72-Year-old Woman with Effort Angina >3 <12 Months after Acute Myocardial Infarction.

A 72-year-old lady complains of chest pain when climbing stairs or walking uphill. The pain recedes as soon as she stops the physical activity. Four months before she was admitted to the hospital with the diagnosis of acute inferior myocardial infarction (Figure 1). The right coronary artery (RCA) was occluded and a primary percutaneous coronary intervention (PCI) with stenting on the proximal RCA was effective. Non-significant lesions (<70% stenosis) were found in the circumflex (CX) and left anterior descending coronary arteries. The evolution was uneventful. An echocardiogram revealed inferior akinesia with left ventricular ejection fraction (LVEF) 50%, and the patient was discharged home with aspirin (ASA), Prasugrel, Enalapril 5mg/b.i.d., Carvedilol 12.5mg/b.i.d., and Atorvastatin 40mg. Blood pressure is 115/75mmHg, heart rate 60b.p.m., cholesterol LDL 130mg/dL, and glucose 110mg/dL. She is 160cm tall and her weight is 75kg. Figure 2 shows her electrocardiogram (ECG). The complains did not improve adding a long-acting nitrate, and the decision was to review the coronary anatomy. During a staged procedure (2nd revascularization), a stent was implanted in both the LAD and CX arteries that presented the same non-significant/borderline lesion. Fractional flow reserve (FFR) was not measured. Enalapril was discontinued due to hypotension, Ticagrelor substituted Prasugrel, and the dose of atorvastatin increase to 80mg/day as the LDL was 115mg/dL (Figure 3). She remained free from angina during a few weeks and complains again of chest discomfort. She discontinued the long-acting nitrate because of hypotension with 1 syncope. Amlodipine 5mg/b.i.d. is added to the treatment but the complains remain the same. A stress echocardiogram revealed myocardial ischaemia with inferior wall dyskinesia. A new cath was decided (3rd revascularization) and a