PERSONAL HISTORY
No known drug allergies. Toxic habits: ex-smoker for 5 years, smoked 1 pack/day for > 20 years. Cardiovascular risk factors: hypertension (HT) (with poor control at home, SBP around 180), dyslipidaemia (LD), type II diabetes mellitus (DM). Cardiological history: chronic ischaemic heart disease since 2006, anterior descending (AD) occlusion with collateral filling, diffuse atheromatosis. Positive ergometry at high loads, so medical management was decided. Paroxysmal AF anticoagulated with synthrom. Medical-surgical: psoriatic arthropathy, treated with methotrexate. Admitted in 2016 for influenza A infection and respiratory failure.
Home treatment: atenolol 50 mg/24h, Uniket reatard 50 mg/24h, telmisartan 80 mg/24h, amlodipine 5 mg/24h, atorvastatin 80 mg/24h, ezetimibe 10 mg/24h, metformin 1000 mg + sitagliptin 50 mg/12h, deflazacort 6 mg/24h, omeprazole 20 mg/24h, sintrom 4 mg, empagliflozin 10 mg/24h, folic acid 5 mg/24h, methotrexate 15 mg sc every 7 days, vesomni 6/0.4 mg/24h.

CURRENT ILLNESS
A 71-year-old male presented to the emergency department for chest pain. The patient reported that in the last few days he had presented approximately 5 episodes per day of central chest tightness associated with dyspnoea triggered by minimal exertion (walking on level ground for less than 50 m) lasting about 10 minutes, which improved after rest. He denied palpitations, syncope, decreased diuresis or increased circumference of the lower limbs.

PHYSICAL EXAMINATION
Blood pressure 114/53 mmHg. Heart rate 87 bpm. Afebrile. Basal sats O2 95%. Head and neck: no IVY at 45 ̊ and no hepatojugular reflux. Cardiac auscultation: rhythmic, no murmurs. Pulmonary auscultation: preserved vesicular murmur with no added sounds, hypophonesis at the bases with no clear crackles. Abdomen: soft, depressible, not painful on palpation. Lower limbs: no oedema.

