HISTORY, CURRENT DISEASE AND PHYSICAL EXAMINATION
We present the case of a 65-year-old male type 2 diabetic of 8 years of evolution (on metformin treatment) who was admitted to our centre
(on treatment with metformin) who was admitted to our centre for congestive heart failure (CHF).
The patient had been a smoker until March 2014, with a pack-year index of 30. In addition, he was overweight (fulfilling metabolic syndrome criteria), hypertensive and hypercholesterolaemic (both under medical treatment with enalapril 5 mg/12 h, bisoprolol 5 mg/24 h and atorvastatin 40 mg/24 h). His past history of interest included an inferior myocardial infarction in 1997, with no information on interventionism and no subsequent follow-up, as well as permanent atrial fibrillation anticoagulated with acenocoumarol.
In 2014 he developed ischaemic colitis and a Forrest III gastric ulcer requiring hospital admission. This was complicated by a new non-ST-elevation type II infarction in the context of rectal bleeding. Once the patient was stabilised, coronary angiography revealed severe 3-vessel coronary artery disease: proximal anterior descending (LAD) occlusion, severe proximal circumflex and first obtuse marginal (OM1) lesion, severe proximal bisector lesion and right coronary artery (RCA) occlusion. The transthoracic echocardiogram showed a severely depressed left ventricular ejection fraction (LVEF) (LVEF 25%). For all these reasons, it was decided in a medical-surgical session to perform coronary revascularisation surgery, which was finally carried out with the implantation of four vascular grafts (mammary artery to distal LAD, saphenous vein in "Y" to bisector and OM1 and saphenous vein to mid-distal DC).
Subsequent evolution was satisfactory, but in 2015 the patient began to present symptoms of CHF, requiring a first hospital admission in relation to dietary transgression. Since then, he had been on treatment with 60 mg of furosemide daily and 25 mg of spironolactone, in functional class (FC) II/IV ambulatory.
She was admitted to our centre in October 2016 due to decompensation of severe CHF with acute hypertensive pulmonary oedema, requiring management in the acute unit with non-invasive mechanical ventilation (NIMV) and intravenous medication. He also initially required inotropic support with dobutamine, which was successfully withdrawn via a course of levosimendan. The electrocardiogram on admission showed atrial fibrillation with ventricular response at 90 bpm, with QRS of 100ms, QS in V1-V3 and flattened T in V5-6, similar to previous records. As part of the diagnostic study, a new coronary angiography was performed, which showed patency of the previous grafts, as well as a cardiac magnetic resonance imaging, which showed an LVEF of 24%, together with a transmural late enhancement pattern in the LAD territory. In addition, the patient had moderate right ventricular systolic dysfunction.
The hospital evolution was again favourable, and after discussion with the Heart Team, it was decided to implant a subcutaneous single-chamber implantable cardioverter defibrillator (ICD). After optimisation of pharmacological treatment (enalapril 10 mg/12 h; bisoprolol 5 mg/24 h; furosemide 80 mg/24 h; spironolactone 25 mg/24 h), a lipid profile control was performed, showing LDL-cholesterol levels of 65 mg/dl and total cholesterol of 160mg/dl. Likewise, the glycosylated haemoglobin value was 7.9%, outside the therapeutic target, so it was decided, together with the Endocrinology Department, to optimise treatment with oral antidiabetic drugs.
As the patient was at high cardiovascular risk, with several decompensations due to CHF, regular blood pressure control and metabolic syndrome, it was decided to add empaglifozin 10 mg daily to the previous treatment with metformin. The patient was discharged from hospital and continued to be closely monitored in the Cardiology day hospital.

