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Clinical Crossroads
June 23/30, 1999

A 75-Year-Old Man With Congestive Heart Failure

Author Affiliations

Author Affiliation: Dr Guyatt is Professor, Departments of Clinical Epidemiology and Biostatistics and Medicine, McMaster University, Hamilton, Ontario.


Clinical Crossroads at Beth Israel Deaconess Medical Center is produced and edited by Thomas L. Delbanco, MD, Jennifer Daley, MD, and Richard A. Parker, MD; Erin E. Hartman, MS, is managing editor. Clinical Crossroads section editor: Margaret A. Winker, MD, Deputy Editor, JAMA.

JAMA. 1999;281(24):2321-2328. doi:10.1001/jama.281.24.2321

DR DELBANCO: Mr C is a 75-year-old retired fisherman who came to the United States from the West Indies more than 10 years ago. He and his wife live in Boston, Mass, with their daughter, who has been an important source of support for him. He has Medicare and supplemental commercial insurance.

In 1988, Mr C developed exertional dyspnea and was diagnosed as having congestive heart failure and chronic obstructive pulmonary disease (COPD), with a forced expiratory volume in 1 second of less than 0.5 L. Chest radiographs showed a large cardiac silhouette, with hyperlucent lung fields and flat diaphragms. Electrocardiogram results showed poor R-wave progression and were consistent with left ventricular hypertrophy and left atrial enlargement. Echocardiogram results showed severe left ventricular dilatation, diffuse hypokinesis, ejection fraction of less than 0.20, and mild right heart dilatation, with 3+ mitral regurgitation and 2+ tricuspid regurgitation. He also had chronic mild renal insufficiency, with a creatinine level of about 221 µmol/L (2.5 mg/dL), and a history of gout, with erosive arthritis, nephrolithiasis, and uric acid stones. There is no known family history of heart disease. Cardiac risk factors include long-standing mild hypertension and 50 pack-years of cigarette smoking, ending in 1988.