A 70-year-old male with hypertension and hepatitis Bassociated cirrhosis and hepatocellular carcinoma (HCC) on lenvatinib therapy presented to the emergency department (ED) with shortness of breath and chest pain for three days. He reported having shortness of breath at rest that worsened with exertion. Initially, his symptoms improved with use of home supplemental oxygen. However, despite oxygen therapy, he developed a constant, left-sided, non-exertional chest pain that did not improve with rest, prompting ED evaluation. At baseline, the patient was able to walk at least one mile without problems but now was only able to walk five feet before developing shortness of breath. He denied orthopnea, paroxysmal nocturnal dyspnea, light headedness, and lower extremity swelling. Of note, the patient was started on lenvatinib one month prior by his oncologist for treatment of his unresectable HCC. However, he recently stopped taking lenvatinib due to dyspnea. Other medications included entecavir and amlodipine. He denied any history of tobacco, alcohol, or illicit substance use and denied any family history of heart disease.
On examination, the patient was afebrile with a heart rate of 88 beats/minute, respiratory rate of 20 respirations/minute, blood pressure of 92/72 mmHg, and oxygen saturation of 97% on room air. Cardiopulmonary examination was notable for a regular rate and rhythm with no murmurs, rubs, or gallops. Chest examines revealed right greater than left bibasilar crackles, and jugular venous distension of 10 cm H2O. There was 1+ pitting edema to bilateral knees.