HISTORY, CURRENT ILLNESS AND PHYSICAL EXAMINATION
An 82-year-old man came to our emergency department for chest pain.

History
Allergic to penicillins with tolerance to cephalosporins.
Toxic habits: ex-smoker (IPA 30 pack-years).
Cardivascular risk factors (CVRF): arterial hypertension (AHT).
Mild chronic obstructive pulmonary disease (COPD) on chronic bronchodilator treatment. Solitary pulmonary nodule, monitored by the pulmonology department, unchanged since 2008.
Multinodular goitre.

Cardiological history:
Paroxysmal atrial fibrillation/flutter (first episode in 2013 in context of admission for septic shock and second episode documented during postoperative knee surgery in January 2020). On anticoagulant treatment with acenocoumarol.
In 2017, after surgery for sacral ulcer, episode of chest pain compatible with unstable angina. Transthoracic echocardiogram (TTE) with no abnormalities, preserved LVEF. An outpatient study was completed with ergometry, negative for ischaemia.
During postoperative knee surgery in January 2020, he presented with non-ST-segment elevation acute coronary syndrome (NSTEACS) with an electrocardiographic image compatible with a left main coronary artery lesion. Given the patient's fragility, he was managed conservatively and discharged with triple antithrombotic therapy (acetylsalicylic acid [ASA] + clopidogrel + acenocoumarol).
Last TTE (March 2020): preserved LVEF without segmental contractility abnormalities, mild aortic root dilatation, mild-moderate mitral regurgitation (grade II). Rest unchanged with respect to previous study.

Digestive history:
Gastro-oesophageal reflux disease (GORD) with grade IV/IV oesophagitis and duodenitis. Achalasia in 2004. Oesophageal diverticulectomy with anti-reflux myocardiomyotomy (2008), complicated with respiratory infection by P. aeruginosa, sacral eschar infection by E. coli. Cholecystectomy for alliasic cholecystitis.
Diverticulosis of the colon with haemorrhage. Gastroscopy and colonoscopy for iron deficiency anaemia in 2018: chronic gastritis as the only notable finding. Pedunculated polyp at 30 cm from the anal margin of approximately 1.5 cm that is resected. Multiple diverticula along the entire explored tract.
Angiodysplasia of the intestine with isolated haemorrhage in 2015.
Baseline functional status: independent for basic activities of daily living, walks with a cane. Higher functions preserved.
Usual treatment: omeprazole 40 mg; acenocoumarol 4 mg as prescribed; clopidogrel 75 mg; ASA 100 mg; bisoprolol 2.5 mg per day; losartan 50 mg per day; atorvastatin 40 mg; lorazepam 1 mg; mirtazapine 15 mg.

Present illness
The patient starts with oppressive central thoracic discomfort on the night before going to the medical services. On the day of admission in the morning, a new episode of sudden onset pain, radiating to the back and neck. She reported no melena, vomiting or macroscopic bleeding in previous days. On arrival at the emergency department, pain persisted with a tendency to arterial hypotension, tachypnoea and poor distal perfusion. Electrocardiogram (ECG) showed diffuse ST-segment depression, with elevation in aVR, suggestive of a lesion in the left main coronary artery. Emergency echocardioscopy was performed, showing moderate left ventricular (LV) dysfunction. Transfer to the coronary unit and emergency coronary angiography was decided.
GRACE risk scale: 36.7% in-hospital mortality, 61.5% estimated risk of death at one year.
CRUSADE risk scale: 59 points, 19.5% risk of major in-hospital bleeding, very high haemorrhagic risk.

Physical examination
Blood pressure (BP) 95/50 mmHg; heart rate (HR) 80 bpm; oxygen saturation 90% with nasal goggles at 3 bpm; afebrile. Conscious and oriented. Mucocutaneous pallor, poor distal perfusion, tachypneic. Jugular plethora. Cardiac auscultation rhythmic, no audible murmurs. Pulmonary auscultation with bilateral pulmonary crackles up to midfields. Abdomen: soft, depressible, non-painful. Discrete lividity in the lower extremities and hands. No palpable paedial pulses, no oedema or evidence of venous thrombosis in the lower limbs.