COMPLEMENTARY TESTS
Posteroanterior and lateral chest X-ray: global cardiomegaly, increased bronchovascular tract compatible with interstitial and alveolar oedema, cisural effusion, sternotomy suture.
Electrocardiogram: atrial fibrillation with ventricular response at 90 bpm, with QRS of 100 ms, QS in V1-V3 and flattened T in V5-6.
Transthoracic echocardiogram: moderately dilated left ventricle, with normal wall thickness. Severely depressed global systolic function (LVEF 20% by visual estimation). Akinesia and thinning of the septum, apical (segment 17 aneurysm) and inferior face and mid and distal segments of the lateral-inferior. Single wave mitral filling. Left atrium slightly dilated. Mildly dilated right atrium. Right ventricle severely dilated, with global systolic function at the lower limit of normal.
TAPSE of 14 mm. Mitral valve with calcium ring, thickening of the leaflets and restriction of the posterior leaflet opening. Mild insufficiency. Sclerosed aortic valve, without pathological transaortic gradients. Mild insufficiency. Morphologically normal tricuspid valve. Moderate insufficiency.
Pulmonary artery systolic pressure estimated at 65 mmHg. Dilated inferior vena cava (24.54 mm), without inspiratory collapse. No pericardial effusion. Epicardial fat.
Aortic root 30 mm. Ascending aorta 37 mm.
Pre-surgical coronary angiography: right dominance. Truncus: no lesions. Anterior descending: chronic occlusion at proximal level, observed by heterocoronary circulation, being a vessel of good calibre and development. Circumflex: artery of good development and calibre. It presents a severe lesion at the proximal level (85-90%), just after the exit of OM1, the rest of the vessel is of good calibre and development. OM1 is a vessel of good development and calibre, with a significant calcified lesion at the proximal level, the rest of the vessel is of good calibre and development. Bisector branch: vessel of good calibre and development, with severe calcified disease at the proximal level, the rest of the vessel with diffuse mild atheromatosis. Right coronary description: right dominant. Chronic occlusion at the middle level, distal vessel is observed by heterocoronary circulation being a vessel of good development. Diagnostic findings: severe 3-vessel coronary artery disease (chronic occlusion of DA and CD), severe Cx lesion (proximal Cx, OM1 and bisector branch).
Cardiac MRI: severely dilated left ventricle (VTD 295 ml, VTS 225 ml), with normal wall thickness. Severely depressed global systolic function (LVEF 24%). Akinesia and thinning of the septum and anterior face and distal third of all faces. Inferior face akinesia.
Late enhancement is observed transmurally affecting the apex and distal third of inferior, lateral, anterior and septum, 75 % subendocardial in mid and distal segment of anterior face and septum, and 50 % in the basal segment of anterior face and septum. 75 % enhancement in lower basal segment. Moderately dilated left atrium (apical plane area 43 cm2). Right atrium slightly dilated (32 cm2). Right ventricle not dilated (VTD 111 ml, VTS 77 ml), with moderately depressed global systolic function with global hypokinesia. RVEF 31%.
Conclusion: dilated cardiomyopathy of ischaemic aetiology with severely depressed global systolic function and late enhancement pattern of ischaemic aetiology with multivessel involvement. Absence of viability in the territory of the anterior descending artery. Moderate right ventricular systolic dysfunction.

EVOLUTION
Three months after hospital discharge, the patient has a glycosylated haemoglobin of 7.3%, has lost 3 kg in weight, maintains good blood pressure control with current figures around 120/70 mmHg and has not been admitted again for CHF, remaining in ambulatory functional class II and having allowed a decrease in diuretic treatment to 60 mg of furosemide. He has not been discharged from the ICD either. As this is a young patient at high cardiovascular risk, it was decided to titrate empaglifozin to 25 mg to improve glycaemic control. At the next outpatient review, four months after the previous one, the glycosylated haemoglobin value was 6.8%, the patient had continued to lose weight, with good control of the rest of the CVRF, no hospital admissions, no ICD discharges and in functional class II.

DIAGNOSIS
Chronic heart failure with LVEF 24% and RVEF 31% by cardiac magnetic resonance imaging.
Chronic ischaemic heart disease with 3-vessel coronary artery disease revascularised by quadruple bypass. Chronic inferior and anterior infarction.
Absence of viability in the territory of the anterior descending artery.
Carrier of Biotronik single-chamber ICD in primary prevention.
Permanent atrial fibrillation anticoagulated with sintrom.
Diabetes mellitus in treatment with metformin and empaglifozin.
Arterial hypertension. Dyslipidaemia. Exobtachism. Metabolic syndrome.
