A 49 year old woman presented to casualty after having been woken by acute shortness of breath (dyspnoea), such that she was unable to talk. Her daughter said that over the past six months, the patient had been getting short of breath when walking on flat ground, as well as being troubled by swelling of the ankles. The patient had recently been woken several times by severe shortness of breath, similar to the present episode, and had been more comfortable when sleeping on 2-3 pillows. She had never complained of chest pain.
On examination, the woman was sitting up in severe respiratory distress. Her heart rate was 130/minute, and was irregular. BP 120/70, jugular venous pressure raised 4 cm above the sternal angle. The apex of the heart was displaced to the 5th left intercostal space in the mid-axillary line. Both mid-diastolic and pansystolic heart murmurs were detected by listening with a stethoscope over the apex of the heart. There were crackles (signs of moisture) heard up to the midzones of both lung fields. There was swelling of both ankles, which remained indented when compressed (pitting oedema). An electrocardiogram (ECG) showed rapid atrial fibrillation and evidence of left ventricular enlargement (hypertrophy). A chest X-ray showed an enlarged heart, and both lung fields were opacified (due to the presence of fluid) up to the midzones.
A diagnosis of congestive cardiac failure (failure of both the left and right ventricles to pump adequately) due to a mixture of mitral valve narrowing (stenosis) and failure to close completely (incompetence) was made, and urgent treatment with intravenous diuretics (to remove excess fluid via the kidneys) and digoxin (to slow the heart rate and increase efficiency of the pump) were given.
The patient responded well, and later gave a history of having suffered from rheumatic fever as a child. She had always had "a weak chest", but was unaware of the presence of valvular heart disease. The patient refused an operation to replace the damaged valve. She remained on medical treatment, but suffered progressively worsening heart failure until her death 12 months later.