An 87-year-old woman was taken to the emergency department of a nearby hospital for evaluation of confusion. The patient’s medical history was notable for hypertension, hyperlipidemia, COPD, and coronary artery bypass grafting. Echocardiography performed 2 weeks prior to hospital admission revealed an estimated ejection fraction of 59%, right ventricular dilation, diastolic and systolic interventricular septal flattening, stable severe tricuspid regurgitation, and no obvious ventricular wall motion abnormalities. In addition to coronary artery disease, the patient had a history of sick sinus syndrome for which a dual-chamber pacemaker had been placed 4 months prior. She was maintained on anticoagulation with warfarin, 3 mg/d, but had variable international normalized ratio values ranging from 1.0 to 3.3. The patient was a former smoker, and recent pulmonary function tests demonstrated FEV1 of 52% of predicted; FVC, 61% of predicted; FEV1/FVC ratio, 86% of predicted; total lung capacity, 113% of predicted; and residual volume, 180% of predicted.