The patient was a 79 year old woman with a history of ischaemic heart disease: two acute myocardial infarcts 10 years ago, followed by longstanding atrial fibrillation and worsening angina. Coronary artery bypass surgery six years ago had fully relieved the angina, and she had been free of symptoms (although still with atrial fibrillation) while taking digoxin, β blockers, and warfarin, among other drugs. Now she reported two days of progressive shortness of breath with intermittent pain in the centre of her chest. She had obvious dyspnoea at rest, slight cyanosis, readily audible bilateral crepitations, a raised jugular venous pulse, marked dependent oedema of her arms and legs, and (I was pretty sure) a palpable tender liver.