HISTORY, CURRENT ILLNESS AND PHYSICAL EXAMINATION
53-year-old woman, diagnosed with mild dyslipidaemia for the last 5 years on dietary treatment. No other known risk factors or toxic habits. No medication at home.
In the previous 48 hours she presented with episodes of self-limiting central thoracic pain, without seeking medical assistance. At around 10 am, while having breakfast, she suffered a new episode of typical central thoracic pain accompanied by vegetative cortex, for which she went to the emergency department accompanied by her family (11:20 am). After syncopal symptoms in the triage area, she was transferred to observation, and VT was observed at 220 bpm. Basic CPR manoeuvres were started (5 min duration), followed by CVE at 200 J, with an asystole rhythm. 2 mg of atropine is administered. Advanced CPR for 5 min, achieving pulse (total CPR 10 min) and sinus rhythm at 85 bpm with significant ST elevation in anterior leads. Amiodarone infusion (1,200 mg) was started and the patient was transferred to the haemodynamics ward for urgent catheterisation. During the transfer, an episode of NSVT at 200 bpm was recorded, followed by sinus rhythm and complete AVB after 10-15 min.
Advanced CPR was performed again for 30 minutes with orotracheal intubation and adrenaline perfusion was started. In the haemodynamics room, a transient pacemaker was implanted via the right femoral artery and cardiac catheterisation was performed via femoral access, which revealed 3-vessel coronary artery disease and complete revascularisation was performed. In addition, an intra-aortic balloon pump was placed with 1:1 assistance. During catheterisation, a nasogastric tube is inserted and 300 mg of ASA and 180 mg of ticagrelor are administered. A bolus of abciximab is administered and the intravenous infusion is continued. A few minutes later, she started bleeding in the oral cavity and through the endotracheal tube, and abciximab was discontinued. At the end of the catheterisation, the adrenaline infusion was withdrawn.
She arrived at the ICU without vasoactive drugs, connected to mechanical ventilation. She suffered another cardiorespiratory arrest, her third, this time in asystole. She was resuscitated for 15 minutes (2 mg of adrenaline), leaving in sinus rhythm.
Examination on admission to the ICU revealed BP 100/80 mmHg, HR 100 bpm, RR 18 rpm. Neurological examination: bilateral mydriasis, Glasgow Coma Scale score of 3. Pulmonary auscultation with bibasal crackles. Cardiac auscultation rhythmic, no murmurs, counterpulsation noises. Extremities with peripheral coldness, weak distal pulses, no signs of deep vein thrombosis.

COMPLEMENTARY TESTS
ECG after 1st CRP: RS at 85 bpm, PR 200 ms, QRS 120 ms, significant ST-segment elevation in anterior leads V1 to V4.
Urgent cardiac catheterisation: 3-vessel coronary artery disease.
Lesions in DA (proximal occlusion), CX (OM with 90% stenosis) and CD (mid-level occlusion). Complete revascularisation with 2 stents in LAD, 1 in OM and 1 in DC.
Chest X-ray on admission: non-selective orotracheal intubation. Bilateral alveolointerstitial pattern.
Echocardiogram in ICU: left ventricle not dilated, not hypertrophic, with moderately depressed systolic function (EF 35-40 %), with septal akinesia, anterior and apical segments. Better contractility in basal and medial lateral and basal and medial anterior. Right ventricle not dilated, with normal systolic function by TAPSE. Left atrium not dilated. Normal aortic root. Inferior vena cava not dilated, collapsing on inspiration.
Laboratory tests on admission: haemoglobin 14.8 mg/dl, leucocytes 11,250/ul, platelets 376,000/ul. Glucose 130 mg/dl, creatinine 1.7 mg/dl, Na 139 mEq/l, K 4.6 mEq/l, GOT 571 IU/l, LDH 1,854 IU/l, peak CK 3,254 IU/l, troponinT US: 20,641 ng/ml, CRP 73.3 mg/l.
Cardiology laboratory tests: haemoglobin 12.5 mg/dl, leucocytes 14.460/ul, platelets 631,000/ul, glycaemia 118 mg/dl, urea 58 mg/dl, creatinine 0.8 mg/dl, triglycerides 385 mg/dl, total cholesterol 199 mg/dl (LDL 145 mg/dl, HDL 30 mg/dl), GOT 74 IU/l, GPT 172 IU/l, GGT 501 IU/l, alkaline phosphatase 243 IU/l, LDH 502 IU/l. Thyroid function: free T4 1.73 mg/dl, TSH 14.43 IUI/ml. ProBNP 2,663 pg/ml.

EVOLUTION
During the first 8 hours in the ICU, he remained in cardiogenic shock and low cardiac output, with cardiac index of 1.5 L/min/m2, need for vasoactive drugs at very high doses (dobutamine and noradrenaline) and signs of peripheral hypoperfusion, with lactate up to 16 mmol/l, oliguric renal dysfunction and pulmonary oedema with severe respiratory failure requiring mechanical ventilation and FiO2 of 100%. It was decided to place cardiorespiratory support in the form of venoarterial ECMO, which was performed in the operating theatre by Cardiac Surgery after 8 hours of stay in the ICU. After ECMO placement, haemodynamic improvement was observed with withdrawal of vasoactive agents after 24 hours. Assistance was started with 4 l/min, which was progressively reduced until weaning was achieved on the fourth day after placement. In the following days haemodynamic stability was maintained with a cardiac index of 3 l/min/m2 under treatment with levosimendan and dobutamine. Echocardiography showed moderate ventricular dysfunction with an estimated LVEF of 35-40%. Initially, the patient presented mild delirium and tetraparesis, which recovered quickly, waking up clearly, without neurological focality.
Given his stability and improvement, it was decided to transfer him to the Cardiology ward for further care and treatment.
Favourable evolution on the cardiology ward, tolerating treatment with beta-blockers, ACE inhibitors and amiodarone until she became asymptomatic from the cardiological point of view. She presented significant elevation of transaminases, myalgias and general malaise that resolved after discontinuation of statin treatment.
Atorvastatin 80-40 mg, simvastatin 40 mg, rosuvastatin 20 mg were tried.
Hypercholesterolaemia persists with total cholesterol 257 mg/dl, LDL 151 mg/dl, HDL 34 mg/dl and triglycerides 580 mg/dl despite treatment with ezetimibe 10 mg and fibrates. It was decided to start treatment with PCSK9 inhibitors (evolocumab 140 mg every 15 days) and she was included in a cardiac rehabilitation programme. She started with very low capacity, which gradually increased, with very good progress. She completed a total of 60 treadmill sessions and completed the cardiac rehabilitation programme without complications. Improvement in functional class for dyspnoea, Borg scale 3-4. Training HR: 85-100 bpm. No clinical signs of angina with the effort achieved. Adequate LDL control is achieved with figures of 31 mg/dl.

DIAGNOSIS
Resuscitated cardiorespiratory arrest. Acute anterior myocardial infarction, Killip IV. 3-vessel coronary artery disease, urgent complete revascularisation.
Moderate-severe LV systolic dysfunction. Transient ECMO support.
Hypercholesterolemia with intolerance to statins. Good LDL control with anti-PCSK9.
