From Severe Dilated Cardiomyopathy to Cardiac Recovery

Case presentation

Clinical presentation

A 58-year-old female nurse with no prior comorbidities, presented in November 2022 with progressive dyspnoea (NYHA class III–IV), orthopnea (requiring 3 pillows), dry nocturnal cough and paroxysmal nocturnal dyspnea
No history of tobacco, alcohol, or substance use; no family history of cardiovascular disease.
On examination she appeared ill; not pale, jaundiced, or edematous. BP 124/92 mmHg, HR 103 bpm, T 36.2°C, SpO₂ 96% (room air), Random blood glucose 5.9 mmol/L, BMI 21.3 kg/m². Laterally displaced heaving apex with S3 gallop and systolic murmurs; lungs were clear.

Notable labs included an elevated NT-proBNP (37,758 pg/mL), troponin I (40.1 ng/L), and CRP (38.3 mg/L); SARS-CoV-2 PCR was positive.

Echo: severe Dilated Cardiomyopathy (DCM) — LVEF 10–15%; LVEDd 81 mm; LVESd 78 mm; apical thrombus
Chest CT: cardiomegaly, pericardial effusion, stage II pulmonary venous congestion; no COVID pneumonia

IV diuretic: furosemide 80 mg at the time of referral, continued until clinical recompensation
Guideline-directed medical therapy (GDMT) was initiated
1. sacubitril/valsartan 12.5 mg BD
2. empagliflozin 10 mg OD
3. eplerenone 12.5 mg BD
4. bisoprolol 1.25 mg BD (uptitrated to 2.5 mg mane and 1.25 mg nocte after 2 weeks)
She also received:
- rivaroxaban 20 mg (remove torasemid!)
- supplemental oxygen
- SC enoxaparin 60 mg BD
- Supportive care: fluid balance monitoring and respiratory physiotherapy
(…)
A cardiology follow-up was scheduled for clinical revaluation, therapy uptitration and further diagnostic work-up with coronary angiography.

NT-proBNP reduced from 37,758 pg/ml to 16,418 pg/ml two days post admission (56.5% reduction).
Clinical improvement over 6 days of admission though BP remained low (83–90/60–65 mmHg).
She was discharged on GDMT, torsemide 20mg od and rivaroxaban 20 mg OD (replaced enoxaparin).
A cardiology follow-up was scheduled for coronary angiography.

3 weeks post discharge: Coronary angiography was performed and excluded obstructive coronary artery disease.
8th week review: Vitals: BP 90/59 mmHg, HR 63 bpm, SpO₂ 98%. No signs of congestion.
Despite full adherence to GDMT (sacubitril/valsartan 12.5 mg BD, empagliflozin 10 mg OD, eplerenone 12.5 mg BD, bisoprolol 2.5 mg mane and 1.25 mg nocte) and torsemide 20mg od; she remained NYHA Class III with severe LV dysfunction (EF 15–20%) and persistent electrical dyssynchrony (QRS 170 ms).
The persistently low blood pressure raised some concern about further GDMT uptitration.

Reference

Declaration of interest

None