A 68-year-old man presents to the clinic complaining of worsening exertional dyspnea. He feels short of breath even after walking with his dog more than a couple of blocks from his home. He has a persistent cough that produces blood-tinged mucus. He does not have chest pain at rest but has experienced retrosternal chest pressure with strenuous exertion. He admits that he passed out a week ago for unclear reasons. He wakes up at night feeling short of breath. His medical history is significant for gout, angina and an episode of endocarditis ten years ago. On physical examination, he is afebrile, with a heart rate of 88 beats per minute (bpm), blood pressure of 140/95 mm Hg, and respiratory rate of 18 breaths per minute. Examination of the head and neck reveals distended neck veins. On cardiac examination, you detect a soft S2 and a coarse, late-peaking crescendo-decrescendo, systolic ejection murmur heard best at the aortic area of the heart. On lung auscultation, you heard bibasilar posterior crackles. He has swelling in his ankles, lower legs and abdomen. He gained over 10 pounds in the last two weeks. Which of the following indicates the worst prognosis for this patient?
