A
69-year-old male is referred for a one month complaint of progressively
increasing exertional dyspnea and palpitations. Two months ago, he was
placed on digitalis because of an irregular heart rate of around 140/min.
Comorbidities inclued hypertension and dyslipidemia and history of drinking
a 6-pack beer per week. He had a negative stress test with a reportedly
normal left ventricular (LV) ejection fraction (EF) a year ago.
On examination, the patient is in moderate respiratory
distress. His BP is 150/92 mm Hg and the pulse is irregularly irregular
at 160/min. There is an S3 gallop at the apex together with a grade
1/6 holosystolic murmur. The lungs are clear.
The Chest x-ray shows moderate cardiomegaly, interstitial
pulmonary edema and small bilateral pleural effusions. The EKG shows
atrial fibrillation with a ventricular response of around 170/min. There
is slow progression of R waves across the precordium and nonspecific
ST-T changes in the inferior and lateral leads. Dig level is 0.2 ng/dl.
Echocardiogram shows mild LV hypertrophy, mild left atrial and LV enlargement
and an LV EF of 35%
What is the most likely diagnosis?
