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A man aged 64 years presented to emergency department with chest pain and shortness of breath. On cardiac auscultation, he had loud P2 and parasternal heave; however, lung auscultation was normal. Bilateral lower limb pitting oedema was present. CBC, CMP and cardiac biomarkers were normal. D-dimer and CT chest were performed and it excluded pulmonary embolism. His EKG was suggestive of right ventricular strain. He was being treated for systemic and pulmonary hypertension, taking carvedilol 3.125 mg two times per day, furosemide 40 mg once daily, sildenafil 20 mg three times a day, treprostinil 0.5 mg two times per day, amlodipine 2.5 mg two times per day, atorvastatin 40 mg once daily, aspirin 81 mg once daily and clopidogrel 75 mg once daily. Trans-thoracic echocardiography showed his systolic function was normal, his estimated ejection fraction was 60–65% with markedly dilated right ventricle (RV), …
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