Figure 1

An 88-year-old man is admitted to your cardiology department with the indication to perform an elective coronary angiography for exercise-induced chest pain. He has a history of smoking, dyslipidemia and type 2 diabetes mellitus which is well controlled by oral antidiabetic treatment. He started to suffer from typical angina during efforts of moderate intensity six months before admission. He underwent an electrocardiogram (ECG) exercise stress test in the absence of anti-ischemic therapy one month before admission, which documented a horizontal ST-segment depression in inferior (1.5 mm) and lateral (1 mm) leads, associated with limiting chest pain, achieving a workload of 7 METS. Furthermore, a myocardial exercise stress perfusion scintigraphy, performed one week before admission under beta-blocker therapy, showed a reversible moderate-to-severe reduction of tracer uptake in the anterior and apical regions, and a mild radionuclide activity reduction in inferior and lateral segments, of the left ventricle, together with a slight post-stress reduction of left ventricular ejection fraction from 55% at rest to 47%, in the absence of symptoms. On admission, the patient is asymptomatic, without relevant comorbidities, and refers that his angina is well controlled by treatment with beta-blockers. The physical examination is unremarkable; body mass index (BMI) was 28 kg/m². Blood tests show normal levels of lipids, blood sugar and troponin; the estimated glomerular filtration rate is 50 ml/min. His electrocardiogram (ECG) showed sinus rhythm with a heart rate of 70 bpm. Echocardiography is normal, except for a slight left atrial enlargement. Coronary angiography shows three-vessel disease, with a SYNTAX score of 27 (see Figure 1). The Euroscore and the STS score are 2.56% and 2.17%, respectively.