Case 2

A rare cause of Heart Failure

 History of Present Illness

o Mr P.K is a 70-year-old male,

o Known to have Systemic HTN and CKD stage III
o Symptoms; 4/12 History of worsening

• Exertional chest pain

• Breathlessness with minimal exertion
• Palpitation
• Lower limb oedema
• Unintentional weight loss; 3 kg within 3 months
Electrocardiogram
 Laboratory Investigations
• Full blood Count:
• White Blood Count: 7.1 10x 9/L , Haemoglobin 130 g/L, Platelets 368 10x9/L

• Renal function test:

• Creatinine: 150 umol/L, Urea: 7.3 mmol/L, GFR 40 ml/min
• Sodium: 135 mmol/L, Potassium 4.1 mmol/L, c Calcium 2.39 mmol/L, Phosphate
1.32 mmol/L

• NT- ProBNP 11 639 ng/L

• hs Troponin: 180.2 ng/L

• CRP: 200 mg/L

• Iron Profile: sFe 4.8 umol/L, Ferritin 358 ug/L, Transferrin saturation: 10%
• Serum ACE levels - Normal
Echocardiogram
 Q: What’s next?

1. Extra Blood investigations

2. CT Coronary Angiogram
3. Cardiac MRI
4. Right heart Catheterization
5. CT cardiac gated with contrast
 Extra Investigations

• LDH: 1884 IU/L

• ESR: 30 mm/hr

• Serum Protein electrophoresis: Pattern associated with acute phase response

• Serum Immunoglobulins: Normal

• Urinary Bence Jones: Not detected

CMR
 Q: What’s next?

1. Endomyocardial biopsy
2. Mediastinal lymph node biopsy
3. Midline sternotomy core Cardiac biopsy
4. Mini thoracotomy core cardiac biopsy
5. Pleural fluid analysis with cytology
 Take home message

European Heart Journal (2021) 42, 3599-3726

• REMAINS A DIAGNOSTIC DILEMMA
Thank You