A 76-year-old African-American man presents with a one-year history of progressive shortness of breath with exertion and bilateral lower extremity swelling. He has also noticed increasing fatigue and episodes of lightheadedness, particularly when standing up. His medical history is notable for hypertension, bilateral carpal tunnel release 10 years prior, and a lumbar laminectomy for spinal stenosis 5 years ago. His hypertension was previously well-controlled on lisinopril, but he has had to reduce the dose due to low blood pressure readings at home. 12 lead ECG shows atrial fibrillation with a rate of 80 bpm, low voltages in the limb leads and poor R wave progression in the anterior leads.