HISTORY, CURRENT ILLNESS AND PHYSICAL EXAMINATION

History
74-year-old male. No known drug allergies.
Cardiovascular risk factors (CVRF): hypertension. Dyslipidaemia. Ex-smoker.
Previous cardiological history:
Chronic ischaemic heart disease with normal LVEF, two-vessel coronary artery disease with complete percutaneous revascularisation. Unstable angina in 1999, implantation of two drug-eluting stents in the right coronary artery and circumflex artery. Aortic valve sclerosis.
Single episode of self-limited atrial fibrillation during treatment with brentuximab for Hodgkin's lymphoma. It was decided not to anticoagulate due to the high haemorrhagic risk and because the paroxysm of atrial fibrillation was considered reactive to treatment.
Follow-up in cardio-oncology consultations. Last check-up in December 2019, without angina.
Infrarenal abdominal aortic aneurysm operated on in 2003, complicated by acute renal failure secondary to right renal ischaemia, with the need for haemofiltration in the postoperative period.
Stage 3 chronic kidney disease, secondary to ischaemic nephropathy (functional annulment of the right kidney). Secondary hyperparathyroidism.
Repeated nephritic colic. Haematological history:
Hodgkin's lymphoma nodular sclerosis type, probable stage IV due to pulmonary involvement.
Treatment within the BREPEM clinical trial (brentuximab with cyclophosphamide, procarbazine, prednisone and mitoxantrone), suspended due to toxicity (febrile neutropenia of abdominal focus and water overload).
Subsequently two cycles of ABVD (adriamycin, bleomycin, vinblastine, dacarbazine). Remission with the exception of lung nodule DS 4, biopsied and without findings.
Recent computed tomography (CT) scan of the chest with suspected progression, pending histological confirmation at present.
Usual medication: atorvastatin 40 mg/24 hours, ezetimibe 10 mg/24 hours, clopidogrel 75 mg/24 hours, nitroglycerin patch 5 mg, atenolol 25 mg/24 hours, furosemide 60 mg/24 hours, allopurinol 100 mg/24 hours, omeprazole 20 mg/24 hours, trimethoprim/cotrimoxazole 160/800 mg/24 hours, folic acid 5 mg/24 hours, hydroferol 0.266 mg monthly.

Present illness
She attended the emergency department for an episode of oppressive central thoracic pain that started at rest, accompanied by general malaise and sweating, self-limited in 30-40 minutes. On arrival at the emergency department, she presented a new episode similar to the previous one, although of shorter duration. At the time of cardiology assessment, he was already asymptomatic for chest pain. In addition, he reported a fever peak of 38.5oC the day before the consultation, accompanied by cough with scant yellowish expectoration.

Physical examination
Blood pressure (BP) 107/63 mmHg. Heart rate (HR) 110 bpm. Temperature 38.3 oC. Oxygen saturation 94% with nasal goggles at 1.5 litres. Eupneic at rest, tolerating decubitus at 30o. Jugular venous pressure (JVP) in the middle third of the neck. Cardiac auscultation: arrhythmic tachycardia, systolic murmurs II/IV in aortic focus with preserved second tone. Pulmonary auscultation: crackles in the lower third of both hemithoraxes and disseminated wheezing. Oedema with fovea in the lower third of both legs.

