Anterior Crackles: A Neglected Sign?

We report on a man, aged 83 years, with chronic heart failure, atrial fibrillation, right ventricular pacing, and worsening exertional dyspnea who was referred for cardiac resynchronization therapy. Detection by anterior chest auscultation of pulmonary crackles during comfortable supine breathing in the context of documented low filling pressures led to the realization that unrecognized pulmonary fibrosis, not congestion, was the principal cause of his shortness of breath. We propose that the incidental finding in chronic heart failure of diffuse anterior crackles during comfortable supine breathing initiate a workup for alternate disorders such as occult pulmonary fibrosis.