A woman in her 70s presented to our hospital with progressive shortness of breath, fatigue, and lower extremity edema. Her history included nonischemic cardiomyopathy with a left ventricular ejection fraction of 25%, New York Heart Association functional class IIIb to IV heart failure, cardiac resynchronization therapy for a left bundle branch block, atrial fibrillation, and stage 3 chronic kidney disease. Her medications included metoprolol succinate, furosemide, digoxin, and dabigatran etexilate. She was intolerant of angiotensin-converting enzyme inhibitors, angiotensin II receptor blockade, and aldosterone antagonists because of symptomatic hypotension. She reported that during the preceding month she had experienced increasing orthopnea, paroxysmal nocturnal dyspnea, and weight gain but denied chest pain, nausea, or vomiting.
Miller PE, Scholten EL, Desai CS, Tedford RJ. A Patient With Systolic Dysfunction and an Alternating Axis. JAMA Intern Med. 2014;174(12):2027-2028. doi:10.1001/jamainternmed.2014.5452