A75-year-old african-american man presents with a 5-month history of gradually progressive dyspnea that is especially pronounced when climbing stairs. he also has been noticing that his ankles and lower legs have "gotten larger" over roughly the same time period, which no longer allows him to fit into his sneakers. he denies fever, chills, chest pain, palpitations, cough, pleurisy, calf pain, abdominal complaints, sick contacts, or travel. his psychosocial history is noteworthy for chronic alcohol use. his physical exam reveals bibasilar rales, jvd of 5cm, an s3 gallop, a holosystolic murmur at the apex that radiates to the left axilla, and 2+ pitting edema to the level of the mid-calves bilaterally. a bedside echocardiogram was remarkable for biventricular enlargement. a tachycardiab feverc asymmetric upper extremity blood pressuresd warm, moist skine acanthosis nigricans