HISTORY, CURRENT ILLNESS AND PHYSICAL EXAMINATION

Personal history
71-year-old patient, with a personal history of:
Cardiovascular risk factors: arterial hypertension, dyslipidaemia, type 2 diabetes mellitus.
Ex-smoker for more than 15 years.
Chronic gastritis. Eradication of Helicobacter pylori in 2010.
Stroke with mild sequelae in 2007.
Intermittent claudication at 100 metres. Bilateral femoro-popliteal occlusion, without considering surgery by Vascular Surgery.
Paroxysmal atrial fibrillation.
Long history of chronic ischaemic heart disease:

-- Anterior infarction in 2000, implanting a conventional stent in the proximal anterior descending A. (ADA).
--Progressive angina in 2005 with left ventricular ejection fraction (LVEF) of 40%: restenosis of the previous stent in the LAD and severe disease of the circumflex artery (CxA) and right coronary artery (RCA). Bypass of saphenous vein from RCA and internal mammary artery (IMA) to RCA is performed. The RCA was not revascularised due to its small calibre.
--In 2012, worsening of functional class (FC) and LVEF (30%), repeating coronary angiography: chronic occlusion of LAD and RCA, bypass of IMA to LAD and saphenous vein to permeable RCA. Single-chamber defibrillator (ICD) implanted for primary prevention (no criteria for resynchronisation, QRS 125 msec).
--In April 2016 he underwent an appropriate ICD shock.
--In May and July 2016 he needed short admissions for decompensation of heart failure and in August he was readmitted again, this time with the need for levosimendan perfusion.

Current illness
Three weeks after discharge from hospital, the patient attended the Heart Failure outpatient clinic, reporting NYHA III CF, two-pillow orthopnoea and no new data of worsening from the congestive point of view, nor symptoms attributable to low cardiac output. Stable weight around 58 kg.

Since hospital discharge with the following treatment: synthroid, bisoprolol 5 mg (1/24 h), enalapril 10 mg (1/12 h), eplerenone 25 mg (2/24 h), furosemide 40 mg (3/24 h), atorvastatin 40 mg (1/24 h), oral iron, metformin 850 mg (1/12 h), pantoprazole 40 mg (1/24 h).

Physical examination
Blood pressure 123/77 mmHg, heart rate 63 bpm, O2 saturation 97 %.
Good general condition. Eupneic in decubitus at 40o. No jugular venous engorgement.
Good distal perfusion and adequate capillary refill. Cardiac auscultation: rhythmic, no murmurs. Pulmonary auscultation: preserved vesicular murmur, no added sounds. Abdomen: no palpable hepatomegaly. No signs of ascites or wall oedema. Lower limbs: no oedema. Trophic changes. Very weak paedial pulses bilaterally.

COMPLEMENTARY TESTS
Electrocardiogram: sinus rhythm at 68 bpm, PR 204 msec, intraventricular conduction disturbance (QRS 128 msec).
Echocardiogram: severely dilated left ventricle with severely depressed global systolic function (23% by Simpson biplane). Restrictive mitral filling. Non-dilated right ventricle with function at low limit of normality (TAPSE 15 mm). Mild mitral insufficiency. Mild TR allowing estimation of systolic pulmonary artery pressure of 43 mmHg. Electrode in right cavities.
No pericardial effusion.
CBC: NTproBNP 6170 pg/mL, haemoglobin 13.4 g/dl, glucose 99 mg/dl, creatinine 1 mg/dl, urea 44 mg/dl, sodium 140 mmol/l, potassium 3.9 mmol/L.

EVOLUTION
It was decided to discontinue enalapril and start sacubitril/valsartan 49/51 mg, one tablet every 12 hours, leaving an enalapril washout period of 36 hours.
After 3 weeks, the patient was re-assessed in consultation, with BP of 119/60 mmHg and maintaining renal function and potassium levels in the normal range, so it was increased to 97/103 mg. Two months after starting treatment, a new NTpro-BNP measurement was performed, which was 2900 pg/mL.
After 6 months of follow-up, the patient has remained in functional class II-III (subjectively somewhat better than before the change in treatment) and has not been admitted for heart failure. He only visited the emergency department on one occasion for mild decompensation of heart failure related to an upper respiratory tract infection, which could be managed from the emergency department and he was discharged early after 24 hours.

DIAGNOSIS
Chronic ischaemic heart disease with severe left ventricular dilatation and dysfunction. CF II-III. Intraventricular conduction disorder without criteria for resynchronisation.
Partial response to treatment with sacubitril/valsartan, with a decrease in readmissions for heart failure during 6 months of follow-up.
