A 58-year-old man presents to the cardiology department with an eight-month history of progressive dyspnea and ankle edema. He is unable to climb a flight of stairs or walk across a room without stopping. He denies chest pain or palpitations, but reports two episodes of light headedness in the past 6 months. He is white, non-diabetic, and admits to drinking three units of whisky a day.

His past medical history includes a peptic ulcer in his twenties and a road traffic accident at age 35 which fractured his right tibia and fibula. He also suffers from systolic hypertension and hypercholesterolemia. He is a bar owner, and is married with two children.

Physician examination reveals no peripheral stigmata of chronic liver disease. He is apyrexial with an irregular pulse of 88 bpm, and blood pressure 170/90 mmHg. Jugular venous pressure is elevated by 4 cm. The apex beat is not palpable, and on auscultation there is a grade 2/6 pansystolic murmur at the apex and an audible third heart sound.

There are no signs of hepatomegaly or ascites. He has mild pedal edema. Auscultation of the lung bases reveals fine end-inspiratory crackles and neurologic examination reveals sensory peripheral neuropathy affecting his feet.