Cardiology Q91

A 72-year-old man is evaluated for a 1-year history of bilateral lower extremity edema and abdominal distention. Eight years ago he had esophageal carcinoma treated with radiotherapy. Medical history is otherwise significant for hypertension, type 2 diabetes mellitus, and hypercholesterolemia. Medications are bumetanide, atorvastatin, metformin, and lisinopril. On physical examination, the patient is afebrile, blood pressure is 170/90 mm Hg, pulse rate is 90/min, and respiration rate is normal. Jugular venous distention is present to the angle of the mandible while seated, with prominent pulsations. Cardiac examination reveals an early diastolic sound at the apex. The liver is palpable 5 cm below the costal margin. The abdomen is distended with ascites. There is bilateral pitting edema to the level of the thighs. Pulmonary examination reveals no crackles. Laboratory studies are significant for a B-type natriuretic peptide level of 96 pg/mL (96 ng/L). Chest radiographs are shown. A 12-lead electrocardiogram demonstrates normal sinus rhythm with normal QRS voltage. Echocardiogram demonstrates normal right and left ventricular size and function. Left ventricular wall thickness is normal. Mild tricuspid regurgitation is present. There is respiratory variation in the filling of the right and left ventricles, ventricular septal shift during respiration, and dilation of the inferior vena cava. The estimated right ventricular systolic pressure is 46 mm Hg. There is no pericardial effusion.

Which of the following is the most likely diagnosis?

A Cardiac amyloidosis

B Constrictive pericarditis

C Heart failure with preserved ejection fraction

D Restrictive cardiomyopathy

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