HISTORY, CURRENT ILLNESS AND PHYSICAL EXAMINATION
75-year-old male patient presenting with chest pain.

BACKGROUND:
No known drug allergies. No toxic habits. Arterial hypertension (AHT). Dyslipidaemia. Obesity. Intermittent claudication. Hepatic steatosis. Benign prostatic hyperplasia.
Admission in November 2017 to the neurology unit for acute ischaemic stroke in right middle cerebral arterial territory of undetermined aetiology (NIHSS 11).
Effective primary mechanical thrombectomy. Complete recovery and no evidence of sequelae at present.
Surgical interventions: bilateral inguinal hernia, appendectomy, hydrocele.
Cardiological history: moderate aortic stenosis under follow-up in valvulopathy module.
Baseline status: independent for basic activities of daily living. Rank 0. Barthel Index 100.
Home treatment: omeprazole 20 mg (1-0-0), furosemide 40 mg (1-0-0), bisoprolol 2.5 mg (1-0-0), rosuvastatin 10 mg (0-0-1), tamsulosin 0.4 mg (0-0-1), finasteride 5 mg (1-0-0), lorazepam 1 mg (0-0-1).

CURRENT ILLNESS:
The patient refers clinical complaints of pain in the left lower limb, also noting it colder than the contralateral leg. The following day he began to experience oppressive central thoracic pain, without irradiation or vegetative cortex, as well as very unspecific abdominal pain, which is why he decided to go to hospital.

PHYSICAL EXAMINATION:
Sweaty. Blood pressure (BP) 120/60 mmHg. Heart rate (HR) 75 bpm. Cardiopulmonary auscultation: arrhythmic heart sounds with systolic ejection murmur in aortic focus grade II/VI in addition to soft murmur in peak grade II/VI. Abdomen: globular, depressible, no masses, diffusely painful with no signs of peritonitis. Left lower limb cold and pale, with absence of paedial pulse.

COMPLEMENTARY TESTS
ANALYSIS: haemoglobin 14.6 g/dl, haematocrit 44.6%, leucocytes 16,000/mm3. Neutrophils 80.3%, platelets 236,000/mm3, D-dimer 1367 ng/ml, INR 1.01, basal glucose 128 mg/dl. BUN 16 mg/dl, creatinine 0.90 mg/dl, GFR MDRD-4 87 ml/min/sup, sodium 139 meq/l, potassium 4.1 meq/l, GOT 333 U/L, GPT 69 U/L, CK-NAC 1486 U/L, CK-MB 144 U/L, peak troponin I 48 ng/ml, NTproBNP 3840 pg/ml.
ECG in the ED: AF with adequate ventricular response with ST elevation less than 1 mm in inferior and high lateral leads with high R in precordial leads.
ECG in coronary ICU: sinus rhythm, lower Q waves with negative T waves (evolving pattern).
Chest X-RAY PA: increased cardiothoracic index. Bilateral congestion with vascular redistribution to apexes.
COMPUTER CAT SCAN (CT) chest-abdomen: image suggestive of posterobasal myocardial infarction in LV. Laminar pleural effusion predominantly on the right, reaching a maximum thickness of 15 mm. Hypodense cortical lesions in both kidneys, predominantly on the left, suggestive of renal infarction. Dorsolumbar spondylosis with stenosis of the L3-L4 and L4-L5 canal, to be correlated with clinical findings.
Arterial DOPPLER ECOGRAPHY of MMII (performed on previous admission to the neurology department): severe stenosis in the right iliac artery and mild stenosis in the left iliac artery. Bilateral femoro-popliteal atheromatosis.
ECHO-CARDIOGRAPHY: moderate concentric left ventricular hypertrophy (LVH), inferior akinesia and lateral hypokinesia with preserved global contractility. Severe aortic calcification with moderate limitation of aortic opening (V. max 3.3 m/sec mean gradient 19 mmHg), mild aortic insufficiency. Mitral valve calcification with mild mitral regurgitation. Non-dilated right ventricle (RV) with normal global contractility (TAPSE 18 mm), mild tricuspid regurgitation (TR) with RV-RA gradient 28 mmHg.
CARDIAC CATHETERISM: coronary artery disease with angiographic image compatible with thrombus in distal first obtuse marginal (OM), which is located at the end of the bifurcation with a secondary branch of small calibre. Rest of the coronary tree free of significant obstructive lesions. Left ventricle (LV) of normal size with mildly depressed global contractility (EF 50%). Lower segmental contractility disorder. Calcified aortic valve disease: unquantified aortic stenosis with mean gradient of 22.5 mmHg.

CLINICAL EVOLUTION
A 75-year-old male patient with the personal history described above was admitted for acute myocardial infarction (AMI) with lower Q wave Killip I and acute ischaemia of the left lower limb. During admission, previously undiagnosed AF was detected. Treatment was started with double antiplatelet therapy and anticoagulation. An angiographic study was performed showing a significant obstructive lesion due to distal thrombus in the first OM that was not revascularised. Given that the patient evolves favourably from the point of view of ischaemia of the left lower limb (mobilises fingers with good perfusion and presence of distal pulse) and without data of recurrence of myocardial ischaemia, discharge and follow-up by cardiology and vascular surgery consultations is decided.

DIAGNOSIS
Acute coronary syndrome with ST-segment elevation (STEACS) lower Killip I.
Peripheral arterial disease: acute ischaemia of the left lower limb.
Bilateral renal infarction.
Debut AF.
