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V felt tightness across his chest. His deepest breaths felt shallow. He sought help at an emergency department, where a resident physician found several worrying signs, including swelling of his hands and legs as well as heart enlargement on a chest X-ray.

Everything seemed to point to one diagnosis: heart failure, in which the heart's inability to pump blood efficiently causes fluid to build up in the body. But one result did not fit.

To diagnose heart failure, doctors often check blood levels of a hormone called BNP, which the heart releases under strain. V's BNP levels came back normal. The resident remembered learning that BNP can be falsely normal in patients with obesity or who are overweight, even when they have heart failure. With that in mind, he dismissed the normal BNP result and ordered a diuretic to help V shed excess fluid—standard treatment for heart failure.

But V did not feel any better. The next day, a colleague of mine who was supervising the medical team examined him with an ultrasound and made a diagnosis that had been overlooked: cardiac tamponade, a life-threatening condition in which a buildup of fluid in the sac surrounding the heart compresses it so tightly that it can barely pump.

A squeezed heart needs more blood running through it, not less, so the diuretic could have been fatal.

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