A 73-year old African-American woman with history of hypertension, diabetes mellitus, liver cirrhosis, atrial fibrillation and diastolic heart failure presented with a one-week history of shortness of breath, increasing dyspnea, eight-pound weight gain, and progressive weakness. She had associated orthopnea, paroxysmal nocturnal dyspnea, and leg swelling. She denied fevers, cough, chills, hemoptysis, recent hospitalization or wheezing. Her initial vitals were: blood pressure 194/127 mmHg, heart rate 74 beats per minute (bpm), respiratory rate 22 and she was afebrile. Examination revealed elevated jugular venous pressure 15 cm above sternal notch at 45 degrees, loud P2, right ventricular heave but regular rate and rhythm. There was a holosystolic murmur grade II/VI present at the left lower sternal border consistent with regurgitation murmur, which increased with inspiration. Initial electrocardiogram showed sinus rhythm with occasional premature ventricular complexes with predominant rightward axis and echocardiogram demonstrated elevated right ventricular systolic pressure of 102 mmHg indicative of severe pulmonary hypertension. The left ventricular ejection fraction was preserved.