Medical history and current illness
40-year-old male. Cardiovascular risk factors: untreated dyslipidaemia, smoking (30 cigarettes/day since the age of 18), obesity. Mother died of stroke at the age of 54. Uncomplicated peptic ulcus 15 years ago. She came to the emergency department for a transient loss of strength in the left hemibody lasting about 30 minutes with deviation of the corner of the mouth and falling to the floor, without loss of consciousness. In the last month she had presented 3 episodes of intense oppressive central thoracic pain, at rest, lasting 30 minutes and spontaneous cessation, for which she did not consult the doctor. Dyspnoea on moderate exertion in recent weeks.

Physical examination:
BP 115/79 mmHg, HR 85 bpm, weight 100 kg, height 177 cm, BMI 32. Abdominal circumference 117, AC: rhythmic, minimal protosystolic murmur in the apex. AP: vesicular murmur preserved. Extremities: peripheral pulses present, symmetrical. Rest without relevant findings.

Complementary tests
- Electrocardiogram (ECG): sinus rhythm at 100 bpm. PR 200 ms. QRS 90 ms. Q wave in II, III and aVF. ST elevation 0.5 mm in III, aVF and V3. ST-segment elevation 0.5 mm in I, aVL, V5 to V6 with negative T wave in V2, isodiphasic in V3 and flattened from V4 to V6.
- Transthoracic echocardiogram: severely dilated left ventricle, without hypertrophy and with severely depressed systolic function (ejection fraction 25%), with extensive alterations of segmental contractility in the inferior and anterior faces. Restrictive transmitral filling. Basal and apical inferior aneurysms. Apical intraventricular thrombus of 14x18 mm. Moderate ischaemic mitral insufficiency.
- Laboratory tests: maximum troponin I 0.43 ng/dL, total cholesterol 223 mg/dL, HDL cholesterol 31 mg/dL, LDL cholesterol 164 mg/dL, triglycerides 142 mg/dL. Basal blood glucose 88 mg/dL. HbA1c 4.9%. Normal haemogram, coagulation, renal function, ions, liver profile, iron profile and thyroid profile.
- Cardiac catheterisation (coronary angiography): severe obstructive coronary artery disease of 3 main vessels, multi-segment, with suboptimal distal beds.
- Cardiac MRI: dilated left ventricle, with severely depressed systolic function. Apical segments of anterior, inferior and septal face non-viable. Remaining segments viable. Apical thrombus.
- Cardiac catheterisation (percutaneous coronary intervention): angioplasty and implantation of 3 drug-eluting stents on proximal and middle anterior descending artery, and angioplasty and implantation of 1 drug-eluting stent on obtuse marginal artery, with good angiographic results. In a second stage, angioplasty and implantation of 1 drug-eluting stent on the distal right coronary artery and posterior interventricular artery and 1 drug-eluting stent at the level of the crux, with good angiographic results.

Clinical course
A 40-year-old man was admitted for a transient ischaemic attack in the right carotid artery and a history of chest pain. The diagnostic study revealed an evolved inferior and apical infarction, severe ventricular dysfunction and an intraventricular thrombus, three-vessel multisegment disease with suboptimal distal beds, and viability in the proximal and middle anterior descending and inferior territory. Given the poor distal quality of the anterior descending artery and the absence of diabetes mellitus, percutaneous revascularisation was chosen, and complete revascularisation was achieved with drug-eluting stents. The patient evolved favourably during admission, with no clinical signs of heart failure or new neurological focality.

Diagnosis
- Ischaemic heart disease: advanced inferior and apical infarction
- Obstructive atherosclerotic coronary artery disease of three main vessels
- Severe left ventricular systolic dysfunction
- Apical intraventricular thrombus
- Transient ischaemic attack due to cardioembolism
- Complete percutaneous revascularisation with drug-eluting stents
- Dyslipidaemia
- Smoking
- Obesity
