Case 3/2011: male, smoker, hypertensive and alcohol consumer, with rapidly progressive heart failure.

Editor: Alfredo José Mansur ([email protected]) Associate Editors: Desidério Favarato ([email protected]) Vera Demarchi Aiello ([email protected]) JV, male, 42 years old, bar owner, from Canto do Buriti (PI); referred for surgical treatment of heart failure. A year before, there was onset of dyspnea on moderate exertion, and a few months before, there were episodes of paroxysmal nocturnal dyspnea; more recently, there was onset of orthopnea and lower limb edema. He denied chest pain and palpitations. He smoked 20 cigarettes daily for 20 years, and consumed alcohol. His parents were alive, and the father hypertensive. He used 0.25 mg of digoxin; 60 mg of furosemide; 25 mg of spironolactone; and 10 mg of enalapril on a daily basis. Physical examination (November 18, 2009) showed weight of 57.1 kg; height, 1.71 m; body mass index of 19.5 kg/ m2; heart rate, 100 bpm; blood pressure, 100 x 80 mmHg; increased jugular pressure; auscultation without changes; heart examination: normal rhythmic sounds with SS++ mitral area; abdomen showed no abnormalities; no edema and peripheral pulses were symmetrical. Laboratory tests showed hemoglobin, 14.1 g/dl; hematocrit, 41%; creatinine, 1.04 mg/dl; sodium 143 mEq/l and potassium 4.1 mEq/l. Serology for Chagas’ disease was negative. Chest radiography revealed pronounced cardiomegaly. The initial ECG revealed sinus rhythm with heart rate of 114 bpm; first degree AV block (PR = 240 ms); QRS duration 100 ms; left chamber overload; intraventricular conduction disturbance of the stimulus; anterior and inferior electrically inactive area; with elevated ST segment of V2 to V4 (Fig. 1). Echocardiography of seven months before (April 13, 2009) revealed: left atrium of 39 mm; 8 mm septum; posterior wall, 7 mm; left ventricle was dilated with diastolic diameter of 85 mmHg and systolic diameter of 77 mm; and ejection fraction of 19% for pronounced diffuse hipokynesia. There was no valve change. Abdomen ultrasound (September 03, 2009) showed fatty liver and gallbladder calculus.