HISTORY, CURRENT ILLNESS AND PHYSICAL EXAMINATION

History
Cardiovascular risk factors: arterial hypertension (AHT). Dyslipidaemia. Obesity. Diabetes mellitus type 2. Smoker of 20 cigarettes/day. Chronic alcoholism 8 UBEs/day. Persistent atrial fibrillation anticoagulated with acenocoumarol. Other history: chronic bronchitis without obstructive pattern, sleep apnoea hypopnoea syndrome (SAHS) in treatment with nocturnal continuous positive airway pressure (CPAP). Usual treatment: glimepiride 2 mg/day, metformin/dapagliflozin 850/5 mg every 12 hours, atorvastatin 30 mg every 24 hours, acetylsalicylic acid 100 mg per day, spironolactone 25 mg per day, amlodipine 5 mg per day, acenocoumarol as prescribed, bisoprolol 2.5 mg every 24 hours, furosemide 40 mg every 24 hours, omeprazole 20 mg daily, indacaterol/glycopyrronium bromide 85/43 mcg 1 capsule inhaled every 24 hours.

Present illness
A 57-year-old patient attended the emergency department with worsening functional class to the point of presenting dyspnoea on minimal effort, orthopnoea, episodes of paroxysmal nocturnal dyspnoea, subjective decrease in diuresis and oedema associated with weight gain.

Physical examination
Weight 108 kg, height 1.71 m. Body mass index (BMI) 36.9 kg/m2. Blood pressure (BP) 178/92 mmHg. Heart rate (HR) 138 bpm. Oxygen saturation (SatO2) 90% with nasal goggles at 2 l/min (FiO2 28%).
Tachypneic at rest. Jugular venous pressure increased. Positive hepatojugular reflex. Cardiac auscultation: irregular, no murmurs. Pulmonary auscultation: bibasal hypophonesis of right predominance with scattered rhonchi. Extremities: tibiomalleolar oedema up to the root of the thighs and in the upper limbs. Peripheral pulses were preserved and symmetrical.

COMPLEMENTARY TESTS
ECG on arrival at the ED: atrial fibrillation at 130 bpm. Narrow QRS. AXIS: 0o. Poor progression of the septal vector in precordial leads. No repolarisation alterations.

CBC: haemoglobin 10.4 g/dl, haematocrit 30%, platelets 344,000 /μl, leukocytes 7400/μl. International normalised ratio (INR) 1.8. Basal blood glucose 260 mg/dl. Urea 27 mg/dl, creatinine 0.81 mg/dl, sodium 134 mEq/l, potassium 3.7 mEq/l. HbA1C: 8.6%. Biomarkers of myocardial damage (normal value range 0.0-11.6 ng/l): troponin I (hsTnI) 28 ng/l --> 33 ng/l. proBNP 2680 pg/ml. CA125 474 IU/ml. RT-PCR for SARS-CoV2: negative. Iron metabolism: ferritin 78 mcg/l, IST 4.5%.

Chest X-ray: centred cardiomediastinal silhouette. Cardiothoracic index greater than 0.5. Bilateral interstitial infiltrate with apical vascular redistribution. Bilateral pleural effusion, predominantly on the right.

Echocardiograms:
Echocardiogram on admission: left ventricle of increased diameters and volumes with moderate ventricular dysfunction secondary to generalised hypokinesia (LVEF 37%). Aortic root normal diameters. Dilated left atrium. Mild mitral insufficiency (MI). Normal filling pressures. Dilated right ventricle with depressed systolic function. Mild-moderate tricuspid insufficiency (TI) allowing estimation of systolic pulmonary artery pressure (PAPS) at 45 mmHg. Absence of pericardial effusion. Dilated inferior vena cava (IVC) without inspiratory collapse greater than 50%. No images compatible with thrombus in the left atrial appendage. Study performed in atrial fibrillation.
Control echocardiography 3 months after discharge: left ventricle with increased diameters and volumes with preserved global systolic function (LVEF 55%). Aortic root normal diameters. Dilated left atrium. Mild MI. Normal filling pressures. Right ventricle of normal diameters with normal systolic function. Mildly moderate TR allowing estimation of PAPS at 40 mmHg. Absence of pericardial effusion. IVC of normal diameters with inspiratory collapse greater than 50%. Study performed in sinus rhythm.

Haemodynamics: coronary angiography during admission. Epicardial coronary arteries with diffuse atheromatosis without significant stenosis.

CLINICAL EVOLUTION
A patient with decompensated heart failure with ventricular dysfunction of probable multifactorial aetiology, who presented atrial fibrillation with rapid ventricular response, left atrial appendage thrombus was ruled out by transesophageal echocardiography and two ineffective electrical cardioversions were performed. Coronary angiography was performed and no significant stenosis was observed.
Treatment was administered with high-dose bolus intravenous diuretics, ferrotherapy with iron carboxymaltose, braking treatment with beta-blockers and oral treatment to prevent alcohol deprivation syndrome.
Good clinical and diuretic response during admission. Difficult to control blood glucose and blood pressure. Discharged 9 days after admission paucisymptomatic and in atrial fibrillation with controlled ventricular response. Treatment at discharge: metformin/dapagliflozin 850/5 mg every 12 hours, atorvastatin 30 mg every 24 hours, acetylsalicylic acid 100 mg daily, amlodipine 5 mg daily, rivaroxaban 20 mg daily, bisoprolol 2.5 mg every 24 hours, furosemide 80 mg every 24 hours, omeprazole 20 mg daily, indacaterol/glycopyrronium bromide 85/43 mcg 1capsule inhaled every 24 hours, amiodarone 200 mg daily, eplerenone 50 mg daily, sacubitrile/valsartan 24/26 mg every 12 hours, clomethiazole 192 mg every 12 hours, semaglutide 0.25 mg once a week for four weeks, then 0.5 mg once a week for four weeks and then 1 mg once a week.
He attended a follow-up appointment with the local cardiology department 3 months later, with improvement in functional class (NYHA I), smoking cessation and alcohol abstinence. Physical examination revealed significant weight loss (12 kg) and no signs of congestion. Complementary tests showed sinus rhythm, HbA1C decreased to 7.2% and proBNP 86.8 pg/ml. Echocardiography showed increased diameters and preserved global systolic function.
Subsequent follow-up was asymptomatic from the cardiovascular point of view, with good glycaemic control (HbA1C 6.2%) and no recurrence of atrial fibrillation.

DIAGNOSIS
Decompensated heart failure with depressed LVEF.
Dilated cardiomyopathy (tachycardiomyopathy versus enolic).
Persistent atrial fibrillation.
Obesity. Type 2 diabetes mellitus. HYPERTENSION. Dyslipidaemia.
Iron deficiency.
Chronic macrocytic anaemia.