COMPLEMENTARY TESTS
ECG on admission to the ED: sinus rhythm at 70 bpm, normal PR, QRS axis at 30o, diffuse ST-segment depression, maximum of 4 mm in V5-V6, with ST-segment elevation of 1 mm in V1 and 2 mm in aVR.
ECG after catheterisation: atrial fibrillation with ventricular response at 80 bpm, ST-segment elevation in V2-V5 (maximum 2 mm in V4).
ECG at discharge from the coronary unit: common atrial flutter with ventricular response at 75 bpm, Q waves in inferior face.
Chest X-ray: cardiomegaly, increased perihilar density predominantly on the right with associated pleural effusion.
Laboratory tests on admission: glucose 102 mg/dl, urea 66 mg/dl, Cr 1.39 mg/dl, GPT 13 U/l, Bi 0.2 mg/dl, Ca 9.9 mg/dl, albumin 4.2 g/dl, Na 132 mEq/l, K 4,3 mEq/l, Cl 96 mEq/l, CK 142 U/l, TnT US 146 ng/l (normal 0-14 ng/l), Hb 6.5 g/dl, (MCV 84 fl, MCH 25 pg, ADE 15.9%), platelets 351.000/ul, leukocytes 12.510/ul (75% neutrophilia). Coagulation in normal range.
Enzymatic peak: maximum CK 1.237 U/l, maximum troponin T us 4.224 ng/l.
Other analytical results: lipidogram: total cholesterol 123 mg/dL, triglycerides 127 mg/dL, HDL cholesterol 48 mg/dL and LDL 50 mg/dL. HbA1c 5.6%

Microbiology:
SARS-CoV2 serology: negative. SARS-CoV2 PCR: not detectable.
On admission to the coronary unit, methicillin-resistant S. aureus (MRSA) was isolated in a nasal sample.
Gram-negative coccobacilli colonies were isolated in sputum, with growth of Haemophilus influenzae.
Sacral ulcer culture isolated gram-positive cocci, with growth of MRSA.
Echocardiogram on admission: dilated LV (DTD 70 mm), with mild septal LV hypertrophy (LVH) (IVS 13 mm, LVSP 10 mm). Moderately to severely depressed LV systolic function (LVEF 30%) due to akinesia of the apex, mid-apical anterior septum, lateral and anterior face. Restrictive relaxation pattern (type III). Aortic root not dilated (36 mm). Sclerocalcified aortic valve, trivalve, with good opening and mild insufficiency. Moderately dilated LA. Sclerocalcified mitral valve, thickened leaflets, with moderate-severe regurgitation consisting of two jets reaching both atrial roofs but no reverse flow in pulmonary veins. Mildly dilated right ventricle (RV) (baseline DTD 42 mm). Borderline RV systolic function (TAPSE 15 mm). Tricuspid insufficiency (TI) mild-moderate. Vd-Ad gradient 45 mmHg. Inferior vena cava (IVC) mildly dilated with complete inspiratory collapse (> 50%). Estimated PSAP 55 mmHg. No pericardial effusion.
Echocardiogram prior to discharge: normal LVEF (53%). No significant valvulopathies. No data suggesting significant pulmonary hypertension.
Emergent coronary angiography on admission: common trunk with critical stenosis of irregular appearance in its ostium and middle segment causing a severe drop in luminal pressure during selective catheterisation of the vessel. The anterior descending artery has only non-significant irregularities. The circumflex artery is a vessel of remarkable development showing no significant lesions. Anatomically dominant right coronary artery, diffusely atheromatous, but without significant focal stenosis. Percutaneous coronary intervention (PCI) was performed in the common trunk, with implantation of a Synergy 4 x 12 mm stent, without reaching the distal bifurcation and allowing some protrusion of the device into the sinus of Valsalva. After overexpanding the proximal portion of the stent with a 4.5 mm NC balloon, a good angiographic result was achieved.
Capsule endoscopic study (during admission to the cardiology ward): absence of haematic debris throughout the examination. Angiodysplasia in the stomach with no evidence of active bleeding. Millimetric polyp in the cecum of little relevance for the patient's age and current clinical situation. Gastroscopy and colonoscopy are recommended when the patient's clinical situation permits.

