In a 45-year-old female presenting with a 5-year history of exertional chest pain acutely worsened for 9 days, a 4-year history of palpitations, bilateral lower‑leg edema for 14 days, dyspnea for 5 days, and yellow discoloration of the eyes, skin, sclera, and urine for 5 days, what is the most likely diagnosis?

Most Likely Diagnosis: Decompensated Heart Failure with Congestive Hepatopathy

This 45-year-old woman most likely has decompensated heart failure (HF) with secondary congestive hepatopathy causing her jaundice, combined with chronic underlying cardiac disease (possibly dilated cardiomyopathy or ischemic heart disease). The constellation of chronic exertional chest pain, palpitations, bilateral lower extremity edema, dyspnea, and acute jaundice points to progressive cardiac dysfunction with right heart failure leading to hepatic congestion.

Clinical Reasoning

Primary Cardiac Pathology

The 5-year history of exertional chest pain with acute worsening suggests either:

• Chronic ischemic heart disease progressing to ischemic cardiomyopathy 1, 2
• Dilated cardiomyopathy (as seen in similar presentations with biventricular dysfunction) 3

The exertional nature of chest pain—worsening with activity over years—is consistent with cardiac ischemia or reduced cardiac output 1. The 4-year history of palpitations suggests underlying arrhythmia (likely atrial fibrillation or ventricular arrhythmias), which commonly accompanies structural heart disease 4.

Acute Decompensation Features

The recent 14-day bilateral lower limb edema and 5-day dyspnea indicate acute-on-chronic heart failure with volume overload 4. These are classic signs of right-sided heart failure with systemic venous congestion.

The Critical Clue: Jaundice

The 5-day yellowish discoloration of eyes, skin, sclera, and urine is the key diagnostic feature pointing to congestive hepatopathy (cardiac cirrhosis). When right heart failure becomes severe, elevated central venous pressure causes hepatic congestion, leading to:

• Hepatocellular injury from chronic passive congestion
• Elevated bilirubin (causing jaundice and dark urine)
• Elevated liver enzymes
• Potential coagulopathy

This represents advanced heart failure with end-organ damage 4.

Differential Considerations

Why Not Primary Hepatic Disease?

While hepatitis was mentioned 40 years ago in the history, the temporal relationship is crucial: the jaundice appeared after the cardiac symptoms worsened, not before. Primary liver disease would not explain the chronic exertional chest pain and palpitations.

Why Not Pulmonary Embolism?

Although PE can present with dyspnea, chest pain, and lower extremity edema (from DVT), it typically does not cause:

• 5 years of exertional chest pain
• 4 years of palpitations
• Jaundice (unless massive PE causes acute right heart failure with hepatic congestion, which would be accompanied by hemodynamic collapse)

The chronic progressive nature argues against acute PE as the primary diagnosis 3.

Why Not Isolated Coronary Disease?

Pure coronary artery disease without heart failure would not explain:

• Bilateral lower extremity edema
• Jaundice
• The combination suggests reduced left ventricular function with secondary right heart failure

Diagnostic Workup Priority

Immediate investigations needed:

1. NT-proBNP or BNP - Will be markedly elevated (expect >125 pg/mL for NT-proBNP) 4

2. Transthoracic echocardiography - To assess:

   • Left ventricular ejection fraction (likely reduced <40%)
   • Right ventricular function
   • Valvular abnormalities
   • Chamber dimensions 5, 4

3. Liver function tests - Expect:

   • Elevated total and direct bilirubin
   • Elevated transaminases (AST/ALT)
   • Elevated alkaline phosphatase
   • Possible coagulopathy (elevated INR)

4. ECG - May show:

   • Atrial fibrillation (explaining palpitations)
   • Evidence of prior myocardial infarction
   • Left ventricular hypertrophy 2

5. Troponin - May be mildly elevated in acute decompensation without acute coronary syndrome 2

Clinical Pitfalls to Avoid

Do not dismiss the jaundice as unrelated to cardiac disease. Congestive hepatopathy is frequently underrecognized and indicates severe, advanced heart failure requiring aggressive management 4.

Do not assume this is acute coronary syndrome based solely on chest pain worsening. The 9-day timeframe with progressive volume overload suggests decompensation rather than acute plaque rupture 2.

Do not delay echocardiography. This is the single most important test to confirm the diagnosis and guide management 5, 4.

Expected Classification

Based on symptoms, this patient has:

• NYHA Class III-IV heart failure (marked limitation with symptoms at rest or minimal activity) 4
• Acute decompensated heart failure with evidence of congestion
• Advanced heart failure with end-organ dysfunction (liver)

The prognosis is guarded without aggressive intervention, and this patient requires hospitalization for diuresis, optimization of guideline-directed medical therapy, and consideration for advanced therapies depending on echocardiographic findings 4.