COMPLEMENTARY TESTS
Electrocardiogram (ECG) with pain: atrial fibrillation with ventricular response at 120 bpm, narrow QRS, abrupt R wave transition in V4, ST elevation in V1 and aVR and diffuse ST descent in the rest of the leads. ST segment alterations corrected in ECG without pain.
Blood tests on admission:
Haemoglobin 8.1 g/dl, MCV 101.4 fl, leucocytes 13,700/mcl, neutrophils 11,800/mcl, platelets
100.000/mcl. INR 1,28, APTT ratio 1,07. Glucose 83 ml/dl, creatinine 1.72 mg/dl, GFR 51 ml/min/m, sodium 136 mEq/l, potassium 3.9 mEq/l, magnesium 1.9 mEq/l, phosphate 2.9 mEq/l, bilirubin 1 mg/dl, alkaline phosphatase 96 U/I, GGT 70 U/I, ALT 37 U/I, CRP 8 mg/dl, procalcitonin 0.5. NT- proBNP 7,490 pg/ml. Troponin I ultrasensitive 831-> 1,600 ng/l (normal < 34 ng/l). CK 47 U/I. Lipid profile: triglycerides 89 mg/dl, total cholesterol 81 mg/dl, HDL 29 mg/dl, LDL 34 mg/dl. Iron profile: iron 26 mg/dl, ferritin 2,703 ng/ml, transterrin saturation index 20%. TSH 1.01 mcIU/ml. Glycosylated Hb 6.4%.
Microbiology:
Blood cultures: sterile after 5 days incubation.
Nasopharyngeal exudate: negative for influenza and RSV. Urine culture: negative.
Legionella and Pneumococcus antigens in urine: negative.
Chest X-ray: cardiothoracic index at the upper limit of normality. Perihilar and peribronchovascular thickening and costophrenic sinus impingement, compatible with heart failure. White left lung (already present in previous cases).
Transthoracic echocardiogram: non-dilated left ventricle, with slight concentric hypertrophy, hyperdynamic, with normal global systolic function, despite basal inferior akinesia and inferior septal akinesia. Transmitral filling pattern with single wave. Left atrium slightly dilated. Non-dilated right atrium. Right ventricle not dilated, hyperdynamic, with normal global systolic function. Aortic valve slightly sclerosed, with maximum transvalvular velocity of 2.1m/s, without insufficiency. Mitral valve functionally normal. Morphologically normal tricuspid valve with mild insufficiency. Pulmonary artery systolic pressure estimated at 43 mmHg. Inferior vena cava not dilated with physiological inspiratory collapse. Slight circumferential pericardial effusion, with no evidence of haemodynamic compromise, with epicardial fat.
Diagnostic coronary angiography: access via right radial artery, contrast 100 cc. Left main coronary artery (LMCA) atheromatous with significant lesion (70%) distal involving the bifurcation. Anterior descending artery (AD): of good development and calibre, with diffuse mild atheromatosis without significant lesions. Circumflex (Cx): well-developed and of good calibre, composed mainly of a main marginal branch with a permeable stent without lesions, vessel with diffuse mild atheromatosis, without significant lesions. Right coronary artery (RCA): dominant, chronic occlusion in its proximal segment; distal vessel of moderate calibre with no significant lesions due to collateral circulation.
Therapeutic coronary angiography: access via the right femoral artery guided by ultrasound, contrast 227 cc. Intervencionsimo on the left coronary trunk: guidewire is crossed to circumflex and anterior descending artery. DK-Crush technique. Drug-eluting implant in TCI-Cx. First kissing-balloon and second drug-eluting stent is implanted in LMCA-AD. Second kissing-balloon is performed. Good angiographic and IVUS results. Vascular closure with percutaneous closure device, checking correct common femoral puncture by fluoroscopy and persistence of flow by echo-Doppler.

CLINICAL EVOLUTION
A 75-year-old man with the aforementioned history was admitted for an episode of angina at rest. He also presented with semiology of decompensated heart failure and rapid atrial fibrillation of uncertain onset. All this in the context of a possible relapse of the underlying haematological pathology, symptoms of respiratory infection and anaemisation with respect to baseline haemoglobin levels. ECG suggestive of TCI disease and elevation of markers of myocardial damage with ascending curve. Asymptomatic for chest pain when assessed by cardiology.
Initially, two red blood cell concentrates were transfused, intravenous depletive treatment was started and, given the respiratory infection in an immunocompromised patient, empirical broad-spectrum antibiotic treatment was started with piperacillin-tazobactam. Double antiplatelet therapy was also started with acetylsalicylic acid and clopidogrel, initially without anticoagulation. Coronary angiography showed significant distal LMCA disease involving the bifurcation with LAD and Cx, in addition to chronic LMCA occlusion. As this was a highly complex patient, with significant comorbidity and high ischaemic and haemorrhagic risk, it was decided not to intervene until the case was presented to the heart team.
Comorbidity included Hodgkin's lymphoma with suspected progression at present (probable stage IV due to pulmonary involvement in recent CT scan), although histological confirmation was pending. During admission, an assessment by haematology was requested, who estimated a poor medium-term prognosis.
In addition, our patient had chronic multifactorial normocytic-normochromic anaemia (haematological disease, chronic disorders, chronic renal disease, chronic treatment with trimethoprim/cotrimoxazole) with usual Hb levels of 10 mg/dl, presenting on arrival with anaemisation up to Hb 8.1 mg/dl.
Despite transfusion with stabilisation of Hb levels around baseline, negative balance, controlled ventricular response and titration of antianginal medical treatment, the patient persisted with minimal effort angina in the cardiology ward.
The case was presented to the heart team, who decided to perform percutaneous revascularisation of the LMCA, given the high surgical risk. A new coronary angiography was performed via the right femoral artery with implantation of two drug-eluting stents in the LMCA-AD and LMCA-Cx using the DK-Crusch technique, without immediate complications and with resolution of angina.
Following the PIONEER strategy, antithrombotic treatment was maintained with simple antiplatelet therapy with clopidogrel 75 mg/24 hours and anticoagulation with low-dose rivaroxaban (10 mg/24 hours adjusted to renal function).
After discharge, the patient remains asymptomatic for angina and without haemorrhagic complications. However, pulmonary progression of Hodgkin's lymphoma was confirmed and he died one month after discharge.

DIAGNOSIS
Acute myocardial infarction without ST elevation, Killip II. Revascularisation of distal left main coronary artery with two drug-eluting stents.
Chronic ischaemic heart disease with preserved LVEF. Coronary artery disease partially revascularised percutaneously, chronic occlusion of the right coronary artery.
Persistent atrial fibrillation.
Decompensation of heart failure secondary to previous events. Respiratory infection in immunosuppressed patient.
Chronic multifactorial exacerbated anaemia.
Stage IV Hodgkin's lymphoma due to pulmonary involvement. Stage 3 chronic kidney disease.
