A remarkable ECG of a patient with swollen legs.

A 69-year-old male, without any remarkable medical history, was admitted to the hospital because of predominantly rightsided heart failure. Despite initiation of furosemide two weeks before admission, his physical condition did not improve. Physical examination revealed oedematous legs and presacral oedema. His blood pressure was 100/60 mmHg with a pulse rate of 88 beats/min. The laboratory results were as follows: normal peripheral blood cell count, ureum 7.5 mmol/l, creatinine 80 mol/l, ASAT 38 U/l, ALAT 40 U/l, -glutamyltransferase 55 U/l, alkaline phosphatase 118 U/l and C-reactive protein 3 mg/l. The ECG (figure 1) showed sinus rhythm with microvoltages in the frontal leads and slow R progression in the precordial leads. Echocardiography revealed a concentric hypertrophic heart with moderate left systolic function, based on diffuse hypokinesia. Doppler showed a restrictive diastolic flow pattern. Hypoalbuminaemia (24g/l) was found, while monoclonal gammopathy was absent. Albuminuria of 2 g/day was documented.