on an emergency