HISTORY, CURRENT ILLNESS AND PHYSICAL EXAMINATION
Male, 75 years old.

History
Cardiovascular risk factors (CVRF): hypertension (HT). Type 2 DM with baseline glycosylated haemoglobin (HbA1c) around 8.5%. Dyslipidaemia. Ex-smoker. Obesity (body mass index [BMI] 34 kg/m2).

Cardiological history:
Chronic ischaemic heart disease: admission for acute myocardial infarction (AMI) not inferior Q 4 years earlier.
*** Catheterisation: left main coronary artery normal. Anterior descending artery (AD) with significant severely calcified lesion in proximal and middle segment. Right coronary artery (RCA) with significant lesion in proximal segment. Conclusions: two-vessel disease. Percutaneous coronary interventionism (PCI) with balloon and implantation of 2 stents in the proximal RCA and proximal-middle LAD.
Implantation of a definitive bicameral pacemaker (MCP) 2 years ago due to syncope and atrioventricular block Mobitz II and 2:1 (programmed in DDD).
Last echocardiogram 1 year ago: preserved left ventricular (LV) systolic function, with no alterations in segmental contractility. No significant valvulopathies.

Other: renal colic. Surgical interventions: appendectomy, cholecystectomy.

Usual treatment:
Empagliflozin 10 mg, 1 tablet daily. Metformin 850 mg, 1 tablet every 12 hours. Bisoprolol 2.5 mg, 1 tablet daily. Ranolazine 500 mg, 1 tablet every 12 hours. Nitroglycerin 15 mg, 1 transdermal patch daily. Clopidogrel 75 mg, 1 tablet daily. Omeprazole 20 mg, 1 capsule daily. Atorvastatin + acetylsalicylic acid (ASA) + ramipril 20/100/5 mg, 1 capsule daily.

Current disease
Chronic stable angina (CCS II/IV) with worsening in the last month, until the onset of angina with mild exertion (walking 10 metres), associated with progressive dyspnoea until it became mild exertion, orthopnoea and oedema in the lower limbs (lower limbs). He reported poor blood pressure control at home (around 150-160/100 mmHg).

Physical examination
On arrival at the hospital the patient was in good general condition, eupneic at rest.
Blood pressure (BP) 170/95 mmHg, heart rate (HR) 84 bpm, oxygen saturation (SatO2) 96% on room air, afebrile.
Presence of jugular engorgement. Cardiac auscultation: rhythmic tones, systolic murmur II/VI in aortic focus. Pulmonary auscultation: mild bibasal crackles. Lower limbs: slight perimalleolar oedema, no signs of deep vein thrombosis, pulses preserved.

COMPLEMENTARY TESTS
Complementary tests during admission:

Electrocardiogram (ECG): rhythm stimulated by bicameral pacemaker at 60 bpm.
Chest X-ray: cardiomegaly, right costophrenic sinus impingement and vascular redistribution to upper fields.

Laboratory tests:
Blood count: haemoglobin 11 g/dl. Haematocrit 30%. Leukocytes, leukocyte formula and platelets without alterations.
Coagulation: no alterations.
Biochemistry: glucose 161 mg/dl. HbA1c 8.3%. Urea 50 mg/dl. Creatinine 1.2 mg/dl. Ions in normal range, liver function without alterations. CRP 1.1 mg/dl. Lipid study: total cholesterol153 mg/dl, triglycerides 77 mg/dl, HDL 44 mg/dl, LDL 94 mg/dl. Iron metabolism: ferritin 59 μg/l. Iron 48 μg/l. IST 13.9%.
Biomarkers of myocardial damage: hsTnI 80 ng/l --> 170 ng/l --> 60 ng/l (normal < 19.8 ng/l).
Heart failure markers: NT-proBNP maximum 6,290 pg/ml, CA125 30 IU/ml.
Echocardiogram: left ventricle slightly dilated, with generalised hypokinesia of all its segments and severely depressed global systolic function (LVEF by Simpson 28%). Mild mitral insufficiency. Sclerosed aortic valve, with normal opening and normal transvalvular gradients. Dilated left atrium. Normal diastolic pattern, with no increase in LV filling pressures. Slightly dilated right ventricle with borderline systolic function (TAPSE 17 mm). Mild tricuspid insufficiency (TI) allowing an estimated PAP of 46 mmHg. Inferior vena cava (IVC) not dilated with inspiratory collapse less than 50%.
Coronary angiography, left radial artery: stents in CD and DA permeable and without restenosis.
Significant stenosis in diagonal branch of reduced calibre, not susceptible to revascularisation.

