Atypical features make echocardiography mandatory in suspected heart failure

One of the key skills of a good diagnostician is to spot when a patient's case has enough atypical features for there to be a strong chance that the “obvious” diagnosis might be wrong. This suspicion would lead a good diagnostician to perform extra investigations.

In this case, the normal electrocardiographic appearance virtually excluded the possibility of left ventricular systolic dysfunction (figure). The other less reliable atypical features were the lack of any history of ischaemic heart disease and the lack of any response to furosemide (although the dose might not have been high enough). Of course, these alerting, atypical features had to be balanced against all the positive features suggesting heart …