HISTORY, CURRENT ILLNESS AND PHYSICAL EXAMINATION

PERSONAL HISTORY
No known drug allergies.
Long-standing high blood pressure, although in recent years her medication has had to be reduced and is currently controlled only with dietary measures.
Diabetes mellitus type 2.
Paroxysmal atrial fibrillation.
Mild chronic kidney disease with a baseline glomerular filtration rate of around 48 ml/min.
Hepatitis C.
Under digestive follow-up for hiatus hernia and history of duodenal ulcer.
Lumbar canal stenosis.
Surgical history: right knee prosthesis and bilateral carpal tunnel surgery.
Usual treatment: acenocoumarol for INR 2-3, metformin 875 mg every 12 hours, paracetamol 1 g every 8 hours, omeprazole 20 mg daily and lorazepam 1 mg before bedtime.

CURRENT ILLNESS
The patient is an 85-year-old woman with symptoms of biventricular heart failure, reporting dyspnoea and orthopnoea as well as oedema of progressive intensity in the last month. She also refers cough with greenish expectoration and fever peaks in the last 3 days, for which her primary care physician has prescribed amoxicillin-clavulanic acid for 7 days. The patient also reports abdominal distension and a burning sensation after meals (more intense in the last few weeks), facial pain, especially when eating, and pain in both knees with a mechanical profile.

PHYSICAL EXAMINATION
Vital signs: blood pressure 116/69 mmHg, oxygen saturation 95% with nasal goggles at 2 l/min, temperature 36.8 ̊C.
Usual weight 48 kg, height 1.50 m, body surface 1.41 m2. Weight on admission 60 kg.
Neck: increased jugular venous pressure with hepatojugular reflux.
Cardiac auscultation: rhythmic and systolic murmur III/VI in aortic focus that does not clear the second tone.
Pulmonary auscultation: crackles up to midfield and abolition of vesicular murmur in both bases.
Abdomen: increased abdominal perimeter with no evidence of peritoneal irritation.
Lower extremities: oedema in both lower limbs up to the groin.

COMPLEMENTARY TESTS
CBC: creatinine 1.2 mg/dl (estimated GFR 32 ml/min), potassium 4.5 mEq/l, sodium 132 mEq/l, BNP 1,890 pg/ml, leukocytes 12,220/μl, haemoglobin 12.3 g/dl, platelets 210,000/μl, INR 2.8.
Electrocardiogram (ECG): sinus rhythm. QRS of 120 ms with normal axis.
Low voltages in limb leads. Millimetric negative T wave in V5-V6.
Echocardiography:
Cavities: non-dilated left ventricle of small cavity with severe concentric hypertrophy. Mild-moderate right ventricular hypertrophy.
Valves:
Mild mitral and tricuspid insufficiency. Moderate pulmonary hypertension (40-45 mmHg estimated systolic pulmonary pressure).
Moderate-severe aortic stenosis. Valvular area by continuity equation is 0.97 cm2, with a mean gradient of 30 mmHg and peak of 47 mmHg.
Diastolic function: restrictive mitral filling. Clear increase in filling pressures.
Other: bilateral pleural effusion and mild pericardial effusion, predominantly at the right retroatrial level.
The study was completed with a longitudinal deformation analysis.
99mTc-DPD scan: moderate uptake of the radiomarker at cardiac level, diffuse and biventricular.
Cardiac magnetic resonance: images corresponding to late enhancement sequences and extracellular volume mapping are attached.

CLINICAL EVOLUTION
After intravenous treatment with diuretics, a weight reduction of 10 kg was achieved with marked improvement in the patient's clinical condition and oedema. Self-limited episode of paroxysmal atrial fibrillation at 100-110 bpm during admission. Once again in sinus rhythm and with a good response to oral diuretics, she was discharged with oral furosemide (80 mg per day) in addition to her usual treatment, to continue studies and outpatient treatment. However, 3 days later, the patient returned to the emergency department for syncope with mild cranioencephalic trauma on getting out of bed. She did not recall any prodromal symptoms, but reported increased asthenia in the last few days. After ECG monitoring for 24 hours and reduction of furosemide treatment to 40 mg per day, the patient was discharged with clinical improvement. She is currently under clinical follow-up, with persistent joint pain and abdominal discomfort, although with a significant improvement in the semiology of heart failure.

DIAGNOSIS
Heart failure with preserved systolic function. Respiratory infection as a probable trigger for exacerbation.
Transthyretin amyloidosis with cardiac involvement.
Moderate-severe aortic stenosis.
