HISTORY, CURRENT ILLNESS AND PHYSICAL EXAMINATION
71-year-old man attending for a scheduled check-up.

BACKGROUND:
No known allergies.
Dyslipidaemia under treatment. Carbohydrate intolerance diagnosed in 2010. Followed diet, losing 8 kg, and glycaemia was controlled with baseline figures of 100-110 mg/dl and glycohaemoglobin (HbA1c) of 5.9%. Ex-smoker until 2007, cumulative dose of 30 packs/year.
Prostate carcinoma clinical stage T1c Nx Mx, treated with brachytherapy in 2014. Normal prostate specific antigen (PSA) test in last controls.
Chronic ischaemic heart disease:
In 2007 acute anterior myocardial infarction, treated with fibrinolysis without reperfusion and rescue angioplasty with conventional stent implantation over anterior descending (DA). 1-vessel coronary artery disease, with complete revascularisation. Left ventricular ejection fraction (LVEF) of 40% at discharge.
In 2014, asymptomatic, he came for a check-up. Echocardiogram (ECG) with moderate LV systolic dysfunction at the expense of extensive segmental alteration in the LAD territory.
Moderate dilatation of the left atrium. No significant valvulopathies.
In 2016, she consulted for exertional dyspnoea class II of the New York Heart Association (NYHA) of 1 month's duration. His primary care physician detected unknown atrial fibrillation with left bundle branch block, which appeared to be frequency-dependent. He was referred to the emergency department, where he was started on oral anticoagulation with rivaroxaban and the dose of beta-blocker was increased to optimise heart rate control.
Home medication: omeprazole 20 mg/24 h, pravastatin 40 mg/24 h, bisoprolol 10 mg/24 h, ramipril 2.5 mg/12 h, rivaroxaban 15 mg/24 h (GFR 46 ml/min when prescribed, isosorbide mononitrate retard 50 mg/24 h, nitroglycerin s.l. which he did not require.

CURRENT ILLNESS:
Subjectively well, no dyspnoea or chest pain with the activities he performs. She does not remember when the last episode of angina occurred, probably in 2007. No palpitations. No oedema. No orthopnoea or paroxysmal nocturnal dyspnoea. His wife states that he has greatly reduced his physical activity. He has stopped going out for walks. He acknowledges that he avoids stairs and slopes.

PHYSICAL EXAMINATION:
Weight 77 kg, height 1.70 m. Muscle mass index (BMI) 26.6 kg/m2. Blood pressure (BP) 130/70 mmHg. Heart rate (HR) 60 bpm. O2 saturation (SatO2) 97% on room air.
Eupneic at rest. Jugular venous pressure slightly elevated. Cardiac auscultation: arrhythmic, no murmurs. Pulmonary auscultation: preserved vesicular murmur. Radial, femoral and pedial pulses present. Lower extremities with 1-2 mm pretibial fovea.

COMPLEMENTARY TESTS
ECG: atrial fibrillation with controlled heart rate at 65 bpm. Amputated R wave from V1 to V4. Narrow QRS, width 100 ms, axis at 30o.
ANALYSIS: haemoglobin 13.1 g/dl, haematocrit 38%, platelets 240,000 /μl, leucocytes 14,000/μl. International normalised ratio (INR) 2.07. Basal glycaemia 128 mg/dl, HbA1c 7.3%. Urea 78 mg/dl, creatinine 1.7 mg/dl (estimated glomerular filtration rate [GFR] 43 ml/min), sodium 139 mEq/l, potassium 4.1 mEq/l. Total cholesterol 141 mg/dl, HDL 47 mg/dl, LDL 67 mg/dl, triglycerides 134 mg/dl. TSH normal. Iron 40 mcg/dl, ferritin 110 ng/ml, transferrin IS 12%. N-terminal pro-brain natriuretic peptide (NT-proBNP) 1,250 pg/ml.
Transthoracic ECG: LV dilated with DTD 65 mm, remodelled. Akinesia and thinning of anterior septum and all apical segments. Severe systolic dysfunction with LVEF 27%. Dilated LA. Mild-moderate functional mitral regurgitation. Normal aortic valve.
Right chambers of normal size and contractility. Mild tricuspid insufficiency, with atrioventricular gradient of 21 mmHg. Inferior vena cava not dilated with inspiratory collapse less than 50%.
ERGOMETRY: Bruce protocol. Exercise time 3:30 min. Under bisoprolol 10 mg daily. Reaches 67% of maximum theoretical heart rate with a workload of 6.6 METs. Dyspnoea from the first stage, which increases and forces to suspend the test. Functional class II-III. Atrial fibrillation as baseline rhythm. No angina or significant ST alterations.

CLINICAL EVOLUTION
An ECG was performed to check LV systolic function, which was currently severely depressed, and ergometry for an objective assessment of functional class, revealing dyspnoea that the patient minimised.
Laboratory tests showed moderate renal insufficiency, poor control of diabetes mellitus and an altered iron profile.
With all this, the treatment was adjusted and the patient was referred to a specific heart failure consultation. After a year of follow-up, with optimisation of medical treatment, improvement of LVEF to 32% was achieved; he persisted with limitation of his physical activity, in functional class II. Implantable cardioverter defibrillator (ICD) implantation was performed for primary prevention.

DIAGNOSIS
Chronic ischaemic heart disease. Old anterior infarction, single-vessel disease with complete revascularisation. Severe LV systolic dysfunction. No current angina.
Chronic heart failure in NYHA functional class II-III.
Permanent atrial fibrillation. Oral anticoagulation and heart rate (HR) control strategy.
Chronic kidney disease, stage IIIb.
Diabetes mellitus.
Iron deficiency without anaemia.
