A 64-year-old patient with heart failure and 'chronic liver disease': looking at the liver, the myocardium or the pericardium?

A 64-year-old male, with type-2 diabetes and arterial hypertension, was referred to the cardiology outpatient clinic due to breathlessness on moderate exertion. He had been drinking ∼40 g/day of alcohol for 20 years. Liver function tests were abnormal (increased AST: 51 U/L, ALT: 73 U/L, gamma GT: 305 U/L, and total bilirubin: 2.23 mg/dL) and the abdominal ultrasonography showed ‘chronic liver disease with mild ascites’. On physical examination, raised jugular venous pulse, wide splitting of S2 on cardiac auscultation, hepatomegaly and lower limb oedema were detected. Echocardiography was performed showing a non-dilated left ventricle, with no hypertrophy and normal ejection fraction. The figure shows typical echocardiographic signs leading to the final diagnosis including the M-mode of the left ventricle (Panel A), the pulsed-wave Doppler at the level of mitral leaflet tips (Panel B), and the tissue-Doppler of the septal mitral annulus (Panel C). A cardiac CT scan (Panel D) and invasive haemodynamic evaluation (Panel E) were requested for additional diagnostic information. What is the correct diagnosis and what is the best management strategy for this patient? Should we look into the liver, the myocardium, or the pericardium? In this interactive educational clinical case, with multiple-choice questions, the diagnostic work-up, differential diagnosis, best treatment alternative will be discussed according to the most recent ESC guidelines. Explore the full case on the ESC's case-based learning website at www.escardio.org/education/eLearning/case-base