P245 IMPLICATIONS IN PHARMACOLOGICAL AND ELECTRICAL OPTIMIZATION IN HEART FAILURE: A EMBLEMATIC CASE

Abstract

Abstract We describe the case of an 82–year–old man with permanent atrial fibrillation in oral anticoagulation therapy. Former smoker. Diabetes mellitus. In 2009, subacute MI with PTCA/DES of anterior descending artery and obtuse marginal branch, critical stenosis of circumflex artery, right coronary artery occluded. Infrarenal aorta occlusion. Echocardiography TT mild–moderate mitral regurgitation. Ejection fraction (EF) preserved. Inferior wall akinesia. In 2019 hospitalization for heart failure due to severe bradyarrhythmia in atrial fibrillation. In therapy with bisoprolol 10 mg/day Echocardiography FE 35%, moderate–severe functional mitral regurgitation, PAPs 55 mmHg. Arterial pressure 100/85 Sat 2O 90% Treatment at discharge: furosemide 75 mg/day, bisoprolol 7,5 mg/day, Metformina 500 mg/day, potassium canrenoate 50 mg/day atorvastatin 40 mgday and warfarin,Ramipril 2.5 mg/day, allopurinol 150 mg/day. In 2020 new hospitalization for heart failure. NYHA III–IV; BNP 1890 pg/ml. Beta–blocker therapy reduced to bisoprolol 3.75 day for pulmonary hypertension and bradycardia, furosemide increased to 100 mg/day, possibly further titratable on the basis of renal function, blood electrolytes and clinical response, maintaining restriction of daily liquids at about 1000 cc. Initiated Sacubitril/Valsartan 24/26 mgx 2 /day. Coronary angiography was not possible due to occlusion of the abdominal aorta and right radial artery (1,2,3). CT CORO performed with relief of the interventricular branch occluded in the middle section; patent obtuse marginal branch stent; right coronary artery occluded. Abdominal aorta occluded at the level of the renal arteries. The patient was submitted to CRT–D implant for bradycardia and wide QRS like left bundle branch block. Glyphozine associated with Metformin. Echocardiography TT LVEF 40%, moderate functional MR, PAPS 35 mmHg. NYHA II. Edema resolution No hospitalizations for decompensation. titrated ARNI at 49/51 mg x 2/day, and the beta blocker Cardicor 5mg/day. At remote monitoring decreased ventricular catheter impedance. What does the case tell us? The combination of Sacubitril/Valsartan and Glifozine determined an inverse remodeling of the heart. The combination of Sacubitril/Valsartan and Glifozine improved cardiac compensation and clinically stabilized the patient.