A 61 year old man presents with worsening exertional dyspnea for 3 months and orthopnea for 2 weeks. His medical history is significant for an anterior STEMI 4 years ago. No other co-morbidities are present. He is currently on aspirin, prasugrel, metoprolol, telmisartan and rosuvastatin.
There is gross cardiomegaly, with plethoric lung fields. Both costophrenic angles are obliterated.
The ECG shows atrial fibrillation with a left bundle branch block.
The ejection fraction is 40%. The left ventricle and atrium are dilated, while marked abnormalities of the anterior wall are noted. Mild mitral regurgitation is present.
Coronary angiography shows a right dominant circulation with a 90% stenosis of the Left Anterior Descending (LAD) artery.