HISTORY, CURRENT ILLNESS AND PHYSICAL EXAMINATION
BACKGROUND:
Patient aged 44 years, with no drug allergies or medical history of interest.
No consumption of toxic substances. No history of early ischaemic heart disease or sudden death in first-degree relatives.

CURRENT ILLNESS:
The patient presented to the emergency department with retrosternal pain associated with vomiting of food, followed by presyncopal symptoms. An electrocardiogram (ECG) was performed and showed ST-segment elevation in the anterior face, so after administration of acetylsalicylic acid (ASA) 300 mg and ticagrelor 180 mg as a loading dose of double antiplatelet therapy, the infarction code was activated for urgent coronary angiography.
This could not be performed due to the impossibility of channelling a peripheral arterial access (chronic occlusion of both radial arteries and both iliac arteries) so, given the impossibility of percutaneous intervention, fibrinolysis was performed with tenecteplase 6000 U iv.
The patient showed no electrocardiographic evidence of reperfusion after fibrinolysis, although she remained asymptomatic. Her blood pressure remained low on non-invasive and peripheral monitoring during her admission. Echocardiogram showed left ventricular dysfunction (LVEF 27%) with akinesia of all apical segments and severe hypokinesia of basal and mid anterior and basal and mid anteroseptal segments. After performing angio-CT and locating the level of vascular occlusions, vascular access to the right brachycephalic trunk was finally achieved by means of interventional radiology. Coronary angiography showed severe stenosis at the proximal-medial level of the anterior descending artery, where a drug-eluting stent was implanted.
Given the case of a young patient with no cardiovascular risk factors and multiple occlusions of arterial trunks, a large vessel vasculitis (possibly Takayasu's disease) was suspected and treatment was started with methylprednisone 60 mg/24 hours and cyclophosphamide 120 mg/24 hours.

PHYSICAL EXAMINATION:
Blood pressure (right arm) 75/45 mmHg; blood pressure (left arm) 92/57 mmHg.
Heart rate (HR) 80 bpm. Cardiac auscultation: rhythmic with systolic murmur II/VI in mitral focus. A murmur was also heard at the level of the right subclavian artery. Lower extremities: no oedema. No palpation of the pedial or tibial pulses.

COMPLEMENTARY TESTS
SELF-IMMUNITY STUDY: ESR 88 mm; C-reactive protein 14.1 mg/dl. ANAs, ENAs, antiDNA, rheumatoid factor, anticardiolipin, lupus anticoagulant, ANCAs: negative. The main serologies were also negative.
MARKERS OF MYOCARDIAL DAMAGE peak: troponin T HS peak: > 10,000 ng/l. CK 8294 U/l; CKMB 1261 U/l.
ECG on admission: RS at 90. ST elevation 6-7 mm in V2-V6, I and aVL. ST-segment depression in inferior face
ECG at discharge: RS at 70 bpm. Q wave in V1-V3, I and aVL. Negative T wave in V2-V6, I and aVL.
Echocardiogram at discharge: moderate depression of ejection fraction (LVEF 41%) due to anterior and mid-septal aneurysm and all apical segments with restrictive filling pattern and high diastolic pressures. Mild mitral insufficiency.
ANGIO-CT of the aorta and supra-aortic trunks: 70% stenosis of the right brachiocephalic trunk. Stenosis of the right subclavian artery in its proximal section in 90%. Anatomical variant with a left common trunk that is 100% obstructed in the initial 2.5 mm long section. Atheromatosis in the aortic arch and descending thoracic artery. Complete obstruction of the vascular lumen in the infrarenal abdominal aorta proximal to the renal arteries and recanalisation in the primitive iliac arteries.
CORONARYGRAPHY: severe stenosis in the middle anterior descending artery in bifurcation with diagonal branch. There is also diffuse atheromatosis at mid and distal level with moderate plaque at that level. Right coronary artery and circumflex without lesions.

CLINICAL EVOLUTION
She was discharged in good functional class with moderately depressed systolic dysfunction (LVEF 41%) at the expense of apical segments.

DIAGNOSIS
Acute myocardial infarction (AMI) Q anterior.
Takayasu's disease.
