HISTORY, CURRENT ILLNESS AND PHYSICAL EXAMINATION

Personal history
47-year-old woman.
Cardiovascular risk factors: hypertension, dyslipidaemia, smoking, long-standing type 2 diabetes with poor metabolic control despite treatment with metformin, vidagliptin, glimepiride and pioglitazone.
No previous cardiological history.
Other personal history: cholelithiasis.
Usual treatment: adiro 100 mg, rosuvastatin 10 mg, enalapril/hydrochlorothiazide 20/12.5 mg, metformin/vildagliptin 1000/50, pioglitazone, glimepiride.

Current illness
Admitted to Cardiology for acute coronary syndrome with Killip I anterolateral ST elevation. An urgent coronary angiography showed an acute subtotal thrombotic lesion of the proximal anterior descending coronary artery which was treated with the implantation of 1 drug-eluting stent. He also had moderate lesions in OM1 and OM2 and diffuse DC disease. Echocardiogram showed moderate ventricular dysfunction (EF 35%) with anterior, apical and anterior septal akinesia. The patient was discharged after 5 days without significant incidents with the following treatment: adiro 100 mg 0-1- 0, prasugrel 10 mg 1-0- 0, pantoprazole 40 mg 1-0- 0, carvedilol 25 mg 1-0- 1, enalapril 5 mg 1-0- 1, atorvastatin 80 mg 0-0- 1, eplerenone 50 mg 1-0- 0, ivabradine 5 mg 1⁄2-0- 1⁄2 and her usual antidiabetic treatment.
He was referred to the cardiac rehabilitation programme.

Physical examination
BP: 107/55 HR: 65 bpm. Good general condition, eupneic at rest, afebrile. Head and neck: no signs of jugular venous engorgement. Cardiac auscultation: rhythmic tones without murmurs or extratonos. AP: preserved vesicular murmur with no extra sounds.
Lower extremities: no oedema. Radial and pedial pulses present and symmetrical.
Anthropometric examination: weight: 84.5 kg. Height: 162 cm. BMI: 32.1 kg/m2. Abdominal circumference: 112 cm.

COMPLEMENTARY TESTS
Blood tests: haemoglobin: 12.7 g/dl. Leukocytes: 10300. Platelets: 354000. Normal coagulation. Creatinine 0.9 mg/dl. Urea 70. Na 140.2. K 3,8. Lipoprotein profile (total cholesterol 125 mg/dl; LDL: 82 mg/dl, HDL: 28 mg/dl, Triglycerides: 223 mg/dl). HbA1C 10 %.
Electrocardiogram: sinus rhythm at 68 bpm. signs of anterior necrosis.
Chest X-ray: slightly increased cardiothoracic index.
No signs of heart failure.
Echocardiogram: left ventricle of normal size, slightly hypertrophic.
Akinesia of the middle and apical segments of the septal, lateral and anterior face, with hypokinesia of the rest of the segments. All this leads to moderate ventricular dysfunction with an estimated ejection fraction of 35%. Right ventricle of normal size and function. No significant valvulopathies. No pericardial effusion.
Catheterisation: TCI: of good calibre, without lesions. LAD: normodeveloped of regular calibre, with subtotal thrombotic lesion in bifurcation with diagonal.
Distally very thin vessel. ACX: of good calibre and development, without lesions in the CX itself. The 1st and 2nd OM have moderate ostial lesions. ACD: dominant, diffuse atheromatous involvement, but without severe lesions. PCI With a 3.5 6F XB guide catheter, a BMW guide is passed through the lesion in the LAD. Predilatation with a 2 x 14 mm balloon at 14 atmospheres and implantation of a 2.5 x 16 mm Promus drug-eluting stent at 18 atmospheres with good angiographic results and no complications.

EVOLUTION
The patient started a 6-week cardiac rehabilitation programme consisting of motivational talks and physical training 2 days a week. During the programme, the importance of smoking cessation and weight loss was emphasised, but one of the main challenges we had to face was undoubtedly the adjustment of the diabetic treatment.
Considering the clinical scenario (young patient with moderate ischaemic ventricular dysfunction and suboptimal diabetic control (HbA1c: 10 %) despite being treated with four oral antidiabetic drugs), we considered the different options and finally decided to: 1) discontinue: pioglitazone, glimepiride and vidagliptin; 2) maintain: metformin; 3) combine: empaglifozin 10 mg/day and insulin therapy (both slow and rapid insulin).
The patient successfully completed the programme and achieved weight loss, remained smoke-free and improved glycaemic control.

DIAGNOSIS
Acute ST-elevation myocardial infarction with Killip 1 anterior ST elevation. Severe proximal CAD treated with 1 drug-eluting stent implantation.
Moderate left ventricular dysfunction.
Arterial hypertension.
Type 2 diabetes mellitus with poor control.
Dyslipidaemia.
