Personal history
Asthmatic bronchitis.
Hypothyroidism.
High blood pressure.
Hypercholesterolemia.
Hepatic steatosis.
Sigmoid diverticulosis.
Carpal tunnel syndrome
Benign prostatic hypertrophy.
Hiatus hernia and dyspepsia in follow-up by the Digestive Department.
Allergic rhinitis.
On regular treatment with: levothyroxine 50 ug/24h, tamsulosin 0.4 mg/dutasteride 0.5 mg/24h, levogastrol 25 mg/24h, cinitrapide every 8 hours.
No known drug allergies.

Present illness
On 14/11/14 he presented with chest pain that persisted until 15/11/14 due to persistent chest pain and was diagnosed with STEMI, and it was decided to revascularise by primary PCI on 15/11/14. The patient evolved favourably and was discharged from hospital. On 16/12/14 he was readmitted to the Internal Medicine department for chest pain with atypical characteristics, heart failure, abundant cough and whitish expectoration due to possible respiratory infection.

Examination on admission (15/11/14)
Good general condition, normohydrated, normal colour, eupneic at rest with no signs of respiratory distress, tolerating decubitus.
RCA: rhythmic heart tones without murmurs. Vesicular murmur preserved with bibasal moist crackles.
Abdomen: soft, depressible, non-painful, without focality.
MMII: no oedema or signs of deep vein thrombosis.

Exploration on re-admission (16/12/14)
Good general condition, normohydrated, normal colour, eupneic at rest with no signs of respiratory distress. He does not tolerate decubitus. No neurological focality, no meningeal signs.
RCA: rhythmic heart tones without audible murmurs. Decreased vesicular murmur, bibasal crackles and scattered rhonchi.
Abdomen: soft, depressible, non-painful, no masses or megaliths, no peritonism. Blumberg, psoas and Murphy negative. Preserved hydro-aerial sounds. PPR negative.
MMII: no oedema or signs of deep vein thrombosis. Peripheral pulses preserved and symmetrical.

COMPLEMENTARY TESTS
On admission (15/11/14): ECG on admission to the ER, prior to PCI: sinus rhythm with ST segment elevation of more than 4 mm from V2-V4 and 2 mm in I and aVL, and negative T waves in I, aVL, therefore administering loading doses of aspirin and clopidogrel, deciding on primary angioplasty and admission to the coronary unit. Analysis: blood count and biochemistry: glycaemia 123 mg/dl, urea 29.9 mg/dl, creatinine 1.2 mg/dl, total bilirubin 0.9 mg/del. Sodium 137 mEq/L, potassium 4.59 mEq/L. Aspartate transaminase 131.3 U/L, alanine transaminase 48.2 U/L, alpha-amylase 52 U/L. CRP 13.12 mg/dl, ultrasensitive troponin T 3390 pg/ml, haemoglobin 16.5g/dl, haematocrit 47.2%, leukocytes 17.27x10 3/ l Coagulation: prothrombin activity (INR) INR 1.3, prothrombin activity (sec.) 12.8 se, prothrombin activity 77.6%, activated partial thromboplastin time (sec) 40.2 se, activated partial thromboplastin time (ratio) 1.3 ratio, fibrinogen 587.20 mg/dl.

Primary PCI: Coronary angiography: right dominance. Middle right coronary artery with 40% stenosis. Middle anterior descending artery with 100% stenosis. Circumflex artery with irregularities without stenosis.
PTCA: middle LAD, stent implantation (Integity 2.75x15 mm) and thrombotic material extractor device.
ECG on the Cardiology ward, after PCI: sinus rhythm at 80 bpm. PR 120 msec. Normal axis. QS V1-V5 with ST segment elevation of more than 2 mm from V1-V5. ECG on discharge from Cardiology ward: sinus rhythm at 70 bpm PR 160 msec Normal axis. QS V1-V5, with persistent elevation of more than 1 mm from V1-V6 with negative T waves in these leads.

