We present the case of a 36-year-old male, hypertensive, with abnormally high plasma levels of LDL-cholesterol, triglycerides and glycated haemoglobin, who presents with ischaemic heart disease.

HISTORY, CURRENT DISEASE AND PHYSICAL EXAMINATION

Personal history
Hypertensive for more than 5 years on treatment with enalapril (he had stopped treatment). Ex-smoker. Hypertriglyceridaemia. Undiagnosed type 2 diabetes mellitus. No known previous heart disease or other medical illnesses of interest.

Family history: father with AMI at the age of 50. Young hypertensive mother.
Grandmother and maternal aunt with type 2 diabetes mellitus (DM) and hypertension.

Previous treatment: omeprazole 20 mg, 1/day, enalapril 20 mg, 1/day.

Present illness
A 36-year-old male patient came to the emergency department for a week with a clinical presentation of central thoracic pain that he described as oppressive, non-radiating and without vegetative cortex, which did not increase with pressure. He reports that it starts in the morning and that after an hour of pain it usually subsides, without palpitations. In the last two days she noticed that the pain appeared with exertion and decreased with rest.
She went to her health centre for the same reason, where they observed supraventricular tachycardia and a tendency to hypertension (she has stopped taking the treatment), which was treated with antihypertensives and benzodiazepines without improvement.

Physical examination
Killip class: I no heart failure - Weight 102.0 kg. Height 1.74 m. BMI 33.69. BP 135/95. HR 166 bpm. Ta 37,7°C. Sat O2 % 97; no tendinous xanthomas or xanthelasmas.
Normal ocular examination, no corneal arcus. Cardiac auscultation: rhythmic heart sounds without murmurs and without pericardial friction. Pulmonary auscultation: VCM without added pathological sounds. MMII without oedema with symmetrical peripheral pulses.

COMPLEMENTARY TESTS
Emergency ECG (first): sinus tachycardia 146 bpm. Normal PR. Normal electrical axis. Narrow QRS with R wave > S in V2-V3 and ST depression of 1.5 mm from V2-V5 that normalises in subsequent ECGs after controlling HR. Meets Sokolow-Lyon criteria for LVH.
Chest X-ray: cardiothoracic index not increased, sinus costo and cardiophrenic sinuses free, without congestive hilarity or vascular redistribution. No parenchymal masses or nodules were observed.
Urgent laboratory tests (icteric and lipemic serum): glucose 309 mg/dl; urea 31 mg/dl; creatinine 0.9 mg/dl, sodium 134 mEq/l; K+ 4.5 mEq/l; haemoglobin 16.4 g/dl; haematocrit 45.7%; MCV 80.7 fl; platelets 308.0 10e3/ul; leukocytes 14.81 10 e3/uL; CrCl (Cockcroft-Gault) 163.7 ml/min; TUS 420-440-610 ng/l. D-dimer 354.
Laboratory tests: glucose 213 mg/dl; urea 48 mg/dl; creatinine 0.85 mg/dl; total cholesterol 274 mg/dl; triglycerides 893 mg/dl; HDL cholesterol 34 mg/dl, with non-HDL 210; sodium 140 mEq/l; potassium 4.1 mEq/l; haemoglobin 16.0 g/dl; haematocrit 47.7 %; MCV 85.5 fl; platelets 274.0 10e3/ul; leukocytes 9.08 10e3/ul; HbA1c 10.6 %; CRP 8.6 mg/dl; T4L 1.08 ng/dl; TSH 0.76 IUI/ml; CrCl (Cockcroft-Gault) 173.33 units ml/min.
Echocardiography: non-dilated left ventricle, normal thickness. Hypokinesia (no thinned wall) of basal-medial segments of lateral and posterior face, with normocontractility of the remaining segments and slightly depressed residual LVEF (biplane EF 44 %). Slight left atrial dilatation, normal sized RA. Tricommissural aortic valve, normal. Mitral, tricuspid and pulmonary valves of normal morphology and mobility. Right ventricle not dilated, of normal thickness, without alterations of regional contractility and with preserved global systolic function. No significant pericardial effusion. Inferior vena cava and suprahepatic vein not dilated, with adequate inspiratory collapse, which excludes the presence of significant systemic venous hypertension. Doppler findings: mitral Doppler compatible with impaired left ventricular relaxation. Absence of tricuspid insufficiency allowing quantification of pulmonary artery systolic pressure. Conclusions: Alterations of segmental contractility in Cx territory. Residual LVEF 44%.
Coronary angiography: left common trunk without lesions. Anterior descending artery with some irregularities along its course and moderate lesion in the proximal third of the 1st diagonal of good development. Circumflex occluded in the proximal third, visible from heterocoronary circulation; obtuse system of good calibre. Right coronary artery with irregularities along its entire length, moderate plaque in the middle third and severe focal lesion on the posterolateral side, this being an artery of good calibre.
Intervention: the occlusion was successfully passed with microcatheter support and the artery was opened with balloon crescents. A long lesion is observed from the distal third to the proximal third, which is covered with two overlapping drug-eluting stents. They are post-dilated for correct apposition with a good final result and without complications.

EVOLUTION
The patient evolves favourably without recurrences of chest pain or clinical signs of heart failure or significant arrhythmic events. During his admission, he was assessed by endocrinology, who started hypoglycaemic drugs with metformin and empagliflozin with good tolerance. On discharge, it was decided to refer the patient to the cardiac rehabilitation programme at our hospital and to closely monitor him in the cardiology consultations to control cardiovascular risk factors, advise on lifestyle changes and achieve therapeutic compliance.

DIAGNOSIS
Acute non-ST-segment elevation myocardial infarction (NSTEMI) Killip I.
Proximal circumflex occlusion, treated by PTCA and coated stent implantation. Severe focal lesion in posterolateral right coronary artery and moderate lesion in 1st diagonal untreated. Basal and medial posterior and lateral hypokinesia with mild systolic dysfunction (LVEF 44%).
Recently diagnosed type 2 diabetes mellitus and hypercholesterolemia under study.
