CONGRESS ABSTRACT

Introduction. It has been known for some time that the angiographic evaluation of coronary stenosis presents several qualitative and quantitative limitations. The clinic is usually a good guide when talking about typical exertional angina or in the context of acute coronary syndromes but in the case of some hypokinetic heart diseases, for example, coronary ischemic etiology is often controversial. In the context of less typical symptoms and with possible multiple causes such as, for example, syncope, a correlation with ischemic coronary artery disease is a rare event. In this regard, I propose a case that contains numerous ideas regard the "modern" angiographic evaluation techniques of coronary stenosis without forgetting the "classic" and "mysterious" importance of the clinic. Discussion: the case concerns a 74 year old man known for chronic ischemic heart disease for which he has already undergone PTCA + Stent on the proximal anterior interventricular coronary (IVA) in the context of documented myocardial scintigraphy ischemia in exertional angina. Admission to cardiology for chest pain followed by traumatic syncope; in the emergency room AF with heart rate  of 80 bpm “asymptomatic” regressed after a few minutes without ischemic changes on the ECG or increase in markers of myocardionecrosis. Head CT negative for pathology, hospitalized and subjected to coronary angiography which showed chronic occlusion of the first diagonal branch, non-critical stenoses of the main trunk-circumflex-IVA and hagiographically moderate stenosis of the proximal-middle right coronary artery (CDx). In relation to the current syncopal event and other recent atraumatic ones, he underwent a tilting test which triggered a syncopal episode characterized by marked bradycardia and elevation of the ST segment in the lower area, which was reversed with nitrate. Given the new data obtained, he underwent an angiographic re-evaluation and intracoronary ultrasound study (IVUS) and an evaluation of the coronary fractional flow reserve (FFR), the latter being positive for myocardial ischemia. Followed PTCA + Stent on CDx. In the subsequent follow-up syncopal symptoms did not relapse. Conclusions: manifestations of right coronary ischemia with this presentation are rare but possible, as is underestimating other manifestations of myocardial ischemia, settling without further investigation with more advanced and currently more usable methods.