HISTORY, CURRENT ILLNESS AND PHYSICAL EXAMINATION

History
84-year-old patient, with no known pharmacological allergies and a personal history of: arterial hypertension (AHT) of long evolution; diabetes mellitus (DM) type 2 of 8 years of evolution, with diabetic retinopathy, in treatment with oral antidiabetics; chronic renal disease stage 4 of arteriosclerotic origin due to AHT and DM of long evolution (usual creatinine 2 mg/dl; estimated GFR CKD-EPI 29 mL/min/1.73 m2); benign prostatic hyperplasia and operated on for left inguinal herniorrhaphy.

Present illness
The patient presented two episodes of syncope in the last 12 hours, with prodrome (general malaise and nausea without vomiting) and subsequent loss of consciousness lasting about 10 seconds with subsequent recovery without post-critical state. Associated sphincter relaxation. No tonic-clonic convulsions or tongue biting. The patient relates the symptoms to possible hypoglycaemia, so he has taken glucose orally without going to a medical centre. In the first episode he suffered cranioencephalic trauma with an incised-contuse wound to the scalp. After the second episode (witnessed by his relatives) he was brought to the emergency department for assessment. The patient reported epigastric pain of approximately one week's duration, episodic, unrelated to ingestion or movement, and associated with nausea. During the anamnesis, the patient presented a new episode of syncope, preceded by nausea and vegetative cortex, lasting a few seconds, with complete recovery of the level of consciousness afterwards, without subsequent confusional state.

Physical examination
Vital signs: BP 120/57 mmHg. HR 80 bpm. Ta 36.5°C. SatO2 97 %. Capillary blood glucose 320. Conscious. Orientation. Normal colour. Normohydrated. Eupneic. No jugular ingurgitation. Cardiac auscultation: rhythmic heart sounds without murmurs. Pulmonary auscultation: normal vesicular murmur. Abdomen: soft, depressible, not painful on palpation, normal peristalsis. Lower extremities: no oedema or signs of deep vein thrombosis.

COMPLEMENTARY TESTS
ECG 1 (performed in the emergency department): sinus rhythm at 60 bpm. Second-degree atrioventricular block, Mobitz 1. ST suprasystolic level in II, III, aVF with a decrease in I and aVL. ECG 2 (performed in the ED): sinus rhythm at 60 bpm. Second-degree atrioventricular block, Mobitz 1. ST elevation in II, III, aVF with a decrease in I and aV; somewhat less marked than in previous ECG. Emergency laboratory tests: troponin I 10.46 ng/ml. Myoglobin 400 ng/ml. ProBNP 10400 pg/ml. Glucose 315 mg/dl. Urea 90 mg/dl. Creatinine 2.21 mg/dl. Chlorine 102 mEq/l. Sodium 135 mEq/l. Potassium 4.8 mEq/l. Leukocytes 17,500 (15,400 neutrophils). Hb 11.9 g/dl. VCM 98. Prothrombin activity 85 %. Cranial CT scan: centred midline. Corticosubcortical atrophy according to age. Calcification of epiphysis and choroid plexus. No signs suggestive of bleeding or other significant radiological alterations. Urgent coronary angiography: left main coronary artery (LMCA): no angiographic disease. Anterior descending (AD): very severe lesion (90-95%) in the proximal segment encompassing the origin of the first diagonal, with significant disease in the middle segment. Distal bed with significant localised patchy involvement.
Circumflex (CX): severe proximal disease (85-90 %). Distal bed formed by three left marginal branches, two of them with significant proximal ostial disease. Right coronary (RC): dominant. Moderate proximal and medial diffuse disease. Acute thrombotic occlusive lesion involving middle segment and first elbow, both calcified. Distal TIMI 1-2 flow. After opening it, a diffusely diseased distal segment with limited calibre was observed. Percutaneous coronary intervention: predilatation with low-pressure balloon with good results, implantation of two drug-eluting stents in tandem. Embolisation to the distal segment, treated with repeated intracoronary nitroprusside boluses and multi-segment low-pressure balloon dilatation. Contained dissection in proximal segment of most proximal stent treated with another drug-eluting stent in tandem. Good final result with TIMI 3 in the entire vessel with recovery of sinus rhythm with first-degree atrioventricular block. Transthoracic echocardiogram: normal sized left ventricle with preserved global LVEF. Akinesia of the basal and middle segments of the inferior wall and hypokinesia of the apical inferior segment. Mild diastolic dysfunction, with increased LVEDP. Mild MI. Normal aortic valve. Minimal TR with mild-moderate pulmonary hypertension. No pericardial effusion. ECG at discharge: sinus rhythm at 67 bpm. First degree AV block. Q waves in inferior face.

EVOLUTION
After the syncope presented in the anamnesis, once the patient had recovered, an ECG was performed which showed Mobitz I grade 2 AV block (AVB) with ST supralow leveling in the inferior face, so the patient was monitored with a defibrillator-monitor and an infarction code was activated with a diagnosis of STEACS in the inferior face. An urgent cranial CT scan was performed to rule out post-traumatic cranioencephalic haemorrhage and therapy was started with loading doses of double platelet antiplatelet therapy with aspirin and clopidogrel. Urgent coronary angiography was requested. While the patient was being monitored, he suffered a new syncope lasting seconds and the monitor showed transient evidence of high-grade atrioventricular block (phases of second-degree AVB type Mobitz II), which subsequently reverted to grade 2 AVB Mobitz I. Urgent coronary angiography was performed, which revealed an acute thrombotic occlusive lesion in the right coronary artery, responsible for the symptoms, and percutaneous coronary intervention was performed with the implantation of 3 drug-eluting stents after balloon dilatation. The transthoracic echocardiogram after the episode showed a left ventricle of normal size, with preserved ejection fraction and the ECG at discharge showed sinus rhythm at 67 beats per minute, first-degree atrioventricular block and Q waves in the inferior face. Given the recovery of the atrioventricular block after coronary reperfusion, pacemaker implantation was not necessary. Subsequently, the case was discussed with haemodynamics to consider revascularisation of the severe lesions of the anterior descending and circumflex arteries, and conservative treatment was decided given the absence of angina, anaemia, chronic renal disease and diffuse distal involvement of the LAD. The patient is currently being followed up in cardiology consultations, with good quality of life and absence of angina with medical treatment.

DIAGNOSIS
Acute coronary syndrome with ST-segment elevation (STEACS) inferoposterior Killip I. Right coronary artery with acute thrombotic occlusive lesion in mid-distal segment. Percutaneous coronary intervention with implantation of 3 drug-eluting stents in tandem.
Grade 2 Mobitz i atrioventricular block with phases of high-grade atrioventricular block of ischaemic origin due to involvement of the right coronary artery. After revascularisation: first-degree atrioventricular block. Syncope of cardiogenic origin with cranioencephalic trauma, without acute cerebral haemorrhagic lesions. Incised-contuse scalp injury. Severe ischaemic multivessel multi-segment ischaemic heart disease.
