Introduction: Coronary artery disease (CAD) is rarely life-threatening in asymptomatic, medium-high risk patients, but when diagnosed it must stir a prompt and complex diagnostic and therapeutic approach. Optimal medical treatment, revascularisation and prevention of sudden cardiac death are the mechanisms to improve prognosis, cardiac function and to prevent overt heart failure.

Methods: A hypertensive, dyslipidemic, diabetic, 54 year-old male, recently diagnosed with severe left ven-tricular (LV) systolic dysfunction during hospitalisati-on for recurrent perianal abscess, is transferred to our Clinic for evaluation after postop resuscitation (VFib). He has short-term hypomnesia, uncomplicated peria-nal incision, is afebrile and shows pulmonary congesti-on, HR 75/min, BP 175/100 mmHg. Although asymp-tomatic for angina, repeat ECG shows accentuating ST elevation in aVR, V1-V3.

Results: Echo confirms severe LV systolic dysfunction (LVEF 30%), anterior and inferior wall akinesia, apical and apical septum dyskinesia, grade II mitral regurgi-tation, normal aorta and pericardium, mild pulmonary hypertension with normal right ventricle. Urgent cathreveals 80% left main stenosis, proximal LAD occlusi-on, 70-80% proximal RCA stenosis and medium RCA occlusion. Heart team discussion considered the severe CAD in a patient with LV apical aneurysm and severe systolic dysfunction and decided to perform MRI for study of myocardial viability and therapeutic strategy. It shows extensive fibrosis of the LV with old myocar-dial infarction in both anterior and inferior territories, rendring the patient unsuitable for surgery. While on optimal medical treatment (OMT), including anti-arrythmics and awaiting ICD for secondary prevention of sudden cardiac death, the patient has 2 episodes of VFib, requiring multiple defibrillations, intensive i.v. medication and mechanical ventilation. After the latter resuscitation, urgent angioplasty with 2 DES is perfor-med successfully for the left main stenosis and desob-struction of the LAD occlusion. 2 days later a VR-ICD was also successfully implanted. Following an in-hos-pital favourable evolution, the patient was discharged on OMT. The 3-months and 6-months reevaluation shows no recurrent Vfib, improved LV systolic functi-on (LVEF 40%).

Conclusions: T his case is representative for under-investigated medium-high risk patients, even when asymptomatic for angina and even in presence of cur-rent guidlines for screening and prevention of CAD. Here, the severity of CAD and the severity of HF and arrythmic events had positive response to interventio-nal therapy, showing that these late-diagnosed patients may still benefit from revascularisation and device the-rapy. Even in the setting of severe CAD and extensive fibrosis, maximum medical and device therapy inclu-ding coronary artery desobstruction may contribute to ceasing life-threatening ventricular arrythmias, to improvement of LV systolic function and prevention of overt heart failure.