HISTORY, CURRENT ILLNESS AND PHYSICAL EXAMINATION

BACKGROUND:
Patient aged 73 years. Allergy to penicillin. Cardiovascular risk factors (CVRF): hypertension (HT), type 2 diabetes mellitus (DM). Dyslipidaemia. Obesity. Neoplasia of the right breast in 2004, with surgery, radiotherapy, chemotherapy and hormone therapy.
Cardiological history: under study due to clinical manifestations of exertional chest pain with angina-like features. In 2015, a stress echocardiogram was performed, which was inconclusive due to the low functional capacity obtained without reaching the theoretical submaximal frequency. The patient refused to undergo cardiac catheterisation. Treatment was started with acetylsalicylic acid (ASA) and nitroglycerin 5 mg patch.

CURRENT ILLNESS:
Admitted to cardiology for presenting again with symptoms suggestive of progressive exertional angina.
Usual New York Heart Association (NYHA) functional class II. No syncope or palpitations.
No oedematization of the extremities. Good adherence to treatment.
Due to the previous inconclusive stress echocardiography, it was decided to perform rest and stress SPECT, which was compatible with mild inducible ischaemia in the lower territory. It was decided to request cardiac catheterisation, which the patient finally accepted.

PHYSICAL EXAMINATION:
Eupneic at rest. Blood pressure (BP) 135/85 mmHg. Heart rate (HR) 70 bpm.
Oxygen saturation 98% basal. Cardiac auscultation: rhythmic heart sounds without murmurs.
Pulmonary auscultation: normoventilation. Lower extremities: no oedema, distal pulses present and symmetrical.

COMPLEMENTARY TESTS
ECG: sinus rhythm at 80 bpm, first degree atrioventricular block (AVB), incomplete left bundle branch block (LBBB). No changes in serial ECG.
ANALYTICS: TnI 0.03, myoglobin 31.6. Glucose 106 mg/dl, urea 61 mg/dl, creatinine 1.03 mg/dl, uric acid 8.1 mg/dl, triglycerides 221 mg/dl, total cholesterol 143 mg/dl, HDL 33 mg/dl, LDL 66 mg/dl, sodium 140 mEq/l, potassium 3.6 mEq/l, AST 35 U/L, ALT 31 U/L, GGT 47 U/L, FA 117 U/L, CK 40 U/L. Bi 0.48 mg/dl. Thyroid function: TSH 0.91 mIU/l, T4 1.02 ng/dl. Haemoglobin 13.4 g/dl, haematocrit 41%, MCV 90 fl, leucocytes 8900/mm3 (46% N), platelets 124000/mm3. HBa1C 7.9%.
Chest X-ray: calcified atheromatosis of the aorta. Cardiomegaly.
Hilar thickening of vascular appearance. No acute pleuroparenchymal alterations are observed. Dorsal spondylosis.
Transthoracic echocardiography: left ventricle (LV) of normal size.
Moderate left ventricular hypertrophy (LVH) with septal predominance. Normal global systolic function, without segmental asymmetries of contractility. Acceleration of flow in the left ventricular outflow tract (LVOT) without significant dynamic gradient (maximum 10 mmHg) either at baseline or after Valsalva manoeuvres. Mild diastolic dysfunction with no current data of elevated left ventricular end-diastolic pressure (LVEDP). Slightly dilated left atrium. Normal right chambers; right ventricle (RV) normocontractile (TAPSE 19 mm S-wave ́13). Mitral valve (MV): calcium in medial posterior annulus, thin leaflets, not limited in its opening, competent. Aortic valve (VAo): trivalve, mild sclerosis of leaflets, not limited in its opening, competent. Aortic root and visualised portion of proximal ascending aorta normal. Minimal end-systolic tricuspid regurgitation (TR) allowing estimation of normal systolic pulmonary artery pressure (PAPS). Inferior vena cava (IVC) not dilated with normal inspiratory collapse. Normal estimated PAPS. Absence of pericardial effusion and intracavitary masses through this access route.
Stress myocardial perfusion SPECT and synchronised resting myocardial perfusion SPECT: radiopharmaceutical: 99mTc-tetrofosmin. Dose: stress: 7.2mCi. Rest: 21.3mCi.
Ergometry in Bruce protocol of 3.30 minutes duration ended due to inability to maintain the rhythm of the treadmill, reaching 86% of the heart rate predicted for age and BP max=130/80140/70. No chest pain. Decreased functional capacity (maximum load reached 5 METs). Absence of arrhythmias. In the low-dose SPECT/CT study, mild hypoperfusion of mild intensity was observed in the effort phase in the basal lower segment, which partially normalised in the rest phase and was compatible with mild inducible ischaemia.
CORONARYGRAPHY: puncture of right radial artery 6F. Right dominance.
Epicardial coronary arteries without significant angiographic stenosis. Multiple coronary fistulas to LV from all major coronary territories.

CLINICAL EVOLUTION
After the result of the cardiac catheterisation, treatment was started with low-dose bisoprolol, which was tolerated, and nitroglycerin and acetylsalicylic acid (ASA) were maintained. The patient was discharged from hospital.
After 6 months of outpatient follow-up, the patient has shown clinical improvement with a decrease in angina, with two isolated episodes of severe exertion.

DIAGNOSIS
Progressive exertional angina.
Multiple conorary-ventricular fistulas.