COMPLEMENTARY TESTS
Electrocardiogram (ECG): sinus rhythm with frequent ventricular extrasystoles (in bigeminy). PR 162 ms, QRS 102 ms, 60o axis, ST segment rectification from V2 to V6 (already described in previous ECGs). Control ECG: sinus bradycardia at 60 bpm, isolated ventricular extrasystoles, unchanged from previous ECG.
Chest X-ray: mediastinal structures centred. Cardiopericardial silhouette of normal morphology. Pulmonary hilae of vascular morphology. Free costodiaphragmatic sinuses. No evidence of active pleuroparenchymal lesions at the present time. Blood gases: pH 7.455, San-pCO2 32.1 mmHg, San-pO2 80.7 mmHg, O2 saturation 95.5 %, San-sodium 133.7 mmol/l, San-potassium 4.58 mmol/l, San-lactate 2.89 mmol/l.
Laboratory ED: leucocytes 6.65. Haemoglobin 11.5. Haematocrit 33.6. MCV 83.7. Platelets 316.0. Neutrophils 67.8. Glucose 100.0. Urea 90.0. Uric acid 6.0. Creatinine 0.86. Sodium 139.0. Potassium 4.4. Total bilirubin 0.9. Aspartate aminotransferase (AST/GOT) 31.0. Alanine aminotransferase (ALT/GPT) 63.0. Gamma-glutamyl transferase (GGT) 28.0. Alkaline phosphatase 136.0. Serial myocardial necrosis markers: negative. Central laboratory: iron 44.0. Ferritin 72.0. Transferrin saturation index 13.0. Transferrin 243.0. Iron binding capacity of transferrin 340.0. Folate 19.7. Vitamin B12 (cobalamin) 283.0. Cholesterol 76.0. Triglycerides 109.0. HDL cholesterol 16.0. Non HDL cholesterol 60.0. LDL cholesterol (calculated) 38.0. Thyrotropin (TSH) 2.2. N-terminal pro-brain natriuretic peptide (NT-proBNP) 2092.0. Haemoglobin A1c 7.7%. Faecal occult blood test: negative.
Transthoracic echocardiogram (TTE): left ventricle not dilated, slightly hypertrophied (VTD 70 ml, VTS 30 ml, SIV 13 mm). Preserved systolic function (LVEF by Simpson 57%), without segmental alterations. Mild mitral insufficiency. Normal transmitral filling pattern (E: 0.90 m/s A: 0.58m/s E/A: 1.5; e ́lateral: 0.08 e ́septal: 0.10 E/e ́ 11). Trivalve aortic valve, sclerocalcified with preserved opening (max transvalvular gradient: 16.5 mmHg mean: 9.32 mmHg). No aortic insufficiency. Slightly dilated left atrium (area: 23 cm2, volume: 66 ml). Ascending atrium not dilated: 37 mm. Non-dilated right ventricle (basal DTD 40 mm, mean DTD 32 mm) TAPSE: 22 mm S: 0.11 m/s. Right atrium slightly dilated (area: 23 cm2). Thin pulmonary valve. Mild pulmonary insufficiency. No pulmonary valve stenosis. Pulmonary artery flow acceleration time of 80 ms. Fine tricuspid valve, mild insufficiency, RV-AD gradient 39 mmHg. Pulmonary systolic pressure 44 mmHg. Cavainferior cavainferior vein not dilated, collapse > 50%. Impressed absence of pericardial effusion.
Diagnostic coronary angiography: atheromatous left main coronary artery (LMCA) with eccentric calcified lesion at distal level leading to significant stenosis at distal level in LMCA-Cx, with distal luminal area of 5.6 cm2 (measured by IVUS). LAD occluded at ostial level; distal vessel by homo and heterocoronary collaterals, of small calibre. Circumflex (CX) diffusely calcified, with severe lesion at ostial (TCI-CX) and proximal level. Dominant right coronary artery (RCA) with diffuse calcification and no significant stenosis.
Colonoscopy and upper gastrointestinal endoscopy: no evidence of blood or bleeding lesions of the visible mucosa. Percutaneous coronary intervention: a guide wire is advanced to distal Cx. The Cx-LCT lesion is predilated and an everolimus-eluting stent (3.5*15 mm at 18 atm) is implanted with good angiographic results covering the lesion. The proximal CX lesion is then predilated and an everolimus-eluting drug-eluting stent (3*18 mm at 18 atm) is implanted with good final angiographic results.  

CLINICAL EVOLUTION
A 71-year-old man was admitted for unstable angina. A transthoracic echocardiogram showed preserved biventricular systolic function and no valvular heart disease. A coronary angiogram was also performed, showing occlusion of the ostial anterior descending artery (already known), a significant lesion in the distal trunk affecting the circumflex ostium and a severe distal lesion. A mild iron deficiency anaemia was found, which is why, after discussing the case in the medical-surgical session, an anaemia study was indicated to exclude bleeding foci prior to percutaneous intervention. Telemetry showed ventricular bigeminy, which was jugulated with beta-blockers; no major ventricular arrhythmias. Digestive endoscopy was performed without documentation of potentially bleeding lesions.
The patient under double antiplatelet therapy and low weight heparins has not presented clinical bleeding and has improved ferrokinetics and haemoglobin with oral iron. Excluding major bleeding and without anaemia under double antiplatelet therapy plus heparin, the patient underwent percutaneous coronary intervention with implantation of two stents with a good final angiographic result. Post-procedural evolution was favourable, with no clinical events.
Given her clinical stability, with no further in-hospital procedures required, she was discharged home.

Treatment at discharge Rivaroxaban 15 mg: 1 tablet at noon. Clopidogrel 75 mg: 1 tablet with food for 1 year. Acetylsalicylic acid (ASA) 100mg: 1 tablet with food for 1 month. Pantoprazole 40 mg: 1 tablet on an empty stomach. Bisoprolol 5 mg. 1 tablet with breakfast. Amlodipine 5 mg. 1 tablet with dinner. Isosorbide mononitrate retard 50 mg. 1 tablet with breakfast. Atorvastatin 80 mg/ezetimibe 10 mg. 1 tablet with evening meal Furosemide 40 mg. 1 tablet with breakfast. Tardyferon 80 mg. 1 tablet 15 minutes before breakfast for 3 months.