COMPLEMENTARY TESTS
On the Cardiology ward (18/11/2014): CBC: blood count and biochemistry: glycaemia 95.5 mg/dl, urea 47.6 g/dl, creatinine 1.2 mg/dl. Ions normal. Liver function normal. Haemogram 14.8 g/dl, haematocrit 45.8%, MCV 96.7 fl. Leukocytes 12070 (neutrophils 75%, lymphocytes 12.3%), platelets 285000. Coagulation: INR 1.13, prothrombin activity 12.9 sec, activated partial thromboplastin time 42.5 sec, T4 0.95. TSH 9.
Chest X-ray: cardiothoracic index at the upper limit of normality, cardiophrenic and costo-diaphragmatic sinuses pinched. No pleural effusion, no infiltrates or consolidation.
Echocardiography: non-dilated left ventricle with apical dyskinesia, akinesia of the middle segments of the anterior face, anterior septum and lateral face. LVEF 30%.

On readmission to the Internal Medicine ward (16/12/14): ECG: sinus rhythm at 93 bpm. Axis at 0. No conduction disturbances. Negative T waves in I and aVL, V5 and V6 (already described in previous ECGs).
Arterial blood gases: pH 7.51, pO2 68.6 pCO2 28.7, saturation 02:94% CBC: haemogram: leucocytes 13110 (79% PMN). Platelets 270000. B 13,7. Biochemistry: glycaemia 115 mg/dl, urea 39.9 mg/dl, creatinine 0.85 mg/dl, sodium 138 mEq/L, potassium 4.65 mEq/L, CRP 12.76. Cardiac markers. TpnT 115-120.
Chest X-ray: probable condensation in the left lower lobe. Urine: Ag. Legionella negative. Ag streptococcus pneumoniane negative.
Sputum culture: development of oropharyngeal flora.
CT: saccular formation in cardiac apex of about 50 mm, compatible with left ventricular aneurysm / pseudoaneurysm. No signs of PTE. Nodule in the left upper lobe of about 11 mm with central calcification probably corresponding to previous granuloma. Laminar bibasal atelectasis. Echocardiography: left ventricle with extensive apical aneurysm and pseudoaneurysm. Contained cardiac rupture. LVEF 15%.
On the Cardiology ward: Echocardiography (26/12/14): dilated left ventricle with thinned apical region, akinetic and expanded (apical aneurysm). Neocavity at the level of the anterolateral apical region communicating with the left ventricle with a neck of 12 mm and a diameter of 5x3 cm, contained by pericardium with flow passage, compatible with pseudoaneurysm on apical aneurysm.
Ejection fraction very severely depressed by visual estimation. Normal left atrium. Right ventricle with normal diameter, walls and ejection fraction. Normal right atrium. Mitral valve with good opening and mild/moderate secondary mitral insufficiency. Aortic valve without significant structural or functional alterations. Right valves without significant structural or functional alterations. Inferolateral pericardial detachment in the peri-pseudoaneurysm area. Inferior cava not dilated with preserved inspiratory collapse

On the Cardiovascular Surgery Ward: Preoperative blood count: haemoglobin 13.4 g/dl, leucocytes 10.4x10 3/L, platelets 384000. Urea 49 mg/dl, creatinine 1 mg/dl, Pro BPN 290. Normal coagulation.
Control after surgery: haemoglobin 9.9, renal function and ions normal. ECG: sinus rhythm with extensive anteroseptal and lateral necrosis wave.
Echocardiography (12/01/14) after surgery: left ventricle with normal diameters. Apical akinesia and part of anteroseptal, anterior and lateral mid-segment with increased echogenicity in endocardial area suggestive of Dacron patch; thickening and increased echogenicity of apical parietal pericardium. Inferior apical hypokinesia. Basal hypokinesia and part of anterior media. Rest lateral and inferolateral with compensatory hyperkinesia. Moderately depressed ejection fraction, around 35-40% by visual estimation. Simpson biplane of 38%, filling pattern suggestive of impaired relaxation. Normal left atrium and right chambers. Left and right valves without significant structural or functional alterations. Aortic root and ascending aorta slightly dilated. Absence of pericardial effusion. Normal inferior vena cava.

