The right man at the right place

Introduction: Ischemic heart disease may take various forms, the acute presentation requiring a rapid approach for a favorable evolution of the patient.
Case presentation: This is the case of a 70 year old patient with a history of atrial fibrillation, embolic cerebral ischemia, arterial hypertension std II JNC8 hospitalized for angina and dyspnea at low efforts, symptomatology progressively aggravated in the last month. At the clinical examination the patient is hemodynamically balanced, TA=120/70 mmHg, AV=67/min, no cardio-vascular breathing, no edema, normal lung examina-tion, digestive and neurological examination within normal limits.The resting ECG revealed sinus rhythm, 1 mm anterolateral ST depression and 1-2 mm elevation in the AVR lead. Echocardiographic findings are normal cavities, mild left ventricular hypertrophy, preserved LV systolic function, grade I diastolic dysfunction, mild mitral and mild tricuspid regurgitation, no pulmonary hypertension, free pericardium.The patient has a coronarographic exploration and is reffered to the catheterization lab. Upon entering the angiography lab, the patient experiences diffuse thoracic pain, diaphoresis, BP=77/50 mmHg, HR=60 bpm. The laboratory monitor highlights the depression in DI, one of the monitored leads.An emergency coronarography is per-formed revealing the sub-occlusion of the medium left main, unstable plaque, the middle anterior interven-tricular artery with up to 50% plaque, the circumflex artery with distal occlusion, the right coronary artery with up to 50% plaque. Emergency angioplasty of the left main with implantation of a pharmacologically active stent of 3.5/19 mm and proximal postdilatati-on with a 4.0/15 mm balloon is performed. After the procedure the blood pressure becomes normal, pain intensity is decreased, ECG reveals enlargement of QRS complex, increased ST segment elevation in AVR and diffuse ST depression. At 24 hours after the procedure the ECG becomes normal. Elevated myocardial cytolysis enzymes after the procedure become normal within 72 hours. At discharge, the patient receives double antiplatelet aggregation with aspirin and ticagrelor, oral anticoagulation with acenocumarol, atorvastatin 40 mg daily, amiodarone and spironolactone with subsequent favorable progression, without angina, without ventricular failure phenomena, without hemorrhagic events and without repetition of atrial fibrillation.
Conclusions: T he patient with myocardial ischaemia is a patient who can become unstable anytime. It is necessary to establish risk factors that would require urgent invasive exploration and interventional salvage treatment.

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
The Romanian Journal of Cardiology is indexed by:
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CODE: 379
CME Credits: 10 (Romanian College of Physicians)
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