HISTORY, CURRENT ILLNESS AND PHYSICAL EXAMINATION
75-year-old woman presenting with dyspnoea and oedema in the lower limbs.

BACKGROUND:
No drug allergies.
Cardiovascular risk factors: systemic arterial hypertension, type 2 diabetes mellitus (DM), dyslipidaemia.
Cardiological history: chronic ischaemic heart disease. Previous acute myocardial infarction (AMI) treated with primary percutaneous transluminal coronary angioplasty (PTCA) and conventional stenting to the anterior descending (AD) artery (with loss of S1 and D2) in 2005. Reinfarction in 2008 due to occlusion of the LAD proximal to D1. Coated stent implanted, with loss of the first diagonal. Left ventricular ejection fraction (LVEF) at discharge 30%. Admission for HF in December 2012 and 2016 in the context of medical-dietary transgression, with incidental finding of atrial fibrillation (AF). A frequency control strategy was decided. Bilateral segmental pulmonary thromboembolism of high intermediate risk in March 2017, with dilatation and moderate residual right ventricular dysfunction. Admission to cardiology in July and November 2017 for HF related to dietary transgressions. In January 2018, a new decompensation. Severe right ventricular dysfunction was observed, forcing discontinuation of beta-blockers. Since then, frequency control with low doses of digoxin. Permanent AF anticoagulated with apixaban.
Other personal history: chronic kidney disease of diabetic aetiology (glomerular filtration rate estimated at 40 ml/min), hyperuricaemia, depression and gonarthrosis. Situation and life at baseline: no cognitive impairment. Good baseline quality of life and adequate family support.
Usual treatment: spironolactone 25 mg (1-0-0), furosemide 40 mg (2-0-0), sitagliptin 50 mg (1-0-0), lisinopril 20 mg (1-0-0), pantoprazole 40 mg (1-0-0), atorvastatin 20 mg (1-0-0), sertraline 50 mg (1-0-0), apixaban 5 mg (1-0-1), digoxin 0.25 mg (0.5-0-0), Monday to Friday.

CURRENT ILLNESS:
She attends for progressive deterioration of functional class to minimal effort dyspnoea, with increasing orthopnoea of up to three pillows and episodes compatible with paroxysmal nocturnal dyspnoea (PND). Increased oedema in the lower limbs. She denies dietary and medication transgressions.

PHYSICAL EXAMINATION:
Blood pressure 139/90 mmHg, heart rate 95 bpm, oxygen saturation (SatO2) 96% with GN at 3l. Haemodynamically stable and eupneic at rest, with intolerance to decubitus.
Jugular venous ingurgitation up to the angle of the jaw. Auscultation: arrhythmic without murmurs or extratonos. Hypoventilation and humid bibasal crackles. Abdomen: hepatomegaly of 2 traverses. Extremities: bilateral oedema with fovea up to two thirds of the legs.

COMPLEMENTARY TESTS
ANALYSIS: haemoglobin 14.0 g/dl, platelets 207,000/μl, leucocytes 6,500/μl, INR 1.61. pH 7.45, pCO2 41 mmHg, bicarbonate 28 mmol/l, glucose 119 mg/dl, uric acid 8.3 mg/dl, glomerular filtration rate eFG 40 ml/min/1.73 m2, sodium 142 mmol/l, potassium 4.6 mmol/l, NT-proBNP 8,505 ng/l.
THORAX X-RAY: increased cardiothoracic index. Bilateral pinching of costophrenic sinuses. Enlarged hilae. Vascular redistribution.
ELECTROCARDIOGRAM (ECG): AF with ventricular response 95 bpm wide QRS with morphology of complete left bundle branch block, secondary repolarisation alterations.
REGULATED TRANSTORACIC ECG: non-dilated left ventricle, with LVEF of 25%, akinesia of apex and distal segments and middle segment of the anterior face.
Right ventricle severely dilated with depressed systolic function. Mitral valve with degenerative changes and mild insufficiency. Sclerosed aortic valve with mild insufficiency.
Tricuspid valve with mild-to-moderate regurgitation. Pulmonary artery systolic pressure estimated at 50 mmHg. Dilated inferior vena cava without inspiratory collapse. No pericardial effusion. Aortic root and ascending aorta not dilated.

CLINICAL EVOLUTION
The patient was readmitted for new decompensation of HF after recent discharge. Intensive intravenous depletive treatment was started with a good initial response, rapidly achieving euvolemia, which was maintained after switching to oral diuretics.
As this was a patient with chronic HF with depressed LVEF and frequent readmissions due to decompensation despite optimal medical treatment (in the last 6 months with adequate medical compliance), lisinopril was replaced during admission by sacubitril/valsartan 24/26 mg every 12 hours pending titration to optimal doses on an outpatient basis.
The patient was last seen in the cardiology day hospital on 20 April 2018.
In the 3 months she has been on sacubitril/valsartan, she has had no readmissions, remains in functional class II-III and on the initial dose of 24/26 mg every 12 hours due to a tendency towards low blood pressure. Renal function has remained stable (creatinine in the last control 1.5 mg/dl and potassium 4.6 mmol/l).

DIAGNOSIS
Decompensated HF with American Heart Association (AHA) stage C reduced LVEF. New York Heart Association (NYHA) ambulatory functional class III.
Chronic ischaemic heart disease. Percutaneous revascularisation of the LAD on two occasions.
Probable pulmonary hypertension of Dana point groups 2 and 4.
Severely depressed LVEF. Severe right ventricular dysfunction.
Permanent non-valvular AF anticoagulated with apixaban.
Chronic kidney disease due to diabetic nephropathy.
Systemic arterial hypertension.
Dyslipidaemia.
Type 2 DM with good glycaemic control.