EVOLUTION
The patient started on 14th November at 23:00 hours with oppressive central thoracic pain radiating to the left arm with sweating. The patient remained at home and decided not to consult the doctor because he did not attach any importance to the situation. After spending the whole night with pain and persisting with the same on the morning of the 15th he decided to go to his reference hospital, where on arrival an ECG was performed (15/11/14 described in complementary tests). STEMI was detected and primary PCI was decided.
On the cardiology ward, the patient evolved favourably and a TSH of 9 was discovered, so levothyroxine was increased. Given the good evolution, the patient was discharged with a diagnosis of:
Anterior STEMI treated with primary angioplasty and implantation of a stent in the mid LAD. Severe ventricular dysfunction.

Pharmacological treatment on discharge from the Cardiology ward (22/11/14):
Usual medication for benign prostatic hypertrophy and dyspepsia.
Acetylsalicylic acid: 100 mg, 1 tablet at noon.
Clopidogrel 75 mg, 1 tablet at breakfast.
Omeprazole 20 mg, 1 tablet at breakfast.
Levothyroxine 75 mcg, 1 tablet at breakfast.
Ramipril 2.5 mg, half a tablet at dinner.
Furosemide 40 mg, half a tablet at breakfast.
Eplerenone 25 mg, 1 tablet at midday.
Atorvastatin 80 mg, 1 tablet at dinner.

It was decided not to introduce beta-blockers due to asthmatic bronchitis.

The patient came to the emergency department on 11 December due to the onset of chest pain of atypical characteristics lasting hours and exacerbating with respiratory movements. No clinical signs of decompensation of heart failure. The analytical tests performed and the ECG were similar to those on discharge from hospital and the pain subsided with the usual intravenous analgesia (paracetamol, metamizole), so he was discharged from the emergency department. He returned to the ED on 16 December due to recurrence of atypical chest pain, which caused shortness of breath, increasing with inspiration and lasting for hours, as well as symptoms compatible with heart failure (dyspnoea on minimal exertion, orthopnoea and paroxysmal nocturnal dyspnoea). He also reported cough with whitish expectoration without thermometric fever.

Pneumonia was suspected in the emergency department and he was admitted to Internal Medicine with a diagnosis of pneumonia.

During admission to Internal Medicine, complementary tests were carried out which revealed a pseudoaneurysm on apical aneurysm and so he was referred to a referral hospital with Cardiac Surgery, being admitted under the care of Cardiology. The patient was presented at the medical-surgical session where he was finally accepted for surgery and underwent surgery on 30 December. He had occasional chest pain with pleuro-pericardial characteristics and clopidogrel was withdrawn 5 days prior to surgery. Surgery was performed: resection of the ventricular aneurysm by means of a central incision and implantation of a Dacron patch. The patch was covered with the walls of the pseudoaneurysm, which was reinforced with three Teflon strips, with no intraoperative incidents. During his stay on the Cardiac Surgery ward, he evolved favourably, starting to ambulate, with no signs of decompensated heart failure, and was discharged on 13/01/15.

Pharmacological treatment on discharge from the Cardiovascular Surgery ward (13/01/15):
Usual medication for benign prostatic hypertrophy, dyspepsia and hypothyroidism same.
Aspirin 100 mg, 1 tablet at breakfast.
Clopidogrel 75 mg, 1 tablet at breakfast.
Omeprazole 20 mg, 1 tablet at breakfast.
Atorvastatin 40 mg, 1 tablet at dinner.
Bisoprolol 2.5 mg, 1 tablet at breakfast.
Ramipril 2.5 mg, 1 tablet at breakfast.
Eplerenone 25 mg, 1 tablet at lunch.
Furosemide 40 mg, at breakfast.

DIAGNOSIS
Contained cardiac rupture: pseudoaneurysm over apical aneurysm.
