We present the case of a 71-year-old patient diagnosed with heart failure with reduced ejection fraction of ischaemic aetiology, who was admitted for an episode of decompensation. During his stay, he underwent global management beyond diuretic therapy, which led to an improvement in his functional class.

HISTORY, CURRENT DISEASE AND PHYSICAL EXAMINATION

History
Cardiovascular risk factors (CVRF): hypertension and dyslipidaemia. No toxic habits. Permanent atrial fibrillation (AF) anticoagulated with acenocoumarol. Heart failure with reduced ejection fraction of ischaemic aetiology. Acute non-ST-segment elevation myocardial infarction (NSTEMI) in 2002 with three-vessel disease and severe ventricular dysfunction without improvement after complete surgical revascularisation in June 2002. Implantable defibrillator with cardiac resynchronisation therapy (ICD-CRT) in primary prevention since 2016. Last TTE performed in consultation (01/2021): severely dilated left ventricle with severe systolic dysfunction (LVEF by Simpson biplane: 24.5%). Septal, apical, inferior and inferolateral akinesia. Anterior and lateral hypokinesia. Severe mitral insufficiency (MI) of probable mixed mechanism. Severe dilatation of the right ventricle (RV) with preserved function. Severe dilatation of both atria. Moderate aortic stenosis. Moderate tricuspid insufficiency (TI) grade III. Estimated systolic pulmonary artery pressure (SPAP) of 50 mmHg. Peripheral arterial disease assessed by vascular surgery with no need for follow-up. Hyperuricaemia. Usual treatment: furosemide 40 mg (2 tablets daily), eplerenone 25 mg (1 tablet at lunch), valsartan 80 mg (half a day), carvedilol 3.25 mg (at breakfast and dinner), acenocoumarol as prescribed, atorvastatin 20 mg (at dinner), nitrate patch 5 mg, allopurinol 300 mg (at dinner), omeprazole 20 mg (at breakfast).

Current disease
Previously in functional class (FC) I-II, he reported increasing dyspnoea until minimal effort, associated with orthopnoea and episodes of paroxysmal nocturnal dyspnoea (PND). In addition, oliguria, oedematisation of the lower extremities (LES) and weight gain. He relates the worsening to the reduction of valsartan doses a few weeks ago due to recurrent episodes of hypotension. Physical examination Weight 88.5 kg (dry weight not recorded), height 1.65m. Body mass index (BMI) 32 kg/m2. Blood pressure (BP) 109/84 mmHg, heart rate (HR) 108 bpm, oxygen saturation breathing room air 96%, afebrile. Eupneic at rest, slight increase in jugular pressure, absent hepatojugular reflux. Cardiac auscultation irregular and without murmurs. Pulmonary auscultation: bibasal crackles. Extremities with bimalleolar oedema. Peripheral pulses weak but preserved and symmetrical.

COMPLEMENTARY TESTS
Electrocardiogram (ECG) on arrival at the emergency department: atrial fibrillation at 80 bpm, ventricular pacing mediated by ICD-CRT. Chest X-ray: mild cardiomegaly (cardiothoracic index [CTI] 0.52), mild vascular redistribution, ICD-CRT generator and electrodes normally positioned, without costophrenic sinus impingement. Blood tests on admission: haemoglobin 13.3 g/dl, leucocytes 4930*103/ul, platelets 103000 /Ul. Biochemistry: glucose 86 mg/dl, creatinine 1.26 mg/dl, urea 48 mg/dl, estimated glomerular filtration rate 57 ml/min/1.73 m2, sodium 137 mg/dl, potassium 3.6 mg/dl, total bilirubin 4.2 mg/dl, direct bilirubin 3.2, lactate dehydrogenase 241 U/l, alanine aminotransferase (ALT) 20, total protein 44 g/l, albumin 36 g/l. TSH 2.16 mU/l. Troponin T 46 ng/l-> 50 ng/l (< 14 ng/l). NT-proBNP 2154 pg/l (< 300 pg/l). Ferrokinetic profile: iron 87 uG/dl (59-156), transferrin saturation index 23% (16-45), ferritin 90 ng/ml (30-400). Transesophageal echocardiography performed during admission: severe ischaemic mitral insufficiency. Posterior leaflet of 7 mm. Thrombus in left atrial appendage. Moderate IT grade III. Moderate aortic stenosis with AVA of 1.3. IT signal allows estimating PAPS of 54 mmHg.

CLINICAL EVOLUTION
On admission, intravenous furosemide was started with a good diuretic response. In addition, given the elevation of direct bilirubin, abdominal ultrasound was requested, which revealed liver stasis in the context of heart failure. The CRT device was checked and the pacing % was found to be in an adequate range.

Transesophageal echocardiography was requested to expand studies on the severe MI described in the last transthoracic echocardiography performed in consultations, which confirmed the severity of the Ml of ischaemic origin and visualised an image compatible with thrombus in the left atrial appendage. The patient had normal haemoglobin levels, with normal iron and transferrin saturation index, but ferritin less than 100 ng/l. In this context, in view of the iron deficiency situation, it was decided to start iron therapy with an infusion of 1,000 mg of iron carboxymaltose. During admission, she showed clinical improvement with a loss of up to 5 kg compared to her admission weight after diuretic therapy and great symptomatic improvement. Throughout his hospital stay, his blood pressure was around 100/70 mmHg, with symptoms of orthostasis when attempting to increase anti-humoral therapy, so it was decided not to start sacubitril/valsartan. Finally, he was discharged with a change of valsartan to losartan 25 mg, bisoprolol 1.25 mg (at breakfast and dinner) instead of carvedilol, and discontinuation of acenocoumarol and start of edoxaban 60 mg (daily) together with furosemide 40 mg (2 tablets daily), eplerenone 25 mg (1 tablet at lunch), atorvastatin 20 mg (at dinner), allopurinol 300 mg (at dinner), omeprazole 20 mg (at breakfast). In addition, an outpatient cardiac CT scan was requested to assess the viability of implanting a Tendyne prosthesis as a treatment for mitral insufficiency and to evaluate the persistence of thrombus in the left atrial appendage after correct oral anticoagulation. One month after discharge and after 3 weeks in NYHA functional class I, the patient came for a check-up. He presented blood tests showing sudden anaemisation with haemoglobin levels of 10.5; in addition, the patient reported clinical manifestations of melena since discharge. It was decided to request invasive studies to investigate the aetiology of the anaemia, with gastroscopy and colonoscopy, which were normal. The patient is currently awaiting capsule endoscopy.

DIAGNOSIS
Heart failure with reduced EF of ischaemic aetiology with episode of decompensation due to systemic congestion.
Severe ischaemic mitral regurgitation. Moderate grade III tricuspid regurgitation.
Ferropenia with normal haemoglobin levels.
Permanent atrial fibrillation. Thrombus in left atrial appendage.
Carrier of ICD-CRT in prevention 1a with adequate pacing %.
