A man with chest tightness and burning limbs

A 73 year old man arrived at the cardiac clinic complaining of chest tightness when walking or speaking loudly. He had oedema in both legs and intermittent burning pain in his abdomen and extremities, especially the forearms and ankles, which had persisted for one month. He had no history of diabetes mellitus, rheumatic disease, or cerebral haemorrhage, and his vital signs were normal. Physical examination revealed acrocyanosis and hyperpigmentation on his abdomen, and tenderness to palpation across his entire chest area. He showed no jugular venous distention or pulmonary rales.

The patient had

• haemoglobin of 10.9 g/dL (normal range 12.0~15.5 g/dL)

• red blood cell count of 3.3610¹²/L (4.0~5.510¹²/L)

• white blood cell count of 4.9810⁹/L (4~1010⁹/L)

• platelet count of 11210⁹/L (100~30010⁹/L), and normal erythrocyte sedimentation and C reactive protein

• A 16 172 pg/mL concentration of N-terminal prohormone brain natriuretic peptide (NT-proBNP) (<400 pg/mL)

• <0.01 ng/mL troponin T (<0.1ng/mL).

An echocardiogram showed a bi-atrial enlargement (left atrium, 58×51 mm; right atrium, 53×43 mm) and left ventricular concentric hypertrophy (ventricular septum thickness, 14 mm; posterior wall thickness, 14 mm). The left ventricular ejection fraction was 65%. Cardiac magnetic resonance imaging (MRI) showed concentric thickening of the left ventricular wall and global transmural late gadolinium enhancement.