Complementary tests at 3 months:

CBC:
Blood count and coagulation: haemoglobin 14 g/dl. Haematocrit 44%. Leukocyte formula, platelets and coagulation without alterations.
Biochemistry: glucose 150 mg/dl, HbA1c 7.5%. Urea 47 mg/dl. Creatinine 1.22 mg/dl. GFR
Estimated CKD-EPI 59 ml/min/1.73 m . Ions in range. Liver function without alterations.
Lipid study: total cholesterol 182 mg/dl, triglycerides 200 mg/dl, HDL 45 mg/dl, LDL 85 mg/dl. Iron metabolism: ferritin 190 μg/l. Iron 70 μg/L. IST 35%.
Heart failure markers: NT-proBNP 2,503 pg/ml, CA125 17 IU/ml.
Echocardiogram: left ventricle slightly dilated, with generalised hypokinesia of all its segments and moderately depressed global systolic function (LVEF 32%), with asynchrony due to RV stimulation. Absence of significant valvulopathies. Normal diastolic pattern. Right ventricle with preserved function. Non-dilated IVC with adequate inspiratory collapse.

Complementary tests at 6 months:

CBC:
Blood count and coagulation: no alterations.
Biochemistry: glucose 140 mg/dl, HbA1c 6.7%. Urea 42 mg/dl. Creatinine 1.17 mg/dl. GFR
Estimated CKD-EPI 60 ml/min/1.73 m . Ions in range. Liver function without alterations.
Lipid study: total cholesterol 162 mg/dl, triglycerides 225 mg/dl, HDL 46 mg/dl, LDL 70 mg/dl. Iron metabolism: ferritin 180 μg/l, iron 68 μg/l, IST 32%.
Heart failure markers: NT-proBNP 1,153 pg/ml, CA125 14 IU/ml.
Echocardiogram (videos 3 and 4): non-dilated left ventricle with preserved LVEF (LVEF by Simpson 61%). Preserved diameters and volumes, basal anterior septal hypokinesia. Mild mitral regurgitation. Diastolic pattern of impaired relaxation with no increase in end-diastolic pressures. Normofunctioning RV with trivial TR and systolic pulmonary artery pressure (PAPs) 40 mmHg. IVC 15 mm. Absence of pericardial effusion.

CLINICAL EVOLUTION
This is a patient with chronic ischaemic heart disease and a bicameral CCM, who presented progression of his angina to minimal effort angina, as well as deterioration of functional class, associated with the appearance of severe left ventricular dysfunction (previously preserved LVEF), for which it was decided to admit him to cardiology for study and treatment.
During his stay in the cardiology ward, depletive and antianginal treatment was administered, with a progressive decrease in dyspnoea, without new episodes of chest pain, tolerating ambulation. Coronary angiography showed progression of the non-revascularisable coronary artery disease, so it was decided to optimise the antianginal and heart failure medical treatment. Spironolactone and sacubitril/valsartan were started without incident. Given the presence of poorly controlled diabetes associated with obesity and difficult-to-control hypertension in a patient with ischaemic heart disease and heart failure, it was decided to add liraglutide 0.6 mg daily to the treatment and the statin dose was increased. Given the iron deficiency anaemia, treatment was associated with intravenous ferrotherapy, with a good response. At hospital discharge, BP 100/66 mmHg, HR 84 bpm, SatO2 99%, in a state of euvolemia. He was admitted to the heart failure unit for close outpatient monitoring.
After 3 months, severe ventricular dysfunction persisted and cardiac resynchronisation therapy (CRT) was decided given the contribution to the dysfunction of continuous RV pacing (pacemaker-dependent patient).
After 6 months of optimal medical treatment titrated to maximum tolerated doses and 3 months of CRT implantation, the patient was re-evaluated clinically, analytically and echocardiographically. The patient presented NYHA I without symptoms of heart failure or signs of pulmonary or peripheral congestion, normalisation of ventricular function, absence of chest pain and adequate blood pressure control at home. Significant weight loss (BMI 28) and marked improvement in glycaemic control were also confirmed, reaching target HbA1c.
The patient has had no new decompensations or admissions during the current 2-year follow-up.

DIAGNOSIS
Main diagnosis:
Chronic ischaemic heart disease. Unstable angina Ib with myocardial damage in AMI range. 2-vessel coronary artery disease with permeable stents and new non-revascularisable lesion in diagonal branch.
Heart failure with severely depressed ejection fraction of multifactorial origin (diabetic, ischaemic and post RV pacing myocardiopathy).
Other diagnoses:
Iron deficiency anaemia.
Arterial hypertension.
Poorly controlled type 2 diabetes mellitus. Dyslipidaemia without meeting LDL targets. Obesity.
