A 63-year-old man with hypertension and paroxysmal atrial fibrillation presents with several months of worsening shortness of breath. He states that any physical activity makes him short of breath, including walking from his bed to a chair a few feet away.

On physical exam, his heart rate is 65 beats per minute, blood pressure is 145/82 mmHg, and oxygen saturation is 92% on room air. His lower extremities are not edematous and he does not have hepatomegaly on abdominal palpation.

Cardiovascular exam reveals a right ventricular heave, but trivial jugular venous pulse (JVD), and lungs that are clear to auscultation. Follow-up labs reveal an N-terminal pro b-type natriuretic peptide level of 200 pg/mL.

A bedside echocardiogram (ECG) is performed in the emergency department and reveals a left ventricular ejection fraction (EF) of 65%, moderate right ventricular hypertrophy with preserved right ventricular EF and right atrial enlargement, mild mitral regurgitation, and pulmonary artery systolic pressure (PAP) estimated at 68 mmHg with a dilated inferior vena cava .

His ECG is consistent with right ventricular hypertrophy. Concerned about possibility of a pulmonary embolism (PE), the physician in the emergency department orders a pulmonary computed tomography (CT) angiogram, which was subsequently negative for a PE.

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