HISTORY, CURRENT ILLNESS AND PHYSICAL EXAMINATION

History
Cardiovascular risk factors: hypertension, type 2 diabetes mellitus, ex-smoker.
Paroxysmal atrial fibrillation (CHA2DS2-VASc = 7) in treatment with acenocoumarol. Chronic obstructive pulmonary disease (COPD).
Stroke in 2010, without sequelae.
Stage 3a chronic kidney disease (secondary to diabetic nephropathy). Deep vein thrombosis in lower limbs in 2006.
Usual treatment: insulin glargine 10 IU at dinner; atorvastatin 10 mg; acenocoumarol 4 mg as prescribed; tiotropium bromide 18 mcg 1-0-0; alogliptin/metformin 12.5/1,000 mg 1-0-0; ranolazine 375 mg 1-0-1.

Present illness
83-year-old male under follow-up in cardiology for stable angina. The patient reports that despite adjustment of medical treatment, he persists with oppressive precordial pain, radiating to the jaw and left arm, which is triggered when he climbs more than two flights of stairs and which disappears after approximately 5 minutes' rest. No dyspnoea, palpitations or syncope. The last transthoracic echocardiogram showed a left ventricle with an ejection fraction of 38%, akinesia of the lower basal and middle segments with thinning of the wall and an image of scarring. He was referred to our hospital for catheterisation.

Physical examination
Blood pressure (BP) 150/95 mmHg. Heart rate (HR) 70 bpm. Oxygen saturation 98% on room air. Good general condition. Conscious and oriented, eupneic, well perfused.

Cardiac auscultation: rhythmic, no murmurs. Pulmonary auscultation: preserved vesicular murmur with no extra sounds. Lower limbs: no oedema or signs of deep vein thrombosis (DVT), pulses present and symmetrical.

COMPLEMENTARY TESTS
Baseline electrocardiogram (ECG): sinus rhythm with PR 280 ms, QRS 140 ms with left bundle branch block (LBBB) and secondary repolarisation alterations.
CBC: haemoglobin 12.4 g/dl. Leukocytes 8,700 μl N 82.3%. Platelets 163,000 μl. INR 1.1.
Creatinine 1.85 mg/dl. Glomerular filtration rate 45 ml/min/1.73 m. Sodium 140 mmol/l. Potassium 3.6 mmol/l. AST 377 IU/l. ALT 88 IU/l. Alkaline phosphatase 48 IU/l. GGT 30 IU/l. Total bilirubin 1.11 mg/dl. CK 1018 IU/l. Protein 5.3 g/dl. HbA1c (NGSP) 7.9%. Total cholesterol 100 mg/dl, HDL 26 mg/dl, LDL 48 mg/dl, triglycerides 133 mg/dl.
Chest X-ray: CTI within normal limits, lung parenchyma without alterations.
Echocardiogram on admission: left ventricle with ejection fraction 38%, akinesia of lower basal and middle segments with wall thinning and scar image. Hypokinesia of the inferolateral side.
Coronary angiography 1: multivessel coronary artery disease. Chronic occlusion of the middle right coronary artery (RCA). Severe atheromatosis of proximal-middle anterior descending artery (AD), percutaneous coronary intervention (PCI) and implantation of overlapping drug-eluting stents. Severe atheromatosis of proximal circumflex artery (Cx) - first obtuse marginal (OM1) treated with drug-eluting stent implantation. Acute stent thrombosis resolved during the procedure.
Coronary angiography 2: proximal Cx stent thrombosis with new implantation of two drug-eluting stents.
Echocardiogram at discharge: left ventricle with ejection fraction 28%, extensive inferoposterolateral akinesia, with anterior hypokinesia. Moderate-severe ischaemic mitral regurgitation.

CLINICAL EVOLUTION
Catheterisation programmed due to angina and ventricular dysfunction. Prior to the procedure, the patient was being treated with acenocoumarol, which was discontinued 48 hours before admission, and 250 mg of acetylsalicylic acid was administered without the addition of a P2Y12 inhibitor, pending confirmation of the need for percutaneous coronary revascularisation. Coronary angiography revealed a severe lesion in the proximal LAD, a moderate-severe lesion in Cx-OM1 and chronic occlusion of the LMCA, with little likelihood of viability in its territory. Clopidogrel 600 mg was administered and revascularisation of the LAD and Cx was performed. She presented with periprocedural AMI due to hyperacute thrombosis of the Cx stent and treatment was started with IV cangrelor.
Admitted to the coronary unit, presenting acute heart failure, acute pulmonary oedema with arterial hypotension, requiring oxygen therapy with high-flow glasses, perfusion of furosemide and noradrenaline at low doses. In addition, renal function deterioration was observed with a pre-renal component and in relation to contrast nephropathy.
After 48 hours of admission, the patient presented an episode of self-limited sustained monomorphic ventricular tachycardia (SMVT) followed by several bouts of non-sustained ventricular tachycardia (NSVT) with ST-segment depression in V3 to V6. In view of these findings, a repeat diagnostic coronary angiography showed thrombosis of the Cx stent, which was revascularised, with a new cangrelor perfusion and a change in antiplatelet therapy from clopidogrel to ticagrelor. He was subsequently transferred to the hospital ward where he presented good clinical evolution, without new episodes of arrhythmias, with improvement in renal function (GFR 48 ml/min).
He was discharged with triple antithrombotic therapy with rivaroxaban 10 mg daily, adiro 100 mg daily and ticagrelor 90 mg every 12 hours for 1 month; to continue with double therapy with rivaroxaban 10 mg and ticagrelor 90 mg for 6 months and then only with rivaroxaban 15 mg daily if the GFR remained below 50 ml/min.

DIAGNOSIS
Ischaemic heart disease, CCS class II stable exertional angina with moderate LV systolic dysfunction.
Paroxysmal atrial fibrillation.
Elective cardiac catheterisation:
Three-vessel coronary artery disease. Percutaneous revascularisation of LAD and Cx. Periprocedural AMI due to hyperacute stent thrombosis in Cx. Acute pulmonary oedema resolved.
SMVT in the context of new subacute Cx stent thrombosis. Severe LV systolic dysfunction.
Acute chronic renal failure.
