History of presentation
A 61-year-old male presented to hospital with dizziness and dyspnea at rest and on exertion of 3 weeks duration. He admitted to running out of his medications about a month prior to presentation to the emergency department. At presentation, the patient was afebrile, New York Heart Association (NYHA) functional class III, with an average pulse of 77, respiratory rate 22 and blood pressure 100/82. An electrocardiograph revealed atrial flutter at a rate of 79 with right bundle branch block. Results of initial biochemical laboratory investigations including High Sensitivity Troponin 1, hemogram, were normal. Significant results of biochemical tests included NT proBNP >3000, and subtherapeutic INR 1.2. Chest x ray showed mild pulmonary vascular congestion.