Abdulla is 54-year-old diabetic man living in the United Arab Emirates with a history of three-vessel coronary artery disease. Fourteen months ago, he had an acute inferior myocardial infarction (AMI) requiring multiple stents in the right coronary artery and left circumflex artery. His left anterior descending artery (LAD) was found to have a chronic total occlusion. He was diagnosed with diabetes at the time of his AMI.

He presented to the clinic with New York Heart Association functional class III heart failure (HF), dyspnea, and fatigue with minimal effort. He has smoked two packs of cigarettes per day since high school and his main concern is erectile dysfunction. He complains of bilateral claudication, even with limited walking; he experiences leg cramps, which he attributes to statin use. He is very worried about symptoms caused by several episodes of hypoglycemia and is not using insulin due to this fear. He has gained weight after being started on "all these medications" and his activity level has declined.

PHYSICAL EXAM

• Body mass index 34 kg/m², waist circumference 117 cm
• Blood pressure 112/79 mm Hg, pulse 87 bpm, jugular venous pressure 8 cm, 1+ lower limb edema, reduced pedal pulses
• Cardiovascular (CV) exam: S₃, mitral regurgitation (MR) murmur
• Chest exam: no crackles

INVESTIGATIONS

• Electrocardiogram: left bundle branch block with QRS 172 ms, left atrial enlargement, normal sinus rhythm
• Echocardiogram: left ventricular ejection fraction (LVEF) 20%, dilated left atrium, moderate (grade 2+) MR, elevated filling pressures
• Nuclear stress: LVEF 24% with peri-infarct ischemia in LAD territory showing partial reversibility. The patient undergoes coronary angiography and LAD shows chronic total occlusion with collaterals.
• Peripheral artery disease (PAD) with ankle-brachial index 0.8
• N-terminal pro-B-type natriuretic peptide 3211 pg/ml, glomerular filtration rate (GFR) 63 ml/min/m², creatinine 1.1 mg/dl
• Lipid profile: low-density lipoprotein cholesterol 72 mg/dl, lipoprotein(a) 119 mg/dl, non-high-density lipoprotein cholesterol 201 mg/dl, triglycerides 260 mg/dl, high-sensitivity C-reactive protein 5.3 mg/L
• Hemoglobin A1c 8.2%, uric acid 461 µmol/L
• Urine microalbumin 217 mg, albumin/creatinine ratio elevated 49 µg/mmol

MEDICATIONS

• Aspirin 100 mg and rivaroxaban 2.5 mg BID
• Atorvastatin 20 mg daily
• Bisoprolol 7.5 mg daily
• Isosorbide dinitrate 60 mg and sublingual nitroglycerin as needed
• Lisinopril 20 mg daily
• Furosemide 40 mg BID
• Allopurinol 300 mg daily
• Gliclazide 60 mg daily, metformin 1000 mg once daily, saxagliptin 2.5 mg once daily, insulin sliding scale (he is neither compliant with measuring fingerstick glucose nor insulin injection)

Over the course of 3 months, guideline-directed medical therapy for HF with reduced EF (HFrEF) has been optimized with increase in the dose of beta-blocker, transition of angiotensin-converting enzyme inhibitor to angiotensin receptor–neprilysin inhibitor (sacubitril/valsartan), and addition of spironolactone.

Repeat echocardiogram showed that LVEF improved to 30% with elevated filling pressures, right atrial pressure of 10 mm Hg, and moderate MR grade 2+. He is enrolled in smoking cessation and cardiac rehabilitation programs. The patient undergoes a biventricular/cardiac resynchronization therapy-defibrillator (CRT-D) implantation – with resynchronization, QRS duration decreases to 157 ms.