CLINICAL EVOLUTION
During the revascularisation procedure, the patient suffers several episodes of hypotension (up to 70/40 mmHg) with poor distal perfusion and respiratory worsening. Four ampoules of i.v. furosemide are administered, oxygen therapy with FiO2 of 50% maintaining oxygen saturation > 90%. He also required boluses of phenylephrine up to 50 mcg and the start of noradrenaline perfusion up to 0.1 mcg/kg/min for TAM > 70 mmHg. He progressively showed respiratory improvement with good diuretic response and haemodynamic improvement.
During his admission to the coronary unit and subsequently to the cardiology ward:
Haemodynamically, he presented good clinical evolution, noradrenaline was discontinued 48 hours after admission, and he was subsequently maintained with AMT > 70 mmHg without the need for vasoactive support. He alternated sinus rhythm with spells of atrial fibrillation, requiring an occasional dose of digoxin to control the ventricular rate. Echocardioscopy 72 hours after admission showed recovery of LVEF. The TTE prior to discharge confirmed this improvement in ventricular function, with no evidence of valvulopathy or pulmonary hypertension.
Respiratory: improvement of congestive signs after negative water balance, maintaining oxygen saturation > 92% initially with nasal goggles and subsequently with ambient air, with no congestive signs on physical examination at discharge. Nephro-urological: forced diuresis with diuretic with good response, being possible to progressively reduce the furosemide boluses, until switching to oral administration, presenting progressive improvement of renal function until normalisation 72 hours after admission, without electrolyte alterations.
Infectious: afebrile, with no need for antibiotic treatment, with negative PCR and serology for COVID-19, with maximum C-reactive protein of 64 mg/dl, but normal procalcitonin and leukocytes. Samples were taken from a pressure ulcer in the sacral area (already known), isolating MRSA, which was treated with local dressings. During her stay on the hospital ward, she presented febrile peaks of 37.2oC with cough and expectoration. When H. Influenzae was found in sputum culture, oral antibiotherapy with cephalosporins was started according to the antibiogram results.
Digestive: in the analysis on admission, there was progressive anaemia (Hb July/2019: 13 g/dl -->January/2020: 10.1 g/dl --> March/2020: 8.3 g/dl) with Hb on admission of 6.5 g/dl, normocytic, hypochromic with high ADE, so despite the patient denying melena or other macroscopic bleeding, intravenous pantoprazole perfusion was started and 2 red blood cell concentrates were transfused. Subsequently, his blood counts remained stable at around 8.5 g/dl, with no signs of macroscopic bleeding and stools with no apparent haematic debris. Initially on an absolute diet, she was well tolerated when starting an oral diet.
Despite having an indication for anticoagulation due to AF (CHA2DS2VASC 5, HAS BLED 5), it was initially decided to maintain double antiplatelet therapy with ASA and clopidogrel. She was referred to the gastrointestinal department of our centre, which indicated an endoscopic capsule study, after clinical stabilisation: absence of haematic debris throughout the examination. Angiodysplasias in the stomach and cecum with no active bleeding. On discharge, treatment with oral iron and follow-up in the outpatient gastroenterology department for gastroscopy/colonoscopy for electrocoagulation of the angiodysplastic lesions was decided.
The time in therapeutic range (TRT) with sintrom is estimated to be in the low range for the last 6 months -TRT 53%-; therefore, treatment with clopidogrel 75 mg + rivaroxaban 15 mg/day as dual therapy is considered as a possibility for discharge, based on the strategy of the PIONEER study, which has shown the same efficacy and lower bleeding rates as the classic triple therapy with vitamin K antagonist anticoagulants and dual antiplatelet therapy.
In good clinical condition, he was discharged home, with subsequent follow-up in cardiology consultations, and pending completion of a digestive study.

DIAGNOSIS
Killip IV NSTEACS. Severe coronary artery disease of the left main coronary artery (LMCA) with critical lesion. Implantation of drug-eluting stent in LMCA. Severe LV systolic dysfunction recovered (at discharge LVEF 53%).
Acute anaemia requiring red blood cell transfusion (probably digestive origin). Angiodysplasias in stomach and cecum.
Paroxysmal atrial fibrillation/flutter. Acute renal failure resolved.
