Presentation

A 67year-old gentlemen was referred to the Acute Medical Unit with decompensated heart failure, vomiting and lethargy.  10 days prior he had had an outpatient percutaneous coronary angiography for ongoing myocardial ischemia symptoms ( exertional chest pain ) and had 2 stents inserted in LAD. The procedure was uneventful and he was discharged on the same day. In outpatients 3 weeks earlier, his creatinine had been 150mmol/L.

His past medical history included the following:

1. T2DM of 6-7 years ago – last HBA1c 5.9%
2. Ischaemic Heart Disease (1 previous myocardial infarctions -NSTEMI- and was treated medically 3 years ago).
3. Congestive cardiac failure (CCF) with a severely impaired biventricular function (EF 35%, NYHA stage III)
4. Asymptomatic peripheral vascular disease
5. Non-proteinuric CKD 3b – baseline creatinine 150mmol/L and eGFR 48ml/min/1.73m2.
6. Life-long smoker

The patient was on the following medications and he denied the use of non-steroidal anti-inflammatory drugs (NSAIDs).

1. Aspirin 75mg OD
2. Atorvastatin 40mg OD
3. Bisoprolol 5mg OD
4. Furosemide 40mg OD
5. Metformin 1g BD
6. Ramipril 10mg OD