BACKGROUND, CURRENT ILLNESS AND PHYSICAL EXPLORATION 60-year-old male.

Personal history
No known adverse drug reactions. Cardiovascular risk factors: ex-smoker (pack-year index 60), risky alcoholism, obesity. No previous cardiological history or family history of heart disease or sudden death. Usual treatment: none.

Current illness
She attended the emergency department due to deterioration of functional class of about 2 weeks of evolution, presenting progressive dyspnoea until minimal effort. Accompanied by orthopnoea and dry cough. No peripheral oedema. No syncope, chest pain or palpitations. No other symptoms of cardiovascular relevance. Denies consumption of toxic substances apart from alcohol (2-3 beers a day). Afebrile and without infectious semiology.

Physical examination
Vital signs: blood pressure (BP) 140/98 mmHg, heart rate (HR) 90 bpm, peripheral oxygen saturation 91% breathing ambient air. Weight 103 -> 97 kg. Body mass index (BMI) at discharge 31.7 kg/m2. Mild tachypnoea with decubitus intolerance. Jugular venous pressure elevated up to the middle third of the neck. Rhythmic cardiac auscultation without murmurs or extratonos. Pulmonary auscultation with hypophonesis in both lung bases with crackles up to the middle third bilaterally. Lower limbs with pretibial oedema. Peripheral pulses present and symmetrical. Well perfused.

COMPLEMENTARY TESTS
Electrocardiogram: sinus rhythm at 90 beats per minute, PR interval 160 ms, narrow QRS with normal positioned axis, adequate R wave transition in precordial leads, negative T waves in I, aVL, V5, V6. Blood tests: haemoglobin 15.9 g/dl with normal corpuscular indices, leucocytes 9,900 cells/microL with normal formula, platelets 197.000 cells/microL; haemostasis: INR 1.26, rAPTT 1.02; venous blood gases: pH 7.34, bicarbonate 31 mmol/l, pCO2 45 mmHg, lactate 2.5 mmol/l; biochemistry glycaemia 277 mg/dl, ALT 48 U/l, GGT 201 U/l, CL 79 U/l, creatinine 0.94 mg/dl, glomerular filtration rate estimated by MDRD-4 > 60 ml/min/1.73 m2, sodium 138 mEq/l, potassium 4.2 mEq/l, CRP < 0.4 g/dl. Cardiac markers: NT-proBNP 3015 -->400 ng/l, ultrasensitive troponin I 18 ng/l. Regular blood tests: glomerular filtration rate estimated by cystatin (CKD-EPI) 78 ml/min/1.73 m2; lipid profile triglycerides 147 mg/dl, total cholesterol 220 mg/dl, HDL cholesterol 35 mg/dl, LDL 156 mg/dl; iron profile: ferritin 490 ng/ml, TSI 21%; thyroid profile TSH 3.2 U/l; HbA1c 11.1%. Microbiology: SARS-CoV-2 PCR negative. Chest X-ray on admission: poorly inspired study. Increased cardiothoracic index. Increase of the bilateral perihilar vascular network, pinching of both lateral costophrenic sinuses, compatible with heart failure component. Increased density in both lung bases, which seems to be due to hypoventilation changes. Transthoracic echocardiogram (videos 1-4): moderately dilated left ventricle, with normal wall thickness. Akinesia of inferior face, inferior septum and inferior lateral face. Severe hypokinesia of the rest. Severely depressed global systolic function (LVEF 25% by visual estimation). Pseudonormalised filling pattern. Slightly dilated left atrium. Non-dilated right atrium. Non-dilated right ventricle, with normal global systolic function. Mitral valve with apicalisation of the coaptation point of both leaflets, mild-moderate insufficiency (II/IV). Aortic valve morphologically and functionally normal. Tricuspid valve morphologically normal. Mild insufficiency. RV-AD gradient 26 mmHg. Inferior vena cava poorly visualised. No pericardial effusion. Aortic root not dilated. No evidence of coarctation. Coronary angiography (videos 5-6): access via right radial artery, contrast 70 cc. Left coronary trunk without lesions. Anterior descending artery of good development and calibre with diffuse mild atheromatosis (mild plaque in the middle segment of 30%). Early diagonal branch of moderate calibre but without significant lesions. Circumflex of good development and calibre with diffuse mild atheromatosis. There are two marginal branches: first obtuse marginal branch with moderate plaque at the origin of a subbranch, the obtuse marginal branch being of borderline calibre at this level. Dominant right coronary artery, of good development and calibre with diffuse mild atheromatosis without significant lesions.

CLINICAL EVOLUTION
The patient was admitted for a first episode of decompensation of heart failure, with predominantly pulmonary congestion. He remained haemodynamically stable at all times, with no evidence of anterograde heart failure. Admitted to the conventional hospital ward in respiratory failure requiring support with oxygen therapy using low-flow nasal cannulas and diuretic treatment with intravenous furosemide. Good evolution with adequate diuretic response and progressive decongestion, with weight loss of up to 6 kg. Once close to euvolemia, prognostically beneficial treatment was started with beta-blockers, ARNI and antialdosteronics with adequate tolerance. The discharge medication included bisoprolol 5 mg/24h, sacubitril/valsartan 24/26 mg/12h, eplerenone 50 mg/24h. In addition, due to the presence of coronary atheromatosis, acetylsalicylic acid 100 mg/24 h and atorvastatin 40 mg/24 h were also started. During the analytical studies on admission, diagnostic criteria for type 2 diabetes mellitus were met (due to altered baseline glycaemia and elevated HbA1c levels), and so, upon debut with HbA1c > 10%, insulinisation was started together with oral antidiabetic drugs appropriate to the patient's clinical profile (established cardiovascular disease, obesity with BMI > 30 kg/m2). Thus, diabetes treatment at discharge consisted of insulin toujeo 24 IU/24 h, metformin/dapagliflozin 1000/5 mg (0.5 comp/12 h the first week and then 1 comp/24 h) and subcutaneous semaglutide (0.25 mg weekly for the first 4 weeks and then 0.5 mg weekly). The patient is being followed up in heart failure and endocrinology consultations, with no new admissions for heart failure. Significant improvement in LVEF up to 35% and NT-proBNP levels (400-> 150 ng/l) was observed after 6 months of treatment, as well as a decrease in HbA1c levels (11.1 -> 8.5%) and weight during follow-up (currently 91 kg and BMI 29.7 kg/m2).

DIAGNOSIS
First episode of decompensation of congestive heart failure.
Dilated cardiomyopathy of non-ischaemic aetiology with severely depressed left ventricular systolic function.
Newly diagnosed type 2 diabetes mellitus. Obesity.
